Journal of neurosurgery. Spine
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Review
The Spine Patient Outcomes Research Trial results for lumbar disc herniation: a critical review.
The long-anticipated results of the Spine Patient Outcomes Research Trial (SPORT) were recently published in the Journal of the American Medical Association. In this trial the investigators compared operative and nonoperative care in patients with symptomatic lumbar disc herniation. Despite the expenditure of several million dollars on this multicenter, prospective, randomized, controlled clinical trial, the SPORT investigators admitted, "conclusions about the superiority or equivalence of the treatments under study are not warranted based on the intent-to-treat analysis." In the present article the author provides a critical review of the SPORT formulation and hypothesis, study design and methodology, and results and interpretations in an attempt to explain why the authors of this study were unable to assess the study's only intended null hypothesis that there would be no difference in outcomes between operative and nonoperative management of herniated lumbar discs. Issues related to misrepresentation and misinterpretation of the SPORT results for herniated lumbar discs are also assessed.
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Case Reports
Spinal epidural arteriovenous fistulas associated with progressive myelopathy. Report of four cases.
The authors report the cases of four patients who presented with progressive myelopathy (one patient had been asymptomatic for 25 years) due to spinal epidural arteriovenous fistulas (AVFs). Clinical symptoms and magnetic resonance imaging findings were similar to those of dural AVFs. ⋯ All fistulas were cured by embolization; arterial access was used in two cases and venous in two. The authors' aim in this paper is to emphasize the differences between dural and epidural AVFs in terms of their physiopathology and angioarchitecture as well as the therapeutic strategy.
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Case Reports
Single-stage total C-2 intralesional spondylectomy for chordoma with three-column reconstruction. Technical note.
Chordomas are locally invasive, malignant bone tumors that rarely occur in the cervical spine. En bloc resection or even fully resecting the tumor along its margin offers improved patient survival and a potential disease cure. ⋯ The authors present a case of a chordoma involving the axis that was treated using a single-stage total intralesional C-2 spondylectomy with preservation of both VAs because the patient did not tolerate a preoperative occlusion test. A three-column reconstruction technique is also presented.
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The incidence of postoperative C-5 spinal nerve root palsy following decompressive cervical spinal surgery has been reported to be as high as 12% for anterior procedures and 30% for posterior procedures. The present study was conducted to document the prevalence of iatrogenic C-5 nerve root deficit during anterior cervical spinal surgery, as well as to evaluate the sensitivity and specificity of intraoperative transcranial electrical stimulation (TES)-induced motor evoked potentials (MEPs) and spontaneous electromyographic (EMG) activity for identifying evolving C-5 nerve root impairment. ⋯ Transcranial electrical stimulation-induced MEPs and spontaneous EMG activity offer complementary information about evolving iatrogenic C-5 spinal nerve root impairment during anterior cervical spinal surgery. The TES-induced MEPs provide prognostic information and show increased sensitivity to C-5 deficit compared with spontaneous EMG activity alone. Monitoring of spinal nerve root function using only EMG activity carries a risk of false-negative findings; without timely warning of impending neurological impairment, timely intervention to prevent permanent deficit cannot occur.
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The nucleus pulposus has been reported to be an immunologically privileged site. The expression of Fas ligand (FasL) on normal and herniated lumbar disc cells has been reported. The relationship between a physiological barrier and the role of FasL has not yet been addressed. To clarify this relationship and to investigate a possible pathogenesis of intervertebral disc degeneration (IDD), the expression of Fas and FasL (a mean apoptosis index) on normal and stabbed-disc cells was examined in a rabbit model of IDD. ⋯ These observations indicate that the nucleus pulposus is an immunologically privileged site. This immunological privilege is maintained by FasL and the physiological barrier together. When the physiological barrier was damaged (by stabbing the disc), the role of FasL changed, and FasL was coexpressed with Fas to induce apoptosis of disc cells. These results indicate that an autoimmune reaction may be a possible pathogenesis of IDD.