Eur Spine J DOI 10.1007/s00586-014-3703-2
YEARLY EUROPEAN SPINE JOURNAL REVIEW
The Michel Benoist and Robert Mulholland yearly European Spine Journal Review: a survey of the ‘‘medical’’ articles in the European Spine Journal, 2014 Michel Benoist
Received: 25 November 2014 Ó Springer-Verlag Berlin Heidelberg 2014
Introduction 2014 was a year of change for the European Spine Journal. From its beginning in 1991, the editorial responsibility for the journal was in the competent hands of Max Aebi who, along with Springer, was the founder and pioneer of the journal. Although no longer Editor-inChief, Max Aebi has announced that he will remain active on the Editorial Board. Thanks to the remarkable professional efforts of its Editors, the European Spine Journal has followed a steady international course upward. The present impact factor is excellent, ranking the European Spine Journal number two among journals dedicated to the spine. An increasing number of paper submissions come from all parts of the world. Maintaining and
M. Benoist (&) Service de Chirurgie Orthope´dique, De´partement de Rhumatologie, Hoˆpital Beaujon, 100 Boulevard Ge´ne´ral Leclerc, 92118 Clichy, France e-mail: [email protected]
improving such a leading position is a challenging task, considering the present difficulties and levels of competition encountered in scientific publishing. I am confident that under Robert Gunzburg, the new Editor-in-Chief, and the Editorial Board, the European Spine Journal will continue to maintain its leadership. In the course of overviewing the 2014 issues, I have observed throughout the editorials and articles that clinicians and researchers are more and more aware of the continuing discrepancy between clinical practice and evidence-based literature. High-quality Cochrane systematic reviews examining efficacy of treatments often conclude that because of the low or very low quality of evidence of efficacy or inefficacy, no clear recommendations can be formulated. This is generally attributed to the poor quality of the RCTs, as shown in the very informative paper by Chen et al. [1]. Several propositions have been made to correct this situation, which leaves decision making based only on the personal experience and preference of physicians and surgeons. It is well known that traditional experience can be misleading and quickly outdated. One proposition made by Gunzburg [2] is, in addition to registries, to pursue higher standard RCTs using various means and at different levels. In this regard, the emergence of the Research Task Force initiated in the USA by the NIH to develop research standards for chronic low-back pain in the hope of improving future research is an important step forward [3]. On the other hand, as pointed out by Mannion et al. [4], evidence is difficult to obtain, especially when dealing with surgical and rehabilitation subjects where RCTs are not easy to perform and can be a source of bias. These authors propose an alternative method based on a detailed systematic review of the literature, followed by a collective multi-disciplinary expert opinion. All these new strategies aim at closing the gap between scientific
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evidence and clinical experience, which when correlated produce the best quality of evidence. Another particularity of the 2014 European Spine Journal production is the presence of a great number of papers dealing with spinal alignment and balance. They are spread throughout many of the monthly issues and are the topic of the October supplement. The global analysis of spine alignment and balance in standing position has strongly influenced the understanding and the therapeutic approach of several spinal pathologies such as trauma, spondylolisthesis, deformities and even the more common non-specific low-back pain. The therapeutic impact essentially concerns surgical indications and techniques. I have consequently chosen not to comment on any of the many papers dedicated to this subject.
Osteoporosis Can imaging studies of osteoporotic vertebral fractures (OVF) predict pseudarthrosis, progression of kyphosis, and late neurological complications? A small number of patients have neurological complications resulting from OVF. In most cases, neurological symptoms are delayed, appearing a few weeks or months after the fracture. Prediction of non-union and of progressive kyphotic deformity would be an important guide for prognosis and treatment. Three articles dealing with this topic are published in the December issue. The paper by Picazo et al. [5] is a case report presented in the context of a Grand Round, concerning a late collapse of an L1 OVF causing paraplegia. The neurological symptoms appeared progressively 3 months after the accident. CT imaging showed an intervertebral cleft. A confined intensity zone was shown on MRI T2-weighted images. The authors, seconded by a short review of the literature, consider that these CT/MRI signs are predictive of non-union, with the subsequent risk of neurological complications. The paper by Omi et al. [6] in the December issue focuses on the interest of short inversion time inversion recovery (STIR) in predicting prognosis of OVF. Two investigators analyzed radiographs and MRIs of 63 fractured vertebrae at the thoracolumbar (T10–L2) level. Two STIR images were evaluated: first, homogenous high-signal change defined as homogenous signal change observed across more than two-thirds of the area of the fractured vertebral body and second, the linear black signal defined as a black signal area of more than half the length of a fractured vertebral body. Pertinent illustrative STIR images can be found in the article. All vertebrae were divided into four groups. Bone union groups were compared to nonunion groups. Results of the statistical analysis are interesting: the 16 vertebrae with homogenous high signal
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achieved bone union whereas 14 of the non-homogenous high signal did not. Ten out of 24 of the linear black signals did not achieve bone fusion, whereas 35 out of 39 without non-linear black signals did achieve bone fusion. The VAS scale of back pain of the linear black signal group was significantly higher than that of the non-linear black signal group. The paper by Patil et al. [7] in the December issue aims to evaluate the radiological predictors of kyphotic deformity following OVF which in some patients results in secondary neurologic complications. Patients were divided into two groups: those who developed a kyphotic angle in the immediate post-injury, and those who did not. The kyphotic angle measured by the Cobb method was used to calculate segmental kyphotic deformity and its progression to the final follow-up. The radiographic characteristics of patients who developed a kyphotic deformity were compared with those who did not. The radiological parameters analyzed included: location of the fracture, endplate fracture, anterior cortical wall fracture, and adjacent level fractures. Sixty-four patients were studied with a mean follow-up of 27.5 months. Location of the fracture at the thoracolumbar junction and superior endplate fracture carry the higher risk for significant segmental deformity. Anterior cortical wall fracture and associated adjacent level fractures are minor predictors of progression.
Treatment of symptomatic lumbar degenerative spondylolisthesis Symptomatic lumbar degenerative spondylolisthesis constitutes an important chapter of spinal pathology frequently encountered in elderly patients. Failure of conservative therapy often leads to a difficult evaluation of the benefit/ risk of surgery. Two review articles deal with this subject. The paper by Steiger et al. [8] in the May issue is a highquality systematic review comparing conservative vs. surgical treatment in LDS. The paper also investigates the indications of surgery and the choice of surgical techniques to be used: decompression alone, fusion alone, decompression and fusion (instrumented or not). Seventeen studies and four reviews, generally of low methodologic quality and with risk of bias, are included in the paper. The study designs of the RCTs were heterogenous and the outcome variables not comparable, thus explaining the difficulty in drawing clear conclusions. Concerning conservative vs. surgical treatment, the authors conclude that after 4 years patients treated surgically maintain greater pain relief and better function than patients treated conservatively. There is a tendency toward better outcomes with fusion (instrumented or not). No clear answers could be found regarding the specific surgical procedures and
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choice of the various techniques. The authors conclude that in the present state of knowledge, there is a need to identify variables to help clinicians to choose the most appropriate therapeutic pathway. Which is the best surgical treatment for symptomatic degenerative lumbar spondylolisthesis? Reading the article by Mannion et al. [4] in the September issue is a must. The paper aims at developing criteria to be used to select the most appropriate procedures adapted to each individual patient with a symptomatic LDS. The authors recognize that RCTs are difficult in spine surgery and can be a source of bias. On the other hand, the present guidelines in this field are not supported by robust scientific evidence as studies are lacking in validated methods. Three surgical procedures are available for LDS: decompression alone, fusion alone, or decompression and fusion—with many variations according to the clinical and imaging features. In absence of clear recommendations, the surgeon’s decision is made according to his personal experience and knowledge. The authors of this review propose an alternative method for defining an appropriate surgical procedure: the RAND appropriateness method (RAM), which combines a detailed review of the literature and a collective expert opinion. Based on the literature review, a list of potential clinical scenarios is generated, according to clinical signs and symptoms as well as many other variables (e.g., radiological) to cover all possible clinical patterns. The constructed scenarios are then assessed and rated in relation to the appropriateness of the three surgical procedures and their multiple variations. A panel of multi-disciplinary international experts is asked to rate the scenarios in two rounds, the second being a face-to-face meeting. Data from the second-round rating (appropriateness and level of agreement) are then analyzed and summarized by the authors. I recommend taking time to read this paper. The discussion raises many questions concerning spine surgery in general.
Tumors The paper by Quaraishi et al. [9] in the July issue deals with a very special category of patients presenting metastatic spinal cord compression (MSCC) related to an unknown primary tumor (UPT). The authors’ purpose was to evaluate retrospectively the proportion of such cases in their population of 285 patients operated for MSCC, to analyze all pre- and post-operative data and compare them with the category of patients presenting an MSCC due to a known primary tumor. During an 8-year study period, the incidence of MSCC of unknown origin was 6 %. The primary tumors were identified post-operatively in 10 out of 17 patients: lungs [6] and GI [4]. Comparison of the
UPT group with the larger KTP is interesting. Most patients in the two groups (88 %) improved or remained the same. The complication rate was similar as was the survival rate: 222 vs. 251 days. Based on these observations and taking into account that earlier surgical treatment (within 48 h) results in better neurological outcome [10], the authors recommend treating the UPT patients urgently to avoid aggravation of the neurological status and perform the tumor work-up post-operatively. Three studies dealing with rare benign tumors are published in the February issue. The paper by Yin et al. [11] is a retrospective study of osteoblastoma in the mobile spine. The clinical and radiological data and the surgical efficacy of 32 operated patients are reviewed. Diagnosis was supported pre-operatively by CT images, differentiating conventional osteoblastoma from aggressive osteoblastoma, and by a needle biopsy yielding osteoblastoma without further classification, which was clearly provided by postoperative histological findings. Pre-operative alkaline phosphatase levels can be a useful diagnostic help. Total surgical excision is strongly recommended by the authors. Subtotal excision plus radiotherapy (still in dispute) may lead to relapse. The paper by Si et al. [12] deals with angiolipomas, benign tumors composed of mature fatty tissue and vascular elements usually found in the subcutaneous tissue. The authors retrospectively review 21 operated cases, differentiating two types of angiolipomas according to CT and MRI images: type 1 (intraspinal) and type 2 (dumbbellshaped) expanding out of the vertebral foramen. They further sub-classify type 1A (without lipomatosis) and type 1B (with lipomatosis). These tumors are extradural and mainly located in the thoracic spine. Surgical resection is relatively easy in type 1A as opposed to type 1B with surrounding lipomatosis, not easy to fully remove. In obese patients the authors recommend a diet aiming at weight loss and reduction of lipomatosis before surgery. Epidural hemangiomas are extremely rare. The review article by Mu¨hmer et al. [13] is a retrospective study of surgical series reporting on spinal hemangiomas during a 10-year period. Thirty spinal hemangiomas comprising 6 epidural, 17 vertebral and 7 intradural were encountered in the authors’ tertiary center, while an extensive literature search identified another 32 cases. The paper is an analysis of the clinical and radiological data of the hemangiomas located in the epidural space.
Systematic reviews evaluating effectiveness of interventions in chronic low-back pain In the October issue, Michaleff et al. [14] have evaluated the effectiveness of conservative treatment used to manage
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or prevent LBP in children and adolescents. The authors identified, after screening, five articles reporting four RCTs in the intervention section, and 12 articles reporting 11 RCTs in the prevention section. The PEDro scale was used to assess the risk of bias and the GRADE criteria to assess the quality of evidence. The overall results and conclusions of this well-written paper are as follows: first, exercise interventions appear promising to treat children and adolescents, a conclusion based only on two RCTs (n = 125) comparing average pain intensity of an exercise program to no treatment. Second, a moderate quality of evidence suggests that back-related education programs are not effective in preventing LBP in children and adolescents. The authors emphasize the paucity of relevant studies in the pediatric population and the poor methodology of the RCTs. The systematic review by Ammendolia et al. [15] published in June aimed to evaluate the effectiveness of surgical and non-surgical interventions to improve walking ability in neurogenic claudication in patients with lumbar spinal stenosis. The study focuses directly on a major clinical intermediate phenotype of LSS. Eighteen RCTs with 1,220 participants were included in the review. Risk of bias was assessed using the criteria recommended by the Cochrane group; quality of evidence was evaluated using the GRADE rating. Only 5 studies were considered to have a low risk of bias; heterogeneity in the source population, interventions and outcome measures precluded pooled analysis of the comparisons. The authors of this excellent paper conclude that the current level of evidence is of low or very low quality, which precludes making any recommendations for clinical practice about the effectiveness on walking ability for any of the interventions evaluated, whether surgical or non-surgical. The authors call for highquality research, requiring standardized methods for measuring walking capacity and outcomes of treatment. It is interesting to note that a Research Task Force has been recently created by the NIH in the USA to develop standards for research in chronic low-back pain. In his editorial appearing in the October issue R. Gunzburg [44] calls attention to the importance of the Focus Article in the same issue by Deyo et al. [3], reporting on this task force. Recommendations of the Task Force include definitions, report of minimal data set, stratification of LBP by its impact (defined by pain intensity, pain interference and physical function) and reporting outcomes.
Low-back pain and Modic 1 changes Most Modic 1 changes associated with low-back pain usually remain unchanged over the months without improvement of LBP intensity [16]. It has also been shown
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that pain in patients with Modic 1 is particularly intense and increases with lumbar motion. The purpose of the case control study reported in the March issue by Bailly et al. [17] was to analyze the clinical characteristics of Modic 1-induced LBP and investigate whether these characteristics could differentiate Modic 1-induced from non-specific mechanical back pain. One hundred and twenty patients with chronic LBP and a recent lumbar MRI were studied prospectively. Sixty patients with Modic 1 were compared to 60 age- and gender-matched controls without Modic changes. Pain characteristics were collected in a questionnaire and completed by the Dallas Pain Questionnaire. A second questionnaire evaluating the physical examination was completed by a rheumatologist. Results of the statistical analysis indicate that patients with Modic 1 changes exhibit an inflammatory pain pattern more frequently than controls, consisting of night pain, worse pain at waking, and prolonged morning stiffness. This pain pattern is similar to that observed in inflammatory arthropathies. It is also in keeping with the high TNF expression in the endplates of patients with Modic 1 changes and with the presence of abundant immuno-reactive nerve fibers in the endplate. The presence of this pain pattern and of pain with lumbar extension should evoke to the clinician the presence of Modic 1 changes and guide an appropriate prognosis and therapy.
Back pain and intradural tumors The revealing symptoms of intradural tumors consist of radicular pain, exacerbated at night with or without neurological deficits. Accompanying back or neck pain, when present, is often considered as related to the degenerative lesions discovered on the imaging studies in addition to the tumor. However, there are reported cases of intradural tumors where back/neck pain is the predominant symptom. In that case, the question is: will surgical removal of the tumor improve the back or neck pain, and is it recommended to perform an additional surgery to treat the degenerative lesions? The study by Bellut et al. [18] in the April issue provides an interesting answer to this question. The authors have operated 58 consecutive patients for intradural tumors with various histopathological diagnoses. Twenty-seven of the 58 patients had back/neck pain as a leading symptom and spinal degenerative changes at the level of the tumor. Surgical ablation of the tumor was performed in the 27 patients without additional surgery on the degenerative lesions. Results were evaluated by the COMI questionnaire pre-operatively and until 24 months post-operatively, and by the Spine Tango form completed by the surgeon. Post-operative remission rate was 85 % without complications. Predominant back/neck pain, the
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pre-operative leading symptoms, disappeared in 67 % of the patients. Only two patients (7 %) required further surgery for degenerative lesions.
Decompression surgery for lumbar spinal stenosis: its effect on low-back pain The primary goal of decompression surgery in LSS patients is to eradicate/reduce leg pain and improve neurologic claudication and walking. In clinical practice, it is sometimes observed that the lower back pain component of the syndrome is also substantially improved. However, few papers have evaluated and quantified separately the effect of decompression surgery in LBP vs. leg pain. The observational study by Jones et al. [19] in the January issue deals with this subject and provides interesting information on 119 LSS-operated patients (laminectomy or laminoplasty). The outcome measures comprised Oswestry Disability Questionnaire and two VAS, separately evaluating leg and low-back pain. Outcome measures were estimated pre-operatively at 6 weeks and at 1 year. The results indicate that there is not only a significant reduction of the ODI score but also a significant decrease in mean LBP at 6 weeks, persisting at 1 year. The possible explanation of this effect is discussed in the paper, which does not evaluate the effect of surgery on claudication.
Intensive combined physical psychological program for chronic low-back pain In the January issue, Miranda et al. [20] report the results of a longitudinal study aiming to determine pre-treatment factors, which could predict a successful combined physical and psychological program outcome. In two previous studies [21, 22], the same group of authors has described the CCP program and reported clinically relevant improvement, persisting at 2 years in terms of daily functioning, disability, and quality of life. In the present study, the authors included a prospective cohort of 524 CLBP patients recruited from spine surgeons. Numerous variables were used in the questionnaire to assess the aspects of physical and psychosocial functioning, pre-treatment and at 1-year follow-up. The originality of this paper is that the primary outcome variable was measured by the Oswestry Disability Index (ODI), the main goal of the program being to reduce disability. Success at 1 year was defined as having reached 22 points or lower on the ODI score— equivalent to normal, healthy populations. At the 1-year follow-up, results showed that 41.4 % of patients reached equal or minus 22 ODI value. Mild and moderate levels of disability, and being at work at the pre-treatment
assessment were the most important predictive factors of a successful outcome. This category of patients, even those with high distress, could therefore be accepted into the program with priority.
Exercise and behavioral therapy for low-back pain in a high educational, socio-economic community The originality of the study by Steffens et al. [23] published in January is to examine the outcomes and prognostic factors of a 10-week group exercise program with cognitive behavioral therapy of high quality in a selected group of patients with high educational and socio-economic status. Patients were paying for the program and many of the adverse factors common to most LBP studies (sick leave, socio-economics, etc.) were more or less eliminated. Results of this community-based program provide a clear evaluation of an exercise program performed in a group of population with an a priori favorable prognosis. Outcomes were evaluated on a numerical painrating scale, Roland Morris Disability Questionnaire, and numerous secondary outcomes. Results were evaluated at 1 year in 112 patients, of which 73 % were women. Pain intensity improved markedly in the first 6 months (35 %) and then more slowly to 1 year (39 %). Disability improved in 48 % of participants at 6 months and continued to improve up to 1 year (60 %). Pain intensity at baseline was the only predictor of the 1-year pain score. Duration of the current episode, baseline disability and educational level were independent predictors of disability at 12 months.
Risk factors for subsequent fractures after vertebroplasty Identification of risk factors for subsequent fractures after vertebroplasty is still a subject of controversy. Rigidity of the treatment segment created by the injected cement and an eventual leakage in the adjacent disk may play a role in the case of subsequent fractures adjacent to the initial vertebroplasty. It is also well known that the history of a vertebral osteoporotic fracture is a major risk factor for subsequent fractures in osteoporotic men or women. The paper by Sun et al. [24] published in June is a retrospective study investigating the risk factors of subsequent fractures adjacent or not adjacent to the initially treated vertebral body. One hundred and seventy-five patients were followed-up 1 year after a single-level, first-time vertebroplasty. Numerous clinical, biological and radiological parameters were recorded. During the 1-year follow-up period, 37 subsequent fractures were observed.
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Interestingly, the only significant risk factors found in the statistical analysis were low BMD T score and treated vertebral levels at the thoracolumbar junction (T10–L2). The authors conclude that subsequent fractures reflect a natural evolution of osteoporosis, regardless of the presence of vertebroplasty.
results of the entire group, the heaviness of the sports bag was underestimated compared to the other two bags. These results confirm that perception of load heaviness can be influenced by subjective variables, thoroughly discussed in the article.
Post-operative meralgia paresthetica Whiplash injury The article by Hertzum-Larsen et al. [25] published in August deals with the etiology of long-lasting pain following whiplash injury. Much research has been done in this domain, providing some agreement that the syndrome is multifactorial, including biological, psychological, social and economic factors. In the present study, the authors examine whether X-ray occult fractures could be detected on SPECT after an acute whiplash injury. Abnormal SPECT is defined as a focal uptake used as an indicator of occult fractures. Following an acute whiplash injury, eighty-eight patients underwent a SPECT a few days after the accident. Thirty-two (36.4 %) had an abnormal scan, which indicates that occult fractures are not uncommon after a whiplash. At 6-month follow-up, only 49 scans could be performed of which 13 were abnormal. The study examined prospectively a hypothetical association between occult fractures with persisting neck pain, headache and arm pain. No such association was found, neither at baseline nor at 6-month follow-up. The authors conclude that the cause of the pain lies elsewhere: increased vulnerability of the victims, cultural, litigation or compensation factors.
Backpacks and school children The paper by Nicolet et al. [26] published in April is worth reading. It deals with the factors, which can influence school children’s perception of the load heaviness of school backpacks. In their introduction, the authors briefly recall the complexity of weight perception in general as well as the conflicting information concerning the weight limits of school bags for children and adolescents [27]. The aim of the present paper was to evaluate the influence of adolescents’ perception of a weight load in the presence of LBP and with the nature of the load. The procedure is clearly described. Eighty schoolboys, all aged 9–16 years, all members of a local sports club were included. During a training session, the volunteers completed a questionnaire evaluating the presence of LBP. They also estimated the weight of three bags: school bag, sports bag, and neutral bag containing two different loads (approximately 3 and 5 kg). Adolescents with a history of LBP (26.2 %) overestimated the weight of the heavier bags. When analyzing
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Injury of the lateral femoral cutaneous nerve (LFCN) has been reported following bone harvesting at the iliac crest for spinal fusion, non-union fracture, and for maxillofacial reconstruction. LFCN injury results in dysesthesia, loss of sensation and neuralgia in the lateral aspect of the thigh of difficult management. I wish to draw the attention of the readers to an interesting anatomical and radiological study aiming at identifying the local anatomical landmarks for optimal harvesting and graft dimensions. This study by Ropars et al. [28] in the May issue involves the dissection of 28 Caucasian female hemi-pelvises, identifying the nerve, anterior superior iliac spine (ASIS) and anterior iliac tubercle. CT scan analysis determined the optimum position for obtaining a 5-mm thickness graft while avoiding LFCN injury. According to their measurements, the authors recommend as an optimal location a point situated anterior to a line passing at the level of the thickest point of the anterior iliac tubercle, at a mean 67 mm from the center of the ASIS.
Dysphagia after anterior surgical surgery Difficulty in swallowing after anterior surgical surgery is a well-known complication of this procedure. The prevalence is not known and the symptoms, when present, are usually mild [29]. However, cases of severe dysphagia have been reported. The possible causes of this disorder include surgical factors such as design of the plates, intraoperative retractions or patients’ characteristics. The study by Kang et al. [30] published in the August issue evaluates a possible association with psychiatric factors: anxiety, depression. The authors have prospectively examined 72 patients operated for a cervical radiculopathy. Demographic data, SF 36, neck disability indices, neck pain and disability scale, the Zung depression scale and the Zung anxiety scale were assessed before surgery and at the final 1-year follow-up. Patients were questioned on the presence or not of dysphagia, classified in four grades, and then divided in two groups: group 1—no or mild dysphagia, and group 2—moderate or severe dysphagia. The prevalence of group 2 was 30.6 % (22 patients) and group 1 was 69.4 % (50 patients). Multivariate logistic regression showed that the presence of a psychiatric problem (ZDS
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and ZAS scores) was the only predictor of chronic dysphagia, moderate or severe. The mechanism of dyspnea/dysphagia (DD) after occipito-cervical fusion is different from that of anterior cervical surgery for radiculopathy. The paper by Izeki et al. [31] in the February issue deals with the occurrence of DD after O–C2 fusion. The authors have already shown that the cause of DD after an O–C2 fusion is the stenosis of the oropharyngeal space. In the present study, the authors emphasize the impact of the O–C2 angle between the McGregor’s line and the inferior plate of C2. Reduction of this angle per-operatively is associated with narrowing of the oropharyngeal space and with the risk of persistent dysphagia [32].
Depression and catastrophizing after lumbar spinal fusion Numerous psychosocial factors contribute to the development and persistence of LBP and affect the subjective experience of pain. Such psychological components may still be present in patients after surgical decompression and/or fusion of the lumbar spine. Fear-avoidance behaviors, catastrophizing and mood alterations are important items determining persistence of chronic pain and disability. The paper by Monticone et al. [33] in the January issue is a randomized controlled trial in which 130 patients after fusion for spondylolisthesis and stenosis were randomly assigned to either exercises and cognitive behavior therapy (CBT, n = 65) or exercises alone (n = 65). Both interventional programs are well described. The originality of the cognitive behavioral therapy is that the psychological program, consisting of 1 hour of CBT twice a week for 4 weeks, precisely targeted catastrophizing and fear of movement. Outcome measures included ODI, pain catastrophizing scale, self-reported Tampa scale for kinesiophobia, numerical rating scale for pain, and SF 36. Results showed that the program including CBT and exercises was significantly superior to exercises alone in terms of pain, disability, and quality of life. There is a good discussion and review of the literature. The paper by Wahlman et al. [34] published in the January issue provides interesting information concerning the evolution of depressive symptoms and association with disability after undergoing lumbar fusion. Data of 232 patients were extracted from a Finnish register dedicated to lumbar fusion. The prevalence of depressive symptoms was evaluated on the depression scale (DEPS), the scores of which identified two groups: those with depressive, and those without depressive symptoms. Disability was measured pre- and post-operatively on ODI. Back and leg pain were evaluated on VAS. The criteria for surgery were
persistent severe back pain and/or radicular pain. The main indications for fusions were degenerative spondylolisthesis, spinal stenosis, instability, pain after previous surgery, disk herniation and degenerative scoliosis. Results show that the prevalence of pre-operative depressive symptoms was high (34 %) and decreased after surgery (13 % at 3 months, 15 % at 1 year). In both groups, the Oswestry score decreased significantly from baseline to 1 year. However, functional disability in patients with depressive symptoms remained significantly more severe in the depressive group. The paper contains a good discussion. The main message of this study is that there is no need to exclude depressive patients from lumbar fusion when indicated, provided that appropriate screening methods and treatments of depression are performed pre- and post-operatively.
MRI evaluation of lumbar spinal stenosis Pain, disability and neurologic claudication are the clinical features involved in the decision to operate patients with central lumbar spinal stenosis (LSS). It is recognized that the clinical symptoms do not always correlate with the degree of stenosis. However, evaluation of stenosis and of its degree on MRI is a key factor for diagnosis and prognosis. How to evaluate lumbar spinal stenosis on MRI is the subject of an interesting article by Lonne et al. [35] in the June issue. The study compares two methods for assessing LSS on MRI: one measures the area on axial view (DSCA), the other, more recently described, uses a morphological grading based on the CSF visibility of the rootlets inside the dural sac [36]. Two independent radiologists classified the degree of stenosis using the two methods. Inter- and intra-observer agreements of DSCA and morphological grading were acceptable. The correlation of the two methods was strong. The authors conclude that as clinicians prefer to evaluate LSS according to their usual assessment, the new less time-consuming morphological grading can be used for decision making.
Lumbar spinal stenosis and paraspinal muscles The article by Chen et al. [37] published in the May issue is worth reading carefully as it deals with the role of the paraspinal muscles (multifidus and psoas) in the clinical performance of patients with lumbar spinal stenosis. Sixtysix LSS patients without mechanical low-back pain or instability on imaging studies were retrospectively studied. Morphologic parameters included measurements of fatty infiltration and relative cross-sectional area of the multifidus and the relative cross-sectional area of the psoas major. Severity of the stenosis was classified according to the
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cross-sectional area of the dural sac. Functional performance was evaluated according to the Japanese Orthopedic Association (JOA) score. Results of the statistical analysis indicate that the status of the paraspinal muscles has a significant effect on the clinical performance in LSS patients. Increased multifidus fatty infiltration was significantly correlated with poorer functional performance and can be used as a prognostic factor in LSS patients, the degree of stenosis being poorly related to symptom severity and functional impairment. In addition, a larger psoas cross-sectional area was significantly correlated with a higher functional performance. The discussion contains an interesting review of the pathophysiology of the paraspinal muscles in general.
group) to 60 patients with intraspinal canal compression (CS group). All patients had a complete set of imaging studies (MRI, CT, CT myelography) and underwent a nerve-root infiltration. The FS group received a decompression of the L5–S1 area associated with a transforaminal interbody fusion; the CS group received an L4–L5 decompression with or without fusion. Outcome measures included the JOA score, VAS of leg pain at rest and at walking, VAS of low-back pain, and prevalence of intermittent claudication. All measures were evaluated pre- and post-operatively. The prevalence of leg pain was significantly higher in the FS group compared to the CS group. Leg pain at rest was significantly higher in the foraminal group (6.6 ± 3.1 vs. 1.3 ± 1.9). The authors hypothesize that compression of the DRG in the foramen was the cause of this prevalence.
Age and degenerative lumbar surgery There are few studies in the literature evaluating the clinical benefit for elderly patients operated for degenerative lumbar pathologies. The study by Pe´rez-Prieto et al. [38] published in the May issue brings a valuable complement of information in this field. The paper evaluates and compares disability, quality of life and satisfaction outcomes between old and young patients operated for degenerative disorders. The study also analyzes the various diagnoses and treatments of the sample and their respective clinical outcomes after surgery. Data of 263 patients including 74 aged 65 years or more, and 189 aged below 65 years were retrospectively collected. Patients were clinically evaluated pre-operatively and at 2-year follow-up using 3 questionnaires: short-form version of SF36, Oswestry Disability Questionnaire (ODI) and the COMI to evaluate patients’ satisfaction. No differences were found between the two groups in terms of quality of life, disability and satisfaction. No differences were found in the distribution relative to pathology or treatments, listed in the paper, between the older and younger group. This study is retrospective and does not evaluate comorbidities or complications. However, the effectiveness of surgery in elderly patients is confirmed.
Leg pain in lumbar stenosis Persistence of leg pain at rest, especially at night, is well known in patients with lumbar stenosis. In the article by Yamada et al. [39] in the March issue, the authors seek to evaluate whether in a single radiculopathy (L5) leg pain at rest differs according to the site of the compression: L5–S1 foraminal stenosis and intraspinal canal stenosis. Demographic, clinical and neurological data were compared between 38 patients with foraminal compression (FS
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Recovery of severe motor deficit secondary to a disk prolapse The paper by Balaji et al. [40] published in September is a systematic review of the literature, aiming first to evaluate whether surgical intervention in patients with severe motor deficit (defined by MRC grade of 3 or less) is beneficial, and second to appreciate whether time to surgery from onset of motor deficit is an important factor of recovery. The article contains a thorough description of the literature as well as the inclusion and exclusion criteria used to select studies eligible for analysis. The flow diagram shows that out of 9,390 potential relevant publications only seven papers contained a full set of data. These include five case series, one RCT and one prospective cohort study. Results are surprising: only two of the 7 studies had a non-operative cohort. The surgical operations are variable between studies and only two of them explain the method of muscular testing. Overall, in a total of 354 patients, complete recovery was seen in 38.4 % of operated patients and 32 % of non-operated patients. Age and grade of motor deficit are significant prognostic factors in some of the studies. Because of the limitations of the studies included and because of their heterogeneity, statistical analysis was not possible. The authors conclude that the current available evidence is not robust enough to address the questions asked. They propose a framework for future studies.
Vocal cord paralysis after anterior cervical discectomy The paper by Chen et al. [41] published in March deals with the long-term evolution of vocal cord paralysis (VCP) after anterior cervical discectomy. The article is
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particularly interesting as it contains the documentation of a large number of patients operated for ACDF and followed-up at least six years by the authors. There is also an excellent review of the literature. The paper concerns a retrospective review of 1,895 patients of whom only nine developed a VCP post-operatively (0.47 %), lasting over 3 months, within the 3 years of follow-up. Four patients had more severe symptoms (dysphagia, choking), and 6 patients had recovered after 9 months. The three remaining patients had persistent symptoms even after 3 years.
Sleep apnea Obstructive sleep apnea syndrome (OSAS) is a multifactorial chronic condition related to an anatomic obstruction or partial collapse of the upper airway during sleep. OSAS generates a serious impairment of quality of life, including daytime sleepiness, decreased cognitive performance, and cardio-vascular complications. The article by Khan et al. [42] published in the March issue investigates whether disorders of the cervical spine could narrow the dimensions of the upper pharyngeal space and possibly cause an obstructive sleep apnea. The paper is a narrative review of the literature data. Only 17 articles discuss a potential relationship between OSAS and cervical spine. Overall, the analysis of the literature is based on case reports and on two studies. The authors separate single lesion from multifocal lesions. The former includes voluminous osteophytes and rare pathologies such as osteochondromas; the latter essentially includes rheumatoid arthritis and endogenous cervical fusions. The authors conclude that the cervical spine is one structure that may cause OSAS. They recommend that clinicians be aware of its possible role in the syndrome. The paper is followed by an interesting in-depth critical comment by Bartels [43]. Analyzing the two studies reported by Khan, Bartels states that the relationship between cervical spine and sleep apnea is not proven and not even suggested, with the exception of rheumatoid arthritis where the relationship seems more convincing. However, both authors agree that the role of cervical spine in sleep apnea remains an interesting and important topic and both agree on the need for future research to clarify this subject. Conflict of interest
None.
References 1. Chen X, Zhai X, Wang X et al (2014) Methodological reporting quality of randomized controlled trials in three spine journals from 2010 to 2012. Eur Spine J 23:1606–1611
2. Gunzburg R (2014) Editorial. Randomized clinical trials: in pursuit of higher standards. Eur Spine J 23:1605 3. Deyo RA, Dworkin SF, Amtmann D et al (2014) Focus article: report of the NIH Task Force on research standards for chronic low-back pain. Eur Spine J 23:2028–2045 4. Mannion AF, Pittet V, Steiger F et al (2014) Development of appropriateness criteria for the surgical treatment of symptomatic lumbar degenerative spondylolisthesis (LDS). Eur Spine J 23:1903–1917 5. Picazo D (2014) Late collapse osteoporotic vertebral fracture in an elderly patient with neurological compromise. Eur Spine J 23:2696–2702 6. Omi H, Yokoyama T, Ono A et al (2014) Can MRI predict subsequent pseudoarthrosis resulting from osteoporotic thoracolumbar vertebral fractures? Eur Spine J 23:2705–2710 7. Patil S, Nene AM (2014) Predictors of kyphotic deformity in osteoporotic vertebral compression fractures: a radiological study. Eur Spine J 23:2737–2742 8. Steiger F, Becker HJ, Standaert CJ et al (2014) Surgery in lumbar degenerative spondylolisthesis: indications, outcomes and complications. A systematic review. Eur Spine J 23:945–973 9. Quraishi NA, Ramoutar D, Suresh kumar D et al (2014) Metastatic spinal cord compression as a result of the unknown primary tumor. Eur Spine J 23:1502–1507 10. Quraishi NA, Rajagopal TS, Manoharan SR et al (2013) Effect of timing of surgery on neurological outcome and survival in metastatic spinal cord compression. Eur Spine J 22:1383–1388 11. Yin H, Zhou W, Yu H et al (2014) Clinical characteristics and treatment options for two types of osteoblastoma in the mobile spine: a retrospective study of 32 cases and outcomes. Eur Spine J 23:411–416 12. Si Y, Wang Z, Lin G et al (2014) Spinal angiolipoma: etiology, imaging findings, classification and prognosis. Eur Spine J 23:417–425 13. Mu¨hmer M, Bostelmann R, Sarikaya-Seiwert S et al (2014) Clinical and radiological presentation of spinal epidural hemangiomas: clinical series in a tertiary care centre during a 10-year period. Eur Spine J 23:417–425 14. Michaleff ZA, Kamper SJ, Maher CG et al (2014) Low back pain in children and adolescents: a systematic review and meta-analysis evaluating the effectiveness of conservative interventions. Eur Spine J 23:2046–2058 15. Ammendolia C, Stuber K, Tomkis-Lanec C et al (2014) What interventions improve walking ability in neurogenic claudication with lumbar spinal stenosis? A systematic review. Eur Spine J 23:1282–1301 16. Jensen RK, Leboeuf-Yde C, Wedderkopp N et al (2012) Is the development of Modic changes associated with clinical symptoms? A 14-month cohort study with MRI. Eur Spine J 21:2271–2279 17. Bailly F, Maigne JY, Genevay S et al (2014) Inflammatory pain pattern and pain with lumbar extension associated with Modic 1 changes on MRI: a prospective case-control study of 120 patients. Eur Spine J 23:493–497 18. Bellut D, Mutter UM, Sutter M et al (2014) Back pain in patients with degenerative spine disease and intradural spinal tumor: what to treat? When to treat? Eur Spine J 23:821–829 19. Jones ADR, Wafai AM, Easterbrook AL (2014) Improvement in low-back pain following spinal decompression: observational study of 119 patients. Eur Spine J 23:135–141 20. Miranda L, Van Hooff ML, Spruit M et al (2014) Predictive factors for successful clinical outcome 1 year after an intensive combined physical and psychological programme for chronic low-back pain. Eur Spine J 23:103–112 21. Van Hoof ML, Van der Merwe JD, O’Dowd J et al (2010) Daily functioning and self-management in patients with chronic low-
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back pain after an intensive cognitive behavioral programme for pain management. Eur Spine J 19:1517–1526 Van Hoof ML, ter Avest W, Horsting PP et al (2012) A short intensive cognitive behavioral pain management programme reduces health-care use in patients with chronic low-back pain: a 2 year follow-up results of a prospective cohort. Eur Spine J 21:1257–1264 Steffens D, Hancock MJ, Maher CG et al (2014) Prognosis of chronic low-back pain in patients presenting to a private community-based group exercise program. Eur Spine J 23:113–119 Sun G, Li M, Liu X et al (2014) Analysis of risk factors of subsequent fractures after vertebroplasty. Eur Spine J 23:1139–1145 Hertzum-Larsen R, Petersen H, Kasch H et al (2014) Do X-ray occult fractures play a role in chronic pain following a whiplash injury? Eur Spine J 23:1673–1679 Nicolet T, Mannion AF, Heini P et al (2014) No kidding: lowback pain and type of container influence adolescents’ perception of load heaviness. Eur Spine J 23:794–799 Dockrell S, Simms C, Blake C (2013) Schoolbag weight limit: can it be defined? J Sch Health 83:368–377 Ropars M, Zadem A, Morandi X et al (2014) How can we optimize anterior iliac crest bone harvesting? An anatomical and radiological study. Eur Spine J 23:1150–1155 Riley LH III, Vaccaro AR, Dettori JR et al (2010) Postoperative dysphagia in anterior cervical spine surgery. Spine 35:576–585 Kang SS, Lee JS, Shin K et al (2014) The association between psychiatric factors and the development of chronic dysphagia after anterior cervical spine surgery. Eur Spine J 23:1694–1698 Izeki M, Takemoto M, Fujihabayashi S et al (2014) The O-C2 angle established at occipito-cervical fusion dictates the patient’s destiny in terms of postoperative dyspnea and/or dysphagia. Eur Spine J 23:328–336 Izeki M, Neo M, Ito H et al (2013) Reduction of atlantoaxial subluxation causes airway stenosis. Spine 38:E513–E520 Monticone M, Ferrante S, Teli M et al (2014) Management of catastrophising and kinesophobia improves rehabilitation after
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fusion for lumbar spondylolisthesis and stenosis. A randomized controlled trial. Eur Spine J 23:87–95 Wahlman M, Ha¨kkinen A, Dekker J et al (2014) The prevalence of depressive symptoms before and after surgery and its association with disability in patients undergoing lumbar spinal fusion. Eur Spine J 23:129–134 Lonne G, Odergard B, Johnsen LG et al (2014) MRI evaluation of lumbar spinal stenosis: is a rapid visual assessment as good as area measurement? Eur Spine J 23:1320–1324 Schizas C, Theumann N, Burn A et al (2010) Qualitative grading of severity of lumbar spinal stenosis based on the morphology of the dural sac on magnetic resonance images. Spine 35:1919–1924 Chen YY, Pao JL, Liaw CK et al (2014) Image changes of paraspinal muscles and clinical correlations in patients with unilateral lumbar spinal stenosis. Eur Spine J 23:999–1006 Pe´rez-Prieto D, Lozano-Alvarez C, Salo G et al (2014) Should age be a contraindication for degenerative lumbar surgery? Eur Spine J 23:1007–1012 Yamada K, Aota Y, Higashi T et al (2014) Lumbar foraminal stenosis causes leg pain at rest. Eur Spine J 23:504–507 Balaji VR, Chin KF, Tucker S et al (2014) Recovery of severe motor deficit secondary to herniated lumbar disc prolapse: is surgical intervention important? A systematic review. Eur Spine J 23:1068–1077 Chen CC, Huang YL, Lee ST et al (2014) Long-term result of vocal cord paralysis after anterior cervical discectomy. Eur Spine J 23:622–626 Khan A, Than KD, Chen KS et al (2014) Sleep apnea and cervical spine pathology. Eur Spine J 23:641–647 Bartels RHMA (2014) Reviewer’s comment concerning ‘‘Sleep apnea and cervical spine pathology’’ by Adam Khan, Khoi D. Than, Kivin S. Chen, Anthony C. Wang, Frank La Marca. Paul Park. Eur Spine J 23:648–649 Gunzburg R (2014) Low-back pain: in search of goddess Panacea. Eur Spine J 23:2027
YEARLY EUROPEAN SPINE JOURNAL REVIEW
The Michel Benoist and Robert Mulholland yearly European Spine Journal Review: a survey of the ‘‘medical’’ articles in the European Spine Journal, 2014 Michel Benoist
Received: 25 November 2014 Ó Springer-Verlag Berlin Heidelberg 2014
Introduction 2014 was a year of change for the European Spine Journal. From its beginning in 1991, the editorial responsibility for the journal was in the competent hands of Max Aebi who, along with Springer, was the founder and pioneer of the journal. Although no longer Editor-inChief, Max Aebi has announced that he will remain active on the Editorial Board. Thanks to the remarkable professional efforts of its Editors, the European Spine Journal has followed a steady international course upward. The present impact factor is excellent, ranking the European Spine Journal number two among journals dedicated to the spine. An increasing number of paper submissions come from all parts of the world. Maintaining and
M. Benoist (&) Service de Chirurgie Orthope´dique, De´partement de Rhumatologie, Hoˆpital Beaujon, 100 Boulevard Ge´ne´ral Leclerc, 92118 Clichy, France e-mail: [email protected]
improving such a leading position is a challenging task, considering the present difficulties and levels of competition encountered in scientific publishing. I am confident that under Robert Gunzburg, the new Editor-in-Chief, and the Editorial Board, the European Spine Journal will continue to maintain its leadership. In the course of overviewing the 2014 issues, I have observed throughout the editorials and articles that clinicians and researchers are more and more aware of the continuing discrepancy between clinical practice and evidence-based literature. High-quality Cochrane systematic reviews examining efficacy of treatments often conclude that because of the low or very low quality of evidence of efficacy or inefficacy, no clear recommendations can be formulated. This is generally attributed to the poor quality of the RCTs, as shown in the very informative paper by Chen et al. [1]. Several propositions have been made to correct this situation, which leaves decision making based only on the personal experience and preference of physicians and surgeons. It is well known that traditional experience can be misleading and quickly outdated. One proposition made by Gunzburg [2] is, in addition to registries, to pursue higher standard RCTs using various means and at different levels. In this regard, the emergence of the Research Task Force initiated in the USA by the NIH to develop research standards for chronic low-back pain in the hope of improving future research is an important step forward [3]. On the other hand, as pointed out by Mannion et al. [4], evidence is difficult to obtain, especially when dealing with surgical and rehabilitation subjects where RCTs are not easy to perform and can be a source of bias. These authors propose an alternative method based on a detailed systematic review of the literature, followed by a collective multi-disciplinary expert opinion. All these new strategies aim at closing the gap between scientific
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evidence and clinical experience, which when correlated produce the best quality of evidence. Another particularity of the 2014 European Spine Journal production is the presence of a great number of papers dealing with spinal alignment and balance. They are spread throughout many of the monthly issues and are the topic of the October supplement. The global analysis of spine alignment and balance in standing position has strongly influenced the understanding and the therapeutic approach of several spinal pathologies such as trauma, spondylolisthesis, deformities and even the more common non-specific low-back pain. The therapeutic impact essentially concerns surgical indications and techniques. I have consequently chosen not to comment on any of the many papers dedicated to this subject.
Osteoporosis Can imaging studies of osteoporotic vertebral fractures (OVF) predict pseudarthrosis, progression of kyphosis, and late neurological complications? A small number of patients have neurological complications resulting from OVF. In most cases, neurological symptoms are delayed, appearing a few weeks or months after the fracture. Prediction of non-union and of progressive kyphotic deformity would be an important guide for prognosis and treatment. Three articles dealing with this topic are published in the December issue. The paper by Picazo et al. [5] is a case report presented in the context of a Grand Round, concerning a late collapse of an L1 OVF causing paraplegia. The neurological symptoms appeared progressively 3 months after the accident. CT imaging showed an intervertebral cleft. A confined intensity zone was shown on MRI T2-weighted images. The authors, seconded by a short review of the literature, consider that these CT/MRI signs are predictive of non-union, with the subsequent risk of neurological complications. The paper by Omi et al. [6] in the December issue focuses on the interest of short inversion time inversion recovery (STIR) in predicting prognosis of OVF. Two investigators analyzed radiographs and MRIs of 63 fractured vertebrae at the thoracolumbar (T10–L2) level. Two STIR images were evaluated: first, homogenous high-signal change defined as homogenous signal change observed across more than two-thirds of the area of the fractured vertebral body and second, the linear black signal defined as a black signal area of more than half the length of a fractured vertebral body. Pertinent illustrative STIR images can be found in the article. All vertebrae were divided into four groups. Bone union groups were compared to nonunion groups. Results of the statistical analysis are interesting: the 16 vertebrae with homogenous high signal
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achieved bone union whereas 14 of the non-homogenous high signal did not. Ten out of 24 of the linear black signals did not achieve bone fusion, whereas 35 out of 39 without non-linear black signals did achieve bone fusion. The VAS scale of back pain of the linear black signal group was significantly higher than that of the non-linear black signal group. The paper by Patil et al. [7] in the December issue aims to evaluate the radiological predictors of kyphotic deformity following OVF which in some patients results in secondary neurologic complications. Patients were divided into two groups: those who developed a kyphotic angle in the immediate post-injury, and those who did not. The kyphotic angle measured by the Cobb method was used to calculate segmental kyphotic deformity and its progression to the final follow-up. The radiographic characteristics of patients who developed a kyphotic deformity were compared with those who did not. The radiological parameters analyzed included: location of the fracture, endplate fracture, anterior cortical wall fracture, and adjacent level fractures. Sixty-four patients were studied with a mean follow-up of 27.5 months. Location of the fracture at the thoracolumbar junction and superior endplate fracture carry the higher risk for significant segmental deformity. Anterior cortical wall fracture and associated adjacent level fractures are minor predictors of progression.
Treatment of symptomatic lumbar degenerative spondylolisthesis Symptomatic lumbar degenerative spondylolisthesis constitutes an important chapter of spinal pathology frequently encountered in elderly patients. Failure of conservative therapy often leads to a difficult evaluation of the benefit/ risk of surgery. Two review articles deal with this subject. The paper by Steiger et al. [8] in the May issue is a highquality systematic review comparing conservative vs. surgical treatment in LDS. The paper also investigates the indications of surgery and the choice of surgical techniques to be used: decompression alone, fusion alone, decompression and fusion (instrumented or not). Seventeen studies and four reviews, generally of low methodologic quality and with risk of bias, are included in the paper. The study designs of the RCTs were heterogenous and the outcome variables not comparable, thus explaining the difficulty in drawing clear conclusions. Concerning conservative vs. surgical treatment, the authors conclude that after 4 years patients treated surgically maintain greater pain relief and better function than patients treated conservatively. There is a tendency toward better outcomes with fusion (instrumented or not). No clear answers could be found regarding the specific surgical procedures and
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choice of the various techniques. The authors conclude that in the present state of knowledge, there is a need to identify variables to help clinicians to choose the most appropriate therapeutic pathway. Which is the best surgical treatment for symptomatic degenerative lumbar spondylolisthesis? Reading the article by Mannion et al. [4] in the September issue is a must. The paper aims at developing criteria to be used to select the most appropriate procedures adapted to each individual patient with a symptomatic LDS. The authors recognize that RCTs are difficult in spine surgery and can be a source of bias. On the other hand, the present guidelines in this field are not supported by robust scientific evidence as studies are lacking in validated methods. Three surgical procedures are available for LDS: decompression alone, fusion alone, or decompression and fusion—with many variations according to the clinical and imaging features. In absence of clear recommendations, the surgeon’s decision is made according to his personal experience and knowledge. The authors of this review propose an alternative method for defining an appropriate surgical procedure: the RAND appropriateness method (RAM), which combines a detailed review of the literature and a collective expert opinion. Based on the literature review, a list of potential clinical scenarios is generated, according to clinical signs and symptoms as well as many other variables (e.g., radiological) to cover all possible clinical patterns. The constructed scenarios are then assessed and rated in relation to the appropriateness of the three surgical procedures and their multiple variations. A panel of multi-disciplinary international experts is asked to rate the scenarios in two rounds, the second being a face-to-face meeting. Data from the second-round rating (appropriateness and level of agreement) are then analyzed and summarized by the authors. I recommend taking time to read this paper. The discussion raises many questions concerning spine surgery in general.
Tumors The paper by Quaraishi et al. [9] in the July issue deals with a very special category of patients presenting metastatic spinal cord compression (MSCC) related to an unknown primary tumor (UPT). The authors’ purpose was to evaluate retrospectively the proportion of such cases in their population of 285 patients operated for MSCC, to analyze all pre- and post-operative data and compare them with the category of patients presenting an MSCC due to a known primary tumor. During an 8-year study period, the incidence of MSCC of unknown origin was 6 %. The primary tumors were identified post-operatively in 10 out of 17 patients: lungs [6] and GI [4]. Comparison of the
UPT group with the larger KTP is interesting. Most patients in the two groups (88 %) improved or remained the same. The complication rate was similar as was the survival rate: 222 vs. 251 days. Based on these observations and taking into account that earlier surgical treatment (within 48 h) results in better neurological outcome [10], the authors recommend treating the UPT patients urgently to avoid aggravation of the neurological status and perform the tumor work-up post-operatively. Three studies dealing with rare benign tumors are published in the February issue. The paper by Yin et al. [11] is a retrospective study of osteoblastoma in the mobile spine. The clinical and radiological data and the surgical efficacy of 32 operated patients are reviewed. Diagnosis was supported pre-operatively by CT images, differentiating conventional osteoblastoma from aggressive osteoblastoma, and by a needle biopsy yielding osteoblastoma without further classification, which was clearly provided by postoperative histological findings. Pre-operative alkaline phosphatase levels can be a useful diagnostic help. Total surgical excision is strongly recommended by the authors. Subtotal excision plus radiotherapy (still in dispute) may lead to relapse. The paper by Si et al. [12] deals with angiolipomas, benign tumors composed of mature fatty tissue and vascular elements usually found in the subcutaneous tissue. The authors retrospectively review 21 operated cases, differentiating two types of angiolipomas according to CT and MRI images: type 1 (intraspinal) and type 2 (dumbbellshaped) expanding out of the vertebral foramen. They further sub-classify type 1A (without lipomatosis) and type 1B (with lipomatosis). These tumors are extradural and mainly located in the thoracic spine. Surgical resection is relatively easy in type 1A as opposed to type 1B with surrounding lipomatosis, not easy to fully remove. In obese patients the authors recommend a diet aiming at weight loss and reduction of lipomatosis before surgery. Epidural hemangiomas are extremely rare. The review article by Mu¨hmer et al. [13] is a retrospective study of surgical series reporting on spinal hemangiomas during a 10-year period. Thirty spinal hemangiomas comprising 6 epidural, 17 vertebral and 7 intradural were encountered in the authors’ tertiary center, while an extensive literature search identified another 32 cases. The paper is an analysis of the clinical and radiological data of the hemangiomas located in the epidural space.
Systematic reviews evaluating effectiveness of interventions in chronic low-back pain In the October issue, Michaleff et al. [14] have evaluated the effectiveness of conservative treatment used to manage
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or prevent LBP in children and adolescents. The authors identified, after screening, five articles reporting four RCTs in the intervention section, and 12 articles reporting 11 RCTs in the prevention section. The PEDro scale was used to assess the risk of bias and the GRADE criteria to assess the quality of evidence. The overall results and conclusions of this well-written paper are as follows: first, exercise interventions appear promising to treat children and adolescents, a conclusion based only on two RCTs (n = 125) comparing average pain intensity of an exercise program to no treatment. Second, a moderate quality of evidence suggests that back-related education programs are not effective in preventing LBP in children and adolescents. The authors emphasize the paucity of relevant studies in the pediatric population and the poor methodology of the RCTs. The systematic review by Ammendolia et al. [15] published in June aimed to evaluate the effectiveness of surgical and non-surgical interventions to improve walking ability in neurogenic claudication in patients with lumbar spinal stenosis. The study focuses directly on a major clinical intermediate phenotype of LSS. Eighteen RCTs with 1,220 participants were included in the review. Risk of bias was assessed using the criteria recommended by the Cochrane group; quality of evidence was evaluated using the GRADE rating. Only 5 studies were considered to have a low risk of bias; heterogeneity in the source population, interventions and outcome measures precluded pooled analysis of the comparisons. The authors of this excellent paper conclude that the current level of evidence is of low or very low quality, which precludes making any recommendations for clinical practice about the effectiveness on walking ability for any of the interventions evaluated, whether surgical or non-surgical. The authors call for highquality research, requiring standardized methods for measuring walking capacity and outcomes of treatment. It is interesting to note that a Research Task Force has been recently created by the NIH in the USA to develop standards for research in chronic low-back pain. In his editorial appearing in the October issue R. Gunzburg [44] calls attention to the importance of the Focus Article in the same issue by Deyo et al. [3], reporting on this task force. Recommendations of the Task Force include definitions, report of minimal data set, stratification of LBP by its impact (defined by pain intensity, pain interference and physical function) and reporting outcomes.
Low-back pain and Modic 1 changes Most Modic 1 changes associated with low-back pain usually remain unchanged over the months without improvement of LBP intensity [16]. It has also been shown
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that pain in patients with Modic 1 is particularly intense and increases with lumbar motion. The purpose of the case control study reported in the March issue by Bailly et al. [17] was to analyze the clinical characteristics of Modic 1-induced LBP and investigate whether these characteristics could differentiate Modic 1-induced from non-specific mechanical back pain. One hundred and twenty patients with chronic LBP and a recent lumbar MRI were studied prospectively. Sixty patients with Modic 1 were compared to 60 age- and gender-matched controls without Modic changes. Pain characteristics were collected in a questionnaire and completed by the Dallas Pain Questionnaire. A second questionnaire evaluating the physical examination was completed by a rheumatologist. Results of the statistical analysis indicate that patients with Modic 1 changes exhibit an inflammatory pain pattern more frequently than controls, consisting of night pain, worse pain at waking, and prolonged morning stiffness. This pain pattern is similar to that observed in inflammatory arthropathies. It is also in keeping with the high TNF expression in the endplates of patients with Modic 1 changes and with the presence of abundant immuno-reactive nerve fibers in the endplate. The presence of this pain pattern and of pain with lumbar extension should evoke to the clinician the presence of Modic 1 changes and guide an appropriate prognosis and therapy.
Back pain and intradural tumors The revealing symptoms of intradural tumors consist of radicular pain, exacerbated at night with or without neurological deficits. Accompanying back or neck pain, when present, is often considered as related to the degenerative lesions discovered on the imaging studies in addition to the tumor. However, there are reported cases of intradural tumors where back/neck pain is the predominant symptom. In that case, the question is: will surgical removal of the tumor improve the back or neck pain, and is it recommended to perform an additional surgery to treat the degenerative lesions? The study by Bellut et al. [18] in the April issue provides an interesting answer to this question. The authors have operated 58 consecutive patients for intradural tumors with various histopathological diagnoses. Twenty-seven of the 58 patients had back/neck pain as a leading symptom and spinal degenerative changes at the level of the tumor. Surgical ablation of the tumor was performed in the 27 patients without additional surgery on the degenerative lesions. Results were evaluated by the COMI questionnaire pre-operatively and until 24 months post-operatively, and by the Spine Tango form completed by the surgeon. Post-operative remission rate was 85 % without complications. Predominant back/neck pain, the
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pre-operative leading symptoms, disappeared in 67 % of the patients. Only two patients (7 %) required further surgery for degenerative lesions.
Decompression surgery for lumbar spinal stenosis: its effect on low-back pain The primary goal of decompression surgery in LSS patients is to eradicate/reduce leg pain and improve neurologic claudication and walking. In clinical practice, it is sometimes observed that the lower back pain component of the syndrome is also substantially improved. However, few papers have evaluated and quantified separately the effect of decompression surgery in LBP vs. leg pain. The observational study by Jones et al. [19] in the January issue deals with this subject and provides interesting information on 119 LSS-operated patients (laminectomy or laminoplasty). The outcome measures comprised Oswestry Disability Questionnaire and two VAS, separately evaluating leg and low-back pain. Outcome measures were estimated pre-operatively at 6 weeks and at 1 year. The results indicate that there is not only a significant reduction of the ODI score but also a significant decrease in mean LBP at 6 weeks, persisting at 1 year. The possible explanation of this effect is discussed in the paper, which does not evaluate the effect of surgery on claudication.
Intensive combined physical psychological program for chronic low-back pain In the January issue, Miranda et al. [20] report the results of a longitudinal study aiming to determine pre-treatment factors, which could predict a successful combined physical and psychological program outcome. In two previous studies [21, 22], the same group of authors has described the CCP program and reported clinically relevant improvement, persisting at 2 years in terms of daily functioning, disability, and quality of life. In the present study, the authors included a prospective cohort of 524 CLBP patients recruited from spine surgeons. Numerous variables were used in the questionnaire to assess the aspects of physical and psychosocial functioning, pre-treatment and at 1-year follow-up. The originality of this paper is that the primary outcome variable was measured by the Oswestry Disability Index (ODI), the main goal of the program being to reduce disability. Success at 1 year was defined as having reached 22 points or lower on the ODI score— equivalent to normal, healthy populations. At the 1-year follow-up, results showed that 41.4 % of patients reached equal or minus 22 ODI value. Mild and moderate levels of disability, and being at work at the pre-treatment
assessment were the most important predictive factors of a successful outcome. This category of patients, even those with high distress, could therefore be accepted into the program with priority.
Exercise and behavioral therapy for low-back pain in a high educational, socio-economic community The originality of the study by Steffens et al. [23] published in January is to examine the outcomes and prognostic factors of a 10-week group exercise program with cognitive behavioral therapy of high quality in a selected group of patients with high educational and socio-economic status. Patients were paying for the program and many of the adverse factors common to most LBP studies (sick leave, socio-economics, etc.) were more or less eliminated. Results of this community-based program provide a clear evaluation of an exercise program performed in a group of population with an a priori favorable prognosis. Outcomes were evaluated on a numerical painrating scale, Roland Morris Disability Questionnaire, and numerous secondary outcomes. Results were evaluated at 1 year in 112 patients, of which 73 % were women. Pain intensity improved markedly in the first 6 months (35 %) and then more slowly to 1 year (39 %). Disability improved in 48 % of participants at 6 months and continued to improve up to 1 year (60 %). Pain intensity at baseline was the only predictor of the 1-year pain score. Duration of the current episode, baseline disability and educational level were independent predictors of disability at 12 months.
Risk factors for subsequent fractures after vertebroplasty Identification of risk factors for subsequent fractures after vertebroplasty is still a subject of controversy. Rigidity of the treatment segment created by the injected cement and an eventual leakage in the adjacent disk may play a role in the case of subsequent fractures adjacent to the initial vertebroplasty. It is also well known that the history of a vertebral osteoporotic fracture is a major risk factor for subsequent fractures in osteoporotic men or women. The paper by Sun et al. [24] published in June is a retrospective study investigating the risk factors of subsequent fractures adjacent or not adjacent to the initially treated vertebral body. One hundred and seventy-five patients were followed-up 1 year after a single-level, first-time vertebroplasty. Numerous clinical, biological and radiological parameters were recorded. During the 1-year follow-up period, 37 subsequent fractures were observed.
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Interestingly, the only significant risk factors found in the statistical analysis were low BMD T score and treated vertebral levels at the thoracolumbar junction (T10–L2). The authors conclude that subsequent fractures reflect a natural evolution of osteoporosis, regardless of the presence of vertebroplasty.
results of the entire group, the heaviness of the sports bag was underestimated compared to the other two bags. These results confirm that perception of load heaviness can be influenced by subjective variables, thoroughly discussed in the article.
Post-operative meralgia paresthetica Whiplash injury The article by Hertzum-Larsen et al. [25] published in August deals with the etiology of long-lasting pain following whiplash injury. Much research has been done in this domain, providing some agreement that the syndrome is multifactorial, including biological, psychological, social and economic factors. In the present study, the authors examine whether X-ray occult fractures could be detected on SPECT after an acute whiplash injury. Abnormal SPECT is defined as a focal uptake used as an indicator of occult fractures. Following an acute whiplash injury, eighty-eight patients underwent a SPECT a few days after the accident. Thirty-two (36.4 %) had an abnormal scan, which indicates that occult fractures are not uncommon after a whiplash. At 6-month follow-up, only 49 scans could be performed of which 13 were abnormal. The study examined prospectively a hypothetical association between occult fractures with persisting neck pain, headache and arm pain. No such association was found, neither at baseline nor at 6-month follow-up. The authors conclude that the cause of the pain lies elsewhere: increased vulnerability of the victims, cultural, litigation or compensation factors.
Backpacks and school children The paper by Nicolet et al. [26] published in April is worth reading. It deals with the factors, which can influence school children’s perception of the load heaviness of school backpacks. In their introduction, the authors briefly recall the complexity of weight perception in general as well as the conflicting information concerning the weight limits of school bags for children and adolescents [27]. The aim of the present paper was to evaluate the influence of adolescents’ perception of a weight load in the presence of LBP and with the nature of the load. The procedure is clearly described. Eighty schoolboys, all aged 9–16 years, all members of a local sports club were included. During a training session, the volunteers completed a questionnaire evaluating the presence of LBP. They also estimated the weight of three bags: school bag, sports bag, and neutral bag containing two different loads (approximately 3 and 5 kg). Adolescents with a history of LBP (26.2 %) overestimated the weight of the heavier bags. When analyzing
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Injury of the lateral femoral cutaneous nerve (LFCN) has been reported following bone harvesting at the iliac crest for spinal fusion, non-union fracture, and for maxillofacial reconstruction. LFCN injury results in dysesthesia, loss of sensation and neuralgia in the lateral aspect of the thigh of difficult management. I wish to draw the attention of the readers to an interesting anatomical and radiological study aiming at identifying the local anatomical landmarks for optimal harvesting and graft dimensions. This study by Ropars et al. [28] in the May issue involves the dissection of 28 Caucasian female hemi-pelvises, identifying the nerve, anterior superior iliac spine (ASIS) and anterior iliac tubercle. CT scan analysis determined the optimum position for obtaining a 5-mm thickness graft while avoiding LFCN injury. According to their measurements, the authors recommend as an optimal location a point situated anterior to a line passing at the level of the thickest point of the anterior iliac tubercle, at a mean 67 mm from the center of the ASIS.
Dysphagia after anterior surgical surgery Difficulty in swallowing after anterior surgical surgery is a well-known complication of this procedure. The prevalence is not known and the symptoms, when present, are usually mild [29]. However, cases of severe dysphagia have been reported. The possible causes of this disorder include surgical factors such as design of the plates, intraoperative retractions or patients’ characteristics. The study by Kang et al. [30] published in the August issue evaluates a possible association with psychiatric factors: anxiety, depression. The authors have prospectively examined 72 patients operated for a cervical radiculopathy. Demographic data, SF 36, neck disability indices, neck pain and disability scale, the Zung depression scale and the Zung anxiety scale were assessed before surgery and at the final 1-year follow-up. Patients were questioned on the presence or not of dysphagia, classified in four grades, and then divided in two groups: group 1—no or mild dysphagia, and group 2—moderate or severe dysphagia. The prevalence of group 2 was 30.6 % (22 patients) and group 1 was 69.4 % (50 patients). Multivariate logistic regression showed that the presence of a psychiatric problem (ZDS
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and ZAS scores) was the only predictor of chronic dysphagia, moderate or severe. The mechanism of dyspnea/dysphagia (DD) after occipito-cervical fusion is different from that of anterior cervical surgery for radiculopathy. The paper by Izeki et al. [31] in the February issue deals with the occurrence of DD after O–C2 fusion. The authors have already shown that the cause of DD after an O–C2 fusion is the stenosis of the oropharyngeal space. In the present study, the authors emphasize the impact of the O–C2 angle between the McGregor’s line and the inferior plate of C2. Reduction of this angle per-operatively is associated with narrowing of the oropharyngeal space and with the risk of persistent dysphagia [32].
Depression and catastrophizing after lumbar spinal fusion Numerous psychosocial factors contribute to the development and persistence of LBP and affect the subjective experience of pain. Such psychological components may still be present in patients after surgical decompression and/or fusion of the lumbar spine. Fear-avoidance behaviors, catastrophizing and mood alterations are important items determining persistence of chronic pain and disability. The paper by Monticone et al. [33] in the January issue is a randomized controlled trial in which 130 patients after fusion for spondylolisthesis and stenosis were randomly assigned to either exercises and cognitive behavior therapy (CBT, n = 65) or exercises alone (n = 65). Both interventional programs are well described. The originality of the cognitive behavioral therapy is that the psychological program, consisting of 1 hour of CBT twice a week for 4 weeks, precisely targeted catastrophizing and fear of movement. Outcome measures included ODI, pain catastrophizing scale, self-reported Tampa scale for kinesiophobia, numerical rating scale for pain, and SF 36. Results showed that the program including CBT and exercises was significantly superior to exercises alone in terms of pain, disability, and quality of life. There is a good discussion and review of the literature. The paper by Wahlman et al. [34] published in the January issue provides interesting information concerning the evolution of depressive symptoms and association with disability after undergoing lumbar fusion. Data of 232 patients were extracted from a Finnish register dedicated to lumbar fusion. The prevalence of depressive symptoms was evaluated on the depression scale (DEPS), the scores of which identified two groups: those with depressive, and those without depressive symptoms. Disability was measured pre- and post-operatively on ODI. Back and leg pain were evaluated on VAS. The criteria for surgery were
persistent severe back pain and/or radicular pain. The main indications for fusions were degenerative spondylolisthesis, spinal stenosis, instability, pain after previous surgery, disk herniation and degenerative scoliosis. Results show that the prevalence of pre-operative depressive symptoms was high (34 %) and decreased after surgery (13 % at 3 months, 15 % at 1 year). In both groups, the Oswestry score decreased significantly from baseline to 1 year. However, functional disability in patients with depressive symptoms remained significantly more severe in the depressive group. The paper contains a good discussion. The main message of this study is that there is no need to exclude depressive patients from lumbar fusion when indicated, provided that appropriate screening methods and treatments of depression are performed pre- and post-operatively.
MRI evaluation of lumbar spinal stenosis Pain, disability and neurologic claudication are the clinical features involved in the decision to operate patients with central lumbar spinal stenosis (LSS). It is recognized that the clinical symptoms do not always correlate with the degree of stenosis. However, evaluation of stenosis and of its degree on MRI is a key factor for diagnosis and prognosis. How to evaluate lumbar spinal stenosis on MRI is the subject of an interesting article by Lonne et al. [35] in the June issue. The study compares two methods for assessing LSS on MRI: one measures the area on axial view (DSCA), the other, more recently described, uses a morphological grading based on the CSF visibility of the rootlets inside the dural sac [36]. Two independent radiologists classified the degree of stenosis using the two methods. Inter- and intra-observer agreements of DSCA and morphological grading were acceptable. The correlation of the two methods was strong. The authors conclude that as clinicians prefer to evaluate LSS according to their usual assessment, the new less time-consuming morphological grading can be used for decision making.
Lumbar spinal stenosis and paraspinal muscles The article by Chen et al. [37] published in the May issue is worth reading carefully as it deals with the role of the paraspinal muscles (multifidus and psoas) in the clinical performance of patients with lumbar spinal stenosis. Sixtysix LSS patients without mechanical low-back pain or instability on imaging studies were retrospectively studied. Morphologic parameters included measurements of fatty infiltration and relative cross-sectional area of the multifidus and the relative cross-sectional area of the psoas major. Severity of the stenosis was classified according to the
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cross-sectional area of the dural sac. Functional performance was evaluated according to the Japanese Orthopedic Association (JOA) score. Results of the statistical analysis indicate that the status of the paraspinal muscles has a significant effect on the clinical performance in LSS patients. Increased multifidus fatty infiltration was significantly correlated with poorer functional performance and can be used as a prognostic factor in LSS patients, the degree of stenosis being poorly related to symptom severity and functional impairment. In addition, a larger psoas cross-sectional area was significantly correlated with a higher functional performance. The discussion contains an interesting review of the pathophysiology of the paraspinal muscles in general.
group) to 60 patients with intraspinal canal compression (CS group). All patients had a complete set of imaging studies (MRI, CT, CT myelography) and underwent a nerve-root infiltration. The FS group received a decompression of the L5–S1 area associated with a transforaminal interbody fusion; the CS group received an L4–L5 decompression with or without fusion. Outcome measures included the JOA score, VAS of leg pain at rest and at walking, VAS of low-back pain, and prevalence of intermittent claudication. All measures were evaluated pre- and post-operatively. The prevalence of leg pain was significantly higher in the FS group compared to the CS group. Leg pain at rest was significantly higher in the foraminal group (6.6 ± 3.1 vs. 1.3 ± 1.9). The authors hypothesize that compression of the DRG in the foramen was the cause of this prevalence.
Age and degenerative lumbar surgery There are few studies in the literature evaluating the clinical benefit for elderly patients operated for degenerative lumbar pathologies. The study by Pe´rez-Prieto et al. [38] published in the May issue brings a valuable complement of information in this field. The paper evaluates and compares disability, quality of life and satisfaction outcomes between old and young patients operated for degenerative disorders. The study also analyzes the various diagnoses and treatments of the sample and their respective clinical outcomes after surgery. Data of 263 patients including 74 aged 65 years or more, and 189 aged below 65 years were retrospectively collected. Patients were clinically evaluated pre-operatively and at 2-year follow-up using 3 questionnaires: short-form version of SF36, Oswestry Disability Questionnaire (ODI) and the COMI to evaluate patients’ satisfaction. No differences were found between the two groups in terms of quality of life, disability and satisfaction. No differences were found in the distribution relative to pathology or treatments, listed in the paper, between the older and younger group. This study is retrospective and does not evaluate comorbidities or complications. However, the effectiveness of surgery in elderly patients is confirmed.
Leg pain in lumbar stenosis Persistence of leg pain at rest, especially at night, is well known in patients with lumbar stenosis. In the article by Yamada et al. [39] in the March issue, the authors seek to evaluate whether in a single radiculopathy (L5) leg pain at rest differs according to the site of the compression: L5–S1 foraminal stenosis and intraspinal canal stenosis. Demographic, clinical and neurological data were compared between 38 patients with foraminal compression (FS
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Recovery of severe motor deficit secondary to a disk prolapse The paper by Balaji et al. [40] published in September is a systematic review of the literature, aiming first to evaluate whether surgical intervention in patients with severe motor deficit (defined by MRC grade of 3 or less) is beneficial, and second to appreciate whether time to surgery from onset of motor deficit is an important factor of recovery. The article contains a thorough description of the literature as well as the inclusion and exclusion criteria used to select studies eligible for analysis. The flow diagram shows that out of 9,390 potential relevant publications only seven papers contained a full set of data. These include five case series, one RCT and one prospective cohort study. Results are surprising: only two of the 7 studies had a non-operative cohort. The surgical operations are variable between studies and only two of them explain the method of muscular testing. Overall, in a total of 354 patients, complete recovery was seen in 38.4 % of operated patients and 32 % of non-operated patients. Age and grade of motor deficit are significant prognostic factors in some of the studies. Because of the limitations of the studies included and because of their heterogeneity, statistical analysis was not possible. The authors conclude that the current available evidence is not robust enough to address the questions asked. They propose a framework for future studies.
Vocal cord paralysis after anterior cervical discectomy The paper by Chen et al. [41] published in March deals with the long-term evolution of vocal cord paralysis (VCP) after anterior cervical discectomy. The article is
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particularly interesting as it contains the documentation of a large number of patients operated for ACDF and followed-up at least six years by the authors. There is also an excellent review of the literature. The paper concerns a retrospective review of 1,895 patients of whom only nine developed a VCP post-operatively (0.47 %), lasting over 3 months, within the 3 years of follow-up. Four patients had more severe symptoms (dysphagia, choking), and 6 patients had recovered after 9 months. The three remaining patients had persistent symptoms even after 3 years.
Sleep apnea Obstructive sleep apnea syndrome (OSAS) is a multifactorial chronic condition related to an anatomic obstruction or partial collapse of the upper airway during sleep. OSAS generates a serious impairment of quality of life, including daytime sleepiness, decreased cognitive performance, and cardio-vascular complications. The article by Khan et al. [42] published in the March issue investigates whether disorders of the cervical spine could narrow the dimensions of the upper pharyngeal space and possibly cause an obstructive sleep apnea. The paper is a narrative review of the literature data. Only 17 articles discuss a potential relationship between OSAS and cervical spine. Overall, the analysis of the literature is based on case reports and on two studies. The authors separate single lesion from multifocal lesions. The former includes voluminous osteophytes and rare pathologies such as osteochondromas; the latter essentially includes rheumatoid arthritis and endogenous cervical fusions. The authors conclude that the cervical spine is one structure that may cause OSAS. They recommend that clinicians be aware of its possible role in the syndrome. The paper is followed by an interesting in-depth critical comment by Bartels [43]. Analyzing the two studies reported by Khan, Bartels states that the relationship between cervical spine and sleep apnea is not proven and not even suggested, with the exception of rheumatoid arthritis where the relationship seems more convincing. However, both authors agree that the role of cervical spine in sleep apnea remains an interesting and important topic and both agree on the need for future research to clarify this subject. Conflict of interest
None.
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