Cost-effectiveness of surgery for degenerative cervical myelopathy in the United Kingdom.

PURPOSE: Degenerative cervical myelopathy (DCM) is the commonest cause of adult spinal cord dysfunction worldwide, for which surgery is the mainstay of treatment. At present, there is limited literature on the costs associated with the surgical management of DCM, and none from the United Kingdom (UK). This study aimed to evaluate the cost-effectiveness of DCM surgery within the National Health Service, UK. MATERIALS AND METHODS: Incidence of DCM was identified from the Hospital Episode Statistics (HES) database for a single year using five ICD-10 diagnostic codes to represent DCM. Health Resource Group (HRG) data was used to estimate the mean incremental surgery (treatment) costs compared to non-surgical care, and the incremental effect (quality adjusted life year (QALY) gain) was based on data from a previous study. A cost per QALY value of <£30,000/QALY (GBP) was considered acceptable and cost-effective, as per the National Institute for Health and Clinical Excellence (NICE) guidance. A sensitivity analysis was undertaken (±5%, ±10% and ±20%) to account for variance in both the cost of admission and QALY gain. RESULTS: The total number of admissions for DCM in 2018 was 4,218. Mean age was 62 years, with 54% of admissions being of working age (18-65 years). The overall estimated cost of admissions for DCM was £38,871,534 for the year. The mean incremental (per patient) cost of surgical management of DCM was estimated to be £9,216 (ranged £2,358 to £9,304), with a QALY gain of 0.64, giving an estimated cost per QALY value of £14,399/QALY. Varying the QALY gain by ±20%, resulted in cost/QALY figures between £12,000 (+20%) and £17,999 (-20%). CONCLUSIONS: Surgery is estimated to be a cost-effective treatment of DCM amongst the UK population.

Factors Influencing Surgical Decision-Making in the Posterior Laminectomy With Fixation for Degenerative Cervical Myelopathy (POLYFIX-DCM) Trial: Survey Study.

BACKGROUND: Degenerative cervical myelopathy (DCM) is estimated to affect 2% of the adult population. DCM occurs when degenerative processes cause compression and injure the spinal cord. Surgery to remove the stress caused by the compression of the spinal cord is the mainstay of treatment, with a range of techniques in use. Although various factors are described to inform the selection of these techniques, there needs to be more consensus and limited comparative evidence. OBJECTIVE: The main objective of this survey was to explore the variation of practice and decision-making, with a focus on laminectomy versus laminectomy and fusion in posterior surgery of the cervical spine. We present the results of a survey conducted among the principal investigators (PIs) of the National Institute for Health and Care Research (NIHR) randomized controlled trial on posterior laminectomy with fixation for degenerative cervical myelopathy (POLYFIX-DCM). METHODS: A series of 7 cases were shared with 24 PIs using SurveyMonkey. Each case consisted of a midsagittal T2-weighted magnetic resonance imaging and lateral cervical x-rays in flexion and extension. Surgeons were asked if their preferred approach was anterior or posterior. If posterior, they were asked whether they preferred to instrument and whether they had the equipoise to randomize in the NIHR POLYFIX-DCM trial. Variability in decision-making was then explored using factors reported to inform decision-making, such as alignment, location of compression, number of levels operated, presence of mobile spondylolisthesis, and patient age. RESULTS: The majority of PIs (16/30, 53%) completed the survey. Overall, PIs favored a posterior approach (12/16, 75%) with instrumentation (75/112, average 66%) and would randomize (67/112, average 62%) most cases. Factors reported to inform decision-making poorly explained variability in responses in both univariate testing and with a multivariate model (R2=0.1). Only surgeon experience of more than 5 years and orthopedic specialty training background were significant predictors, both associated with an anterior approach (odds ratio [OR] 1.255; P=.02 and OR 1.344; P=.007, respectively) and fusion for posterior procedures (OR 0.628; P<.001 and OR 1.344; P<.001, respectively). Surgeon experience also significantly affected the openness to randomize, with those with more than 5 years of experience less likely to randomize (OR -0.68; P<.001). CONCLUSIONS: In this representative sample of spine surgeons participating in the POLYFIX-DCM trial as investigators, there is no consensus on surgical strategy, including the role of instrumented fusion following posterior decompression. Overall, this study supports the view that there appears to be a clinical equipoise, and conceptually, a randomized controlled trial appears feasible, which sets the scene for the NIHR POLYFIX-DCM trial.

Minimally invasive anterior cervical discectomy and fusion: a valid alternative to open techniques.

BACKGROUND: Anterior cervical discectomy and fusion (ACDF) is a well-standardized treatment for cervical myelopathy/radiculopathy. The aim of this study is to assess the feasibility of minimally invasive ACDF. METHOD: Retrospective review of six patients who underwent minimally invasive ACDF using microscope and tubular retractors. Clinical and radiological outcomes and surgical complications were reviewed. CONCLUSION: Minimally invasive microscopic ACDF through tubular retractors is a feasible option and therefore an alternative to conventional open procedures. However, it does require advanced technical skills and good understanding of the MIS principles and limitations of the technique.

Minimally Invasive Excision of Thoracic Arachnoid Web.

OBJECTIVE: Arachnoid webs are rare intradural lesions that can cause direct spinal cord compression or alteration of the cerebrospinal fluid flow with syringomyelia. Surgery has been historically performed through wide-open laminectomies. The aim of this study is to prove the feasibility of minimally invasive techniques for the excision of arachnoid webs. METHODS: A retrospective review of two cases of minimally invasive excision of thoracic arachnoid webs was performed. Surgery was undertaken through expandable tubular retractors. RESULTS: Complete excision was achieved through the described approach, with minimal bony removal and soft tissue disruption. There were no intraoperative or perioperative complications. Both patients were mobilized early and discharged home within 24 hours after surgery. Postoperative imaging showed good re-expansion of the spinal cord, with no evidence of residual compression or tethering. CONCLUSIONS: For symptomatic arachnoid webs, surgery remains the only definitive treatment. In expert hands, the excision of arachnoid webs can be achieved with tubular retractors and minimally invasive techniques.

Is the complete excision of circumferential intradural spinal meningiomas achievable?

BACKGROUND: Circumferential intradural spinal meningiomas are exceptionally rare. They pose several surgical challenges and a complete excision is not easy. The aim of this study is to provide surgical strategies to facilitate a full excision of such tumors. METHODS: A fully circumferential intradural meningioma at T9/10 was fully removed via a posterior approach and a structured single procedure, with no intra or perioperative complications. CONCLUSIONS: Complete removal of circumferential spinal meningiomas can be achieved with wise preoperative planning, familiarity with techniques needed to transpose the spinal cord, and a structured staged excision of the four components of these tumors.

Minimally Invasive Versus Open Surgery for Lumbar Synovial Cysts.

OBJECTIVE: Lumbar synovial cysts are relatively infrequent. Historically, these benign lesions have been treated with open excision, sometimes associated with fusion. The aim of this study is to compare minimally invasive surgery (MIS) with open surgery (OS) for the treatment of lumbar synovial cysts. METHODS: This was a retrospective review of patients who underwent minimally invasive or open excision of lumbar synovial cysts. Clinical outcomes, recurrence rate, and surgical complications were compared in the 2 groups. RESULTS: A total of 37 cases were identified, of which 24 were MIS and 13 were OS. MIS was significantly more effective in improving leg pain and radicular symptoms. There was no statistical difference between the 2 groups with regard to improvements of back pain and neurogenic claudication. Postoperative length of hospital stay and postoperative pain were significantly reduced in the MIS group (15 hours vs. 24 hours and 0.9/10 vs. 4.7/10 respectively, P < 0.5). There were no statistical differences in duration of surgery, intra- or postoperative complications, no recurrence of cyst in either of the 2 groups, and no patients required fusion at a later stage. CONCLUSIONS: In this study, MIS for the treatment of lumbar synovial cysts appears to be more effective than OS in relieving radicular symptoms. Furthermore, MIS is better tolerated by patients and is potentially cost saving for the Health Service, due to the reduction in hospital stay and the reduced requirement for painkillers.

Erratum: Against the odds: extraordinary recovery from complete cauda equina syndrome following L3 fracture. Time still matters.

[This corrects the article DOI: 10.1038/scsandc.2016.27.].

Minimally Invasive Microscopic Posterior Cervical Decompression: Simple, Safe, and Effective.

Background and Study Aims Cervical spondylotic myelopathy (CSM) is the most common cause of spinal cord dysfunction in the elderly population. Surgery is usually successful in preventing any deterioration, as well as improving functional status and quality of life. This study assesses the safety and efficacy of minimally invasive microscopic posterior cervical decompression for the treatment of CSM. Materials and Methods A retrospective review of patients with myelopathy from cervical stenosis treated with minimally invasive posterior cervical decompression was performed. The operation was performed through a nonexpandable tubular retractor and operating microscope. Results Twelve patients were identified. There were no early or late complications. Average age was 74.5 years. Three patients were > 80 years of age and tolerated the operation extremely well. Three cases were two-level decompressions; nine were single level. Eight patients were operated on as elective cases, with average postoperative length of stay of 0.9 days. Average surgical time was 77.5 minutes per level. Postoperative neck pain was minimal (1.5/10). All patients improved postoperatively, particularly those who started with severe deficits. In fact, five patients were unable to walk preoperatively and were wheelchair- or bed-bound, and they returned to walking within weeks. The modified Japanese Orthopedic Association score improved from 8.4 (range: 4-14) to 13.5 (range: 10-15); the Nurick score changed from 3.8 (range: 2-5) to 2.3 (range: 1-4). Conclusions Minimally invasive microscopic posterior cervical decompression is a safe and effective treatment for CSM in selected cases. Our initial experience highlights the potential benefits of this relatively new technique.

Minimally Invasive Excision of Lumbar Tophaceous Gout: Case Report.

BACKGROUND: Symptomatic spinal gout is relatively rare. Open laminectomy, with or without fusion, has been so far the standard treatment for symptomatic spinal gout. We describe here the first case of spinal tophaceus gout treated with minimally invasive surgery. METHODS: A 60-year-old patient, morbidly obese, with no previous history of gout, presented with neurogenic claudication due to severe lumbar canal stenosis at L3/4. Surgery was performed through a minimally invasive approach, using tubular retractors. During surgery, an extradural mass with a thin capsule and containing white "chalky" partially calcified material, slightly adherent to and compressing the theca, was removed. RESULTS: There were no intra- or perioperative complications. Surgery successfully improved the functional status, with a significant increase in walking distance and no residual leg pain or neurogenic claudication. Histopathology confirmed the diagnosis of spinal tophaceous gout. CONCLUSIONS/LEVEL OF EVIDENCE: Although spinal gout is usually responsive to medical treatment, surgery is often the first line treatment, particularly in patients with neurological deficits. Would surgery be indicated, we believe that minimally invasive surgery can be effective in treating symptomatic spinal tophaceous gout. Level of Evidence: Class IV.

A Novel Less Invasive Technique for the Excision of Large Intradural and Extradural Dumbbell Lumbar Schwannomas: The "Dual Approach".

OBJECTIVE: Large schwannomas with intradural and extradural extensions are often challenging surgical lesions. A variety of approaches, usually requiring large exposures, removal of facets and pars interarticularis, and spinal stabilization, have been described. The aim of this study is to describe the "dual approach," a less invasive technique for the excision of these lesions. METHODS: A large intradural and extradural schwannoma with paraspinal extension (Eden type II) was removed by a unilateral approach-midline, pars and facet sparing and no supplemental instrumentation. RESULTS: Complete excision was achieved through the described approach, with minimal removal of bone and soft tissue disruption. There were no intraoperative or perioperative complications and no evidence of residual tumor or instability/deformity. CONCLUSIONS: The dual approach is a novel and unique technique that allows complete and safe removal of large intradural and extradural dumbbell tumors through a less invasive approach and no need for instrumentation.

Against the odds: extraordinary recovery from complete cauda equina syndrome following L3 fracture. Time still matters.

INTRODUCTION: Cauda equina syndrome secondary to lumbar fracture is a relative rare event. Although it is usually considered as an emergency, there is still controversy in the literature regarding the optimal timeframe of surgical intervention in complete spinal cord and cauda equina injuries. CASE PRESENTATION: We report a case of a 24-year-old victim of a road traffic accident admitted with an L3 fracture causing complete cauda equina syndrome, who underwent early surgery within 12 h and made an extraordinary recovery (from AIS A to E). DISCUSSION: Although the timing of surgery in complete traumatic spinal cord injury and cauda equina syndrome remains controversial, this case highlights the importance of early surgical intervention even in complete injuries.

The surgical management of the rheumatoid spine: Has the evolution of surgical intervention changed outcomes?

CONTEXT: Surgery for the rheumatoid cervical spine has been shown to stabilize the unstable spine; arrest/improve the progression of neurological deficit, help neck pain, and possibly decelerate the degenerative disease process. Operative intervention for the rheumatoid spine has significantly changed over the last 30 years. AIMS: The purpose of this study was to review all cases of cervical rheumatoid spine requiring surgical intervention in a single unit over the last 30 years. MATERIALS AND METHODS: A prospectively-maintained spine database was retrospectively searched for all cases of rheumatoid spine, leading to a review of indications, imaging, Ranawat and Myelopathy Disability Index measures, surgical morbidity, and survival curve analysis. RESULTS: A total of 224 cases were identified between 1981 and 2011. Dividing the data into three time-epochs, there has been a significant increase in the ratio of segment-saving Goel-Harms C1-C2: Occipitocervical fixation (OCF) surgery and survival has increased between 1981 and 2011 from 30% to 51%. Patients undergoing C1-C2 fixation were comparatively less myelopathic and in a better Ranawat class preoperatively, but postoperative outcome measures were well-preserved with favorable mortality rates over mean 39.6 months of follow-up. However, 11% of cases required OCF at mean 28 months post-C1-C2 fixation, largely due to instrumentation failure (80%). CONCLUSION: We present the largest series of surgically managed rheumatoid spines, revealing comparative data on OCF and C1-C2 fixation. Although survival has improved over the last 30 years, there have been changes in medical, surgical and perioperative management over that period of time too confounding the interpretation; however, the analysis presented suggests that rheumatoid patients presenting early in the disease process may benefit from C1 to C2 fixation, albeit with a proportion requiring OCF at a later time.

Dural tentorial arteriovenous fistula causing isolated trochlear nerve palsy: remission after endovascular embolization.

OBJECTIVES: To report an exceptional case of dural arteriovenous fistula of the tentorial incisura presenting as transient and recurrent isolated paresis of the fourth cranial nerve, and treated by endovascular embolization. CASE REPORT: A 63-year-old man presented several episodes of intermittent diplopia which appeared during sudden head movements and in the left lower gaze. Magnetic resonance and cerebral angiography showed a dural arteriovenous fistula of the right tentorial incisura fed mainly by branches of the right occipital artery as well as intracavernous branches of the right internal carotid artery. Embolization of the occipital artery branches resulted in significantly decreased flow within the fistula and in rapid and complete remission of diplopia. Stereotactic radiosurgery of the residual malformation was then performed. The treatment resulted in a good clinical and radiological outcome at the 5-year follow-up. CONCLUSION: An arteriovenous fistula of the tentorial incisura may exceptionally cause intermittent diplopia owing to compression of the trochlear nerve due to transient increase of blood flow within the malformation. Remission of diplopia may be achieved by endovascular embolization. Dural arteriovenous fistulas with low risk of hemorrhage and brain neurological symptoms may successfully be treated by partial endovascular embolization and radiosurgery.

C1-C2 posterior fixation: are 4 screws better than 2?

BACKGROUND: Several types of C1-C2 fixation techniques have been described over the years in order to treat atlantoaxial instability. OBJECTIVE: To compare the pros and cons of the most popular C1-C2 posterior fixation used today: C1 lateral mass-C2 pedicle screw and rods (Harms) and transarticular screw (Magerl) fixations. METHODS: Retrospective review of 122 patients who underwent Harms or Magerl fixation for atlantoaxial instability. Surgical, clinical, and radiological outcomes were compared in the 2 groups. RESULTS: 123 operations were performed, of which 47 were by the Harms technique (group H) and 76 by the Magerl technique (group M). No significant differences were found in duration of surgery, blood loss, postoperative pain, and length of hospitalization. Postoperatively, neck pain, C2-radiculopathy, and hand function improved in both groups, with better, but not statistically significant, results for group H. The intraoperative complication rate was 2.1% in group H and 21% in group M (P < .05); postoperative complication rate was 10.6% in group H and 21% in group M (P > .05). The major complications were vertebral artery injury (2.1% in group H, 13.1% in group M, P = .05) and screw fracture (2.1% in group H, 9.2% in group M, P > .05). Fusion rate at the end of follow-up was not significantly higher in group H. C1-C2 range of movements in flexion/extension at the end of follow-up was lower in group H (P = .017). CONCLUSION: Magerl with posterior wiring and Harms techniques are both effective options for stabilizing the atlantoaxial complex. However, the Harms technique appears to be safer, to have fewer complications, and to demonstrate a more robust long-term fixation.

Meningiomas of the transverse--sigmoid sinus junction area.

Meningiomas with exclusive or prevalent dural attachment over the transverse-sigmoid sinus junction area represent a well-defined subgroup of posterior fossa meningiomas. This study reports 13 cases of this localisation (10.8% of all infratentorial meningiomas). In this series, six patients (46%) were discovered as an incidental MR finding. One patient with a small (1.5 cm) meningioma presented with an intracranial hypertension syndrome due to severe obstruction of the unique transverse-sigmoid sinus junction. A MR angiography was performed in 11 patients; it showed intraluminal tumour in two cases with dominant and unique transverse sinus, respectively. Tumour removal with excision of the outer dural layer and coagulation of the dural attachment (Simpson II) was performed in 11 cases; in two others with focal sinus invasion, removal of the small intravenous tumour fragment was not performed (Simpson III). No post-operative complications occurred. Remission of pre-operative symptoms was obtained in all symptomatic cases. The management of the transverse-sigmoid sinus junction is the main problem of meningiomas of this region. Excision of the outer dural layer and coagulation of the dural attachment are in our opinion sufficient in most cases, even when there is tumour invasion of the patent venous lumen. The resection of the sinus wall should be reserved to cases with a totally obstructed segment and symmetrical or asymmetrical but present transverse and sigmoid sinuses.