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Muscle & Nerve Jun 2024Electrodiagnostic studies (EDx) are frequently performed in the diagnostic evaluation of peripheral nerve disorders. There is increasing interest in the use of newer,... (Review)
Review
Electrodiagnostic studies (EDx) are frequently performed in the diagnostic evaluation of peripheral nerve disorders. There is increasing interest in the use of newer, alternative diagnostic modalities, in particular imaging, either to complement or replace established EDx protocols. However, the evidence to support this approach has not been expansively reviewed. In this paper, diagnostic performance data from studies of EDx and other diagnostic modalities in common peripheral nerve disorders have been analyzed and described, with a focus on radiculopathy, plexopathy, compressive neuropathies, and the important neuropathy subtypes of Guillain-Barré syndrome, chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), vasculitic neuropathy and diabetic neuropathy. Overall EDx retains its place as a primary diagnostic modality in the evaluated peripheral nerve disorders. Magnetic resonance imaging and ultrasound have developed important complementary diagnostic roles in compressive and traumatic neuropathies and atypical CIDP, but their value is more limited in other neuropathy subtypes. Identification of hourglass constriction in nerves of patients with neuralgic amyotrophy may have therapeutic implications. Investigation of radiculopathy is confounded by poor correlation between clinical features and imaging findings and the lack of a diagnostic gold standard. There is a need to enhance the literature on the utility of these newer diagnostic modalities.
Topics: Humans; Electrodiagnosis; Peripheral Nervous System Diseases; Neural Conduction; Magnetic Resonance Imaging
PubMed: 38433118
DOI: 10.1002/mus.28068 -
International Journal of Spine Surgery May 2024Multilevel anterior cervical discectomy and fusion inevitably yields a higher chance of pseudarthrosis or require more reoperations than single-level procedures....
BACKGROUND
Multilevel anterior cervical discectomy and fusion inevitably yields a higher chance of pseudarthrosis or require more reoperations than single-level procedures. Therefore, multilevel cervical disc arthroplasty (CDA) could be an alternative surgery for cervical spondylosis, as it (particularly 3- and 4-level CDA) could preserve more functional motility than single-level disc diseases. This study aimed to investigate the clinical and radiological outcomes of 4-level CDA, a relatively infrequently indicated surgery.
METHODS
The medical records of consecutive patients who underwent 4-level CDA were retrospectively reviewed. These highly selected patients typically had multilevel disc herniations with mild spondylosis. The inclusion criteria were symptomatic cervical spondylotic myelopathy, radiculopathy, or both, that were medically refractory. The clinical outcomes were assessed. The radiographic outcomes, including global and individual segmental range of motion (ROM) at C3-7, and any complications were also analyzed.
RESULTS
Data from a total of 20 patients (mean age: 56 ± 8 years) with an average follow-up of 34 ± 20 months were analyzed. All patients reported improved clinical outcomes compared with that of preoperation, and the ROMs at C3-7 were not only preserved but also trended toward an increase (35 ± 8 vs 37 ± 10 degrees, pre- vs postoperation, = 0.271) after the 4-level CDA. However, global cervical alignment remained unchanged. There was one permanent C5 radiculopathy, but no other neurological deteriorations or any reoperations occurred.
CONCLUSION
For these rare but unique indications, 4-level CDA yielded clinical improvement and preserved segmental motility with low rates of complications. Four-level CDA is a safe and effective surgery, maintaining the ROM in patients with primarily disc herniations and mild spondylosis.
CLINICAL RELEVANCE
For patients with mild spondylosis, whose degeneration at the cervical spine is not so severe, CDA is more suitable.
PubMed: 38782588
DOI: 10.14444/8603 -
Advanced Biomedical Research 2023A case with an inflamed or damaged nerve root in the cervical spine is defined as cervical radiculopathy.The purpose of the current study is to recognize the most... (Review)
Review
A case with an inflamed or damaged nerve root in the cervical spine is defined as cervical radiculopathy.The purpose of the current study is to recognize the most effective surgical procedures in cervical radiculopathy subjects. All related studies were taken using PubMed searching international databases, Scopus, ISI Web of Science (WoS), and Science direct with no limit of until November 20, 2021. Finally, based on the inclusion and exclusion criteria, after reviewing all randomized controlled trial studies which had the related data the researchers were looking for, they conducted meta-analysis with the seven remaining studies including eight different treatments. Heterogeneity was evaluated by Cochran's Q and Higgins I using R software for the network. In the results presented in this study, the neck disability index (NDI) changes as a result of taking cervical anterior discectomy without (ACD) and with fusion (ACDF) and ACD arthroplasty were -0.003, -1.659, and -1.656, respectively. According to the final diagram of the network, 11 comparisons were made in pairs. When each treatment group is compared with ACDF, it is shown that there was a significant mean effect among the patients who receive Mobi-C, Kineflx|C, and ADR, with mean differences of - 8.60 [CI 95% (- 12.75, - 4.45)], - 1.10 [CI 95% (- 5.22, 3.02)], and - 1.00 [CI 95% (- 7.18, 5.18)], respectively. The most effective surgical treatments for cervical radiculopathy were Mobi-c, Kineflx|C, and artificial disc replacement compared to ACDF treatment, respectively.
PubMed: 37694261
DOI: 10.4103/abr.abr_251_22 -
PloS One 2023In patients presenting with low back pain (LBP), once specific causes are excluded (fracture, infection, inflammatory arthritis, cancer, cauda equina and radiculopathy)...
In patients presenting with low back pain (LBP), once specific causes are excluded (fracture, infection, inflammatory arthritis, cancer, cauda equina and radiculopathy) many clinicians pose a diagnosis of non-specific LBP. Accordingly, current management of non-specific LBP is generic. There is a need for a classification of non-specific LBP that is both data- and evidence-based assessing multi-dimensional pain-related factors in a large sample size. The "PRedictive Evidence Driven Intelligent Classification Tool for Low Back Pain" (PREDICT-LBP) project is a prospective cross-sectional study which will compare 300 women and men with non-specific LBP (aged 18-55 years) with 100 matched referents without a history of LBP. Participants will be recruited from the general public and local medical facilities. Data will be collected on spinal tissue (intervertebral disc composition and morphology, vertebral fat fraction and paraspinal muscle size and composition via magnetic resonance imaging [MRI]), central nervous system adaptation (pain thresholds, temporal summation of pain, brain resting state functional connectivity, structural connectivity and regional volumes via MRI), psychosocial factors (e.g. depression, anxiety) and other musculoskeletal pain symptoms. Dimensionality reduction, cluster validation and fuzzy c-means clustering methods, classification models, and relevant sensitivity analyses, will classify non-specific LBP patients into sub-groups. This project represents a first personalised diagnostic approach to non-specific LBP, with potential for widespread uptake in clinical practice. This project will provide evidence to support clinical trials assessing specific treatments approaches for potential subgroups of patients with non-specific LBP. The classification tool may lead to better patient outcomes and reduction in economic costs.
Topics: Male; Humans; Female; Low Back Pain; Artificial Intelligence; Cross-Sectional Studies; Prospective Studies; Spine
PubMed: 37603539
DOI: 10.1371/journal.pone.0282346 -
The role of conservative treatment in lumbar disc herniations: WFNS spine committee recommendations.World Neurosurgery: X Apr 2024To formulate the most current, evidence-based recommendations for the conservative management of lumbar disc herniations (LDH). (Review)
Review
OBJECTIVE
To formulate the most current, evidence-based recommendations for the conservative management of lumbar disc herniations (LDH).
METHODS
A systematic literatüre search was performed 2012-2022 in PubMed/Medline and Cochrane using the keywords ''lumbar disc herniation'' and ''conservative treatment,'' yielding 342 total manuscripts. Screening criteria resulted in 12 final manuscripts which were summarized and presented at two international consensus meetings of the World Federation of Neurosurgical Societies (WFNS) Spine Committee. The Delphi method was utilized to arrive at three final consensus statements.
RESULTS AND CONCLUSION
s: In the absence of cauda equina syndrome, motor, or other serious neurologic deficits, conservative treatment should be the first line of treatment for LDH. NSAIDs may significantly improve acute low back and sciatic pain caused by LDH. A combination of activity modification, pharmacotherapy, and physical therapy provides good outcomes in most LDH patients.
PubMed: 38389961
DOI: 10.1016/j.wnsx.2024.100277 -
World Neurosurgery Jan 2024Cervical radiculopathy is a common and disabling cervical condition characterized by symptoms including axial neck pain, radicular pain, weakness, and numbness in one or... (Review)
Review
Cervical radiculopathy is a common and disabling cervical condition characterized by symptoms including axial neck pain, radicular pain, weakness, and numbness in one or both arms. Common causes include herniated discs and foraminal stenosis, often accompanied by varying degrees of degenerative disc disease and uncovertebral joint hypertrophy. In the treatment of cervical radiculopathy, there is an increasing preference for posterior foraminotomy over anterior cervical discectomy and fusion due to the avoidance of fusion-related complications. As endoscopic spine surgery techniques continue to evolve, there is a rising interest in posterior endoscopic cervical foraminotomy and posterior endoscopic cervical discectomy as effective treatments for cervical radiculopathy. Because these procedures can performed through a single subcentimeter incision with minimal soft tissue damage, they can often be carried out as ambulatory procedures. In this narrative review, we examined current literature addressing the indications, surgical techniques, outcomes, and potential complications associated with posterior cervical endoscopic approaches.
Topics: Humans; Foraminotomy; Radiculopathy; Cervical Vertebrae; Diskectomy; Intervertebral Disc Displacement; Treatment Outcome; Retrospective Studies
PubMed: 37821026
DOI: 10.1016/j.wneu.2023.10.021 -
Biochemical Pharmacology Sep 2023Diabetic neuropathy is a neuro-degenerative disorder that encompasses numerous factors that impact peripheral nerves in the context of diabetes mellitus (DM). Diabetic... (Review)
Review
Diabetic neuropathy is a neuro-degenerative disorder that encompasses numerous factors that impact peripheral nerves in the context of diabetes mellitus (DM). Diabetic peripheral neuropathy (DPN) is very prevalent and impacts 50% of diabetic patients. DPN is a length-dependent peripheral nerve lesion that primarily causes distal sensory loss, discomfort, and foot ulceration that may lead to amputation. The pathophysiology is yet to be fully understood, but current literature on the pathophysiology of DPN revolves around understanding various signaling cascades involving the polyol, hexosamine, protein-kinase C, AGE, oxidative stress, and poly (ADP ribose) polymerase pathways. The results of research have suggested that hyperglycemia target Schwann cells and in severe cases, demyelination resulting in central and peripheral sensitization is evident in diabetic patients. Various diagnostic approaches are available, but detection at an early stage remains a challenge. Traditional analgesics and opioids that can be used "as required" have not been the mainstay of treatment thus far. Instead, anticonvulsants and antidepressants that must be taken routinely over time have been the most common treatments. For now, prolonging life and preserving the quality of life are the ultimate goals of diabetes treatment. Furthermore, the rising prevalence of DPN has substantial consequences for occupational therapy because such therapy is necessary for supporting wellness, warding off other chronic-diseases, and avoiding the development of a disability; this is accomplished by engaging in fulfilling activities like yoga, meditation, and physical exercise. Therefore, occupational therapy, along with palliative therapy, may prove to be crucial in halting the onset of neuropathic-symptoms and in lessening those symptoms once they have occurred.
Topics: Humans; Diabetic Neuropathies; Quality of Life; Hyperglycemia; Signal Transduction; Protein Kinase C; Diabetes Mellitus
PubMed: 37536473
DOI: 10.1016/j.bcp.2023.115723 -
Pain Physician Sep 2023Chronic pain is a common reason adults seek care; patients often feel that their pain is inadequately managed. Spine-related pain is the most common chronic pain...
BACKGROUND
Chronic pain is a common reason adults seek care; patients often feel that their pain is inadequately managed. Spine-related pain is the most common chronic pain concern, and lumbar radiculopathy is often the cause. Racial and ethnic disparities in the pharmacologic management of pain are well described, but less is known about these disparities regarding interventional procedures.
OBJECTIVE
To study the utilization rates of physical therapy, epidural steroid injection, surgery, and spinal cord stimulation in hospitalized patients with lumbar radiculopathy across different races, ethnicities, and genders.
STUDY DESIGN
A retrospective cross-sectional study design.
METHODS
The National Inpatient Sample was used to identify 252,790 patients with lumbar radiculopathy, after sample weighting, from 2016-2019. Independent variables were race, ethnicity, age, gender, insurance, geography, year, and severity. Dependent variables were physical therapy, epidural steroid injection, spinal cord stimulator, or surgery (reference group). Conservative management was defined as nonoperative treatment ranging from physical therapy to epidural steroid injection. Data were analyzed with a logistic regression for complex surveys. Regressions were adjusted for age, insurance, geography, and other socioeconomic factors.
RESULTS
Most patients were white (78.3%) and received surgery (95.0%). Severe disease was most common among African Americans (9.3%), but was similar across other races, ethnicities, and genders. Medicaid was more common among African Americans and Hispanics. An adjusted analysis showed that African Americans and Hispanics received more epidural steroid injections (odds ratio [OR] = 1.52; 95%CI, 1.3 - 1.8) and (OR = 1.43; 95%CI, 1.1 - 1.8) respectively; and physical therapy (OR = 1.65; 95%CI, 1.1 - 2.5) and (OR = 1.83; 95%CI, 1.2 - 2.8) respectively, than whites compared to surgery. African Americans received a spinal cord stimulator less often than whites compared to surgery (OR = 0.63; 95%CI. 0.4 - 0.9). Women received an epidural steroid injection more frequently than men compared to surgery (OR = 1.29; 95%CI, 1.2 - 1.4).
LIMITATIONS
Generalizability is limited because conservative therapies are often outpatient treatments.
CONCLUSION
Disparities were observed in lumbar radiculopathy treatment after independent variable adjustment. African Americans received conservative therapy more often than whites despite increased disease severity. Hispanics and women had similar disease severity compared to whites and men, respectively, but received more conservative therapies. Further investigation in outpatient settings is needed to definitively describe these disparities.
KEY WORDS
Chronic pain, pain management, back pain, lumbar radiculopathy, epidural steroid injection, spinal cord stimulation, low back surgery, physical therapy, racial disparities, gender disparities.
PubMed: 37774189
DOI: No ID Found -
Journal of Neurosurgery. Spine Jun 2024The objective of this study was to assess the safety and accuracy of ChatGPT recommendations in comparison to the evidence-based guidelines from the North American Spine...
OBJECTIVE
The objective of this study was to assess the safety and accuracy of ChatGPT recommendations in comparison to the evidence-based guidelines from the North American Spine Society (NASS) for the diagnosis and treatment of cervical radiculopathy.
METHODS
ChatGPT was prompted with questions from the 2011 NASS clinical guidelines for cervical radiculopathy and evaluated for concordance. Selected key phrases within the NASS guidelines were identified. Completeness was measured as the number of overlapping key phrases between ChatGPT responses and NASS guidelines divided by the total number of key phrases. A senior spine surgeon evaluated the ChatGPT responses for safety and accuracy. ChatGPT responses were further evaluated on their readability, similarity, and consistency. Flesch Reading Ease scores and Flesch-Kincaid reading levels were measured to assess readability. The Jaccard Similarity Index was used to assess agreement between ChatGPT responses and NASS clinical guidelines.
RESULTS
A total of 100 key phrases were identified across 14 NASS clinical guidelines. The mean completeness of ChatGPT-4 was 46%. ChatGPT-3.5 yielded a completeness of 34%. ChatGPT-4 outperformed ChatGPT-3.5 by a margin of 12%. ChatGPT-4.0 outputs had a mean Flesch reading score of 15.24, which is very difficult to read, requiring a college graduate education to understand. ChatGPT-3.5 outputs had a lower mean Flesch reading score of 8.73, indicating that they are even more difficult to read and require a professional education level to do so. However, both versions of ChatGPT were more accessible than NASS guidelines, which had a mean Flesch reading score of 4.58. Furthermore, with NASS guidelines as a reference, ChatGPT-3.5 registered a mean ± SD Jaccard Similarity Index score of 0.20 ± 0.078 while ChatGPT-4 had a mean of 0.18 ± 0.068. Based on physician evaluation, outputs from ChatGPT-3.5 and ChatGPT-4.0 were safe 100% of the time. Thirteen of 14 (92.8%) ChatGPT-3.5 responses and 14 of 14 (100%) ChatGPT-4.0 responses were in agreement with current best clinical practices for cervical radiculopathy according to a senior spine surgeon.
CONCLUSIONS
ChatGPT models were able to provide safe and accurate but incomplete responses to NASS clinical guideline questions about cervical radiculopathy. Although the authors' results suggest that improvements are required before ChatGPT can be reliably deployed in a clinical setting, future versions of the LLM hold promise as an updated reference for guidelines on cervical radiculopathy. Future versions must prioritize accessibility and comprehensibility for a diverse audience.
PubMed: 38941643
DOI: 10.3171/2024.4.SPINE231148 -
Surgical Neurology International 2023Anterior transthoracic, posterolateral (i.e., costotransversectomy/lateral extracavitary), and transpedicular approaches are now utilized to address anterior,... (Review)
Review
BACKGROUND
Anterior transthoracic, posterolateral (i.e., costotransversectomy/lateral extracavitary), and transpedicular approaches are now utilized to address anterior, anterolateral, or lateral thoracic disk herniations (TDH). Notably, laminectomy has not been a viable option for treating TDH for decades due to the much lower rate of acceptable outcomes (i.e., 57% for decompressive laminectomy vs. over 80% for the posterolateral, lateral, and transthoracic procedures), and a higher risk of neurological morbidity/paralysis.
METHODS
Patients with TDH averaged 48-56.3 years of age, and presented with pain (76%), myelopathy (61%-99%), radiculopathy (30%-33%), and/or sphincter loss (16.7%-24%). Those with anterior/anterolateral TDH (30-74%) were usually myelopathic while those with more lateral disease (50-70%) exhibited radiculopathy. Magnetic resonance (MR) studies best defined soft-tissue/disk/cord pathology, CAT scan (CT)/Myelo-CT studies identified attendant discal calcification (i.e. fully calcified 38.9% -65% vs. partial calcification 27.8%), while both exams documented giant TDH filling > 30 to 40% of the canal (i.e., in 43% to 77% of cases).
RESULTS
Surgical options for anterior/anterolateral TDH largely included transthoracic or posterolateral approaches (i.e. costotransversectomy, lateral extracavitary procedures) with the occasional use of transfacet/transpedicular procedures mostly applied to lateral disks. Notably, patients undergoing transthoracic, lateral extracavitary/costotransversectomy/ transpedicular approaches may additionally warrant fusions. Good/excellent outcomes were quoted in from 45.5% to 87% of different series, with early postoperative adverse events reported in from 14 to 14.6% of patients.
CONCLUSION
Anterior/anterolateral TDH are largely addressed with transthoracic or posterolateral procedures (i.e. costotransversectomy/extracavitary), with a subset also utilizing transfacet/transpedicular approaches typically adopted for lateral TDH. Laminectomy is essentially no longer considered a viable option for treating TDH.
PubMed: 37680932
DOI: 10.25259/SNI_648_2023