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

Degenerative cervical myelopathy encompasses a spectrum of age-related structural changes of the cervical spine that result in static and dynamic injury to the spinal cord and collectively represent the most common cause of myelopathy in adults. Although cervical myelopathy is determined clinically, the diagnosis requires confirmation via imaging, and MRI is the preferred modality. Because of the heterogeneity of the condition and evolution of MRI technology, multiple techniques have been developed over the years in an attempt to quantify the degree of baseline severity and potential for neurological recovery. In this review, these techniques are categorized anatomically into those that focus on bone, ligaments, discs, and the spinal cord. In addition, measurements for the cervical spine canal size and sagittal alignment are also described briefly. These tools have resulted collectively in the identification of numerous useful parameters. However, the development of multiple techniques for assessing the same feature, such as cord compression, has also resulted in a number of challenges, including introducing ambiguity in terms of which methods to use and hindering effective comparisons of analysis in the literature. In addition, newer techniques that use advanced MRI are emerging and providing exciting new tools for assessing the spinal cord in patients with degenerative cervical myelopathy.

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Jetan H. Badhiwala, Sean N. Leung, Yosef Ellenbogen, Muhammad A. Akbar, Allan R. Martin, Fan Jiang, Jamie R. F. Wilson, Farshad Nassiri, Christopher D. Witiw, Jefferson R. Wilson and Michael G. Fehlings

OBJECTIVE

Degenerative cervical myelopathy (DCM) is the most common cause of spinal cord dysfunction in adults. Multilevel ventral compressive pathology is routinely managed through anterior decompression and reconstruction, but there remains uncertainty regarding the relative safety and efficacy of multiple discectomies, multiple corpectomies, or hybrid corpectomy-discectomy. To that end, using a large national administrative healthcare data set, the authors sought to compare the perioperative outcomes of anterior cervical discectomy and fusion (ACDF), anterior cervical corpectomy and fusion (ACCF), and hybrid corpectomy-discectomy for multilevel DCM.

METHODS

Patients with a primary diagnosis of DCM who underwent an elective anterior cervical decompression and reconstruction operation over 3 cervical spinal segments were identified from the 2012–2017 National Surgical Quality Improvement Program database. Patients were separated into those undergoing 3-level discectomy, 2-level corpectomy, or a hybrid procedure (single-level corpectomy plus additional single-level discectomy). Outcomes included 30-day mortality, major complication, reoperation, and readmission, as well as operative duration, length of stay (LOS), and routine discharge home. Outcomes were compared between treatment groups by multivariable regression, adjusting for age and comorbidities (modified Frailty Index). Effect sizes were reported by adjusted odds ratio (aOR) or mean difference (aMD) and associated 95% confidence interval.

RESULTS

The study cohort consisted of 1298 patients; of these, 713 underwent 3-level ACDF, 314 2-level ACCF, and 271 hybrid corpectomy-discectomy. There was no difference in 30-day mortality, reoperation, or readmission among the 3 procedures. However, on both univariate and adjusted analyses, compared to 3-level ACDF, 2-level ACCF was associated with significantly greater risk of major complication (aOR 2.82, p = 0.005), longer hospital LOS (aMD 0.8 days, p = 0.002), and less frequent discharge home (aOR 0.59, p = 0.046). In contrast, hybrid corpectomy-discectomy had comparable outcomes to 3-level ACDF but was associated with significantly shorter operative duration (aMD −16.9 minutes, p = 0.002).

CONCLUSIONS

The authors found multiple discectomies and hybrid corpectomy-discectomy to have a comparable safety profile in treating multilevel DCM. In contrast, multiple corpectomies were associated with a higher complication rate, longer hospital LOS, and lower likelihood of being discharged directly home from the hospital, and may therefore be a higher-risk operation.

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Editorial

Convection-enhanced delivery

John H. Sampson, Raghu Raghavan, Martin Brady, Allan H. Friedman and Darell Bigner

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Albert Moghrabi, Henry S. Friedman, David M. Ashley, Krystal S. Bottom, Tracy Kerby, Elizabeth Stewart, Carol Bruggers, James M. Provenzale, Martin Champagne, Linda Hershon, Melody Watral, Janis Ryan, Karima Rasheed, Shelley Lovell, David Korones, Herbert Fuchs, Timothy George, Roger E. McLendon, Allan H. Friedman, Edward Buckley and Darryl C. Longee

In this study, the authors sought to investigate the response rate and toxicity of carboplatin in patients with progressive low-grade glioma (LGG). Thirty-two patients with progressive LGG were treated with carboplatin at a dosage of 560 mg/m2. Treatment was given at 4-week intervals and continued until the disease progressed, unacceptable toxicity supervened, or for 12 additional courses after achieving maximal response. Patients with stable disease were treated with a total of 12 cycles. All patients were treated as outpatients. Patients were evaluated for response to treatment and toxicity.

All patients received a minimum of two cycles of carboplatin, and were examined for response. A partial response was achieved in nine patients (28%) and a minimal response in two (6%), for an overall response rate of 34% (11 of 32 patients). Eighteen patients (56%) had stable disease. A partial response was achieved in the nine patients after a median of six cycles (range 4-11 cycles), a minimal response was achieved in the two patients after five cycles. Glioma progression was noted in three patients after three, five, and five cycles, respectively. The 11 patients in whom some response was achieved had either an optic pathway tumor or a juvenile pilocytic astrocytoma. Twenty-six of the 32 patients had those characteristics, making the response rate in that group 42% (11 of 26 patients). Thirty-two patients received a total of 387 cycles of chemotherapy. Hematological toxicity was moderate. Twenty-one patients developed thrombocytopenia (platelet count < 50,000/μl); three patients required one platelet transfusion each. Nine patients developed neutropenia (absolute neutrophil count < 500/μl); one developed fever and required administration of antibiotic agents. One dose adjustment in each of the patients prevented further thrombocytopenia and neutropenia. Two patients with stable disease died of respiratory complications. One patient developed Grade III ototoxicity after receiving five cycles, one patient developed hypersensitivity to carboplatin, and none developed nephrotoxicity.

Carboplatin given at a dosage of 560 mg/m2 every 4 weeks has activity in patients with progressive LGG. This drug regimen is relatively simple and well tolerated. Further investigation and longer follow-up study are warranted.