Case study: breakthrough mpox infection in Aotearoa New Zealand and Australia after completed two-dose course of subcutaneous modified vaccinia Ankara (MVA-BN) vaccines.

BACKGROUND: In August 2022, in response to a global mpox outbreak, the World Health Organization recommended the Vaccinia vaccination for at-risk people. METHODS: Case study. RESULTS: We describe a case of a HIV-negative bisexual man who developed a symptomatic mpox infection 13weeks after completing a two-dose course of subcutaneous third-generation modified vaccinia Ankara vaccines. The case likely acquired his mpox infection in the USA; was diagnosed in Aotearoa, New Zealand; and was followed-up in Australia, as he was actively travelling during his infection. CONCLUSIONS: This case highlights the importance of maintaining clinical suspicion for mpox in people who present with consistent symptoms, even if they are fully vaccinated. Also, as he travelled around Aotearoa, New Zealand, and Australia during his infection, this case highlights how public health authorities and clinicians can cooperate across jurisdictional boundaries to support cases and minimise the risk of onward transmission.

Stand-alone anterior cervical decompression and fusion surgery: A cohort study evaluating a shaped cage without plates or screws.

Background: The anterior approach to the cervical spine is the most commonly used surgery with effective decompression and less surgical trauma. Anterior plate construct (APC) is considered a standard technique. However, it appears to cause implant failure and postoperative dysphagia. Due to these reasons, locking stand-alone cages (LSCs) without the addition of an anterior plate have been developed and gained popularity in the past decade. In theory, an LSC could provide immediate load-bearing support to the anterior column of the cervical spine and may enhance the rate of arthrodesis. However, screw skiving and backing off are known complications of LSC. Given the characteristic shape of cervical discs, we wondered whether there may be a role for a shape-conforming cage without screws and plates to achieve desired outcomes, i.e., a true stand-alone cage (TSC). A single surgeon cohort using the cage in a heterogenic set of indications was evaluated. Methods: A total of 45 patients with degenerative cervical conditions who underwent surgery using TSC using CoRoent Small Contoured peek cage (Nuvasive, San Diego, CA) and Orthoblend™ (Medtronics, Memphis, TN) were retrospectively reviewed. Comparisons between preoperative and postoperative Numeric Rating Scale (NRS), the modified AAOS-Modems disability outcome, Neck Disability Index (NDI) scores, and Short Form 36 were evaluated. Operative time, the occurrence rate of fusion, lordosis change of cervical spine, and occurrence rate of complications were evaluated. Results: There were one-level (n = 15), two-level (n = 24), and three-level (n = 6) cases making a total of 81 cages implanted and studied. The mean operative time was 132.7 min. The group demonstrated significant improvements in NRS, AAOS-Modems disability outcome, and NDI scores after surgery (mean follow-up 12 months). The cervical lordosis at pre- and last follow-up period was 8.7 ± 2.2° and 8.3 ± 3.2°, respectively. The complication rate was 21.2%. Conclusions: TSC yielded satisfactory long-term clinical and radiological outcomes; this preliminary report can form the basis of a cost-benefit analysis study either prospectively or by way of meta-modeling comparing APC, LSC to TSC.

The association between pain scores and disc height change following discectomy surgery in lumbar disc herniation patients: a systematic review and meta-analysis.

PURPOSE: To evaluate the impact of discectomy on disc height (DH) in lumbar disc herniation (LDH) patients following discectomy surgery and address the association of DH change with pain score change. METHODS: We searched three online databases for randomized controlled trials (RCTs) and observational studies. In LDH patients, eligible for discectomy surgery, the changes in pre- and post-operative back and/or leg pain score and DH and/or disc height index (DHI) were considered as primary outcomes. Standardize mean difference (SMD) and their 95% confidence intervals (CI) were evaluated. The GRADE approach was used to summarize the strength of evidence. RESULTS: Two RCTs and sixteen observational studies were included in the analysis of 893 LDH patients undergoing discectomy surgery. The mean overall follow-up was 211 weeks. There was a statistically significant reduction in DH (14.4% reduction: SMD = -0.74 (95% CI = -0.86 to -0.61)) and DHI (11.5% reduction: SMD = -0.81 (95% CI = -0.97 to -0.65)) following discectomy surgery. There was a significant relationship between the reduction in DH and decrease in back pain score (r = 0.68, (95% CI = 0.07-1.30), p = 0.034) after discectomy surgery. No significant relationship between DHI change and decrease in clinical pain scores (back and leg pain) could be established. CONCLUSION: Discectomy surgery produces significant and quantifiable reductions in DH and DHI. Additionally, the reduction in DH is responsible for the decrease in back pain scores post discectomy, but further studies will improve understanding and aid preoperative counselling.

Degenerative Cervical Myelopathy: Insights into Its Pathobiology and Molecular Mechanisms.

Degenerative cervical myelopathy (DCM), earlier referred to as cervical spondylotic myelopathy (CSM), is the most common and serious neurological disorder in the elderly population caused by chronic progressive compression or irritation of the spinal cord in the neck. The clinical features of DCM include localised neck pain and functional impairment of motor function in the arms, fingers and hands. If left untreated, this can lead to significant and permanent nerve damage including paralysis and death. Despite recent advancements in understanding the DCM pathology, prognosis remains poor and little is known about the molecular mechanisms underlying its pathogenesis. Moreover, there is scant evidence for the best treatment suitable for DCM patients. Decompressive surgery remains the most effective long-term treatment for this pathology, although the decision of when to perform such a procedure remains challenging. Given the fact that the aged population in the world is continuously increasing, DCM is posing a formidable challenge that needs urgent attention. Here, in this comprehensive review, we discuss the current knowledge of DCM pathology, including epidemiology, diagnosis, natural history, pathophysiology, risk factors, molecular features and treatment options. In addition to describing different scoring and classification systems used by clinicians in diagnosing DCM, we also highlight how advanced imaging techniques are being used to study the disease process. Last but not the least, we discuss several molecular underpinnings of DCM aetiology, including the cells involved and the pathways and molecules that are hallmarks of this disease.

Complication rates of different discectomy techniques for symptomatic lumbar disc herniation: a systematic review and meta-analysis.

PURPOSE: This meta-analysis aims to compare the complication rates of discectomy/microdiscectomy (OD/MD), microendoscopic discectomy (MED), percutaneous endoscopic lumbar discectomy (PELD), percutaneous laser disc decompression (PLDD), and tubular discectomy for symptomatic lumbar disc herniation (LDH) using general classification and modified Clavien-Dindo classification (MCDC) schemes. METHODS: We searched three online databases for randomized controlled trials (RCTs) and cohort studies. Overall complication rates and complication rates per the above-mentioned classification schemes were considered as primary outcomes. Risk ratio (RR) and their 95% confidence intervals (CI) were evaluated. RESULTS: Seventeen RCTs and 20 cohort studies met the eligibility criteria. RCTs reporting OD/MD, MED, PELD, PLDD, and tubular discectomies had overall complication rates of 16.8% and 16.1%, 21.2%, 5.8%, 8.4%, and 25.8%, respectively. Compared with the OD/MD, there was moderate-quality evidence suggesting that PELD had a lower risk of overall complications (RR = 0.52, 95% CI 0.29-0.91) and high-quality evidence suggesting a lower risk of Type I complications per MCDC (RR = 0.37, 95% CI 0.16-0.81). Compared with the OD/MD data from cohort studies, there was low-quality evidence suggesting a higher risk of Type III complications per MCDC (RR = 10.83, 95% CI 1.29-91.18) for MED, higher risk of reherniations (RR = 1.67,95% CI 1.05-2.64) and reoperations (RR = 1.75, 95% CI 1.20-2.55) for PELD, lower risk of overall complication rates (RR = 0.42, 95% CI 0.25-0.70), post-operative complication rates (RR = 0.42, 95% CI 0.25-0.70), Type III complications per MCDC (RR = 0.39, 95% CI 0.22-0.69), reherniations (RR = 0.56, 95% CI 0.33-0.97) and reoperations (RR = 0.39, 95% CI 0.22-0.69) for PLDD. CONCLUSIONS: Compared with the OD/MD, results of this meta-analysis suggest that PELD has a lower risk of overall complications and a lower risk of complications necessitating conservative treatment. These slides can be retrieved under Electronic Supplementary Material.