Faculty Bibliography

OBJECT/OBJECTIVE:The objective of this systematic review was to use evidence-based medicine to examine the efficacy of anterior cervical surgery for the treatment of cervical spondylotic myelopathy (CSM). METHODS:The National Library of Medicine and Cochrane Database were queried using MeSH headings and key words relevant to anterior cervical surgery and CSM. Abstracts were reviewed, and studies meeting inclusion criteria were selected. The guidelines group assembled an evidentiary table summarizing the quality of evidence (Classes I-III). Disagreements regarding the level of evidence were resolved through an expert consensus conference. The group formulated recommendations that contained the degree of strength based on the Scottish Intercollegiate Guidelines network. Validation was done through peer review by the Joint Guidelines Committee of the American Association of Neurological Surgeons/Congress of Neurological Surgeons. RESULTS:Mild CSM (modified Japanese Orthopaedic Association [mJOA] scale scores > 12) responds in the short term (3 years) to either surgical decompression or nonoperative therapy (prolonged immobilization in a stiff cervical collar, "low-risk" activity modification or bed rest, and antiinflammatory medications) (Class II). More severe CSM responds to surgical decompression with benefits being maintained a minimum of 5 years and as long as 15 years postoperatively (Class III). CONCLUSIONS:Treatment of mild CSM may involve surgical decompression or nonoperative therapy for the first 3 years after diagnosis. More severe CSM (mJOA scale score <or= 12) should be considered for surgery depending upon the individual case. The shortcomings of this systematic review are that the group was not able to determine whether an mJOA scale score of 12 was indicative of a more severe CSM disease course, and whether patients who received nonsurgical treatment for 3 years had a significant probability for clinical deterioration after that time point.

OBJECT/OBJECTIVE:The objective of this systematic review was to use evidence-based medicine to identify the indications and utility of anterior cervical nerve root decompression. METHODS:The National Library of Medicine and Cochrane Database were queried using MeSH headings and key words relevant to surgical management of cervical radiculopathy. Abstracts were reviewed after which studies meeting inclusion criteria were selected. The guidelines group assembled an evidentiary table summarizing the quality of evidence (Classes I-III). Disagreements regarding the level of evidence were resolved through an expert consensus conference. The group formulated recommendations that contained the degree of strength based on the Scottish Intercollegiate Guidelines network. Validation was done through peer review by the Joint Guidelines Committee of the American Association of Neurological Surgeons/Congress of Neurological Surgeons. RESULTS:Anterior nerve root decompression via anterior cervical discectomy (ACD) with or without fusion for radiculopathy is associated with rapid relief (3-4 months) of arm/neck pain, weakness, and/or sensory loss compared with physical therapy (PT) or cervical collar immobilization. Anterior cervical discectomy and ACD with fusion (ACDF) are associated with longer term (12 months) improvement in certain motor functions compared to PT. Other rapid gains observed after anterior decompression (diminished pain, improved sensation, and improved strength in certain muscle groups) are also maintained over the course of 12 months. However, comparable clinical improvements with PT or cervical immobilization therapy are also present in these clinical modalities (Class I). Conflicting evidence exists as to the efficacy of anterior cervical foraminotomy with reported success rates of 52-99% but recurrent symptoms as high as 30% (Class III). CONCLUSIONS:Anterior cervical discectomy, ACDF, and anterior cervical foraminotomy may improve cervical radicular symptoms. With regard to ACD and ACDF compared to PT or cervical immobilization, more rapid relief (within 3-4 months) may be seen with ACD or ACDF with maintenance of gains over the course of 12 months (Class I). Anterior cervical foraminotomy is associated with improvement in clinical function but the quality of data are weaker (Class III), and there is a wide range of efficacy (52-99%).

OBJECTIVE: In this case report, we present a patient with normal pressure hydrocephalus in whom a lumbar drainage trial yielded a false-negative result secondary to cervical spondylosis. CLINICAL PRESENTATION: An 80-year-old woman presented with classic symptoms of normal pressure hydrocephalus as well as evidence of cervical myelopathy. Magnetic resonance imaging of the brain and spine showed enlarged ventricles and single-level cervical canal narrowing. INTERVENTION: An initial lumbar drainage trial was performed, which revealed negative results. The patient then underwent cervical decompression and fusion. Despite this procedure, the patient's symptoms continued to worsen. A repeat lumbar drainage trial was performed with positive results. Subsequently, a ventriculoperitoneal shunt was placed, resulting in significant improvement of her symptoms. CONCLUSION: This case report illustrates how altered cerebrospinal fluid flow dynamics may impact the accuracy of the lumbar spinal drainage trial in patients with normal pressure hydrocephalus.

The evaluation and treatment of spinal deformities begins with the accurate measurement of appropriate spinal parameters. The surgeon must ensure that the patient is positioned properly for all necessary x-ray scans and that the proper studies are completed. The relevant measurements must be identified and recorded for each study. Understanding the proper measurement techniques will increase the accuracy and reliability of the measurements. From these precise measurements the surgeon can begin to determine key characteristics of the deformity and develop an appropriate treatment plan.

Intramedullary inclusion cysts are extremely rare within the rostral spinal cord. In this case report the authors outline the clinical features and surgical treatment of one dermoid cyst and one epidermoid cyst of the cervicothoracic junction. The authors also include a relevant literature discussion regarding the treatment and the embryological origin of these lesions.

Posterior dynamic stabilization in the lumbar spine is performed in an attempt to reduce loading across the intervertebral disc for the purpose of relieving pain and limiting degeneration while preserving motion. The AccuFlex rod system (Globus Medical, Inc.), a first-generation device, achieves this by changing the properties of the rod within the Protex pedicle screw-based rigid rod system. Helical cuts that have been created in the standard 6.5-mm rod allow for a limited range of motion while providing a posterior tension band that relieves a significant amount of disc loading. The AccuFlex rod system has been approved by the Food and Drug Administration for single-level fusion when used in conjunction with an interbody graft. In a study involving 170 patients who underwent fusion surgery for back pain, the 54 who received the AccuFlex construct had statistically similar fusion rates and outcomes (as assessed by visual analog scale and Short Form-16 scores) when compared with 116 patients treated with rigid rod fixation after 1 year of follow up. Future clinical studies will examine and provide information regarding the impact of AccuFlex on the incidence of adjacent-level disease. Information gained through the clinical experience with AccuFlex will serve as a foundation for the development of a stand-alone dynamic construct.

The authors describe the case of a patient with an enhancing, intramedullary cervical spinal cord lesion and associated syrinx. Biopsy sampling of the cervical lesion was performed, and the histological findings were consistent with a demyelinating process supporting the diagnosis of multiple sclerosis (MS). Syrinx formation associated with demyelinating disease has only been described in isolated cases, almost exclusively in Japanese patients with MS. A 22-year-old woman of Caribbean descent presented with a subacute, progressive myelopathy including symptoms of pain and weakness in all extremities, bladder incontinence, and the inability to ambulate. Magnetic resonance imaging of the brain and spinal cord demonstrated an enlarged cervical cord with enhancement and central cavitation consistent with a syrinx. The patient underwent a C3-7 laminoplasty and placement of a dural graft for cord decompression as well as fenestration of the central syrinx. Biopsy sampling of the lesion was performed, and the histopathological analysis, in conjunction with subsequent laboratory and diagnostic testing, supported the diagnosis of demyelinating disease. After treatment with a course of high-dose dexamethasone and inpatient rehabilitation therapy, the patient demonstrated significant clinical improvement. Spinal cord involvement is not uncommon in patients with demyelinating disease; however, enhancing lesions associated with extensive tissue loss and syrinx formation have rarely been reported. For the consulting neurological surgeon, demyelinating disease should be included in the differential diagnosis of such lesions given the level of complexity and risk to the patient associated with open biopsy of the spinal cord.

We examined mRNA expression of 11 genes: BAK, Bcl-x, Interferon [IFN]-gamma, Interleukin [IL]-1beta, IL-6, IL-10, IL-12alpha, IL-12beta, IL-18, CXCLi2 [IL-8/CAF], and a MIP family chemokine, CCLi2, in the spleen and cecum of day-old chicks after oral inoculation with Salmonella enteritidis (SE) or medium. Three distinct chicken breeds (broiler, Fayoumi, and Leghorn) were evaluated for mRNA expression levels at 2 and 18h post-inoculation using quantitative reverse transcriptase-polymerase chain reaction (RT-PCR). SE exposure significantly increased splenic IL-18 and IFN-gamma expression. Breed effect was significant (P<0.05) for CXCLi2, IL-10, IL-12alpha, and CCLi2 mRNA expression in the spleen, and for IL-12alpha, IL-12beta, IL-18, and CCLi2 mRNA expression in the cecum. Generally, mRNA expression levels were higher in the spleen, and lower in the cecum, of Leghorns versus broilers. These results support a role for breed genetics influencing cytokine mRNA expression in young chickens and may potentially explain some generalized immune response differences between breeds.