The failure of subcategorization of cauda equina syndrome.

The diagnostic sub-categorization of cauda equina syndrome (CES) is used to aid communication between doctors and other healthcare professionals. It is also used to determine the need for, and urgency of, MRI and surgery in these patients. A recent paper by Hoeritzauer et al (2023) in this journal examined the interobserver reliability of the widely accepted subcategories in 100 patients with cauda equina syndrome. They found that there is no useful interobserver agreement for the subcategories, even for experienced spinal surgeons. This observation is supported by the largest prospective study of the treatment of cauda equina syndrome in the UK by Woodfield et al (2023). If the accepted subcategories are unreliable, they cannot be used in the way that they are currently, and they should be revised or abandoned. This paper presents a reassessment of the diagnostic and prognostic subcategories of cauda equina syndrome in the light of this evidence, with a suggested cure based on a more inclusive synthesis of symptoms, signs, bladder ultrasound scan results, and pre-intervention urinary catheterization. This paper presents a reassessment of the diagnostic and prognostic subcategories of CES the light of this evidence, with a suggested cure based on a more inclusive synthesis of symptoms, signs, bladder ultrasound scan results, and pre-intervention urinary catheterization.

Sacral Tarlov cysts: Neurophysiology abnormalities and correlation with pelvic sensory and visceral symptoms.

BACKGROUND AND PURPOSE: Recent studies suggest a possible association between Tarlov cysts (TCs), usually considered as incidental radiological findings, and neurological symptoms such as pain, numbness and urogenital complaints. The aim was to explore the relationship between TCs and sacral nerve root functions using pelvic neurophysiology tests, and to correlate changes with clinical symptoms and magnetic resonance imaging (MRI) findings. METHODS: Consecutive patients with sacral TCs, referred for pelvic neurophysiology testing and presenting with at least one symptom related to the pelvic area, participated in a cross-sectional review of symptoms using validated questionnaires. Findings of pelvic neurophysiology (pudendal sensory evoked potentials, sacral dermatomal sensory evoked potentials, external anal sphincter electromyography) and urodynamics testing were collected retrospectively. The relationship between neurophysiology, MRI findings and patients' symptoms was assessed using Fisher and ANOVA tests. RESULTS: Sixty-five females were included (mean age 51.2 ± 12.1 years). The commonest symptom was pain (92%). Urinary (91%), bowel (71%) and sexual (80%) symptoms were also frequently reported. Thirty-seven patients (57%) had abnormal neurophysiology findings reflecting sacral root dysfunction. No association was seen between MRI findings (size, location of the cysts, severity of compression) and neurophysiology. A negative association was observed between neurophysiology abnormalities and occurrence of urgency urinary incontinence (p = 0.03), detrusor overactivity (p < 0.01) and stress urinary incontinence (p = 0.04); however, there was no association with voiding difficulties. CONCLUSIONS: Contrary to current understanding, TCs are associated with injury to the sacral somatic innervation in the majority of patients with presumed symptomatic cysts. However, urinary incontinence is unlikely to be related to TC-induced nerve damage.

Iatrogenic dorsal spinal cord herniation and repair with clip-based expansile duraplasty: a case report.

INTRODUCTION: Myelopathy arising due to dorsal herniation of the spinal cord is a rare phenomenon, particularly so in the thoracic region. Where cases of thoracic dorsal cord herniation have been reported, the aetiology has typically been non-iatrogenic. CASE PRESENTATION: We report the case of a paediatric oncology patient who presented with neurological deterioration secondary to thoracic dorsal spinal cord herniation, manifesting three months after laminectomy for biopsy of a spinal medulloblastoma lesion. We repaired the dural defect using non-penetrating titanium clips to create a secure expansile duraplasty, resulting in radiologically evident reduction of the cord herniation as well as corresponding clinical improvement. DISCUSSION: Thoracic dorsal spinal cord herniation is an extremely rare occurrence after spinal surgery. Non-penetrating titanium clips can be used to form a secure expansile duraplasty following reduction of the cord herniation. Successful repair of the dural defect re-anteriorises the cord and can confer neurological benefit.

Midline sacral meningeal cyst decompression and repair.

BACKGROUND: Symptomatic midline sacral meningeal cysts (MSMC) are rare, and, as a consequence, so are reports on the surgical techniques to address these lesions. Here we provide a description of the senior author's (ATC) technique. METHOD: A sacral laminectomy is performed. The cyst's relation with the dural sac and sacral nerves is inspected; it is then opened and drained. Its lumen is explored for its point of communication with the dural sac, and this ostium is closed off with non-penetrating clips. A lumbar drain is inserted in select cases. CONCLUSION: Cyst wall resection is unnecessary and closing the ostium is sufficient to treat MSMC.

Surgical Management of Giant Thoracic Paraspinal Schwannomas.

BACKGROUND: Giant paraspinal thoracic schwannomas (GPTSs) are benign, slow-growing, encapsulated lesions. They can be intracanalicular, span more than 2 vertebral bodies, and/or have a foraminal component with extraspinal extension >2.5 cm. They pose surgical challenges because of the often unfamiliar complex regional anatomy. We report the largest series of GPTSs and discuss regional surgical strategies for tumors in the thoracic spine. METHODS: We conducted a retrospective review of GPTSs operated at a national spinal referral center between December 2008 and October 2019. Inclusion criteria included World Health Organization grade 1 GPTS. Patient demographics, clinical features, radiology, and histopathology were assessed. RESULTS: Seventeen patients (12 females, 5 males) had a mean age of 48.1 years (range 21-65 years). Five GPTS (29%) were located at T1-T3, 6 (35%) at T4-6, and 6 (35%) below T6. The mean maximum diameter was 58.5 ± 19.1 mm (range 30-91 mm). Mean volume was 90.9 cm3 (range 19.1-350.6 cm3). Twelve (70%) had a fluorodeoxyglucose positron emission tomography scan showing low (25%) or moderate to high (75%) uptake. Six patients (35%) had preoperative computed tomography-guided biopsy. Surgical approaches included 1) manubriotomy and variations (4/17); 2) high lateral thoracotomy (4/17); 3) posterior parascapular (1/17); 4) standard lateral thoracotomy (3/16); 5) posterior/posterolateral (2/17); and 6) combined posterior and thoracotomy (3/17). All patients had gross total resection and were grade 1 cellular schwannomas. No recurrence at final follow-up (mean 36.1 months, range 8-130 months). CONCLUSIONS: A number of approaches are available to resect GPST in specific locations in the thoracic spine. Total resection is achievable despite complex regional anatomy, location, and tumor extension but often requires anterior or combined approaches.

Delayed periprosthetic collection after cervical disc arthroplasty.

Cervical disc arthroplasty is a treatment option for symptomatic cervical disc disease. There is a paucity of literature on long-term safety outcomes, durability, and device-related failure rates. The M6-C artificial cervical disc is a device with titanium alloy endplates and a complex polymeric centerpiece. To date, trials have exhibited acceptable safety profiles.This case series describes the presentation, management, and pathological findings of a delayed prevertebral periprosthetic mass anterior to the M6-C disc. Four patients at 3 different institutions underwent cervical disc replacement with the M6-C disc. Two to seven years postoperatively, they presented with dysphagia secondary to a compressive mass anterior to the disc. Case notes were reviewed to collect data on symptoms, management, and outcomes. The patients were systemically well and presented with progressive dysphagia. They had imaging findings of a mass anterior to the disc. They underwent a decompressive procedure, with 2 patients undergoing device removal and fusion. In 2 cases, a soft-tissue mass was seen intraoperatively, with frank pus. In 3 cases, Propionibacterium acnes was identified and antibiotic treatment given. Histopathology demonstrated mixed inflammatory infiltrates with foreign body-type granulomas. Postoperatively, the dysphagia resolved.The development of delayed dysphagia in a patient with an M6-C disc should prompt investigation to identify a mass lesion. To the authors' knowledge, this is the first report of delayed infection, or suspected delayed-type hypersensitivity reaction, following M6-C disc implantation. It is important for this to be added to the device safety concerns. Further prospective studies are needed to establish the incidence and the long-term safety and failure rates of the M6-C disc.

The role of bone SPECT/CT in patients with persistent or recurrent lumbar pain following lumbar spine stabilization surgery.

PURPOSE: Despite recent advances in lumbar spine stabilization surgery (LSSS), a high number of patients continue to complain of persistent/recurrent lumbar pain after LSSS. Conventional imaging (plain radiography, CT and MRI) is commonly performed to assess potential lumbar pain generators, but findings are equivocal in approximately 20% of patients. The purpose of this study was to assess the diagnostic performance of 99mTc-HDP bone SPECT/CT in identifying potential pain generators in patients with persistent/recurrent lumbar pain after LSSS but in whom conventional diagnostic imaging is inconclusive. METHODS: A total of 187 patients (median age 56 years, 70 men) with persistent/recurrent lumbar pain following LSSS with inconclusive conventional imaging (plain radiography, CT and/or MRI) underwent 99mTc-HDP bone SPECT/CT and were included in the study. Tracer uptake on SPECT/CT, as an indicator of ongoing or altered osteoblastic activity, was assessed in the lumbar spine stabilization segment(s) and in adjacent segments. Uptake intensity was graded as (1) high (the same as or more than iliac crest uptake), (2) mild (the same as or more than nondiseased vertebral uptake but less than iliac crest uptake), or (3) negative (normal scan). Mild and high uptake were regarded as positive. RESULTS: In 160 of the 187 patients (85.6%), SPECT/CT showed positive mild or high tracer uptake in the LSSS region. More than half of the patients had abnormal tracer uptake in the stabilized segments (56.7%) and/or in the adjacent segments (55.6%). Although positive stabilized segment findings were commonly seen at <2 years (70.3%) and the rate decreased with time after LSSS, they were seen at >6 years after surgery in 38.2% of patients. In 51.4% of patients, abnormal activity was seen in the adjacent segments <2 years after LSSS, suggesting early/accelerated degeneration after surgery. The proportion of patients with abnormal activity in the adjacent segments increased to 67.3% at >6 years after LSSS (p < 0.05). Positive SPECT/CT findings in the stabilized segments were more frequent in patients with three or more stabilized segments (p < 0.05), but were not more frequent in the adjacent segments. Overall, positive SPECT/CT guided therapy in 64% of patients, which included facet joint/nerve root injections or re-do surgery at active sites and/or adjacent sites. CONCLUSION: Bone SPECT/CT is a sensitive diagnostic tool for identifying altered osteoblastic activity, which might be a pain generator in patients with persistent/recurrent pain after lumbar surgery especially when conventional imaging is inconclusive.

Outcome of adult patients with X-linked hypophosphatemia caused by PHEX gene mutations.

X-linked hypophosphatemia (XLH) is the most common monogenic disorder causing hypophosphatemia. This case-note review documents the clinical features and the complications of treatment in 59 adults (19 male, 40 female) with XLH. XLH is associated with a large number of private mutations; 37 different mutations in the PHEX gene were identified in this cohort, 14 of which have not been previously reported. Orthopaedic involvement requiring surgical intervention (osteotomy) was frequent. Joint replacement and decompressive laminectomy were observed in those older than 40 years. Dental disease (63%), nephrocalcinosis (42%), and hearing impairment (14%) were also common. The rarity of the disease and the large number of variants make it difficult to discern specific genotype-phenotype relationships. A new treatment, an anti-FGF23 antibody, that may affect the natural history of the disease is currently being investigated in clinical trials.

Paravertebral tumours of the cervicothoracic junction extending into the mediastinum: surgical strategies in a no man's land.

PURPOSE: Cervicothoracic paravertebral neoplasms extending into the mediastinum pose a surgical challenge due the complex regional anatomy, their biological nature, rarity and surgeon's unfamiliarity with the region. We aim to define a surgical access framework addressing the aforementioned complexities whilst achieving oncological clearance. METHODS: We carried out a retrospective review of 28 consecutive patients operated in two tertiary referral centres between 1998 and 2015. Pathology was located paravertebrally from C6 to T4 with superior mediastinum invasion. Patients were operated jointly by a spinal and a thoracic surgeon. RESULTS: Tumours were classified according to subclavian fossa involvement as anteromedial, anterolateral and posterior and according to histology in benign nerve sheath tumour group (n = 10) and malignant bone or soft tissue tumours (n = 18). Three surgical routes were utilised: (1) median sternotomy (n = 11), (2) anterior cervical transsternal approach (n = 7) and (3) high posterolateral thoracotomy (n = 10). Resection was en bloc with wide margins in 22 cases, marginally complete in 3 and incomplete in 3. Complications included Horner's syndrome (n = 3), infection (n = 2) and transient neurological deficit (n = 4). In the nerve sheath tumour group, no recurrence or reoperation took place with a median follow-up of 4.5 years. In the malignant bone and soft tissue group, 96% of the patients were alive at 1 year, 67% at 2 years and 33% at 5 years. No vascular injuries or operative related deaths were observed. CONCLUSIONS: Classification of cervicothoracic paravertebral neoplasms with mediastinal extension according to the relationship with the subclavicular fossa and dual speciality involvement allows for a structured surgical approach and provides minimal morbidity/maximum resection and satisfactory oncological outcomes. These slides can be retrieved under Electronic Supplementary Material.

Hybrid Bone SPECT/CT Imaging in Evaluation of Chronic Low Back Pain: Correlation with Facet Joint Arthropathy.

BACKGROUND: Evidence to support the use of bone hydroxydiphosphonate (HDP) single photon emission computed tomography (SPECT/CT) in patients with facetogenic low back pain (LBP) is still limited. In this study we compared the scintigraphic patterns on bone SPECT/CT with the degree of structural facet joint (FJ) degeneration on CT in patients with LBP. METHODS: Ninety-nine consecutive patients with LBP were prospectively evaluated. Patients with known or suspected malignancy, trauma, infectious processes, chronic inflammatory diseases, and previous surgery were excluded. The effect of LBP on the daily quality of life was assessed with the Oswestry disability index (ODI). The Pathria grading system was used to score FJ degeneration on CT scans. The correlation between the degree of FJ degeneration and osteoblastic activity on SPECT/CT was analyzed with Kappa statistics. RESULTS: Ninety-nine patients were included (59 female, mean age 56.2 years). The mean ODI score was 38.5% (range, 8% to 72%). In all, 792 FJ (L2-3 to L5-S1) were examined. Of the FJs, 49.6% were Pathria grade 0-1 (normal to mild degeneration) on CT, 35% were grade 2 (moderate degeneration), and 16% were grade 3 (severe degeneration). Sixty-seven percent of the patients had scintigraphically active FJs on SPECT/CT. Sixty-nine percent of Pathria grade 3 FJs were scintigraphically active; 5.5% and 16.8% of Pathria grade 0-1 and Pathria grade 2, respectively, were active. Of the metabolically active FJs, 71.4% were at the L4-5/L5-S1 levels. CONCLUSIONS: The ability of SPECT/CT to precisely localize scintigraphically active FJs may provide significant improvement in the diagnosis and treatment of patients with LBP. In this study we demonstrate that in >40% of FJs, the scintigraphic patterns on SPECT/CT did not correlate with the degree of degeneration on CT.

Hybrid Bone Single Photon Emission Computed Tomography Imaging in Evaluation of Chronic Low Back Pain: Correlation with Modic Changes and Degenerative Disc Disease.

BACKGROUND AND OBJECTIVE: Multiple radiologic modalities are used in the evaluation of patients with low back pain (LBP). Only limited evidence currently exists to support the use of bone hydroxydiphosphonate single photon emission computed tomography (SPECT/CT) in patients with Modic changes (MCs) and degenerative disc disease. The aim of this study was to assess the value of the hybrid bone SPECT/CT imaging in patients with chronic LBP. We evaluate the correlation of hybrid bone SPECT/CT imaging patterns with MCs and disc abnormalities on magnetic resonance imaging (MRI). METHODS: This was a prospective study. Ninety-nine consecutive patients with LBP from a single center. The degree of lumbar intervertebral disc and endplate degeneration on MRI and osteoblastic activity was shown on SPECT/CT. These 99 consecutive patients with LBP were prospectively evaluated. Patients with contemporary lumbosacral spine MRI and bone SPECT/CT were included. Patients with known or suspected malignancy, trauma, infectious processes, and previous surgery were excluded. The effect of LBP on the daily quality of life was assessed using Oswestry disability index. We analyzed the correlation between the degenerative changes at the intervertebral disc spaces and endplates on MRI and bone SPECT/CT findings using receiver operating characteristic curve analysis and Kappa statistics. The Pfirrmann grading system was used to score the severity of disc space degeneration on MRI scans. RESULTS: A total of 99 patients were included in the study (58 women, 41 men; mean age, 56.2 years). Mean Oswestry disability index score was 38.5% (range, 8%-72%). The L2-3 through to L5-S1 levels were studied. MCs were found in 54% of patients. Of the 396 levels examined 85 were found to have MCs (21.5%). The most affected levels were L4-5 (31.3%) and L5-S1 (40.9%). Pfirrmann grade 5 disc space (72.9%) was associated with MC (Pp<0.001). MC (70.6%) and Pfirrmann grade 5 disc spaces (73%) resulted in scintigraphically active endplate/disc space on SPECT/CT (P< 0.001). Bone SPECT/CT showed high metabolic activity in 96.1% of endplates with MC type I, 56% with MC type II, and 77.8% with MC type III. CONCLUSIONS: In this study we found a high agreement between MCs and increased metabolic activity on bone SPECT/CT imaging. MC type 1 and Pfirrmann grade 5 were the best binary predictors for positivity on bone SPECT/CT and had equivalent correlations. Lower vertebral levels in the lumbar spine were associated with higher degree of disc degeneration, high frequency of MCs, and positivity on bone SPECT/CT.

Intramuscular Local Anesthetic Infiltration at Closure for Postoperative Analgesia in Lumbar Spine Surgery: A Systematic Review and Meta-Analysis.

STUDY DESIGN: Systematic Review and Meta-Analysis OBJECTIVE.: To identify whether intramuscular local anesthetic infiltration prior to wound closure was effective in reducing postoperative pain and facilitating early discharge following lumbar spine surgery. SUMMARY OF BACKGROUND DATA: Local anesthetic infiltration prior to wound closure may form part of the multimodal strategy for postoperative analgesia, facilitating early mobilization and discharge. Although there are a number of small studies investigating its utility, a quantitative meta-analysis of the data has never been performed. METHODS: This review was conducted according the PRISMA statement and was registered with the PROSPERO database. Only randomized controlled trials were eligible for inclusion. Key outcomes of interest included time to first analgesic demand, total postoperative opiate usage in the first 24 hours, visual analogue score (VAS) at 1, 12 and 24 hours and postoperative length of stay. RESULTS: Eleven publications fulfilled the inclusion criteria. A total of 438 patients were include; 212 in the control group and 226 in the intervention group. Local anesthetic infiltration resulted in a prolonged time to first analgesic demand (mean difference (MD) 65.88 minutes, 95% confidence interval (95% CI) 23.70 to 108.06, P.0.002) as well as a significantly reduced postoperative opiate demand (M.D. -9.71 mg, 95% CI -15.07, -4.34, p = 0.0004). There was a small but statistically significant reduction in postoperative visual analogue score (VAS) at 1 hour (M.D. -0.87 95%CI -1.55, -0.20, p = 0.01), but no significant reduction at 12 or 24 hours (p = 0.93 and 0.85 respectively). CONCLUSION: This systematic review and meta-analysis provides evidence that postoperative intramuscular local anaesthetic infiltration reduces postoperative analgesic requirements and the time to first analgesic demands for patients undergoing lumbar spine surgery. Key research priorities include optimization of the choice and strength of local anaesthetic agent and health-economic analyses to strengthen the case for routine use of postoperative local anesthetics in lumbar spine surgery. LEVEL OF EVIDENCE: 1.

Joint arthropathy at the cranio-vertebral junction. Scintigraphic patterns on bone SPECT/CT.

Osteoarthritic degeneration at the cranio-vertebral junction (CVJ) is an underrecognized source of suboccipital and neck pain, limited range of motion and cervicogenic headaches. Correlation of radiographic findings with clinical symptoms is often difficult. Limited evidence currently exists to support the use of bone single-photon emission computed tomography/computed tomography (SPECT/CT) in this subgroup of patients. The aim of this study was to describe the scintigraphic patterns of joint arthropathy at the CVJ on bone SPECT/CT in patients with suboccipital/neck pain and cervicogenic headache. Patients with more than 3 months of suboccipital/neck pain/cervicogenic headache and abnormal SPECT/CT findings at the CVJ were included. Patients with known/suspected malignancy, trauma, infectious processes and previous surgery at the CVJ were excluded. Neck disability index (NDI), visual analogue scale (VAS) and treatment were recorded for each patient. Patterns of osteoblastic activity at the CVJ on bone SPECT/CT were described and correlated with arthritic changes on conventional scans. Eighteen patients were included (10 females, mean age 68). Mean NDI score was 22. Mean VAS was 7.5. On bone SPECT/CT, it was found that 13 patients had high osteoblastic activity unilaterally at the atlanto-axial joint (AAJ); two patients at the atlanto-dental joint (ADJ), one at the occipito-atlantal joint (OAJ), one at both OAJ and ADJ and one at the level of C2 pars/pedicle unilaterally. Metabolic activity on SPECT/CT was associated with severe degenerative changes on CT scans. The ability of hybrid bone SPECT/CT to precisely localize osteoblastic activity at the CVJ may provide significant improvement in the diagnosis and treatment of patients with suboccipital/neck pain and joint arthropathy at the CVJ. Further clinical studies are needed to establish the real clinical impact of bone SPECT/CT in the treatment of patients with suboccipital neck pain.

Spinal Cervical Meningiomas: The Challenge Posed by Ventral Location.

OBJECTIVE: To evaluate the incidence, clinical presentation, operative techniques, and long-term outcome of spinal cervical meningiomas after surgery. METHODS: Twenty-two patients harboring spinal meningiomas on cervical region were treated between 2004 and 2014 in our department. Diagnosis was made via magnetic resonance imaging and confirmed histologically. Microsurgical resection was performed through different surgical approaches according to location of the tumor. To remove the tumor, the posterior, far-lateral, and combined approaches were used, respectively, in 13 patients (56%), 8 patients (35%), and 2 patients (9%). RESULTS: The mean follow-up was 40 ± 26.5 months. The most common site of dural attachment of meningioma was ventral or ventrolateral to the spinal cord. Macroscopic resection was considered complete in 55% of cases. Neurologic improvement was observed in 60% of cases. The rate of operative mortality and morbidity was high (26.5%). Five patients underwent postoperative radiotherapy according to the actual recommendation, and the overall recurrence rate was 9%. CONCLUSIONS: Spinal meningiomas are benign tumors for which advances in imaging tools and microsurgical techniques have yielded better results. The goal of surgery should be the total resection, which significantly decreases the risk of recurrence with an acceptable morbidity. Cervical locations represent a challenge particularly for ventro and ventrolaterally located tumors. Despite the difficulty of performing a complete resection, the results obtained in this work advocate for the use of the far-lateral approach to manage meningiomas locate anterior to the neural axis.

British Association of Spine Surgeons standards of care for cauda equina syndrome.

This group of articles looks at the BASS guidelines for CES. TG and AC gave us the background on the long journey taken in publishing this, SA summarized the forum discussion on the BASS Web site, and NT gave us a medicolegal comment. The guidelines are concise, highlighting the need for prompt MRI scanning and as a consequence emergency surgery in appropriate cases. This has resource implication in terms of MRI availability and a comprehensive spinal on-call system. The question of whether operating "in the small hours" carries increased risk or whether we are using this as an excuse not to get out of bed needs to be addressed. CES discs tend to be more difficult than standard ones and probably associated with a higher complication rate. Literature on complications from night-time trauma surgery has considerably reduced out-of-hour operating in trauma. Guidelines on CES will allow the spinal community to prospectively collect data on a national registry which in time will allow us to further improve our understanding and treatment of this condition. Spinal surgery is quickly evolving into a separate specialty. These guidelines further highlight the need for a single spinal society to help set standards, educate, and revalidate our members. It is important that we all engage in this debate to get a consensus opinion to improve spinal practice across the United Kingdom.

A summary of assessment tools for patients suffering from cervical spondylotic myelopathy: a systematic review on validity, reliability and responsiveness.

PURPOSE: One of the objectives of this review is to summarize the important features of a good scale. A second aim is to conduct a systematic review to identify scales that can detect the presence of cervical myelopathy and to determine their psychometric properties including validity, reliability and responsiveness. METHODS: A thorough literature search was performed using MEDLINE, MEDLINE in process, EMBASE, and Cochrane Central Register of Controlled Trials. Articles were included in this study if they compared scale measurements between a control and a myelopathic patient population or if they discussed any psychometric property of a scale. RESULTS: An ideal scale should be one that is quantifiable, valid, sensitive, responsive and easy to perform, has high inter/intra-rater reliability, internal consistency and a suitable distribution, and is one-dimensional and relevant. In the context of cervical spondylotic myelopathy, it is essential that the scale also addresses the pathophysiology, its key signs and symptoms as well as its natural history. For the systematic review, the search yielded 5,745 citations. Of these, 37 met inclusion criteria, 10 explored the ability of a scale to detect myelopathy, 23 examined validity by assessing correlation between scales, 10 reported reliability, 8 analyzed responsiveness, and 6 discussed internal consistency. The most frequently reported scale was short form-36 (n = 16) followed by Nurick grade (n = 14), Japanese Orthopaedic Association (n = 13), (modified) Japanese Orthopaedic Association (n = 7) and grip and release test (n = 6). Four studies each presented results on the Cooper, Harsh and 30-m walking test. CONCLUSION: This review summarizes outcome measures used to assess the presence and severity of cervical myelopathy. It includes several validation studies as well as those that have reported the responsiveness and reliability of various measures.

Spinal cord herniation as a complication of en bloc, multilevel, anterior thoracic vertebrectomy for a giant cell tumor: success of posterior cord reduction and dural repair.

Iatrogenic spinal cord herniation is a rare complication following spinal stabilization surgery. The authors present a case of circumferential thoracic tumor decompression and fixation by anterior instrumentation complicated by delayed anterior spinal cord herniation. This complication resulted in progressive paraparesis 5 years after the original procedure. The patient underwent reexploration and repair of the dural defect, resulting in the reduction of the spinal cord to its normal position. The patient's paraparesis improved significantly after dural repair. Although progression of neurological deficit can be very slow, repair of the dural defect can restore normal spinal cord alignment and improve neurological deficit. To the best of the authors' knowledge, this is the first reported case of spinal cord herniation following an anterior thoracic vertebrectomy.