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The Spine Journal : Official Journal of... Oct 2023Excessive production of epidural fibrosis in the nerve root can be a pain source after laminectomy. Pharmacotherapy is a minimally invasive treatment option to attenuate... (Review)
Review
BACKGROUND CONTEXT
Excessive production of epidural fibrosis in the nerve root can be a pain source after laminectomy. Pharmacotherapy is a minimally invasive treatment option to attenuate epidural fibrosis by suppressing proliferation and activation of fibroblasts, inflammation, and angiogenesis, and inducing apoptosis.
PURPOSE
We reviewed and tabulated pharmaceuticals with their respective signaling axes implicated in reducing epidural fibrosis. Additionally, we summarized current literature for the feasibility of novel biologics and microRNA to lessen epidural fibrosis.
STUDY DESIGN/SETTING
Systematic Review.
METHODS
According to the PRISMA guidelines, we systematically reviewed the literature in October 2022. The exclusion criteria included duplicates, nonrelevant articles, and insufficient detail of drug mechanism.
RESULTS
We obtained a total of 2,499 articles from PubMed and Embase databases. After screening the articles, 74 articles were finally selected for the systematic review and classified based on the functions of drugs and microRNAs which included inhibition of fibroblast proliferation and activation, pro-apoptosis, anti-inflammation, and antiangiogenesis. In addition, we summarized various pathways to prevent epidural fibrosis.
CONCLUSION
This study allows a comprehensive review of pharmacotherapies to prevent epidural fibrosis during laminectomy.
CLINICAL SIGNIFICANCE
We expect that our review would enable researchers and clinicians to better understand the mechanism of anti-fibrosis drugs for the clinical application of epidural fibrosis therapies.
Topics: Animals; Laminectomy; Fibrosis; Apoptosis; MicroRNAs; Models, Animal; Epidural Space
PubMed: 37187251
DOI: 10.1016/j.spinee.2023.05.007 -
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 2013Systematic review. (Review)
Review
Systematic review of magnetic resonance imaging characteristics that affect treatment decision making and predict clinical outcome in patients with cervical spondylotic myelopathy.
STUDY DESIGN
Systematic review.
OBJECTIVE
To determine whether there are magnetic resonance imaging (MRI) characteristics in patients with cervical spondylotic myelopathy that affect treatment decisions or predict postsurgical outcomes or adverse events.
SUMMARY OF BACKGROUND DATA
Although the role of MRI in confirming the clinical diagnosis of cervical spondylotic myelopathy and directing surgical management is well established, its potential value as a prognostic tool is largely unknown.
METHODS
A systematic search was conducted using PubMed and the Cochrane Collaboration Library for articles published between January 1, 1956, and November 20, 2012. The overall body of evidence with respect to each clinical question was determined on the basis of precepts outlined by the Grading of Recommendation Assessment, Development and Evaluation Working Group and recommendations made by the Agency for Healthcare Research and Quality.
RESULTS
The initial search yielded 268 citations. Twenty publications met all inclusion criteria and were included in the review. Three of these assessed MRI predictors of clinical deterioration in the case of conservative treatment and 17 evaluated MRI anatomic or cord characteristics that could predict surgical outcome or adverse events. There is low evidence suggesting that a high signal intensity (SI) grade on T2WI is not associated with patient deterioration during conservative treatment. High SI grade on T2WI, along with compression ratio and canal diameter, was not an important predictor of outcome. There is low evidence identifying number of high SI segments on T2WI, low SI segments on T1WI, combined T1/T2 SI, and SI ratio as important negative predictors of surgical outcome.
CONCLUSION
On the basis of this review and on low-quality evidence, we have identified 3 important negative predictors of surgical outcome: number of high SI segments on T2WI, combined T1/T2 signal change, and SI ratio.EVIDENCE-BASED CLINICAL RECOMMENDATIONS:
RECOMMENDATION 1
We suggest that when clinically feasible, surgeons rely on MRI to confirm the diagnosis of CSM and rely on clinical history and examination to determine progression and severity of disease.
OVERALL STRENGTH OF EVIDENCE
Low.
STRENGTH OF RECOMMENDATION
Weak.
RECOMMENDATION 2
T2 signal may be a useful prognostic indicator when used in combination with low SI change on T1WI, or as a ratio comparing compressed with noncompressed segments, or as a ratio of T2 compared with T1WI. We suggest that if surgeons use MRI signal intensity to estimate the risk of a poor outcome after surgery, they use high SI change on T2WI in combination with other signal intensity parameters, and not in isolation.
OVERALL STRENGTH OF EVIDENCE
Low. StrENGTH OF RECOMMENDATION: Weak.
Topics: Cervical Vertebrae; Decision Making; Humans; Magnetic Resonance Imaging; Prognosis; Radiography; Sensitivity and Specificity; Spinal Cord Diseases; Spondylosis; Treatment Outcome
PubMed: 23962996
DOI: 10.1097/BRS.0b013e3182a7eae0 -
Spine Oct 2013Systematic review. (Review)
Review
STUDY DESIGN
Systematic review.
OBJECTIVE
To determine whether various preoperative factors affect patient outcome after cervical laminoplasty for cervical spondylotic myelopathy (CSM) and/or ossification of posterior longitudinal ligament (OPLL).
SUMMARY OF BACKGROUND DATA
Cervical laminoplasty is a procedure designed to decompress the spinal cord by enlarging the spinal canal while preserving the lamina. Prior research has identified a variety of potential predictive factors that might affect outcomes after this procedure.
METHODS
A systematic search of multiple major medical reference databases was conducted to identify studies explicitly designed to evaluate the effect of preoperative factors on patient outcome after cervical laminoplasty for CSM or OPLL. Studies specifically designed to evaluate potential predictive factors and their associations with outcome were included. Only cohort studies that used multivariate analysis, enrolled at least 20 patients, and adjusted for age as a potential confounding variable were included. JOA (Japanese Orthopaedic Association), modified JOA, and JOACMEQ-L (JOA Cervical Myelopathy Evaluation Questionnaire lower extremity function section) scores were the main outcome measures. Clinical recommendations and consensus statements were made through a modified Delphi approach by applying the GRADE (Grading of Recommendation Assessment, Development and Evaluation)/AHRQ (Agency for Healthcare Research and Quality) criteria.
RESULTS
The search strategy yielded 433 citations, of which 1 prospective and 11 retrospective cohort studies met our inclusion criteria. Overall, the strength of evidence from the 12 studies is low or insufficient for most of the predictive factors. Increased age was not associated with poorer JOA outcomes for patients with CSM, but there is insufficient evidence to make a conclusion for patients with OPLL. Increased severity of disease and a longer duration of symptoms might be associated with JOA outcomes for patients with CSM. Hill-shaped lesions might be associated with poorer JOA outcomes for patients with OPLL. There is insufficient evidence to permit conclusions regarding other predictive factors.
CONCLUSION
Overall, the strength of evidence for all of the predictive factors was insufficient or low. Given that cervical myelopathy due to CSM tends to be progressive and that increased severity of myelopathy and duration of symptoms might be associated with poorer outcomes after cervical laminoplasty for CSM, it is preferable to perform laminoplasty in patients with CSM earlier rather than waiting for symptoms to get worse. Further research is needed to more clearly identify predictive factors that affect outcomes after cervical laminoplasty because there were relatively few studies identified that used multivariate analyses to control for confounding factors and many of these studies did not provide a detailed description of the multivariate analyses or the magnitude of effect estimates. EVIDENCE-BASED CLINICAL RECOMMENDATIONS:
RECOMMENDATION 1
For patients with CSM, increased age is not a strong predictor of clinical neurological outcomes after laminoplasty; therefore, age by itself should not preclude cervical laminoplasty for CSM.
OVERALL STRENGTH OF EVIDENCE
Low.
STRENGTH OF RECOMMENDATION
Strong.
RECOMMENDATION 2
For patients with CSM, increased severity of disease and a longer duration of symptoms might be associated with poorer clinical neurological outcomes after laminoplasty; therefore, we recommend that patients be informed about this.
OVERALL STRENGTH OF EVIDENCE
Low.
STRENGTH OF RECOMMENDATION
Strong. SUMMARY STATEMENTS: For patients with OPLL, hill-shaped lesions might be associated with poorer clinical neurological outcomes after laminoplasty; therefore, surgeons might consider potential benefits and risks of alternative or additional surgery.
Topics: Cervical Vertebrae; Humans; Orthopedic Procedures; Ossification of Posterior Longitudinal Ligament; Prognosis; Risk Factors; Spinal Cord Diseases; Spondylosis; Time Factors; Treatment Outcome
PubMed: 23962999
DOI: 10.1097/BRS.0b013e3182a7eb55 -
Spine Oct 2013Systematic review. (Review)
Review
STUDY DESIGN
Systematic review.
OBJECTIVE
We performed a systematic review to determine the comparative effectiveness and safety profiles of anterior versus posterior decompression procedures for multilevel cervical spondylotic myelopathy (CSM).
SUMMARY OF BACKGROUND DATA
CSM is a common cause of neurological dysfunction. It is well established that surgical decompression of the cervical spinal cord is an effective treatment option for CSM. Because of the lack of well-designed prospective studies, there remains a lack of consensus whether multilevel spondylotic compression is best treated via an anterior or posterior surgical route and whether one of these surgical approaches is superior in terms of patient outcomes and/or complication profiles.
METHODS
We conducted a systematic search for literature published through September 2012. We sought to identify comparative studies (e.g., randomized controlled trials, cohort studies) comparing anterior with posterior procedures in patients with 2-level or greater cord compression resulting in CSM. Standardized mean differences were calculated to allow comparisons of the change (i.e., improvement or decline) in scores between anterior and posterior surgical procedures by study. Clinical recommendations were made through a modified Delphi approach by applying the GRADE (Grading of Recommendation Assessment, Development and Evaluation)/AHRQ (Agency for Healthcare Research and Quality) criteria.
RESULTS
We identified 8 level III retrospective cohort studies that met the inclusion criteria from a total of 135 possible studies for review. With regard to effectiveness between the 2 approaches, improvements in JOA (Japanese Orthopaedic Association) scores were similar, whereas canal diameter change was larger after posterior surgery. With regard to safety, postoperative C5 palsy rates were similar, infection rates were lower with anterior surgery, and dysphagia rates were lower with posterior surgery.
CONCLUSION
This systematic review demonstrates that, for both effectiveness and safety, there is no clear advantage to either an anterior surgical approach or a posterior surgical approach when treating patients with multilevel CSM. With that, a surgical strategy developed on a patient-to-patient basis should be used to achieve optimal patient outcomes. In addition, development of a consensus for standardized reporting of outcome measures and complication profiles would facilitate improved comparisons across differing treatment centers and surgical techniques. EVIDENCE-BASED CLINICAL RECOMMENDATIONS:
RECOMMENDATION
We recommend an individualized approach when treating patients with CSM accounting for pathoanatomical variations (ventral vs. dorsal, focal vs. diffuse, sagittal, dynamic instability) because there are similar outcomes between the anterior and posterior approaches with regard to effectiveness and safety.
OVERALL STRENGTH OF EVIDENCE
Low.
STRENGTH OF RECOMMENDATION
Strong.
Topics: Cervical Vertebrae; Decompression, Surgical; Humans; Spinal Cord Diseases; Spondylosis; Treatment Outcome
PubMed: 23962995
DOI: 10.1097/BRS.0b013e3182a7eaaf -
The Cochrane Database of Systematic... Jun 2013Spinal burst fractures result from the failure of both the anterior and the middle columns of the spine under axial compression loads. Conservative management is through... (Comparative Study)
Comparative Study Meta-Analysis Review
BACKGROUND
Spinal burst fractures result from the failure of both the anterior and the middle columns of the spine under axial compression loads. Conservative management is through bed rest and immobilisation once the acute symptoms have settled. Surgical treatment involves either anterior or posterior stabilisation of the fracture, sometimes with decompression involving the removal of bone fragments that have intruded into the vertebral canal. This is an update of a review first published in 2006.
OBJECTIVES
To compare the outcomes of surgical with non-surgical treatment for thoracolumbar burst fractures without neurological deficit.
SEARCH METHODS
We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (October 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 8), MEDLINE (1946 to October 2012), EMBASE (1980 to October 2012) and the Chinese Biomedical Literature Database (1978 to October 2012). We also searched trial registers and reference lists of articles.
SELECTION CRITERIA
Randomised or quasi-randomised controlled trials comparing surgical with non-surgical treatment of thoracolumbar burst fractures without neurological deficit.
DATA COLLECTION AND ANALYSIS
Two review authors independently assessed risk of bias and extracted data independently. Only limited pooling of data was done.
MAIN RESULTS
We included two trials that compared surgical with non-surgical treatment for patients with thoracolumbar burst fractures without neurological deficit. These recruited a total of 87 participants and reported outcomes for 79 participants at follow-up of two years or more. Both trials were judged at unclear risk of selection bias and at high risk of performance and detection biases, resulting from lack of blinding.The two trials reported contrasting results for pain and function-related outcomes at final follow-up, and numbers returning to work. One trial found less pain (mean difference (MD) -15.09 mm, 95% CI -27.81 to -2.37; 100 mm visual analogue scale), and better function based on the Roland and Morris disability questionnaire results (MD -5.87, 95% CI -10.10 to -1.64; 24 points = maximum disability) in the surgical group. Based on the same outcome measures, the other trial found the surgical group had more pain (MD 13.60 mm, 95% CI -0.31 to 27.51) and worse function (MD 4.31, 95% CI 0.54 to 8.08). Neither trial reported a statistically significant difference in return to work. There were greater numbers of participants with complications in the surgical group of both trials (21/41 versus 6/38; RR 2.85, 95% CI 0.83 to 9.75; 2 trials), and only participants of this group had subsequent surgery, involving implant removal either for complications or as a matter of course. One trial reported that surgery was over four times more costly than non-surgical treatment.
AUTHORS' CONCLUSIONS
The contradictory evidence provided by two small and potentially biased randomised controlled trials is insufficient to conclude whether surgical or non-surgical treatment yields superior pain and functional outcomes for people with thoracolumbar burst fractures without neurological deficit. It is likely, however, that surgery is associated with more early complications and the need for subsequent surgery, as well as greater initial healthcare costs.
Topics: Fracture Fixation; Humans; Lumbar Vertebrae; Return to Work; Spinal Fractures; Thoracic Vertebrae; Treatment Outcome
PubMed: 23740669
DOI: 10.1002/14651858.CD005079.pub3 -
Child's Nervous System : ChNS :... May 2022Here, we report a case of a 3-year-old female who presented to clinic with an enlarging mass in the posterior cervical midline. The mass was present since birth and...
Here, we report a case of a 3-year-old female who presented to clinic with an enlarging mass in the posterior cervical midline. The mass was present since birth and demonstrated no cutaneous stigmata. Plain film, CT, and MRI of the cervical spine (C3-C5) revealed enlargement of the spinal canal, soft tissue calcification, spinal dysraphism, and an intramedullary, predominantly fatty, mass. The mass had associated calcifications and a highly proteinaceous cyst. Surgical resection of the spinal lesion was subsequently performed. Histopathological evaluation revealed a mature teratoma. Cervical spinal teratomas in the pediatric population are rare entities with few cases currently reported in the literature. We conducted a systematic review to outline the current evidence detailing cases of intramedullary spinal cord teratomas. Six articles were included for final review. All patients in the included articles underwent maximal surgical resection with one patient also receiving chemotherapy and radiation. With our report, we aim to add to the literature on cervical intramedullary spinal cord teratomas in the pediatric population.
Topics: Cervical Vertebrae; Child; Child, Preschool; Female; Humans; Neck; Spinal Cord Neoplasms; Spinal Dysraphism; Teratoma
PubMed: 34676426
DOI: 10.1007/s00381-021-05385-4 -
Scandinavian Journal of Gastroenterology May 2010Transanal irrigation for treatment of disordered defecation has been widely used among caregivers. Unique in its simplicity, reversible and minimally invasive, transanal... (Review)
Review
Transanal irrigation for treatment of disordered defecation has been widely used among caregivers. Unique in its simplicity, reversible and minimally invasive, transanal irrigation has begun to find its place in the treatment hierarchy. Scheduled transanal irrigation aims to ensure emptying of the left colon and rectum. This prevents faecal leakage between washouts, providing a state of pseudocontinence, and re-establishes control over the time and place of defecation. Furthermore, regular evacuation of the rectosigmoid prevents constipation. The studies presented in this review represent the continuum of increasing evidence and knowledge of transanal irrigation for disordered defecation: from proof in principle through better knowledge of the physiology, towards establishing the indications and ensuring the safety of the treatment. Evidence of the superiority of transanal irrigation in spinal cord injury patients with neurogenic bowel dysfunction is provided, also from a health-economic perspective. Finally, a proposal is presented for an algorithm for the introduction of transanal irrigation for disordered defecation before irreversible surgery is considered.
Topics: Algorithms; Anal Canal; Constipation; Equipment Design; Fecal Incontinence; Humans; Rectum; Therapeutic Irrigation
PubMed: 20199336
DOI: 10.3109/00365520903583855 -
No Shinkei Geka. Neurological Surgery Mar 2014A systematic review of the English- and Japanese-language literature related to complications and reoperation rates of spinal surgery for degenerative lumbar disease was... (Review)
Review
A systematic review of the English- and Japanese-language literature related to complications and reoperation rates of spinal surgery for degenerative lumbar disease was undertaken for articles published between 1993 and 2012. From these references, key articles were selected to determine the incidence of clinical perioperative and postoperative adverse events for different types of degenerative lumbar diseases. The mortality rate after lumbar degenerative spinal surgery was 0.20% in the large-scale clinical studies evaluated. In this review series, the complication rates for lumbar canal stenosis(LCS), degenerative spondylolisthesis(DS), and lumbar disc herniation(LDH)were 7.6%, 8.5%, and 3.5%, respectively. The reoperation rates for LCS, DS, and LDH were 8.1%, 8.0%, and 6.2%, respectively. These data are helpful for spinal surgeons to apprise patients who have spinal surgery for degenerative lumbar disease of the possible risks of surgical procedures and reoperation rates.
Topics: Decompression, Surgical; Humans; Informed Consent; Lumbar Vertebrae; Postoperative Complications; Spondylolisthesis; Treatment Outcome
PubMed: 24598875
DOI: No ID Found -
Neuromodulation : Journal of the... Oct 2017Conventional dorsal column spinal cord stimulation (SCS) provides less than optimal pain relief for certain pain syndromes and anatomic pain distributions. Practitioners... (Review)
Review
BACKGROUND
Conventional dorsal column spinal cord stimulation (SCS) provides less than optimal pain relief for certain pain syndromes and anatomic pain distributions. Practitioners have sought to treat these challenging therapeutic areas with stimulation of alternate intraspinal targets.
OBJECTIVE
To identify and systematically review the evidence for the value neuromodulating specific neuronal targets within the spinal canal to achieve relief of chronic pain.
METHODS
A systematic literature search was conducted using PubMed for clinical trials published from 1966 to March 1, 2015 to identify neurostimulation studies that employed non-dorsal column intraspinal stimulation to achieve pain relief. Identified studies on such targeted intraspinal stimulation were reviewed and graded using Evidence Based Interventional Pain Medicine criteria.
RESULTS
We found a total of 13 articles that satisfied our search criteria on targeted, non-dorsal column intraspinal stimulation for pain. We identified five studies on neurostimulation of the cervicomedullary junction, six studies on neurostimulation of the dorsal root ganglion, two studies on the neurostimulation of the conus medullaris, unfortunately none was found on intraspinal nerve root stimulation.
LIMITATIONS
The limitations of this review include the relative paucity of well-designed prospective studies on targeted SCS.
CONCLUSIONS
Clinical use of intraspinal neurostimulation is expanding at a very fast pace. Intraspinal stimulation of non-dorsal column targets may well be the future of neurostimulation as it provides new clinically significant neuromodulation of specific therapeutic targets that are not well or not easily addressed with conventional dorsal column SCS. In addition, they may avoid undesired stimulation induced paraesthesia, particularly in non-painful areas of the body.
Topics: Chronic Pain; Humans; Pain Management; Spinal Cord Stimulation
PubMed: 28160397
DOI: 10.1111/ner.12568