Cervical radiculopathy: pain, muscle weakness and sensory loss in patients with cervical radiculopathy treated with surgery, physiotherapy or cervical collar. A prospective, controlled study

(Cost-)effectiveness of personalised multimodal physiotherapy compared to surgery in patients with cervical radiculopathy: A systematic review

RATIONALE

Cervical radiculopathy is initially typically managed conservatively. Surgery is indicated when conservative management fails or with severe/progressive neurological signs. Personalised multimodal physiotherapy could be a promising conservative strategy. However, aggregated evidence on the (cost-)effectiveness of personalised multimodal physiotherapy compared to surgery with/without post-operative physiotherapy is lacking.

AIM/OBJECTIVES

To systematically summarise the literature on the (cost-)effectiveness of personalised multimodal physiotherapy compared to surgery with or without post-operative physiotherapy in patients with cervical radiculopathy.

METHODS

PubMed, Embase, CINAHL, PsycINFO and Web of Science were searched from inception to 1st of March 2023. Primary outcomes were effectiveness regarding costs, arm pain intensity and disability. Neck pain intensity, perceived recovery, quality of life, neurological symptoms, range-of-motion, return-to-work, medication use, (re)surgeries and adverse events were considered secondary outcomes. Randomised clinical trials comparing personalised multimodal physiotherapy versus surgical approaches with/without post-operative physiotherapy were included. Two independent reviewers performed study selection, data-extraction, and risk of bias assessment using the Cochrane RoB 2 and Consolidated Health Economic Evaluation Reporting Standards statement. Certainty of the evidence was determined using Grading of Recommendations, Assessment, Development and Evaluations.

RESULTS

From 2109 records, eight papers from two original trials, with 117 participants in total were included. Low certainty evidence showed there were no significant differences on arm pain intensity and disability, except for the subscale 'heavy work' related disability (12 months) and disability at 5-8 years. Cost-effectiveness was not assessed. There was low certainty evidence that physiotherapy improved significantly less on neck pain intensity, sensory loss and perceived recovery compared to surgery with/without physiotherapy. Low certainty evidence showed there were no significant differences on numbness, range of motion, medication use, and quality of life. No adverse events were reported.

CONCLUSION

Considering the clinical importance of accurate management recommendations and the current low level of certainty, high-quality cost-effectiveness studies are needed.

Rapid qualitative analysis of recruitment obstacles in the FORVAD (Posterior Cervical Foraminotomy surgery versus Anterior Cervical Discectomy surgery in the treatment of cervical brachialgia) randomised, controlled trial

BACKGROUND

The number of surgical trials is increasing but such trials can be complex to deliver and pose specific challenges. A multi-centre, Phase III, RCT comparing Posterior Cervical Foraminotomy versus Anterior Cervical Discectomy and Fusion in the Treatment of Cervical Brachialgia (FORVAD Trial) was unable to recruit to target. A rapid qualitative study was conducted during trial closedown to understand the experiences of healthcare professionals who participated in the FORVAD Trial, with the aim of informing future research in this area.

METHODS

Semi-structured interviews were conducted with 18 healthcare professionals who had participated in the FORVAD Trial. Interviews explored participants' experiences of the FORVAD trial. A rapid qualitative analysis was conducted, informed by Normalisation Process Theory.

RESULTS

Four main themes were generated in the data analysis: (1) individual vs. community equipoise; (2) trial set-up and delivery; (3) identifying and approaching patients; and (4) timing of randomisation. The objectives of the FORVAD trial made sense to participants and they supported the idea that there was clinical or collective equipoise regarding the two FORVAD interventions; however, many surgeons had treatment preferences and lacked individual equipoise. The site which had most recruitment success had adopted a more structured process for identification and recruitment of patients, whereas other sites that adopted more "ad hoc" screening strategies struggled to identify patients. Randomisation on the day of surgery caused both medico-legal and practical concerns at some sites.

CONCLUSIONS

Organisation and implementation of a surgical trial in neurosurgery is complex and presents many challenges. Sites often reported low recruitment and discussed the logistical issues of conducting a complex surgical RCT. Future trials in neurosurgery may need to offer more flexibility and time during set-up to maximise opportunities for larger recruitment numbers. Rapid qualitative analysis informed by Normalisation Process Theory was able to quickly identify key issues with trial implementation so rapid qualitative analysis may be a useful approach for teams conducting qualitative research in trials.

TRIAL REGISTRATION

ISRCTN, ISRCTN reference: 10,133,661. Registered 23rd November 2018.

Efficacy of neck muscle activation versus strengthening for adults with chronic cervical radiculopathy: a study protocol for a randomised clinical trial

Introduction

Chronic cervical radiculopathy is a common condition characterised by neck and arm pain, numbness and weakness. Both neck muscle activation and strengthening exercises are widely recognised treatments for cervical radiculopathy, but there is a research gap on the efficacy of neck muscle activation versus strengthening. This protocol will determine the efficacy of neck muscle activation alongside conventional care versus strengthening exercise and conventional care for cervical radiculopathy.

Methods and analysis

We planned a 5-week parallel, two-arm randomised clinical trial on 80 participants with chronic cervical radiculopathy (lasting over 3 months) between July and December 2023. Participants will be recruited from Dhaka's Agrani Specialised Physiotherapy Centre in Bangladesh and randomly assigned to two groups in a 1:1 ratio. Both groups will receive 14 sessions, each lasting 30-45 min. Post-treatment evaluations will be employed on Brief Pain Inventory (BPI), range of motion, craniovertebral angle (CVA), strength, endurance and Neck Disability Index (NDI) after 5 weeks and follow-up after 12 weeks of post-test analysis. Primary outcomes (strength, endurance and CVA) will be measured using a handheld dynamometer, digital inclinometer and goniometer. Secondary outcomes (pain, range of motion and disability) will be assessed through the BPI scale, digital inclinometer and NDI.

Ethics and dissemination

The Institute of Physiotherapy Rehabilitation and Research of Bangladesh Physiotherapy Association has approved the study. All participants will provide informed consent, and data will be anonymised and accessible only to authorised personnel. The study's findings will be disseminated in peer-reviewed journals and conferences.

Clinical trial registry India

CTRI/2023/09/057587 (13/09/2023).

Eligibility Criteria of Participants in Randomized Controlled Trials Assessing Conservative Management of Cervical Radiculopathy: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVE

The aim of this study was to evaluate the inclusion and exclusion criteria for participants in randomized control trials (RCTs) assessing conservative management for cervical radiculopathy (CR), to determine if any consensus exists within the literature.

SUMMARY OF BACKGROUND DATA

A 2012 systematic review identified a lack of uniformity for the eligibility criteria of participants in RCTs evaluating conservative interventions for CR. Since then, a large number of RCTs have been published, signaling the need for an updated evaluation of this topic.

MATERIALS AND METHODS

We electronically searched MEDLINE, CENTRAL, CINAHL, Embase, and PsycINFO from inception to June 15, 2022, to identify RCTs assessing conservative management of CR. Information extracted was analyzed to determine the level of homogeneity and/or heterogeneity of the inclusion and exclusion criteria across studies.

RESULTS

Seventy-six RCTs met our inclusion criteria with 68 distinct trials identified. The inclusion of arm pain with or without another symptom ( i.e. numbness, paresthesia, or weakness) was required in 69.12% of trials, 50% of trials required participants to exhibit neck symptoms, and 73.53% of studies required some form of clinical examination findings, but inconsistencies existed for the number and type of tests used. Furthermore, 41.18% of trials included imaging, with 33.82% of trials requiring magnetic resonance imaging findings. The most common exclusion criteria included were the presence of red flags and cervical myelopathy in 66.18% and 58.82% of trials, respectively.

CONCLUSIONS

Overall, there is still a lack of uniformity for the inclusion/exclusion criteria of trials assessing the conservative management of CR, with some improvements noted compared with the 2012 review. Based on the current literature assessing the diagnostic utility of clinical symptoms and confirmatory tests, we proposed inclusion criteria for trials assessing conservative interventions. Future research should aim to develop standardized classification criteria to improve consistency among studies.

Microscopic Anterior Cervical Discectomy and Fusion Versus Posterior Percutaneous Endoscopic Cervical Keyhole Foraminotomy for Single-level Unilateral Cervical Radiculopathy: A Systematic Review and Meta-analysis

STUDY DESIGN

A systematic review and meta-analysis.

OBJECTIVE

The objective of this study was to compare the safety of microscopic anterior cervical discectomy and fusion (MI-ACDF) and posterior percutaneous endoscopic keyhole foraminotomy (PPEKF) in patients diagnosed with single-level unilateral cervical radiculopathy.

SUMMARY OF BACKGROUND DATA

After conservative treatment, the symptoms will be relieved in about 90% of cervical radiculopathy patients. For the other one tenth of patients, surgical treatment is needed. The overall complication rate of MI-ACDF and PPEKF ranges from 0% to 25%, and the reoperation rate ranges from 0% to 20%.

MATERIALS AND METHODS

Electronic retrieval of studies from PubMed, Embase, and Cochrane Library was performed to identify comparative or single-arm studies on MI-ACDF and PPEKF. A total of 24 studies were included in our meta-analysis by screening according to the inclusion and exclusion criteria. After data extraction and quality assessment of the included studies, a meta-analysis was performed by using the R software. The pooled incidences of efficient rate, total complication rate, and reoperation rate were calculated.

RESULTS

A total of 24 studies with 1345 patients (MI-ACDF: 644, PPEKF: 701) were identified. There was no significantly statistical difference in pooled patient effective rate (MI-ACDF: 94.3% vs. PPEKF: 93.3%, P =0.625), total complication rate (MI-ACDF: 7.1% vs. PPEKF: 4.7%, P =0.198), and reoperation rate (MI-ACDF: 1.8% vs. PPEKF: 1.1%, P =0.312). However, the common complications of the 2 procedures were different. The most common complications of MI-ACDF were dysphagia and vertebral body sinking, whereas the most common complication of PPEKF was nerve root palsy.

CONCLUSIONS

Both MI-ACDF and PPEKF can provide a relatively safe and reliable treatment for single-level unilateral cervical radiculopathy. The 2 techniques are not significantly different in terms of effective rate, total complication rate, and reoperation rate.

Conservative Management of Cervical Radiculopathy: A Systematic Review

OBJECTIVE

The purpose of this systematic review was to assess the effectiveness and safety of conservative interventions compared with other interventions, placebo/sham interventions, or no intervention on disability, pain, function, quality of life, and psychological impact in adults with cervical radiculopathy (CR).

METHODS

We searched MEDLINE, CENTRAL, CINAHL, Embase, and PsycINFO from inception to June 15, 2022 to identify studies that were randomized controlled trials, had at least one conservative treatment arm, and diagnosed participants with CR through confirmatory clinical examination and/or diagnostic tests. Studies were appraised using the Cochrane Risk of Bias 2 tool and the quality of the evidence was rated using the Grades of Recommendations, Assessment, Development, and Evaluation approach.

RESULTS

Of the 2561 records identified, 59 trials met our inclusion criteria (n = 4108 participants). Due to clinical and statistical heterogeneity, the findings were synthesized narratively. There is very-low certainty evidence supporting the use of acupuncture, prednisolone, cervical manipulation, and low-level laser therapy for pain and disability in the immediate to short-term, and thoracic manipulation and low-level laser therapy for improvements in cervical range of motion in the immediate term. There is low to very-low certainty evidence for multimodal interventions, providing inconclusive evidence for pain, disability, and range of motion. There is inconclusive evidence for pain reduction after conservative management compared with surgery, rated as very-low certainty.

DISCUSSION

There is a lack of high-quality evidence, limiting our ability to make any meaningful conclusions. As the number of people with CR is expected to increase, there is an urgent need for future research to help address these gaps.

Appraising The Evidence for Conservative versus Surgical Management of Motor Deficits in Degenerative Cervical Radiculopathy

STUDY DESIGN

Systematic review.

OBJECTIVES

Understanding the prevalence and outcome of motor deficits in degenerative cervical radiculopathy is important to guide management. We compared motor radiculopathy outcomes after conservative and surgical management, a particular focus being painful vs painless radiculopathy.

METHODS

MEDLINE and EMBASE databases were searched. We stratified each study cohort into 1 of 6 groups, I-VI, based on whether radiculopathy was painful, painless or unspecified, and whether interventions were surgical or non-surgical.

RESULTS

Of 10 514 initial studies, 44 matched the selection criteria. Whilst 42 (95.5%) provided baseline motor radiculopathy data, only 22 (50.0%) provided follow-up motor outcomes. Mean baseline prevalence of motor deficits was 39.1% (9.2%-73.3%) in conservative cohorts and 60.5% (18.5%-94.1%) in surgical cohorts. Group VI, 'surgically-managed motor radiculopathy with unclear pain status' had the largest number of cohorts. Conversely, no cohorts were found in Group III, 'conservatively-managed painless motor radiculopathy'. Large disparities in data quality made direct comparison of conservative vs operative management difficult.

CONCLUSIONS

Overall pre-intervention prevalence of motor deficits in degenerative cervical radiculopathy is 56.4%. Many studies fail to report motor outcomes after intervention, meaning statistical evidence to guide optimal management of motor radiculopathy is currently lacking. Our study highlights the need for more evidence, preferably from a prospective long-term study, to allow direct comparisons of motor outcomes after conservative and surgical management.

Indicators for Substantial Neurological Recovery Following Elective Anterior Cervical Discectomy and Fusion

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The purposes of this study were to determine the rate of improvement of significant preoperative weakness, identify risk factors for failure to improve, and characterize the motor recovery of individual motor groups.

SUMMARY OF BACKGROUND DATA

While neck and arm pain reliably improve following anterior cervical discectomy and fusion (ACDF), the frequency and magnitude of motor recovery following ACDF remain unclear.

METHODS

We performed a retrospective review of patients undergoing 1-4-level ACDF at a single institution between September 2015 and June 2016. Patients were subdivided into 2 groups based upon the presence or absence of significant preoperative weakness, which was defined as a motor grade <4 in any single upper extremity muscle group. Clinical notes were reviewed to determine affected muscle groups, rates of motor recovery, and risk factors for failure to improve.

RESULTS

We identified 618 patients for inclusion. Significant preoperative upper extremity weakness was present in 27 patients (4.4%). Postoperatively, 19 of the affected patients (70.3%) experienced complete strength recovery, and 5 patients (18.5%) experienced an improvement in muscle strength to a motor grade ≥4. The rate of motor recovery postoperatively was 85.7% in the triceps, 83.3% in the finger flexors, 83.3% in the hand intrinsics, 50.0% in the biceps, and 25.0% in the deltoids. Risk factors for failure to experience significant motor improvement were the presence of myelomalacia (odds ratio: 28.9, P <0.01) and the performance of >2 levels of ACDF (odds ratio: 10.1, P <0.01).

CONCLUSIONS

Patients with substantial preoperative upper extremity weakness can expect high rates of motor recovery following ACDF, though patients with deltoid weakness, myelomalacia, and >2 levels of ACDF are less likely to experience significant motor improvement.

Clinical adjacent segment pathology after anterior cervical discectomy, with and without fusion, for cervical degenerative disc disease: A single center retrospective cohort study with long-term follow-up

Introduction

Clinical adjacent segment pathology (CASP) continues to be a cause of concern after anterior surgical treatment for single- or multilevel cervical degenerative disc disease (CDDD). The current literature reports inconsistent incidence rates and contended risk factors in the development of CASP.

Research question

The aim is to determine the incidence of additional CASP-related surgeries after anterior cervical discectomy with fusion (ACDF) or without fusion (ACD) for CDDD. Secondary outcomes include risk factors for the development of CASP and long-term clinical outcomes.

Materials & methods

This is a single-center, retrospective cohort study with a long-term follow up. Patients undergoing ACD(F) for CDDD between January 2012 and December 2019 were included.

Results

A total of 601 patients were included, with an average follow-up period of 5.0 years. Most patients underwent ACDF with stand-alone cages (87.7%). CASP developed in 58 (9.7%) patients, 41 (70.7%) of which required additional adjacent level surgery. ACD significantly accelerated the development of CASP. The C2-C7 Cobb angle appeared less lordotic upon early post-operative imaging in ACDF patients that later-on developed CASP. Baseline degeneration at the index level and adjacent levels was not significantly different between patients with and without CASP.

Discussion & conclusion

In this retrospective cohort, we observe a relatively low rate of additional surgery for CASP in ACDF with stand-alone cages. We suggest that surgical technique, fusion, segmental kyphosis and natural degeneration play a multifactorial role in the development of CASP. Complication rates were low and clinical outcomes were similar for all techniques used.

Biomechanical effect of different plate-to-disc distance on surgical and adjacent segment in anterior cervical discectomy and fusion - a finite element analysis

Background

The plate-to-disc distance (PDD) is an important factor affecting the degeneration of adjacent segments after anterior cervical discectomy and fusion (ACDF). However, the most suitable PDD is controversial. This study examined the adjacent intervertebral disc stress, bone graft stress, titanium plate stress and screw stress to evaluate the biomechanical effect of different PDD on surgical segment and adjacent segment following C5/C6 ACDF.

Methods

We constructed 10 preoperative finite element models of intact C4–C7 segments and validated them in the present study. We simulated ACDF surgery based on the 10 intact models in software. We designed three different distance of plate-to-disc titanium plates: long PDD (10 mm), medium PDD (5 mm) and short PDD (0 mm). The changes in C4/C5 and C6/C7 intervertebral disc stress, bone graft stress, titanium plate stress and screw stress were analyzed.

Results

The von Mises stress of C4/C5 and C6/C7 intervertebral discs had no significant differences (P > 0.05) in three different PDD groups. Titanium plate stress increased as the PDD decreased. The bone graft stress and screws stress decreased as the PDD decreased. The maximum stress of each part occurred was mostly in the conditions of rotation and lateral bending.

Conclusions

The PDD has no effect on adjacent intervertebral disc stress, but it is an important factor that affecting the bone graft stress, titanium plate stress and screws stress after ACDF. Shorter PDD plate can provide better stability to reduce stress on screws and bone graft, which may be helpful to prevent cage subsidence, pseudarthrosis and instrument failure. This can serve as a reference for clinical choice of plate.

ACDF plus Uncovertebrectomy versus ACDF alone for the Treatment of Cervical Spondylotic Radiculopathy: Minimum 5-Year Follow-Up

OBJECTIVE

 The surgical approach for cervical spondylotic radiculopathy (CSR) is controversial. This study aims to investigate the effectiveness of the combined anterior cervical diskectomy and fusion (ACDF) and uncovertebrectomy for treatment of CSR.

METHODS

 This is a retrospective case control study. One hundred and forty-six patients with CSR who underwent two different procedures (ACDF alone [group A]) and a combination of ACDF and uncovertebrectomy [group B]) from March 2008 to April 2013 were included. The operation time, blood loss, Visual Analog Scale scores of the neck (VAS-neck) and arm (VAS-arm), Neck Disability Index (NDI) score, 36-Item Short Form Health Survey (SF-36) score, fusion segment curvature, global cervical curvature, and the rate of surgical complication were evaluated.

RESULTS

 There were no significant differences in the basic demographic and clinical characteristics between the two groups (p > 0.05). No significant differences were noticed in the fusion segment curvature and global cervical curvature between the two groups (p > 0.05). Whereas the operation time and blood loss in group B were greater than those in group A (p < 0.05), the VAS-neck, VAS-arm, NDI, and SF-36 scores were better in group B (p < 0.05). The surgical complication rate between the two groups was not significantly different (p > 0.05).

CONCLUSIONS

 Clinical efficacy of ACDF plus uncovertebrectomy for the treatment of patients with CSR may be better than that of ACDF alone, but at the expense of more operation time and blood loss.

Impact of preoperative weakness and duration of symptoms on health-related quality-of-life outcomes following anterior cervical discectomy and fusion

BACKGROUND CONTEXT

The majority of patients with preoperative upper extremity weakness show improvements in motor function after anterior cervical discectomy and fusion (ACDF). Although numerous studies have examined both the extent and time course to which motor function can be expected to improve, few have shown that these improvements in motor function translate to improved health related quality of life (HRQOL) outcomes.

PURPOSE

The purpose of this study was to examine the effect of preoperative weakness and duration of symptoms on HRQOL outcomes in patients who underwent ACDF.

STUDY DESIGN

Retrospective cohort study.

PATIENT SAMPLE

Adult patients who underwent an ACDF procedure at an academic hospital from January 2015 to December 2016 by a fellowship-trained spine surgeon.

OUTCOME MEASURES

The primary outcomes of interest were HRQOL outcomes: Short Form-12 Physical/Mental Component Scores (SF-12 PCS/MCS), Neck Disability Index (NDI), and Visual Analog Scale Arm/Neck scores (VAS Arm/Neck).

METHODS

Patient demographics, surgical case characteristics, and motor strength exams were collected in patients who underwent ACDF over a 2-year period. Preoperative weakness was defined by a strength grade ≤3 (on a scale from 0 to 5) in at least one upper extremity muscle group. Multivariate linear regression analysis was performed to determine the effect of the preoperative weakness on HRQOL outcomes.

RESULTS

Of the 276 patients identified, 45 (16.3%) showed evidence of preoperative weakness, 44 (97.8%) of which showed subsequent postoperative motor improvements after ACDF. All patients reported significant improvements in all HRQOL outcome measures. Patients with preoperative weakness reported significantly worse preoperative VAS Arm (6.9 vs. 5.2; p=.01) and VAS Neck (6.1 vs. 4.8; p=.02) pain scores. Compared with patients without preoperative weakness, those with preoperative weakness reported significantly more improvement in NDI (β: -10.9; p=.001). Patients with symptoms greater than or equal to 12 months and preoperative weakness showed significantly less improvement in NDI (β: 14.8; p=.03).

CONCLUSIONS

Patients with preoperative weakness generally exhibited worse pain and HRQOL measures preoperatively, and showed greater potential for improvement after ACDF. Patients with a shorter duration of preoperative weakness had greater potential for improvement in HRQOL measures after ACDF compared with those with longer duration of symptoms. ACDF is an effective procedure to improve strength and HRQOL measures across all patient groups under appropriate indications.

Clinicians' User Experience of Telemedicine in Neurosurgery During COVID-19

BACKGROUND

Restricted access to hospitals due to the 2019 novel coronavirus disease (COVID-19) pandemic has significantly altered practice patterns for elective neurosurgical care. Particularly, telemedicine has become the primary modality of patient visits for nonemergent conditions. This study aimed to characterize user experiences of neurosurgeons and advanced practice providers focusing on perceived utility and barriers of telemedicine in management of elective neurosurgical patients during COVID-19.

METHODS

An online survey was sent to clinicians involved in neurosurgical care using telemedicine with questions focusing on frequency of utilization, duration of patient encounters, benefits of telemedicine, and barriers to current forms of remote patient visits. Survey responses were stratified by clinical position (neurosurgeon vs. advanced practice provider) and subspecialty focus (cranial vs. spinal neurosurgery).

RESULTS

The survey was completed by 14 of 17 eligible clinicians. Respondents included 10 neurosurgeons and 4 APPs with 57% specializing in cranial neurosurgery and 43% specializing in spinal neurosurgery. During the COVID-19 period, 78% of respondents used teleconference/video conference visits multiple times in a week, and 86% planned to continue using telemedicine after the pandemic. The most common barrier for telemedicine was the inability to perform a neurological examination, while the most common perceived benefit was increased convenience for patients.

CONCLUSIONS

During the COVID-19 period, telemedicine was heavily relied on to ensure the continuation of perioperative care for patients with elective neurosurgical pathologies. While clinicians identified numerous barriers for current telemedicine platforms, the use of telemedicine will likely continue, as it has provided unique benefits for patients, clinicians, and hospitals.

Cervical spine thrust and non-thrust mobilization for the management of recalcitrant C6 paresthesias associated with a cervical radiculopathy: a case report

BACKGROUND

The conservative management of cervical radiculopathy is supported by moderate evidence to include interventions such as manual therapy, traction, and therapeutic exercise. There is sparse evidence, however, to support specific manual therapy techniques, particularly thrust manipulation.

CASE DESCRIPTION

A 35-year-old male presented to physical therapy with a clinical diagnosis of cervical radiculopathy. He complained of neck and upper arm pain with 1st and 2nd digit paresthesias. He was initially managed with repeated movements that restored the cervical range of motion and centralized neck and upper arm pain. Non-thrust upslope joint mobilizations resulted in improved sensation detection in the hand, but the paresthesias did not completely resolve. Immediately following cervical spine upslope thrust manipulation, symptoms fully resolved. Outcomes: The patient fully returned to prior level of function. His DASH score reduced from 40/100 to 2/100, PSFS improved from 1.66/10 to 9.66/10, and he reported to be 'a great deal better' on the GROC.

DISCUSSION

This case demonstrates the safe and effective utilization of cervical spine thrust manipulation and non-thrust mobilization in the management of a patient with cervical radiculopathy with lingering paresthesias in the distal upper extremity.

Psychological predictors of quality of life after anterior cervical discectomy and fusion for degenerative cervical spine disease

We aimed to identify independent psychological predictors of quality of life (QOL) and functional outcome after anterior cervical discectomy and fusion (ACDF) for degenerative cervical spine disease. We prospectively included patients undergoing ACDF for degenerative cervical disc herniation and stenosis. Patients completed a structured psychological assessment including the Center for Epidemiological Studies Depression Scale (ADS-K), Post-Traumatic Stress Scale-10 (PTSS-10), State Trait Anxiety Inventory-State Anxiety and - Trait Anxiety (STAI-S and STAI-T) and Anxiety Sensitivity Index-3 (ASI-3) before surgery, after 3 and 12 months. Outcome measures included EuroQol-5D (EQ), Short Form-36 (SF-36) and Oswestry Disability Index (ODI) scores. Of 104 included patients who underwent ACDF between March 2013 and November 2017, 92 completed follow-up after 3 and 12 months. The mean Visual Analogue Scale (VAS) scores for neck pain (− 1.4; p < .001) and arm pain (− 1.8; p = .031) significantly decreased by 12 months. QOL scores significantly increased by 3 months (EQ: + 0.2; p < .001; SF-36 PCS: + 6.2; p < .001; SF-36 MCS: + 2.5; p = .044), a benefit which was retained at 12 months. Linear regression analyses identified statistically significant predictors in preoperative ASI-3, SF-36 MCS and STAI-S for postoperative QOL and ODI scores. There is a benefit for patients in terms of quality of life and function after undergoing surgery for degenerative cervical spine disease. With the ASI-3, SF-36 MCS and STAI-S there exist some predictors for postoperative QOL and ODI scores.

Anterior cervical discectomy and fusion versus posterior cervical foraminotomy for the treatment of single-level unilateral cervical radiculopathy: a meta-analysis

BACKGROUND

To compare the effectiveness and safety of anterior cervical discectomy and fusion (ACDF) with posterior cervical foraminotomy (PCF) for patients diagnosed with single-level unilateral cervical radiculopathy.

METHODS

Relevant studies comparing ACDF with PCF for cervical radiculopathy were searched in an electronic database. After data extraction and quality assessment of included studies, a meta-analysis was done by using the RevMan 5.3 software. The random effects model was used if there was heterogeneity between studies; otherwise, the fixed effects model was used.

RESULTS

A total of 3 randomized controlled trials (RCT) and 12 retrospective studies including 52705 patients were included in the meta-analysis. There were no significant differences in Neck Disability Index (NDI), Visual Analog Scale (VAS), and patients' satisfaction (P > 0.05) between treatment groups. The complication rate of the PCF group was equivalent compared with the ACDF group (P = 0.60), but the reoperation rate following PCF was on the higher side (P = 0.02). Data analysis also showed that the PCF group was associated with shorter operation time (P = 0.001) and shorter length of hospital stay (P = 0.002).

CONCLUSIONS

Among patients with single-level unilateral cervical radiculopathy, PCF has comparable effectiveness and complication rate compared with ACDF. It seems that PCF is a sufficient alternative procedure with shorter operation time, shorter length of hospital stay, and less total hospital cost for the treatment of cervical radiculopathy. However, the higher reoperation rate following PCF should be also taken into consideration.

Optimization of Three-Level Cervical Hybrid Surgery to Prevent Adjacent Segment Disease: A Finite Element Study

Hybrid surgery (HS) allows surgeons to tailor fusion and arthroplasty in the treatment of multiple-level cervical disc degeneration. However, the decision making of selecting either ACDF or ADR for each level in three-level HS remains controversial and has not been fully investigated. This study was aimed to optimize three-level cervical hybrid constructs by systematically investigating their biomechanical properties and their effect on adjacent levels. A finite element model of cervical spine (C2–C7) was developed, and eight C3–C6 surgical models including six HS were constructed. The range of motion (ROM) in flexion, extension, lateral bending, and axial rotation under 2.0 Nm moments with 30 N follower load were simulated. The von Mises stress, strain energy at the adjacent intervertebral disc (IVD) and force at the adjacent facet were calculated. The ROM of the hybrid constructs and adjacent levels was close to that of the intact spine. HS with arthroplasty performed at C5-6 had better performance in terms of ROM reduction at the inferior adjacent level (C6-7). Moreover, C-D-D and 3ADR had best performance in reducing the von Mises stress and strain energy at C6-7. All HS reduced the facet burden at both C2-3 and C6-7 levels. However, the major drawback of HS revealed here is that the effect of C6-7 protection is at the cost of increased C2-3 IVD burden. In conclusion, we recommend C-D-D and 3ADR for patient with C3–C6 disc degeneration without predisposing C2-3 condition. C-C-D could be a good alternative with a lower medical cost. This analysis guides the decision making in three-level cervical HS before future cadaver studies or human clinical trials.

Postoperative structured rehabilitation in patients undergoing surgery for cervical radiculopathy: a 2-year follow-up of a randomized controlled trial

OBJECTIVE

Information about postoperative rehabilitation for cervical radiculopathy (CR) is scarce. The aim of this study was to investigate the additional benefits of structured postoperative rehabilitation (SPT), which was performed in all patients, compared with a pragmatic standard postoperative approach (SA), in which rehabilitation was used as needed and patients sought physiotherapy on their own without a referral, in patients with MRI evidence of disc herniation and concomitant clinical signs who underwent surgery for CR.

METHODS

Patients (n = 202) were randomized to receive SPT or SA. Included key variables in the present study were primary and selected secondary outcomes of a prospective randomized controlled multicenter study. The main outcome was the Neck Disability Index (NDI) score. The NDI score, pain variables, self-efficacy, and health-related quality of life were investigated at baseline and 3, 6, 12, and 24 months postoperatively.

RESULTS

SPT provided no additional benefits over SA (p = 0.08 to p = 0.99) at the postoperative 2-year follow-up. Both groups improved over time (p < 0.0001), with no reported adverse effects.

CONCLUSIONS

One can conclude that SPT offered no additional benefits over SA; however, patients tolerated postoperative neck exercises without any negative side effects. These findings are important for the development of future active and neck-specific postoperative rehabilitation interventions for patients with CR.Clinical trial registration no.: NCT01547611 (clinicaltrials.gov).

Clinical Outcomes After Four-Level Anterior Cervical Discectomy and Fusion

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

Anterior cervical discectomy and fusion (ACDF) demonstrates reliable improvement in neurologic symptoms associated with anterior compression of the cervical spine. There is a paucity of data on outcomes following 4-level ACDFs. The purpose of this study was to evaluate clinical outcomes for patients undergoing 4-level ACDF.

METHODS

All 4-level ACDFs with at least 1-year clinical follow-up were identified. Clinical outcomes, including fusion rates, neurologic outcomes, and reoperation rates were determined.

RESULTS

Retrospective review of our institutional database revealed 25 patients who underwent 4-level ACDF with at least 1-year clinical follow-up. Average age was 57.5 years (range 38.2-75.0 years); 14 (56%) were male, and average body mass index was 30.2 kg/m² (range 19.9-43.4 kg/m²). Two (8%) required secondary cervical surgery at an average of 94.5 days postoperatively while the remaining 23 did not with an average follow-up of 19 months. Of 23 patients not requiring revision surgery, 16 (69%) patients fused by definition of less than 1 mm of spinous process motion per fused level in flexion and extension. Fifteen (65%) had at least one muscle group with one grade of weakness preoperatively. Nineteen of these patients (83%) had improved to full strength while no patients lost muscle strength.

CONCLUSIONS

Review of our institution's experience demonstrated a low rate of revision cervical surgery for any reason of 8% at mean 19 months follow-up, and neurological examinations consistently improved, despite a high rate of radiographic nonunion (31%).

The effect of stabilization exercise training on pain and functional status in patients with cervical radiculopathy

BACKGROUND

There is no consensus about treatment of neck patients who have radicular symptoms.

OBJECTIVE

The purpose of the study was to investigate the effect of stabilization exercise training on pain and functional status in patients with cervical radiculopathy.

METHODS

The patients (n= 32) with cervical radiculopathy were randomized to two groups as follows: Stabilization exercise group (Group 1; n= 18); Home-exercise group (Group 2; n= 16). The patients were evaluated with visual analog scale, Neck Disability Index, SF-36 (Short-Form), Corbin postural assessment scale and hand grip at baseline, after treatment at 4th week and 3rd month.

RESULTS

At baseline, there were no statistically differences between groups in terms of evaluated parameters (p> 0.05). After treatment and three months later, pain and Neck Disability Index decreased; Corbin postural scores, hand grip and SF-36 scores improved statistically in both groups (p< 0.05). Changes of the measurements in both groups were similar and there were no significant differences between group 1 and group 2 at 4th week and 3rd month (p> 0.05) except postural scores.

CONCLUSIONS

This study demonstrates that stabilization exercise training could be an effective intervention for decreasing pain and improving quality of life and posture in patients with cervical radiculopathy.

Prolonged Preoperative Weakness Affects Recovery of Motor Function After Anterior Cervical Diskectomy and Fusion

INTRODUCTION

Some patients who undergo anterior cervical diskectomy and fusion for radiculopathy or myelopathy demonstrate preoperative weakness. The purpose of this study was to determine which factors predict motor recovery in patients undergoing anterior cervical diskectomy and fusion.

METHODS

A retrospective review of our institutional database identified patients undergoing anterior cervical diskectomy and fusion between 2010 and 2013 with 2 years of clinical follow-up. Patients with substantial weakness, defined as preoperative grade ≤3 (on a scale from 0 to 5) in one or more upper extremity muscle groups, were identified. Regression analysis was used to determine risk factors associated with persistent postoperative weakness.

RESULTS

Of the 1,001 patients who were included, 54 (5.4%) demonstrated substantial weakness. By 2 years postoperatively, 47 of 54 patients (87%) demonstrated motor recovery. The duration of preoperative weakness was an independent predictor of recovery (median, 4 months of preoperative weakness among patients with recovery versus 10 months in patients with persistent weakness; P = 0.012).

DISCUSSION

Duration of preoperative motor weakness is an independent predictor of motor recovery after anterior cervical diskectomy and fusion in patients with substantial motor weakness.

CONCLUSION

Patients being considered for anterior cervical diskectomy and fusion who have substantial preoperative motor deficits may benefit from earlier surgical intervention.

The effectiveness of therapeutic strategies for patients with radiculopathy: A network meta-analysis

Objectives The aim of this network meta-analysis is to assess the effectiveness of therapeutic strategies for patients with radiculopathy, including physical, medical, surgical, and other therapies. Methods We electronically searched electronic databases including PubMed and Embase for randomized controlled trials. The response rate and visual analog scale of pain change were considered as primary outcomes. The outcomes were measured by odds ratio (OR) value and corresponding 95% credible intervals (CrIs) or standardized mean difference (MD) with 95% CrIs. Besides, surface under cumulative ranking curve (SUCRA) were performed to rank efficacy and safety of treatments on each end points. Results A total of 16 eligible studies with 1071 subjects were included in this analysis. Our results showed that corticosteroid was significantly more effective than control regarding the response rate (OR = 3.86, 95% CrI: 1.16, 12.55). Surgery had a better performance in pain change compared with control (MD = -1.92, 95% CrI: -3.58, -0.15). According to the SUCRA results, corticosteroid, collar, and physiotherapy ranked the highest concerning response rate (SUCRA = 0.656, 0.652, and 0.610, respectively). Surgery, traction, and corticosteroid were superior to others in pain change (SUCRA = 0.866, 0.748, and 0.589, respectively). Conclusion According to the network meta-analysis result, we recommended surgery as the optimal treatment for radiculopathy patients; traction and corticosteroids were also recommended for their beneficial interventions.

Inter- and intrarater reliability of goniometry and hand held dynamometry for patients with subacromial impingement syndrome

The purpose of this study was to examine the intra- and interrater reliability of measuring shoulder range of motion (ROM) and strength among patients diagnosed with subacromial impingement syndrome (SAIS). Twenty-five patients (14 female patients; mean age, 60.4± 7.84 years) diagnosed with SAIS were assessed to determine the intrarater reliability for glenohumeral ROM. Twenty-five patients (16 female patients; mean age, 60.4± 7.80 years) and 76 asymptomatic volunteers (52 female volunteers; mean age, 29.4± 14.1 years) were assessed for interrater reliability. Dependent variables were active shoulder ROM and isometric strength. Intrarater reliability was fair-to-excellent for the SAIS patients (intraclass correlation coefficient [ICC], 0.52–0.97; standard error of measurement [SEM], 4.4°–9.9° N; coefficient of variation [CV], 7.1%–44.9%). Based on the ICC, 11 of 12 parameters (92%) displayed an excellent reliability (ICC> 0.75). The interrater reliability showed fair-to-excellent results (SAIS patients: ICC, 0.13–0.98; SEM, 2.3°–8.8°; CV, 3.6%–37.0%; controls: ICC, 0.11–0.96; SEM, 3.0°–35.4°; CV, 5.6%–26.4%). In accordance with the intrarater reliability, glenohumeral adduction ROM was the only parameter with an ICC below 0.75 for both samples. Painful shoulder ROM in the SAIS patients showed no influence on the quality of reliability for measurement. Therefore, these protocols should be considered reliable assessment techniques in the prevention, diagnosis, and treatment of painful shoulder conditions such as SAIS.

Characterization of a novel caudal vertebral interbody fusion in a rat tail model: An implication for future material and mechanical testing

Background

Of the proposed animal interbody fusion models, rat caudal discs have gained popularity in disc research due to their strong resemblance to human discs with respect to geometry, composition and mechanical properties. The purpose of this study is to demonstrate an efficient, repeatable and easily accessible animal model of interbody fusion for future research into mechanical testing and graft materials.

Methods

Twelve 12-week-old female Sprague–Dawley (SD) rats underwent caudal interbody fusion of the third and fourth coccygeal vertebrae of the tail. Serial radiological evaluation, and histological evaluation and manual palpation after sacrifice were performed to assess the fusion quality. Mechanical testing of functional units (FUs) of non-operated and operated segments was compared using a three-point bending test.

Results

At postoperative 12 weeks, callus formation was observed at the fusion sites in all rats, with the mean radiological evaluations of 2.75/3 according to the Bransford classification. Newly formed bone tissue was also observed in all rats with the mean histological score of 5.85/7, according to the Emery grading system. No palpable gaps and obvious change of bending stiffness was observed in the operated segments. The mean bending stiffness of the FUs was statistically higher than that of the control FUs (26.57 ± 6.71 N/mm vs. 12.45 ± 3.21 N/mm, p < 0.01).

Conclusion

The rat caudal disc interbody fusion model proved to be an efficient, repeatable and easily accessible model. Future research into adjuvant treatments like growth factor injection and alternative fusion materials under conditions of osteoporosis using this model would be worthwhile.

Evolution of Muscles Dysfunction From Myofascial Pain Syndrome Through Cervical Disc-Root Conflict to Degenerative Spine Disease

STUDY DESIGN

Comparative clinical and neurophysiological study in three groups of patients with general diagnosis of neck pain.

OBJECTIVE

To determine symptoms of muscles dysfunction in patients with myofascial pain syndrome, disc-root conflict, and degenerative changes at cervical spine.

SUMMARY AND BACKGROUND DATA

The explanation for cervical pain origin should be based on results from chosen clinical and neurophysiological studies in correlation with neuroimaging findings.

METHODS

Three subgroups of patients (N = 60 each) with certain symptoms were examined. Clinical evaluation included examination of pain intensity in VAS scale, muscle strength in Lovett scale, evaluation of reflexes, Spurling test, assessment of active trigger points (TRPs), and superficial sensory perception. Neurophysiological testing included surface electromyography at rest (rEMG) and during maximal contraction (mcEMG) as well as electroneurography (ENG).

RESULTS

The greatest pain intensity with its decentralization phenomenon occurred in patients with disc-root conflict. Significant decrease of muscle strength was detected in trapezius muscle in myofascial pain syndrome subgroup. Weakness of abductor pollicis brevis muscle in patients with disc-root conflict differed them from patients with myofascial pain syndrome (P = 0.05). Patients with disc-root conflict and degenerative spine disease showed differences (P = 0.03) in reflexes evoked from triceps brachii. Positive Spurling symptom was most common (56.7%) in disc-root conflict subgroup. TRPs in trapezius muscle were found in all patients with myofascial pain syndrome. Results of rEMG amplitude measurements differed patients at P = 0.05. Only mcEMG recording from abductor pollicis brevis muscle allows for their clear cut differentiation. ENG studies showed abnormalities in patients with disc-root conflict and degenerative spine disease (P from 0.05 to 0.02). Positive correlation of VAS, TRPs, and rEMG as well as Lovett scores, mcEMG, and ENG results was found.

CONCLUSION

Only applying several clinical and neurophysiological tests together makes it possible to differentiate patients with different etiological reasons of pain at cervical spine.

LEVEL OF EVIDENCE

4.

Effectiveness of manual therapy for cervical radiculopathy, a review

Manual therapy is often used for patients with neck pain with or without radicular symptoms. There is sparse evidence on the effectiveness in cervical radiculopathy. The aim of this study was to assess current levels of evidence on the effectiveness of manual therapy interventions for patients with cervical radiculopathy. Electronic data bases were systematically searched for clinical guidelines, reviews and randomised clinical trials (RCTs) reporting on the effectiveness of manual therapy for patients with cervical radiculopathy. Eight relevant reviews, two guidelines and two recent RCTs, that had not yet been included in either, were retrieved. The overall quality of the evidence of included studies was evaluated using the GRADE method. Most interventions were only studied in one single RCT. There is low level evidence that cervical manipulation and mobilisation as unimodal interventions are effective on pain and range of motion at the immediate follow up, but no evidence on the effectiveness of thoracic manipulation or mobilisation as unimodal interventions. There is low level evidence that a combination of spinal mobilisation and motor control exercises is more effective on pain and activity limitations than separate interventions or a wait-and-see policy. There is low level evidence of the effectiveness of cervical mobilisation with a neurodynamical intent as unimodal intervention, on the effectiveness of a multimodal intervention with neurodynamic intent on pain activity limitations and global perceived effect compared to a wait-and-see policy. There is also low level evidence that a multimodal intervention consisting of spinal and neurodynamic mobilisations and specific exercises is effective on pain in patients with CR. There is low level evidence that traction is no more effective than placebo traction.

Cervical disc arthroplasty for symptomatic cervical disc disease: Traditional and Bayesian meta-analysis with trial sequential analysis

OBJECTIVE

Cervical disc arthroplasty (CDA) has been designed as a substitute for anterior cervical discectomy and fusion (ACDF) in the treatment of symptomatic cervical disc disease (CDD). Several researchers have compared CDA with ACDF for the treatment of symptomatic CDD; however, the findings of these studies are inconclusive. Using recently published evidence, this meta-analysis was conducted to further verify the benefits and harms of using CDA for treatment of symptomatic CDD.

METHODS

Relevant trials were identified by searching the PubMed, EMBASE, and Cochrane Library databases. Outcomes were reported as odds ratio or standardized mean difference. Both traditional frequentist and Bayesian approaches were used to synthesize evidence within random-effects models. Trial sequential analysis (TSA) was applied to test the robustness of our findings and obtain more conservative estimates.

RESULTS

Nineteen trials were included. The findings of this meta-analysis demonstrated better overall, neck disability index (NDI), and neurological success; lower NDI and neck and arm pain scores; higher 36-Item Short Form Health Survey (SF-36) Physical Component Summary (PCS) and Mental Component Summary (MCS) scores; more patient satisfaction; greater range of motion at the operative level; and fewer secondary surgical procedures (all P < 0.05) in the CDA group compared with the ACDF group. CDA was not significantly different from ACDF in the rate of adverse events (P > 0.05). TSA of overall success suggested that the cumulative z-curve crossed both the conventional boundary and the trial sequential monitoring boundary for benefit, indicating sufficient and conclusive evidence had been ascertained.

CONCLUSIONS

For treating symptomatic CDD, CDA was superior to ACDF in terms of overall, NDI, and neurological success; NDI and neck and arm pain scores; SF-36 PCS and MCS scores; patient satisfaction; ROM at the operative level; and secondary surgical procedures rate. Additionally, there was no significant difference between CDA and ACDF in the rate of adverse events. However, as the CDA procedure is a relatively newer operative technique, long-term results and evaluation are necessary before CDA is routinely used in clinical practice.

Management of neck pain and associated disorders: A clinical practice guideline from the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration

PURPOSE

To develop an evidence-based guideline for the management of grades I-III neck pain and associated disorders (NAD).

METHODS

This guideline is based on recent systematic reviews of high-quality studies. A multidisciplinary expert panel considered the evidence of effectiveness, safety, cost-effectiveness, societal and ethical values, and patient experiences (obtained from qualitative research) when formulating recommendations. Target audience includes clinicians; target population is adults with grades I-III NAD <6 months duration.

RECOMMENDATION 1

Clinicians should rule out major structural or other pathologies as the cause of NAD. Once major pathology has been ruled out, clinicians should classify NAD as grade I, II, or III.

RECOMMENDATION 2

Clinicians should assess prognostic factors for delayed recovery from NAD.

RECOMMENDATION 3

Clinicians should educate and reassure patients about the benign and self-limited nature of the typical course of NAD grades I-III and the importance of maintaining activity and movement. Patients with worsening symptoms and those who develop new physical or psychological symptoms should be referred to a physician for further evaluation at any time during their care.

RECOMMENDATION 4

For NAD grades I-II ≤3 months duration, clinicians may consider structured patient education in combination with: range of motion exercise, multimodal care (range of motion exercise with manipulation or mobilization), or muscle relaxants. In view of evidence of no effectiveness, clinicians should not offer structured patient education alone, strain-counterstrain therapy, relaxation massage, cervical collar, electroacupuncture, electrotherapy, or clinic-based heat.

RECOMMENDATION 5

For NAD grades I-II >3 months duration, clinicians may consider structured patient education in combination with: range of motion and strengthening exercises, qigong, yoga, multimodal care (exercise with manipulation or mobilization), clinical massage, low-level laser therapy, or non-steroidal anti-inflammatory drugs. In view of evidence of no effectiveness, clinicians should not offer strengthening exercises alone, strain-counterstrain therapy, relaxation massage, relaxation therapy for pain or disability, electrotherapy, shortwave diathermy, clinic-based heat, electroacupuncture, or botulinum toxin injections.

RECOMMENDATION 6

For NAD grade III ≤3 months duration, clinicians may consider supervised strengthening exercises in addition to structured patient education. In view of evidence of no effectiveness, clinicians should not offer structured patient education alone, cervical collar, low-level laser therapy, or traction. RECOMMENDATION 7: For NAD grade III >3 months duration, clinicians should not offer a cervical collar. Patients who continue to experience neurological signs and disability more than 3 months after injury should be referred to a physician for investigation and management. RECOMMENDATION 8: Clinicians should reassess the patient at every visit to determine if additional care is necessary, the condition is worsening, or the patient has recovered. Patients reporting significant recovery should be discharged.

Treatment of degenerative cervical spondylosis with radiculopathy. Clinical practice guidelines endorsed by The Polish Society of Spinal Surgery

INTRODUCTION

Degenerative cervical spondylosis (DCS) with radiculopathy is the most common indication for cervical spine surgery despite favorable natural history. Advances in spinal surgery in conjunction with difficulties in measuring the outcomes caused the paucity of uniform guidelines for the surgical management of DCS.

AIMS

The aim of this paper is to develop guidelines for surgical treatment of DCS. For this purpose the available up-to-date literature relevant on the topic was critically reviewed.

METHODS AND RESULTS

Six questions regarding most important clinical questions encountered in the daily practice were formulated. They were answered based upon the systematic literature review, thus creating a set of guidelines. The guidelines were categorized into four tiers based on the level of evidence (I-III and X). They were designed to assist in the selection of optimal and effective treatment leading to the most successful outcome.

CONCLUSIONS

The evidence based medicine (EBM) is increasingly popular among spinal surgeons. It allows making unbiased, optimal clinical decisions, eliminating the detrimental effect of numerous conflicts of interest. The key role of opinion leaders as well as professional societies is to provide guidelines for practice based on available clinical evidence. The present work contains a set of guidelines for surgical treatment of DCS officially endorsed by the Polish Spine Surgery Society.

Exercise training for non-operative and post-operative patient with cervical radiculopathy: a literature review

[Purpose] Cervical radiculopathy is a clinical condition associated with pain, numbness and/or muscle weaknesses of the upper extremities due to a compression or irritation of the cervical nerve roots. It is usually managed conservatively but surgical intervention is sometimes required for those who fail to respond adequately. This study performed a literature review to determine the effects of exercise on non-operative and post-operative cervical radiculopathy patients. [Methods] The PubMed, MEDLINE, CINAHL and Scopus databases were searched to identify relevant articles published from January 1997 to May 2014, which explicitly stated that an exercise program was employed as an intervention for cervical radiculopathy. The therapeutic effectiveness and outcomes were then classified based on the International Classification of Functioning, Disability and Health (ICF) model. [Results] Eleven studies were identified and included in the final analysis. In these studies, the main forms of exercise training were specific strengthening and general stretching exercises. Levels of evidence were graded as either I or II for all studies according to the Oxford Centre for Evidence-based Medicine. The PEDro Scale score of these studies ranged from 5 to 8. [Conclusion] A review of eleven high-level evidence and high-quality studies revealed that, based on the ICF model, exercise training is beneficial for improving the body function as well as activity participation of cervical radiculopathy patients.

Manipulation and mobilisation for neck pain contrasted against an inactive control or another active treatment

BACKGROUND

Manipulation and mobilisation are commonly used to treat neck pain. This is an update of a Cochrane review first published in 2003, and previously updated in 2010.

OBJECTIVES

To assess the effects of manipulation or mobilisation alone compared wiith those of an inactive control or another active treatment on pain, function, disability, patient satisfaction, quality of life and global perceived effect in adults experiencing neck pain with or without radicular symptoms and cervicogenic headache (CGH) at immediate- to long-term follow-up. When appropriate, to assess the influence of treatment characteristics (i.e. technique, dosage), methodological quality, symptom duration and subtypes of neck disorder on treatment outcomes.

SEARCH METHODS

Review authors searched the following computerised databases to November 2014 to identify additional studies: the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and the Cumulative Index to Nursing and Allied Health Literature (CINAHL). We also searched ClinicalTrials.gov, checked references, searched citations and contacted study authors to find relevant studies. We updated this search in June 2015, but these results have not yet been incorporated.

SELECTION CRITERIA

Randomised controlled trials (RCTs) undertaken to assess whether manipulation or mobilisation improves clinical outcomes for adults with acute/subacute/chronic neck pain.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, abstracted data, assessed risk of bias and applied Grades of Recommendation, Assessment, Development and Evaluation (GRADE) methods (very low, low, moderate, high quality). We calculated pooled risk ratios (RRs) and standardised mean differences (SMDs).

MAIN RESULTS

We included 51 trials (2920 participants, 18 trials of manipulation/mobilisation versus control; 34 trials of manipulation/mobilisation versus another treatment, 1 trial had two comparisons). Cervical manipulation versus inactive control: For subacute and chronic neck pain, a single manipulation (three trials, no meta-analysis, 154 participants, ranged from very low to low quality) relieved pain at immediate- but not short-term follow-up. Cervical manipulation versus another active treatment: For acute and chronic neck pain, multiple sessions of cervical manipulation (two trials, 446 participants, ranged from moderate to high quality) produced similar changes in pain, function, quality of life (QoL), global perceived effect (GPE) and patient satisfaction when compared with multiple sessions of cervical mobilisation at immediate-, short- and intermediate-term follow-up. For acute and subacute neck pain, multiple sessions of cervical manipulation were more effective than certain medications in improving pain and function at immediate- (one trial, 182 participants, moderate quality) and long-term follow-up (one trial, 181 participants, moderate quality). These findings are consistent for function at intermediate-term follow-up (one trial, 182 participants, moderate quality). For chronic CGH, multiple sessions of cervical manipulation (two trials, 125 participants, low quality) may be more effective than massage in improving pain and function at short/intermediate-term follow-up. Multiple sessions of cervical manipulation (one trial, 65 participants, very low quality) may be favoured over transcutaneous electrical nerve stimulation (TENS) for pain reduction at short-term follow-up. For acute neck pain, multiple sessions of cervical manipulation (one trial, 20 participants, very low quality) may be more effective than thoracic manipulation in improving pain and function at short/intermediate-term follow-up. Thoracic manipulation versus inactive control: Three trials (150 participants) using a single session were assessed at immediate-, short- and intermediate-term follow-up. At short-term follow-up, manipulation improved pain in participants with acute and subacute neck pain (five trials, 346 participants, moderate quality, pooled SMD -1.26, 95% confidence interval (CI) -1.86 to -0.66) and improved function (four trials, 258 participants, moderate quality, pooled SMD -1.40, 95% CI -2.24 to -0.55) in participants with acute and chronic neck pain. A funnel plot of these data suggests publication bias. These findings were consistent at intermediate follow-up for pain/function/quality of life (one trial, 111 participants, low quality). Thoracic manipulation versus another active treatment: No studies provided sufficient data for statistical analyses. A single session of thoracic manipulation (one trial, 100 participants, moderate quality) was comparable with thoracic mobilisation for pain relief at immediate-term follow-up for chronic neck pain. Mobilisation versus inactive control: Mobilisation as a stand-alone intervention (two trials, 57 participants, ranged from very low to low quality) may not reduce pain more than an inactive control. Mobilisation versus another active treatment: For acute and subacute neck pain, anterior-posterior mobilisation (one trial, 95 participants, very low quality) may favour pain reduction over rotatory or transverse mobilisations at immediate-term follow-up. For chronic CGH with temporomandibular joint (TMJ) dysfunction, multiple sessions of TMJ manual therapy (one trial, 38 participants, very low quality) may be more effective than cervical mobilisation in improving pain/function at immediate- and intermediate-term follow-up. For subacute and chronic neck pain, cervical mobilisation alone (four trials, 165 participants, ranged from low to very low quality) may not be different from ultrasound, TENS, acupuncture and massage in improving pain, function, QoL and participant satisfaction at immediate- and intermediate-term follow-up. Additionally, combining laser with manipulation may be superior to using manipulation or laser alone (one trial, 56 participants, very low quality).

AUTHORS' CONCLUSIONS

Although support can be found for use of thoracic manipulation versus control for neck pain, function and QoL, results for cervical manipulation and mobilisation versus control are few and diverse. Publication bias cannot be ruled out. Research designed to protect against various biases is needed. Findings suggest that manipulation and mobilisation present similar results for every outcome at immediate/short/intermediate-term follow-up. Multiple cervical manipulation sessions may provide better pain relief and functional improvement than certain medications at immediate/intermediate/long-term follow-up. Since the risk of rare but serious adverse events for manipulation exists, further high-quality research focusing on mobilisation and comparing mobilisation or manipulation versus other treatment options is needed to guide clinicians in their optimal treatment choices.

Anterior cervical discectomy and fusion versus posterior cervical foraminotomy in the treatment of brachialgia: the Leeds spinal unit experience (2008-2013)

BACKGROUND

The surgical management of cervical brachialgia utilising anterior cervical discectomy and fusion (ACDF) or posterior cervical foraminotomy (PCF) is a controversial area in spinal surgery. Previous studies are limited by utilisation of non-validated outcome measures and, importantly, absence of pre-operative analysis to ensure both groups are matched. The authors aimed to compare the effectiveness of ACDF and PCF using validated outcome measures. To our knowledge, it is the first study in the literature to do this.

METHODS

The authors conducted a 5-year retrospective review (2008-2013) of outcomes following both the above procedures and also compared the effectiveness of both techniques. Patients with myelopathy and large central discs were excluded. The main outcome variables measured were the neck disability index (NDI) and visual analogue scores (VAS) for neck and arm pain pre-operatively and again at 2-year follow-up. The Wilcoxon signed-rank test and Student t-tests were used to test differences.

RESULTS

A total of 150 ACDFs and 51 PCFs were performed for brachialgia. There was no differences in the pre-operative NDI, VAS neck and arm scores between both groups (p > 0.05). As expected, both ACDF and PCF delivered statistically significant improvement in NDI, VAS-neck and VAS-arm scores. The degree of improvement of NDI, VAS-neck and VAS-arm were the same between both groups of patients (p > 0.05) with a trend favouring the PCF group. In the ACDF group, two (1.3 %) patients needed repeat ACDF due to adjacent segment disease. One patient (0.7 %) needed further decompression via a foraminotomy. In the PCF group one (2.0 %) patient needed ACDF due to persistent brachialgia.

CONCLUSIONS

We found both interventions delivered similar improvements in the VAS and NDI scores in patients. Both techniques may be appropriately utilised when treating a patient with cervical brachialgia.

Herpes zoster segmental paresis in an immunocompromised breast cancer woman

Herpes zoster is an infectious disease with neurological complications caused by reactivation of varicella zoster virus in dorsal root ganglia of spinal cord which is also known as "Shingles." Suppression of immune system is the major predisposing factor for reactivation of latent virus. Disease is mainly characterized by rash, vesicles and pain along one or more dermatomes which are innervated from one or more spinal nerve roots. Complications may be present after a while despite of patient treatment. Motor involvement is included. Some previous studies showed segmental zoster paresis as a rare complication, a few weeks after first presentation, among immunocompetent individuals. We present post herpetic motor involvement of C5 and C6 in a 59-year-old woman who underwent chemotherapy and radiotherapy due to breast cancer, manifesting left upper limb weakness and paresis, 6 months after left partial mastectomy. Segmental paresis of zoster virus should be considered as a cause of motor impairment in an immunocompromised person suffering from shingles.

WITHDRAWN: Arthroplasty versus fusion in single-level cervical degenerative disc disease

Background

There is ongoing debate about whether fusion or arthroplasty is superior in the treatment of single level cervical degenerative disc disease. Mainly because the intended advantage of arthroplasty over fusion, that is, the prevention of symptoms due to adjacent segment degeneration in the long term, is not confirmed yet. Until sufficient long‐term results become available, it is important to know whether results of one of the two treatments are superior to the other in the first one to two years.

Objectives

To assess the effects of arthroplasty versus fusion for radiculopathy or myelopathy, or both due to single level cervical degenerative disc disease.

Search methods

We searched the following databases for randomised controlled trials (RCTs): CENTRAL (The Cochrane Library 2011, Issue 2), MEDLINE, EMBASE, and EBMR. Additionally, we searched the System for Information on Grey Literature (SIGLE), subheading Biological and Medical Sciences, the US Food and Drug Administration (FDA) database on medical devices, and Clinicaltrials.gov to identify trials in progress. We also screened the reference list of all selected papers. Date of search: 25 May 2011.

Selection criteria

We included RCTs that directly compared any type of cervical fusion with any type of arthroplasty, with at least one year of follow‐up. Primary outcomes were arm pain, neck pain, neck‐related functional status, patient satisfaction, neurological outcome, and global health status. Secondary outcomes were the presence of (radiological) fusion, revision surgery at the treated level, secondary surgery on adjacent levels, segmental mobility of treated and adjacent levels, and work status.

Data collection and analysis

Study selection was performed independently by three review authors, and 'Risk of bias' assessment and data extraction were performed by two review authors. In case of missing data or insufficient information for a judgement about risk of bias, we tried to contact the study authors or the study sponsor. The data were entered into RevMan by one review author and subsequently checked by a second review author. We assessed the quality of evidence using GRADE. We analysed heterogeneity and performed sensitivity analyses for the pooled analyses.

Main results

We included nine studies (2400 participants), five of which had a low risk of bias. Eight of these studies were industry sponsored. The most important results showed low‐quality evidence for a small but significant difference in alleviation of arm pain at one to two years in favour of arthroplasty (mean difference (MD) ‐1.54; 95% confidence interval (CI) ‐2.86 to ‐0.22; 100‐point scale). A small study effect could not be ruled out for this outcome in the sensitivity analyses. This means that smaller studies (or small published subsets of larger studies) showed larger differences for this outcome, which may indicate publication bias. Also, moderate‐quality evidence showed a small difference in neck‐related functional status at one to two years in favour of arthroplasty (MD ‐2.79; 95% CI ‐4.73 to ‐0.85; 100‐point scale) and a small difference in neurological outcome in favour of arthroplasty (risk ratio (RR) 1.05; 95% CI 1.01 to 1.09). These two outcomes were robust to sensitivity analyses. For none of the primary outcomes, was a clinically relevant difference shown. Additionally, there was high‐quality evidence for a large, statistically significant difference in segmental mobility at one to two years (measured as degrees segmental range of motion) at the treated level (MD 6.90; 95% CI 5.45 to 8.35). There was low‐quality evidence that there was no statistically significant difference in secondary surgery at the adjacent levels at one to two years (RR 0.60; 95% CI 0.35 to 1.02). The latter was not robust to sensitivity analyses.

Authors' conclusions

There was a tendency for clinical results to be in favour of arthroplasty; often these were statistically significant. However, differences in effect size were invariably small and not clinically relevant for all primary outcomes. Significance was often gained or lost in the varying sensitivity analyses, probably owing to the relatively small number of studies, in combination with the small differences that were found. Given the fact that all of the included studies were not blinded, this could be due to patient or carer expectations. However, at this time both treatments can be seen as valid options with respect to results at a maximum of one to two years. Given the current absence of truly long‐term results, use of these mobile disc prostheses should still be limited to clinical trials. There was high‐quality evidence that the goal of preservation of segmental mobility in arthroplasty was met. A statistically significant effect on the incidence of secondary symptoms at adjacent levels, the primary goal of arthroplasty over fusion, was not found at one to two years. If there was a protective effect, this should become clearer over time. A future update, when studies with 'truly long‐term' results (five years or more) become available, should focus on this issue.

A herniated disc in the neck often causes radiating pain, numbness, and weakness in muscles of the neck, shoulders, arms, and hands. It may also lead to symptoms in the trunk and legs.

When there is no or insufficient relief of symptoms with non‐surgical treatment, surgery can be an option. Traditional 'fusion' surgery involves fusion of the two bones of the spine (the vertebrae) that form the disc space. Motion between these two vertebrae is then no longer possible.

It has been suggested that this may cause the adjacent parts of the spine to become more mobile, as compensation. This in turn might accelerate normal wear and tear in these parts of the spine, which could lead to new symptoms. At present this is not confirmed.

Mobile disc prostheses have been introduced in an effort to reduce the amount of new symptoms at the longer term after surgery by preserving motion between the vertebrae involved. Long‐term results are not available yet. However, it is important to know whether disc arthroplasty is at least as effective as fusion in relieving symptoms, the primary aim of surgery.

In this review we have searched for all studies in which the patient receives one of these two possible treatments at random.

We identified nine studies (2400 participants), and considered five of these to have high methodological quality. This review shows that patients who were treated with a mobile disc prosthesis had less pain radiating to the arm one to two years after surgery, and less disability owing to these complaints. However, the actual differences were very small, only between 1 and 5 points on a 100‐point scale. The overall quality of the evidence was low to moderate, which means that including new studies in future years could change these conclusions. The conclusion that mobility is in fact preserved after placement of a mobile disc prosthesis, compared to traditional 'fusion' surgery, is unlikely to change. Whether this preserved mobility will lead to fewer new symptoms in the future is uncertain based on results for the first one to two years after surgery.

Therefore, a comparison of results in the long term (five years or more) will be made when more studies with long‐term results have become available.

Epidemiology, diagnosis, and treatment of neck pain

Neck pain is the fourth leading cause of disability, with an annual prevalence rate exceeding 30%. Most episodes of acute neck pain will resolve with or without treatment, but nearly 50% of individuals will continue to experience some degree of pain or frequent occurrences. History and physical examination can provide important clues as to whether the pain is neuropathic or mechanical and can also be used to identify "red flags" that may signify serious pathology, such as myelopathy, atlantoaxial subluxation, and metastases. Magnetic resonance imaging is characterized by a high prevalence of abnormal findings in asymptomatic individuals but should be considered for cases involving focal neurologic symptoms, pain refractory to conventional treatment, and when referring a patient for interventional treatment. Few clinical trials have evaluated treatments for neck pain. Exercise treatment appears to be beneficial in patients with neck pain. There is some evidence to support muscle relaxants in acute neck pain associated with muscle spasm, conflicting evidence for epidural corticosteroid injections for radiculopathy, and weak positive evidence for cervical facet joint radiofrequency denervation. In patients with radiculopathy or myelopathy, surgery appears to be more effective than nonsurgical therapy in the short term but not in the long term for most people.

Exercises for mechanical neck disorders

BACKGROUND

Neck pain is common, disabling and costly. Exercise is one treatment approach.

OBJECTIVES

To assess the effectiveness of exercises to improve pain, disability, function, patient satisfaction, quality of life and global perceived effect in adults with neck pain.

SEARCH METHODS

We searched MEDLINE, MANTIS, ClinicalTrials.gov and three other computerized databases up to between January and May 2014 plus additional sources (reference checking, citation searching, contact with authors).

SELECTION CRITERIA

We included randomized controlled trials (RCTs) comparing single therapeutic exercise with a control for adults suffering from neck pain with or without cervicogenic headache or radiculopathy.

DATA COLLECTION AND ANALYSIS

Two review authors independently conducted trial selection, data extraction, 'Risk of bias' assessment and clinical relevance. The quality of the evidence was assessed using GRADE. Meta-analyses were performed for relative risk and standardized mean differences (SMD) with 95% confidence intervals (CIs) after judging clinical and statistical heterogeneity.

MAIN RESULTS

Twenty-seven trials (2485 analyzed /3005 randomized participants) met our inclusion criteria.For acute neck pain only, no evidence was found.For chronic neck pain, moderate quality evidence supports 1) cervico-scapulothoracic and upper extremity strength training to improve pain of a moderate to large amount immediately post treatment [pooled SMD (SMDp) -0.71 (95% CI: -1.33 to -0.10)] and at short-term follow-up; 2) scapulothoracic and upper extremity endurance training for slight beneficial effect on pain at immediate post treatment and short-term follow-up; 3) combined cervical, shoulder and scapulothoracic strengthening and stretching exercises varied from a small to large magnitude of beneficial effect on pain at immediate post treatment [SMDp -0.33 (95% CI: -0.55 to -0.10)] and up to long-term follow-up and a medium magnitude of effect improving function at both immediate post treatment and at short-term follow-up [SMDp -0.45 (95%CI: -0.72 to -0.18)]; 4) cervico-scapulothoracic strengthening/stabilization exercises to improve pain and function at intermediate term [SMDp -14.90 (95% CI:-22.40 to -7.39)]; 5) Mindfulness exercises (Qigong) minimally improved function but not global perceived effect at short term. Low evidence suggests 1) breathing exercises; 2) general fitness training; 3) stretching alone; and 4) feedback exercises combined with pattern synchronization may not change pain or function at immediate post treatment to short-term follow-up. Very low evidence suggests neuromuscular eye-neck co-ordination/proprioceptive exercises may improve pain and function at short-term follow-up.For chronic cervicogenic headache, moderate quality evidence supports static-dynamic cervico-scapulothoracic strengthening/endurance exercises including pressure biofeedback immediate post treatment and probably improves pain, function and global perceived effect at long-term follow-up. Low grade evidence supports sustained natural apophyseal glides (SNAG) exercises.For acute radiculopathy, low quality evidence suggests a small benefit for pain reduction at immediate post treatment with cervical stretch/strengthening/stabilization exercises.

AUTHORS' CONCLUSIONS

No high quality evidence was found, indicating that there is still uncertainty about the effectiveness of exercise for neck pain. Using specific strengthening exercises as a part of routine practice for chronic neck pain, cervicogenic headache and radiculopathy may be beneficial. Research showed the use of strengthening and endurance exercises for the cervico-scapulothoracic and shoulder may be beneficial in reducing pain and improving function. However, when only stretching exercises were used no beneficial effects may be expected. Future research should explore optimal dosage.

Anterior cervical discectomy with arthroplasty versus anterior cervical discectomy and fusion for cervical spondylosis

This meta-analysis aims to estimate the benefits and drawbacks associated with anterior cervical discectomy with arthroplasty (ACDA) versus anterior cervical discectomy and fusion (ACDF) for cervical spondylosis. Of 3651 identified citations, 10 randomised controlled studies involving 2380 participants were included. Moderate quality evidence supports that patients in the ACDA group had: (1) a higher Neck Disability Index (NDI) success rate at 3 month (relative risk [RR]=0.85, 95% confidence interval [CI] 0.78 to 0.93, p=0.0002) and 2 year follow-up (RR=0.95, 95%CI 0.91 to 1.00, p=0.04); (2) greater neurological success at 2 year follow-up (RR=0.95, 95%CI 0.92 to 0.98); and (3) were more likely to be employed within 6 weeks after surgery (RR=0.80 95%CI 0.66 to 0.96). In summary, the current evidence indicates that ACDA is associated with a higher NDI success rate in the short and long-term as well as a higher neurological success rate. Patients who undergo ACDA may also have a greater likelihood of being employed in the short-term. However, all of the evidence reviewed is of moderate or low quality and the clinical significance often marginal or unclear. Additional data are needed to compare the benefits and limitations of ACDA and ACDF.

The orthotic treatment of acute and chronic disease of the cervical and lumbar spine

BACKGROUND

Orthoses are external aids that are often used to treat pain and diseases affecting the spine, such as lumbago, whiplash, and disc herniation. In this review, we assess the effectiveness and complications of orthotic treatment for typical spinal conditions and after spinal surgery. The orthotic treatment of fractures and postural abnormalities are beyond the scope of this article.

METHOD

This review is based on a selective search in the Medline database with consideration of controlled trials, systematic reviews, and the recommendations of the relevant medical societies.

RESULTS

Three relevant systematic reviews and four controlled trials were found. Very few controlled trials to date have studied the efficacy of orthotic treatment compared to other conservative treatments and surgery. No definitive evidence was found to support the use of orthoses after surgery, in lumbar radiculopathy, or after whiplash injuries of the cervical spine. In a single trial, short-term immobilization was an effective treatment of cervical radiculopathy. Orthoses are not recommended for nonspecific low back pain. The potential complications of cervical orthoses include pressure-related skin injuries and dysphagia.

CONCLUSION

No definitive evidence as yet supports the use of orthoses after spinal interventions or in painful conditions of the cervical or lumbar spine. They should, therefore, be used only after individual consideration of the indications in each case.

Feasibility of Early and Repeated Low-dose Interscalene Brachial Plexus Block for Residual Pain in Acute Cervical Radiculopathy Treated with NSAIDS

Background

To improve residual pain management in acute cervical radiculopathy treated with NSAIDs, the feasibility of early and repeated low-dose interscalene brachial plexus block (IS-BPB) needs to be assessed.

Methods

This was a prospective study on patients receiving NSAIDs (loxoprofen) for cervical radiculopathy of ≤ 2-week onset. Pain was assessed using the visual analogue scale (VAS). A low-dose ultrasonography (USG)-guided IS-BPB (dexamethasone [1.65 mg; 0.5 ml] and mepivacaine [1%; 3.0 ml]) was performed at baseline and weekly thereafter for 4 weeks in an outpatient setting for the intervention group. All patients were evaluated using a visual satisfaction score (VSS) at week 4. Patients with baseline VAS scores < 70 (mild to moderate pain; MM group) and ≥ 70 (severe pain; SE group) were compared to the controls receiving NSAIDs.

Results

A total of 316 IS-BPBs were performed in the intervention group. There was a significant difference in the decline in the VAS from week 0 to week 3 in the MM and SE groups (P < 0.05); however, from week 3 to week 4, the therapeutic effect exhibited no significant difference. Thirteen patients at week 2 (15.5%; MM: 27.7%; SE: 0%), 43 at week 3 (51.2%; MM: 83.0%; SE: 10.8%), and 47 at week 4 (56.0%; MM: 85.1%; SE: 18.9%) achieved a VAS score of ≤ 20. Patient satisfaction was high, and the decrease in VAS scores in both groups was significant (P < 0.05) compared to the controls.

Conclusions

Weekly, low-dose, USG-guided IS-BPB can be implemented for early pain relief in acute cervical radiculopathy, with high patient satisfaction.

Test-retest reliability of handgrip strength measurement using a hydraulic hand dynamometer in patients with cervical radiculopathy

OBJECTIVE

The purpose of this study was to evaluate the test-retest reliability of handgrip strength measurement using a hydraulic hand dynamometer in patients with cervical radiculopathy (CR).

METHODS

A convenience sample of 19 participants (14 men and 5 women; mean ± SD age, 50.5 ± 12 years) with CR was measured using a Jamar hydraulic hand dynamometer by the same rater on 2 different testing sessions with an interval of 7 days between sessions. Data collection procedures followed standardized grip strength testing guidelines established by the American Society of Hand Therapists. During the repeated measures, patients were advised to rest their upper limb in the standardized arm position and encouraged to exert 3 maximum gripping efforts. The mean value of the 3 efforts (measured in kilogram force [Kgf]) was used for data analysis. The intraclass correlation coefficient, SEM, and the Bland-Altman plot were used to estimate test-retest reliability and measurement precision.

RESULTS

Grip strength measurement in CR demonstrated an intraclass correlation coefficient of 0.976, suggesting excellent test-retest reliability. The small SEM in both testing sessions (SEM1, 2.41 Kgf; SEM2, 2.51 Kgf) as well as the narrow width of the 95% limits of agreements (95% limits of agreement, -4.9 to 4.4 Kgf) in the Bland-Altman plot reflected precise measurements of grip strength in both occasions.

CONCLUSIONS

Excellent test-retest reliability for grip strength measurement was measured in patients with CR, demonstrating that a hydraulic hand dynamometer could be used as an outcome measure for these patients.

Neurologic recovery after anterior cervical discectomy and fusion

Study Design Retrospective review. Objective The objective of this study is to describe the natural history of neurologic recovery after anterior cervical discectomy and fusion (ACDF). Methods Patients between 18 and 80 years of age, diagnosed with cervical radiculopathy, who underwent single-level ACDF and were followed for a minimum of 2 years were identified from a single-center database. Sensory and motor deficits were documented and graded based on physical examination findings at preoperative and postoperative visits, and used to calculate deficit rates. Results One hundred eighteen patients were included in the study. Mean age was 46 ± 9.2 years and mean follow-up time was 3.8 ± 2.1 years. At the time of surgery, 66% had a sensory deficit. Recovery of sensory function was seen in 85% of patients within 1 year. At final follow-up, new sensory deficits had developed in 30% of patients, 60% of whom had adjacent-level sensory deficits. Patients with preoperative sensory deficits tended to be more likely to develop a new deficit postoperatively (p = 0.05). At the time of surgery, 55% had a motor deficit. Recovery of motor function was seen in 95% of patients within 1 year, and 14% developed new postoperative motor deficits by final follow-up. Of those patients who developed a new motor deficit postoperatively, 76% did so at an adjacent level. Conclusions In our series, a high percentage of patients recovered neurologic function during the first year after ACDF. Adjacent-level and remote-level degeneration were large contributors to neurologic deficits that occurred in subsequent years.

Cost-utility analysis modeling at 2-year follow-up for cervical disc arthroplasty versus anterior cervical discectomy and fusion: A single-center contribution to the randomized controlled trial

BACKGROUND

Patients with cervical disc herniations resulting in radiculopathy or myelopathy from single level disease have traditionally been treated with Anterior Cervical Discectomy and Fusion (ACDF), yet Cervical Disc Arthroplasty (CDA) is a new alternative. Expert suggestion of reduced adjacent segment degeneration is a promising future result of CDA. A cost-utility analysis of these procedures with long-term follow-up has not been previously reported.

METHODS

We reviewed single institution prospective data from a randomized trial comparing single-level ACDF and CDA in cervical disc disease. Both Medicare reimbursement schedules and actual hospital cost data for peri-operative care were separately reviewed and analyzed to estimate the cost of treatment of each patient. QALYs were calculated at 1 and 2 years based on NDI and SF-36 outcome scores, and incremental cost effectiveness ratio (ICER) analysis was performed to determine relative cost-effectiveness.

RESULTS

Patients of both groups showed improvement in NDI and SF-36 outcome scores. Medicare reimbursement rates to the hospital were $11,747 and $10,015 for ACDF and CDA, respectively; these figures rose to $16,162 and $13,171 when including physician and anesthesiologist reimbursement. The estimated actual cost to the hospital of ACDF averaged $16,108, while CDA averaged $16,004 (p = 0.97); when including estimated physicians fees, total hospital costs came to $19,811 and $18,440, respectively. The cost/QALY analyses therefore varied widely with these discrepancies in cost values. The ICERs of ACDF vs CDA with Medicare reimbursements were $18,593 (NDI) and $19,940 (SF-36), while ICERs based on actual total hospital cost were $13,710 (NDI) and $9,140 (SF-36).

CONCLUSIONS

We confirm the efficacy of ACDF and CDA in the treatment of cervical disc disease, as our results suggest similar clinical outcomes at one and two year follow-up. The ICER suggests that the non-significant added benefit via ACDF comes at a reasonable cost, whether we use actual hospital costs or Medicare reimbursement values, though the actual ICER values vary widely depending upon the CUA modality used. Long term follow-up may illustrate a different profile for CDA due to reduced cost and greater long-term utility scores. It is crucial to note that financial modeling plays an important role in how economic treatment dominance is portrayed.

Electrotherapy for neck pain

BACKGROUND

Neck pain is common, disabling and costly. The effectiveness of electrotherapy as a physiotherapeutic option remains unclear. This is an update of a Cochrane review first published in 2005 and previously updated in 2009.

OBJECTIVES

This systematic review assessed the short, intermediate and long-term effects of electrotherapy on pain, function, disability, patient satisfaction, global perceived effect, and quality of life in adults with neck pain with and without radiculopathy or cervicogenic headache.

SEARCH METHODS

We searched CENTRAL, MEDLINE, EMBASE, MANTIS, CINAHL, and ICL, without language restrictions, from their beginning to August 2012; handsearched relevant conference proceedings; and consulted content experts.

SELECTION CRITERIA

Randomized controlled trials (RCTs), in any language, investigating the effects of electrotherapy used primarily as unimodal treatment for neck pain. Quasi-RCTs and controlled clinical trials were excluded.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by The Cochrane Collaboration. We were unable to statistically pool any of the results, but we assessed the quality of the evidence using an adapted GRADE approach.

MAIN RESULTS

Twenty small trials (1239 people with neck pain) containing 38 comparisons were included. Analysis was limited by trials of varied quality, heterogeneous treatment subtypes and conflicting results. The main findings for reduction of neck pain by treatment with electrotherapeutic modalities were as follows.Very low quality evidence determined that pulsed electromagnetic field therapy (PEMF) and repetitive magnetic stimulation (rMS) were more effective than placebo, while transcutaneous electrical nerve stimulation (TENS) showed inconsistent results.Very low quality evidence determined that PEMF, rMS and TENS were more effective than placebo.Low quality evidence (1 trial, 52 participants) determined that permanent magnets (necklace) were no more effective than placebo (standardized mean difference (SMD) 0.27, 95% CI -0.27 to 0.82, random-effects model).Very low quality evidence showed that modulated galvanic current, iontophoresis and electric muscle stimulation (EMS) were not more effective than placebo.There were four trials that reported on other outcomes such as function and global perceived effects, but none of the effects were of clinical importance. When TENS, iontophoresis and PEMF were compared to another treatment, very low quality evidence prevented us from suggesting any recommendations. No adverse side effects were reported in any of the included studies.

AUTHORS' CONCLUSIONS

We cannot make any definite statements on the efficacy and clinical usefulness of electrotherapy modalities for neck pain. Since the evidence is of low or very low quality, we are uncertain about the estimate of the effect. Further research is very likely to change both the estimate of effect and our confidence in the results. Current evidence for PEMF, rMS, and TENS shows that these modalities might be more effective than placebo. When compared to other interventions the quality of evidence was very low thus preventing further recommendations.Funding bias should be considered, especially in PEMF studies. Galvanic current, iontophoresis, EMS, and a static magnetic field did not reduce pain or disability. Future trials on these interventions should have larger patient samples, include more precise standardization, and detail treatment characteristics.

Arthroplasty versus fusion in single-level cervical degenerative disc disease: a Cochrane review

STUDY DESIGN

A systematic review of randomized controlled trials (RCTs).

OBJECTIVE

To assess the effects of arthroplasty versus fusion in the treatment of radiculopathy or myelopathy, or both, due to single-level cervical degenerative disc disease.

SUMMARY OF BACKGROUND DATA

There is ongoing debate about whether fusion or arthroplasty is superior in the treatment of single-level cervical degenerative disc disease. Mainly because the intended advantage of arthroplasty compared with fusion, prevention of symptoms due to adjacent segment degeneration in the long term, is not confirmed yet. Until sufficient long-term results become available, it is important to know whether results of 1 of the 2 treatments are superior to the other in the first 1 to 2 years.

METHODS

We searched electronic databases for randomized controlled trials. We included randomized controlled trials that directly compared any type of cervical fusion with any type of cervical arthroplasty, with at least 1 year of follow-up. Study selection was performed independently by 3 review authors, and "risk of bias" assessment and data extraction were independently performed by 2 review authors. In case of missing data, we contacted the study authors or the study sponsor. We assessed the quality of evidence.

RESULTS

Nine studies (2400 participants) were included in this review; 5 of these studies had a low risk of bias. Results for the arthroplasty group were better than the fusion group for all primary comparisons, often statistically significant. For none of the primary outcomes was a clinically relevant difference in effect size shown. Quality of the evidence was low to moderate.

CONCLUSION

There is low to moderate quality evidence that results are consistently in favor of arthroplasty, often statistically significant. However, differences in effect size were invariably small and not clinically relevant for all primary outcomes.

LEVEL OF EVIDENCE

1.

Clinical outcomes of epidural neuroplasty for cervical disc herniation

Cervical disc herniation is a common disorder characterized by neck pain radiating to the arm and fingers as determined by the affected dermatome. This condition has a favorable prognosis, but pain can have a serious detrimental impact on daily activities. Epidural neuroplasty has been applied as a treatment option for cervical disc herniation; however, no study has addressed the clinical outcomes. This retrospective study evaluated the clinical outcomes of epidural neuroplasty on 128 patients for the treatment of cervical disc herniation. To measure pain-related disabilities over time, the changes of pain scores in neck and arm were evaluated using a numerical rating scale (NRS) and the neck disability index (NDI). Compared with preprocedural values, the pain NRS of neck and arm demonstrated significant improvement at day 1, and 1, 3, 6, and 12 months after the procedure (P < 0.001). Likewise, the NDI was significantly reduced at 3, 6, and 12 months after the procedure (P < 0.001). There were no serious complications. Cervical epidural neuroplasty shows good clinical outcomes in the treatment of cervical disc herniation and can be considered a treatment modality for cervical disc herniation refractory to conservative treatment.