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Study Design Prospective cohort study. Objective To report the clinical course of patients with MRI-confirmed lumbar disc herniation-related radicular noncentralizing pain who received transforaminal epidural steroid injections ( TESIs) and mechanical diagnosis and therapy ( MDT). Summary of Background Data Noncentralizing symptoms in patients with lumbar disc herniation are associated with poor outcome. Commonly used treatments for these patients include TESIs and MDT. No study has evaluated the outcome of combining both strategies. Methods Consecutive candidates for herniated lumbar disc surgery with noncentralizing chronic pain were eligible. Patients received TESIs followed by MDT. The primary outcomes were pain severity in the leg, disability ( Roland- Morris Disability Questionnaire for Sciatica), and global perceived effect ( GPE). Outcomes were measured at baseline, discharge, and 12 months. Linear mixed-models and McNemar's tests were used to analyze outcome data. Results Sixty-nine patients receive TESIs. After TESIs, symptoms were resolved completely in 11 patients (16%). In these patients, symptom resolution was maintained at 12 months. A second subgroup of 32 patients (46%) reported significantly less pain after TESIs and showed centralization with MDT reassessment (significant reductions in leg pain and disability [ P < 0.001]) and a satisfaction rate of 90% at 12 months. A third subgroup of 11 patients (16%) reported significantly less pain after TESIs but still showed noncentralization with MDT reassessment (significant reductions in leg pain and disability [ P < 0.05] and a satisfaction rate of 50% at 12 months). A fourth subgroup of 15 patients (22%) did not respond on TESIs and received an operative intervention. Conclusion The results indicate that a course of TESIs followed by MDT may be able to avoid surgery in a substantial proportion of candidates for herniated lumbar disc surgery. [ABSTRACT FROM AUTHOR]

Background: Thoracic disc surgery can lead to a lifethreatening complication: intracranial hypotension due to a subarachnoidpleural fistula. Case Description: We report a 63yearold male with paraparesis due to multiple herniated thoracic discs, with compressive myelopathy. The patient required a circumferential procedure including a laminectomy/fusion followed by an anterior thoracic decompression to address both diffuse idiopathic skeletal hyperostosis (DISH) anteriorly and posterior stenosis. The postoperative course was complicated by severe intracranial hypotension attributed to the erroneous placement of a lowpressure drain placed in the pleural cavity instead of a lumbar drain; this resulted in subdural hematoma's necessitating subsequent surgery. Conclusion: Severe neurological deterioration occurring after thoracic decompressive surgery may rarely be attributed to intracranial hypotension due to a subarachnoidpleural fistula. Patients should be treated with external lumbar drainage of cerebrospinal fluid for 3-5 days rather than a lowpressure pleural drain to avoid the onset of intracranial hypotension leading to symptomatic subdural hematomas. [ABSTRACT FROM AUTHOR]

Objective: To determine whether implanting an annular closure device (ACD) following a lumbar discectomy procedure in patients with large defects in the annulus fibrosus lowers the risk of reoperation after 4 years., Methods: In a multicenter randomized trial, patients with large annular defects following single-level lumbar discectomy were intraoperatively randomized to additionally receive an ACD or no treatment (Controls). Clinical and imaging follow-up were performed at routine intervals over 4 years of follow-up. Main outcomes included reoperations at the treated lumbar level, leg pain scores on a visual analog scale, Oswestry Disability Index (ODI), and Physical Component Summary (PCS) and Mental Component Summary (MCS) scores from the SF-36 questionnaire., Results: Among 550 patients (ACD 272, Control 278), the risk of reoperation over 4 years was 14.4% with ACD and 21.1% with Controls ( P =0.03). The reduction in reoperation risk with ACD was not significantly influenced by patient age ( P =0.51), sex ( P =0.34), body mass index ( P =0.21), smoking status ( P =0.85), level of herniation ( P =0.26), leg pain severity at baseline ( P =0.90), or ODI at baseline ( P =0.54). All patient-reported outcomes improved in each group from baseline to 4 years (all P <0.001). The percentage of patients who achieved the minimal clinically important difference without a reoperation was proportionally higher in the ACD group compared to Controls for leg pain ( P =0.07), ODI ( P =0.10), PCS ( P =0.02), and MCS ( P =0.06)., Conclusion: The addition of a bone-anchored ACD following lumbar discectomy in patients with large post-surgical annular defects reduces the risk of reoperation and provides better long-term pain and disability relief over 4 years compared to lumbar discectomy only., Competing Interests: Mark P Arts reports consultancy with Intrinsic Therapeutics; personal fees from Zimmer-Biomet, EIT, and Silony, outside the submitted work; and receipt of royalties from EIT. Larry Miller reports consultancy with Intrinsic Therapeutics. The authors report no other conflicts of interest in this work., (© 2019 Nanda et al.)

Purpose: Anterior cervical discectomy with fusion is a common procedure for treating radicular arm pain. Polyetheretherketone (PEEK) plastic is a frequently used material in cages for interbody fusion. Silicon nitride is a new alternative with desirable bone compatibility and imaging characteristics. The aim of the present study is to compare silicon nitride implants with PEEK cages filled with autograft harvested from osteophytes., Methods: The study is a prospective, randomized, blinded study of 100 patients with 2 years follow-up. The primary outcome measure was improvement in the Neck Disability Index. Other outcome measures included SF-36, VAS arm pain, VAS neck pain, assessment of recovery, operative characteristics, complications, fusion and subsidence based on dynamic X-ray and CT scan., Results: There was no significant difference in NDI scores between the groups at 24 months follow-up. At 3 and 12 months the NDI scores were in favor of PEEK although the differences were not clinically relevant. On most follow-up moments there was no difference in VAS neck and VAS arm between both groups, and there was no statistically significant difference in patients' perceived recovery during follow-up. Fusion rate and subsidence were similar for the two study arms and about 90% of the implants were fused at 24 months., Conclusions: Patients treated with silicon nitride and PEEK reported similar recovery rates during follow-up. There was no significant difference in clinical outcome at 24 months. Fusion rates improved over time and are comparable between both groups.

Question: Is referral for early rehabilitation after lumbar disc surgery effective and cost-effective compared to no referral?, Design: Multicentre, randomised, controlled trial, and economic evaluation with concealed allocation and intention-to-treat-analysis., Participants: Adults who underwent discectomy for a herniated lumbar disc, confirmed by magnetic resonance imaging, and signs of nerve root compression corresponding to the herniation level., Intervention: Early rehabilitation (exercise therapy) for 6 to 8 weeks, versus no referral, immediately after discharge., Outcome Measures: In line with the recommended core outcome set, the co-primary outcomes were: functional status (Oswestry Disability Index); leg and back pain (numerical rating scale 0 to 10); global perceived recovery (7-point Likert scale); and general physical and mental health (SF12), assessed 3, 6, 9, 12 and 26 weeks after surgery. The outcomes for the economic evaluation were quality of life and costs, measured at 6, 12 and 26 weeks after surgery., Results: There were no clinically relevant or statistically significant overall mean differences between rehabilitation and control for any outcome adjusted for baseline characteristics: global perceived recovery (OR 1.0, 95% CI 0.6 to 1.7), functional status (MD 1.5, 95% CI -3.6 to 6.7), leg pain (MD 0.1, 95% CI -0.7 to 0.8), back pain (MD 0.3, 95% CI -0.3 to 0.9), physical health (MD -3.5, 95% CI -11.3 to 4.3), and mental health (MD -4.1, 95% CI -9.4 to 1.3). After 26 weeks, there were no significant differences in quality-adjusted life years (MD 0.01, 95% CI -0.02 to 0.04 points) and societal costs (MD -€527, 95% CI -2846 to 1506). The maximum probability for the intervention to be cost-effective was 0.75 at a willingness-to-pay of €32 000/quality-adjusted life year., Conclusion: Early rehabilitation after lumbar disc surgery was neither more effective nor more cost-effective than no referral., Trial Registration: Netherlands Trial Register NTR3156. [Oosterhuis T, Ostelo RW, van Dongen JM, Peul WC, de Boer MR, Bosmans JE, Vleggeert-Lankamp CL, Arts MP, van Tulder MW (2017) Early rehabilitation after lumbar disc surgery is not effective or cost-effective compared to no referral: a randomised trial and economic evaluation. Journal of Physiotherapy 63: 144-153]., (Copyright © 2017. Published by Elsevier B.V.)

Background: Cervical spondylotic myelopathy (CSM) is often encountered in daily practice. In this randomized controlled trial, laminectomy without fusion is compared with laminectomy followed by fusion., Methods: Patients with clinical signs and symptoms of CSM were included. At regular follow-up moments a Modified Japanese Orthopedic Association (mJOA) Score, a Short Form (36) (SF-36) and upright cervical radiographs to measure the angle between C2 and C7, were obtained., Results: Nine patients were included in each group (total 18 patients). At the last follow-up, a difference in mJOA or SF-36 could not be established. However, it was clearly shown that a more successful outcome, as measured by mJOA and SF-36, was obtained in patients who had fewer complaints preoperatively., Conclusions: A difference in clinical outcome or quality of life between the groups did not exist. It was clearly shown that the outcome of the patients was strongly dependent on the preoperative clinical situation.

Background Context: In the 1980s, a new implant was developed to treat patients with intermittent neurogenic claudication caused by lumbar spinal stenosis (LSS). This implant is now widely used., Purpose: The objective of this study is to determine whether a favorable cost-effectiveness for interspinous process devices (IPDs) compared with conventional bony decompression is attained., Study Design/setting: Cost-utility analysis was performed alongside a double-blind randomized controlled trial. Five neurosurgical centers (including one academic and four secondary level care centers) included participants for this study., Patient Sample: One hundred fifty-nine patients with LSS were treated with the implantation of IPD and with bony decompression. Eighty participants received an IPD, and seventy-nine participants underwent spinal bony decompression., Outcome Measures: Outcome measures were quality-adjusted life-years (QALYs) and societal costs in the first year (estimated per quarter), estimated from patient-reported utilities (US and The Netherlands EuroQol 5D [EQ-5D] and EuroQol visual analog scale) and diaries on costs (health-care costs, patient costs, and productivity costs)., Methods: All analyses followed the intention-to-treat principle. Given the statistical uncertainty of differences between costs and QALYs, cost-effectiveness acceptability curves graph the probability that a strategy is cost effective, as a function of willingness to pay. Paradigm Spine funded this trial but did not have any part in data analysis or the design and preparation of this article., Results: According to the EQ-5D, the valuation of quality of life after IPD and decompression was not different. Mean utilities during all four quarters were, not significantly, less favorable after IPD according to the EQ-5D with a decrease in QALYs according to the US EQ-5D of 0.024 (95% confidence interval, -0.031 to 0.079). From a health-care perspective, the costs of IPD treatment were higher (difference €3,030 per patient, 95% confidence interval, €561-€5,498). This significant difference is mainly because of additional cost of implants of €2,350 apiece. From a societal perspective, a nonsignificant difference of €2,762 (95% confidence interval, -€1,572 to €7,095) in favor of conventional bony decompression was found., Conclusions: Implantation of IPD as indirect decompressing device is highly unlikely to be cost effective compared with bony decompression for patients with intermittent neurogenic claudication caused by LSS., Trial Registration: Dutch Trial Register Number: NTR1307., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: Thoracic disc surgery can lead to a life-threatening complication: intracranial hypotension due to a subarachnoid-pleural fistula., Case Description: We report a 63-year-old male with paraparesis due to multiple herniated thoracic discs, with compressive myelopathy. The patient required a circumferential procedure including a laminectomy/fusion followed by an anterior thoracic decompression to address both diffuse idiopathic skeletal hyperostosis (DISH) anteriorly and posterior stenosis. The postoperative course was complicated by severe intracranial hypotension attributed to the erroneous placement of a low-pressure drain placed in the pleural cavity instead of a lumbar drain; this resulted in subdural hematoma's necessitating subsequent surgery., Conclusion: Severe neurological deterioration occurring after thoracic decompressive surgery may rarely be attributed to intracranial hypotension due to a subarachnoid-pleural fistula. Patients should be treated with external lumbar drainage of cerebrospinal fluid for 3-5 days rather than a low-pressure pleural drain to avoid the onset of intracranial hypotension leading to symptomatic subdural hematomas.

Background Context: Percutaneous laser disc decompression (PLDD) is a minimally invasive treatment for lumbar disc herniation, with Food and Drug Administration approval since 1991. However, no randomized trial comparing PLDD to conventional treatment has been performed., Purpose: In this trial, we assessed the effectiveness of a strategy of PLDD as compared with conventional surgery., Study Design/setting: This randomized prospective trial with a noninferiority design was carried out in two academic and six teaching hospitals in the Netherlands according to an intent-to-treat protocol with full institutional review board approval., Patient Sample: One hundred fifteen eligible surgical candidates, with sciatica from a disc herniation smaller than one-third of the spinal canal, were included., Outcome Measures: The main outcome measures for this trial were the Roland-Morris Disability Questionnaire for sciatica, visual analog scores for back and leg pain, and the patient's report of perceived recovery., Methods: Patients were randomly allocated to PLDD (n=57) or conventional surgery (n=58). Blinding was impossible because of the nature of the interventions. This study was funded by the Healthcare Insurance Board of the Netherlands., Results: The primary outcome, Roland-Morris Disability Questionnaire, showed noninferiority of PLDD at 8 (-0.1; [95% confidence interval (CI), -2.3 to 2.1]) and 52 weeks (-1.1; 95% CI, -3.4 to 1.1) compared with conventional surgery. There was, however, a higher speed of recovery in favor of conventional surgery (hazard ratio, 0.64 [95% CI, 0.42-0.97]). The number of reoperations was significantly less in the conventional surgery group (38% vs. 16%). Overall, a strategy of PLDD, with delayed surgery if needed, resulted in noninferior outcomes at 1 year., Conclusions: At 1 year, a strategy of PLDD, followed by surgery if needed, resulted in noninferior outcomes compared with surgery., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background Context: Expandable cages are widely used to reconstruct the spine after the removal of vertebral metastases. Long-term results, however, are lacking, and there is little information on reconstruction after multilevel corpectomies., Purpose: To determine long-term outcome for reconstruction of the spine with expandable cages after single and multilevel corpectomies for spinal metastases., Study Design: A prospective cohort study of 60 consecutive patients with spinal metastases treated with expandable cages., Methods: All patients were prospectively followed with regular clinical and radiographic evaluation. Outcome measures were the Frankel score, patients' self-reported recovery, radiological alignment of the spine, and neurologic plus biomechanical complications., Results: Sixty patients were treated with expandable cages in our hospital in a 5-year period with a maximum follow-up of 6 years. Single-level reconstruction was performed in 48 cases, 2-level in 8, and 3-level in 4. Postoperatively, the Frankel score had improved significantly (p=.03), the segment height had increased (p=.02), and, in severe cases of kyphosis (>20°), the regional angulation had been corrected compared with preoperatively (p<.001). Complication rate, however, was high (36.7%), in particular after multilevel reconstruction, in which three cases had to be reoperated years after the initial surgery; reasons for this were hardware failure, progressive kyphosis, and bronchial perforation. Good recovery was reported in 70% of all patients., Conclusions: Expandable cages can be used successfully in reconstruction of the spine after single and multilevel corpectomies for spinal metastases. However, long-term complication rate is high. Promotion of bony fusion, prevention of soft-tissue damage, adequate posterior stabilization, and careful patient selection may reduce these complications., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background Context: The optimal surgical treatment of thoracic disc herniations remains controversial and depends on the consistency of the herniation and its location related to the spinal cord., Purpose: To compare the outcomes of patients with symptomatic thoracic disc herniations treated with anterolateral mini-transthoracic approach (TTA) versus posterior transpedicular discectomy., Study Design: This is a prospective comparative cohort study., Patient Sample: One hundred consecutive patients with symptomatic thoracic herniated discs were operated by mini-TTA (56 patients) or transpedicular discectomy (44 patients)., Outcome Measures: Neurologic assessment by American Spinal Injury Association (ASIA) Impairment Scale and patients' self reported perceived recovery and complications., Methods: The consistency and location of the herniated disc in relation to the spinal cord was evaluated by preoperative computed tomography and magnetic resonance imaging. Patients were assessed neurologically before surgery and at regular outpatient controls at 2 months or later. Long-term follow-up was achieved by questionnaires sent by mail., Results: In both groups, most patients had symptoms of myelopathy and radicular pain; patients who underwent mini-TTA, more frequently suffered from spasticity. Fifty-eight percent of the herniated discs were calcified and 77% were larger than one-third of the spinal canal. All patients presented with ASIA Grade C or D (64%) or ASIA Grade E (36%). Postoperatively, 50% of the patients treated with mini-TTA and 37% of the transpedicular group improved at least one grade on the ASIA scale (p=.19). The duration of surgery, blood loss, hospital stay, and complication rate were significantly higher in patients treated with mini-TTA and were mainly related to the magnitude and consistency of the herniated disc. At long-term follow-up, 72% of the mini-TTA patients reported good outcome versus 76% of the transpedicular discectomy group (p=.80)., Conclusions: Surgical treatment of a symptomatic herniated disc contributed to a clinical improvement in most cases. The approach is dependent on the location, the magnitude, and the consistency of the herniated thoracic disc. Medially located large calcified discs should be operated through an anterolateral approach, whereas noncalcified or lateral herniated discs can be treated from a posterior approach as well. For optimal treatment of this rare entity, the treatment should be performed in selected centers., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Introduction: Juvenile chronic arthritis (JCA) is a systemic disease of childhood affecting particularly joints. JCA is a heterogeneous group of inflammatory joint disorders with onset before the age of 16 years and is comprised of 7 subtype groups. The pathogenesis of JCA seen in the cervical spine is synovial inflammation, hyperaemia, and pannus formation at the occipitoatlantoaxial joints resulting in characteristic craniovertebral junction findings. Treatment of craniovertebral junction instability as a result of JCA is a challenge. The best treatment strategy may be difficult because of various radiological and clinical severities. A review of the literature and management considerations is presented., Review: No randomised controlled trial or systematic review on this subject has been published. Only experts' opinions, case reports, and case series have been described. Thirty-four studies have been reviewed in this study. Involvement of the cervical spine in patients with JCA can lead to pain and functional disability. The subtypes that usually affect the cervical spine are the polyarticular type and systemic onset type and rarely the pauciarticular type. The most common cervical spine changes related to JCA are as follows: (1) apophyseal joint ankylosis at C2-C3, (2) atlantoaxial subluxation, (3) atlantoaxial impaction, (4) atlantoaxial rotatory fixation, and (5) growth disturbances of the cervical spine. The incidence of severe subluxations has decreased in the last decade as result of antirheumatoid drugs and biologicals. However, neurological compromise still occurs in JCA patients necessitating surgical treatment., Conclusion: Whenever the cervical spine is involved in rheumatoid arthritis patients without neurological deficits, conservative treatment is legitimate. Once patients develop neurological signs and symptoms, surgical treatment should be considered with particular focus to age, severity of the disease, and general health condition. Skilled anaesthesia is crucial and the surgical procedure should only be carried out in centres with experience in craniovertebral junction abnormalities.