The objective of this study is to evaluate the effect of anterior cervical discectomy and fusion (ACDF) on the motion of the cervical spine and dynamic stress (tendency to kyphosis) on adjacent segments and on the overall spinal alignment which may predispose to symptomatic disc diseases at other levels. Twenty consecutive patients underwent ACDF with a mean follow-up of 28 months (range 13-38). Preoperative and postoperative clinical assessments were done by using the neck disability index (NDI) and the Japanese Orthopedic Association (JOA) score. In all cases, at the last follow-up control, a neuro-radiographic assessment [cervical spine static and dynamic X-ray and magnetic resonance imaging (MRI)] was done. The angle of the operated disc space, the disc space angle of contiguous segments, and their range of motion (ROM) and the kyphotic Cobb angle (C2-7) were measured by computer software. The study was done at Sant'Andrea Hospital, Rome, Italy in the period from November 2003 to November 2005. We observed that: the mean Cobb angle improved significantly (p < 0.001) from 3.4 degrees (kyphosis) to postoperative 14.5 degrees. This normalization of angle showed a direct effect on improvement of myelopathic patients, but it had a statistically nonsignificant effect on adjacent segments degeneration (ASD). The mean segmental ROM of adjacent segments did not show significant instability. The mean was 11.1 degrees at upper and 10.2 degrees at lower levels (close to normal). In six cases, the ROM was higher than normal: five of these patients demonstrated symptomatic adjacent segment pathology. Postoperative improvement of mean JOA and NDI scores was statistically significant (p < 0.001). Anyway, symptomatic ASD was observed in five patients (20%): in four of them, the higher disc spaces and in one, the lower disc spaces were involved. In four cases, the preoperative MRI showed slight and asymptomatic disc degeneration at the same levels involved subsequently. This ASD was significantly related to the increased ROM at the segments involved. Follow-up X-rays showed solid fusion with absence of movement in all but one case (at 13-month follow-up), who showed slight movement in the operated level in spite of clinical improvement. The follow-up MRI showed, in all cases, good decompression in the treated levels. Compensatory increase in ROM of the contiguous motion segments in patients subjected to ACDF may lead to ASD especially in those cases with asymptomatic adjacent subclinical degenerative disease. If these preliminary results will be confirmed by larger series, it could be reasonable in young selected patients with soft disc herniation to adopt total disc arthroplasty instead of fusion after cervical micro-discectomy.

Object Areas of intramedullary signal intensity changes (hypointensity on T1-weighted magnetic resonance [MR] images and hyperintensity on T2-weighted MR images) in patients with cervical spondylotic myelopathy (CSM) have been described by several investigators. The role of postoperative evolution of these alterations is still not well known. Methods A total of 47 patients underwent MR imaging before and at the end of the surgical procedure (intraoperative MR imaging [iMRI]) for cervical spine decompression and fusion using an anterior approach. Imaging was performed with a 1.5-tesla scanner integrated with the operative room (BrainSuite). Patients were followed clinically and evaluated using the Japanese Orthopaedic Association (JOA) and Nurick scales and also underwent MR imaging 3 and 6 months after surgery. Results Preoperative MR imaging showed an alteration (from the normal) of the intramedullary signal in 37 (78.7%) of 47 cases. In 23 cases, signal changes were altered on both T1- and T2-weighted images, and in 14 cases only on T2-weighted images. In 12 (52.2%) of the 23 cases, regression of hyperintensity on T2-weighted imaging was observed postoperatively. In 4 (17.4%) of these 23 cases, regression of hyperintensity was observed during the iMRI at the end of surgery. Residual compression on postoperative iMRI was not detected in any patients. A nonsignificant correlation was observed between postoperative expansion of the transverse diameter of the spinal cord at the level of maximal compression and the postoperative JOA score and Nurick grade. A statistically significant correlation was observed between the surgical result and the length of a patient's clinical history. A significant correlation was also observed according to the preoperative presence of intramedullary signal alteration. The best results were found in patients without spinal cord changes of signal, acceptable results were observed in the presence of changes on T2-weighted imaging only, and the worst results were observed in patients with spinal cord signal changes on both T1- and T2-weighted imaging. Finally, a statistically significant correlation was observed between patients with postoperative spinal cord signal change regression and better outcomes. Conclusions Intramedullary spinal cord changes in signal intensity in patients with CSM can be reversible (hyperintensity on T2-weighted imaging) or nonreversible (hypointensity on T1-weighted imaging). The regression of areas of hyperintensity on T2-weighted imaging is associated with a better prognosis, whereas the T1-weighted hypointensity is an expression of irreversible damage and, therefore, the worst prognosis. The preliminary experience with this patient series appears to exclude a relationship between the time of signal intensity recovery and outcome of CSM.

Cyst excision is an effective and safe technique for symptomatic sacral perineural (Tarlov) cysts. Careful patient selection is vital to the management and treatment of this difficult and controversial pathology.

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Cervical spine tuberculosis is a rare infectious disease that is not yet discussed well regarding the optimal method of its management. This is a prospective study of a total of 29 patients with cervical spine tuberculosis with a mean follow-up of 14 months (range, 10-21); they were classified randomly into two groups: group I, patients who underwent anterior cervical decompression and fixation and followed by the anti-tuberculous medications (16 patients) and group II, patients who had conservative anti-tuberculous medications only without surgical intervention (13 patients). All patients had complete clinical assessments using Nurick scale and the modified Japanese Orthopaedic Association score for myelopathy and the visual analogue scale for assessment of cervical pain. We had also neuro-radiographic assessment (cervical spine X-ray and MRI) at the first presentation and at 3, 6, and 12 months later. At final follow-up, significant neurological improvement was demonstrated in both management approaches, more obvious in the surgical group. Cervical pain showed a statistically significant improvement (P < 0.05) in surgical group rather than in conservatively treated group. In the surgical group, the mean Cobb angle showed a significant change from a preoperative mean of -3.1 ± 1.6° to postoperative mean of 16.6 ± 5.4°, significantly correlated to the improvement of cervical pain (P = 0.004), while it was changed from a mean of -0.8 ± 2.2 to a mean of 9.2 ± 3.8 1 year after starting of medical treatment in group II. In spite of the conservative trend in the management of Pott's disease, surgical management of cervical spine myelopathy secondary to cervical tuberculosis could be the optimal treatment even in an early stage of the disease.

Epidural application of morphine-vaseline sterile-oil compound after lumbar microdiscectomy proved to be safe and effective, improving postoperative pain control and return to function. At clinical and neuroradiological follow-up epidural fibrosis was acceptable. To confirm the efficacy of the compound, large prospective studies are warranted.

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Background Data: After anterior cervical discectomy; the effect of cervical fusion or cervical arthroplasty on the dynamics of adjacent segments and the overall cervical spine has a direct impact on the final clinical outcome Purpose: To compare the effect of the cervical fusion (ACDF) versus arthroplasty after anterior cervical discectomy on the cervical dynamics, this can predispose to adjacent segment diseases at those levels. Study Design: A comparative retrospective study between two groups; cervical arthroplasty group, and the cervical fusion group. Patients and Methods: A total of 36 consecutive patients underwent anterior cervical discectomy with a mean follow-up of 24 months. Patients were classified into two groups; Group I (20 patients) were operated for (ACDF), Group II (16 patients) were operated for anterior cervical discectomy and prosthesis (arthroplasty). Preoperative and postoperative clinical assessments were done by using the Neck Disability Index (NDI) and the Japanese Orthopedic Association (JOA) score for myelopathy patients. In all patients, at final follow-up, a neuro-radiographic assessment (cervical spine static and dynamic x-ray and MRI) was done. The angle of the operated disc level, the angle of above and below adjacent segments and their range of motion (ROM), and global cervical curve Cobb angle (C2-7) were measured. Results: In group I; the mean angle of the global cervical curve improved from 3.4° preoperative (kyphosis) to 14.5°postoperative (P<0.001), where in group II, angle improved from 4.6° to 16.5° (P=0.6). The mean segmental ROM of adjacent segments didn't show significant instability. The mean ROM at upper adjacent levels was 11.1°, and at the lower adjacent levels was 10.2° (normally up to 10 degrees). In group II, however, the mean angle of ROM was 7.8° at upper adjacent levels and 9.6° at lower adjacent levels. Postoperative improvement of JOA and NDI scores was statistically significant (P<0.001) in group-I (JOA improved from14.3±1.25 to 16.6±0.9, and NDI improved from 21.1±5.8 to 7.63±4.9), where in group-II JOA improved from 15.7±1.2 to 16.2±1.1 and NDI improved from 19±2.1 to 16±8.7. Symptomatic ASD was observed in 5 patients (20%) in group I and in none of group II patients Conclusion: Compensatory increase in ROM of the contiguous adjacent segments in patients subjected to ACDF may lead to ASD especially in those with asymptomatic adjacent sub-clinical degenerative disease. In contrary, arthroplasty reduce the incidence of adjacent segment diseases. (2017ESJ147)