Secukinumab demonstrates high and sustained efficacy in nail psoriasis: post hoc analysis from phase III trials in patients with psoriatic arthritis.

Secukinumab showed consistent and sustained efficacy in clearing nail psoriasis in patients with psoriatic arthritis, with or without axial manifestations, irrespective of severity of nail involvement. Reduction of nail disease was also associated with response across all musculoskeletal and skin manifestations of psoriatic arthritis.

Surgical treatment of anterior cervical osteophytes causing dysphagia.

PURPOSE: Dysphagia due to anterior cervical osteophytes is a rare condition. However, it can become serious enough to permanently impair the quality of life up to making normal food intake impossible. If conservative treatment fails, there is the option of surgical resection of the osteophytes. The objective of this study was to assess the outcomes of resections of anterior cervical osteophytes causing spondylogenic dysphagia, taking literature into consideration. METHOD: Resection of anterior cervical osteophytes using a standard anterior approach was performed in 14 consecutive patients with spondylogenic dysphagia between 2009 and 2015. Indomethacin or radiation was used to prevent recurrence. Imaging and clinical data were collected in follow-up examinations over an average of 50 months. RESULTS: The osteophytes were sufficiently resected in all cases. Anterior plates were placed in three patients due to pronounced segmental mobility. Five patients were given recurrence prevention in the form of indomethacin, nine with radiation. One patient required revision surgery for a hematoma. No other serious complications were observed. All patients had significant improvement of their symptoms. No recurrences or signs of increasing instability were found during the follow-up period. CONCLUSION: When conservative treatment fails, surgical resection of cervical osteophytes is a sufficient method for treating spondylogenic dysphagia. High patient satisfaction and improvement of the quality of life are achieved with a low complication rate. Routine additional stabilization has been discussed as recurrence prevention. Prophylaxis using indomethacin or radiation, known primarily from hip replacement, also appears to be an option.

Full-endoscopic uniportal retropharyngeal odontoidectomy for anterior craniocervical infection.

BACKGROUND: Infections of the anterior craniocervical junction may require surgery. There are various techniques with individual advantages and disadvantages. This study evaluates the full-endoscopic uniportal technique via the anterior retropharyngeal approach for odontoidectomy, decompression, and debridement. MATERIAL AND METHODS: Three patients with an infection of the anterior craniocervical junction with retrodental involvement were operated on between 2014 and 2016 using the full-endoscopic uniportal technique. Posterior stabilization was also performed with the same procedure for all patients. RESULTS: The operation was technically satisfactory in all cases. No problems due to swelling of the pharyngeal soft tissue occurred. No other complications were observed. All patients had a satisfactory outcome with stable regression of the myelopathy symptoms and/or complete healing of the infection. The follow-up images showed sufficient decompression of bone and soft tissues in all cases. CONCLUSIONS: The full-endoscopic uniportal technique with an anterior retropharyngeal approach can be an adequate and minimally invasive surgical technique for odontoidectomy, decompression, and debridement in infections of the craniocervical junction and can reduce access-related problems. The transoral, transnasal, and retropharyngeal approaches have different surgical fields due to the access trajectories, which must be taken into consideration depending on the anatomy and pathology when selecting a suitable technique.

The full-endoscopic uniportal technique for decompression of the anterior craniocervical junction using the retropharyngeal approach: an anatomical feasibility study in human cadavers and review of the literature.

Objective: Acute or progressive myelopathy may necessitate direct anterior decompression of the craniocervical junction and odontoidectomy. Different techniques with individual advantages and disadvantages can be used. In addition to the gold standard-the transoral approach-there is also increasing experience with the endoscopic transnasal technique. Other alternative methods are also being developed to reduce technical and perioperative problems. The aim of this anatomical study was to investigate the feasibility of the full-endoscopic uniportal technique with a retropharyngeal approach for decompression of the craniocervical junction, taking into consideration the specific advantages and disadvantages compared with conventional methods and the currently available data in the literature. Methods: Five fresh adult cadavers were operated on. The endoscope used has a shaft cross-section of 6.9 × 5.9 mm and a 25° viewing angle. It contains an eccentric intraendoscopic working channel with a diameter of 4.1 mm. An anterior retropharyngeal approach was used. The anatomical structures of the anterior craniocervical junction were dissected and the bulbomedullary junction was decompressed. Results: The planned steps of the operation were performed in all cadavers. The retropharyngeal approach allowed the target region to be accessed easily. The anatomical structures of the anterior craniocervical junction could be identified and dissected. The bulbomedullary junction could be adequately decompressed. No resections of the anterior arch of the atlas were necessary in the odontoidectomy. Conclusions: Using the full-endoscopic uniportal technique with an anterior retropharyngeal approach, the craniocervical region can be adequately reached, dissected, and decompressed. This is a minimally invasive technique with the known advantages of an endoscopic procedure under continuous irrigation. The retropharyngeal approach allows direct, sterile access. The instruments are available for clinical use and have been established for years in other operations of the entire spine.

Operation of Soft or Calcified Thoracic Disc Herniations in the Full-Endoscopic Uniportal Extraforaminal Technique.

BACKGROUND: Surgery for thoracic disc herniation and stenosis is comparatively rare and often demanding. The goal is to achieve sufficient decompression without manipulating the spinal cord and to minimize surgical trauma and its consequences. Individual planning and various surgical techniques and approaches are required. The key factors for selecting the technique are anatomical location, consistency of the pathology, general condition of the patient, and the surgeon's experience. OBJECTIVES: The objective of the study was the evaluation of the technical implementation and outcomes of a full-endoscopic uniportal technique via the extraforaminal approach in patients with symptomatic soft or calcified disc herniation of the thoracic spine, taking specific advantages and disadvantages and literature into consideration. STUDY DESIGN: Retrospective study. SETTING: A center for spine surgery and pain medicine. METHODS: Between 2009 and 2015, decompression was performed on 26 patients with thoracic disc herniation or stenosis with radicular or myelopathic symptoms in a full-endoscopic uniportal technique with an extraforaminal approach. No patients underwent additional posterior stabilization. Imaging and clinical data were collected in follow-up examinations for 18 months. RESULTS: Sufficient decompression was achieved in the full-endoscopic uniportal technique in all cases. The individual selection of the respective approach made it possible to reach the target area without manipulating the spinal cord. One patient experienced deterioration of a myelopathy. No other serious complications were observed. All patients, except one, experienced regression or improvement of symptoms. No evidence of increasing instability was found in imaging. LIMITATIONS: This is a retrospective study. The limited number of cases must be considered. CONCLUSIONS: The full-endoscopic uniportal technique with an extraforaminal approach was found to be a sufficient and minimally invasive method with the known advantages of an endoscopic procedure under continuous irrigation for monosegmental disc herniations. The inclusion criteria must be taken into consideration. If they are not met, an alternative full-endoscopic approach (interlaminar, transthoracic retropleural) or decompression in a conventional method must be selected. Additional stabilization does not appear to be necessary due to the low level of trauma. KEY WORDS: Extraforaminal approach, thoracic disc herniation, giant disc herniation, Full-endoscopic, minimally invasive, thoracic spine.

Full-endoscopic uniportal decompression in disc herniations and stenosis of the thoracic spine using the interlaminar, extraforaminal, or transthoracic retropleural approach.

OBJECTIVE Surgery for thoracic disc herniation and spinal canal stenosis is comparatively rare and often challenging. Individual planning and various surgical techniques and approaches are required. The key factors for selecting the technique and approach are anatomical location, consistency of the pathology, general condition of the patient, and the surgeon's experience. The objective of the study was to evaluate the technical implementation and outcomes of a full-endoscopic uniportal technique via the interlaminar, extraforaminal, or transthoracic retropleural approach in patients with symptomatic disc herniation and stenosis of the thoracic spine, taking specific advantages and disadvantages and literature into consideration. METHODS Between 2009 and 2015, decompression was performed in 55 patients with thoracic disc herniation or stenosis using a full-endoscopic uniportal technique via an interlaminar, extraforaminal, or transthoracic retropleural approach. Imaging and clinical data were collected during follow-up examinations for 18 months. RESULTS Sufficient decompression was achieved in the full-endoscopic uniportal technique. One patient required revision due to secondary bleeding, and another exhibited persistent deterioration on myelopathy. No other serious complications were observed. All but one patient experienced regression or improvement of their symptoms. CONCLUSIONS The full-endoscopic uniportal technique with an interlaminar, extraforaminal, or transthoracic retropleural approach was found to be a sufficient and minimally invasive method. To cover the entire range of thoracic disc herniations and stenosis within the criteria named, all full-endoscopic approaches are required.

Surgical treatment of cervical subaxial intraspinal extradural cysts using a full-endoscopic uniportal posterior approach.

PURPOSE: Symptomatic intraspinal extradural cysts of the cervical subaxial spine are rare, but usually require surgery. Conventional posterior decompression is the gold standard. However, there is increasing experience with endoscopic surgical techniques. The purpose of the study is to evaluate the technical implementation and outcomes of a full-endoscopic uniportal technique via the posterior approach in patients with symptomatic intraspinal extradural cysts of the cervical subaxial spine. METHODS: Seven consecutive patients with a subaxial location of symptomatic intraspinal extradural cysts were decompressed in a full-endoscopic uniportal technique via the posterior approach between 2009 and 2015. Imaging and clinical data were collected in follow-up examinations for 18 months. RESULTS: In all cases, the cyst was completely removed and adequate decompression was achieved using the full-endoscopic uniportal technique. One patient developed a dural leak that was sutured and covered intraoperatively. No other complications requiring treatment were observed. All patients had a good clinical outcome with stable regression of the radicular and central nerve pain or neurological deficits. The imaging follow-up showed sufficient decompression in all cases. No evidence was found of increasing instability during the follow-up period. CONCLUSION: The full-endoscopic uniportal operation with a posterior approach allows the resection of the cyst and can minimize trauma and destabilization and has technical benefits and a low complication rate. It is an alternative surgical method that can offer advantages and is considered by the authors to be the surgical technique of choice for cervical subaxial intraspinal extradural cysts.

Decompression of the anterior thoracic spinal canal using a novel full-endoscopic uniportal transthoracic retropleural technique-an anatomical feasibility study in human cadavers.

Surgery for thoracic disc herniation and spinal stenosis is comparatively rare and often demanding. The goal is to achieve sufficient decompression without manipulating the spinal cord. Individual planning and various surgical techniques and approaches are required. This anatomical study examines the feasibility of a novel full-endoscopic uniportal technique with a transthoracic retropleural approach for decompression of the anterior thoracic spinal canal. Operations were performed on three fresh adult cadavers. The endoscope used, from RIWOspine, Germany, has a shaft cross-section of 6.9 × 5.9 mm and a 25° view angle. It contains an eccentric intraendoscopic working channel with a diameter of 4.1 mm. A transthoracic retropleural approach was used. The anatomical structures were dissected and the anterior thoracic epidural space was decompressed. The planned steps of the operation were performed on all cadavers. The transthoracic retropleural approach allowed the target region to be accessed easily. The anatomical structures could be identified and dissected. The anterior thoracic epidural space could be decompressed sufficiently. Using the uniportal full-endoscopic operation technique with a transthoracic retropleural approach, the anterior thoracic epidural space can be adequately reached. This is a minimally invasive method with the known advantages of an endoscopic technique under continuous irrigation. The retropleural approach allows direct access. The instruments are available for clinical use and have been established for years in other operations on the entire spine. Clin. Anat. 31:716-723, 2018. © 2018 Wiley Periodicals, Inc.

Full-endoscopic Uniportal Odontoidectomy and Decompression of the Anterior Cervicomedullary Junction Using the Retropharyngeal Approach.

STUDY DESIGN: A study of a series of consecutive full-endoscopic uniportal decompressions of the anterior craniocervical junction with retropharyngeal approach. OBJECTIVE: The aim of this study was to evaluate the direct anterior decompression of the craniocervical junction in patients with bulbomedullary compression using a full-endoscopic uniportal technique via an anterolateral retropharyngeal approach. SUMMARY OF BACKGROUND DATA: Acute or progressive myelopathy may necessitate direct anterior decompression of the craniocervical junction and odontoidectomy. Different techniques with individual advantages and disadvantages can be used. In addition to the gold standard - the transoral approach - there is increasing experience with the endoscopic transnasal technique. Other alternative procedures are also being developed. METHODS: Between 2013 and 2016, eight patients with basilar impression, retrodental pannus, or retrodental infection were operated in the full-endoscopic uniportal technique with a retropharyngeal approach. Anterior decompression of the bulbomedullary junction with odontoidectomy was performed. All patients additionally underwent posterior stabilization. Imaging and clinical data were collected in follow-up examinations for 1 year. RESULTS: The bulbomedullary junction was adequately decompressed. No problems due to swelling of pharyngeal soft tissue occurred. One patient required revision due to secondary bleeding. No other complications were observed. All patients had a good clinical outcome with stable regression of the myelopathy symptoms and/or healing of the infection. The imaging follow-up showed sufficient decompression of bone and soft tissue in all cases. No evidence was found of increasing instability or failure of posterior fusion. CONCLUSION: In the operated patients, the full-endoscopic uniportal surgical technique with anterior retropharyngeal approach was found to be a sufficient and minimally invasive method with the known advantages of an endoscopic procedure under continuous irrigation. It should not be viewed only as competition for other surgical techniques - due to its individual technical parameters, it can also be considered to be an alternative or complementary procedure. LEVEL OF EVIDENCE: 4.

Imaging in the diagnosis and management of axial spondyloarthritis.

Magnetic resonance imaging (MRI) is the imaging modality of choice for diagnosing axial spondyloarthritis (SpA) when the pelvic radiograph is normal or equivocal. Subchodral bone marrow edema (BME) is the primary feature of early SpA, although structural changes, particularly erosions, may also be seen at an early stage. It is unclear whether incorporation of structural lesions enhances the classification performance of a positive MRI definition based on BME alone. Neither spinal imaging nor contrast-enhanced imaging are useful for routine diagnostic evaluation. Fat metaplasia is a key intermediary in the pathway from inflammation to ankylosis, although the histopathology remains to be determined. Both active and structural lesions can be reliably detected and quantified on MRI. Tumor necrosis factor inhibitor therapies ameliorate inflammation; however, it is unclear whether complete suppression of inflammation is necessary to prevent structural damage. Structural lesions on MRI require further validation using computed tomography and prospective follow-up to determine their prognostic significance.

Scoring sacroiliac joints by magnetic resonance imaging. A multiple-reader reliability experiment.

Magnetic resonance imaging (MRI) of the sacroiliac (SI) joints and the spine is increasingly important in the assessment of inflammatory activity and structural damage in clinical trials with patients with ankylosing spondylitis (AS). We investigated inter-reader reliability and sensitivity to change of several scoring systems to assess disease activity and change in disease activity in patients with AS. Twenty sets of consecutive MRI, derived from a randomized clinical trial comparing an active drug with placebo and selected on the basis of the presence of activity at baseline, were presented electronically to 7 experienced readers from different countries (Europe, Canada). Readers scored the MRI by 3 different methods including: a global score (grading activity per SI joint); a more comprehensive global score (grading activity per SI joint per quadrant); and a detailed scoring system [Spondyloarthritis Research Consortium of Canada (SPARCC) scoring system], which scores 6 images, divided into quadrants, with additional scores for "depth" and "intensity." A fourth and a fifth scoring system were constructed afterwards. The fourth method included the SPARCC score minus the additional scores for "depth" and "intensity," and the fifth method included the SPARCC slice with the maximum score. Inter-reader reliability was investigated by calculating intraclass correlation coefficients (ICC) for all readers together and for all possible reader pairs. Sensitivity to change was investigated by calculating standardized response means (SRM) on change scores that were made positive. Overall inter-reader ICC per method were between 0.47 and 0.58 for scoring status, and between 0.40 and 0.53 for scoring change. ICC per possible reader pairs showed much more fluctuation per method, with lowest observed values close to zero (no agreement) and highest observed values over 0.80 (excellent agreement). In general, agreement of status scores was somewhat better than agreement of change scores, and agreement of the comprehensive SPARCC scoring system was somewhat better than agreement of the more condensed systems. Sensitivity to change differed per reader, but in general was somewhat better for the comprehensive SPARCC system. This experiment under "real life," far from optimal conditions demonstrates the feasibility of scoring exercises for method comparison, provides evidence for the reliability and sensitivity to change of scoring systems to be used in assessing activity of SI joints in clinical trials, and sets the conditions for further validation research in this field.