Athrodesis of the lateral atlanto-axial joint for the relief of neck pain and cervicogenic headache.

BACKGROUND: Osteoarthrosis of the lateral atlanto-axial joint (LAAJ) may be a cause of upper neck pain and headache. Intra-articular injection of steroids may provide only short-lasting relief. For intractable pain, arthrodesis of the joint might be considered. OBJECTIVE: To determine the success rates of arthrodesis of the lateral atlanto-axial joint for relieving neck pain and disability. DESIGN: Practice audit. SETTING: Private practice of senior author. SUBJECTS: Prospective series of 23 consecutive patients. METHODS: Outcomes were measured using a numerical rating scale for neck pain, and the Neck Disability Index for disability. Success rates were calculated for various degrees of improvement of neck pain at long-term follow-up (8-40 months), and for achieving various combinations of improvement of both neck pain and disability. RESULTS: Complete relief of pain was achieved in 40% of patients, with a further 40% achieving at least 50% relief. At long-term follow-up, 30% of patients had no neck pain and no disability, and a further 25% had only minimal pain, minimal disability, or both. CONCLUSIONS: The present study did not corroborate earlier studies that claimed outstanding outcomes for arthrodesis of the LAAJ, but its outcomes are consonant with more recent studies that provided transparent outcome data. These studies provide Pain Physicians with empirical data on success rates and outcomes, upon which they can base their consideration of referral for arthrodesis.

Identifying factors influencing mortality in patients aged over 65 following an acute type II odontoid process fracture. A retrospective cohort study.

OBJECTIVE: Compare short-term mortality rates following operative and nonoperative management of geriatric patients following an acute type II odontoid process fracture. METHODS: One hundred forty-one patients with a type II odontoid fracture were identified from a single centre between 2002 and 2018. Patient demographics, details of injury and management, plus mortality data were collected. The incidence of mortality at 3 and 12 months was calculated, and a multivariate model built which included the treatment modality variable and allowed adjustment for six individual confounders. RESULTS: Of the 141 patients with a type II odontoid process fracture, 39 were managed operatively, while 102 were managed nonoperatively. Relative to the nonoperative group, the operative group was younger (79.0 ± 7.0 vs. 83.7 ± 7.6), more likely to have odontoid angulation > 15° (74.4% vs. 43.1%, p < 0.01), and a greater proportion having fracture displacement > 2 mm (74.4% vs. 31.4%, p < 0.01). Both groups were comparable for gender, comorbidities, and associated injuries. On univariate analysis of treatment modality, the odds ratio of 3-month mortality with nonoperative management was 2.55 (95% CI: 0.82-7.92; p = 0.08), whilst at 12-months it was 3.12 (95% CI: 1.11-8.69; p = 0.02). On multivariate analysis of 12-month mortality, however, treatment modality was not found to be significant. This multivariate analysis suggested that increasing age, male gender, and injury severity were significant predictors of 12-month mortality. CONCLUSION: In contrast to the findings of a number of previous studies, operative management may not influence survival at 3- and 12-months.

Long-term follow-up of minimal-access and open posterior lumbar interbody fusion for spondylolisthesis.

BACKGROUND: Although posterior lumbar interbody fusion (PLIF) is regarded as an effective treatment for spondylolisthesis, few studies have reported comprehensive, long-term outcome data, and none has investigated the incidence of deterioration of outcomes. OBJECTIVE: To determine and compare the success rates and long-term stability of outcomes of open PLIF and minimal-access PLIF in the treatment of radicular pain and back pain in patients with spondylolisthesis. METHODS: Forty-three patients were followed for a minimum of 3 years. They completed a Short-Form Health Survey and visual analog scores for back pain and leg pain and underwent lumbar spine radiography. Outcomes were compared with baseline data and 12-month data. RESULTS: Surgery succeeded in reducing listhesis and increasing disc height, but had little effect on lumbar lordosis or the angulation of the segment treated. At 12 months after surgery, listhesis was reduced, disc height was increased, leg pain was reduced or eliminated, and physical functioning restored. Back pain was less often relieved. These outcomes were largely maintained over the ensuing 2 years. Only 5% to 10% of patients reported deterioration in their relief of pain. Depending on the definition adopted for success, the long-term success rate of PLIF may be as high as 70%. CONCLUSION: For the relief of leg pain, the success rates of open PLIF (70%) and minimal-access PLIF (67%) for spondylolisthesis are high and durable in the long-term. PLIF is less often successful in relieving back pain, but the outcomes are maintained. The outcomes of open PLIF and minimal-access PLIF were statistically indistinguishable. ABBREVIATIONS: MCIC, minimally clinically important changeMPLIF, minimal-access posterior lumbar interbody fusionOPLIF, open-access posterior lumbar interbody fusionPLIF, posterior lumbar interbody fusionSF-36, Short-Form Health Survey.

Minimal access versus open posterior lumbar interbody fusion in the treatment of spondylolisthesis.

OBJECTIVE: To compare the safety and effectiveness of minimal access posterior lumbar interbody fusion (MAPLIF) with open posterior lumbar interbody fusion (OPLIF) in patients with spondylolisthesis and radicular pain. METHODS: A prospective study was performed of 47 patients with radicular pain resulting from lumbar spondylolisthesis with a slip of less than 50% who underwent either MAPLIF (n = 23) or OPLIF (n = 24). At 12 months after treatment, clinical outcomes were measured using the Short-Form Health Survey 36 and the visual analog score for both leg pain and back pain, and the degree of reduction of spondylolisthesis, restoration of disc height, and presence of fusion were assessed. RESULTS: Both groups were similar in demographic and baseline clinical features. Both exhibited statistically and clinically significant improvements in back pain (OPLIF, 64%; MAPLIF, 78%), and leg pain (88% for both groups). This was corroborated by improvements in social and physical functioning, which were similar for both groups. The reduction of spondylolisthesis and fusion rates were also similar between the 2 groups. MAPLIF patients commenced mobilization sooner, achieved independent mobilization earlier, and had a shorter hospital stay (4 days versus 7 days). CONCLUSION: MAPLIF and OPLIF both reduce leg and back pain and restore function to a similar extent. MAPLIF is as effective as OPLIF in reducing the slip in patients with spondylolisthesis of less than 50%. MAPLIF promotes faster recovery and shortens hospital stay.

Dynamic plates in anterior cervical fusion surgery: graft settling and cervical alignment.

STUDY DESIGN: Retrospective cohort. OBJECTIVE: To evaluate the effect of graft subsidence associated with the use of dynamic cervical plates on cervical alignment and clinical outcome of patients undergoing anterior cervical decompression and fusion. SUMMARY AND BACKGROUND DATA: Dynamic cervical plates allow graft loading which may enhance fusion. However, subsidence of the bone graft may result in changes in cervical alignment. The extent of settling of the graft and its impact on cervical alignment has not been determined. Also whether such change in alignment has an impact on clinical outcome is not known. METHODS: Fifty-five patients with spondylitic myelopathy or radiculopathy underwent anterior cervical decompression and fusion using a dynamic plate for stabilization (ABC, Braun/Aesculap). The surgical indications included myelopathy (n = 21), radiculopathy (n = 30), or myeloradiculopathy (n = 4). Regional and local cervical angles, graft subsidence, and fusion rates were assessed before surgery, immediately after surgery and at 6 months after surgery. Visual analogue scores for neck and radicular pain, Neck Disability Indexes, and Nurick grades for myelopathy were recorded. Patients were observed up for at least 6 months with a median of 14 months (range: 6-48 months). RESULTS: Radicular pain improved by a median of 5 points (P < 0.0001), whereas Neck pain improved by a median score of 3 (P < 0.0001). A median improvement in Neck Disability Index score of 18 (P < 0.0001) was observed. Nurick grades improved in 68% of patients with myelopathy. Fusion was achieved in 96% of cases. The mean graft subsidence at 6 months was 1.7 mm (range: 0-6 mm). A change of local cervical angle toward lordosis of 5.8 degrees (P < 0.0001) was obtained as a result of surgery. However, there was a loss of 2.7 degrees of lordosis in the first 6 months following surgery (P = 0.001). The extent of subsidence correlated with the local loss of lordosis (P = 0.0003). There was no change in the regional cervical angle in the 6 months following surgery. There was no significant association between clinical outcome and changes in cervical angles. CONCLUSION: Dynamic anterior cervical plating after anterior decompression and grafting provides comparable fusion rates to that reported following the use of rigid cervical plating. Immediate changes in cervical alignment towards lordosis are partially lost on follow-up. The loss of lordosis is related to the amount of graft settling.

Recovery of ankle dorsiflexion weakness following lumbar decompressive surgery.

This retrospective study evaluated the recovery of ankle dorsiflexion (ADF) weakness following decompressive surgery in order to identify factors indicative of a better outcome. Fifty-six consecutive patients with ADF weakness secondary to nerve root compression underwent lumbar decompressive surgery. The demographic features, duration and severity of preoperative ADF weakness, associated radicular pain, as well as the radiological and intraoperative findings were recorded. ADF weakness at the time of initial follow-up at 6 weeks following surgery, and the latest follow-up at a median of 24 months was recorded. The patients had a mean age of 50.5 years with equal numbers of men and women. Acute disc prolapse was the compressive pathology in 88%. Clinical foot drop, defined as an ADF power of <3 by manual testing according to the Medical Research Council classification, was present in 66% of patients on presentation. Grade 3 power was present in 27% of patients and 7% had grade 4 power on presentation. The mean ADF power on presentation was 1.8. This improved to a mean of 3.2 at 6 weeks following surgery (p < 0.0001). A further small improvement in ADF power occurred after 6 weeks following surgery to a power of 3.5 at the latest follow-up (p < 0.0001). The degree of ADF weakness at latest follow-up correlates with the deficit at presentation (p <0.001). Younger patients made a better recovery (p = 0.03). No other significant associations between the demographic or clinical features and the recovery of the weakness could be identified. Thus, decompressive surgery was associated with an early improvement in ADF weakness. Only small improvements take place beyond 6 weeks following surgery. The degree of deficit at presentation is predictive of the extent of recovery. Recovery in ADF strength is more evident in younger patients.

Clinical and functional outcomes of anterior cervical discectomy without fusion.

Anterior cervical discectomy without fusion is an effective treatment for myeloradiculopathy arising from a medial disc prolapse. However, the long-term clinical results are not well known. Between 2000 and 2006, 38 patients with persistent radiculopathy and medial disc prolapse or myelopathy due to acute disc prolapse underwent subtotal anterior cervical discectomy without fusion. Patients were evaluated with respect to pain, myelopathy and functional outcome. Thirty-four patients were followed up for an average of 48.6 months. Following surgery, neck pain improved by 69% in 88% of patients, arm pain improved by 76% in 91% of patients and 76% of the patients were able to resume working in their previous occupation. We conclude anterior cervical decompression without fusion can be associated with good clinical results that are sustained in patients with predominant acute soft disc prolapse generating medial nerve root compression or cord compression.

Anterior correction of cervical kyphotic deformity: effects on myelopathy, neck pain, and sagittal alignment.

OBJECT: Cervical myelopathy may develop as a result of spinal cord compression with or without deformity. The effect of persistent kyphotic deformity on the ability of the cervical cord to recover following decompressive surgery is not known. METHODS: Between 1997 and 2000, a total of 28 patients with progressive myelopathy and kyphotic deformity underwent anterior decompression, deformity correction (0-4 degrees of lordosis), and fusion with anterior plating. Patients received clinical and radiological follow-up care, with independent analysis. Variables assessed included patient characteristics, severity of preoperative myelopathy, neck pain, and cervical sagittal alignment. Twenty-six patients (93%) underwent follow-up review for a minimum of 18 months. Two patients died: one died in the perioperative period and was excluded from further analysis, and in the other only 3 months of follow-up data could be obtained. Local deformity was corrected to neutral or lordosis in 24 cases (89%), and the overall cervical curve was corrected to neutral or lordosis in 20 cases (74%). There was a significant improvement in myelopathy scores in those patients in whom the target (0 to 4 degrees of lordosis) local angle was achieved (p = 0.04). There was a variable change in overall cervical sagittal alignment following local correction. Improvement in myelopathy was unrelated to patient age, previous surgery, or number of segments fused. Improvement in pain score was not related to correction of kyphotic angle. CONCLUSIONS: The correction of sagittal alignment may promote recovery in spinal cord function in patients with kyphotic deformity.

Bypass to the intracranial internal carotid artery.

Extracranial to intracranial internal carotid artery bypass surgery with vein is well described for a number of diverse conditions. They provide high blood flow with good initial patency. However, long term patencies for specific graft types remains unknown. This is an analysis of consecutive interposition saphenous vein bypass cases between the common carotid artery (CCA) and the intracranial internal carotid artery (ICA) where the distal anastomosis was placed end-to-end immediately proximal to the posterior communicating artery in 55 patients undergoing 57 bypass procedures (bilateral in 2 cases). Twenty-five patients underwent grafting for planned vessel obliteration where the pathology required vessel sacrifice. Twenty-eight patients had bypass grafting for stroke risk reduction in the setting of threatening stroke and 4 patients had bypass grafts for emergency revascularisation in the setting of stroke in evolution. Patients were assessed preoperatively and at follow-up with modified Rankin scores. Procedural related complications included a 7% mortality and 7% functional decline. Early graft occlusion occurred in 5% of grafts leading to death in each case. A further patient died of rupture at the distal anastomosis site. In surviving patients, patency was present in 100% at last follow-up (mean 5 years and maximum 11 years) with no patient sustaining new hemispheric ischemic events. One patient developed a delayed asymptomatic stenosis within the vein graft requiring stenting. Because of the high initial management risks this technique of common carotid to intracranial internal carotid artery saphenous vein bypass surgery should be reserved for patients at considerable risk by alternate management. However, once the acute postoperative period is past the bypass appears to be robust and capable of supplying the entire distribution of a normal internal carotid artery.

The neuro-cardio-endocrine response to acute subarachnoid haemorrhage.

OBJECTIVE: Whereas cardiac hormones increase after subarachnoid haemorrhage (SAH), and may contribute to sodium wastage and hyponatraemia, there is controversy concerning the relative roles of atrial natriuretic peptide (ANP) vs. brain natriuretic peptide (BNP) and the factors initiating their secretion. Noting previous work linking stress hormone responses with cardiac injury after SAH, we have studied responses in stress hormones, markers of cardiac injury and the temporal changes in ANP and BNP and related them to changes in sodium status post ictus and during recovery from acute SAH. DESIGN, PATIENTS, MEASUREMENTS: Eighteen patients with verified SAH of variable severity were studied in a single unit for a 14-day period post ictus under controlled conditions of sodium and fluid intake. All received a standardized protocol of daily dexamethasone and nimodipine throughout the study. Severity was graded using criteria of Hess and Hunt at admission. Stress hormones (AVP, catecholamines and admission plasma cortisol), markers of cardiac injury (ECG and daily plasma troponin T) and cardiac hormones (ANP and BNP) were measured daily and related to severity, plasma sodium and renin-aldosterone activity. Hormone levels (ANP, BNP and endothelin) in cerebrospinal fluid (CSF) were also measured in nine patients. RESULTS: Intense neurohormonal activation (AVP, cortisol and catecholamines) at admission was associated with increased levels of both plasma ANP and BNP whereas levels in CSF were unaffected. In individual patients plasma levels of ANP and BNP were strongly correlated (P < 0.001). Cardiac events (abnormal ECG and/or elevated troponin) occurred in six of seven patients graded severe but neither stress hormones nor cardiac peptides differed significantly in patients with mild (n = 11) vs. severe (n = 7) SAH. During the course of a progressive fall in plasma sodium concentration (P = 0.001), there was a delayed activation of renin-aldosterone which was inversely correlated with declining levels of plasma ANP/BNP (P < 0.002). CONCLUSIONS: Excessive secretion of both ANP and BNP occurs in all patients after acute subarachnoid haemorrhage and is unrelated to severity, stress hormone activation or markers of cardiac injury. Inhibition of renin-aldosterone by cardiac hormones may impair renal sodium conservation and contribute to developing hyponatraemia. In the absence of evidence for activation of natriuretic peptides within the brain, the prompt and consistent increase in both ANP and BNP strongly supports the view that the heart is the source of increased natriuretic peptide secretion after acute subarachnoid haemorrhage.

High-grade arteriovenous malformations and their management.

The aim of this study was to compare operatively and non-operatively managed high-grade arteriovenous malformations (AVMs) and to identify risk factors for surgical morbidity. Three hundred and ninety-one consecutively enrolled patients with AVMs were graded using the Spetzler Martin grading scheme. Forty-six of these patients had grade 4 or 5 AVMs. Twenty-nine patients underwent surgery and 17 were conservatively managed. During an average of 33 months follow-up the non-operative group experienced a decline in function in 27% of cases followed. These deteriorations were due to haemorrhage, progressive neurological deficits and seizures. In the surgical group completing treatment there was a mortality and morbidity impacting on self-care of 15%. In those without deep perforating arterial supply the morbidity was 10% and with deep perforating arterial supply or deep meningeal recruitment there was a combined morbidity and mortality of 44%. This difference in outcome was statistically significant (P<0.01). We conclude that high-grade AVMs have a high operative morbidity. However, these lesions often have a poor natural history and with careful selection (based on the presence or absence of deep perforating arterial supply) a group can be selected that benefits from surgery. Grade 4 and 5 AVMs with supply from lenticulostriate, choroidal, thalamic deep perforating arteries or deep meningeal recruitment may be best treated conservatively or possibly by multimodality treatment utilising radiotherapy and embolisation combined with surgery.