Long-Term Clinical Results of Percutaneous Cervical Nucleoplasty for Cervical Radicular Pain: A Retrospective Cohort Study.

Purpose: Percutaneous cervical nucleoplasty (PCN) is a minimally invasive treatment for cervical radicular pain due to a disc herniation. Preliminary results show equivalent patient-reported outcomes of PCN as compared to conventional anterior cervical discectomy. However, there is a paucity of long-term outcome data. Therefore, the primary objective of this study is to investigate the long-term clinical results of PCN. Patients and Methods: A retrospective analysis was conducted on patients who underwent PCN at a secondary referral center between 2010 and 2014. Before surgery and five days after surgery, numeric rating scales (NRS) for arm pain and neck pain and data on complications were collected. To determine long-term follow-up outcomes, patients were sent a questionnaire booklet containing the Core Outcome Measures Index-Neck (COMI-Neck), NRS for arm pain and neck pain, Likert-scales on patient satisfaction and questions regarding the incidence of reoperations and complications. Results: The baseline characteristics were collected for 158 patients. At a median follow-up of 41.5 months (interquartile range (IQR) 27.0 to 57.5), data were available for 118 patients (74.7%). At short-term follow-up, patients that underwent PCN had a mean decrease of 3.0 on the NRS for arm pain (95% CI 2.5 to 3.6) compared to baseline, while at long-term follow-up, a mean decrease of 2.8 (95% CI 1.0 to 3.6) was observed. At the long-term follow-up, 67.8% of the patients were fully recovered from all symptoms and 93.3% remained satisfied with the PCN treatment results. The reoperation rate for recurrent disc herniation was 21.4% at long-term follow-up. Conclusion: PCN appears to be a safe and effective treatment at short-term and long-term follow-up of a specific selection of cervical herniated discs, with an acceptable long-term reoperation rate. These study results suggest a potential role of PCN as a less invasive treatment option for cervical radicular pain due to a soft disc herniation, before anterior cervical discectomy should be considered.

Honorary authorship in high-impact journals in anaesthesia and pain medicine.

Enlisting an author on a published paper, whose input was insufficient, is called honorary authorship. The aim of this study is to assess the proportion of honorary authorship in the field of pain medicine. Data were collected from seven high-impact journals. Corresponding authors were sent a survey regarding their awareness on authorship guidelines, the decision-making in authorship and specific contributions made to the surveyed article. We identified two types of honorary authorship: (1) self-perceived honorary authorship, which is measured by asking the corresponding author if honorary authorship was present according to their opinion and (2) International Committee of Medical Journal Editors (ICMJE)-defined honorary authorship, which is honorary authorship based on the guidelines. In total, 1051 mails were sent and 231 responded, leading to a response rate of 22.0%. 81.3% of the respondents were familiar with the ICMJE authorship guidelines, while 59.6% were aware of the issue of honorary authorship. 13.3% of the respondents were employed at a department in which the senior member is automatically included on all manuscripts. The ICMJE-defined honorary authorship was 40%, while self-perceived honorary authorship was 13.5%. There seems to be a high awareness of the ICMJE guidelines among corresponding authors in the field of Pain Medicine. Despite this high awareness, a high proportion of journal articles had honorary authorship, suggesting that authorship guidelines fail to be applied in a significant proportion of the literature.

Mistreatment, discrimination and burn-out in Neurosurgery.

OBJECTIVE: Issues concerning harassment, bullying and discrimination are not unknown to medical specialties and are likely to be present in neurosurgery as well. The aim of this study was to estimate the extent to which neurosurgeons are faced with issues pertaining to this mistreatment. METHODS: A survey consisting of fourteen questions was distributed among members of the Congress of Neurological Surgeons (CNS). The survey consisted of three parts: 1) demographics; 2) exposure to mistreatment; 3) experienced burnout symptoms. RESULTS: In total 503 out of the 5665 approached CNS members filled in a survey (response rate 8.9 %). Respondents consisted for 85.9 % out of neurosurgeons and for 13.9 % out of residents. Overall, 61.4 % of the respondents was a victim of form of abusive behavior, while 47.9 % was a victim of at least one form of discrimination. Most reported sources of these mistreatments were other neurosurgeons or (family of) patients. Overall, 49.9 % of the respondents experienced burnout symptoms. Multivariable logistic regression analysis showed that female respondents had higher odds of being a victim of abuse (OR 2.5, 95 % CI 1.4-4.6). Female respondents (OR 19.8, 95 % CI 8.9-43.9) and ethnic minorities (OR 3.8, 95 % CI 2.3-6.2) had higher odds of being a victim of discrimination. Furthermore, victims of abuse were at higher odds (OR 1.7, 95 % CI 1.1-2.6) of having burnout symptoms. CONCLUSIONS: Mistreatment and experiencing burnout symptoms frequently occurs among neurosurgeons and residents.

The Dorsal Root Ganglion as a Novel Neuromodulatory Target to Evoke Strong and Reproducible Motor Responses in Chronic Motor Complete Spinal Cord Injury: A Case Series of Five Patients.

OBJECTIVES: Current strategies for motor recovery after spinal cord injury (SCI) aim to facilitate motor performance through modulation of afferent input to the spinal cord using epidural electrical stimulation (EES). The dorsal root ganglion (DRG) itself, the first relay station of these afferent inputs, has not yet been targeted for this purpose. The current study aimed to determine whether DRG stimulation can facilitate clinically relevant motor response in motor complete SCI. MATERIALS AND METHODS: Five patients with chronic motor complete SCI were implanted with DRG leads placed bilaterally on level L4 during five days. Based on personalized stimulation protocols, we aimed to evoke dynamic (phase 1) and isotonic (phase 2) motor responses in the bilateral quadriceps muscles. On days 1 and 5, EMG-measurements (root mean square [RMS] values) and clinical muscle force measurements (MRC scoring) were used to measure motor responses and their reproducibility. RESULTS: In all patients, DRG-stimulation evoked significant phase 1 and phase 2 motor responses with an MRC ≥4 for all upper leg muscles (rectus femoris, vastus lateralis, vastus medialis, and biceps femoris) (p < 0.05 and p < 0.01, respectively), leading to a knee extension movement strong enough to facilitate assisted weight bearing. No significant differences in RMS values were observed between days 1 and 5 of the study, indicating that motor responses were reproducible. CONCLUSION: The current paper provides first evidence that bilateral L4 DRG stimulation can evoke reproducible motor responses in the upper leg, sufficient for assisted weight bearing in patients with chronic motor complete SCI. As such, a new target for SCI treatment has surfaced, using existing stimulation devices, making the technique directly clinically accessible.

The Effect of Percutaneous Nucleoplasty vs Anterior Discectomy in Patients with Cervical Radicular Pain due to a Single-Level Contained Soft-Disc Herniation: A Randomized Controlled Trial.

BACKGROUND: Cervical radicular pain (CRP) is a common problem in the adult population. When conservative treatment fails and the severe pain persist, surgical treatment is considered. However, surgery is associated with some serious risks. To reduce these risks, new minimally invasive techniques have been developed, such as percutaneous nucleoplasty. Several studies have shown that percutaneous nucleoplasty is a safe and effective technique for the treatment of CRP, but until now no randomized controlled trials have been conducted that compare percutaneous cervical nucleoplasty (PCN) to anterior cervical discectomy (ACD) in patients with a single-level contained soft-disc herniation. OBJECTIVES: To compare the effects of PCN and ACD in a group of patients with CRP caused by a single-level contained soft-disc herniation. STUDY DESIGN: A randomized, controlled, multi-center trial. SETTING: Medical University Center and local hospitals. METHODS: Forty-eight patients with CRP as a result of a single-level contained soft-disc herniation were randomized to one of the following 2 treatments: PCN or ACD. The primary outcome measure was arm pain intensity, measured with a Visual Analog Scale (VAS). Secondary outcomes were arm pain intensity during heavy effort, neck pain, global perceived effect, Neck Disability Index (NDI), and the patients' general health (Short Form Generated Health Survey [SF-36]). All parameters were measured at baseline (T0), 3 months after intervention (T2), and one year after intervention (T3). One week after the intervention (T1), an intermediate assessment of arm pain, arm pain during heavy effort, neck pain, satisfaction, and improvement were performed. RESULTS: At 3 months, the intention to treat analyses revealed a statistical significant interaction between the groups on the primary outcome, arm pain intensity, and on the secondary outcome of the SF-36 item pain, in favor of the ACD group. On the other secondary outcomes, no statistical significant differences were found between the groups over time. At 12 months, there was a trend for more improvement of arm pain in favor of the ACD group and no statistical interactions were found on the secondary outcomes. LIMITATIONS: Firstly, the inclusion by the participating hospitals was limited. Secondly, the trial was ended before reaching the required sample size. Thirdly, at baseline, after the inclusion by the neurosurgeon, 13 patients scored less than 50.0 mm on the VAS. Fourthly, the withdrawal of the physiotherapy (PT) group and finally, the patients and interventionists could not be blinded for the treatment. CONCLUSIONS: At 3 months, the ACD group performed significantly better on arm pain reduction than the PCN group in patients with CRP as a result of a single-level contained soft-disc hernia. However, the clinical relevancy of this treatment effect can be debated. For all parameters, after one year, no significant differences between the groups were found. When it comes to the longer-term effectiveness, we conclude that PCN can be a good alternative for ACD.

Percutaneous Nucleoplasty for the Treatment of a Contained Cervical Disk Herniation.

Cervical radiculopathy is characterized by compression of the roots of the nerve. When conservative treatment fails and symptoms persist or increase in severity, surgical treatment is considered. Anterior cervical discectomy with or without fusion is regarded as the standard treatment for cervical disk herniation. Recently, there is an evolving trend in spinal surgery towards less invasive techniques. Nucleoplasty is a minimally invasive technique in which radiofrequency technology is used for percutaneous decompression. During the last years nucleoplasty has been proven to be a safe and effective treatment to alleviate radiculopathy, caused by a contained disk herniation. Nucleoplasty is usually performed on an outpatient basis and is associated with a fast recovery time. This paper will describe the preoperative and postoperative management of cervical nucleoplasty as well as the surgical technique, accompanied by a video.

Anterior cervical discectomy without fusion for a symptomatic cervical disk herniation.

BACKGROUND: Cervical radiculopathy is characterized by dysfunction of the nerve root usually caused by a cervical disk herniation. The most important symptom is pain, radiating from the neck to the arm. When conservative treatment fails, surgical treatment is indicated to relieve symptoms. During the last decades, multiple fusion techniques have been developed, although without clinical evidence for added value of fusion over non-fusion. METHODS: The surgical procedure of anterior cervical discectomy without fusion is performed step by step, leading to removal of the entire intervertebral disk. CONCLUSION: Anterior cervical discectomy without fusion is a safe and effective treatment for cervical disk herniation.

Management of Symptomatic Cervical Disk Herniation: A Survey Among Dutch Neurosurgeons.

STUDY DESIGN: A questionnaire survey. OBJECTIVE: To assess the preferred surgical technique, the optimal timing of surgery, and the expectations of different surgical techniques of neurosurgeons in the Netherlands, regarding patients with cervical disc herniation (CDH). SUMMARY OF BACKGROUND DATA: To treat CDH, multiple surgical techniques are performed. Due to the lack of consensus, the daily routine management may vary. METHODS: All 134 neurosurgeons of the Dutch Association of Neurosurgery were sent a survey, evaluating the operative management as well as the attitude towards different surgical treatments for CDH. RESULTS: Ninety-six (74.4%) of the neurosurgeons treating CDH completed the survey. Anterior cervical discectomy with fusion (ACDF) was the standard procedure for the majority of neurosurgeons (76.3%). ACDF was expected to have the highest effectiveness on arm pain, yet also a higher risk for complications as compared with anterior cervical discectomy (ACD). Approximately, 47.9% of the surgeons regarded a minimal duration of 8 to 12 weeks of radicular arm pain before deciding to perform surgery. Regarding the risk of recurrent CDH, DCF was expected to give the highest risk, whereas ACDF the lowest. CONCLUSION: Despite the lack of solid evidence in favor for ACDF this survey showed that ACDF is the preferred technique to treat cervical radiculopathy. A minimum duration of 8 to 12 weeks of radicular arm pain was considered the optimal timing to perform surgery for CDH by the majority of the neurosurgeons. Whether to fuse or not remains a controversial subject in degenerative spinal surgery. This study emphasizes the need of high-quality evidence on the optimal surgical management of CDH. LEVEL OF EVIDENCE: N/A.