Neurologic deficits after cervical laminectomy in the prone position.

New neurologic deficits are known to occur after spine surgery. We present four patients with cervical myeloradiculopathy who underwent cervical laminectomy, fusion, or both in the prone position, supported by chest rolls. Three patients were intubated and positioned while awake, whereas the fourth patient was positioned after induction. Surgeries were successfully carried out, except for transient episodes of relative hypotension intraoperatively. On recovery from anesthesia, all patients were noted to have new neurologic deficits. Immediate CT myelography or surgical reexploration was unremarkable. All patients improved gradually with administration of high-dose steroids and induction of hypertension. Use of the prone position with abdominal compression may compromise spinal cord perfusion and lead to spinal cord ischemia. The use of frames that prevent abdominal compression, as well as avoidance of perioperative arterial hypotension, is important in maintaining adequate spinal cord perfusion during and after decompressive spinal cord surgery.

A critical appraisal of the reporting of the National Acute Spinal Cord Injury Studies (II and III) of methylprednisolone in acute spinal cord injury.

From the beginning, the reporting of the results of National Acute Spinal Cord Injury Studies (NASCIS) II and III has been incomplete, leaving clinicians in the spinal cord injury (SCI) community to use or avoid using methylprednisolone in acute SCI on the basis of faith rather than a publicly developed scientific consensus. NASCIS II was initially reported by National Institutes of Health announcements, National Institutes of Health facsimiles to emergency room physicians, and the news media. The subsequent report in the New England Journal of Medicine implied that there was a positive result in the primary efficacy analysis for the entire 487 patient sample. However, this analysis was in fact negative, and the positive result was found only in a secondary analysis of the subgroup of patients who received treatment within 8 hours. In addition, that subgroup apparently had only 62 patients taking methylprednisolone and 67 receiving placebo. The NASCIS II and III reports embody specific choices of statistical methods that have strongly shaped the reporting of results but have not been adequately challenged or or even explained. These studies show statistical artifacts that call their results into question. In NASCIS II, the placebo group treated before 8 hours did poorly, not only when compared with the methylprednisolone group treated before 8 hours but even when compared with the placebo group treated after 8 hours. Thus, the positive result may have been caused by a weakness in the control group rather than any strength of methylprednisolone. In NASCIS III, a randomization imbalance occurred that allocated a disproportionate number of patients with no motor deficit (and therefore no chance for recovery) to the lower dose control group. When this imbalance is controlled for, much of the superiority of the higher dose group seems to disappear. The NASCIS group's decision to admit persons with minor SCIs with minimal or no motor deficit not only enables statistical artifacts it complicates the interpretation of results from the population actually sampled. Perhaps one half of the NASCIS III sample may have had at most a minor deficit. Thus, we do not know whether the results of these studies reflect the severely injured population to which they have been applied. The numbers, tables, and figures in the published reports are scant and are inconsistently defined, making it impossible even for professional statisticians to duplicate the analyses, to guess the effect of changes in assumptions, or to supply the missing parts of the picture. Nonetheless, even 9 years after NASCIS II, the primary data have not been made public. The reporting of the NASCIS studies has fallen far short of the guidelines of the ICH/FDA and of the Evidence-based Medicine Group. Despite the lucrative "off label" markets for methylprednisolone in SCI, no Food and Drug Association indication has been obtained. There has been no public process of validation. These shortcomings have denied physicians the chance to use confidently a drug that many were enthusiastic about and has left them in an intolerably ambiguous position in their therapeutic choices, in their legal exposure, and in their ability to perform further research to help their patients.

Intradural cervical disc herniation and Brown-Séquard's syndrome. Report of three cases and review of the literature.

Although cervical disc herniation commonly requires surgical intervention, the intradural sequestration of a herniated cervical disc fragment is rare. In searching the world literature on this topic, the authors found six case reports. They report three new cases of intradural cervical disc herniation in which the patients presented with Brown-Séquard's syndrome and they review the literature. Although Brown-Séquard's syndrome is a rare clinical finding in extradural disc herniation, six of the nine patients with intradural cervical disc herniation (our cases and those from the literature) presented with symptoms of this syndrome. The remaining patients presented with para- or quadriparesis. This suggests that intradural disc herniation should be considered preoperatively in patients in whom there is magnetic resonance imaging or myelographic evidence of cervical disc herniation and Brown-Séquard's syndrome. In patients who underwent anterior cervical discectomy for the treatment of intradural cervical disc herniations, better outcomes were demonstrated than in those in whom posterior procedures were performed.

Outcome of patients treated for cervical myelopathy. A prospective, multicenter study with independent clinical review.

STUDY DESIGN: This Cervical Spine Research Society (CSRS) Study is a prospective, multicenter, nonrandomized investigation of patients with cervical spondylosis and disc disease. In this analysis, only patients with cervical myelopathy as the predominant syndrome were considered. OBJECTIVES: To determine demographics, surgeon treatment practices, and outcomes in patients with symptomatic myelopathy. SUMMARY OF BACKGROUND DATA: Current data on patient demographics and treatment practices of surgeons do not exist. There are no published prospective studies in which neurologic, functional, pain, and activities of daily living outcomes are systematically quantified. METHODS: Patients were recruited by participating CSRS surgeons. Demographic information, patients' symptoms, and patients' functional data were compiled from patient and physician surveys completed at the time of initial examination, and outcomes were assessed from patient surveys completed after treatment. Data were compiled and statistically analyzed by a blinded third party. RESULTS: Sixty-two (12%) of the 503 patients enrolled by 41 CSRS surgeons had myelopathy. Patients (48.4% male; mean age, 48.7 +/- 12.03 years) had a mean duration of symptoms of 29.8 months (range, 8 weeks to 180 months). Surgery was recommended for 31 (50%) of these patients. Forty-three patients (69%) returned for follow-up and completed the questionnaire adequately for analysis. Twenty (46%) of the 43 patients on whom follow-up data are available underwent surgery, and 23 (54%) received medical treatment. Surgically treated patients had a significant improvement in functional status and overall pain, with improvement also observed in neurologic symptoms. Patients treated nonsurgically had a significant worsening of their ability to perform activities of daily living, with worsening of neurologic symptoms. CONCLUSIONS: When medical and surgical treatments are compared, surgically treated patients appear to have better outcomes, despite exhibiting a greater number of neurologic and nonneurologic symptoms and having greater functional disability before treatment. Randomized studies, if feasible, should be performed to address outcome in cervical myelopathy further.

Outcome in patients with cervical radiculopathy. Prospective, multicenter study with independent clinical review.

STUDY DESIGN: The Cervical Spine Research Society study is a prospective, nonrandomized, multicenter investigation of patients with cervical spondylosis and disc disease. In this analysis, only patients who had radiculopathy without myelopathy as the predominant symptom were considered. OBJECTIVES: To determine demographics, surgeon treatment practices, and outcomes in patients with symptomatic radiculopathy. SUMMARY OF BACKGROUND DATA: Current data on patient demographics and treatment practices of surgeons do not exist. There are no published prospective studies in which outcomes, including pain, function, neurologic symptoms, and ability to perform activities of daily living, are systematically quantified. METHODS: Patients were recruited by participating Cervical Spine Research Society surgeons. Demographic, symptomologic, and functional patient data were compiled from surveys of patients and physicians completed at the time of initial examination, and outcomes were assessed from surveys of patients completed after treatment. Data were compiled and statistically analyzed by a blinded third party. RESULTS: Of the 503 patients enrolled by 41 CSRS surgeons, 246 (49%) had radiculopathy. Patients had a mean duration of symptoms of 26.7 months (range, 8 weeks to > 352 months) and a mean age of 48.1 +/- 12.42 years; 44.7% were female. Surgery was recommended for 86 (35%) of these patients. Of the 155 patients on whom there were follow-up data, 51 (33%) underwent surgery, whereas 104 (67%) received medical treatment. Surgically treated patients had a significant improvement in pain, neurologic symptoms, functional status, and ability to perform activities of daily living. A significant number of patients who underwent surgery reported persistent excruciating or horrible pain on follow-up (26%). Patients treated medically also had significant improvement in pain and overall functional status. CONCLUSIONS: In summary, this study represents the first in-depth, prospective outcome analysis of patients with cervical spondylotic and discogenic radiculopathy.

Trends and complications in cervical spine surgery: 1989-1993.

In an effort to determine trends in surgery of cervical spine disorders and the incidence of complications resulting from this treatment, a mechanism was established for the collection and analysis of multicenter data on an every-5-year basis. This data collection technique allowed the tracking of trends in the treatment for specific diagnoses and determination of complication rates for individual procedures. We present the results occurring in 4,589 patients operated on by 35 surgeons per year between 1989 and 1993. Principal diagnoses included spondylosis, herniated nucleus pulposus, trauma, rheumatoid arthritis, ankylosing spondylitis, ossification of the posterior longitudinal ligament, and tumor. Surgical procedures included anterior cervical discectomy, anterior cervical discectomy and fusion, corpectomy, laminectomies, posterior arthrodesis, laminoplasty, and cervical plating. Complications reported include: bone graft failure, cerebrospinal fluid leak, recurrent laryngeal nerve injury, root injury, quadriplegia, and death. The yearly percentages of each diagnosis have been roughly stable for each year of the study. However, the operative procedures revealed some interesting trends. There was no overall trend with regard to complications over time, and the overall complication risk was approximately 5%. The present data confirm that cervical spine disease is primarily degenerative or discogenic. However, trauma still remains a major part of the practice, accounting for upwards of 17% of reported cases. Anterior procedures were twice as common as posterior ones. The risk of operative complications remains small yet significant.

Clinical applications of pharmacologic therapies for spinal cord injury.

We review the evidence supporting the role of glucocorticosteroids, trilazad, and GM1 ganglioside in spinal cord injury and provide our critique of the published studies, along with our recommendations for pharmacologic therapy for this complex and difficult problem.

Luteinizing hormone and human chorionic gonadotropin fragment the migrating myoelectric complex in rat small intestine.

We hypothesized that sex hormones may affect motility disorders because these diseases occur more often in women than in men, and symptoms often occur or worsen after ovulation. Luteinizing hormone (LH) is predominantly secreted by the anterior pituitary midway through the menstrual cycle; it results in the development of the corpus luteum. LH levels also increase after bilateral gonadectomy. LH and human chorionic gonadotropin (hCG) bind to the same receptor, but rats lack hCG. To assess how LH and hCG influence myoelectric activity of the small intestine and to test the specificity of the LH receptor, we implanted electrodes on the jejunum of female rats. LH (0.1 or 0.5 NIH units) was administered intraperitoneally to intact and gonadectomized rats and 0.5 NIH units to rats that had been both hypophysectomized and gonadectomized; intact animals were treated with 100 units USP of hCG. Recordings were made with the rats in fasted and in fed states, and their intestinal motility was analysed. The most striking effects of LH, hypophysectomy, and hCG were the same: phase III of the migrating myoelectric complex was markedly fragmented and its duration lengthened (P < 0.0001). Gonadectomy alone and gonadectomy with hypophysectomy also increased fragmentation and phase III duration (P < 0.01 or better). LH receptors respond similarly to LH and hCG, and both hormones alter myoelectric activity of the rat small intestine in comparable ways.

One-stage anterior cervical decompression and posterior stabilization. A study of one hundred patients with a minimum of two years of follow-up.

One hundred patients were managed with one-stage anterior decompression and posterior stabilization of the cervical spine. The underlying indication for the operation was cervical trauma in thirty-one patients; a neoplasm with a pathological fracture or an incomplete neurological deficit in fifty-five; and a miscellaneous condition, such as infection, rheumatoid arthritis, or cervical spondylotic myelopathy, in fourteen. The duration of follow-up ranged from twenty-four to 108 months (mean, thirty-two months) for the living patients. Sixteen patients had the procedure after the failure of an operation that had been performed elsewhere. The development of more biomechanically rigid cervical instrumentation did not obviate the need for a combined anterior and posterior approach. Twenty-six patients (26 per cent) had supplemental cervical instrumentation as part of the circumferential arthrodesis: seventeen had insertion of an anterior cervical plate and nine had insertion of a posterior facet plate. There were no iatrogenic neurological deficits. Of the seventy-five patients who had had a neurological deficit preoperatively, fifty-one improved one grade and six improved two grades according to the system of Frankel et al. Of the thirty-five patients who had not been able to walk preoperatively, twenty-one regained enough motor strength to walk postoperatively. Because the anterior and posterior procedures were performed during one session of general anesthesia, the prevalence of perioperative complications related to the airway was lower than that previously reported in the literature. No patient had an obstruction of the airway.