Recommendations for rheumatology ultrasound training and practice in the UK.

OBJECTIVE: The aim of this paper is to present a UK-based consensus of principles and recommendations to guide rheumatology US training and practice. METHOD: A Delphi process was conducted involving 19 US experts representing each of the 14 regions of the UK. A working group of experienced British Society for Rheumatology Ultrasound Special Interest Group (BSRUSSIG) members made seven proposals that were presented to the whole group for further discussion. This resulted in minor modifications and seven preliminary recommendations. Members were then asked to anonymously agree or disagree with each recommendation using an electronic ballot. A threshold of 75% was used to determine consensus agreement. Results were collated by an independent chairperson and presented to the BSRUSSIG in a face to face meeting where agreement for each recommendation was ratified and an action plan agreed for dissemination of the results and future development work. RESULTS: Using a validated process, experts in rheumatology US have worked through an iterative process and have unanimously agreed seven recommendations for rheumatology training and practice. These cover a hierarchy of practice indications, education and training, including the need for practitioners to demonstrate lifelong learning, as well as a commitment to support mentors and trainers through the BSRUSSIG. CONCLUSION: These are the first specific education and practice recommendations for rheumatology US in the UK and have been developed and endorsed by the BSRUSSIG. We intend that these proposals will help to support and validate rheumatology US practice and inform the development of future rheumatology training curricula and education programmes.

Laser acceleration of absorbing particles.

A Yb-doped fiber laser is used to accelerate and evaporate absorbing particles in air. Optical intensities of 1MW/cm2 and 2MW/cm2 illuminate stainless steel particles. These particles are accelerated to velocities of tens of meters per second before evaporating within a few tenths of a millisecond. Position measurements are made using direct imaging with a high-speed camera. A fundamental system of coupled differential equations to track particle momentum, velocity, mass, radius, temperature, vapor opacity, and temperature distribution is developed and shown to accurately model the trajectories and lifetimes of laser heated particles. Atoms evaporating from the particle impart momentum to the larger particle, which accelerates until it is slowed by drag forces. Heat transfer within the evaporating particles is dominated by radiation diffusion, a process that usually only dominates in astrophysical objects, for example in the photospheres of stars.

Continuous-wave laser damage of uniform and nanolaminate hafnia and titania optical coatings.

The laser-damage thresholds of single material and nanolaminate thin films were compared under continuous-wave (CW) illumination conditions. Nanolaminate films consist of uniform material interrupted by the periodic insertion of one or more atomic layers of an alternative material. Hafnia and titania were used as the base materials, and the films were deposited using atomic-layer deposition. The nanolaminates were less polycrystalline than the uniform films, as quantified using x-ray diffraction. It was found that the nanolaminate films had reduced laser-damage thresholds on smooth and patterned substrates as compared to uniform single-material films. This behavior is unusual as prior art indicates that amorphous (less polycrystalline) materials have higher laser-damage thresholds under short-pulse excitation. It is speculated that this may indicate that local thermal conduction affects breakdown more strongly under CW excitation than the dielectric properties that are important for short-pulse excitation.

Can flare be predicted in DMARD treated RA patients in remission, and is it important? A cohort study.

OBJECTIVES: The treatment target for patients with rheumatoid arthritis (RA) is remission. Imaging techniques and remission criteria may identify patients at risk of flare and associated consequences. This study aimed to determine the clinical, functional and imaging associations of disease flare in patients with RA in remission and any effect on long-term outcomes. METHODS: RA patients in clinical remission as determined by their treating rheumatologist were assessed using clinical, remission criteria, imaging, functional and quality of life measures over 12 months. Flare was defined as any increase in disease activity requiring a change in therapy. RESULTS: 26% of patients (24/93) in remission experienced a flare within 1 year. Fulfilment of remission criteria was not associated with a reduced likelihood of flare. Increased baseline ultrasound power Doppler (PD) activity (unadjusted OR (95% CI) 4.08 (1.26 to 13.19), p=0.014) and functional disability (Health Assessment Questionnaire Disability Index (HAQ-DI) per 0.1 unit1.27 (1.07 to 1.52), p=0.006) were independently associated with risk of flare. Patients who had a flare had significantly worse long-term clinical (Disease Activity Score 28; mean (95% CI) 2.90 (2.55 to 3.24) vs 2.26 (2.06 to 2.46), p=0.002) and functional outcomes (HAQ-DI; 0.412 (0.344 to 0.481) vs 0.322 (0.282 to 0.362), p=0.029) at 12 months compared with patients in sustained remission. CONCLUSION: The presence of PD activity was the most accurate determinant of flare in RA patients in remission. Flare was associated with worse clinical and functional outcomes. These results suggest ultrasound could form an important part of remission assessment in RA.

Should imaging be a component of rheumatoid arthritis remission criteria? A comparison between traditional and modified composite remission scores and imaging assessments.

OBJECTIVES: Patients can fulfil clinical criteria for remission, yet still have evidence of synovitis detectable clinically and by ultrasound, and this is associated with structural damage. Stricter remission criteria may more accurately reflect true remission (no synovitis). This hypothesis was examined by studying patients using more stringent thresholds for clinical remission and determining their levels of ultrasound synovitis. METHODS: Rheumatoid arthritis patients with a disease activity score in 28 joints (DAS28) ≤2.6 for at least 6 months were classified using standard and more stringent DAS28 and simplified disease activity index (SDAI) remission thresholds and the corresponding clinical and ultrasound imaging measures of synovitis recorded. RESULTS: 128 patients (all DAS28 <2.6, median DAS28 1.70) receiving either disease-modifying antirheumatic drugs alone (n=66) or with a tumour necrosis factor blocker (n=62) were recruited. Of the 640 imaged joints, 5% had moderate or severe power Doppler (PD) activity, 8% were clinically swollen and 1% tender. In patients fulfilling DAS28, American College of Rheumatology or SDAI remission criteria, moderate or severe PD activity was present in 21%, 15% and 19%, respectively. More stringent DAS28 and SDAI criteria reduced the mean number of swollen and tender joints (p<0.001) but not the percentage of patients with PD activity: 32 patients had a DAS28 <1.17 but eight (25%) had significant PD activity. CONCLUSION: Using more stringent remission criteria resulted in reduced signs and symptoms of inflammation, but the percentage of joints with PD activity was not reduced, even in those without signs or symptoms. These data suggest that clinical criteria are sufficiently insensitive to detect low but clinically relevant levels of inflammation accurately.

Contemporary treatment principles for early rheumatoid arthritis: a consensus statement.

OBJECTIVE: RA has a substantial impact on both patients and healthcare systems. Our objective is to advance the understanding of modern management principles in light of recent evidence concerning the condition's diagnosis and treatment. METHODS: A group of practicing UK rheumatologists formulated contemporary management principles and clinical practice recommendations concerning both diagnosis and treatment. Areas of clinical uncertainty were documented, leading to research recommendations. RESULTS: A fundamental concept governing treatment of RA is minimization of cumulative inflammation, referred to as the inflammation-time area under the curve (AUC). To achieve this, four core principles of management were identified: (i) detect and refer patients early, even if the diagnosis is uncertain: patients should be referred at the first suspicion of persistent inflammatory polyarthritis and rheumatology departments should provide rapid access to a diagnostic and prognostic service; (ii) treat RA immediately: optimizing outcomes with conventional DMARDs and biologics requires that effective treatment be started early-ideally within 3 months of symptom onset; (iii) tight control of inflammation in RA improves outcome: frequent assessments and an objective protocol should be used to make treatment changes that maintain low-disease activity/remission at an agreed target; (iv) consider the risk-benefit ratio and tailor treatment to each patient: differing patient, disease and drug characteristics require long-term monitoring of risks and benefits with adaptations of treatments to suit individual circumstances. CONCLUSION: These principles focus on effective control of the inflammatory process in RA, but optimal uptake may require changes in service provision to accommodate appropriate care pathways.

Photon diffusion in microscale solids.

This paper presents a theoretical and experimental investigation of photon diffusion in highly absorbing microscale graphite. A Nd:YAG continuous wave laser is used to heat the graphite samples with thicknesses of 40 µm and 100 µm. Optical intensities of 10 kW cm-2 and 20 kW cm-2 are used in the laser heating. The graphite samples are heated to temperatures of thousands of kelvins within milliseconds, which are recorded by a 2-color, high speed pyrometer. To compare the observed temperatures, differential equation of heat conduction is solved across the samples with proper initial and boundary conditions. In addition to lattice vibrations, photon diffusion is incorporated in the analytical model of thermal conductivity for solving the heat equation. The numerical simulations showed close matching between experiment and theory only when including the photon diffusion equations and existing material properties data found in the previously published works with no fitting constants. The results indicate that the commonly-overlooked mechanism of photon diffusion dominates the heat transfer of many microscale structures near their evaporation temperatures. In addition, the treatment explains the discrepancies between thermal conductivity measurements and theory that were previously described in the scientific literature.

Contemporary posterior occipital fixation.

Occipitocervical fixation is technically demanding but necessary in many clinical scenarios where junctional occiptocervical instability is present. The surgeon must have a thorough knowledge of the associated anatomy, biomechanics of spinal instrumentation, and familiarity with an ever-growing number of stabilization techniques and implants. The nature of the injury, the patient's anatomy, and the quality of the host bone will ultimately determine which form of fixation is optimal. Although the contemporary modular systems, at first glance, appear to add significant surgical complexity, in truth the designs actually simplify the process by allowing the surgeon to place occipital and spinal anchors in optimal anatomic locations.

MRI and musculoskeletal ultrasonography as diagnostic tools in early arthritis.

Rheumatoid arthritis (RA) is a chronic and progressive inflammatory disorder primarily affecting the synovium and is characterized by destruction of bone and cartilage. Early diagnosis and treatment of RA can improve disease outcomes substantially. Magnetic resonance imaging and musculoskeletal ultrasonography may facilitate early diagnosis and aid the targeting of intensive therapy. Magnetic resonance imaging and musculoskeletal ultrasonography also are able to monitor temporal changes in disease activity (ie, synovitis) and damage (ie, erosions). These imaging modalities are likely to be increasingly used in the management of early rheumatoid arthritis to ensure the best patient outcomes, although more work is required to determine their optimal roles.

Determining a magnetic resonance imaging inflammatory activity acceptable state without subsequent radiographic progression in rheumatoid arthritis: results from a followup MRI study of 254 patients in clinical remission or low disease activity.

OBJECTIVE: To assess the predictive value of magnetic resonance imaging (MRI)-detected subclinical inflammation for subsequent radiographic progression in a longitudinal study of patients with rheumatoid arthritis (RA) in clinical remission or low disease activity (LDA), and to determine cutoffs for an MRI inflammatory activity acceptable state in RA in which radiographic progression rarely occurs. METHODS: Patients with RA in clinical remission [28-joint Disease Activity Score-C-reactive protein (DAS28-CRP) < 2.6, n = 185] or LDA state (2.6 ≤ DAS28-CRP < 3.2, n = 69) with longitudinal MRI and radiographic data were included from 5 cohorts (4 international centers). MRI were assessed according to the Outcome Measures in Rheumatology (OMERACT) RA MRI scoring system (RAMRIS). Statistical analyses included an underlying conditional logistic regression model stratified per cohort, with radiographic progression as dependent variable. RESULTS: A total of 254 patients were included in the multivariate analyses. At baseline, synovitis was observed in 95% and osteitis in 49% of patients. Radiographic progression was observed in 60 patients (24%). RAMRIS synovitis was the only independent predictive factor in multivariate analysis. ROC analysis identified a cutoff value for baseline RAMRIS synovitis score of 5 (maximum possible score 21). Rheumatoid factor (RF) status yielded a significant interaction with synovitis (p value = 0.044). RF-positive patients with a RAMRIS synovitis score of > 5 vs ≤ 5, had an OR of 4.4 (95% CI 1.72-11.4) for radiographic progression. CONCLUSION: High MRI synovitis score predicts radiographic progression in patients in clinical remission/LDA. A cutoff point for determining an MRI inflammatory activity acceptable state based on the RAMRIS synovitis score was established. Incorporating MRI in future remission criteria should be considered.

How to interpret plain radiographs in clinical practice.

In this article I will consider the basic principles of requesting, acquiring, interpreting and reporting plain radiographs of joints, including assessment of the distribution of joint abnormalities, and specific pathological changes that may occur in bone, cartilage and soft tissues. I will then move on to a more specific discussion of the major arthropathies and the role of radiographs in the diagnosis and assessment in each condition as well as reviewing the combined abnormalities that may be visible on radiographs and how these relate to underlying pathological processes.

Relationship between early bone mineral density changes and long-term function and radiographic progression in rheumatoid arthritis.

OBJECTIVE: To ascertain whether bone mineral density loss during the first year of treatment for early rheumatoid arthritis (RA) as assessed by dual x-ray absorptiometry (DXA) is associated with long-term function, quality of life, and radiographic progression. METHODS: Early RA patients, prior to commencing disease-modifying antirheumatic drug therapy, underwent evaluation with DXA scans of both hands, femoral neck, and lumbar spine at the time of diagnosis, then at 1 year and final followup at >6 years. Clinical and laboratory data and hands and feet radiographs were obtained at baseline and final followup. RESULTS: Sixty-four patients were assessed. At baseline, median disease duration was 6 months, mean 28-joint Disease Activity Score was 5.85, and median Health Assessment Questionnaire score was 1.38. Median followup was 6.4 years (range 5.1-7.2 years). For erosion scores, 86% of patients with hand bone density loss above the smallest detectable change after 1 year progressed versus 55% of those with no hand bone density loss (P = 0.006). However, baseline radiographs showed a similar strength of association. Eighty-four percent of patients with erosions at baseline had erosion progression versus 57% of those with no baseline erosions (P = 0.021). Additionally, first-year bone density loss was not associated with function and quality of life status at followup. CONCLUSION: Hand bone loss during the first year of treatment in early RA, as assessed with DXA, was associated with a high likelihood of radiographic progression; however, in the current study this was not superior to baseline radiographs. Furthermore, it was not associated with patient-reported outcomes.

History of Medicine student selected components at UK medical schools: a questionnaire-based study.

OBJECTIVES: To determine the current status of History of Medicine student selected components (SSC) at UK medical schools. This includes the frequency, methods of delivery, assessment, and evaluation of such courses. DESIGN: An 18-item questionnaire was created, piloted, and then sent electronically in January 2010 to participants pertaining to their History of Medicine SSC provision as of 1 January 2010. Initial non-responders were re-sent the questionnaire in February 2010. SETTING: All UK medical schools. PARTICIPANTS: The History of Medicine SSC lead or overall SSC lead at each UK medical school were contacted to ascertain their History of Medicine SSC provision. MAIN OUTCOME MEASURES: Percentages of History of Medicine SSCs for each objective characteristic were obtained as well as general descriptive data. RESULTS: Fifteen of the 32 medical schools in the UK offer a History of Medicine SSC. Eleven medical schools (offering a total of 12 SSCs) completed the questionnaire (response rate 73.3%). Eight different teaching methods are used within the SSCs. Medical professionals most frequently deliver the teaching, which most frequently covers the 20th and 21st centuries. Four assessment methods are used among the SSCs, the most common being a group presentation. Questionnaires are the most frequent method of evaluation. There are several factors limiting the provision of some current SSCs, most commonly a lack of staff, teaching facilities, and available time within the curriculum. CONCLUSION: History of Medicine is being delivered more frequently in UK medical schools than when previously researched 40 years ago. However, the subject is still offered in a minority of the medical schools. This study offers useful information to consider for the development of current and potential new History of Medicine SSCs.

Utility and feasibility of musculoskeletal ultrasonography (MSK US) in rheumatology practice in Canada: needs assessment.

The utility of musculoskeletal ultrasound (MSK US) is being extensively explored and evaluated amongst European rheumatologists. However, utilization of MSK US by rheumatologists in Canada is much less common. This study aimed to evaluate the current use of MSK US in Canadian rheumatology practice, to determine beliefs and attitudes towards MSK US, and to determine factors that may encourage or limit its use. A 13-question needs assessment questionnaire was developed. All Canadian rheumatologists were invited via e-mail to participate in the survey. The overall response rate was 156/470 (33%). Fifty-one percent of participants used MSK US in their clinical practice. Lack of training appeared to be the main obstacle to its current use. Eighty-three percent believed that MSK US should be performed by rheumatologists and expressed a willingness to learn the technique. Skills offering greatest clinical utility were the assessment of inflammatory arthritis in small joints (i.e., hands (metacarpophalyngeal and proximal interphalangeal joints), wrists, feet (metatarsophalyngeal), shoulders, and ankles. Limited available time, equipment costs, and difficulties with billing were the main obstacles to MSK US utilization in the clinical setting. There is a great level of interest in learning and applying MSK US in Canadian rheumatology practice. The balance between added clinical value and lack of remuneration, equipment associated costs, and time to complete training is the major limiting factor influencing rheumatologists' willingness to take on MSK US. Training programs must be relevant to rheumatologists' needs before MSK US will be adopted into routine clinical practice in Canada.

Synovitis and osteitis are very frequent in rheumatoid arthritis clinical remission: results from an MRI study of 294 patients in clinical remission or low disease activity state.

OBJECTIVE: In rheumatoid arthritis (RA), radiographic progression may occur despite clinical remission. This may be explained by subclinical inflammation. Magnetic resonance imaging (MRI) provides a greater sensitivity than clinical examination and radiography for assessing disease activity. Our objective was to determine the MRI characteristics of RA patients in clinical remission or low disease activity (LDA) state. METHODS: Databases from 6 cohorts were collected from 5 international centers. RA patients in clinical remission according to Disease Activity Score28-C-reactive protein (DAS28-CRP < 2.6; n = 213) or LDA-state (2.6 ≤ DAS28-CRP < 3.2; n = 81) with available MRI data were included. MRI were assessed according to the OMERACT RA MRI scoring system (RAMRIS). PATIENT CHARACTERISTICS: 70% women, median age 55 (interquartile range, IQR 43-63) years, disease duration 2.3 (IQR 0.7-5.1) years, DAS28-CRP 2.2 (IQR 1.8-2.6), Simplified Disease Activity Index, SDAI, 3.9 (IQR 1.9-6.5), Clinical Disease Activity Index, CDAI, 3.1 (IQR 1.5- 5.8), rheumatoid factor/anti-cyclic citrullinated peptide positivity 57%/54%, presence of radiographic erosions: 66%. Wrist and metacarpophalangeal MRI (MCP-MRI) data were available for 287 and 241 patients, respectively. MRI inflammatory activity in wrist and/or MCP joints was observed in the majority [synovitis: 95%, bone edema (osteitis): 35%] of patients. The median (IQR) RAMRIS score was 6 (3-9) for synovitis and 0 (0-2) for osteitis. Synovitis and osteitis were not less frequent in DAS28 clinical remission (synovitis/osteitis 96%/35%) than LDA (91/36). A trend towards lower frequencies of osteitis in patients in SDAI and CDAI remission was observed. CONCLUSION: Subclinical inflammation was identified by MRI in the majority of RA patients in clinical remission or LDA state. This may explain structural progression in such patients. Further work is required to understand the place of modern imaging in future remission criteria.

Using ultrasonography to facilitate best practice in diagnosis and management of RA.

The key to successful management of rheumatoid arthritis (RA) is early objective quantification of inflammation and ongoing precise, tailored therapy to ensure long term suppression of inflammatory disease activity. Musculoskeletal ultrasonography (MSKUS) has emerged as a tool with the potential to enhance disease assessment and management in this area. This includes applications in patients with undifferentiated arthropathy attending an early inflammatory arthritis clinic, in which the diagnosis of inflammatory disease may be confirmed or refuted at an early stage, and those with treated RA where accurate measurement of outcomes, such as response to therapy, structural damage and disease remission, are extremely important. This imaging modality is safe and portable, making it ideal for outpatient and inpatient settings, and can be used to assess many joints in multiple planes and to demonstrate changes in disease activity and structural damage over time. MSKUS is gaining popularity among rheumatologists, as increasing evidence supports the added value of a physician-performed ultrasonography assessment above traditional clinical, laboratory and radiographic measures, enabling greater confidence in diagnostic and management decisions. Although additional longitudinal data are required and further applications are likely to arise, MSKUS may well possess the necessary attributes to facilitate best practice in inflammatory arthritis management.

Disease remission state in patients treated with the combination of tumor necrosis factor blockade and methotrexate or with disease-modifying antirheumatic drugs: A clinical and imaging comparative study.

OBJECTIVE: For patients with rheumatoid arthritis (RA) in remission who are receiving disease-modifying antirheumatic drugs (DMARDs), radiographic progression correlates with imaging-detected synovitis as measured by power Doppler activity. In contrast, patients with disease in remission who are receiving the combination of tumor necrosis factor (TNF) blockade with methotrexate (MTX) (combination treatment) have reduced radiographic damage for the equivalent clinical state. We undertook this study to determine whether the difference in radiographic outcome is a result of more complete suppression of imaging-detected synovitis. METHODS: One hundred patients with RA in remission (Disease Activity Score in 28 joints [DAS28] <2.6) for at least 6 months while receiving either combination treatment (n = 50) or DMARDs (n = 50) were matched for clinical variables. Ultrasound of metacarpophalangeal joints 1-5 and the wrist joints was performed. Remission according to imaging results was defined as a score of 0 for both grey scale synovitis and power Doppler activity. RESULTS: In patients receiving combination treatment or DMARDs (median DAS28 1.65 versus 1.78, median disease duration 120 months versus 90 months, and median duration of remission 13 months versus 18 months), the proportion with remission according to imaging results was not significantly different (10% versus 16%, respectively). The combination treatment group had more grey scale synovitis (P < 0.001) but similar power Doppler activity (48% versus 60%, respectively; P = 0.229) in any joint as compared with the DMARD group. Results were not affected by stratification for duration of disease or remission. CONCLUSION: In RA patients with disease in remission, imaging-detected synovitis persists, with power Doppler activity seen in >or=48% of the patients regardless of therapy. These results suggest that superior radiographic outcomes in patients treated with the combination of TNF blockade and MTX may not be due to complete suppression of imaging-detected synovitis.

Response to intramuscular methyl prednisolone in inflammatory hand pain: evidence for a targeted clinical, ultrasonographic and therapeutic approach.

BACKGROUND: Hand pain with stiffness is a common clinical presentation to early arthritis clinics, with outcome varying from resolution to the development of rheumatoid arthritis. OBJECTIVE: To assess the response and predictors of response to intramuscular methylprednisolone (MP) and hydroxychloroquine (HCQ) using a standardised treatment protocol. METHODS: Patients with inflammatory hand pain (IHP), defined as predominantly hand pain and morning stiffness of at least 30 min duration, received a standardised assessment prior to receiving intramuscular MP. Response (primary outcome) at 4 weeks was a 50% improvement in symptoms as perceived by the patient; responders who relapsed received repeat intramuscular MP and HCQ. RESULTS: 102 patients were recruited, of which 21% were rheumatoid factor (RF) positive, 23% had clinical synovitis, 25% had raised C-reactive protein level and 55% had ultrasound-detected synovitis. 73% responded, with associated significant reductions in morning stiffness, Health Assessment Questionnaire, painful and tender joint counts, and visual analogue scores (p < or = 0.006 for all). Ultrasound-detected synovitis (p<0.001) and RF (p = 0.04), but not clinical synovitis (p = 0.74), were significantly associated with response to intramuscular MP. 86% who remained on HCQ long term reported a benefit. CONCLUSIONS: Patients with IHP have significant improvement in symptoms and function following intramuscular MP. Further placebo-controlled trials are required to assess the role of intramuscular MP and ultrasonography in managing this patient group.

An aneurysmal bone cyst in the cervical spine of a 10-year-old girl: a case report.

STUDY DESIGN: An aneurysmal bone cyst in the neural arch of the fourth cervical vertebra of a 10-year-old girl is reported, along with a brief review of the literature on the topic. OBJECTIVE: To report the presentation and diagnosis of this disorder along with a discussion of the major pitfalls of treatment. SUMMARY OF BACKGROUND DATA: An aneurysmal bone cyst occurs commonly in the second decade, with a predilection for the lumbar spine. With occurrence in the neural arch of a cervical vertebra, the potential for instability following surgical excision is high. METHODS: A 10-year-old white female presented with neck pain of 3 months' duration. Diagnostic imaging revealed an expansile lytic lesion in the spinous process and lamina of the fourth cervical vertebra. Surgical treatment consisted of excisional biopsy and a segmental instrumented posterior fusion from C3-C5. The histopathology was consistent with an aneurysmal bone cyst. RESULTS: Surgical excision consisting of laminectomy and instrumented segmental fusion provided a good clinical result, and minimized the risk and degree of the 2 most common complications: recurrence of the tumor; and postlaminectomy kyphosis, a frequent occurrence in the pediatric population. CONCLUSIONS: In pediatric patients who develop a bone tumor of the posterior elements of the cervical spine, careful clinical and radiologic evaluation is necessary to narrow the differential diagnosis. In most cases, a complete excision should be performed if possible. The risk of postlaminectomy kyphosis is high in the pediatric age population. As such, a fusion should be considered whenever a laminectomy is performed in the immature cervical spine. Risk factors for kyphosis include a high cervical level, multiple laminectomy levels, and postoperative irradiation.