Cervical spine pathology and treatment: a global overview

Prescription Trends of Opioid and Nonopioid Controlled Prescription Adjunctive Analgesics Before and After Cervical Spinal Surgery: A Retrospective Cohort Study

OBJECTIVE

Cervical spine surgery may be needed in those with refractory pain or neurologic deficits to improve outcomes in patients with cervical spine disease. However, consensus varies in the literature on the effect of surgery on opioid use. The objectives of this study were to analyze prescription rates of multiple controlled substances before and after cervical spine surgery and distinguish factors that may have contributed to opioid use after surgery.

DESIGN

This is a retrospective cohort study analyzing prescription trends of various controlled substances in 632 patients who underwent cervical spine surgery from 2019 to 2021.

RESULTS

Opioids have the largest rise in prescriptions at 3- and 6-mo time points after cervical spine surgery. A significant association ( P < 0.001) was found between opioid use 1 yr before and 1 yr after cervical spine surgery. Exposure to opioids before surgery (odds ratio = 2.77, 95% confidence interval = 1.43-5.51, P = 0.003) and higher morphine milligram equivalent dose (odds ratio = 1.02, 95% confidence interval =1.01-1.04, P = 0.012) were found to be associated with opioid use after surgery. Significantly more females were prescribed controlled substances ( P = 0002).

CONCLUSIONS

Higher morphine milligram equivalent dose and opioid exposure before surgery are important factors in predicting postsurgical opioid use.

Identification of a lumped-parameter model of the intervertebral joint from experimental data

Through predictive simulations, multibody models can aid the treatment of spinal pathologies by identifying optimal surgical procedures. Critical to achieving accurate predictions is the definition of the intervertebral joint. The joint pose is often defined by virtual palpation. Intervertebral joint stiffnesses are either derived from literature, or specimen-specific stiffnesses are calculated with optimisation methods. This study tested the feasibility of an optimisation method for determining the specimen-specific stiffnesses and investigated the influence of the assigned joint pose on the subject-specific estimated stiffness. Furthermore, the influence of the joint pose and the stiffness on the accuracy of the predicted motion was investigated. A computed tomography based model of a lumbar spine segment was created. Joints were defined from virtually palpated landmarks sampled with a Latin Hypercube technique from a possible Cartesian space. An optimisation method was used to determine specimen-specific stiffnesses for 500 models. A two-factor analysis was performed by running forward dynamic simulations for ten different stiffnesses for each successfully optimised model. The optimisations calculated a large range of stiffnesses, indicating the optimised specimen-specific stiffnesses were highly sensitive to the assigned joint pose and related uncertainties. A limited number of combinations of optimised joint stiffnesses and joint poses could accurately predict the kinematics. The two-factor analysis indicated that, for the ranges explored, the joint pose definition was more important than the stiffness. To obtain kinematic prediction errors below 1 mm and 1° and suitable specimen-specific stiffnesses the precision of virtually palpated landmarks for joint definition should be better than 2.9 mm.

Biomechanical analysis of cervical spine (C2-C7) at different flexed postures

Musculoskeletal diseases are often related with postural changes in the neck region that can be caused by prolonged cervical flexion. This is one of the contributing factors. When determining the prevalence, causes, and related risks of neck discomfort, having a solid understanding of the biomechanics of the cervical spine (C1-C7) is absolutely necessary. The objective of this study is to make predictions regarding the intervertebral disc (IVD) stress values across C2-C7 IVD, the ligament stress, and the variation at 0°, 15°, 30°, 45°, and 60° of cervical neck angle using finite element analysis (FEA). In order to evaluate the mechanical properties of the cervical spine (particularly, C2-C7), this investigation makes use of computed tomography (CT) scans to develop a three-dimensional FEA model of the cervical spine. A preload of 50 N compression force was applied at the apex of the C2 vertebra, and all degrees of freedom below the C7 level were constrained. The primary objective of this investigation is to assess the distribution of von Mises stress within the IVDs and ligaments spanning C2-C7 at various flexion angles: 0°, 15°, 30°, 45°, and 60°, utilizing FEA. The outcomes derived from this analysis were subsequently compared to previously published experimental and FEA data to validate the model's ability to replicate the physiological motion of the cervical spine across different flexion angles.

Toward Shared Decision-Making in Degenerative Cervical Myelopathy: Protocol for a Mixed Methods Study

BACKGROUND

Health care decisions are a critical determinant in the evolution of chronic illness. In shared decision-making (SDM), patients and clinicians work collaboratively to reach evidence-based health decisions that align with individual circumstances, values, and preferences. This personalized approach to clinical care likely has substantial benefits in the oversight of degenerative cervical myelopathy (DCM), a type of nontraumatic spinal cord injury. Its chronicity, heterogeneous clinical presentation, complex management, and variable disease course engenders an imperative for a patient-centric approach that accounts for each patient's unique needs and priorities. Inadequate patient knowledge about the condition and an incomplete understanding of the critical decision points that arise during the course of care currently hinder the fruitful participation of health care providers and patients in SDM. This study protocol presents the rationale for deploying SDM for DCM and delineates the groundwork required to achieve this.

OBJECTIVE

The study's primary outcome is the development of a comprehensive checklist to be implemented upon diagnosis that provides patients with essential information necessary to support their informed decision-making. This is known as a core information set (CIS). The secondary outcome is the creation of a detailed process map that provides a diagrammatic representation of the global care workflows and cognitive processes involved in DCM care. Characterizing the critical decision points along a patient's journey will allow for an effective exploration of SDM tools for routine clinical practice to enhance patient-centered care and improve clinical outcomes.

METHODS

Both CISs and process maps are coproduced iteratively through a collaborative process involving the input and consensus of key stakeholders. This will be facilitated by Myelopathy.org, a global DCM charity, through its Research Objectives and Common Data Elements for Degenerative Cervical Myelopathy community. To develop the CIS, a 3-round, web-based Delphi process will be used, starting with a baseline list of information items derived from a recent scoping review of educational materials in DCM, patient interviews, and a qualitative survey of professionals. A priori criteria for achieving consensus are specified. The process map will be developed iteratively using semistructured interviews with patients and professionals and validated by key stakeholders.

RESULTS

Recruitment for the Delphi consensus study began in April 2023. The pilot-testing of process map interview participants started simultaneously, with the formulation of an initial baseline map underway.

CONCLUSIONS

This protocol marks the first attempt to provide a starting point for investigating SDM in DCM. The primary work centers on developing an educational tool for use in diagnosis to enable enhanced onward decision-making. The wider objective is to aid stakeholders in developing SDM tools by identifying critical decision junctures in DCM care. Through these approaches, we aim to provide an exhaustive launchpad for formulating SDM tools in the wider DCM community.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/46809.

Previous Emergency Department Admission Is Associated With Increased 90-Day Readmission Following Cervical Spine Surgery: Evidenced Using Propensity Score Matching

STUDY DESIGN

This was a retrospective case-control study.

OBJECTIVE

The objective of this study was to evaluate whether prior emergency department admission was associated with an increased risk for 90-day readmission following elective cervical spinal fusion.

SUMMARY OF BACKGROUND DATA

The incidence of cervical spine fusion reoperations has increased, necessitating the improvement of patient outcomes following surgery. Currently, there are no studies assessing the impact of emergency department visits before surgery on the risk of 90-day readmission following elective cervical spine surgery. This study aimed to fill this gap and identify a novel risk factor for readmission following elective cervical fusion.

METHODS

The 2016-2018 Nationwide Readmissions Database was queried for patients aged 18 years and older who underwent an elective cervical fusion. Prior emergency admissions were defined using the variable HCUP_ED in the Nationwide Readmissions Database database. Univariate analysis of patient demographic details, comorbidities, discharge disposition, and perioperative complication was evaluated using a χ 2 test followed by multivariate logistic regression.

RESULTS

In all, 2766 patients fit the inclusion criteria, and 18.62% of patients were readmitted within 90 days. Intraoperative complications, gastrointestinal complications, valvular, uncomplicated hypertension, peripheral vascular disorders, chronic obstructive pulmonary disease, cancer, and experiencing less than 3 Charlson comorbidities were identified as independent predictors of 90-day readmission. Patients with greater than 3 Charlson comorbidities (OR=0.04, 95% CI 0.01-0.12, P <0.001) and neurological complications (OR=0.29, 95% CI 0.10-0.86, P =0.026) had decreased odds for 90-day readmission. Importantly, previous emergency department visits within the calendar year before surgery were a new independent predictor of 90-day readmission (OR=9.74, 95% CI 6.86-13.83, P <0.001).

CONCLUSIONS

A positive association exists between emergency department admission history and 90-day readmission following elective cervical fusion. Screening cervical fusion patients for this history and optimizing outcomes in those patients may reduce 90-day readmission rates.

Incidence and pattern of traumatic spine injury in a single level I trauma center of southern Iran

PURPOSE

Spine injury is one of the leading causes of death and mortality worldwide. The objective of this study was to determine the incidence, pattern and outcome of trauma patients with spine injury referred to the largest trauma center in southern Iran during the last three years.

METHODS

This is a cross-sectional study conducted between 2018 and 2021 in the largest trauma center in the southern Iran. The data collection form included the age, sex, injury location (cervical, thoracic, and lumbar), canuse of injury (traffic accidents, falls, and assaults), length of hospital stay, injured segment of spine injury, severity of injury, and outcome. Statistical analyzes were performed using SPSS software version 24.

RESULTS

Totally 776 cases of spine injury were identified. The spine injury rate was 17.0%, and the mortality rate was 15.5%. Cervical spine injury (20.4%) more often occulted in motorcycle accident, and thoracic spine injury (20.1%) occulted in falls. The highest and lowest rates of spine injurys were related to lumbar spine injury (30.2%) and cervical spine injury (21.5%), respectively. There was a statistically significant relationship between the mechanism of injury and the location of spine injury (p ≤ 0.001). And patients with lumbar spine injury had the highest mortality rate (16.7%). Injury severity score (OR= 1.041, p ≤ 0.001) and length of stay (OR = 1.018, p ≤ 0.001) were strong predictors of mortality in trauma patients with spine injury.

CONCLUSION

The results of the study showed that the incidence of traumatic spine injury rate was approximately 17.0% in southern of Iran. Road traffic injury and falls are the common mechanism of injury to spine. It is important to improve the safety of roads, passages, and work environment, and increase the quality of cars. Also, paying attention to the pattern of spine injury may assist to prevent the missing diagnosis of SCI in multiple trauma patients.

Evaluating a novel, low-cost technique for cervical-spine immobilization for application in resource-limited LMICs: a non-inferiority trial

STUDY DESIGN

Non-inferiority trial.

OBJECTIVE

Limited cervical spinal (c-spine) immobilization in resource-limited settings of LMICs suggests alternatives are necessary for patients with traumatic injuries. We propose a novel method of c-spine immobilization using folded towels.

SETTING

Washington University in St. Louis.

METHODS

Using non-inferiority trial design, thirty healthy patients (median age = 22) were enrolled to test the efficacy of folded towels in comparison with rigid cervical collars, foam neck braces, and no immobilization. We measured cervical range of motion (CROM) in six cardinal directions in seated and supine positions. A weighted composite score (CS) was generated to compare immobilization methods. A preserved fraction of 75% was determined for non-inferiority, corresponding to the difference between the median values for CROM between control (no immobilization) and c-collar states.

RESULTS

C-collars reduce median CROM in six cardinal directions in seated and supine positions by an average of -36.83° seated (-17.75° supine) vs. no immobilization. Folded towels and foam neck braces reduced CROM by -27° seated (-16.75° supine) and -14.25° seated (-9.5° supine), respectively. Compared to a 25% non-inferiority margin (permitting an average 9.21° of cervical movement across six cardinal directions), the CS determined folded towels are non-inferior (CS_seated = 0.89, CS_supine = 0.47). Foam neck braces are inferior (CS_seated = 2.35, CS_supine = 2.10). CS > 1 surpassed the non-inferiority margin and were deemed inferior.

CONCLUSIONS

Folded towels are a non-inferior means of immobilizing c-spine in extension and rotation, but not flexion, vs. c-collars. We propose folded towels could be trialed in combination with backboards to deliver affordable and effective prehospital TSCI management in resource-limited settings.

The biomechanical study of cervical spine: A Finite Element Analysis

The biomechanical study helps us to understand the mechanics of the human cervical spine. A three dimensional Finite Element (FE) model for C3 to C6 level was developed using computed tomography (CT) scan data to study the mechanical behaviour of the cervical spine. A moment of 1 Nm was applied at the top of C3 vertebral end plate and all degrees of freedom of bottom end plate of C6 were constrained. The physiological motion of the cervical spine was validated using published experimental and FE analysis results. The von Mises stress distribution across the intervertebral disc was calculated along with range of motion. It was observed that the predicted results of functional spine units using FE analysis replicate the real behaviour of the cervical spine.

Mash-1 modified neural stem cells transplantation promotes neural stem cells differentiation into neurons to further improve locomotor functional recovery in spinal cord injury rats

BACKGROUND

Spinal cord injury (SCI) leads to severe motor and sensory dysfunctions. Neural stem cells (NSCs) transplantation therapy plays a positive role in functional recovery after SCI, but the effectiveness of this therapy is limited by inadequate differentiation ability of transplanted NSCs. Mammalian achaete-scute homologue-1 (Mash-1) has been reported to improve differentiation of NSCs. Thus, this study modified NSCs with Mash-1 to repair SCI.

METHODS

NSCs isolated from rat embryo hippocampus were cultured and identified in vitro and further transfected with the lentiviral vectors (Lv-Mash-1). After establishing a SCI rat model, the rats were transplanted with Mash-1 modified NSCs, the histopathological changes of rat spinal cord were detected by hematoxylin-eosin (HE) staining, and the locomotor activity of rats was evaluated with the Basso, Beattie and Bresnahan (BBB) scale. The NSCs cultured in vitro or extracted from SCI rat spinal cord were identified by immunofluorescence (IF). Mash-1, β3-Tubulin, and NeuN expressions in those cells were determined by Western blotting and reverse transcription‑quantitative polymerase chain reaction (RT‑qPCR).

RESULTS

NSCs isolated from rat embryo hippocampus were Nestin- and NeuN-positive. NSC transplantation modified by Mash-1 increased BBB score of SCI rats and promoted recovery in lesion site of SCI rats. Mash-1 overexpression also promoted β3-Tubulin and NeuN expressions in NSCs cultured in vitro or extracted from spinal cord of SCI rats.

CONCLUSION

Mash-1 overexpression promoted NSC differentiation into neurons, and further improved locomotor functional recovery of SCI rats.

The Advent of Spinoplastics: Easing the Growing Global Disease Burden of Spinal Injury

Epidemiologic studies have demonstrated a growing global disease burden of pathologies affecting the vertebral column. Allograft or implant-based reconstruction and fusion surgeries have been the mainstay of treatment. The efficacy of various surgical methods and the reliability of instrumentation or implants to execute these surgeries continue to be debated in the literature. Advances such as the free-tissue transfer have improved postoperative measures; however, they add high operative risk. The advent of spinoplastics introduces a practical surgical model to augment these spinal surgeries using vascularized bone grafts. As this technique becomes more widespread, it can be utilized to ease the growing disease burden that spinal injury places on both patients and the health care system. Ultimately, it will ameliorate strains on health care resources, reduce health care costs, and improve patient outcomes and quality of life.