Roberto Assietti, Federica Beretta, and Cesare Arienta
Anterior cervical discectomy (ACD) is an effective and safe treatment for nerve root or spinal cord compression caused by disc herniation or spondylosis. Cervical interbody fusion allows preservation of the physiological lordosis and stability of the cervical spine. Based on data reported in the literature, fusion rates decrease significantly when more than one level undergoes surgery, and some authors recommend the addition of a plate system to improve results. At the authors' institution cervical carbon fiber cages (CFCs) are routinely used after ACD. They describe their experience in the treatment of 24 patients with two-level disease treated with CFCs alone.
Twenty-one patients with cervical radiculopathy and three with radiculomyelopathy underwent ACD. Surgery was performed at C5–6 and C6–7 in 18, at C4–5 and C5–6 in four, and at C3–4 and C5–6 in two patients. All the patients underwent magnetic resonance imaging and 15 also underwent computerized tomography (CT) to assess the results of surgery.
Radiculopathy improved after surgery in all the cases, whereas myelopathy resolved in only one patient. At 1 year fusion was achieved in 96% of the surgically treated discs; this was verified on cervical spine x-ray films in all patients and on CT scans in three patients. Cervical lordosis was restored in eight of the nine patients in whom it was lost preoperatively. No complications related to cage extrusion and no cases of symptomatic pseudarthrosis were observed.
Interbody fusion cages have a load-sharing function and stabilize the spine to increase segmental stiffness, thus achieving fusion rates similar to those associated with bone grafts, even in multilevel disease.
Roberto Assietti, Mario Morosi, and Jon E. Block
Degeneration of the intervertebral disc can be the source of severe low-back pain. Intradiscal electrothermal therapy (IDET) is a minimally invasive treatment option for patients with symptomatic internal disc disruption unresponsive to conservative medical care. This study was undertaken in the neurosurgical setting to evaluate 24-month pain and functional outcomes and predictors of clinical success in patients with discogenic back pain treated with IDET.
Using MR imaging and discography findings, 50 patients with lumbar discogenic pain were identified, underwent IDET treatment, and were followed up for 24 months. Outcomes included assessments of back pain severity based on an 11-point numeric scale and back function based on the Oswestry Disability Index. The Prolo scale was applied to determine economic and functional status at 24 months.
There was an average 68 and 66% improvement in back pain and function, respectively, between pretreatment and 24 months after treatment (p < 0.0001 for both comparisons). A maximum score of 5 on the Prolo scale for economic and functional status was achieved in 63 and 22% of patients, respectively. The global clinical success rate was 78% (39 of 50 patients) based on no reoperations at the affected level due to persistent symptoms, with a ≥ 2-point improvement in pain severity and a ≥ 15-point improvement in back function. Predictors of 24-month clinical success included discographic concordance (p < 0.0001), a high-intensity zone on MR imaging (p = 0.0003), low Pfirrmann grade (p = 0.0002), and more extensive anulus coverage (p < 0.0001). There were no procedure-related adverse events.
The findings of this study suggest that durable clinical improvements can be realized after IDET in highly select surgical candidates with mild disc degeneration, confirmatory imaging evidence of anular disruption, and highly concordant pain provocation on low-pressure discography.
Fabio Galbusera, Chiara M. Bellini, Francesco Costa, Roberto Assietti, and Maurizio Fornari
Cervical instrumented fusion is currently performed using several fixation methods. In the present paper, the authors compare the following 4 implantation methods: a stand-alone cage, a cage supplemented by an anterior locking plate, a cage supplemented by an anterior dynamic plate, and a dynamic combined plate–cage device.
Four finite element models of the C4–7 segments were built, each including a different instrumented fixation type at the C5–6 level. A compressive preload of 100 N combined with a pure moment of 2.5 Nm in flexion, extension, right lateral bending, and right axial rotation was applied to the 4 models. The segmental principal ranges of motion and the load shared by the interbody cage were obtained for each simulation.
The stand-alone cage showed the lowest stabilization capability among the 4 configurations investigated, but it was still significant. The cage supplemented by the locking plate was very stiff in all directions. The 2 dynamic plate configurations reduced flexibility in all directions compared with the intact case, but they left significant mobility in the implanted segment. These configurations were able to share a significant part of the load (up to 40% for the combined plate–cage) through the posterior cage. The highest risk of subsidence was obtained with the model of the stand-alone cage.
Noticeable differences in the results were detected for the 4 configurations. The actual clinical relevance of these differences, currently considered not of critical importance, should be investigated by randomized clinical trials.
Francesco Doglietto, Marika Vezzoli, Antonio Biroli, Giorgio Saraceno, Luca Zanin, Marta Pertichetti, Stefano Calza, Edoardo Agosti, Jahard Mijail Aliaga Arias, Roberto Assietti, Silvio Bellocchi, Claudio Bernucci, Simona Bistazzoni, Daniele Bongetta, Andrea Fanti, Antonio Fioravanti, Alessandro Fiorindi, Alberto Franzin, Davide Locatelli, Raffaelino Pugliese, Elena Roca, Giovanni Marco Sicuri, Roberto Stefini, Martina Venturini, Oscar Vivaldi, Costanza Zattra, Cesare Zoia, and Marco Maria Fontanella
The COVID-19 pandemic has forced many countries into lockdown and has led to the postponement of nonurgent neurosurgical procedures. Although stress has been investigated during this pandemic, there are no reports on anxiety in neurosurgical patients undergoing nonurgent surgical procedures.
Neurosurgical patients admitted to hospitals in eastern Lombardy for nonurgent surgery after the lockdown prospectively completed a pre- and postoperative structured questionnaire. Recorded data included demographics, pathology, time on surgical waiting list, anxiety related to COVID-19, primary pathology and surgery, safety perception during hospital admission before and after surgery, and surgical outcomes. Anxiety was measured with the State-Trait Anxiety Inventory. Descriptive statistics were computed on the different variables and data were stratified according to pathology (oncological vs nononcological). Three different models were used to investigate which variables had the greatest impact on anxiety, oncological patients, and safety perception, respectively. Because the variables (Xs) were of a different nature (qualitative and quantitative), mostly asymmetrical, and related to outcome (Y) by nonlinear relationships, a machine learning approach composed of three steps (1, random forest growing; 2, relative variable importance measure; and 3, partial dependence plots) was chosen.
One hundred twenty-three patients from 10 different hospitals were included in the study. None of the patients developed COVID-19 after surgery. State and trait anxiety were reported by 30.3% and 18.9% of patients, respectively. Higher values of state anxiety were documented in oncological compared to nononcological patients (46.7% vs 25%; p = 0.055). Anxiety was strongly associated with worry about primary pathology, surgery, disease worsening, and with stress during waiting time, as expected. Worry about positivity to SARS-CoV-2, however, was the strongest factor associated with anxiety, even though none of the patients were infected. Neuro-oncological disease was associated with state anxiety and with worry about surgery and COVID-19. Increased bed distance and availability of hand sanitizer were associated with a feeling of safety.
These data underline the importance of psychological support, especially for neuro-oncological patients, during a pandemic.