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Michael G. Fehlings and Babak Arvin

of CSM, is based on Class I evidence showing the predictive power of electrophysiological assessments in the development of myelopathy. 2 There is controversy and a lack of consensus related to the clinical value of intraoperative evoked potential monitoring in the surgical management of CSM, as summarized by Resnick et al. 16 in this issue of JNS: Spine . In particular, the lack of specificity in the recordings and the lack of clarity as to whether electrophysiological changes influence a clear change in the surgical approach or plan makes many studies of

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Henry Ahn and Michael G. Fehlings

P erioperative SCI is one of the most feared complications of spine surgery, potentially resulting in a devastating and debilitating outcome for the patient and tremendous stress for the surgeon. Fortunately, the incidence of POSCI is relatively uncommon with an estimated incidence varying from 0 to 3%, depending on the pathological entity treated, the spinal level, and surgical approach. 25 , 28 Perioperative SCI involves a direct or indirect physiological insult to the spinal cord during immediate preparation for surgery, intraoperatively, or

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Editorial

Importance of sagittal balance in determining the outcome of anterior versus posterior surgery for cervical spondylotic myelopathy

Michael G. Fehlings and Randolph Gray

appropriate surgical approach in patients with CSM. 3 In the current issue of the Journal of Neurosurgery: Spine , Uchida and colleagues examine the use of anterior and posterior surgical approaches in a subset of patients with cervical myelopathy together with kyphotic deformity. The overall sagittal balance of the spine depends on the interplay between mutually articulating regions of the pelvis and the lumbar, thoracic, and cervical spine. Imbalance at either end of this cascade can have a profound impact on the sacral vertical line, the center of gravity, and the

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Michael G. Fehlings and Babak Arvin

spasticity, and neuropathic pain. Their results indicate that timing of surgery (before and after 4 days), surgical approach (anterior vs posterior) and different pathology make no difference in outcome according to the aforementioned indices. Furthermore, they showed that the younger spine had more capacity for recovery based on ASIA motor score improvements and WISCI scores. Overall based on patient satisfaction scores, one-third of the participants expressed dissatisfaction with their final outcome, while there were clear improvements in ASIA motor scores. The results

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Aria Nouri, Allan R. Martin, David Mikulis and Michael G. Fehlings

can be helpful, particularly if anterior surgical decompression is being contemplated and the LF contributes substantially to cord compression. Sagittal Alignment It is becoming increasingly recognized that sagittal alignment might be a contributor to disease severity in patients with DCM and is certainly an important factor in the selection of an anterior or posterior surgical approach. 4 , 68 Therefore, assessment of the cervical spine should include evaluation for scoliosis, hyperlordosis, and kyphosis. Sagittal balance and alignment can be assessed

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Lindsay Tetreault, Ahmed Ibrahim, Pierre Côté, Anoushka Singh and Michael G. Fehlings

C ervical spondylotic myelopathy (CSM) is a progressive degenerative spine disease and the most common cause of spinal cord dysfunction in adults worldwide. 33 , 65 Although generally safe and effective, surgery for the treatment of CSM is associated with complications in 11%–38% of patients. 6 , 15 These include dysphagia, C-5 radiculopathy, wound infection, axial pain, and postoperative kyphosis. Guidelines for the surgical management of CSM are rapidly evolving, and surgeons must consider several variables when selecting a surgical approach. 69

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Julio C. Furlan, Sukhvinder Kalsi-Ryan, Ahilan Kailaya-Vasan, Eric M. Massicotte and Michael G. Fehlings

patients with CSM who underwent cervical decompressive surgery from December 2005 to October 2007 at the Toronto Western Hospital. Baseline Data and Potential Covariates The baseline data included age at the time of surgery, sex, period of time since symptom onset, date of surgical intervention, and preexisting medical comorbidities at hospital admission. Preexisting medical comorbidities were quantified using the number of ICD-9 codes and the CCI. 8 Other potential covariates for postoperative complications included surgical approach and the number of spinal

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Editorial

Sacral tumors

Michael G. Fehlings and Sean R. Smith

11 have made an effort to correct this deficit in the spinal literature. Ideally, the most useful surgical classification system should possess several features: 1) include the salient prognostic factors relating to progressive degrees of risk to the patient, 2) outline progressive stages that have specific implications for clinical management, 3) offer guidelines for the role of adjunctive therapies, 4) allow easy communication between surgeons and other clinicians, and, importantly, 5) inform the surgical approach. 5 , 6 However, the complex nature of the

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Michael G. Fehlings and Babak Arvin

'Shaughnessy BA , Bierbrauer K , Crone KR , : Posterior vertebral column subtraction osteotomy: a novel surgical approach for the treatment of multiple recurrences of tethered cord syndrome. Technical note . J Neurosurg Spine 10 : 278 – 286 , 2009 5 Inoue HK , Kobayashi S , Ohbayashi K , Kohga H , Nakamura M : Treatment and prevention of tethered and retethered spinal cord using a Gore-Tex surgical membrane . J Neurosurg 80 : 689 – 693 , 1994 6 Kokubun S : [Shortening spinal osteotomy for tethered cord syndrome in adults.] . Spine Spinal

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Editorial

En bloc resection for metastatic spinal tumors: is it worth it?

Michael G. Fehlings and Doron Rabin

tumors is well accepted in the literature. Prospective data indicate that en bloc resection with negative margins confers acceptable morbidity and long-term survival, whereas violating the margins may increase the risk of local recurrence. 4 The objective for TES in patients with primary tumors becomes one of long-term survival, in addition to maintaining or improving QOL. Efforts to standardize the staging and surgical approach to these tumors 1 , 2 should help optimize clinical results. In contrast to primary tumors, the goal of surgical management of spinal