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Journal of Clinical Monitoring and... Dec 2023To review the use of epidural electric stimulation test, pressure waveform analysis, and ultrasound assessment of injection as bedside methods for confirming... (Meta-Analysis)
Meta-Analysis Review
Confirming identification of the epidural space: a systematic review of electric stimulation, pressure waveform analysis, and ultrasound and a meta-analysis of diagnostic accuracy in acute pain.
To review the use of epidural electric stimulation test, pressure waveform analysis, and ultrasound assessment of injection as bedside methods for confirming identification of the epidural space in adults with acute pain, the PubMed database was searched for relevant reports between May and August 2022. Studies reporting diagnostic accuracy with conventional Touhy needles and epidural catheters were further selected for meta-analysis. Sensitivity and specificity were estimated using univariate logistic regression for electric stimulation and pressure analysis, and pooling of similar studies for ultrasound. Risk of bias and applicability was assessed using QUADAS-2. For electric stimulation, pressure waveform analysis, and ultrasound, respectively 35, 22, and 28 reports were included in the review and 9, 9, and 7 studies in the meta-analysis. Electric stimulation requires wire-reinforced catheters and an adequate nerve stimulator, does not reliably identify intravascular placement, and is affected by local anaesthetics. Sensitivity was 95% (95% CI 93-96%, N = 550) and specificity unknown (95% CI 33-94%, N = 44). Pressure waveform analysis is unaffected by local anaesthetics, but does not identify intravascular nor intrathecal catheters. Sensitivity was 90% (95% CI 72-97%, N = 694) and specificity 88% (95% CI 78-94%, N = 67). B-mode, M-mode and doppler ultrasound may be challenging, and data is still limited. Risk of bias was significant and accuracy estimates must be interpreted with caution. Electric stimulation and pressure waveform analysis seem clinically useful, although they must be interpreted cautiously. In the future, clinical trials in patients with difficult anatomy will likely be most useful. Ultrasound requires further investigation.
Topics: Adult; Humans; Epidural Space; Anesthetics, Local; Acute Pain; Anesthesia, Epidural; Electric Stimulation
PubMed: 37481480
DOI: 10.1007/s10877-023-01056-8 -
Cureus Apr 2023Lumbar spinal stenosis refers to the narrowing of the spinal canal in the lumbar region. There is an increasing need to determine the treatment modality for lumbar... (Review)
Review
Lumbar spinal stenosis refers to the narrowing of the spinal canal in the lumbar region. There is an increasing need to determine the treatment modality for lumbar spinal stenosis by comparing the outcomes of X-stop interspinous distractors and laminectomy. The objective of this study is to determine the effectiveness of the X-stop interspinous distractor compared to laminectomy. This systematic review fundamentally abides by the procedures delineated in the Cochrane methodology while the reporting is done according to the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. Three databases searched generated a total of 943 studies, with PubMed being the source for the bulk of the articles. Six studies were selected for inclusion in this study. The effectiveness of the interspinous distractor devices and laminectomy can be determined through their impact on the quality of life, rates of complications, and the amount of money utilized. This meta-analysis fundamentally emphasizes that laminectomy is a more effective intervention for the treatment of lumbar spinal stenosis as it is more cost-effective and results in fewer complications in the long term.
PubMed: 37077368
DOI: 10.7759/cureus.37535 -
European Spine Journal : Official... Mar 2024Lumbar spinal stenosis is one of the most common diseases affecting the elderly that is characterized by the narrowing of the spinal canal and peripheral neural pathways... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND CONTEXT
Lumbar spinal stenosis is one of the most common diseases affecting the elderly that is characterized by the narrowing of the spinal canal and peripheral neural pathways which may cause back pain and neurogenic intermittent claudication in affected patients. Recently, as an alternative treatment between conservative therapy and decompression surgery, interspinous process device (IPD) such as X-stop, Coflex, DIAM, Aperius, Wallis, etc., has gained enough popularity.
PURPOSE
The purpose of this study was to evaluate the efficacy and safety of IPD in the treatment of degenerative lumbar spinal stenosis compared with decompression surgery.
STUDY DESIGN
This study was a systematic review and meta-analysis of randomized controlled trials.
PATIENT SAMPLE
555 patients' samples were collected for this study.
OUTCOME MEASURES
The Visual Analogue Scale and the Oswestry Disability Index were analyzed, as well as the Zurich Claudication Questionnaire For efficacy evaluation. Complication and reoperation rate was utilized for the assessment of safety.
METHODS
A comprehensive literature search was performed through Pubmed, EMBASE, Web of Science, and Cochrane Library until October 2023. Among the studies meeting the eligible criteria, any study in which IPD was utilized in the treatment of degenerative lumbar spinal stenosis was included in the current review. For efficacy evaluation, the Visual Analogue Scale and the Oswestry Disability Index were analyzed, as well as the Zurich Claudication Questionnaire. Complication and reoperation rates were utilized for the assessment of safety.
RESULTS
Five randomized controlled trials with 555 patients were included. There were no significant differences in VAS leg pain (SMD - 0.08, 95% CI - 0.32 to 0.15) and back pain (SMD 0.09, 95%CI-0.27 to 0.45), ODI scores (MD 1.08, 95% CI - 11.23 to 13.39) and ZCQ physical function (MD-0.09, 95% CI-0.22 to 0.05) for IPD compared with decompression surgery. In terms of ZCQ symptom severity (MD - 0.22, 95% CI - 0.27 to - 016), decompression surgery showed superior to the IPD. As for complications (RR 1.08, 95% CI 0.36 to 3.27), the IPD had no advantages compared to decompression surgery, whereas inferior to it in reoperation rate (RR 2.58, 95% CI 1.67 to 3.96).
CONCLUSIONS
This systematic review and meta-analysis indicated no superiority in the clinical outcome for IPD compared with decompression surgery. However, more clinical studies are warranted to determine the efficacy and safety of IPD.
Topics: Humans; Aged; Spinal Stenosis; Decompression, Surgical; Lumbar Vertebrae; Randomized Controlled Trials as Topic; Back Pain; Treatment Outcome
PubMed: 38342843
DOI: 10.1007/s00586-023-08119-z -
European Spine Journal : Official... Oct 2021Metastatic epidural spinal cord compression (MESCC) is a debilitating sequela of cancer that results in pain, disability, and neurologic deficits. Surgical techniques...
BACKGROUND
Metastatic epidural spinal cord compression (MESCC) is a debilitating sequela of cancer that results in pain, disability, and neurologic deficits. Surgical techniques have included open surgical (OS) techniques with anterior and/or posterior decompression and fusion procedures. Further technical evolution has led to minimally invasive spinal (MIS) decompression and fusion. The objective of this study is to compare MIS to OS techniques in the treatment of thoracolumbar MESCC.
METHODS
A review of the literature was performed using PubMed database. Inclusion criteria included patients 18 years or older, thoracolumbar MESCC, and surgeries with instrumented fusion. A total of 451 articles met the inclusion criteria and further analysis narrowed them down to 81 articles. Variables collected included blood loss, length of stay, operative time, pre- and postoperative Frankel grade, and complications.
RESULTS
A total of 5726 papers were collected, with a total of 81 papers meeting final inclusion criteria: 26 papers with MIS technique and 55 with OS. A total of 2267 patients were evaluated. They were split into three surgical subtypes of MIS and OS: posterior decompression and fusion, partial corpectomy, and complete corpectomy. Overall, MIS had lower operative time, blood loss, and complications compared to OS. A timeline analysis showed reduction of complication rates in MIS surgery between papers published over a 28-year period.
CONCLUSION
MESCC carries significant morbidity and mortality. Surgical approaches for palliative treatment should account for this fact. We conclude that MIS techniques offer a viable alternative to traditional OS approaches with lower overall morbidity and complications.
Topics: Decompression, Surgical; Epidural Space; Humans; Minimally Invasive Surgical Procedures; Spinal Cord Compression; Spinal Fusion
PubMed: 34052895
DOI: 10.1007/s00586-021-06880-7 -
Global Spine Journal Mar 2024Systematic review and meta-analysis. (Review)
Review
STUDY DESIGN
Systematic review and meta-analysis.
OBJECTIVES
To assess the radiographic risk factors for adjacent segment disease (ASD) following anterior cervical discectomy and fusion (ACDF) for degenerative cervical spine pathologies.
METHODS
PubMed, Embase and the Cochrane Library databases were searched up to December 2023. The primary inclusion criteria were degenerative spinal conditions treated with ACDF, comparing radiological parameters in patients with and without postoperative ASD. The radiographic parameters included intervertebral disc height, cervical sagittal alignment, sagittal segmental alignment, range of motion, segmental height, T1 slope, sagittal vertical axis (SVA), thoracic inlet angle (TIA), and plate to disc distance (PPD). Risk of bias was assessed for all studies. The Cochrane Review Manager was utilized to perform the meta-analysis.
RESULTS
From 7044 articles, 13 retrospective studies were included in the final analysis. Three studies had "not serious" bias and the other 10 studies had serious or very serious bias. The total number of patients in the included studies was 1799 patients. Five studies included single-level ACDF, 2 studies included multi-level ACDF, and 6 studies included single or multi-level ACDF. On meta-analysis, the significant risk factors associated with ASD development were reduced postoperative cervical lordosis (mean difference [MD] = 3.35°, = .002), reduced last-follow-up cervical lordosis (MD = -3.02°, = .0003), increased preoperative to postoperative cervical sagittal alignment change (MD = -3.68°, = .03), and the presence of developmental cervical canal stenosis (Odds ratio [OR] = 4.17, < .001).
CONCLUSIONS
Decreased postoperative cervical lordosis, greater change in cervical sagittal alignment and developmental cervical canal stenosis were associated with an increased risk of ASD following ACDF.
PubMed: 38469858
DOI: 10.1177/21925682241237500 -
Child's Nervous System : ChNS :... Feb 2020While it has been extensively studied in adults, the role of spinal angiography in children with suspected spinal vascular malformations is not fully characterized. With...
OBJECT
While it has been extensively studied in adults, the role of spinal angiography in children with suspected spinal vascular malformations is not fully characterized. With special implications regarding technique, radiation dose, and pathology, we sought to review our single-center experience with pediatric spinal vascular pathology and use a systematic review of the literature to further identify its role in pediatrics.
METHODS
A retrospective chart review was conducted under IRB approval for all patients age 0-18 years old who underwent spinal angiography at our institution between 2007 and 2018 for concern for spinal vascular pathology. A simultaneous systematic review was conducted via dedicated search terms in two distinct databases and reviewed to identify all studies referring to spinal angiography or angiograms in pediatric patients.
RESULTS
Six patients were included. Three patients (50%) had vascular malformations confirmed on diagnostic angiography and underwent subsequent endovascular treatment. Two patients (33.3%), one with hematomyelia and one with spinal cord infarction, had negative diagnostic angiograms. One patient (16.7%) had a spinal tumor and underwent angiography for further evaluation preoperatively. Spinal angiography was used to aid in diagnosis, preoperative planning, and treatment in these cases. It was demonstrated to be safe in this patient population, with no untoward events, minimal radiation dose, and possible therapeutic applications in select cases. The systematic review identified 11 studies regarding pediatric spinal angiography. These ranged from single case reports to case series of up to 38 patients and highlighted the role of spinal angiography in diagnosis, endovascular treatment, preoperative planning, and postoperative follow-up.
CONCLUSIONS
Spinal angiography may be used in a variety of scenarios to better understand the architecture of vascular spinal lesions and facilitate endovascular intervention. While its application in both adult and pediatric pathology is limited to select cases, spinal angiography remains a key diagnostic procedure when approaching vascular lesions or tumors of the spine, assessing for etiology of spinal cord infarcts, and in the evaluation of unexplained hemorrhage in the spinal canal.
Topics: Adolescent; Adult; Angiography; Central Nervous System Vascular Malformations; Child; Child, Preschool; Embolization, Therapeutic; Humans; Infant; Infant, Newborn; Pediatrics; Retrospective Studies; Spinal Cord; Spine
PubMed: 31414169
DOI: 10.1007/s00381-019-04329-3 -
Spine Surgery and Related Research Jan 2023Magnetic resonance imaging (MRI) is a potential tool for the objective assessment of spinal cord injury (SCI) because it correlates well with the spatial and temporal... (Review)
Review
BACKGROUND
Magnetic resonance imaging (MRI) is a potential tool for the objective assessment of spinal cord injury (SCI) because it correlates well with the spatial and temporal extension of spinal cord pathology. This study aimed to systematically identify currently available scoring system based on MRI parameters, including measurement of the spinal cord lesion length in sagittal view (intramedullary lesion length (IMLL)) and morphology of the lesion in axial view (Brain and Spinal Injury Center (BASIC) score).
METHODS
A systematic search was conducted using the PubMed/MEDLINE database for English-language studies with the keywords "cervical," "spinal cord injury," "scoring system," "scoring," "classification," and "magnetic resonance imaging" to systematically identify the scoring system based on MRI parameters. The main outcomes of interest are the scoring system's inter- and intraobserver reliabilities and its predictive accuracy of neurological outcome.
RESULTS
After assessing the full text and applying the inclusion and exclusion criteria, 13 articles were found to be eligible. The inter- and intraobserver reliabilities were rated as good until perfect for increased signal intensity (ISI), maximum canal compromise (MCC), maximum spinal cord compression (MSCC), BASIC score, cord-canal-area ratio, space available for the cord, and the compression ratio. The weighted mean difference of IML between the group with converted ASIA Impairment Scale (AIS) grade and the group without conversion is 31.79 ( =93%, =0.008). The percentage of agreement between the initial BASIC score of 4 with AIS grade of A at follow-up is 100%.
CONCLUSIONS
Certain MRI parameters, including IML and BASIC score, have good reliability and correlate well with neurological outcome, making them candidates for building simple and objective scoring system for cervical SCI. Level of Evidence: 2A.
PubMed: 36819628
DOI: 10.22603/ssrr.2021-0255 -
Neurosurgical Review Apr 2021Pneumorrhachis (PR) refers to free air in the spinal canal. We aim to describe a case report and conduct a systematic review focused on the clinical presentation,...
Pneumorrhachis (PR) refers to free air in the spinal canal. We aim to describe a case report and conduct a systematic review focused on the clinical presentation, diagnosis, and management of traumatic PR. We conducted a language-restricted PubMed, SciELO, Scopus, and Ovid database search for traumatic PR cases published till June 2019. Categorical variables were assessed by Fisher's exact test. In addition to our reported index case, there were 82 articles (96 individual cases) eligible for meta-analysis according to our inclusion/exclusion criteria. Eighty per cent of patients had blunt trauma, while 17% had penetrating injuries. Thirty-four per cent of cases were extradural PR, 21% intradural PR, and unreported PR type in 43%. Nine per cent of patients presented with symptoms directly attributed to PR: sensory radiculopathy (2%), motor radiculopathy (1%), and myelopathy (6%). CT had a 100% sensitivity for diagnosing PR, MRI 60%, and plain radiograph 48%. Concurrent injuries reported include pneumocephalus (42%), pneumothorax (36%), spine fracture (27%), skull fracture (27%), pneumomediastinum (24%), and cerebrospinal fluid leak (14%). PR was managed conservatively in every case, with spontaneous resolution in 96% on follow-up (median = 10 days). Prophylactic antibiotics for meningitis were given in 13% PR cases, but there was no association with the incidence of meningitis (overall incidence: 3%; prophylaxis group (0%) vs non-prophylaxis group (4%) (p = 1)). Occasionally, traumatic PR may present with radiculopathy or myelopathy. Traumatic PR is almost always associated with further air distributions and/or underlying injuries. There is insufficient evidence to support the use of prophylactic antibiotic in preventing meningitis in traumatic PR patients.
Topics: Aged; Humans; Male; Pneumocephalus; Pneumorrhachis; Radiography; Spinal Canal; Spinal Cord Injuries; Thoracic Vertebrae
PubMed: 32307638
DOI: 10.1007/s10143-020-01300-8 -
International Journal of Surgery... Mar 2016The purpose of the study is to perform a systematic review and meta-analysis to evaluate the clinical results of anterior and posterior approaches for the treatment of... (Meta-Analysis)
Meta-Analysis Review
Anterior versus posterior approach for the treatment of cervical compressive myelopathy due to ossification of the posterior longitudinal ligament: A systematic review and meta-analysis.
PURPOSE
The purpose of the study is to perform a systematic review and meta-analysis to evaluate the clinical results of anterior and posterior approaches for the treatment of cervical compressive myelopathy due to cervical ossification of the posterior longitudinal ligament (OPLL).
METHODS
Randomized controlled trials or non-randomized controlled trials published since January 1995 to October 2015 that compared the clinical effectiveness of anterior and posterior surgical approaches for the treatment of cervical OPLL were acquired by a comprehensive search in three electronic databases (PubMed, EMBASE, Cochrane library). A total of 13 studies (1050 patients) were included in this systematic review and meta-analysis.
RESULT
The results indicated that no statistically significant differences between the anterior group and posterior group in terms of preoperative JOA score [P = 0.16, SMD = 0.1 (-0.04, 0.23)] and recovery rate of patients with canal-occupying ratio < 50%-60% [p = 0.89, SMD = 0.03 (-0.35, 0.41)]. The anterior group showed higher postoperative JOA score [P < 0.05, SMD = 0.23 (0.05, 0.41)], overall recovery rate (regardless of canal-occupying ratio) [P < 0.01, SMD = 0.79 (0.31, 1.27)], especially a significant higher recovery rate of patients with canal-occupying ratio > 50%-60% [P < 0.01, SMD = 1.50 (0.52, 2.47)]. However, it also revealed that the postoperative complication rate [P < 0.05, OR = 1.90 (1.08, 3.36)], blood loss [P < 0.01, SMD = 0.63 (0.34, 0.93)] and operative time [P < 0.01, SMD = 1.86 (1.07, 2.65)] were significantly higher.
CONCLUSION
Based on the results above, anterior approach surgery was associated with better overall (regardless of the canal-occupying ratio) postoperative neural function than posterior approach in the treatment of cervical compressive myelopathy due to OPLL. We thought anterior approach especially preferable to patients with canal-occupying ratio > 50%-60%, although it leads to a higher surgical trauma and incidence of surgery-related complications. Posterior approach surgery was relatively safer with lower surgical trauma and incidence of complications. We also suggest posterior approach for patients with canal-occupying ratio < 50%-60%, since the postoperative neural function was similar between the two groups for this part of patients.
Topics: Cervical Vertebrae; Decompression, Surgical; Humans; Non-Randomized Controlled Trials as Topic; Operative Time; Ossification of Posterior Longitudinal Ligament; Postoperative Complications; Postoperative Period; Randomized Controlled Trials as Topic; Spinal Cord Compression; Spinal Fusion; Treatment Outcome
PubMed: 26804354
DOI: 10.1016/j.ijsu.2016.01.038 -
Spine Oct 2016Systematic literature review and expert survey OBJECTIVE.: The aim of this study was to determine factors associated with neurologic improvement in patients with... (Review)
Review
STUDY DESIGN
Systematic literature review and expert survey OBJECTIVE.: The aim of this study was to determine factors associated with neurologic improvement in patients with neurologic deficits secondary to metastatic epidural spinal cord compression (MESCC). Clear understanding of these factors will guide surgical decision-making by helping to elucidate which patients are more likely to benefit from surgery and how surgeons can increase the probability of neurologic and functional restoration.
SUMMARY OF BACKGROUND DATA
Surgical spinal cord decompression has been shown to improve neurologic function in patients with symptomatic MESCC. However, prognostication of neurologic improvement after surgery remains challenging, owing to sparse data and complexity of these patients.
METHODS
PubMed and Embase databases were searched for relevant publications. PRISMA Statement guided publication selection and data reporting. GRADE guidelines were used for evidence quality evaluation and recommendation formulation.
RESULTS
Low-quality evidence supports the use of the duration and severity of neurologic deficit as predictors of neurological recovery in patients with MESCC. Low-quality evidence supports the use of thoracic level of compression and previous irradiation as adverse predictors of neurological recovery. Nearly all of the AOSpine Knowledge Forum Tumor members who responded to the survey agreed that ambulation with assistance represented a successful surgical result and that duration of ambulation loss and the severity of weakness should be considered when trying to predict whether surgery would result in restoration of ambulation.
CONCLUSIONS
Review of literature and expert opinion support the importance of duration of ambulation loss and the severity of neurologic deficit (muscle strength, bladder function) in prediction of neurologic recovery among patients with symptomatic MESCC. Efforts to reduce the duration of ambulation loss and to prevent progression of neurologic deficits should be made to improve the probability of neurologic recovery.
LEVEL OF EVIDENCE
2.
Topics: Decompression, Surgical; Epidural Space; Humans; Recovery of Function; Spinal Cord Compression; Spinal Neoplasms
PubMed: 27488300
DOI: 10.1097/BRS.0000000000001827