Neurosurgery
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Spinal osteobiologics have evolved substantially in this century after the development of many product categories such as growth factors, allograft, and stem cells. The indications for the use of novel biologics within spine surgery are rapidly expanding as the mechanism of each is elucidated. While the knowledge base of bone morphogenetic protein increases with each subsequent year, the application of new nanotechnology and cell-based strategies are being reported. This review will discuss the most recent data in novel osteobiologics, and where we could use future study.
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Review
State of the Art in Degenerative Cervical Myelopathy: An Update on Current Clinical Evidence.
Degenerative cervical myelopathy (DCM) is a common cause of spinal cord dysfunction that confronts clinicians on a daily basis. Research performed over the past few decades has provided improved insight into the diagnosis, evaluation, and treatment of this disorder. We aim to provide clinicians with an update regarding the state of the art in DCM, focusing on more recent research pertaining to pathophysiology, natural history, treatment, consideration of the minimally symptomatic patient, surgical outcome prediction, and outcome measurement. ⋯ When selecting the specific surgical intervention for a patient with DCM, anterior (discectomy, corpectomy, hybrid discectomy/corpectomy), posterior (laminectomy and fusion, laminoplasty), and combined approaches may be considered as options depending on the specifics of the patient in question; evidence supporting each of these approaches is reviewed in detail. Recently developed clinical prediction models allow for accurate forecasting of postoperative outcomes, permitting enhanced communication and management of patient expectations in the preoperative setting. Finally, an overview of outcome measures recommended for use in the assessment of DCM patients is provided.
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Management of spinal trauma is a complex and rapidly evolving field. To optimize patient treatment algorithms, an understanding of and appreciation for current controversies and advancing technologies in the field of spinal trauma is necessary. Therefore, members of the AOSpine Knowledge Forum Trauma initiative used a modified Delphi method to compile a list of controversial issues and emerging technologies in the field of spinal trauma, and a list of the 14 most relevant topics was generated. ⋯ In summary, despite recent advances, the field of spinal trauma has many ongoing points of controversy. We must continue to refine our ability to care for this patient population through education, research, and development. It is anticipated that the new AOSpine fracture classification system will assist with prospective research efforts.
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Review
The Advancing Role of Neuromodulation for the Management of Chronic Treatment-Refractory Pain.
Neuropathic pain is a common cause of disability and health care utilization. While judicious pharmacotherapy and management of comorbid psychological distress can provide for improved quality of life, some patients with treatment-refractory disease require more invasive therapies. Spinal cord stimulation can provide for improvement in pain and decrease in medication utilization, with level 1 evidence supporting its use across various pain etiologies including persistent postoperative neuropathic pain, complex regional pain syndrome, chronic inoperable limb ischemia, treatment refractory angina, and painful diabetic neuropathy. ⋯ Technological innovation in lead design, implantable pulse generator capability, and stimulation algorithms and parameters may further enhance the success of this therapy. Neuromodulation of distal targets such as dorsal root ganglion may permit greater anatomic specificity of the therapy, whereas subthreshold stimulation with high-frequency or burst energy delivery may eliminate noxious and off-target paresthesiae. Such new technologies should be subject to rigorous evaluation as their mechanisms of action and long-term outcomes remain hitherto undefined.
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Glioblastoma patients can develop hydrocephalus, either obstructive, typically at diagnosis as a result of mass effect, or communicating, usually later in the disease. ⋯ VP shunting improves symptoms in most glioblastoma patients with suspected CH or OH, specifically younger patients. Symptomatic improvement, shorter duration between glioblastoma diagnosis and shunt placement, and CH rather than OH improve postshunt survival.