Acute quadriplegia and death following a routine MRI for undiagnosed degenerative cervical myelopathy.

Bilateral upper limb paraesthesia and pain are common symptoms of degenerative cervical myelopathy (DCM). Such symptoms instigate investigation by cervical spine magnetic resonance imaging (MRI). This was the case for our patient, who was 72-years-in age and otherwise fit and well. During the scan he unfortunately developed sudden onset quadriplegia secondary to an intervertebral disc prolapse. This necessitated intubation due to respiratory failure and urgent transfer to the neurosciences critical care unit at a tertiary neurosciences centre. Despite prompt surgical decompression, he did not regain function. Extubation was unsuccessful on three occasions. Following discussion between the patient and his family, ventilation was withdrawn, and he died the following day. This case highlights the potentially devastating consequences of DCM and poses questions about the aetiology of DCM.

Establishing mild, moderate and severe criteria for the myelopathy disability index in cervical spondylotic myelopathy.

AIM: Cervical Spondylotic Myelopathy (CSM) is a disabling condition arising from arthritic compression and consequent injury of the cervical spinal cord. Stratification of CSM severity has been useful to inform clinical practice and research analysis. In the UK the Myelopathy Disability Index (MDI) is a popular assessment tool and has been adopted by the British Spinal Registry. However, no categories of severity exist. Therefore, the aim of this study was to define categories of mild, moderate and severe. METHOD: An anchor-based analysis was carried out on previously collected data from a prospective observational cohort (N = 404) of patients with CSM scheduled for surgery and assessed pre-operatively and at 3, 12, 24 and 60 months post-operatively. Outcomes collected included the SF-36 version-1 quality of life measure, visual analogue scales for neck/arm/hand pain, MDI and Neck Disability Index (NDI). A Receiver Operating Curve (ROC) analysis, using the NDI for an anchor-based approach, was performed to identify MDI thresholds. RESULTS: Complete data was available for 404 patients (219 Men, 185 Women). The majority of patients underwent anterior surgery (284, 70.3%). ROC curves plotted to identify the thresholds from mild to moderate to severe disease, selected optimal thresholds of 4-5 (AUC 0.83) and 8-9 (AUC 0.87). These MDI categories were validated against domains of the SF36 and VAS scores with expected positive linear correlations. CONCLUSION: Categories of mild, moderate and severe CSM according to the MDI of 4-5 and 8-9 were established based on the NDI.

Comparison of health-related quality of life in patients with traumatic brain injury, subarachnoid haemorrhage and cervical spine disease.

PURPOSE: The degree of disability that is acceptable to patients following traumatic brain injury (TBI) continues to be debated. While the dichotomization of outcome on the Glasgow Outcome Score (GOSE) into 'favourable' and 'unfavourable' continues to guide clinical decisions, this may not reflect an individual's subjective experience. The aim of this study is to assess how patients' self-reported quality of life (QoL) relates to objective outcome assessments and how it compares to other debilitating neurosurgical pathologies, including subarachnoid haemorrhage (SAH) and cervical myelopathy. METHOD: A retrospective analysis of over 1300 patients seen in Addenbrooke's Hospital, Cambridge, UK with TBI, SAH and patients pre- and post- cervical surgery was performed. QoL was assessed using the SF-36 questionnaire. Kruskal-Wallis test was used to analyse the difference in SF-36 domain scores between the four unpaired patient groups. To determine how the point of dichotomization of GOSE into 'favourable' and 'unfavourable' outcome affected QOL, SF-36 scores were compared between GOSE and mRS. RESULTS: There was a statistically significant difference in the median Physical Component Score (PCS) and Mental Component Score (MCS) of SF-36 between the three neurosurgical pathologies. Patients with TBI and SAH scored higher on most SF-36 domains when compared with cervical myelopathy patients in the severe category. While patients with Upper Severe Disability on GOSE showed significantly higher PC and MC scores compared to GOSE 3, there was a significant degree of variability in individual responses across the groups. CONCLUSION: A significant number of patients following TBI and SAH have better self-reported QOL than cervical spine patients and patients' subjective perception and expectations following injury do not always correspond to objective disability. These results can guide discussion of treatment and outcomes with patients and families.

Current surgical practice for multi-level degenerative cervical myelopathy: Findings from an international survey of spinal surgeons.

Degenerative cervical myelopathy (DCM) results from compression of the cervical spine cord as a result of age related changes in the cervical spine, and affects up to 2% of adults, leading to progressive disability. Surgical decompression is the mainstay of treatment, but there remains significant variation in surgical approaches used. This survey was conducted in order to define current practice amongst spine surgeons worldwide, as a possible prelude to further studies comparing surgical approaches. METHODS: An electronic survey was developed and piloted by the investigators using SurveyMonkey. Collected data was categorical and is presented using summary statistics. Where applicable, statistical comparisons were made using a Chi-Squared test. The level of significance for all statistical analyses was defined as p < 0.05. All analysis, including graphs was performed using R (R Studio). RESULTS: 127 surgeons, from 30 countries completed the survey; principally UK (66, 52%) and North America (15, 12%). Respondents were predominantly Neurosurgeons by training (108, 85%) of whom 84 (75%) reported Spinal Surgery as the principal part of their practice. The majority indicated they selected their surgical procedure for multi-level DCM on a case by case basis (62, 49%). Overall, a posterior approach was more popular for multi-level DCM (74, 58%). Region, speciality or annual multi-level case load did not influence this significantly. However, there was a trend for North American surgeons to be more likely to favour a posterior approach. CONCLUSIONS: A posterior approach was favoured and more commonly used to treat multi-level DCM, in an international cohort of surgeons. Posterior techniques including laminectomy, laminectomy and fusion or laminoplasty appeared to be equally popular.

Transient perioperative brainstem paralysis secondary to a local anesthetic.

Local anesthesia is widely used, in isolation or in conjunction with general anesthesia. The authors describe 2 adolescent patients presenting with absent brainstem reflexes and delayed awakening following elective foramen magnum decompression for Chiari Type I malformation. In both cases, neurological deficits were closely associated with the administration of a levobupivacaine field block following wound closure. In the absence of any structural or biochemical abnormalities, and with spontaneous recovery approximating the anesthetic half-life, the authors' observations are consistent with transient brainstem paralysis caused by perioperative local anesthetic infiltration.

Psychological distress does not compromise outcome in spinal surgery.

SUMMARY OF BACKGROUND DATA: Physical outcomes following surgery for degenerative spine disease have been well studied whereas the importance of psychological factors has only recently been acknowledged. Previous studies suggest that pre-operative psychological distress predicts poor outcome from spinal surgery. In the drive to identify patients who will not benefit, these patients risk being denied surgery. STUDY DESIGN: This is a prospective series from a spinal surgical register. AIM: The study examines the relationship between the physical symptoms, pre-operative psychological distress and outcome following surgery. METHODS: The Short Form 36 (SF36) Health Survey Questionnaire and the Hospital Anxiety and Depression Scale (HADS) were administered to patients undergoing elective surgery for degenerative spine disease pre-operatively and at 3 and 12 months post-operatively. Levels of physical disability (SF-36 physical functioning (SF36PF) and bodily pain (SF36BP) scores) and psychological distress (HADS-anxiety and HADS-depression scores) before and after surgery were compared. RESULTS: A total of 302 patients were included (169 men, 133 women, mean age 55 years). Pre-operatively patients had worse physical scores than age-matched controls (SF36PF normative mean (S.D.) 80.97 (12.69) vs. pre-op 33.31 (24.7) P < 0.05). Of the 302 patients, 117 (39%) had significant anxiety or depression. Increased levels of anxiety or depression pre-operatively correlated with worse physical (SF-36PF and SF-36BP) scores pre-operatively (Spearman's r P < 0.05). Levels of anxiety and depression were reduced post-operatively and physical outcomes improved post-operatively. Physical function remained worse in those groups who had high levels of anxiety and depression pre-operatively but when matched for pre-operative physical function, psychological distress did not have any additional effect on outcome. CONCLUSIONS: Poor physical function pre-operatively correlates with psychological distress. Both physical and psychological symptoms improve after surgery. Physical outcome after surgery is strongly influenced by pre-operative physical functioning but not independently by psychological distress. Anxious and depressed patients should continue to be offered surgery if clinically indicated.

A modified Roland-Morris disability scale for the assessment of sciatica.

BACKGROUND: The Roland-Morris disability scale (RMS) for disability secondary to low back pain is a validated and popular instrument in clinical practice and research. We have made a simple modification to the questionnaire to increase sensitivity to sciatica (RMS-L) and validated this in patients with lumbar disc prolapse and radiculopathy. METHODS: The original RMS and modified RMS-L were prospectively administered to 203 patients presenting with lumbar radiculopathy and intervertebral disc prolapse demonstrated on MRI. Scores at pre-operative assessment and follow-up at 3 months and 12-24 months were compared against visual analogue scores (VAS) and Short Form 36 generic health domains. FINDINGS: Correlation between RMS-L and VAS leg pain was significantly greater than between original RMS and VAS leg pain pre-operatively (r = 0.57 vs. 0.17, p < 0.001) and at 3 months follow-up (r = 0.78 vs. 0.49, p < 0.001). Conversely, correlation between RMS and VAS back pain was significantly higher (r = 0.58 vs. 0.15, p < 0.001). Compared with RMS, at pre-operative assessment, RMS-L showed greater correlation with SF-36 physical function (PF; r = -0.57 vs. -0.32, p < 0.001) and bodily pain (r = -0.58 vs. -0.35, p < 0.001). Similarly, the change in PF to 3 months follow-up showed significantly higher correlation with change in RMS-L compared with the change in RMS (r = -0.60 vs. -0.37, p < 0.001). Effect sizes were good for RMS-L (1.19-1.24) but only moderate for RMS (0.69-0.79). CONCLUSIONS: The original and modified RMS can discriminate disability due to low back pain and sciatica, respectively. Separate assessment of these symptoms and their contribution to functional impairment is useful in assessing suitability for surgery and predicting outcome.

A novel tool for the assessment of pain: validation in low back pain.

BACKGROUND: Adequate pain assessment is critical for evaluating the efficacy of analgesic treatment in clinical practice and during the development of new therapies. Yet the currently used scores of global pain intensity fail to reflect the diversity of pain manifestations and the complexity of underlying biological mechanisms. We have developed a tool for a standardized assessment of pain-related symptoms and signs that differentiates pain phenotypes independent of etiology. METHODS AND FINDINGS: Using a structured interview (16 questions) and a standardized bedside examination (23 tests), we prospectively assessed symptoms and signs in 130 patients with peripheral neuropathic pain caused by diabetic polyneuropathy, postherpetic neuralgia, or radicular low back pain (LBP), and in 57 patients with non-neuropathic (axial) LBP. A hierarchical cluster analysis revealed distinct association patterns of symptoms and signs (pain subtypes) that characterized six subgroups of patients with neuropathic pain and two subgroups of patients with non-neuropathic pain. Using a classification tree analysis, we identified the most discriminatory assessment items for the identification of pain subtypes. We combined these six interview questions and ten physical tests in a pain assessment tool that we named Standardized Evaluation of Pain (StEP). We validated StEP for the distinction between radicular and axial LBP in an independent group of 137 patients. StEP identified patients with radicular pain with high sensitivity (92%; 95% confidence interval [CI] 83%-97%) and specificity (97%; 95% CI 89%-100%). The diagnostic accuracy of StEP exceeded that of a dedicated screening tool for neuropathic pain and spinal magnetic resonance imaging. In addition, we were able to reproduce subtypes of radicular and axial LBP, underscoring the utility of StEP for discerning distinct constellations of symptoms and signs. CONCLUSIONS: We present a novel method of identifying pain subtypes that we believe reflect underlying pain mechanisms. We demonstrate that this new approach to pain assessment helps separate radicular from axial back pain. Beyond diagnostic utility, a standardized differentiation of pain subtypes that is independent of disease etiology may offer a unique opportunity to improve targeted analgesic treatment.