Cost-effectiveness of lumbar discectomy and single-level fusion for spondylolisthesis: experience with the NeuroPoint-SD registry.

OBJECT: There is significant practice variation and uncertainty as to the value of surgical treatments for lumbar spine disorders. The authors' aim was to establish a multicenter registry to assess the efficacy and costs of common lumbar spinal procedures by using prospectively collected outcomes. METHODS: An observational prospective cohort study was completed at 13 academic and community sites. Patients undergoing single-level fusion for spondylolisthesis or single-level lumbar discectomy were included. The 36-Item Short Form Health Survey (SF-36) and Oswestry Disability Index (ODI) data were obtained preoperatively and at 1, 3, 6, and 12 months postoperatively. Power analysis estimated a sample size of 160 patients: lumbar disc (125 patients) and lumbar listhesis (35 patients). The quality-adjusted life year (QALY) data were calculated using 6-dimension utility index scores. Direct costs and complication costs were estimated using Medicare reimbursement values from 2011, and indirect costs were estimated using the human capital approach with the 2011 US national wage index. Total costs equaled $14,980 for lumbar discectomy and $43,852 for surgery for lumbar spondylolisthesis. RESULTS: There were 198 patients enrolled over 1 year. The mean age was 46 years (49% female) for lumbar discectomy (n = 148) and 58.1 years (60% female) for lumbar spondylolisthesis (n = 50). Ten patients with disc herniation (6.8%) and 1 with listhesis (2%) required repeat operation at 1 year. The overall 1-year follow-up rate was 88%. At 30 days, both lumbar discectomy and single-level fusion procedures were associated with significant improvements in ODI, visual analog scale, and SF-36 scores (p = 0.0002), which persisted at the 1-year evaluation (p < 0.0001). By 1 year, more than 80% of patients in each cohort who were working preoperatively had returned to work. Lumbar discectomy was associated with a gain of 0.225 QALYs over the 1-year study period ($66,578/QALY gained). Lumbar spinal fusion for Grade I listhesis was associated with a gain of 0.195 QALYs over the 1-year study period ($224,420/QALY gained). CONCLUSIONS: This national spine registry demonstrated successful collection of high-quality outcomes data for spinal procedures in actual practice. These data are useful for demonstrating return to work and cost-effectiveness following surgical treatment of single-level lumbar disc herniation or spondylolisthesis. One-year cost per QALY was obtained, and this cost per QALY is expected to improve further by 2 years. This work sets the stage for real-world analysis of the value of health interventions.

Platelet-derived growth factor receptor (PDGFR) expression in primary spinal cord gliomas.

Abnormal signaling through the platelet-derived growth factor receptor (PDGFR) has been proposed as a possible mechanism of spinal cord glioma initiation and progression. However, the extent of PDGFR expression in human spinal cord gliomas remains unknown. In this study we perform immunohistochemical analysis of PDGFRα expression in a series of 33 primary intramedullary spinal cord gliomas of different types and grades. PDGFRα was seen to be expressed in a significant subset of these tumors across all major glioma types including ependymoma, oligodendroglioma, pilocytic astrocytoma, astrocytoma, and glioblastoma. These results support the hypothesis that growth factor signaling through the PDGFR may be important for the development of at least a subset of human spinal cord gliomas. Further studies investigating the prognostic significance of PDGFR expression as well as the role of PDGF signaling on the development of intramedullary spinal cord gliomas are warranted.

Differential immunological response detected in mRNA expression profiles among diverse chicken lines in response to Salmonella challenge.

Salmonella enterica serovar Enteritidis is a bacterial pathogen that contributes to poultry production losses and human foodborne illness. The bacterium elicits a broad immune response involving both the innate and adaptive components of the immune system. Coordination of the immune response is largely directed by cytokines. The objective of the current study was to characterize the expression of a select set of cytokines and regulatory immune genes in three genetically diverse chicken lines after infection with S. Enteritidis. Leghorn, Fayoumi and broiler day-old chicks were orally infected with pathogenic S. Enteritidis or culture medium. At 2 and 18 h postinfection, spleens and ceca were collected and mRNA expression levels for 7 genes (GM-CSF, IL2, IL15, TGF-ß1, SOCS3, P20K, and MHC class IIß) were evaluated by real-time quantitative PCR. Genetic line had a significant effect on mRNA expression levels of IL15, TGF-ß1, SOCS3 and P20K in the spleen and on P20K and MHC class IIß in the cecum. Comparing challenged vs. unchallenged birds, the expression of SOCS3 and P20K mRNA were significantly higher in the spleen and cecum, while MHC class IIß mRNA was significantly lower in spleen. Combining the current RNA expression results with those of previously reported studies on the same samples reveals distinct RNA expression profiles among the three genetic chicken lines and the 2 tissues. This study illustrates that these diverse genetic lines have distinctively different immune response to S. Enteritidis challenge within the spleen and the cecum.

Primitive neuroectodermal tumors of the spine: a comprehensive review with illustrative clinical cases.

Primary spinal primitive neuroectodermal tumors (PNETs) are uncommon malignancies that are increasingly reported in the literature. Spinal PNETs, like their cranial counterparts, are aggressive tumors and patients with these tumors typically have short survival times despite maximal surgery, chemotherapy, and radiation. Because no standard management guidelines exist for treating these tumors, a multitude of therapeutic strategies have been employed with varying success. In this study the authors perform a comprehensive review of the literature on primary spinal PNETs and provide 2 new cases that highlight the salient features of their clinical management.

Transcriptome Analysis Reveals Inhibitory Effects of Lentogenic Newcastle Disease Virus on Cell Survival and Immune Function in Spleen of Commercial Layer Chicks.

As a major infectious disease in chickens, Newcastle disease virus (NDV) causes considerable economic losses in the poultry industry, especially in developing countries where there is limited access to effective vaccination. Therefore, enhancing resistance to the virus in commercial chickens through breeding is a promising way to promote poultry production. In this study, we investigated gene expression changes at 2 and 6 days post inoculation (dpi) at day 21 with a lentogenic NDV in a commercial egg-laying chicken hybrid using RNA sequencing analysis. By comparing NDV-challenged and non-challenged groups, 526 differentially expressed genes (DEGs) (false discovery rate (FDR) < 0.05) were identified at 2 dpi, and only 36 at 6 dpi. For the DEGs at 2 dpi, Ingenuity Pathway Analysis predicted inhibition of multiple signaling pathways in response to NDV that regulate immune cell development and activity, neurogenesis, and angiogenesis. Up-regulation of interferon induced protein with tetratricopeptide repeats 5 (IFIT5) in response to NDV was consistent between the current and most previous studies. Sprouty RTK signaling antagonist 1 (SPRY1), a DEG in the current study, is in a significant quantitative trait locus associated with virus load at 6 dpi in the same population. These identified pathways and DEGs provide potential targets to further study breeding strategy to enhance NDV resistance in chickens.

Genetic responses of inbred chicken lines illustrate importance of eIF2 family and immune-related genes in resistance to Newcastle disease virus.

Newcastle disease virus (NDV) replication depends on the translation machinery of the host cell; therefore, the eukaryotic translation initiation factor 2 (eIF2) gene family is a likely candidate for control of viral replication. We hypothesized that differential expression of host genes related to translation and innate immune response could contribute to differential resistance to NDV in inbred Fayoumi and Leghorn lines. The expression of twenty-one genes related to the interferon signaling pathway and the eIF2 family was evaluated at two- and six-days post infection (dpi) in the spleen from both lines, either challenged by NDV or nonchallenged. Higher expression of OASL in NDV challenged versus nonchallenged spleen was observed in Leghorns at 2 dpi. Lower expression of EIF2B5 was found in NDV challenged than nonchallenged Fayoumis and Leghorns at 2 dpi. At 2 dpi, NDV challenged Fayoumis had lower expression of EIF2B5 and EIF2S3 than NDV challenged Leghorns. At 6 dpi, NDV challenged Fayoumis had lower expression of EIF2S3 and EIF2B4 than NDV challenged Leghorns. The genetic line differences in expression of eIF2-related genes may contribute to their differential resistance to NDV and also to understanding the interaction between protein synthesis shut-off and virus control in chickens.

Preoperative patient selection with magnetic resonance imaging, computed tomography, and electroencephalography: does the test predict outcome after cervical surgery?

OBJECT: The objective of this systematic review was to use evidence-based medicine to assess whether preoperative imaging or electromyography (EMG) predicts surgical outcomes in patients undergoing cervical surgery. METHODS: The National Library of Medicine and Cochrane Database were queried using MeSH headings and keywords relevant to the preoperative imaging and EMG. Abstracts were reviewed after which studies meeting inclusion criteria were selected. The guidelines group assembled an evidentiary table summarizing the quality of evidence (Classes I-III). Disagreements regarding the level of evidence were resolved through an expert consensus conference. The group formulated recommendations that contained the degree of strength based on the Scottish Intercollegiate Guidelines network. Validation was done through peer review by the Joint Guidelines Committee of the American Association of Neurological Surgeons/Congress of Neurological Surgeons. RESULTS: Preoperative MR imaging and CT myelography are successful in confirming clinical radiculopathy (Class II). Multilevel T2 hyperintensity, T1 focal hypointensity combined with T2 focal hyperintensity, and spinal cord atrophy each convey a poor prognosis (Class III). There is conflicting data concerning whether focal T2 hyperintensity or cervical stenosis are associated with a worse outcome. Electromyography has mixed utility in predicting outcome (Class III). CONCLUSIONS: Magnetic resonance imaging or CT myelography are important for preoperative assessment. Magnetic resonance imaging may be helpful in assessing prognosis, whereas EMG has mixed utility in assessing outcome.

Introduction and methodology: guidelines for the surgical management of cervical degenerative disease.

In March 2006, the Joint Section on Disorders of the Spine and Peripheral Nerves of the American Association of Neurological Surgeons and Congress of Neurological Surgeons compiled an expert group to perform an evidence-based review of the clinical literature on management of cervical degenerative spine disease. This process culminated in the formation of the Guidelines for the Surgical Management of Cervical Degenerative Disease. The purpose of the Guidelines was to address questions regarding the therapy, diagnosis, and prognosis of cervical degenerative disease using an evidence-based approach. Development of an evidence-based review and recommendations is a multitiered process. Typical guideline development consists of 5 processes: 1) collection and selection of the evidence; 2) assessment of the quality and strength of the evidence; 3) analysis of the evidentiary data; 4) formulation of recommendations; and 5) guideline validation. This manuscript details the methodology in compiling the Guidelines for the Surgical Management of Cervical Degenerative Disease.

The natural history of cervical spondylotic myelopathy.

OBJECT: The objective of this systematic review was to use evidence-based medicine to delineate the natural history of cervical spondylotic myelopathy (CSM) and identify factors associated with clinical deterioration. METHODS: The National Library of Medicine and Cochrane Database were queried using MeSH headings and keywords relevant to the natural history of CSM. Abstracts were reviewed and studies meeting the inclusion criteria were selected. The guidelines group assembled an evidentiary table summarizing the quality of evidence (Classes I-III). Disagreements regarding the level of evidence were resolved through an expert consensus conference. The group formulated recommendations that contained the degree of strength based on the Scottish Intercollegiate Guidelines network. Validation was done through peer review by the Joint Guidelines Committee of the American Association of Neurological Surgeons and the Congress of Neurological Surgeons. RESULTS: The natural history of CSM is mixed: it may manifest as a slow, stepwise decline or there may be a long period of quiescence (Class III). Long periods of severe stenosis are associated with demyelination and may result in necrosis of both gray and white matter. With severe and/or long lasting CSM symptoms, the likelihood of improvement with nonoperative measures is low. Objectively measurable deterioration is rarely seen acutely in patients younger than 75 years of age with mild CSM (modified Japanese Orthopaedic Association scale score > 12; Class I). In patients with cervical stenosis without myelopathy, the presence of abnormal electromyography findings or the presence of clinical radiculopathy is associated with the development of symptomatic CSM in this patient population (Class I). CONCLUSIONS: The natural history of CSM is variable, which may affect treatment decisions.

Clinical prognostic indicators of surgical outcome in cervical spondylotic myelopathy.

OBJECT: The objective of this systematic review was to use evidence-based medicine to assess whether clinical factors predict surgical outcomes in patients undergoing cervical surgery. METHODS: The National Library of Medicine and Cochrane Database were queried using MeSH headings and keywords relevant to clinical preoperative factors. Abstracts were reviewed, and studies that met the inclusion criteria were selected. The guidelines group assembled an evidentiary table summarizing the quality of evidence (Classes I-III). Disagreements regarding the level of evidence were resolved through an expert consensus conference. The group formulated recommendations that contained the degree of strength based on the Scottish Intercollegiate Guidelines network. Validation was done through peer review by the Joint Guidelines Committee of the American Association of Neurological Surgeons/Congress of Neurological Surgeons. RESULTS: Preoperative sensory-evoked potentials may aid in providing prognostic information in selected patients in whom clinical factors do not provide clear guidance (Class II). Age, duration of symptoms, and preoperative neurological function may commonly affect outcome (Class III). CONCLUSIONS: Age, duration of symptoms, and preoperative neurological function should be discussed with patients when surgical intervention for cervical spondylotic myelopathy is considered. Preoperative sensory-evoked potentials may be considered for patients in whom clinical factors do not provide clear guidance if such information would potentially change therapeutic decisions.

Cervical surgical techniques for the treatment of cervical spondylotic myelopathy.

OBJECT: The objective of this systematic review was to use evidence-based medicine to compare the efficacy of different surgical techniques for the treatment of cervical spondylotic myelopathy (CSM). METHODS: The National Library of Medicine and Cochrane Database were queried using MeSH headings and keywords relevant to anterior and posterior cervical spine surgery and CSM. The guidelines group assembled an evidentiary table summarizing the quality of evidence (Classes I-III). The group formulated recommendations that contained the degree of strength based on the Scottish Intercollegiate Guidelines network. Validation was done through peer review by the Joint Guidelines Committee of the American Association of Neurological Surgeons/Congress of Neurological Surgeons. RESULTS: A variety of techniques have improved functional outcome after surgical treatment for CSM, including anterior cervical discectomy with fusion (ACDF), anterior cervical corpectomy with fusion (ACCF), laminoplasty, laminectomy, and laminectomy with fusion (Class III). Anterior cervical discectomy with fusion and ACCF appear to yield similar results in multilevel spine decompression for lesions at the disc level. The use of anterior plating allows for equivalent fusion rates between these techniques (Class III). If anterior fixation is not used, ACCF may provide a higher fusion rate than multilevel ACDF but also a higher graft failure rate than multilevel ACDF (Class III). Anterior cervical discectomy with fusion, ACCF, laminectomy, laminoplasty, and laminectomy with arthrodesis all provide near-term functional improvement for CSM. However, laminectomy is associated with late deterioration compared with the other types of anterior and posterior surgeries (Class III). CONCLUSIONS: Multiple approaches exist with similar near-term improvements; however, laminectomy appears to have a late deterioration rate that may need to be considered when appropriate.

Cervical laminectomy for the treatment of cervical degenerative myelopathy.

OBJECT: The objective of this systematic review was to use evidence-based medicine to examine the efficacy of cervical laminectomy for the treatment of cervical spondylotic myelopathy (CSM). METHODS: The National Library of Medicine and Cochrane Database were queried using MeSH headings and keywords relevant to cervical laminectomy and CSM. Abstracts were reviewed after which studies meeting inclusion criteria were selected. The guidelines group assembled an evidentiary table summarizing the quality of evidence (Classes I-III). Disagreements regarding the level of evidence were resolved through an expert consensus conference. The group formulated recommendations that contained the degree of strength based on the Scottish Intercollegiate Guidelines network. Validation was done through peer review by the Joint Guidelines Committee of the American Association of Neurological Surgeons/Congress of Neurological Surgeons. RESULTS: Laminectomy has improved functional outcome for symptomatic cervical myelopathy (Class III). The limitations of the technique are an increased risk of postoperative kyphosis compared to anterior techniques or laminoplasty or laminectomy with fusion (Class III). However, the development of kyphosis may not necessarily to diminish the clinical outcome (Class III). CONCLUSIONS: Laminectomy is an acceptable therapy for near-term functional improvement of CSM (Class III). It is associated with development of kyphosis, however.

Laminectomy and fusion for the treatment of cervical degenerative myelopathy.

OBJECT: The objective of this systematic review was to use evidence-based medicine to examine the efficacy of cervical laminectomy and fusion for the treatment of cervical spondylotic myelopathy (CSM). METHODS: The National Library of Medicine and Cochrane Database were queried using MeSH headings and keywords relevant to cervical laminectomy, fusion, and CSM. Abstracts were reviewed, after which studies that met the inclusion criteria were selected. The guidelines group assembled an evidentiary table summarizing the quality of evidence (Class I-III). Disagreements regarding the level of evidence were resolved through an expert consensus conference. The group formulated recommendations which contained the degree of strength based on the Scottish Intercollegiate Guidelines network. Validation was done through peer-review by the Joint Guidelines Committee of the American Association of Neurological Surgeons/Congress of Neurological Surgeons. RESULTS: Cervical laminectomy with fusion (arthrodesis) improves functional outcome in patients with CSM and ossification of the posterior longitudinal ligament (OPLL). Functional improvement is similar to laminectomy or laminoplasty for patients with CSM and OPLL. In contrast to laminectomy, cervical laminectomy with fusion it is not associated with late deformity (Class III). CONCLUSIONS: Laminectomy with fusion (arthrodesis) is an effective strategy to improve functional outcome in CSM and OPLL.

Cervical laminoplasty for the treatment of cervical degenerative myelopathy.

OBJECT: The objective of this systematic review was to use evidence-based medicine to examine the efficacy of cervical laminoplasty in the treatment of cervical spondylotic myelopathy (CSM). METHODS: The National Library of Medicine and Cochrane Database were queried using MeSH headings and keywords relevant to cervical laminoplasty and CSM. Abstracts were reviewed and studies meeting the inclusion criteria were selected. The guidelines group assembled an evidentiary table summarizing the quality of evidence (Classes I-III). Disagreements regarding the level of evidence were resolved through an expert consensus conference. The group formulated recommendations that contained the degree of strength based on the Scottish Intercollegiate Guidelines network. Validation was done through peer review by the Joint Guidelines Committee of the American Association of Neurological Surgeons and Congress of Neurological Surgeons. RESULTS: Cervical laminoplasty has improved functional outcome in the setting of CSM or ossification of the posterior longitudinal ligament. Using the Japanese Orthopaedic Association scale score, approximately 55-60% average recovery rate has been observed (Class III). The functional improvement observed after laminoplasty may be limited by duration of symptoms, severity of stenosis, severity of myelopathy, and poorly controlled diabetes as negative risk factors (Class II). There is conflicting evidence regarding age, with 1 study citing it as a negative risk factor, and another not demonstrating this result. CONCLUSIONS: Cervical laminoplasty is recommended for the treatment of CSM or ossification of the posterior longitudinal ligament (Class III).

Anterior cervical surgery for the treatment of cervical degenerative myelopathy.

OBJECT: The objective of this systematic review was to use evidence-based medicine to examine the efficacy of anterior cervical surgery for the treatment of cervical spondylotic myelopathy (CSM). METHODS: The National Library of Medicine and Cochrane Database were queried using MeSH headings and key words relevant to anterior cervical surgery and CSM. Abstracts were reviewed, and studies meeting inclusion criteria were selected. The guidelines group assembled an evidentiary table summarizing the quality of evidence (Classes I-III). Disagreements regarding the level of evidence were resolved through an expert consensus conference. The group formulated recommendations that contained the degree of strength based on the Scottish Intercollegiate Guidelines network. Validation was done through peer review by the Joint Guidelines Committee of the American Association of Neurological Surgeons/Congress of Neurological Surgeons. RESULTS: Mild CSM (modified Japanese Orthopaedic Association [mJOA] scale scores > 12) responds in the short term (3 years) to either surgical decompression or nonoperative therapy (prolonged immobilization in a stiff cervical collar, "low-risk" activity modification or bed rest, and antiinflammatory medications) (Class II). More severe CSM responds to surgical decompression with benefits being maintained a minimum of 5 years and as long as 15 years postoperatively (Class III). CONCLUSIONS: Treatment of mild CSM may involve surgical decompression or nonoperative therapy for the first 3 years after diagnosis. More severe CSM (mJOA scale score

Techniques for anterior cervical decompression for radiculopathy.

OBJECT: The objective of this systematic review was to use evidence-based medicine to identify the best techniques for anterior cervical nerve root decompression. METHODS: The National Library of Medicine and Cochrane Database were queried using MeSH headings and keywords relevant to techniques for the surgical management of cervical radiculopathy. The guidelines group assembled an evidentiary table summarizing the quality of evidence (Classes I-III). The group formulated recommendations that contained the degree of strength based on the Scottish Intercollegiate Guidelines network. Validation was done through peer-review by the Joint Guidelines Committee of the American Association of Neurological Surgeons/Congress of Neurological Surgeons. RESULTS: Both anterior cervical discectomy (ACD) and anterior cervical discectomy with fusion (ACDF) are equivalent treatment strategies for 1-level disease with regard to functional outcome (Class II). Anterior cervical discectomy with fusion may achieve a more rapid reduction of neck and arm pain compared to ACD with a reduced risk of kyphosis, although functional outcomes may be similar. Anterior cervical discectomy with fusion is not a lasting means of increasing foraminal or disc height compared to ACD. Anterior cervical plating (ACDF with instrumentation) improves arm pain (but not other clinical parameters) better than ACDF in the treatment of 2-level disease (Class II). With respect to 1-level disease, plating may reduce the risk of pseudarthrosis and graft problems (Class III) but does not necessarily improve clinical outcome alone (Class II). Cervical arthroplasty is recommended as an alternative to ACDF in selected patients for control of neck and arm pain (Class II). CONCLUSIONS: Anterior cervical discectomy, ACDF, and arthroplasty are effective techniques for addressing surgical cervical radiculopathy.

Cervical laminoforaminotomy for the treatment of cervical degenerative radiculopathy.

OBJECT: The objective of this systematic review was to use evidence-based medicine to examine the efficacy of posterior laminoforaminotomy in the treatment of cervical radiculopathy. METHODS: The National Library of Medicine and Cochrane Database were queried using MeSH headings and key words relevant to posterior laminoforaminotomy and cervical radiculopathy. Abstracts were reviewed, and studies meeting inclusion criteria were selected. The guidelines group assembled an evidentiary table summarizing the quality of evidence (Classes I-III). Disagreements regarding the level of evidence were resolved through an expert consensus conference. The group formulated recommendations which contained the degree of strength based on the Scottish Intercollegiate Guidelines network. Validation was done through peer review by the Joint Guidelines Committee of the American Association of Neurological Surgeons/Congress of Neurological Surgeons. RESULTS: Posterior laminoforaminotomy improves clinical outcome in the treatment of cervical radiculopathy resulting from soft lateral cervical disc displacement or cervical spondylosis with resulting narrowing of the lateral recess. All studies were Class III. The most frequent design flaw involved the lack of utilization of validated outcomes measures. In addition, few historical studies included a detailed preoperative analysis of the patients. As such, the vast majority of studies that included both pre- and postoperative assessments with legitimate outcomes measures have been performed since 1990. CONCLUSIONS: Posterior laminoforaminotomy is an effective treatment for cervical radiculopathy.

Indications for anterior cervical decompression for the treatment of cervical degenerative radiculopathy.

OBJECT: The objective of this systematic review was to use evidence-based medicine to identify the indications and utility of anterior cervical nerve root decompression. METHODS: The National Library of Medicine and Cochrane Database were queried using MeSH headings and key words relevant to surgical management of cervical radiculopathy. Abstracts were reviewed after which studies meeting inclusion criteria were selected. The guidelines group assembled an evidentiary table summarizing the quality of evidence (Classes I-III). Disagreements regarding the level of evidence were resolved through an expert consensus conference. The group formulated recommendations that contained the degree of strength based on the Scottish Intercollegiate Guidelines network. Validation was done through peer review by the Joint Guidelines Committee of the American Association of Neurological Surgeons/Congress of Neurological Surgeons. RESULTS: Anterior nerve root decompression via anterior cervical discectomy (ACD) with or without fusion for radiculopathy is associated with rapid relief (3-4 months) of arm/neck pain, weakness, and/or sensory loss compared with physical therapy (PT) or cervical collar immobilization. Anterior cervical discectomy and ACD with fusion (ACDF) are associated with longer term (12 months) improvement in certain motor functions compared to PT. Other rapid gains observed after anterior decompression (diminished pain, improved sensation, and improved strength in certain muscle groups) are also maintained over the course of 12 months. However, comparable clinical improvements with PT or cervical immobilization therapy are also present in these clinical modalities (Class I). Conflicting evidence exists as to the efficacy of anterior cervical foraminotomy with reported success rates of 52-99% but recurrent symptoms as high as 30% (Class III). CONCLUSIONS: Anterior cervical discectomy, ACDF, and anterior cervical foraminotomy may improve cervical radicular symptoms. With regard to ACD and ACDF compared to PT or cervical immobilization, more rapid relief (within 3-4 months) may be seen with ACD or ACDF with maintenance of gains over the course of 12 months (Class I). Anterior cervical foraminotomy is associated with improvement in clinical function but the quality of data are weaker (Class III), and there is a wide range of efficacy (52-99%).

Techniques for cervical interbody grafting.

OBJECT: The objective of this systematic review was to use evidence-based medicine to determine the efficacy of interbody graft techniques. METHODS: The National Library of Medicine and Cochrane Database were queried using MeSH headings and keywords relevant to cervical interbody grafting. Abstracts were reviewed and studies that met the inclusion criteria were selected. The guidelines group assembled an evidentiary table summarizing the quality of evidence (Classes I-III). Disagreements regarding the level of evidence were resolved through an expert consensus conference. The group formulated recommendations that contained the degree of strength based on the Scottish Intercollegiate Guidelines network. Validation was done through peer review by the Joint Guidelines Committee of the American Association of Neurological Surgeons/Congress of Neurological Surgeons. RESULTS: Autograft bone harvested from the iliac crest, allograft bone from either cadaveric iliac crest or fibula, or titanium cages and rectangular fusion devices, with or without the use of autologous graft or substitute, have been successful in creating arthrodesis after 1- or 2-level anterior cervical discectomy with fusion (Class II). Alternatives to autograft, allograft, or titanium cages include polyetheretherketone cages and carbon fiber cages (Class III). Polyetheretherketone cages have been used successfully with or without hydroxyapatite for anterior cervical discectomy with fusion. Importantly, recombinant human bone morphogenic protein-2 carries a complication rate of up to 23-27% (especially local edema) compared with 3% for a standard approach. CONCLUSIONS: Current evidence does not support the routine use of interbody grafting for cervical arthrodesis. Multiple strategies for interbody grafting have been successful with Class II evidence supporting the use of autograft, allograft, and titanium cages.

Radiographic assessment of cervical subaxial fusion.

OBJECT: The objective of this systematic review was to use evidence-based medicine to identify the best methodology for radiographic assessment of cervical subaxial fusion. METHODS: The National Library of Medicine and Cochrane Database were queried using MeSH headings and keywords relevant to cervical fusion. Abstracts were reviewed and studies meeting inclusion criteria were selected. The guidelines group assembled an evidentiary table summarizing the quality of evidence (Classes I-III). Disagreements regarding the level of evidence were resolved through an expert consensus conference. The group formulated recommendations that contained the degree of strength based on the Scottish Intercollegiate Guidelines network. Validation was done through peer review by the Joint Guidelines Committee of the American Association of Neurological Surgeons/Congress of Neurological Surgeons. RESULTS: Pseudarthrosis is best assessed through the absence of motion detected between the spinous processes on dynamic radiographs (Class II). The measurement of interspinous distance on dynamic radiographs of >or= 2 mm is a more reliable indicator for pseudarthrosis than angular motion of 2 degrees based on Cobb angle measurements (Class II). Similarly, it is also understood that the pseudarthrosis rate will increase as the threshold for allowable motion on dynamic radiographs decreases. The combination of interspinous distance measurements and identification of bone trabeculation is unreliable when performed by the treating surgeon (Class II). Identification of bone trabeculation on static radiographs should be considered a less reliable indicator of cervical arthrodesis than dynamic films (Class III). CONCLUSIONS: Consideration should be given to dynamic radiographs and interspinous distance when assessing for pseudarthrosis.