To Örebro University

Cervical radiculopathy is the most frequent condition of the cervical spine. Operative treatment is a commonly performed when nonsurgical treatment fails. The main cause of cervical radiculopathy is degenerative disease of the spine, leading to foraminal stenosis and ultimately a nerve-root impingement. Often patients ask about the heredity of their condition, but no clear answers can be given. The controversy is in the choice of operative treatment, conducting either Anterior Cervical Decompression and Fusion (ACDF) or Posterior Foraminotomy (PF). Both methods have been around since the late 1950’s but despite this, evidence is still lacking to confirm superiority of either method. The objective of this thesis is to ascertain the outcomes of ACDF and PF as well as the hereditary factors for requiring surgery. We used the Swespine registry to ascertain the clinical outcomes of surgery for CR, subsequently, by using pseudo-randomization we evaluated the patient reported outcomes and reoperation rates between ACDF and PF. Our results revealed that both methods have equal clinical outcomes at 1,2- and 5-years of follow-up. We showed higher reoperation rate for PF than ACDF at index level. Subsequently, we could move forward in creating a multicentre randomized controlled trial with ACDF as control, and PF as intervention with a non-inferiority design. A study protocol was designed using the reporting guidelines for clinical trials and published. Thus, Örebro Multicentre Study on Operative Treatment of Cervical Radiculopathy: Anterior Cervical Decompression and Fusion Versus Posterior Foraminotomy (OMSAP) was born and the study started in 2020. Interim analysis after 5-years of recruiting concludes higher reoperation rates for PF and statistically non-significant outcomes in favour of ACDF, no severe adverse events have been found in the analysis. Finally, we used the Swespine registry and the Twin registry to ascertain the hereditary factors for the surgical phenotype by examining the operation rates in 145 twins for cervical degenerative diseases. We conclude that the probability for hereditary factor for surgically treated diseases is low.

PURPOSE: Genetic factors are considered important in the development of degenerative spine disease. The aim of this study was to determine the twin concordance rates for the common cervical spine diseases cervical disk herniation (CDH), cervical foraminal stenosis (CFS), and degenerative cervical myelopathy (DCM) requiring surgical treatment by studying monozygotic (MZ) and dizygotic (DZ) twin pairs.

METHODS: Patients, aged 18-85 years, operated for CDH, CFS, or DCM between 1996 and 2022 were identified in the national Swedish spine register (5962 CDH, 3801 CFS, and 3131 DCM) and matched with the Swedish twin registry to identify MZ and DZ twins. Concordance rates were calculated.

RESULTS: There were 64 twin pairs where one or both twins had surgical treatment for CDH. The corresponding numbers for surgically treated CFS and DCM were 37 twin pairs and 44 twin pairs respectively. For twins with CDH we found one concordant MZ pair and no concordant DZ pair (MZ probandwise concordance rate 0.12 [95% CI 0-0.33]). For twins with CFS we found one concordant MZ pair and no concordant DZ pair (MZ probandwise concordance rate 0.14 [95% CI 0-0.38]). In DCM patients we found no concordant twin pair.

CONCLUSIONS: In this national observational study, including 145 twin pairs, the concordance rates were low for surgically treated CDH, CFS, and DCM conditions. Our findings suggest that not only genetic factors, but also environmental factors and personal preferences are important whether a patient goes to surgery for this type of condition.

Study Design: Case series with surgical technical note.

Objectives: This article reports experiences and results of muscle-preserving temporary C0-C2 fixation for the treatment of atlanto-occipital dislocation (AOD).

Methods: AOD is a rare injury caused by high-energy trauma, occurring in less than 1% of pediatric trauma patients. Recommended treatment is C0-C2 fusion which, however, will result in significant loss of mobility in the craniocervical junction (CCJ), especially C1-C2 rotation. An alternative approach, with the ability of preserving mobility in the C1-C2 segment, is a temporary fixation that allows the ligaments to heal, after which the implants can be removed to regain function in the CCJ joints. By using a muscle-preserving approach and navigation for the C2 screws, a relatively atraumatic fixation of the CCJ can be achieved with motion recovery after implant removal.

Results: We present two cases of AOD treated with temporary fixation. A 12-year-old boy involved in a frontal car collision, as a strapped back seat passenger, was treated with temporary C0-C2 fixation for 10 months. Follow-up at 11 months after implant removal included clinical evaluation, computed tomography, magnetic resonance imaging (MRI), and flexion-extension X-rays. He was free of symptoms at follow-up. The CCJ was radiographically stable and he had 45 degrees of C1-C2 rotation. A 7-year-old girl was hit by a car as she got off a bus. She was treated with temporary fixation for 4 months after which the implant was removed. Follow-up at 8 years included clinical evaluation and MRI in rotation. She was free of symptoms. The ligaments of the CCJ appeared normal and her C1-C2 rotation was 30 degrees.

Conclusion: C0-C2 fixation without fusion allows the CCJ ligaments to heal in pediatric AOD. By removing the implants after ligament healing, rotation in the C1-C2 segment can be regained without subsequent instability. Both our patients tolerated the treatment well and were free of symptoms at follow-up. By using minimally invasive muscle-preserving technique and navigation, temporary fixation of the CCJ can be achieved with minimal damage to the soft tissues allowing recovery of almost normal function after implant removal.

Background: A 25-year-old patient was treated for post-traumatic neck pain with intradiscal injections at the C3-4 and C4-5 levels using radiopaque gelified ethanol. After the injections, the axial neck pain increased. Laboratory infection parameters were normal despite the progressive disc destruction observed on CT scans at both index levels. The patient underwent debridement and anterior cervical discectomy and fusion. Staphylococcus epi-dermidis and Cutibacterium acnes grew in all the intraoperative cultures. The patient was subsequently treated with Rifampicin and Moxifloxacin and after 3 months no signs of infection were observed. CT scan showed solid fusion of the at the index segments 7 months postoperatively.

Conclusion: Infections after intradiscal injections are rare and we believe this is the first case describing iatrogenic spondylodiscitis after DiscoGel injection. When increased axial neck pain is experienced after injection with DiscoGel, post-operative spondylodiscitis should be suspected. Even if laboratory parameters are normal, examinations with MRI and CT should be performed and if these studies show signs of infection, surgical revision should be conducted.

STUDY DESIGN: Register study with prospectively collected data.

OBJECTIVE: The aim was to investigate reoperation rates at the index level and the adjacent levels after surgery for lumbar L3-4 spinal stenosis with concomitant degenerative spondylolisthesis (DS).

SUMMARY OF BACKGROUND DATA: There are different opinions on how to surgically address lumbar spinal stenosis with DS. The potential benefit of fusion surgery should be weighed against the risks of future reoperations because of adjacent segment degeneration. Data on the reoperation rate at adjacent segments after single level L3-4 fusion surgery are limited.

MATERIALS AND METHODS: A total of 372 patients, who underwent surgery for lumbar L3-4 spinal stenosis with DS (slip >3 mm) between 2007 and 2012, were followed between 2007 and 2017 to identify reoperations at the index level and adjacent levels. The reoperation rate for decompression and fusion was compared with the reoperation rate for decompression only. Patient-reported outcome measures before and 1 year after surgery were evaluated.

RESULTS: The reoperation rate at the index level (L3-4) was 3.5% for decompression and fusion and 5.6% for decompression only. At the cranial adjacent level (L2-3), the corresponding numbers were 6.6% and 4.2%, respectively, and the caudal adjacent level (L4-5), the corresponding numbers were 3.1% and 4.9%, respectively. The effect sizes of change were larger for decompression and fusion compared with decompression only. The effect sizes of change were similar for leg pain and back pain.

CONCLUSIONS: We could not identify any differences in reoperation rates at the cranial or caudal adjacent segment after decompression and fusion compared with decompression only for L3-4 spinal stenosis with DS. The improvement in back pain is similar to the improvement in leg pain after surgery for L3-4 spinal stenosis with DS.

BACKGROUND: Cervical radiculopathy is the most common disease in the cervical spine, affecting patients around 50-55 year of age. An operative treatment is common clinical praxis when non-operative treatment fails. The controversy is in the choice of operative treatment, conducting either anterior cervical decompression and fusion or posterior foraminotomy. The study objective is to evaluate short- and long-term outcome of anterior cervical decompression and fusion (ACDF) and posterior foraminotomy (PF)

METHODS: A multicenter prospective randomized controlled trial with 1:1 randomization, ACDF vs. PF including 110 patients. The primary aim is to evaluate if PF is non-inferior to ACDF using a non-inferiority design with ACDF as "active control." The neck disability index (NDI) is the primary outcome measure, and duration of follow-up is 2 years.

DISCUSSION: Due to absence of high level of evidence, the authors believe that a RCT will improve the evidence for using the different surgical treatments for cervical radiculopathy and strengthen current surgical treatment recommendation.

TRIAL REGISTRATION: ClinicalTrials.gov NCT04177849. Registered on November 26, 2019.

Background and purpose: There are different opinions on how to surgically address lumbar spinal stenosis with concomitant degenerative spondylolisthesis (DS). We investigated reoperation rates at the index and adjacent levels after L4-5 fusion surgery in a large cohort of unselected patients registered in Swespine, the national Swedish spine register.

Patients and methods: 6,532 patients, who underwent surgery for L4-5 spinal stenosis with or without DS between 2007 and 2012, were followed up to 2017 to identify reoperations at the index and adjacent levels. The reoperation rates for decompression and fusion were compared with the reoperation rates for decompression only and for patients with or without DS. Patient-reported outcome data were collected preoperatively, and at 1 and 2 years after surgery and used to evaluate differences in outcome between index operations and reoperations.

Results: For spinal stenosis with DS, the reoperation rate at the index level was 3.0% for decompression and fusion and 6.0% for decompression only. At the adjacent level, the corresponding numbers were 9.7% and 4.2% respectively. For spinal stenosis without DS, the reoperation rate at the index level was 3.7% for decompression and fusion and 6.2% after decompression only. At the adjacent level, the corresponding numbers were 8.1% and 3.8% respectively. For the reoperations at the adjacent level, there was no difference in patient-reported outcome between extended fusion or decompression only.

Interpretation: Single-level lumbar fusion surgery is associated with an increased rate of reoperations at the adjacent level compared with decompression only. When reoperations at the index level are included there is no difference in reoperation rates between fusion and decompression only.

Brugada Syndrome (BrS) is a genetic condition associated with ventricular fibrillation and sudden cardiac death. In BrS, several pharmacological agents may increase the risk for arrhythmia and total intravenous anesthesia with propofol (TIVA) may be contraindicated due to the increased risk of perioperative cardiac arrest. Anesthesia with halogenated volatile agents has to be used instead, making monitoring of sensory and motor evoked potentials in spine surgery problematic. Furthermore, hyperthermia may induce ventricular arrhythmia in BrS, thus making temperature control of paramount importance. The purpose of this paper is to describe the particular challenges of anesthesia and intraoperative neuromonitoring associated with corrective spinal surgery in an adolescent girl with BrS. We present an analysis of a multidisciplinary approach to performing corrective spine surgery in an otherwise healthy 14-year-old girl with scoliosis. Before surgery, multidisciplinary meetings were conducted, including anesthesia and intensive care, pediatric cardiology as well as the spine team. The surgery was performed with inhalation anesthesia using sevoflurane and cardiac monitoring. Continuous somatosensory potentials were monitored as well as motor evoked potentials. The patient underwent corrective surgery from Th3 to L2. With a multidisciplinary team approach involving anesthesia and cardiology outlining the appropriate precautions, scoliosis correction with intraoperative neuromonitoring, can be safely performed in patients with BrS using inhalation anesthesia.

BACKGROUND: Acute bilateral vocal fold paralysis is a life-threatening complication that can occur during spinal surgery but has almost exclusively occurred with anterior approaches. Bilateral vocal fold paralysis after posterior spinal surgery has been exceedingly rare.

CASE DESCRIPTION: We present a case of acute postoperative dyspnea due to vocal fold paralysis requiring intubation and surgical intervention after posterior spinal correction for the treatment of dropped head syndrome. The patient had had a previous diagnosis of atypical Parkinson disease but was later diagnosed with multiple system atrophy.

CONCLUSIONS: We suggest that multiple system atrophy can result in an increased risk of bilateral vocal fold paralysis during surgical intervention of dropped head syndrome. Thus, our report could be of interest for those who perform spinal surgery in patients with neurological conditions.