Anterior discectomy and fusion for the management of neck pain.

STUDY DESIGN: Data were collected prospectively on 38 patients who underwent anterior cervical discectomy and fusion for neck pain with no symptoms or signs of radiculopathy or myelopathy. OBJECTIVES: To determine the changes in pain and function after anterior cervical discectomy and fusion for nonradicular neck pain. SUMMARY OF BACKGROUND DATA: There is considerable controversy regarding the role of anterior cervical discectomy and fusion for neck pain in the absence of radiculopathy or myelopathy. Although no studies have addressed this specific and common problem, it is known that anterior cervical discectomy and fusion for radiculopathy or myelopathy may also provide relief of neck pain for many patients. METHODS: Thirty-eight patients who underwent anterior cervical discectomy and fusion for neck pain were evaluated. Before and after surgery, the authors measured pain with a numerical rating scale, function with the Oswestry Disability Questionnaire, and final patient satisfaction. Final evaluation was done by a disinterested third party. RESULTS: All 38 patients were available for follow-up study. Mean age was 42.4 years, and mean duration of follow-up study was 53 months. All patients had painful disc(s) proven by discography. No patients had nerve root compression. Anterior cervical discectomy and fusion was performed at one level in 21 patients, two levels in 16 patients, and three levels in one patient. The mean score on the numerical rating scale for neck pain before surgery was 8.3 (range, 3-10) versus 4.1 (range, 0-10) after surgery. This difference is significant (P < 0.001). The mean score on the Oswestry Disability Questionnaire was 57.5 (range, 0-89) before surgery versus 38.9 (range, 0-80) after surgery. This difference is significant (P < 0.001). There were 30 (79%) patients who were satisfied with their outcome, and 8 (21%) who were not satisfied. There was no statistical difference in change of pain or function between patients with worker's compensation and those with other insurance or between men and women. Twenty patients were not working because of neck pain before surgery, and 15 were not working at the time of follow-up examination. CONCLUSION: A significant decrease in pain, a significant increase in function, and a high degree of patient satisfaction were found with anterior cervical discectomy and fusion for neck pain. Improvements were not affected by worker's compensation status or gender.

Viral and immunologic aspects of Epstein-Barr virus infection in pediatric liver transplant recipients.

Pediatric allograft recipients in particular are at increased risk for Epstein-Barr virus (EBV)-associated disorders. Early identification and diagnosis of EBV-associated disorders is critical, since disease progression can often be halted by reduction of immunosuppression. In this study we examined viral and immunologic parameters of EBV infection in the circulation of pediatric liver recipients to identify factors associated with disease. Peripheral blood DNA from pediatric liver recipients was analyzed by PCR for the EBV genes coding for the nuclear antigen 1 (EBNA-1) and the viral capsid antigen gp220. Sequences for these viral genes could be readily detected in the circulation of 36.5% of patients. Moreover, identification of the EBV genome was associated with symptomatic infection, suggesting that circulating EBV may be a useful marker of disease. Since EBV-infected B cells release the low-affinity IgE receptor (sCD23), we measured sCD23 in the circulation of pediatric liver recipients and found it to be elevated in patients with detectable virus or symptoms of infection. However, sCD23 was also elevated in cases where no EBV was detectable, suggesting that factors other than viral infection could stimulate release of sCD23. To further characterize the immune response to EBV infection, the peripheral levels of IL-4, IL-5, IL-10, and IFN-gamma were determined in pediatric liver recipients. Each of these cytokines was elevated in patients with symptoms or circulating virus compared with stable, age-matched liver recipients. IL-4, in particular, was significantly increased, indicating an important role for this cytokine in EBV infection. Together, these findings suggest that (1) monitoring circulating levels of EBV may be useful in patients at high risk and (2) cytokines that promote B cell growth and differentiation contribute to EBV-associated disorders.

An increased incidence of Epstein-Barr virus infection and lymphoproliferative disorder in young children on FK506 after liver transplantation.

The incidence of Epstein-Barr virus (EBV) infection and lymphoproliferative disorder (LPD) was determined in a pediatric liver transplant population consisting of 51 children treated with FK506 and 91 treated with cyclosporine. The incidence of symptomatic EBV infection was 21.9% (23 of 105 cases) in children < 5 yr old and 10.8% (4 of 37 cases) in children 5 to 17 yr old as compared with 2.7% (9 of 323 cases) in adults (P < 0.0001). In the under 5 yr old group on cyclosporine, the incidences of EBV infection and LPD were 9 of 68 (13.2%) and 2 of 68 children, (2.9%), respectively. In contrast, in children under 5 yr old group on FK506, the incidences of EBV infection and LPD in the FK506 group were 14 of 37 (37.8%) and 7 of 37 children (18.9%), respectively. The difference between these two groups was statistically significant (P < 0.02). There were no cases of LPD in the 5-17 yr-old children on either cyclosporine (n = 23) or FK506 (n = 14). The incidence of EBV infections in the 5 to 17 yr age group, 17.4% on cyclosporine and 0% on FK506, was less than for the younger children on FK506 (37.8%). A total of 39% (9 of 23) of children under 5 yr old who had symptomatic EBV infections developed LPD, and 44% (4 of 9) with LPD died. The higher incidence of EBV infections and LPD in the younger children treated with FK506 was probably related to a greater intensity of immunosuppression for patients on FK506 than those on cyclosporine.