What’s New in Spine Surgery

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What’s New in the Treatment of the Cervical SpineDiagnostic EvaluationThe Spurling test is performed to test the irritability of a cervical nerve root by hyperextending the neck and compressing downward, which, when positive, reproduces a specific dermatomal pain pattern. Based on the gold standard of computed tomography (CT) or magnetic resonance imaging (MRI), this simple test has high sensitivity (95%) and specificity (95%) for identifying nerve root compression.Evaluation of the cervical spine in patients with blunt trauma remains controversial. Clearing the spine in asymptomatic patients with normal mentation and no distracting injuries on the basis of National Emergency X-Radiography Utilization Study (NEXUS) clinical criteria without radiographs was questioned by investigators in Virginia. In a three-year study, the investigators found that twenty-five of 2606 patients had fractures that were missed when cervical spines were cleared with use of the NEXUS criteria. Two fractures required surgery, and one required halo-vest treatment. Clearing the cervical spine in the obtunded patient is more difficult, and CT and other modalities are often recommended. A meta-analysis involving >14,000 patients in which CT alone was compared with CT plus another modality demonstrated that CT alone had 99.9% sensitivity and specificity and a 100% negative predictive value. The authors concluded that CT alone is adequate to clear the cervical spine in obtunded patients.The use of CT for clearing the cervical spine is not without risk. Low-dose ionizing radiation, such as diagnostic CT, can induce neoplasia. The thyroid has the highest growing incidence of cancer and is particularly sensitive to radiation. Furthermore, females and children have increased sensitivity of the thyroid to radiation. Muchow et al. evaluated 617 children with level-1 or 2 trauma who had CT or radiographs for cervical spine clearance. The radiation dose and the excess relative risk of cancer induction were calculated, with CT having sixty times higher radiation exposure than radiographs. The excessive lifetime thyroid cancer risk of a single CT was increased 25% for females and 13% for males. The authors concluded that this risk needs to be considered when ordering CT imaging for pediatric patients.Disc ArthroplastyThe results of five cervical disc arthroplasty trials with five-year follow-up have been reported. The studies showed equal or better clinical outcomes compared with those following anterior discectomy and fusion for single-level radiculopathy and myelopathy. The reoperation rates at the index intervertebral disc level generally were equivalent to those following fusion. There was variation in the reoperation rates at adjacent levels, with some studies showing equivalency and others favoring arthroplasty over fusion. Failures due to loosening or inflammatory reactions to wear debris have been reported as small case reports, with an incidence of <1% in randomized trials.OutcomesThe measurement of patient satisfaction on the basis of meeting patient expectations is becoming increasingly utilized and will become an important measure of the quality of care. In cervical and lumbar spine surgery, meeting expectations is associated with greater satisfaction and better functional outcomes. However, higher preoperative patient expectations are associated with lower satisfaction, despite these patients having better outcomes. Discussion of expectations during the informed consent process based on patient preferences is important to maximize satisfaction.Posterior SurgeryThe use of recombinant human bone morphogenetic protein-2 (rhBMP-2) for posterior cervical surgery is not approved by the U.S. Food and Drug Administration (FDA), but this “off-label” use has been reported to produce excellent fusion rates. However, safety has been questioned.

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