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The overall frequency of troublesome neck pain is estimated to be approximately 34%, and it was observed that the frequency of complaints lasting 1 month or longer was higher in women than in men. The prevalence increased with age with regard to both pain duration and chronic pain. A total of approximately 14% of a randomly selected population meets the criteria for chronic neck pain, with complaints lasting for more than 6 months. It could be that the structural transformation of the intervertebral disc, the uncovertebral processes, and the zygapophyseal joints is a process accompanied by disturbed function, ultimately inducing pain. For diagnosis of radicular and myelopathic syndromes, the physical and neurologic examination is enhanced by neurophysiologic assessment. Electromyography, performed with needle electrodes, is the oldest method to diagnose nerve root compression syndromes and is claimed to have no false positive results. Electromyography for radiculopathy is justified if clinical symptoms, such as muscular weakness, don't correlate with clinical findings (diminished or absent reflex), or for documentation of muscle activity if difficult decompressive surgery is expected. For diagnosis of cervical myelopathy by routine examination, the sensory evoked potentials by stimulation of tibial nerve as well as motor evoked potentials from upper and lower extremities are recommended because clinically "silent" myelopathy can be verified by abnormalities in evoked potentials. During history taking, the symptoms possibly attributed to radiculopathy or myelopathy should be differentiated from primary systemic neurologic disorders such as shoulder angiotrophy ("plexus neuritis"), multiple sclerosis, amyotrophic laterals sclerosis, and peripheral neuropathy. The assessment of range of motion, the functional status of shoulder and neck muscles, and palpatory examination of soft tissue is widely used to determine non-operative therapeutic procedures. However, scientifically, the validity of the different testing procedures has not been evaluated satisfactorily.

Study Design: This study investigated the changes in the lumbar muscles after posterior fusion of the lumbar spine and the potential correlation between muscular changes and the persistence of low back pain., Objectives: To evaluate prospectively the effect of the posterior approach to the spine on the lumbar erector spinae., Summary of Background Data: The posterior approach to the spine leads to considerable alteration of the erector spinae muscles. An eventual correlation between these changes and persisting pain or other clinical symptoms has not been investigated previously., Methods: Seventy-five patients undergoing spondylosyndesis for different indications (43 patients) or a second operation for the removal of internal fixation (32 patients) were allotted to the study. In each patient, four biopsy specimens from the lumbar multifidus muscle were harvested; in 14 patients, biopsies were taken at both operations. Size and distribution of the fiber types (I, IIA, IIB, IIC) were determined, and pain scoring (visual analogue scale) and the presence of neurologic deficits were recorded., Results: At the time of the first operation, 88% of the patients showed pathologic changes (altered internal structure, atrophy, type grouping) in one or more biopsies. Statistical analysis showed a correlation between both age and pain and type II (A + B) atrophy. After surgery, the patients showed significantly more biopsies with denervation signs than before surgery. No correlation could be made, however, between the intensity of pain before or after surgery and the relative number of biopsies with signs of denervation., Conclusions: Posterior surgery causes muscular alterations; however, no correlation with pain or other clinical symptoms could be established. Therefore, in the case of unsatisfactory results after surgery of the lumbar spine, reasons other than muscle damage caused by use of the posterior approach must be considered.

Patients with lumboradicular pain syndromes with or without sensomotor symptoms and signs often present with discrepancies in clinical and neuroradiologic (magnetic resonance imaging, computed tomography, myelogram) findings that make it difficult to identify a particular nerve root responsible for the patient's complaints. However, two questions usually are discussed for patients with relative indications for surgery: 1) positive predictors for an operation: who are the good candidates for surgery?; and 2) which level or nerve root should be approached to perform minimally invasive surgery? When imaging and clinical findings are not in complete agreement, the surgeon may need additional tests to make important decisions regarding surgery. Neurophysiologic tests can provide such information. However, the surgeon's expectation cannot be satisfied fully because of unanswered questions related to sensitivity, specificity, and positive predictive value of a particular electrophysiologic study.

Study Design: Based on prospective assessment, patients with lumbar disc surgery were examined to determine reliable predictors for clinical outcome., Objectives: The prognostic value of a screening checklist developed in a previous study was evaluated in a 2-year follow-up., Summary of Background Data: Outcome studies of lumbar disc surgery document a success rate between 49-90%. It has been shown that a number of medical history data and sociodemographic and psychodiagnostic findings are of prognostic value for the outcome of lumbar spine surgery., Methods: In addition to clinical and neuroradiologic examinations, 164 patients took part in a standardized interview. Eighty-two percent participated in a follow-up performed 2 years after the operation. Preoperative findings, outcome, and prediction of three diagnostic subgroups were compared. Eighty-three (51%) patients had disc herniation only, 29 (18%) had disc herniation and other relevant back diagnoses, and 51 (31%) had no disc herniation but had other relevant back diagnoses., Results: In patients with disc herniation only, good results were observed in 53%, moderate in 19%, and bad in 28%. The accuracy of prediction of the postoperative result was 75% for the patients with good outcome and 86% for those with bad outcome. In the group of patients with diagnoses other than disc herniation, the success rate of the operation was 38% good, 28% moderate, and 41% bad, but the predictor score was not as useful as for the other groups., Conclusion: Patients with a high risk of a bad operation outcome after lumbar discectomy could be identified preoperatively. It is suggested that those patients take part in a pain management approach instead of or in addition to surgical intervention.

The aim of this study was to determine the clinical validity of functional flexion/extension radiographs of the cervical spine in a defined patient population. Sixty-four adults with functional disorders of the cervical spine underwent passive flexion/extension radiographic examinations. The radiographs were analyzed using a computer assisted method to calculate segmental motion parameters, such as rotations, translations, and centers of rotation. The patients were separated into three groups based on their specific functional disorders, and their motion parameters were compared with those of a healthy population. The three groups consisted of patients with degenerative changes, those with radicular syndrome, and those with whiplash trauma. Most of the patients displayed trends toward hypomobile segmental motion. This trend is displayed more substantially in the groups with degeneration and radicular syndrome. Hypomobility in segmental rotation was significant at C6-C7 for the degenerative and radicular groups. The trauma group showed trends toward hypermobility in the upper and middle cervical levels, and the locations of the centers of rotation were shifted in the anterior direction when compared with those of the healthy population.

A pair of functional radiographs, taken at each end of the range of motion, are used to determine spinal motions. Graphic construction and computer-assisted methods are available for the radiographic analysis. The later provides many more motion parameters. A study of lumbar spine lateral radiographs was conducted to determine errors in the motion parameters due to spinal level, radiographic quality, and errors in the two digitizing instruments. Significant differences were found in the errors due to the two digitizers when the same radiographic pair was redigitized several times. There were only minimal differences, however, between the digitizers when the radiographic films were remarked and redigitized. The error ranges (2 x SD) for the motion parameters were 1) rotation = +/- 1.25 degrees; 2) translation of the inferior posterior vertebral body corner = +/- 0.86 degrees; and 3) coordinates for the center of rotation = +/- 4.3 mm. Both the spinal level and radiographic quality affected the magnitude of errors in all motion parameters.

Fifty-one patients suffering from soft tissue injury of the cervical spine underwent clinical and psychometric examination. Clinical interview evaluated subjective complaints and formal testing of self-estimated cognitive impairment, divided attention, and speed of information processing. Results indicated at least two different syndromes: 1) the "cervicoencephalic syndrome," characterized by headache, fatigue, dizziness, poor concentration, disturbed accommodation, and impaired adaptation to light intensity; and 2) the "lower cervical spine syndrome," which is accompanied by cervical and cervicobrachial pain. When comparing patients with either of these two syndromes, those suffering from cervicoencephalic syndrome had significantly poorer results when tested for divided attention. Speed of information processing was reduced to a comparable extent in both syndromes. These findings were not related to the length of the post-traumatic interval. Reduced processing of working memory is assumed, which may account for more global cognitive problems as well as secondary neurotic reaction.

The purpose of this study was to examine the mechanical function of the C1-C2 capsular ligaments. Physiologic torques of up to 1.5 Nm were applied to human fresh cadaveric specimens (C0-C1-C2-C3) in three dimensions, and the three-dimensional motion of C1 relative to C2 was recorded. Two groups of cadaveric specimens were used to study the effect of two different sequential ligamentous transections. In the first group (n = 4), the transection of the left capsular ligament was followed by transection of the right capsular ligament. In the second group (n = 10), the transection of the left capsular ligament was preceded by transection of the left and right alar and transverse ligaments. The greatest changes in motion occurred in axial rotation to the side opposite the transection. In the first group, left capsular transections resulted in a significant increase in axial rotation range of motion to the right of 1 degree. After the right capsular ligament was transected, there was a further significant increase of 1.8 degrees to the left and 1.0 degree to the right. Lateral bending to the left also increased significantly by 1.5 degrees after both ligaments were cut. In the second group, with the nonfunctional alar and transverse ligaments, transection of the left capsular ligament resulted in greater increases in range of motion: 3.3 degrees to the right and 1.3 degrees to the left. Lateral bending to the right also increased significantly by 4.2 degrees.

The purpose of this study was to determine the clinical validity of functional flexion-extension roentgenograms of the lumbar spine in a defined patient population. One hundred and one adults with low-back pain or functional disorders underwent passive functional flexion-extension examinations. Their roentgenograms were analyzed using a computer-assisted method to determine segmental motion parameters such as rotation and translation of the lumbar vertebrae. The patient population was broken down into five groups with similar pathologies or physical conditions, and their motion parameters compared to a normal population and to each other. It was found that all of the patient groups exhibited significantly hypomobile motion, spread equally among all levels, in comparison to the normal population, except for the group of high-performance athletes, who had significant hypermobility. The uniform spread of hypomobility limits the ability to distinguish with any confidence between the four pathologic groups by their motion. Thus, we believe that the analysis of the segmental motion of the lumbar spine using passive flexion-extension roentgenograms does not aid in differentiating the underlying pathologic condition of patients with low-back pain, and that no useful information can be derived form this procedure, especially in relation to the need for surgical intervention.

Magnetic stimulation of the motor cortex, motor roots, and proximal nerve trunks was performed in 46 healthy adults and in 73 consecutive patients with disorders of the lumbar spine. In combination with neurography and F-wave recordings, the fractionated stimulation of the motor pathways allowed calculation of conduction times of the pyramidal tract fibers, of the motor roots (ie, caudal fibers), and of the motor fibers of the lumbosacral plexus. Normal values for motor conduction times to the quadriceps, anterior tibial, and extensor digitorum brevis muscles were established. Patients had clinical and radiologic diagnoses of spinal stenosis (n = 43) and nerve root compression syndromes (n = 30). Motor conduction times to lower limb muscles were significantly delayed (above mean normal value +/- 2 x SD) in 65% of the patients with spinal stenosis and 50% of the patients with nerve root compression syndromes. Conduction slowing could be localized within the motor root and caudal fiber segment of the motor pathways in 80% of the patients in whom F-waves could be recorded. This method can be used to verify, quantify, and locate lesions of the motor pathways in conditions such as compression of the spinal cord, the caudal fibers (spinal stenosis), or the motor root passing through the intervertebral canal.

Several attempts have been made to measure the segmental range of motion in the lumbar spine during flexion-extension with the purpose of gathering additional data for the diagnosis of instability. The previous studies were performed in vitro or in vivo during active motion. The aim of this study was to obtain normal values of passively performed segmental motions. Forty-one healthy adults were examined by means of functional radiographs during flexion-extension and lateral bending. A graphic construction method and a computer-assisted method were used to measure rotations. Comparing with recent in vivo studies, the values obtained for normal angles of rotation were predominately larger. This might be due to the passive examination used in the study. The graphic construction method and computer-assisted method techniques are equally reliable, but the computer-assisted method method yields other important kinematic data, such as translations. It is proposed that passive motion be applied during functional examination of patients with suspected instabilities. However, the large variation of rotational values between individuals in the normal population may limit the clinical usefulness of functional lumbar analysis using this parameter. Future studies should explore the clinical relevance of determining altered segmental mobility in low-back pain patients.

Care must be exercised in interpreting the clinical and radiologic findings when assessing patients with cervical spondylosis and involvement of neural structures for surgery. If the clinical picture cannot logically be explained by the radiologic findings, further investigation is indicated to exclude a coexistent disorder. Investigations may include electrophysiologic tests, transcranial magnetic stimulation, cerebrospinal fluid (CSF) analysis, and magnetic resonance imaging (MRI). Only then can the indication for surgical intervention be properly determined.

Measurements of motor-evoked potentials by means of fractionated magnetic stimulation of motor pathways to the upper limbs was performed as part of the clinical assessment in 268 patients with cervical spine disorders. Seventy-two percent of the 127 patients with degenerative changes of the cervical spine, 67% of the 55 patients with rheumatoid arthritis (RA), and 57% of the 51 patients with trauma of the cervical spine showed a pathologic delay of central motor latency (CML). The data suggest that this method has a high sensitivity and therefore is recommended in the diagnosis of cervical spine disorders in patients with suspected compression of neural structures.

Painless transcranial magnetic stimulation has been performed on 53 healthy adults in order to obtain normal values of central motor pathway conduction times to cervical segments innervating upper limb muscles. Central motor latency was 5.1 msec when recording from the biceps brachii and 5.2 msec when recording from the abductor pollicis brevis or abductor digiti minimi muscles. The plexus motor latency as the conduction time between the cervical motor root and the proximal nerve trunks in the axillary region was 2.2 msec and 2.6 msec when recorded from the abductor pollicis brevis and abductor digiti minimi muscles, respectively. Conduction times higher than mean latency + 2 standard deviation may indicate a pathologic conduction slowing. Magnetic stimulation of the motor system is a new painless neurophysiologic technique enabling examination of the central motor pathways in awake subjects. With respect to spinal cord diagnostics, this method is useful in conditions such as compression of the spinal cord or of the motor root in the intervertebral foramen or canal.

Study Design: Retrospective cohort study., Objective: The objective of this study is to determine differences in outcomes in patients with adolescent idiopathic scoliosis undergoing spinal deformity correction surgery using a posterior spinal fusion (PSF) approach versus single and triple-incision minimally invasive surgery (MIS)., Summary of Background Data: MIS increased in popularity as surgeons' focus moved towards soft tissue preservation, but it carries technical demands and increased surgical time compared with PSF., Patients and Methods: Surgeries performed from 2016 to 2020 were included. Cohorts were formed based on surgical approach: PSF versus single long-incision MIS (SLIM) versus traditional MIS [3-incision MIS (3MIS)]. There were a total of 7 subanalyses. Demographic, radiographic, and perioperative data were collected for the 3 groups. Kruskal-Wallis and χ 2 tests were used for continuous and categorical variables, respectively., Results: Five hundred thirty-two patients met our inclusion criteria, 294 PSF, 179 3MIS, and 59 SLIM.Estimated blood loss (mL) ( P < 0.00001) and length of stay (LOS) ( P < 0.00001) was significantly higher in PSF than in SLIM and 3MIS. Surgical time was significantly higher in 3MIS than in PSF and SLIM ( P = 0.0012).Patients who underwent PSF had significantly lower postoperative T5 to T12 kyphosis ( P < 0.00001) and percentage kyphosis change ( P < 0.00001). Morphine equivalence was significantly higher in the PSF group during total hospital stay ( P = 0.0042).Patients who underwent SLIM and 3MIS were more likely to return to noncontact ( P = 0.0096) and contact sports ( P = 0.0095) within 6 months and reported lower pain scores ( P < 0.001) at 6 months postoperation., Conclusion: SLIM has a similar operative time to PSF and is technically similar to PSF while maintaining the surgical and postoperative outcome advantages of 3MIS., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: Retrospective review of prospective case-control study., Objective: To compare minimally invasive scoliosis surgery (MIS) and posterior spinal fusion (PSF) in a large group of patients., Summary of Background Data: MIS, has been shown to have benefits over standard PSF in adolescent idiopathic scoliosis (AIS)., Methods: Radiographic, clinical, and operative review of a multi-institutional prospective database from 2013 to 2018. MIS patients with minimum 2-year XR follow up were compared with open PSF technique patients., Results: Four hundred eighty five patients were included; 192 MIS and 293 PSF. Preoperative Cobb (P = 0.231) and kyphosis were similar (P = 0.501). Cobb correction was comparable (P = 0.46), however percent improvement in thoracic kyphosis was significantly higher in MIS (P < 0.001). MIS had significantly lower blood loss (P < 0.001), transfusions (P < 0.001), fixation points (P < 0.001), opioid consumption (P = 0.001), and hospital stay (P < 0.001). Operative time was shorter (P = 0.001) and 30-day complications rate was similar (P = 0.81)., Conclusion: This is the largest study comparing the surgical outcomes of MIS and PSF. MIS patients benefit from increased kyphosis, fewer transfusion, lower opioid consumption, and shorter hospital stay with similar Cobb correction. Increased postoperative kyphosis is likely from muscle sparing dissection in MIS.Level of Evidence: 3., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: Kinematics of the cervical spine was investigated using cone beam computed tomography (CBCT) images combined with three dimensions to three dimensions (3D-3D) registration technology in patients after anterior odontoid screw fixation (AOSF) surgery., Objective: The aim of this study was to investigate in vivo 3D cervical motion characteristics of patients who had undergone AOSF surgeries., Summary of Background Data: AOSF surgery is a classic surgical method for the treatment of odontoid fracture, but there are few studies that investigated its effect on in vivo biomechanics of the cervical spine. Postoperative biomechanical characters of the atlantoaxial joint (C1-C2) and the caudal adjacent segment (C2-C3) have yet to be clarified., Methods: The study involved 14 patients subjected to a procedure of AOSF with lag screw. Subjects were matched with 14 healthy controls. All subjects underwent CBCT scanning of the cervical spine under seven functional positions. A 3D-3D registration was performed for each vertebra at each functional position to calculate the segmental motion characteristics. The ranges of motion (ROMs) of the C1-C2, C2-C3, and the overall cervical spine (C1-C7) for each of the functional positions were determined., Results: The ROMs of the AOSF group were significantly (P < 0.05) smaller than the control group in flexion-extension positions for the C1-C2 (7.0°vs.11.0°), C2-C3 (3.7°vs.6.7°) and C1-C7 (43.3°vs.54.4°). The twisting ROM of the C1-C2 was 39.3° in the AOSF group and 65.7° in the control (P < 0.05), the bending ROM of the C2-C3 was 2.8° in the AOSF group and 8.9° in the control (P < 0.05). The twisting ROM of C1-C7 segment was 63.2° for the AOSF and 98.1° for the healthy control groups (P < 0.05)., Conclusion: Although AOSF surgery reduced the flexion-extension ROMs of all investigated spinal segments, additionally, it reduced twisting ROMs of C1-C2 and C1-C7, but only lateral bending ROM of C2-C3, when compared with the control group. The data implied that the AOSF surgery would result in different biomechanics changes in the atlantoaxial segment and caudal adjacent segment. Longer-term follow-up studies of larger patient cohorts are necessary to evaluate the clinical outcomes of patients after the AOSF surgery.Level of Evidence: 3., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Study Design: Cross-sectional case-control study., Objective: To compare isolated lumbar extension strength between healthy asymptomatic participants and participants with chronic low back pain (CLBP), while controlling for previous lumbar spine surgery., Summary of Background Data: Deconditioning of the lumbar musculature is common in those with previous lumbar surgery, resulting in decreased strength and endurance. Evidence is required to support whether this is the case for participants with CLBP yet no previous surgery compared with asymptomatic participants., Methods: Forty-two healthy (25 males and 17 females) asymptomatic participants, and 53 participants with non-specific CLBP (30 males and 23 females) aged between 19 and 76 years were recruited. Maximal isometric isolated lumbar extension (ILEX) strength was examined., Results: A Mann-Whitney U test indicated that ILEX strength was significantly greater in the asymptomatic group compared with the CLBP group (Z = 1441.00, P = 0.014). Post-hoc effect size was calculated to be d = 0.56, showing a moderate effect., Conclusion: These results indicate that ILEX weakness and lumbar extensor deconditioning is present independent of surgery and may be a factor involved in CLBP. As such, lumbar extensor deconditioning would appear to be a reasonable target for interventions in CLBP., Level of Evidence: 3.