Management of REM sleep behavior disorder: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment.

This systematic review provides supporting evidence for a clinical practice guideline for the management of rapid eye movement (REM) sleep behavior disorder in adults and children. The American Academy of Sleep Medicine commissioned a task force of 7 experts in sleep medicine. A systematic review was conducted to identify randomized controlled trials and observational studies that addressed interventions for the management of REM sleep behavior disorder in adults and children. Statistical analyses were performed to determine the clinical significance of critical and important outcomes. Finally, the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) process was used to assess the evidence for making recommendations. The literature search identified 4,690 studies; 148 studies provided data suitable for statistical analyses; evidence for 45 interventions is presented. The task force provided a detailed summary of the evidence assessing the certainty of evidence, the balance of benefits and harms, patient values and preferences, and resource use considerations. CITATION: Howell M, Avidan AY, Foldvary-Schaefer N, et al. Management of REM sleep behavior disorder: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment. J Clin Sleep Med. 2023;19(4):769-810.

Kinematic assessment of an elastic-core cervical disc prosthesis in one and two-level constructs.

INTRODUCTION: Anterior cervical discectomy and fusion has been associated with the development of adjacent segment degeneration (ASD), with clinical incidence of approximately 3% per year. Cervical total disc arthroplasty (TDA) has been proposed as an alternative to prevent ASD. HYPOTHESES: TDA in optimal placement using an elastic-core cervical disc (RHINE, K2M Inc., Leesburg, Virginia) will replicate natural kinematics and will improve with optimal vs anterior placement. METHODS: Seven C3-T1 cervical cadaver spines were tested intact first, then after one-level TDA at C5-C6 anterior placement, after TDA at C5-C6 optimal placement, after two-level TDA at C5-C6 and C6-C7 optimal placement, and finally after two-level TDA at C5-C6 lateral placement and C6-C7 optimal placement. The specimens were subjected to: Flexion-Extension moments (+1.5 Nm) with compressive preloads of 0 N and 150 N, lateral bending (LB) and axial rotation (AR) (+1.5 Nm) without preload. RESULTS: C5-C6 TDA in optimal placement resulted in a non-significant increase in flexion-extension ROM compared to intact under 0 N and 150 N preload (P > 0.05). Both LB and AR ROM decreased with arthroplasty (P < 0.01). Optimal placement of C6-C7 TDA resulted in an increase in flexion-extension ROM with preload compared to intact (P < 0.05) while LB and AR ROM decreased with arthroplasty (P < 0.01). CONCLUSION: This six degree of freedom elastic-core disc arthroplasty effectively restored flexion-extension motion to intact levels. In LB the TDA maintained 42% ROM at C5-C6 and 60% at C6-C7. In AR 57% of the ROM was maintained at C5-C6 and 70% at C6-C7. These findings are supported by literature which shows cervical TDA results in restoration of approximately 50% ROM in LB and AR, which is a multifactorial phenomenon encompassing TDA design parameters and anatomical constraints. Anterior placement of this viscoelastic TDA device shows motion restoration similar to optimal placement suggesting its design may be less sensitive to suboptimal placement.

Bilateral posterior cervical cages provide biomechanical stability: assessment of stand-alone and supplemental fixation for anterior cervical discectomy and fusion.

INTRODUCTION: Supplemental posterior instrumentation has been widely used to enhance stability and improve fusion rates in higher risk patients undergoing anterior cervical discectomy and fusion (ACDF). These typically involve posterior lateral mass or pedicle screw fixation with significant inherent risks and morbidities. More recently, cervical cages placed bilaterally between the facet joints (posterior cervical cages) have been used as a less disruptive alternative for posterior fixation. The purpose of this study was to compare the stability achieved by both posterior cages and ACDF at a single motion segment and determine the stability achieved with posterior cervical cages used as an adjunct to single- and multilevel ACDF. METHODS: Seven cadaveric cervical spine (C2-T1) specimens were tested in the following sequence: intact, C5-C6 bilateral posterior cages, C6-C7 plated ACDF with and without posterior cages, and C3-C5 plated ACDF with and without posterior cages. Range of motion in flexion-extension, lateral bending, and axial rotation was measured for each condition under moment loading up to ±1.5 Nm. RESULTS: All fusion constructs significantly reduced the range of motion compared to intact in flexion-extension, lateral bending, and axial rotation (P<0.05). Similar stability was achieved with bilateral posterior cages and plated ACDF at a single level. Posterior cages, when placed as an adjunct to ACDF, further reduced range of motion in both single- and multilevel constructs (P<0.05). CONCLUSION: The biomechanical effectiveness of bilateral posterior cages in limiting cervical segmental motion is comparable to single-level plated ACDF. Furthermore, supplementation of single- and multilevel ACDF with posterior cervical cages provided a significant increase in stability and therefore may be a potential, minimally disruptive option for supplemental fixation for improving ACDF fusion rates.