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  • Author or Editor: Praveen Mummaneni x
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Praveen V. Mummaneni, Michael G. Kaiser, Paul G. Matz, Paul A. Anderson, Michael Groff, Robert Heary, Langston Holly, Timothy Ryken, Tanvir Choudhri, Edward Vresilovic and Daniel Resnick

Object

The objective of this systematic review was to use evidence-based medicine to assess whether preoperative imaging or electromyography (EMG) predicts surgical outcomes in patients undergoing cervical surgery.

Methods

The National Library of Medicine and Cochrane Database were queried using MeSH headings and keywords relevant to the preoperative imaging and EMG. Abstracts were reviewed after which studies meeting inclusion criteria were selected. The guidelines group assembled an evidentiary table summarizing the quality of evidence (Classes I–III). Disagreements regarding the level of evidence were resolved through an expert consensus conference. The group formulated recommendations that contained the degree of strength based on the Scottish Intercollegiate Guidelines network. Validation was done through peer review by the Joint Guidelines Committee of the American Association of Neurological Surgeons/Congress of Neurological Surgeons.

Results

Preoperative MR imaging and CT myelography are successful in confirming clinical radiculopathy (Class II). Multilevel T2 hyperintensity, T1 focal hypointensity combined with T2 focal hyperintensity, and spinal cord atrophy each convey a poor prognosis (Class III). There is conflicting data concerning whether focal T2 hyperintensity or cervical stenosis are associated with a worse outcome. Electromyography has mixed utility in predicting outcome (Class III).

Conclusions

Magnetic resonance imaging or CT myelography are important for preoperative assessment. Magnetic resonance imaging may be helpful in assessing prognosis, whereas EMG has mixed utility in assessing outcome.

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Paul G. Matz, Timothy C. Ryken, Michael W. Groff, Edward J. Vresilovic, Paul A. Anderson, Robert F. Heary, Langston T. Holly, Michael G. Kaiser, Praveen V. Mummaneni, Tanvir F. Choudhri and Daniel K. Resnick

Object

The objective of this systematic review was to use evidence-based medicine to identify the best techniques for anterior cervical nerve root decompression.

Methods

The National Library of Medicine and Cochrane Database were queried using MeSH headings and keywords relevant to techniques for the surgical management of cervical radiculopathy. The guidelines group assembled an evidentiary table summarizing the quality of evidence (Classes I–III). The group formulated recommendations that contained the degree of strength based on the Scottish Intercollegiate Guidelines network. Validation was done through peer-review by the Joint Guidelines Committee of the American Association of Neurological Surgeons/Congress of Neurological Surgeons.

Results

Both anterior cervical discectomy (ACD) and anterior cervical discectomy with fusion (ACDF) are equivalent treatment strategies for 1-level disease with regard to functional outcome (Class II). Anterior cervical discectomy with fusion may achieve a more rapid reduction of neck and arm pain compared to ACD with a reduced risk of kyphosis, although functional outcomes may be similar. Anterior cervical discectomy with fusion is not a lasting means of increasing foraminal or disc height compared to ACD. Anterior cervical plating (ACDF with instrumentation) improves arm pain (but not other clinical parameters) better than ACDF in the treatment of 2-level disease (Class II). With respect to 1-level disease, plating may reduce the risk of pseudarthrosis and graft problems (Class III) but does not necessarily improve clinical outcome alone (Class II). Cervical arthroplasty is recommended as an alternative to ACDF in selected patients for control of neck and arm pain (Class II).

Conclusions

Anterior cervical discectomy, ACDF, and arthroplasty are effective techniques for addressing surgical cervical radiculopathy.

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Michael G. Kaiser, Praveen V. Mummaneni, Paul G. Matz, Paul A. Anderson, Michael W. Groff, Robert F. Heary, Langston T. Holly, Timothy C. Ryken, Tanvir F. Choudhri, Edward J. Vresilovic and Daniel K. Resnick

Object

The objective of this systematic review was to use evidence-based medicine to identify the best methodology for radiographic assessment of cervical subaxial fusion.

Methods

The National Library of Medicine and Cochrane Database were queried using MeSH headings and keywords relevant to cervical fusion. Abstracts were reviewed and studies meeting inclusion criteria were selected. The guidelines group assembled an evidentiary table summarizing the quality of evidence (Classes I–III). Disagreements regarding the level of evidence were resolved through an expert consensus conference. The group formulated recommendations that contained the degree of strength based on the Scottish Intercollegiate Guidelines network. Validation was done through peer review by the Joint Guidelines Committee of the American Association of Neurological Surgeons/Congress of Neurological Surgeons.

Results

Pseudarthrosis is best assessed through the absence of motion detected between the spinous processes on dynamic radiographs (Class II). The measurement of interspinous distance on dynamic radiographs of ≥ 2 mm is a more reliable indicator for pseudarthrosis than angular motion of 2° based on Cobb angle measurements (Class II). Similarly, it is also understood that the pseudarthrosis rate will increase as the threshold for allowable motion on dynamic radiographs decreases. The combination of interspinous distance measurements and identification of bone trabeculation is unreliable when performed by the treating surgeon (Class II). Identification of bone trabeculation on static radiographs should be considered a less reliable indicator of cervical arthrodesis than dynamic films (Class III).

Conclusions

Consideration should be given to dynamic radiographs and interspinous distance when assessing for pseudarthrosis.

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Paul G. Matz, Paul A. Anderson, Langston T. Holly, Michael W. Groff, Robert F. Heary, Michael G. Kaiser, Praveen V. Mummaneni, Timothy C. Ryken, Tanvir F. Choudhri, Edward J. Vresilovic and Daniel K. Resnick

Object

The objective of this systematic review was to use evidence-based medicine to delineate the natural history of cervical spondylotic myelopathy (CSM) and identify factors associated with clinical deterioration.

Methods

The National Library of Medicine and Cochrane Database were queried using MeSH headings and keywords relevant to the natural history of CSM. Abstracts were reviewed and studies meeting the inclusion criteria were selected. The guidelines group assembled an evidentiary table summarizing the quality of evidence (Classes I–III). Disagreements regarding the level of evidence were resolved through an expert consensus conference. The group formulated recommendations that contained the degree of strength based on the Scottish Intercollegiate Guidelines network. Validation was done through peer review by the Joint Guidelines Committee of the American Association of Neurological Surgeons and the Congress of Neurological Surgeons.

Results

The natural history of CSM is mixed: it may manifest as a slow, stepwise decline or there may be a long period of quiescence (Class III). Long periods of severe stenosis are associated with demyelination and may result in necrosis of both gray and white matter. With severe and/or long lasting CSM symptoms, the likelihood of improvement with nonoperative measures is low. Objectively measurable deterioration is rarely seen acutely in patients younger than 75 years of age with mild CSM (modified Japanese Orthopaedic Association scale score > 12; Class I). In patients with cervical stenosis without myelopathy, the presence of abnormal electromyography findings or the presence of clinical radiculopathy is associated with the development of symptomatic CSM in this patient population (Class I).

Conclusions

The natural history of CSM is variable, which may affect treatment decisions.

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Paul A. Anderson, Paul G. Matz, Michael W. Groff, Robert F. Heary, Langston T. Holly, Michael G. Kaiser, Praveen V. Mummaneni, Timothy C. Ryken, Tanvir F. Choudhri, Edward J. Vresilovic and Daniel K. Resnick

Object

The objective of this systematic review was to use evidence-based medicine to examine the efficacy of cervical laminectomy and fusion for the treatment of cervical spondylotic myelopathy (CSM).

Methods

The National Library of Medicine and Cochrane Database were queried using MeSH headings and keywords relevant to cervical laminectomy, fusion, and CSM. Abstracts were reviewed, after which studies that met the inclusion criteria were selected. The guidelines group assembled an evidentiary table summarizing the quality of evidence (Class I–III). Disagreements regarding the level of evidence were resolved through an expert consensus conference. The group formulated recommendations which contained the degree of strength based on the Scottish Intercollegiate Guidelines network. Validation was done through peer-review by the Joint Guidelines Committee of the American Association of Neurological Surgeons/Congress of Neurological Surgeons.

Results

Cervical laminectomy with fusion (arthrodesis) improves functional outcome in patients with CSM and ossification of the posterior longitudinal ligament (OPLL). Functional improvement is similar to laminectomy or laminoplasty for patients with CSM and OPLL. In contrast to laminectomy, cervical laminectomy with fusion it is not associated with late deformity (Class III).

Conclusions

Laminectomy with fusion (arthrodesis) is an effective strategy to improve functional outcome in CSM and OPLL.

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Paul G. Matz, Paul A. Anderson, Michael W. Groff, Robert F. Heary, Langston T. Holly, Michael G. Kaiser, Praveen V. Mummaneni, Timothy C. Ryken, Tanvir F. Choudhri, Edward J. Vresilovic and Daniel K. Resnick

Object

The objective of this systematic review was to use evidence-based medicine to examine the efficacy of cervical laminoplasty in the treatment of cervical spondylotic myelopathy (CSM).

Methods

The National Library of Medicine and Cochrane Database were queried using MeSH headings and keywords relevant to cervical laminoplasty and CSM. Abstracts were reviewed and studies meeting the inclusion criteria were selected. The guidelines group assembled an evidentiary table summarizing the quality of evidence (Classes I–III). Disagreements regarding the level of evidence were resolved through an expert consensus conference. The group formulated recommendations that contained the degree of strength based on the Scottish Intercollegiate Guidelines network. Validation was done through peer review by the Joint Guidelines Committee of the American Association of Neurological Surgeons and Congress of Neurological Surgeons.

Results

Cervical laminoplasty has improved functional outcome in the setting of CSM or ossification of the posterior longitudinal ligament. Using the Japanese Orthopaedic Association scale score, ~ 55–60% average recovery rate has been observed (Class III). The functional improvement observed after laminoplasty may be limited by duration of symptoms, severity of stenosis, severity of myelopathy, and poorly controlled diabetes as negative risk factors (Class II). There is conflicting evidence regarding age, with 1 study citing it as a negative risk factor, and another not demonstrating this result.

Conclusions

Cervical laminoplasty is recommended for the treatment of CSM or ossification of the posterior longitudinal ligament (Class III).

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Paul G. Matz, Langston T. Holly, Michael W. Groff, Edward J. Vresilovic, Paul A. Anderson, Robert F. Heary, Michael G. Kaiser, Praveen V. Mummaneni, Timothy C. Ryken, Tanvir F. Choudhri and Daniel K. Resnick

Object

The objective of this systematic review was to use evidence-based medicine to identify the indications and utility of anterior cervical nerve root decompression.

Methods

The National Library of Medicine and Cochrane Database were queried using MeSH headings and key words relevant to surgical management of cervical radiculopathy. Abstracts were reviewed after which studies meeting inclusion criteria were selected. The guidelines group assembled an evidentiary table summarizing the quality of evidence (Classes I–III). Disagreements regarding the level of evidence were resolved through an expert consensus conference. The group formulated recommendations that contained the degree of strength based on the Scottish Intercollegiate Guidelines network. Validation was done through peer review by the Joint Guidelines Committee of the American Association of Neurological Surgeons/Congress of Neurological Surgeons.

Results

Anterior nerve root decompression via anterior cervical discectomy (ACD) with or without fusion for radiculopathy is associated with rapid relief (3–4 months) of arm/neck pain, weakness, and/or sensory loss compared with physical therapy (PT) or cervical collar immobilization. Anterior cervical discectomy and ACD with fusion (ACDF) are associated with longer term (12 months) improvement in certain motor functions compared to PT. Other rapid gains observed after anterior decompression (diminished pain, improved sensation, and improved strength in certain muscle groups) are also maintained over the course of 12 months. However, comparable clinical improvements with PT or cervical immobilization therapy are also present in these clinical modalities (Class I). Conflicting evidence exists as to the efficacy of anterior cervical foraminotomy with reported success rates of 52–99% but recurrent symptoms as high as 30% (Class III).

Conclusions

Anterior cervical discectomy, ACDF, and anterior cervical foraminotomy may improve cervical radicular symptoms. With regard to ACD and ACDF compared to PT or cervical immobilization, more rapid relief (within 3–4 months) may be seen with ACD or ACDF with maintenance of gains over the course of 12 months (Class I). Anterior cervical foraminotomy is associated with improvement in clinical function but the quality of data are weaker (Class III), and there is a wide range of efficacy (52–99%).

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Langston T. Holly, Paul G. Matz, Paul A. Anderson, Michael W. Groff, Robert F. Heary, Michael G. Kaiser, Praveen V. Mummaneni, Timothy C. Ryken, Tanvir F. Choudhri, Edward J. Vresilovic and Daniel K. Resnick

Object

The objective of this systematic review was to use evidence-based medicine to assess whether clinical factors predict surgical outcomes in patients undergoing cervical surgery.

Methods

The National Library of Medicine and Cochrane Database were queried using MeSH headings and keywords relevant to clinical preoperative factors. Abstracts were reviewed, and studies that met the inclusion criteria were selected. The guidelines group assembled an evidentiary table summarizing the quality of evidence (Classes I–III). Disagreements regarding the level of evidence were resolved through an expert consensus conference. The group formulated recommendations that contained the degree of strength based on the Scottish Intercollegiate Guidelines network. Validation was done through peer review by the Joint Guidelines Committee of the American Association of Neurological Surgeons/Congress of Neurological Surgeons.

Results

Preoperative sensory-evoked potentials may aid in providing prognostic information in selected patients in whom clinical factors do not provide clear guidance (Class II). Age, duration of symptoms, and preoperative neurological function may commonly affect outcome (Class III).

Conclusions

Age, duration of symptoms, and preoperative neurological function should be discussed with patients when surgical intervention for cervical spondylotic myelopathy is considered. Preoperative sensory-evoked potentials may be considered for patients in whom clinical factors do not provide clear guidance if such information would potentially change therapeutic decisions.

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Michael G. Kaiser, Praveen V. Mummaneni, Paul G. Matz, Paul A. Anderson, Michael W. Groff, Robert F. Heary, Langston T. Holly, Timothy C. Ryken, Tanvir F. Choudhri, Edward J. Vresilovic and Daniel K. Resnick

Object

The objective of this systematic review was to use evidence-based medicine to identify the best methodology for diagnosis and treatment of anterior pseudarthrosis.

Methods

The National Library of Medicine and Cochrane Database were queried using MeSH headings and key words relevant to pseudarthrosis and cervical spine surgery. Abstracts were reviewed, after which studies meeting inclusion criteria were selected. The guidelines group assembled an evidentiary table summarizing the quality of evidence (Classes I–III). Disagreements regarding the level of evidence were resolved through an expert consensus conference. The group formulated recommendations that contained the degree of strength based on the Scottish Intercollegiate Guidelines network. Validation was done through peer review by the Joint Guidelines Committee of the American Association of Neurological Surgeons/Congress of Neurological Surgeons.

Results

Evaluation for pseudarthrosis is warranted, as there may be an association between clinical outcome and pseudarthrosis. The strength of this association cannot be accurately determined because of the variable incidence of symptomatic and asymptomatic pseudarthroses (Class III). Revision of a symptomatic pseudarthrosis may be considered because arthrodesis is associated with improved clinical outcome (Class III). Both posterior and anterior approaches have proven successful for surgical correction of an anterior pseudarthrosis. Posterior approaches may be associated with higher fusion rates following repair of an anterior pseudarthrosis (Class III).

Conclusions

If suspected, pseudarthrosis should be investigated because there may be an association between arthrodesis and outcome. However, the strength of this association cannot be accurately determined. Anterior and posterior approaches have been successful.

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Paul G. Matz, Langston T. Holly, Praveen V. Mummaneni, Paul A. Anderson, Michael W. Groff, Robert F. Heary, Michael G. Kaiser, Timothy C. Ryken, Tanvir F. Choudhri, Edward J. Vresilovic and Daniel K. Resnick

Object

The objective of this systematic review was to use evidence-based medicine to examine the efficacy of anterior cervical surgery for the treatment of cervical spondylotic myelopathy (CSM).

Methods

The National Library of Medicine and Cochrane Database were queried using MeSH headings and key words relevant to anterior cervical surgery and CSM. Abstracts were reviewed, and studies meeting inclusion criteria were selected. The guidelines group assembled an evidentiary table summarizing the quality of evidence (Classes I–III). Disagreements regarding the level of evidence were resolved through an expert consensus conference. The group formulated recommendations that contained the degree of strength based on the Scottish Intercollegiate Guidelines network. Validation was done through peer review by the Joint Guidelines Committee of the American Association of Neurological Surgeons/Congress of Neurological Surgeons.

Results

Mild CSM (modified Japanese Orthopaedic Association [mJOA] scale scores > 12) responds in the short term (3 years) to either surgical decompression or nonoperative therapy (prolonged immobilization in a stiff cervical collar, “low-risk” activity modification or bed rest, and antiinflammatory medications) (Class II). More severe CSM responds to surgical decompression with benefits being maintained a minimum of 5 years and as long as 15 years postoperatively (Class III).

Conclusions

Treatment of mild CSM may involve surgical decompression or nonoperative therapy for the first 3 years after diagnosis. More severe CSM (mJOA scale score ≤ 12) should be considered for surgery depending upon the individual case. The shortcomings of this systematic review are that the group was not able to determine whether an mJOA scale score of 12 was indicative of a more severe CSM disease course, and whether patients who received nonsurgical treatment for 3 years had a significant probability for clinical deterioration after that time point.