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The Journal of Bone and Joint Surgery.... Nov 2022Adjacent segment disease (ASD) following anterior cervical discectomy and fusion with plating (ACDF-P) may yield a poor prognosis or reoperation. This review aimed to... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Adjacent segment disease (ASD) following anterior cervical discectomy and fusion with plating (ACDF-P) may yield a poor prognosis or reoperation. This review aimed to summarize risk factors for radiographic ASD (RASD) and clinical ASD (CASD) after ACDF-P.
METHODS
Six electronic databases were searched from inception to October 30, 2021. Four reviewers independently screened titles, abstracts, and full-text articles to identify relevant studies. Methodological quality of the included studies was evaluated. Meta-analyses for risk factors were conducted, if possible.
RESULTS
Sixteen cohort and 3 case-control studies (3,563 participants) were included. These studies showed low (n = 2), moderate (n = 9), and high (n = 8) risk of bias. One risk factor for RASD was pooled for 2 meta-analyses based on the follow-up period. Four different risk factors for CASD at ≥4 years were pooled for meta-analyses. Limited evidence showed that multi-level fusion, greater asymmetry in total or functional cross-sectional area of the cervical paraspinal muscle, and preoperative degeneration in a greater number of segments were associated with a higher RASD incidence <4 years after ACDF-P. In contrast, no significant risk factors were identified for CASD <4 years after ACDF-P. At ≥4 years after ACDF-P, limited evidence supported that both cephalad and caudal plate-to-disc distances of <5 mm were associated with a higher RASD incidence, and very limited evidence supported that developmental canal stenosis, preoperative RASD, unfused C5-C6 or C6-C7 adjacent segments, use of autogenous bone graft, and spondylosis-related ACDF-P were associated with a higher CASD incidence.
CONCLUSIONS
Although several risk factors for RASD and CASD development after ACDF-P were identified, the supporting evidence was very limited to limited. Future prospective studies should extend the existing knowledge by more robustly identifying risk factors for RASD and CASD after ACDF-P to inform clinical practice.
LEVEL OF EVIDENCE
Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Topics: Humans; Cervical Vertebrae; Spinal Fusion; Prospective Studies; Diskectomy; Risk Factors; Intervertebral Disc Degeneration
PubMed: 36321969
DOI: 10.2106/JBJS.21.01494 -
The Journal of Foot and Ankle Surgery :... 2021The purpose of this study was to perform a systematic review of the literature examining postoperative outcomes following single site and combined peripheral nerve... (Review)
Review
The purpose of this study was to perform a systematic review of the literature examining postoperative outcomes following single site and combined peripheral nerve blocks (PNBs), including (1) sciatic and femoral nerve, (2) popliteal and saphenous nerve, and (3) popliteal and ankle nerve, during elective foot and ankle surgery. We hypothesized that combination blocks would decrease postoperative narcotic consumption and afford more effective postoperative pain control as compared to general anesthesia, spinal anesthesia, or single site PNBs. A review of the literature was performed according to the PRISMA guidelines. Medline, EMBASE, and the Cochrane Library were searched from January 2009 to October 2019. We identified studies by using synonyms for "foot," "ankle" "pain management," "opioid," and "nerve block." Included articles explicitly focused on elective foot and ankle procedures performed under general anesthesia, spinal anesthesia, PNB, or with some combination of these techniques. PNB techniques included femoral, adductor canal, sciatic, popliteal, saphenous, and ankle blocks, as well as blocks that combined multiple anatomic sites. Outcomes measured included postoperative narcotic consumption as well as patient-reported efficacy of pain control. Twenty-eight studies encompassing 6703 patients were included. Of the included studies, 57% were randomized controlled trials, 18% were prospective comparison studies, and 25% were retrospective comparison studies. Postoperative opioid consumption and postoperative pain levels were reduced over the first 24 to 48 hours with the use of combined PNBs when compared with single site PNBs, both when used as primary anesthesia or when used in concert with general anesthesia either alone or combined with systemic/local anesthesia in the first 24 to 48 hours following surgery. Studies demonstrated higher reported patient satisfaction of postoperative pain control in patients who received combined PNB. Nine of 14 (64%) studies reported no neurologic related complications with an overall reported rate among all studies ranging from 0% to 41%. Our study identified substantial improvement in postoperative pain levels, postoperative opioid consumption, and patient satisfaction in patients receiving PNB when compared with patients who did not receive PNB. Published data also demonstrated that combination PNB are more effective than single-site PNB for all data points. Notably, the addition of a femoral nerve block to a popliteal nerve block during use of a thigh tourniquet, as well as addition of either saphenous or ankle blockade to popliteal nerve block during use of calf tourniquet, may increase overall block effectiveness. Serious complications including neurologic damage following PNB administration are rare but do exist.
Topics: Analgesics, Opioid; Ankle; Humans; Nerve Block; Orthopedic Procedures; Pain Measurement; Pain, Postoperative; Prospective Studies; Retrospective Studies; Sciatic Nerve
PubMed: 33168443
DOI: 10.1053/j.jfas.2020.08.026 -
Spine Jan 2022Systematic review.
STUDY DESIGN
Systematic review.
OBJECTIVE
The aim of this study was to review the current spine surgery literature to establish a definition for adequate spine decompression using intraoperative ultrasound (IOUS) imaging.
SUMMARY OF BACKGROUND DATA
IOUS remains one of the few imaging modalities that allows spine surgeons to continuously monitor the spinal cord in real-time, while also allowing visualization of surrounding soft tissue anatomy during an operation. Although this has valuable applications for decompression surgery in spinal canal stenosis, it remains unclear how to best characterize adequacy of spinal decompression using IOUS.
METHODS
We conducted a systematic search of multiple databases including: Medline, Embase, and Cochrane Central Register of Controlled Trials Strategy. Our search terms were spine, spinal cord diseases, decompression surgery, ultrasonogra-phy, and intraoperative period. We were interested in studies that used intraoperative use of ultrasound imaging in spinal decompression surgery for the cervical, thoracic, and lumbar spine. Study quality was evaluated using the Methodological Index for Non-Randomized Studies (MINORS).
RESULTS
Our search strategy yielded 985 of potentially relevant publications, 776 underwent title and abstract screening, and 31 full-text articles were reviewed. We found IOUS to be useful in spine surgery for decompression of degenerative cases in all regions of the spine. The thoracic spine was unique for IOUS-guided decompression of fractures, and the lumbar spine for decompressing nerve roots. Although we did not identify a universal definition for adequate decompression, there was common description of decompression that qualitatively described the ventral aspect of the spinal cord being "free floating" within the cerebrospinal fluid. Other measurable definitions, such as spinal cord diameter or spinal cord pulsatility, were not good definitions given there was insufficient evidence and/or poor reliability.
CONCLUSION
The systematic review examines the current literature on IOUS and spinal decompression surgery. We identified a common qualitative definition for adequate decompression involving a "free floating" spinal cord within the cerebrospinal fluid which indicates that the spinal cord is free from contact of the anterior elements.Level of Evidence: 1.
Topics: Decompression, Surgical; Humans; Reproducibility of Results; Spinal Stenosis; Ultrasonography
PubMed: 34474449
DOI: 10.1097/BRS.0000000000004111 -
Journal of Orthopaedic Science :... Jan 2020The optimal surgical procedure for the treatment of cervical ossification of the posterior longitudinal ligament (OPLL) remains controversial because there are few... (Comparative Study)
Comparative Study Meta-Analysis
A systematic review and meta-analysis comparing anterior decompression with fusion and posterior laminoplasty for cervical ossification of the posterior longitudinal ligament.
BACKGROUND
The optimal surgical procedure for the treatment of cervical ossification of the posterior longitudinal ligament (OPLL) remains controversial because there are few comprehensive studies investigating the surgical methods. Therefore, we conducted a systematic review and meta-analysis to evaluate evidence in the literature and compare the surgical outcomes of anterior decompression with fusion (ADF) and laminoplasty (LAMP), which are representative procedures for cervical OPLL.
METHODS
An extensive literature search was performed using PubMed, Embase, and the Cochrane Library to identify comparative studies of ADF and LAMP for cervical OPLL. The language was restricted to English, and the year of publication was from January 1980 to December 2018. We extracted outcomes from the studies, such as preoperative and postoperative Japanese Orthopaedic Association (JOA) score, cervical alignment, surgical complications and reoperation rate. Then, meta-analysis was performed for these surgical outcomes.
RESULTS
Twelve studies were obtained, including 1 prospective cohort study and 11 retrospective cohort studies. In the meta-analysis, neurological recovery rate in JOA score was greater in ADF than in LAMP, especially in patients with a large canal occupying ratio (≥60%) and preoperative kyphotic alignment. ADF also exhibited more favorable results in postoperative cervical alignment. In contrast, operating time and intraoperative blood loss were greater in ADF. Surgical complications were more frequently seen in ADF, leading to higher rates of reoperation.
CONCLUSIONS
This systematic review and meta-analysis showed both the merits and shortcomings of ADF and LAMP. ADF resulted in more favorable neurological recovery compared to LAMP, especially for patients with massive OPLL and kyphotic alignment. Postoperative cervical lordosis was also better preserved in ADF. However, ADF was associated with greater surgical invasion and higher incidences of surgical complications.
Topics: Cervical Vertebrae; Decompression, Surgical; Humans; Laminoplasty; Ossification of Posterior Longitudinal Ligament; Spinal Fusion
PubMed: 30905611
DOI: 10.1016/j.jos.2019.03.004 -
Neurosurgical Review Oct 2018The purpose of this study was to compare clinical outcomes after preganglionic versus ganglionic epidural steroid injection (ESI) using a systematic review and network... (Meta-Analysis)
Meta-Analysis Review
The short and midterm outcomes of lumbar transforaminal epidural injection with preganglionic and postganglionic approach in lumbosacral radiculopathy: a systematic review and meta-analysis.
The purpose of this study was to compare clinical outcomes after preganglionic versus ganglionic epidural steroid injection (ESI) using a systematic review and network meta-analysis. A systematic review and meta-regression was performed to compare postoperative outcomes between the two difference injection techniques. Relevant randomized controlled trials were identified from Medline and Scopus up to September 24, 2016. Sixteen out of 598 studies were eligible; 3, 2, and 3 studies were included in the pooling of outcomes including effectiveness, visual analog score (VAS), and complications (nerve root, injury, dural puncture, and intraneural injection). Preganglionic ESI has a 2.38 (95% CI 1.12, 5.04) times statistically significantly higher chance of effectiveness when compared to ganglionic ESI. There were differences in pain VAS and complications in lumbar radiculopathy, but these displayed no statistical significance. This meta-analysis indicated that preganglionic ESI has a statistically significantly higher chance of effectiveness when compared to ganglionic ESI. In terms of pain score and complications, there were no statistically significant differences between the two groups. These results were generally homogeneous and with little publication bias, thus should be generalizable.
Topics: Analgesia, Epidural; Epidural Space; Ganglia, Spinal; Humans; Injections, Epidural; Lumbosacral Region; Radiculopathy; Treatment Outcome
PubMed: 28168618
DOI: 10.1007/s10143-017-0826-z -
BMC Musculoskeletal Disorders Jul 2011Beside symptoms and clinical signs radiological findings are crucial in the diagnosis of lumbar spinal stenosis (LSS). We investigate which quantitative radiological... (Review)
Review
BACKGROUND
Beside symptoms and clinical signs radiological findings are crucial in the diagnosis of lumbar spinal stenosis (LSS). We investigate which quantitative radiological signs are described in the literature and which radiological criteria are used to establish inclusion criteria in clinical studies evaluating different treatments in patients with lumbar spinal stenosis.
METHODS
A literature search was performed in Medline, Embase and the Cochrane library to identify papers reporting on radiological criteria to describe LSS and systematic reviews investigating the effects of different treatment modalities.
RESULTS
25 studies reporting on radiological signs of LSS and four systematic reviews related to the evaluation of different treatments were found. Ten different parameters were identified to quantify lumbar spinal stenosis. Most often reported measures for central stenosis were antero-posterior diameter (< 10 mm) and cross-sectional area (< 70 mm(2)) of spinal canal. For lateral stenosis height and depth of the lateral recess, and for foraminal stenosis the foraminal diameter were typically used. Only four of 63 primary studies included in the systematic reviews reported on quantitative measures for defining inclusion criteria of patients in prognostic studies.
CONCLUSIONS
There is a need for consensus on well-defined, unambiguous radiological criteria to define lumbar spinal stenosis in order to improve diagnostic accuracy and to formulate reliable inclusion criteria for clinical studies.
Topics: Humans; Lumbar Vertebrae; Magnetic Resonance Imaging; Predictive Value of Tests; Prognosis; Severity of Illness Index; Spinal Stenosis; Tomography, X-Ray Computed
PubMed: 21798008
DOI: 10.1186/1471-2474-12-175 -
Complications of epidural spinal stimulation: lessons from the past and alternatives for the future.Spinal Cord Oct 2020Systematic review.
STUDY DESIGN
Systematic review.
OBJECTIVES
Over the past decade, an increasing number of studies have demonstrated that epidural spinal cord stimulation (SCS) can successfully assist with neurorehabilitation following spinal cord injury (SCI). This approach is quickly garnering the attention of clinicians. Therefore, the potential benefits of individuals undergoing epidural SCS therapy to regain sensorimotor and autonomic control, must be considered along with the lessons learned from other studies on the risks associated with implantable systems.
METHODS
Systematic analysis of literature, as well as preclinical and clinical reports.
RESULTS
The use of SCS for neuropathic pain management has revealed that epidural electrodes can lose their therapeutic effects over time and lead to complications, such as electrode migration, infection, foreign body reactions, and even SCI. Several authors have also described the formation of a mass composed of glia, collagen, and fibrosis around epidural electrodes. Clinically, this mass can cause myelopathy and spinal compression, and it is only treatable by surgically removing both the electrode and scar tissue.
CONCLUSIONS
In order to reduce the risk of encapsulation, many innovative efforts focus on technological improvements of electrode biocompatibility; however, they require time and resources to develop and confirm safety and efficiency. Alternatively, some studies have demonstrated similar outcomes of non-invasive, transcutaneous SCS following SCI to those seen with epidural SCS, without the complications associated with implanted electrodes. Thus, transcutaneous SCS can be proposed as a promising candidate for a safer and more accessible SCS modality for some individuals with SCI.
Topics: Electrodes, Implanted; Epidural Space; Forecasting; Humans; Neurological Rehabilitation; Spinal Cord Compression; Spinal Cord Injuries; Spinal Cord Stimulation
PubMed: 32576946
DOI: 10.1038/s41393-020-0505-8 -
Child's Nervous System : ChNS :... Apr 2013Spinal intradural arachnoid cysts are rare with only a few patients reported so far. Idiopathic, traumatic, posthemorrhagic, and postinflammatory causes have been... (Review)
Review
BACKGROUND
Spinal intradural arachnoid cysts are rare with only a few patients reported so far. Idiopathic, traumatic, posthemorrhagic, and postinflammatory causes have been reported in the literature. Especially, idiopathic lesions, in which other possible etiological factors have been ruled out, seem to be rare.
PATIENTS AND METHODS
We systematically reviewed the literature in regards to localization within the spinal canal, treatment options, complications, and outcome. Additionally, we present management strategies in two progressively symptomatic children less than 3 years of age with idiopathic intradural arachnoid cysts.
RESULTS
In total, 21 pediatric cases including the presented cases have been analyzed. Anterior idiopathic spinal arachnoid cysts are predominantly located in the cervical spine in 87.5 % of all cases, whereas posterior cysts can be found at thoracic and thoracolumbar segments in 84.6 % of the patients. Most children presented with motor deficits (76.2 %). Twenty-five percent of anterior spinal arachnoid cysts caused back pain as the only presenting symptom. Open fenestration by a dorsal approach has been used in the vast majority of cases. No major surgical complications have been reported. Ninety-four percent of all patients did improve or showed no neurological deficits. Recurrence rate after successful surgical treatment was low (9.5 %).
CONCLUSION
Idiopathic spinal intradural arachnoid cysts can present with neurological deficits in children. Pathologies are predominantly located in the cervical spine anteriorly and in thoracic and thoracolumbar segments posteriorly to the spinal cord. In symptomatic cases, microsurgical excision and cyst wall fenestration via laminotomy are recommended. Our radiological, intraoperative, and pathological findings support the cerebrospinal fluid obstruction and vent mechanism theory of arachnoid cysts.
Topics: Arachnoid Cysts; Child; Humans; Laminectomy; Spinal Cord; Spinal Cord Compression; Spinal Cord Diseases; Treatment Outcome
PubMed: 23224408
DOI: 10.1007/s00381-012-1990-7 -
PloS One 2018Degenerative lumbar spinal stenosis is a condition related to aging in which structural changes cause narrowing of the central canal and intervertebral foramen. It is... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Degenerative lumbar spinal stenosis is a condition related to aging in which structural changes cause narrowing of the central canal and intervertebral foramen. It is currently the leading cause for spinal surgery in patients over 65 years. Interspinous process devices (IPDs) were introduced as a less invasive surgical alternative, but questions regarding safety, efficacy, and cost-effectiveness are still unanswered.
OBJECTIVES
The aim of this study was to provide complete and reliable information regarding benefits and harms of IPDs when compared to conservative treatment or decompression surgery and suggest directions for forthcoming RCTs.
METHODS
We searched MEDLINE, EMBASE, Cochrane Library, Scopus, and LILACS for randomized and quasi-randomized trials, without language or period restrictions, comparing IPDs to conservative treatment or decompressive surgery in adults with symptomatic degenerative lumbar spine stenosis. Data extraction and analysis were conducted following the Cochrane Handbook. Primary outcomes were pain assessment, functional impairment, Zurich Claudication Questionnaire, and reoperation rates. Secondary outcomes were quality of life, complications, and cost-effectiveness. This systematic review was registered at Prospero (International prospective register of systematic reviews) under number 42015023604.
RESULTS
The search strategy resulted in 17 potentially eligible reports. At the end, nine reports were included and eight were excluded. Overall quality of evidence was low. One trial compared IPDs to conservative treatment: IPDs presented better pain, functional status, quality of life outcomes, and higher complication risk. Five trials compared IPDs to decompressive surgery: pain, functional status, and quality of life had similar outcomes. IPD implant presented a significantly higher risk of reoperation. We found low-quality evidence that IPDs resulted in similar outcomes when compared to standard decompression surgery. Primary and secondary outcomes were not measured in all studies and were often published in incomplete form. Subgroup analysis was not feasible. Difficulty in contacting authors may have prevented us of including data in quantitative analysis.
CONCLUSIONS
Patients submitted to IPD implants had significantly higher rates of reoperation, with lower cost-effectiveness. Future trials should improve in design quality and data reporting, with longer follow-up periods.
Topics: Combined Modality Therapy; Decompression, Surgical; Humans; Magnetic Resonance Imaging; Publication Bias; Spinal Stenosis; Surgical Fixation Devices; Tomography, X-Ray Computed; Treatment Outcome
PubMed: 29979691
DOI: 10.1371/journal.pone.0199623 -
Neurosurgical Focus Oct 2015OBJECT Decompression without fusion for degenerative lumbar stenosis is an effective treatment for both the pain and disability of neurogenic claudication. Iatrogenic... (Review)
Review
OBJECT Decompression without fusion for degenerative lumbar stenosis is an effective treatment for both the pain and disability of neurogenic claudication. Iatrogenic instability following decompression may require further intervention to stabilize the spine. The authors review the incidence of postsurgical instability following lumbar decompression, and assess the impact of surgical technique as well as study design on the incidence of instability. METHODS A comprehensive literature search was performed to identify surgical cohorts of patients with degenerative lumbar stenosis, with and without preexisting spondylolisthesis, who were treated with laminectomy or minimally invasive decompression without fusion. Data on patient characteristics, surgical indications and techniques, clinical and radiographic outcomes, and reoperation rates were collected and analyzed. RESULTS A systematic review of 24 studies involving 2496 patients was performed, assessing both open laminectomy and minimally invasive bilateral canal enlargement. Postoperative pain and functional outcomes were similar across the various studies, and postoperative radiographie instability was seen in 5.5% of patients. Instability was seen more frequently in patients with preexisting spondylolisthesis (12.6%) and in those treated with open laminectomy (12%). Reoperation for instability was required in 1.8% of all patients, and was higher for patients with preoperative spondylolisthesis (9.3%) and for those treated with open laminectomy (4.1%). CONCLUSIONS Instability following lumbar decompression is a common occurrence. This is particularly true if decompression alone is selected as a surgical approach in patients with established spondylolisthesis. This complication may occur less commonly with the use of minimally invasive techniques; however, larger prospective cohort studies are necessary to more thoroughly explore these findings.
Topics: Constriction, Pathologic; Humans; Intervertebral Disc Degeneration; Laminectomy; Postoperative Complications; Spinal Stenosis; Spondylolisthesis
PubMed: 26424349
DOI: 10.3171/2015.7.FOCUS15259