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AimsRepeated lumbar spine surgery has been associated with inferior clinical outcomes. This study aimed to examine and quantify the impact of this association in a national clinical register cohort.MethodsThis is a population-based study from the Norwegian Registry for Spine surgery (NORspine). We included 26,723 consecutive cases operated for lumbar spinal stenosis or lumbar disc herniation from January 2007 to December 2018. The primary outcome was the Oswestry Disability Index (ODI), presented as the proportions reaching a patient-acceptable symptom state (PASS; defined as an ODI raw score ≤ 22) and ODI raw and change scores at 12-month follow-up. Secondary outcomes were the Global Perceived Effect scale, the numerical rating scale for pain, the EuroQoL five-dimensions health questionnaire, occurrence of perioperative complications and wound infections, and working capability. Binary logistic regression analysis was conducted to examine how the number of previous operations influenced the odds of not reaching a PASS.ResultsThe proportion reaching a PASS decreased from 66.0% (95% confidence interval (CI) 65.4 to 66.7) in cases with no previous operation to 22.0% (95% CI 15.2 to 30.3) in cases with four or more previous operations (p < 0.001). The odds of not reaching a PASS were 2.1 (95% CI 1.9 to 2.2) in cases with one previous operation, 2.6 (95% CI 2.3 to 3.0) in cases with two, 4.4 (95% CI 3.4 to 5.5) in cases with three, and 6.9 (95% CI 4.5 to 10.5) in cases with four or more previous operations. The ODI raw and change scores and the secondary outcomes showed similar trends.ConclusionWe found a dose-response relationship between increasing number of previous operations and inferior outcomes among patients operated for degenerative conditions in the lumbar spine. This information should be considered in the shared decision-making process prior to elective spine surgery.Cite this article: Bone Joint J 2023;105-B(4):422–430.

Background The Norwegian registry for spine surgery (NORspine) is a national clinical quality registry which has recorded more than 10,000 operations for degenerative conditions of the cervical spine since 2012. Registries are large observational cohorts, at risk for attrition bias. We therefore aimed to examine whether clinical outcomes differed between respondents and non-respondents to standardized questionnaire-based 12-month follow-up. Methods All eight public and private providers of cervical spine surgery in Norway report to NORspine. We included 334 consecutive patients who were registered with surgical treatment of degenerative conditions in the cervical spine in 2018 and did a retrospective analysis of prospectively collected register data and data on non-respondents’ outcomes collected by telephone interviews. The primary outcome measure was patient-reported change in arm pain assessed with the numeric rating scale (NRS). Secondary outcome measures were change in neck pain assessed with the NRS, change in health-related quality of life assessed with EuroQol 5 Dimensions (EQ-5D), and patients’ perceived benefit of the operation assessed by the Global Perceived Effect (GPE) scale. Results At baseline, there were few and small differences between the 238 (71.3%) respondents and the 96 (28.7%) non-respondents. We reached 76 (79.2%) non-respondents by telephone, and 63 (65.6%) consented to an interview. There was no statistically significant difference between groups in change in NRS score for arm pain (3.26 (95% CI 2.84 to 3.69) points for respondents and 2.77 (1.92 to 3.63) points for telephone interviewees) or any of the secondary outcome measures. Conclusions The results indicate that patients lost to follow-up were missing at random. Analyses of outcomes based on data from respondents can be considered representative for the complete register cohort, if patient characteristics associated with attrition are controlled for.

Purpose By using data from the Norwegian Registry for Spine Surgery, we wanted to develop and validate prediction models for non-success in patients operated with anterior surgical techniques for cervical degenerative radiculopathy (CDR). Methods This is a multicentre longitudinal study of 2022 patients undergoing CDR surgery and followed for 12 months to find prognostic models for non-success in neck disability and arm pain using multivariable logistic regression analysis. Model performance was evaluated by area under the receiver operating characteristic curve (AUC) and a calibration test. Internal validation by bootstrapping re-sampling with 1000 repetitions was applied to correct for over-optimism. The clinical usefulness of the neck disability model was explored by developing a risk matrix for individual case examples. Results Thirty-eight percent of patients experienced non-success in neck disability and 35% in arm pain. Loss to follow-up was 35% for both groups. Predictors for non-success in neck disability were high physical demands in work, low level of education, pending litigation, previous neck surgery, long duration of arm pain, medium-to-high baseline disability score and presence of anxiety/depression. AUC was 0.78 (95% CI, 0.75, 0.82). For the arm pain model, all predictors for non-success in neck disability, except for anxiety/depression, were found to be significant in addition to foreign mother tongue, smoking and medium-to-high baseline arm pain. AUC was 0.68 (95% CI, 0.64, 0.72). Conclusion The neck disability model showed high discriminative performance, whereas the arm pain model was shown to be acceptable. Based upon the models, individualized risk estimates can be made and applied in shared decision-making with patients referred for surgical assessment.

Purpose Treatment success can be defined by asking a patient how they perceive their condition compared to prior to treatment, but it can also be defined by establishing success criteria in advance. We evaluated treatment outcome expectations in patients undergoing surgery or non-operative treatment for cervical radiculopathy. Methods The first 100 consecutive patients from an ongoing randomized controlled trial (NCT03674619) comparing the effectiveness of surgical and nonsurgical treatment for cervical radiculopathy were included. Patient-reported outcome measures and expected outcome and improvement were obtained before treatment. We compared these with previously published cut-off values for success. Arm pain, neck pain and headache were measured by a numeric rating scale. Neck disability index (NDI) was used to record pain-related disability. We applied Wilcoxon signed-rank test to compare the expected outcome scores for the two treatments. Results Patients reported mean NDI of 42.2 (95% CI 39.6–44.7) at baseline. The expected mean NDI one year after the treatment was 4 (95% CI 3.0–5.1). The expected mean reduction in NDI was 38.3 (95% CI 35.8–40.8). Calculated as a percentage change score, the patients expected a mean reduction of 91.2% (95% CI 89.2–93.2). Patient expectations were higher regarding surgical treatment for arm pain, neck pain and working ability, P Conclusions The expected improvement after treatment of cervical radiculopathy was much higher than the previously reported cut-off values for success. Patients with cervical radiculopathy had higher expectations to surgical treatment.

Key Points Question In patients with cervical radiculopathy, are there any differences in long-term outcomes after surgery with arthroplasty or fusion? Findings In this randomized clinical trial that included 136 patients with cervical radiculopathy, there were similar and significant improvements in Neck Disability Index scores for both treatment groups at the 5-year follow-up. There was no statistically significant difference in change of Neck Disability Index score at 5 years between patients who underwent arthroplasty and fusion. Meaning These findings suggest that arthroplasty and fusion are both good treatment options for cervical radiculopathy and have similar long-term efficacy., This randomized clinical trial examines 5-year outcomes among patients who underwent surgical treatment for cervical radiculopathy with arthroplasty vs fusion., Importance Surgical treatment for cervical radiculopathy is increasing. Treatment with motion preserving anterior cervical disc arthroplasty was introduced to prevent symptomatic adjacent segment disease, and there is need to evaluate results of this treatment compared with standard anterior cervical discectomy and fusion. Objective To investigate clinical outcomes at 5 years for arthroplasty vs fusion in patients who underwent surgical treatment for cervical radiculopathy. Design, Setting, and Participants This multicenter, single-blinded, randomized clinical trial included patients aged 25 to 60 years with C6 or C7 radiculopathy referred to study sites’ outpatient clinics from 2008 to 2013. Data were analyzed from December 2019 to December 2020. Interventions Patients were randomly assigned to arthroplasty or fusion. Patients were blinded to which treatment they received. The surgical team was blinded until nerve root decompression was completed. Main Outcomes and Measures The primary end point was change in Neck Disability Index (NDI) score. Secondary outcomes were arm and neck pain, measured with numeric rating scales (NRS); quality of life, measured with the EuroQol-5D (EQ-5D); reoperation rates; and adjacent segment disease. Results Among 147 eligible patients, 4 (2.7%) declined to participate and 7 (4.8%) were excluded. A total of 136 patients were randomized (mean [SD] age, 44.1 [7.0] years; 73 (53.7%) women), with 68 patients randomized to arthroplasty and 68 patients randomized to fusion. A total of 114 patients (83.8%) completed the 5-year follow-up. In the arthroplasty group, the mean NDI score was 45.9 (95% CI, 43.3 to 48.4) points at baseline and 22.2 (95% CI, 18.0 to 26.3) points at 5 years follow-up, and in the fusion group, mean NDI score was 51.3 (95% CI, 48.1 to 54.4) points at baseline, and 21.3 (95% CI, 17.0 to 25.6) points at 5 years follow-up. The changes in mean NDI scores between baseline and 5 years were statistically significant for arthroplasty (mean change, 24.8 [95% CI, 19.8 to 29.9] points; P

Background Cervical radiculopathy is usually caused by disc herniation or spondylosis. The prognosis is expected to be good in most patients, but there is limited scientific evidence on the indications for nonsurgical and surgical treatments. The aim of the present study is to evaluate and compare the effectiveness of surgical and nonsurgical treatment in two trials – including disc herniation and spondylosis, respectively, and to evaluate factors that contribute to better decision making. Methods/design Patients with disabling radicular arm pain and MRI-proven cervical disc herniation or spondylosis will be randomised to receive nonsurgical or surgical treatment. The follow-up period is one year and the sample size is estimated to be 50 for each arm in the two trials, giving a total of 200 patients. The primary outcomes are the Neck Disability Index and arm pain. Secondary outcomes include neck pain; EQ-5D and costs to evaluate cost-effectiveness; prognostic factors; CT and MRI scans, to estimate intervertebral foraminal area and nerve root compression; and the expected minimal improvement for willingness to undergo treatment. Discussion The outcomes of this study will contribute to better decision making in the treatment of cervical radiculopathy. Trial registration This study has been registered at ClinicalTrials.gov as NCT03674619, on September 17, 2018.

An active man in his fifties was treated for atrial fibrillation with ablation. One week later he noticed variable weakness in his lower extremities. In the days that followed, his symptoms improved but could vary from day to day.On admission 3 months after the initial symptoms, he had spasticity and weakness in both lower extremities, with hyperreflexia and positive Babinski. Spinal fluid contained slightly elevated protein levels. Spinal MRI showed cord oedema and gadolinium enhancement over multiple spinal levels. Autoimmune myelitis was suspected, and he was treated with high dose steroids and rituximab. Due to lack of effect, repeated examinations were initiated. Information from his patient history regarding symptom exacerbation by walking or bending forward was emphasised. Repeated MRI showed unchanged spinal oedema and dilated peri- and intramedullary vessels. MRA and spinal digital DSA revealed a dural fistula at third lumbar level, with the left L3 radiculomedullary artery as the feed artery. The fistula was successfully ligated by the neurosurgeon.Spinal vascular lesions are rare and the diagnosis may be challenging due to atypical presentation. The case shows that detailed information from the patient history and thorough clinical investigation is of paramount importance to disclose this probably underreported condition.

The incidence rate of surgical treatment of cervical degenerative diseases (CDD) has increased in the USA and a large geographic variation has been shown. Little is known about such rates in Scandinavia and Europe. The aim of this population-based study was to (1) investigate annual incidence rates of operations performed in Norway, (2) to compare trends and variations in rates for surgical indications with and without myelopathy, and (3) to compare variations in the use of surgery between residential areas. Patients operated for CDD and recorded in the Norwegian Patient Registry from 2008 to 2014 were evaluated according to residential areas (resident county and Regional Health Authority (RHA) area), age, gender, treating hospital, and whether myelopathy was present or not. Surgical rates were adjusted for age and gender. Data from private health care were also included. The annual surgical rates increased by 74.1 % from 2008 to 2014 (12.5/100,000 inhabitants). The largest increase was for surgical treatment of radiculopathy, 86.5 %. Surgical rates for CDD varied in 2014 with a ratio of 1.5 between the highest and lowest RHA and with a ratio of 2.5 between the different residential counties within one RHA. The treatment rates for myelopathy were relatively stable over time, but showed an increase of 2.1/100,000 (44.6 %) from 2013 to 2014. Our study shows that the rate of surgical treatment for radiculopathy due to CDD has increased substantially from 2008 to 2014 for all RHAs in Norway. The incidence rate for surgical treatment of myelopathy was more stable. An unexplained and moderate geographic variation was found.

Background An active man in his fifties was treated for atrial fibrillation with ablation. One week later he noticed variable weakness in his lower extremities. In the days that followed, his symptoms improved but could vary from day to day. Case presentation On admission 3 months after the initial symptoms, he had spasticity and weakness in both lower extremities, with hyperreflexia and positive Babinski. Spinal fluid contained slightly elevated protein levels. Spinal MRI showed cord oedema and gadolinium enhancement over multiple spinal levels. Autoimmune myelitis was suspected, and he was treated with high dose steroids and rituximab. Due to lack of effect, repeated examinations were initiated. Information from his patient history regarding symptom exacerbation by walking or bending forward was emphasised. Repeated MRI showed unchanged spinal oedema and dilated peri- and intramedullary vessels. MRA and spinal digital DSA revealed a dural fistula at third lumbar level, with the left L3 radiculomedullary artery as the feed artery. The fistula was successfully ligated by the neurosurgeon. Interpretation Spinal vascular lesions are rare and the diagnosis may be challenging due to atypical presentation. The case shows that detailed information from the patient history and thorough clinical investigation is of paramount importance to disclose this probably underreported condition.

The Neck Disability Index (NDI) is widely used as a self-rated disability score in patients with cervical radiculopathy. The purpose of this study was to evaluate whether the NDI score correlated with other assessments of quality of life and mental health in a specific group of patients with single-level cervical disc disease and corresponding radiculopathy. One hundred thirty-six patients were included in a prospective, randomized controlled clinical multicenter study on one-level anterior cervical discectomy with arthroplasty (ACDA) versus one-level anterior cervical discectomy with fusion (ACDF). The preoperative data were obtained at hospital admission 1 to 3 days prior to surgery. The NDI score was used as the dependent variable and correlation as well as regression analyses were conducted to assess the relationship with the short form-36, EuroQol-5Dimension-3 level and Hospital Anxiety and Depression Scale. The mean age at inclusion was 44.1 years (SD ±7.0, range 26–59 years), of which 46.3 % were male. Mean NDI score was 48.6 (SD = 12.3, minimum 30 and maximum 88). Simple linear regression analysis demonstrated a significant correlation between NDI and the EuroQol-5Dimension-3 level [R = -0.64, 95 % confidence interval (CI) -30.1– -19.8, p

[ In this issue of the Scandinavian Journal of Pain, Jarvimaki et al. ocus on problems and complications arising in pre-obese and bese patients who need back surgery, discectomy in particular 1]. The epidemic of obesity has reached the Nordic countries, and or persons above 60 years of age, Western Europe has prevalence bout 20% for men and about 30% for women [2]. Excess bodyweight is among the highest risk factors for ncreased burden of disease globally, contributing to development f ischaemic heart disease, hypertension, osteoarthritis, diabetes ellitus, and stroke, cancer of the colon, breast and endometrium 2]. In their survey of lumbar discectomy patients, Jarvimaki et al. ound that outcomes of surgery with respect to functional disabilty, depressed mood, and social activities were worse among those ith BMI in the obese category (BMI >30 kg/m2) [1]. Both the prebese (BMI >25 and

Background A rare, but important cause of torticollis in children is atlantoaxial rotatory fixation. If the patient remains undiagnosed for more than three months, surgery is generally the only therapeutic alternative. In this article we present our experiences of surgical treatment of late-diagnosed atlantoaxial rotatory fixation in children. Material and method This article is based on a review of the case notes of patients who underwent surgery for atlantoaxial rotatory fixation in the Department for Neurosurgery at Oslo University Hospital, Rikshospitalet, during the period 2004-10. Results The material sample consists of six children aged from seven to 14 years. Five had suffered minor trauma to the upper neck region, while one had had an upper respiratory tract infection. The diagnosis was made 5-36 months after the onset of symptoms. In three of the patients, an attempt was made at closed reduction without success. A CT scan one year postoperatively showed a normal position of the atlantoaxial joint in two patients and partial reduction in three. In the sixth patient there was bone fusion at the time of the operation, and open reduction was unsuccessful. All six patients had reduced rotational movement of the neck at the one-year check-up. Interpretation All our patients were diagnosed more than five months after the onset of symptoms. Full or partial reduction was achieved in five of the six.

Purpose Standard surgical treatment for symptomatic cervical disc disease has been discectomy and fusion, but the use of arthroplasty, designed to preserve motion, has increased, and most studies report clinical outcome in its favor. Few of these trials, however, blinded the patients. We, therefore, conducted the Norwegian Cervical Arthroplasty Trial, and present 2-year clinical outcome after arthroplasty or fusion. Methods This multicenter trial included 136 patients with single-level cervical disc disease. The patients were randomized to arthroplasty or fusion, and blinded to the treatment modality. The surgical team was blinded to randomization until nerve root decompression was completed. Primary outcome was the self-rated Neck Disability Index. Secondary outcomes were the numeric rating scale for pain and quality of life questionnaires Short Form-36 and EuroQol-5Dimension-3 Level. Results There was a significant improvement in the primary and all secondary outcomes from baseline to 2-year follow-up for both arthroplasty and fusion (P P = 0.049), and arm pain (P = 0.027) in favor of fusion at 2 years. The duration of surgery was longer (P P = 0.029) with arthroplasty. Conclusion The present study showed excellent clinical results and no significant difference between treatments at any scheduled follow-up. However, the rate of index level reoperations was higher and the duration of surgery longer with arthroplasty. Trial registration http://www.clinicaltrials.gov NCT 00735176.19.

Background Chronic subdural haematoma (CSDH) is a common entity in neurosurgery with a considerable postoperative recurrence rate. Computerised tomography (CT) scanning remains the most important diagnostic test for this disorder. The aim of this study was to characterise the relationship between the recurrence of CSDH after treatment with burr-hole irrigation and closed-system drainage technique and CT scan features of these lesions to assess whether CT findings can be used to predict recurrence. Methods We investigated preoperative and postoperative CT scan features and recurrence rate of 107 consecutive adult surgical cases of CSDH and assessed any relationship with univariate and multivariate regression analyses. Results Seventeen patients (15.9 %) experienced recurrence of CSDH. The preoperative haematoma volume, the isodense, hyperdense, laminar and separated CT densities and the residual total haematoma cavity volume on the 1st postoperative day after removal of the drainage were identified as radiological predictors of recurrence. If the preoperative haematoma volume was under 115 ml and the residual total haematoma cavity volume postoperatively was under 80 ml, the probability of no recurrence was very high (94.4 % and 97.4 % respectively). Conclusions These findings from CT imaging may help to identify patients at risk for postoperative recurrence.

BACKGROUND: Objective: To evaluate progression-free survival, overall survival (OS) and long-term clinical outcome in a consecutive series of 86 patients with intraspinal ependymomas. METHODS: Medical charts were retrospectively reviewed. Surviving patients voluntarily participated in a clinical history and physical examination that focused on neurological function and current tumor status. RESULTS: Follow-up data are nearly 100% complete; mean follow-up time was 82 months. Eighty-five patients (99%) had surgery as a first-line treatment; 14 (17%) of these patients received adjuvant radiotherapy. Of the 85 patients who underwent primary surgery, gross total resection was performed in 60 patients (71 %) and subtotal resection in 25 patients (29%). Ten-year progression-free survival rate was 75%; 5-year OS, 97%; and 10-year OS, 91%. Reduced preoperative neurological function and older age at diagnosis were significantly associated with increased risk of death. At follow-up, spontaneous regression of residual tumor after primary surgery may have occurred in 7 of 19 patients (37%). More than 75% of patients had neurological function compatible with an independent life at follow-up. Good preoperative neurological function was significantly associated with favorable outcome. It was not possible to evaluate the effect of radiotherapy on progression-free survival and OS. CONCLUSION: Gross total resection remains the optimal treatment for patients with spinal ependymoma. Patients should be monitored with a clinical examination and magnetic resonance imaging at regular intervals up to 10 years after surgery.

Halvorsen CM, Lied B, Harr ME, Ronning P, Sundseth J, Kolstad F, Helseth E. Surgical mortality and complications leading to reoperation in 318 consecutive posterior decompressions for cervical spondylotic myelopathy. Acta Neurol Scand: 2011: 123: 358–365. © 2010 John Wiley & Sons A/S. Objective – To determine surgical mortality, incidence of surgery-related neurological deterioration and incidence of postoperative infection or hematoma requiring reoperation in a consecutive series of 318 patients surgically treated with laminectomy or laminoplasty for cervical spondylotic myelopathy (CSM). Materials and methods – This is a retrospective study of 318 consecutive patients treated with laminectomy or laminoplasty for CSM at Oslo University Hospital in the time period 2003–2008. The defined neurosurgical catchment area for OUS is the southeast region of Norway with 2.7 mill inhabitants. The patient charts were systematically reviewed, focusing primarily on operative notes, postoperative (po) complications, such as po deterioration of neurological function, po hematoma and po infection and neurological function at most recent follow-up. Results – The mean age was 64 years (range 29–90 years). Laminectomy was performed in 310/318 (97.5%) and laminoplasty in 8/318 (2.5%) of the patients. The incidence of laminectomy/laminoplasty for CSM was 2.0/100,000 inhabitants per year. The surgical mortality was 0%, and 37 (11.6%) patients had a deterioration of neurological function in the immediate postoperative period. Four (1.3%) patients were reoperated because of po hematoma. We found a statistically significant association between po hematoma and previous posterior neck surgery and American Association of Anaesthetists (ASA) score. Five (1.6%) patients were reoperated because of postoperative infection. Univariate logistic regression analysis showed a statistically significant association between po infection and the number of levels decompressed. Conclusions – The incidence of laminectomy/laminoplasty for CSM is 2.0/100,000 inhabitants per year. Surgical mortality, postoperative hematoma and postoperative infection are rare complications of laminectomy/laminoplasty for CSM. Neurological deterioration is not an uncommon complication after posterior decompression for CSM.

Study design Prospective, observational study. Objective To evaluate biomechanical changes associated with cervical arthrodesis using a cylindrical titanium cage. Summary of background data Anterior cervical discectomy and fusion (ACDF) is the "gold standard" for treating cervical disc disease. In an effort to avoid the morbidity associated with autogenous bone graft harvesting, cervical cages are used to achieve fusion. The cages should allow for restoration and maintenance of natural disc height, angulations, and displacements at the operated levels. Methods Fifty-four patients underwent standard ACDF using a "stand alone" cylindrical cage implant. Lateral radiographic views of the cervical spine were obtained before surgery, on the first day postoperatively, and at 12 months postoperatively. Disc height, vertebral alignment, angle of lordosis, and range of motion at operated levels were quantified prospectively by distortion compensated Roentgen analysis. Results At 12 months postoperatively, solid fusion was achieved but the cylindrical cage failed to preserve disc height, prevent kyphosis, and preserve natural intervertebral alignment. We observed significant cage subsidence and malalignment. Conclusion We noticed several unfavorable outcomes when performing an analysis of radiographic parameters after ACDF using a cylindrical titanium cage. Thus, the use of a "stand alone" cylindrical cage in ACDF should be considered with caution.

Purpose Heterotopic ossification is a phenomenon in cervical arthroplasty. Previous reports have mainly focused on various semiconstrained devices and only a few publications have focused on ossification around devices that are nonconstrained. The purpose of this study was to assess the occurrence of heterotopic ossification around a nonconstrained cervical device and how it affects clinical outcome 2 years after surgery. Methods Thirty-seven patients were included from a larger cohort of a randomized controlled trial (NORCAT) which compared single-level cervical arthroplasty with fusion. The occurrence of heterotopic ossification was assessed with a CT scan and two neuroradiologists determined its degree. For grading, we used the Mehren/Suchomel classification system (grade 0–4). The patients were divided by level of ossification, low grade (0–2) or high grade (3–4), and clinical outcomes were compared. Self-rated disability for neck and arm pain (Neck Disability Index), health-related quality of life (the Short Form-36 and EuroQol-5D), and pain (the Numeric Rating Scale 11) were used as clinical outcome measures. Results Heterotopic ossification was encountered in all patients 2 years after surgery. Complete fusion (grade 4) was found in 16 % of participants, and high-grade ossification (grade 3–4) occurred in 62 %. The remaining patients were classified as having low-grade ossification (grade 2). There were no differences in the clinical outcomes of patients with low- and high-grade ossification. Conclusion High-grade heterotopic ossification and spontaneous fusion 2 years after surgery were seen in a significant number of patients. However, the degree of ossification did not influence the clinical outcome.

BACKGROUND The existing literature on recurrence rates and long-term clinical outcome after resection of intraspinal nerve sheath tumors is limited. OBJECTIVE To evaluate progression-free survival, overall survival, and long-term clinical outcome in a consecutive series of 131 patients with symptomatic intraspinal nerve sheath tumors. METHODS Medical charts were retrospectively reviewed. Surviving patients voluntarily participated in a clinical history and physical examination that focused on neurological function and current tumor status. RESULTS Follow-up data are 100% complete; median follow-up time was 6.1 years. All patients (100%) had surgery as the first line of treatment; gross total resection was performed in 112 patients (85.5%) and subtotal resection in 19 patients (14.5%). Five-year progression-free survival was 89%. The following risk factors for recurrence were identified: neurofibroma, malignant peripheral nerve sheath tumor, subtotal resection, neurofibromatoses/schwannomatosis, and advancing age at diagnosis. More than 95% of patients had neurological function compatible with an independent life at follow-up. The rate of tumor recurrence in nonneurofibromatosis patients undergoing total resection of a single schwannoma was 3% (3/93), in comparison with a recurrence rate of 32% (12/38) in the remaining patients. CONCLUSION Gross total resection is the gold standard treatment for patients with intraspinal nerve sheath tumors. In a time of limited health care resources, we recommend that follow-up be focused on the subgroup of patients with a high risk of recurrence. The benefit of long-term, yearly magnetic resonance imaging follow-up with respect to recurrence in nonneurofibromatosis patients undergoing gross total resection of a single schwannoma is, in our opinion, questionable. 1NF2, neurofibromatosis 2NST, nerve sheath tumorOS, overall survivalPFS, progression-free survivalSTR, subtotal resectionWHO, World Health Organization.

Two methods to measure sagittal plane segmental motion in the cervical spine are compared. Translational and rotational motion was measured in nine cervical motion segments of nine patients by distortion-compensated (DCRA) as well as by stereophotogrammetric Roentgen analysis (RSA). To compare measurement precision of the new DCRA protocol with the established RSA technique under realistic clinical conditions and to discuss advantages and disadvantages of both methods in clinical studies. RSA constitutes the most precise method available to assess segmental motion or to monitor fusion in the cervical spine. Due to the invasive nature of the procedure there is an interest in alternative, non-invasive protocols, based on conventional, lateral radiographic views. In nine patients, segmental motion of nine cervical segments with spinal surgery and fusion had previously been assessed from stereo views by RSA. From the archive radiographs, sagittal plane segmental motion was re-assessed by DCRA. Results for sagittal plane translational and rotational motion obtained by both methods are compared. With respect to RSA, sagittal plane rotation was determined by DCRA with an error of 2.4 degrees and a mean difference not significantly different from zero. Sagittal plane translation was determined by DCRA with an error of less than 0.78 mm and a mean difference not significantly different from zero. As two methods are compared, these errors represent the combined (propagated) errors of RSA and DCRA. Averaged over the cohort investigated, measurement of sagittal plane segmental motion exhibited no significant difference between DCRA and RSA.

Study design: Descriptive study comparing MRI classifications with measurements from radiographs. Objectives: 1. Define the relationship between MRI classified cervical disc degeneration and objectively measured disc height. 2. Assess the level of inter- and intra-observer errors using MRI in defining cervical disc degeneration. Summary of background data: Cervical spine degeneration has been defined radiologically by loss of disc height, decreased disc and bone marrow signal intensity and disc protrusion/herniation on MRI. The intra- and inter-observer error using MRI in defining cervical degeneration influences data interpretation. Few previous studies have addressed this source of error. The relation and time sequence between cervical disc degeneration classified by MRI and cervical disc height decrease measured from radiographs is unclear. Methods: The MRI classification of degeneration was based on nucleus signal, prolaps identification and bone marrow signal. Two neuro-radiologists evaluated the MR-images independently in a blinded fashion. The radiographic disc height measurements were done by a new computer-assisted method compensating for image distortion and permitting comparison with normal level-, age- and gender-appropriate disc height. Results/conclusions: 1. Progressing disc degeneration classified from MRI is on average significantly associated with a decrease of disc height as measured from radiographs. Within each MRI defined category of degeneration measured disc heights, however, scatter in a wide range. 2. The inter-observer agreement between two neuro-radiologists in both defining degeneration and disc height by MRI was only moderate. Studies addressing questions related to cervical disc degeneration should take this into consideration.

The aim of this study was to assess if transforaminal steroid injections applied to cohort of patients waiting for cervical disc surgery, reduce the pain of cervical radiculopathy and hence reduce the need for surgical intervention. Cervical radiculopathy due to cervical disc herniation or spondylosis is a common indication for cervical disc surgery. Surgery is however not always successful, and is not done without risk of complications. Transforaminal injection of steroids has gained popularity due to the rationale that inflammation of the spinal nerve roots causes radicular pain, and therefore steroids placed locally should relieve symptoms.During a 12-month period, 21 secondary referral patients with unilateral cervical radiculopathy entered the study. Cervical disc herniation or spondylosis affecting the corresponding nerve root was demonstrated by appropriate investigation (MRI or myelography). The patients then received 2 transforaminal steroid injections, at 2 weeks interval, while waiting for operative treatment. The pain intensity (VAS), Odom's criteria and operative indications were registered at 6 weeks and 4 months.After receiving injection treatment 5 of the 21 patients decided to cancel the operation due to clinical improvement. A statistically significant reduction (0.02) in radicular pain score was simultaneously measured. This corresponds well with the reduction in operative requirements since radicular pain is the main indication for operative treatment. The responders experienced a long-lasting effect. Those responding positively however improved neck pain to the same extent as radicular pain, and patients with cervical spondylosis responded as positively as those with disc herniation.This prospective cohort study indicates a reduction in the need for operative treatment due to injection treatment. The clinical effect is measurable, and a statistically significant improvement of the radicular pain is registered. Routine transforaminal injection treatment prior to surgery seems rewarding, but the complication risk must be taken into consideration.

Idiopathic spinal cord herniation (ISCH), where a segment of the spinal cord has herniated through a ventral defect in the dura, is a rarely encountered cause of thoracic myelopathy. The purpose of our study was to increase the clinical awareness of this condition by presenting our experience with seven consecutive cases treated in our department since 2005. All the patients developed pronounced spastic paraparesis or Brown-Séquard syndrome for several years (mean, 4.7 years) prior to diagnosis. MRI was consistent with a transdural spinal cord herniation in the mid-thoracic region in all the cases. The patients underwent surgical reduction of the herniated spinal cord and closure of the dural defect using an artificial dural patch. At follow-up, three patients experienced considerable clinical improvement, one had slight improvement, one had transient improvement, and two were unchanged. Two of the four patients with sphincter dysfunction regained sphincter control. MRI showed realignment of the spinal cord in all the patients. ISCH is probably a more common cause of thoracic myelopathy than previously recognized. The patients usually develop progressive myelopathy for several years before the correct diagnosis is made. Early diagnosis is important in order to treat the patients before the myelopathy has become advanced.

A rare, but important cause of torticollis in children is atlantoaxial rotatory fixation. If the patient remains undiagnosed for more than three months, surgery is generally the only therapeutic alternative. In this article we present our experiences of surgical treatment of late-diagnosed atlantoaxial rotatory fixation in children.This article is based on a review of the case notes of patients who underwent surgery for atlantoaxial rotatory fixation in the Department for Neurosurgery at Oslo University Hospital, Rikshospitalet, during the period 2004-10.The material sample consists of six children aged from seven to 14 years. Five had suffered minor trauma to the upper neck region, while one had had an upper respiratory tract infection. The diagnosis was made 5-36 months after the onset of symptoms. In three of the patients, an attempt was made at closed reduction without success. A CT scan one year postoperatively showed a normal position of the atlantoaxial joint in two patients and partial reduction in three. In the sixth patient there was bone fusion at the time of the operation, and open reduction was unsuccessful. All six patients had reduced rotational movement of the neck at the one-year check-up.All our patients were diagnosed more than five months after the onset of symptoms. Full or partial reduction was achieved in five of the six.

In this issue of the Scandinavian Journal of Pain Jarvimaki and coorkers [1] from Northern Finland publish a cross-sectional postal uestionnaire survey on functional capacity and quality of life 1–4 ears after lumbar spine surgery due to disc herniation, instability stabilizing-spondylosyndesis), or spinal stenosis (decompression). hey focused on patients in working age, i.e.18–65 years of age, perated in the Oulu University Hospital during 3 years from June 005. Their response rate was 66%. Among the 537 responders 2/3 ad disc surgery, 1/6 had stabilizing, and 1/6 had decompression urgery. Half of those who had disc-surgery had no or negligible ain, whereas after both stabilizing and decompressing lumbar pine surgery almost 2/3 had daily pain with axial pain around /10 and slightly less radicular pain. Results from the Owestry Low ack Disability Questionnaire and the SF-36 Quality of Life Quesionnaire documented acceptable outcome for the disc-surgery atients, but significantly poorer functional and quality of life outomes after stabilizing fusion surgery and after decompression urgery for spinal stenosis.

The authors describe the technical application of three-dimensional (3D) ultrasonography navigation in spinal cord tumor surgery. The spinal cord is a complex neurological structure in which there is the potential for causing neurological morbidity during tumor resection. Standard neuronavigation systems based on computed tomography or C-arm images are not adapted to tumor surgery in the spinal cord. Since 2004 the authors have been using a 3D ultrasonography-based neuronavigation system. During surgery, two-dimensional ultrasound images were acquired and reconstructed into 3D image data to assist in tumor resection. The navigation cameras read the position of a patient reference frame attached to a spinous process, the ultrasonography probe, and surgical instruments. Five- and 10-MHz phased-array ultrasonography probes equipped with optical tracking frames were used for image data acquisition. Spinal cord tumors were visualized using ultrasonography, and 3D ultrasonography-guided tumor biopsy sampling and resection were performed. The practice of attaching the reference frame to a spinous process adjacent to the spinal cord tumor, as well as performing image acquisition just before starting the resection, reduced the possible sources of inaccuracy. The technical application of a navigation system based on intraoperative 3D ultrasound image reconstruction seems feasible and may have the potential of improving functional outcome in association with spinal cord tumor surgery.

Throughout many years, a large number of publications have focused on structural changes in soft tissues in the cervical spine in patients with whiplash associated disorders I-II. In recent years the development in MRI techniques have made it possible to visualize the small ligaments in the craniocervical junction; a small number of publications have investigated the association between signal changes in these ligaments and whiplash associated disorders I-II. The results are, however, not conclusive, and no prospective studies have demonstrated any causal connection between type of whiplash injury and signal changes in these ligaments. Craniocervical fixation is major surgery with a moderate level of perioperative complications. There is also a theoretical risk of increasing the degenerative process in the level below the fixation. The indications for craniocervical fixation are now serious conditions like instability caused by rheumatic arthritis, tumours and fractures. The scientific evidence for introducing a new indication for craniocervical fixation is lacking, and craniocervical fixation in WAD I-II must be considered experimental surgery.

In recent years there has been a considerable improvement in the quality of ultrasound (US) imaging. The integration of 3D US with neuronavigation technology has created an efficient and inexpensive tool for intra-operative imaging in neurosurgery. In this review we present the technological background and an overview of the wide range of different applications. The technology has so far mostly been applied to improve surgery of tumours in brain tissue, but it has also been found to be useful in other procedures such as operations for cavernous haemangiomas, skull base tumours, syringomyelia, medulla tumours, aneurysms, AVMs and endoscopy guidance.

Purpose Cervical disc prostheses induce significant amount of artifact in magnetic resonance imaging which may complicate radiologic follow-up after surgery. The purpose of this study was to investigate as to what extent the artifact, induced by the frequently used Discover® cervical disc prosthesis, impedes interpretation of the MR images at operated and adjacent levels in 1.5 and 3 Tesla MR. Methods Ten subsequent patients were investigated in both 1.5 and 3 Tesla MR with standard image sequences one year following anterior cervical discectomy with arthroplasty. Outcome measures Two neuroradiologists evaluated the images by consensus. Emphasis was made on signal changes in medulla at all levels and visualization of root canals at operated and adjacent levels. A “blur artifact ratio” was calculated and defined as the height of the artifact on T1 sagittal images related to the operated level. Results The artifacts induced in 1.5 and 3 Tesla MR were of entirely different character and evaluation of the spinal cord at operated level was impossible in both magnets. Artifacts also made the root canals difficult to assess at operated level and more pronounced in the 3 Tesla MR. At the adjacent levels however, the spinal cord and root canals were completely visualized in all patients. The “blur artifact” induced at operated level was also more pronounced in the 3 Tesla MR. Conclusions The artifact induced by the Discover® titanium disc prosthesis in both 1.5 and 3 Tesla MR, makes interpretation of the spinal cord impossible and visualization of the root canals difficult at operated level. Adjusting the MR sequences to produce the least amount of artifact is important. © The Author(s) 2013 Open Access This article is distributed under the terms of the Creative Commons Attribution License which permits any use, distribution, and reproduction in any medium, provided the original author(s) and the source are credited.