Journal of neurosurgery. Spine
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Health-related quality of life (HRQOL) measures have become the mainstay for outcome appraisal in spine surgery. Clinically meaningful interpretation of HRQOL improvement has centered on the minimum clinically important difference (MCID). The purpose of this study was to calculate clinically important deterioration (CIDET) thresholds and determine a CIDET value for each HRQOL measure for patients undergoing lumbar fusion. ⋯ A threshold for clinical deterioration was difficult to identify. This may be due to the small number of patients reporting being worse after surgery and the variability across methods to determine CIDET thresholds. Overall, it appears that patients may interpret the absence of change as deterioration.
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Several controversial issues arise in the management of unstable hangman's fractures. Some surgeons perform external reduction and immobilize the patient's neck in a halo vest, while others perform surgical reduction and internal fixation. The nonsurgical treatments with rigid collar or halo vest immobilization present problems, including nonunion, pseudarthrosis, skull fracture, and scalp laceration and may also fail to achieve anatomical realignment of the local C2-3 kyphosis. With recent advances in surgical technique and technology, surgical intervention is increasingly performed as the primary treatment in high cervical fractures. The outcomes of such surgeries are often superior to those of conservative treatment. The authors propose that surgical intervention as a primary management for hangman's fracture may avoid risks inherent in conservative management when severe circumferential discoligamentous instability is present and may reduce the risk of catastrophic results at the fracture site. The purposes of this study were to assess fracture healing following expedient reduction and surgical fixation and to propose a guideline for treatment of unstable hangman's fractures. ⋯ The authors observed effective reduction and bony healing in cases of unstable hangman's fractures after fixation, and all patients experienced favorable clinical outcomes with neck pain improvement. The protocols allowed for physiological reconstruction of the fractured deformities and avoided external fixation. The authors suggest that posterior reduction and screw fixation should be used as a primary treatment to promote stability of hangman's fracture in the presence of discoligamentous instability or combined fractures.
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Clearance of the cervical spine in patients who have sustained trauma remains a contentious issue. Clinical examination alone is sufficient in neurologically intact patients without neck pain. Patients with neck pain or those with altered mental status or a depressed level of consciousness require further radiographic evaluation. However, no consensus exists as to the appropriate imaging modality. Some advocate multidetector CT (MDCT) scanning alone, but this has been criticized because MDCT is not sensitive in detecting ligamentous injuries that can often only be identified on MRI. ⋯ In this study population, MRI did not add any additional information beyond MDCT in identifying unstable cervical spine injuries. Magnetic resonance imaging frequently detected ligamentous injuries, none of which were found to be unstable at the time of detection, during the course of admission, or on follow-up. Magnetic resonance imaging provided beneficial clinical information and guided surgical procedures in patients with neurological deficits or radicular pain. An MDCT study with sagittal and coronal reconstructions negative for acute injury in patients without an abnormal motor examination may be sufficient alone for clearance.
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Comparative Study
Cost-effectiveness analysis: comparing single-level cervical disc replacement and single-level anterior cervical discectomy and fusion: clinical article.
In recent years, there has been increased interest in the use of cervical disc replacement (CDR) as an alternative to anterior cervical discectomy and fusion (ACDF). While ACDF is a proven intervention for patients with myelopathy or radiculopathy, it does have inherent limitations. Cervical disc replacement was designed to preserve motion, avoid the limitations of fusion, and theoretically allow for a quicker return to activity. A number of recently published systematic reviews and randomized controlled trials have demonstrated positive clinical results for CDR, but no studies have revealed which of the 2 treatment strategies is more cost-effective. The purpose of this study was to evaluate the cost-effectiveness of CDR and ACDF by using the power of decision analysis. Additionally, the authors aimed to identify the most critical factors affecting procedural cost and effectiveness and to define thresholds for durability and function to focus and guide future research. ⋯ Both CDR and ACDF were shown to be cost-effective procedures in the reference case. Results of the sensitivity analysis indicated that CDR must remain functional for at least 14 years to establish greater cost-effectiveness than ACDF. Since the current literature has yet to demonstrate with certainty the actual durability and long-term functionality of CDR, future long-term studies are required to validate the present analysis.