Cervical Disorders Research Articles

P67. Effects cognitive behavioral therapy on cervical spine surgery: results of a randomized controlled trial

BACKGROUND CONTEXT Recent studies have suggested that for patients with chronic neck pain, both psychological and physical symptoms need to be addressed. Studies have shown that psychological distress is associated with poor outcomes in these patients. The fear avoidance model has been used to explain how maladaptive thoughts and behaviors contribute to chronicity and disability. Cognitive behavioral therapy (CBT) addresses these risk factors through education about pain, modification of maladaptive beliefs, and increasing patient's self-efficacy. PURPOSE Determine the effectiveness of brief psychological intervention on psychological outcomes in cervical spine surgery. STUDY DESIGN/SETTING Prospective, blind, and placebo-controlled trial. PATIENT SAMPLE A total of 42 symptomatic Cervical Degenerative Disorders patients. OUTCOME MEASURES Distress and Risk Assessment Method (DRAM), Fear Avoidance Beliefs Questionnaire (FABQ), Pain Catastrophizing Scale (PCS), Outcome Expectation Question (OEQ). Neck Disability Index (NDI), modified Japanese Orthopedic Association (mJOA). METHODS Forty-two patients age >18 with symptomatic cervical degenerative disease have been enrolled in the study. If patients met psychological distress criteria, they were in the treatment group: DRAM >17 and 49/66, PCS >30/52 or OEQ ≤2 (randomized to CBT or Placebo). CBT and Placebo treatment groups had 6 sessions prior to surgery. The control group had no intervention prior to surgery. Baseline and 1-year (1Y) changes were assessed for all outcome measures. RESULTS Forty-two patients were enrolled (53.6 years, BMI 29.4 kg/m2); 23 patients met psychological distress criteria and were randomized into a treatment group (14 CBT vs 9 placebo). Ten patients were in the control group, with nine exceeding DRAM scores to be CBT candidates. At enrollment, the CBT group had greater EQ5D scores (CBT: 10.8, Placebo: 9.5, Control: 7.5, DRAM:8.7) while the Placebo group had greater PCS scores (Placebo: 33.1, CBT: 32.4, Control:18.6, DRAM: 30.8; all p CONCLUSIONS Cognitive behavior treatment can be beneficial in patients undergoing cervical surgery as it was identified in our study to minimize fear avoidance beliefs more than the Placebo group. This type of professional treatment has also shown a steady improvement in all psychological questionnaires and spine related neck disability from baseline to 1-year postoperatively. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Comparative study of anterior cervical discectomy and fusion by anterior cervical plate and stand-alone cervical cage

<p class="abstract"><strong>Background:</strong> Anterior cervical discectomy (ACD) was used for management of degenerative cervical disc disorders (DCDD) in previous days. Further research and developments in management of DCDD led to evolution of standard and widely used operative technique as anterior cervical discectomy and fusion (ACDF) by either anterior cervical plate (ACDF-ACP) with bone grafting or stand-alone cage (ACDF-SAC). There is less data available in literature regarding when and where to use ACDF-ACP and ACDF-SAC.</p><p class="abstract"><strong>Methods:</strong> The study was conducted on 20 patients operated in Government Medical College and Hospital and Pacific Hospital and Research Centre, Aurangabad from June 2018 to March 2020. These patients divided into group A - 10 patients, operated by ACDF-SAC which are further divided as group Aa - 6 patients - operated for single level ACDF-SAC and group Ab - 4 patients - operated for two level ACDF-SAC, group B - 10 patients, operated by ACDF-ACP which are further divided as group Ba - 5 patients - operated for single level ACDF-ACP and group Bb - 5 patients - operated for two level ACDF-ACP. Patients evaluated preoperatively and postoperatively using X-ray cervical spine anteroposterior (AP) and lateral views, MRI cervical spine, visual analogue scale (VAS) for pain, Robinson’s criteria and Cobb’s angle.<strong></strong></p><p class="abstract"><strong>Results:</strong> In our study we found, ACDF-SAC has small incision size, less intraoperative time, easy to carry out for surgeons, less intraoperative complications and better clinical outcome as compared to ACDF-ACP. Whereas only radiological results were better in ACDF-ACP than ACDF-SAC.</p><p class="abstract"><strong>Conclusions:</strong> ACDF-SAC is superior to ACDF-ACP for appropriately selected patients and in well experienced hands.</p>

Surgical Interventions for Cervical Radiculopathy without Myelopathy: A Systematic Review and Meta-Analysis.

The effectiveness of surgical interventions for cervical degenerative disorders has been investigated in multiple systematic reviews. Differences in study population (e.g., patients with myelopathy and/or radiculopathy) were often neglected. Therefore, the objective of this study was to investigate the effectiveness of surgical interventions for patients with symptoms of cervical radiculopathy without myelopathy by conducting a systematic review and meta-analysis based on randomized controlled trials (RCTs). A comprehensive systematic search was conducted in MEDLINE, Embase, and CENTRAL (Cochrane Central Register of Controlled Trials) to identify RCTs that investigated the effectiveness of surgical interventions using an anterior or posterior approach compared with other interventions for patients with pure cervical radiculopathy. Outcomes were success rates (Odom criteria, similar rating scales, or percentage of patients who improved), complication and reoperation rates, work status, disability (Neck Disability Index), and pain (arm and neck). The Cochrane risk-of-bias tool was used to assess the likelihood of the risk of bias. A random-effects model was used. Heterogeneity among study results (I2 ≥ 50% or p < 0.05) was explored by conducting subgroup analyses. Funnel plots were used to assess the likelihood of publication bias. A total of 21 RCTs were included, comprising 1,567 patients. For all outcomes, among all surgical techniques, only 1 pooled estimate showed a significant effect on success rate, which was in favor of anterior cervical discectomy with fusion compared with anterior cervical discectomy without an intervertebral spacer (p = 0.02; risk ratio [RR] = 0.87; 95% confidence interval [CI] = 0.77 to 0.98). Complication rates were higher when autologous bone graft from the iliac crest was used as an intervertebral spacer (p < 0.01; RR = 3.40; 95% CI = 1.56 to 7.43), related to donor-site morbidity. This meta-analysis demonstrated consistent results regarding clinical outcome for pure cervical radiculopathy among all studied interventions. Complication and reoperation rates were also similar, with the exception of higher complication rates in patients in whom autologous bone grafts were used. On the basis of clinical outcome and safety, there is no superior surgical intervention for pure cervical radiculopathy. Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Apolipoprotein E (APOE) genotype-associated disease risks: a phenome-wide, registry-based, case-control study utilising the UK Biobank.

BackgroundThe three main alleles of the APOE gene (ε4, ε3 and ε2) carry differential risks for conditions including Alzheimer's disease (AD) and cardiovascular disease. Due to their clinical significance, we explored disease associations of the APOE genotypes using a hypothesis-free, data-driven, phenome-wide association study (PheWAS) approach.MethodsWe used data from the UK Biobank to screen for associations between APOE genotypes and over 950 disease outcomes using genotype ε3ε3 as a reference. Data was restricted to 337,484 white British participants (aged 37–73 years).FindingsAfter correction for multiple testing, PheWAS analyses identified associations with 37 outcomes, representing 18 distinct diseases. As expected, ε3ε4 and ε4ε4 genotypes associated with increased odds of AD (p ≤ 7.6 × 10−46), hypercholesterolaemia (p ≤ 7.1 × 10−17) and ischaemic heart disease (p ≤ 2.3 × 10−4), while ε2ε3 provided protection for the latter two conditions (p ≤ 3.7 × 10−10) compared to ε3ε3. In contrast, ε4-associated disease protection was seen against obesity, chronic airway obstruction, type 2 diabetes, gallbladder disease, and liver disease (all p ≤ 5.2 × 10−4) while ε2ε2 homozygosity increased risks of peripheral vascular disease, thromboembolism, arterial aneurysm, peptic ulcer, cervical disorders, and hallux valgus (all p ≤ 6.1 × 10−4). Sensitivity analyses using brain neuroimaging, blood biochemistry, anthropometric, and spirometric biomarkers supported the PheWAS findings on APOE associations with respective disease outcomes.InterpretationPheWAS confirms strong associations between APOE and AD, hypercholesterolaemia, and ischaemic heart disease, and suggests potential ε4-associated disease protection and harmful effects of the ε2ε2 genotype, for several conditions.FundingNational Health and Medical Research Council of Australia.

Recent trends in medicare utilization and reimbursement for anterior cervical discectomy and fusion

Anterior cervical discectomy and fusion (ACDF) has been considered the gold standard for treating various cervical spine pathologies stemming from cervical degenerative disorders. While cervical artificial disc replacement has emerged as an alternative in select cases, ACDF still remains a commonly performed procedure. This study seeks to define the costs of ACDF and identify trends and variations in ACDF volume, utilization, and surgeon and hospital reimbursement rates. Retrospective analysis of patients undergoing ACDF PATIENT SAMPLE: Medicare patients undergoing ACDF between 2012 and 2017 OUTCOME MEASURES: ACDF volume, utilization rates, and surgeon/hospital reimbursement rates METHODS: This study tracked annual Medicare claims and payments to ACDF surgeons using publicly-available databases and aggregated data at the county level. Descriptive statistics and multivariate regression models were used to evaluate trends in procedure volume, utilization rates (per 10,000 Medicare beneficiaries), and reimbursement rates, and to examine associations between county-specific variables (ie, urban or rural, average household income, poverty rate, percent Medicare population, race/ethnicity demographics), and ACDF utilization and reimbursement rates. A total of 264,673 ACDF surgeries were performed in the Medicare population from 2012 to 2017, with a 24.2% increase in annual procedure volume. Utilization also increased by 6.5% from 8.0 surgeries per 10,000 Medicare beneficiaries in 2012 to 8.5 in 2017. Hospital reimbursements for cervical spine fusion surgeries without complications or co-morbidities experienced nominal and inflation-adjusted increases of 9.5% and 0.7%, respectively, from $12,030.11 in 2012 to $13,167.64 in 2017. Surgeon reimbursements for single-level and multilevel ACDF each nominally decreased from $958.11 and $1,173.01, respectively, in 2012 to $950.34 and $1,138.41 in 2017 (a 0.8% and 2.9% decrease, respectively), but after adjusting for inflation, reimbursements per case fell by an average of 8.7% and 10.7%, respectively. In contrast, mean reimbursements per case for hospitals rose by 7.1% (1.5% inflation-adjusted decrease). A significant upward yearly trend in ambulatory surgical centers volume, resulted in a net increase of 184.5% between 2015 and 2017 (p<.001). While ACDF volume and utilization has continued to increase since 2012, Medicare payments to hospitals and surgeons have struggled to keep up with inflation. Our study confirms that Medicare reimbursement per case continues to decrease at a disproportionate rate for surgeons, compared to hospitals. The increasing trend in procedures performed at ambulatory surgical centers shows promise for a future model of cost-efficient and value-based care.

Effectiveness of Nerve Blocks for the Management of Head and Neck Cancer Associated Neuropathic Pain Disorders; a Retrospective Study.

A portion of patients with head and neck cancer (HNC)- associated pain may not experience relief in symptoms with non-invasive modalities. A nerve block is a procedure in which a local anaesthetic agent is injected along the nerve track to preferentially block sensory transmission. The literature on the effectiveness of nerve blocks in the management of HNC-related pain is limited. The purpose of this study was to determine the effectiveness of nerve blocks in the management of breakthrough HNC-associated trigeminal or cervical neuropathic pain disorders. A retrospective chart review of patients who underwent a nerve block or infiltration procedure in the regions of head and neck for the management of breakthrough HNC-associated trigeminal or cervical neuropathic pain disorders in the Orofacial Pain Medicine Clinic, Shaukat Khanum Memorial Cancer Hospital and Research Centre, between November 2018 and November 2019 was completed. Information regarding demographics, diagnosis and pain characteristics was extracted and reviewed. The Fisher's exact test and Mann-Whitney U-test were used for analysis between independent and dependent variables. A total of 27 participants were included in the investigation, of which 66.7% were male. The average pre-procedure pain score was 6.85±2.54. Following intervention, 81.5% of the participants experienced >75% relief in pain for longer than 48 hours. The mean immediate post-procedure pain score was 0.26±1.02 and the average duration of relief was 6.10±6.50 weeks. The significant effect of nerve blocks was found to be statistically associated with the concurrent use of amitriptyline (P = 0.017). Nerve blocks, as an adjunctive therapy to pharmacologic treatment, can provide significant relief to patients with breakthrough HNC-associated trigeminal and cervical neuropathic pain disorders. However, the duration of relief experienced by the participants is inconsistent. The beneficial effect of nerve blocks appears to be more common in patients that were concurrently using amitriptyline.

Does Obesity Correlate with Postoperative Complications After Elective Posterior Cervical Spine Fusion?

With the increasing prevalence of obesity, there is a need to understand the impact of body mass index (BMI) on spine surgery outcomes. Previous literature has reported the influence of obesity in thoracolumbar surgery; however, the impact of obesity on postoperative complications after posterior cervical fusion (PCF) is unknown. Consecutive patients who underwent cervical laminectomy and multi-level instrumented fusion for degenerative spinal conditions at an academic tertiary care hospital between 2012 and 2019 were evaluated. Patients were categorized into groups with a BMI ≥30.0 kg/m2. The modified Japanese Orthopedic Association (mJOA) score, Nurick grading, complications, and postoperative radiographic factors were analyzed. Correlations between postoperative outcomes and obesity were calculated at baseline and 1 year. A total of 275 patients were included, with 80 obese (29.1%) and 195 nonobese (70.9%) patients. At baseline, obesity was associated with worse myelopathy (mJOA score: 10.2 vs. 13.1, P = 0.04 and Nurick grading: 3.2 vs. 1.1, P = 0.05) and abnormal cervical radiographic alignment (C2-7 sagittal vertical axis: 43.9 vs. 38.1 mm, P = 0.04). The intraoperative estimated blood loss was higher among obese patients (561.1 vs. 391.2 mL, P < 0.001). There was no significant difference in absolute scores for neurologic outcomes and radiographic alignment at 12 months after surgery. However, obese patients had significantly more complications than nonobese patients in terms of mechanical failure (6.3% vs. 0.5%, P = 0.05) and wound infection (8.7% vs. 0.0%, P = 0.04). Our results corroborate that PCF surgery provides significant improvement in neurologic and radiographic outcomes at 12 months after surgery for degenerative cervical spinal disorders. Obesity is a factor to consider in the pre-operative risk assessment.

The Effect of SNAGs and Biofeedback Training on the Integrative Propriocepcion and Function of the Patients with Cervical Disorder

The Effect of SNAGs and Biofeedback Training on the Integrative Propriocepcion and Function of the Patients with Cervical Disorder

A Case Report on Mild Left Para-Central Bulge of Intervertebral Disc- C4/5 and C5/6 with Mild Narrowing of Left Intervertebral Foramen Inducing Severe Neck Pain and Ipsilateral Symptoms

Cervical disc bulge or other cervical spine diseases often results into neck and arm pain in patients formulating an etiology of direct impingement of nerve roots and associated inflammatory process. The clinical presentation also corresponds with the ipsilateral symptoms associated with the cervical disorder as depicted in the patient. A 33 year’s old South Indian male is diagnosed with Para-central bulge at the level of C4/5 and C5/C6-Intervertebral disc presented to the physical therapy with neck pain radiating into left sided upper and lower extremity pain. A magnetic resonance imaging revealed mild Para central bulge of C4/5 and C5/6-Intervertebral disc with mild narrowing of the left intervertebral foramen. Results from MRI scan show the alignment and the morphology of the vertebrae to be normal. Also, the CSF displays normal intensity in all sequences. The patient reported to physical therapy for cervical pain and Radiculopathy. After evaluation he was asked to continue with regular home exercise programme like cervical lateral flexion stretch, unilateral wall stretch which resulted to reduce the cervical pain and shows improvement in its subsequent symptoms. Key words: Cervical bulge, Intervertebral disc C4/5 and C5/6, Ipsilateral symptoms, Radiculopathy, Medical Respresntative, Severe Neck Pain.

Anterior cervical discectomy and fusion in young adults leads to favorable outcome in long-term follow-up

Background ContextAnterior cervical discectomy and fusion (ACDF) procedures is thought to lead to accelerated degeneration of the adjacent cervical discs and in some cases can be symptomatic (adjacent segment disease, or ASD). The occurrence of ASD is of particular interest when treating young individuals, as the cumulative disease burden may become increasingly significant during their expectedly long lifetime. However, the overall impact of a surgical intervention on the lifetime prognosis of ASD remains unclear. PurposeOur goal was to study the long-term outcomes of ACDF surgery among those members of the young adult population who have been operated on between the ages of 18 and 40. Study DesignRetrospective study. Patient SampleAll patients between 18 and 40 years of age at the time of surgery who underwent ACDF due to degenerative cervical disorders at Helsinki University Hospital between the years of 1990 and 2005 (476 patients). Outcome MeasuresCervical reoperation rate, satisfaction with the surgery, employment status, Neck Disability Index (NDI). MethodsWe retrospectively analyzed the medical records of all patients between 18 and 40 years of age at the time of surgery who underwent ACDF due to degenerative cervical disorders at Helsinki University Hospital between the years of 1990 and 2005. We sent questionnaires to all available patients at the end of the follow-up (median 17.5 years) to assess their current neck symptoms, general situations, and levels of satisfaction with the surgery. Furthermore, we compared the results for different types of ACDF surgeries (ie, discectomy only vs. synthetic cage or bone autograft implantation for fusion) in propensity-score-matched groups. ResultsOf the 476 patients who were included in the study, surgery was performed in 72% of the cases due to intervertebral disc herniation and in 28% due to spondylotic changes. The total reoperation rate during the entire follow-up (median 17.5 years) was 24%, and 19.5% if early reoperations (<28 days from index surgery) were excluded. At 10 years postsurgery, the total reoperation rate was 16.8% and 12.8% with early reoperations excluded. The probability of surgery for adjacent level disease was 10.3% at 10 years and 16.8% for the duration of the entire follow-up, with the annual incidence rate of 1.1% for those with ASD requiring surgery. Statistically significant risk factors leading to the need for further cervical surgery included central spinal cord compression and smoking at the time of the index operation. After propensity score matching, there was no significant difference found between the outcomes of different types of surgery. A total of 443 patients were still able to be contacted 12–28 years after the surgery. Of the 281 patients responding to the questionnaires, 92% were still satisfied with the results. With respect to employment, 67% of patients were working, 7% were unemployed, and 7% were on disability due to cervical problems. The median NDI score was 12%, with 56% of patients having an NDI score lower than 15%; it has been suggested that this latter NDI score serves as a cut-off value for significant neck morbidity. The NDI scores were significantly higher among female patients, patients with spondylosis, and patients having undergone further cervical surgeries during the follow-up. ConclusionsLong-term satisfaction with the surgery was very high, and the employment rate among patients resembled that of the general population in Finland. Thus, the long-term prognosis after having ACDF surgery at a younger age seems to be good, even though nearly half of the patients experienced some persistent neck symptoms later in life.

The role of the styloid apophysis of the temporal bone in the biomechanics of the tongue, mandible, hyoid system: a case study.

Temporomandibular disorders are characterized by ear pain, tinnitus, difficulty in chewing, dysphagia and dizziness, cervical limitation of range of movement (ROM) and other less common disorders. Numerous recent studies associate the presence of these signs and symptoms with an elongated styloid apophysis, as in the case of Eagle syndrome. The purpose of this clinical case is to support the thesis of a common syndrome that temporomandibular joint (TMJ) disorders with an elongated styloid process affirming the relationship between temporal bone, mandible, hyoid bone and tongue. The patient was a 57-year-old woman who reported having ear algia and tinnitus all on the right side with difficulty chewing accompanied by odynophagia and dysphagia of solid and liquid foods, as well as cervical disorders. Computed tomography (CT) scans of the neck showed elongation and ossification of the styloid processes of the temporal bone. Magnetic resonance imaging (MRI) showed an anterior right dislocation of the TMJ articular disc. The patient presented classic symptoms of temporomandibular disorders, with the primary examinations showing an anterior right dislocation of the articular disc of the TMJ, as well as a longer styloid process on the same side. We therefore suggested that, in this case report, TMJ disorders might be associated with a longer styloid process on the same side.

Degenerative Cervical Disorder-Stand-alone Cage Versus Cage and Cervical Plate: A Systematic Review.

Study Design:Systematic review.Objectives:The objective of this study was to compare clinical and radiological outcomes following discectomy and anterior cervical fusion for the treatment of cervical degenerative disorder performed with stand-alone cages and anterior cervical plates.Methods:Electronic searches were performed in the MEDLINE, LILACS, and Cochrane Systematic Reviews databases, according to PRISMA guidelines, with no language or date restriction. The review was registered in PROSPERO under number CRD42018109180.Results:Six randomized clinical trials were selected, which evaluated at least one of the objectives of this work, such as pain control, bone consolidation, neurological symptoms, and cervical lordosis, thus satisfying the inclusion criteria. Articles that did not directly compare the 2 surgical techniques were excluded. A total of 309 patients were included and the results showed no significant difference in clinical (visual analogue scale and neck disability index) or radiological (cervical lordosis and fusion) outcome between the 2 groups. The operative time was shorter in the group with stand-alone cages (mean difference = −18.40; 95% CI = [−24.89, −11.92]; P < .66).Conclusion:The stand-alone cages and anterior cervical plate techniques have similar clinical and radiological outcomes. Despite the significantly shorter operative time for one group, other randomized clinical trials are needed to establish conclusive evidence in favor of one of the comparative treatments.

Clinical Aspects of Cervicogenic Headache

Cervicogenic headache (CEH) is a lateralized non-pulsative headache syndrome caused by cervical spine disorders. The headache is initiated in the neck, which subsequently spreads to the occipital, frontal, and orbital regions, and is accompanied by ipsilateral shoulder pain. The prevalence of CEH is considered to be 15-20% among cases of chronic headache. With regard to the mechanism of CEH, convergence of upper cervical nerves and trigeminocervical complex might play an important role. However, CEH in many patients has been reported to be associated with middle to lower cervical disorders, which cannot be explained by this theory. We therefore proposed the possibility that the condition reported here is another type of CEH. The treatment of CEH requires a multidisciplinary approach, because pharmacological treatment is often ineffective. (Received August 16 2019; Accepted November 25, 2019; Published March 1, 2020).

Physical rehabilitation therapy and research of lipid spectrum in students with vertebro-basilar disease within

The purpose of the work was to study the effect of physical therapy on the course of vertebrobasilar syndrome in adolescents. Materials and methods. In the complex of physical therapy, methods of therapeutic exercises, treatment, massage, traction-manual therapy, and electrophysiotherapeutic procedures were used. The tissues lipid spectrum study was carried out according to the modified Folch method and permits to obtain the largest amount of lipids from the tissues. Results . The therapeutic effect of physical therapy was manifested not only in the normalization of lipid metabolism, but in reducing the severity of the main clinical disease manifestations, which makes expedient the use of this therapy. Conclusions . Correction of the cervical spine vertebral disorders by means of physical therapy leads to the elimination of extravascular compression signs and the restoration of lipid metabolism.

The engaged patient: patient activation can predict satisfaction with surgical treatment of lumbar and cervical spine disorders.

Care satisfaction is an important metric to health systems and payers. Patient activation is a hierarchical construct following 4 stages: 1) having a belief that taking an active role in their care is important, 2) having knowledge and skills to manage their condition, 3) having the confidence to make necessary behavioral changes, and 4) having an ability to maintain those changes in times of stress. The authors hypothesized that patients with a high level of activation, measured using the Patient Activation Measure (PAM), will be more engaged in their care and, therefore, will be more likely to be satisfied with the results of their surgical treatment. Using a prospectively collected registry at a multiprovider university practice, the authors examined patients who underwent elective surgery (n = 257) for cervical or lumbar spinal disorders. Patients were assessed before and after surgery (6 weeks and 3, 6, and 12 months) using Patient-Reported Outcomes Measurement Information System (PROMIS) health domains and the PAM. Satisfaction was assessed using the Patient Satisfaction Index. Using repeated-measures logistic regression, the authors compared the likelihood of being satisfied across stages of patient activation after adjusting for baseline characteristics (i.e., age, sex, race, education, income, and marital status). While a majority of patients endorsed the highest level of activation (56%), 51 (20%) endorsed the lower two stages (neither believing that taking an active role was important nor having the knowledge and skills to manage their condition). Preoperative patient activation was weakly correlated (r ≤ 0.2) with PROMIS health domains. The most activated patients were 3 times more likely to be satisfied with their treatment at 1 year (OR 3.23, 95% CI 1.8-5.8). Similarly, patients in the second-highest stage of activation also demonstrated significantly greater odds of being satisfied (OR 2.8, 95% CI 1.5-5.3). Patients who are more engaged in their healthcare prior to elective spine surgery are significantly more likely to be satisfied with their postoperative outcome. Clinicians may want to implement previously proven techniques to increase patient activation in order to improve patient satisfaction following elective spine surgery.

The Necessity of Upper Extremity Neurologic Examination while Evaluating Breast Pain

Introduction: Breast pain is one of the most frequent complaints and occurs in 45–69% of all women. Cervical disc herniation is a common cause of cervical radiculopathy with an incidence rate of 18.6 per 100,000, and it should be considered as a cause of breast pain. Objective: To identify the extent to which upper extremity neurologic findings and cervical root disorders accompany breast pain. Methods: We prospectively collected clinical features of patients with breast pain. An upper extremity neurologic examination was performed in patients and controls. Patients who had neurologic findings underwent cervical spine magnetic resonance imaging (MRI) to identify cervical root disorders. Results: Out of the 554 participants, 233 had breast pain, and 321 were controls. Women with breast pain had more numbness (116 [49.8%] vs. 104 [32.4%], p < 0.001) and more dysesthesia (36 [15.5%] vs. 17 [5.3%], p < 0.001) than the controls, but they had similar upper extremity weakness (10 [4.3%] vs. 14 [4.4%], p > 0.05). The number of women with one neurologic finding was significantly greater in the group with breast pain (119 [51.1%] vs. 111 [34.6%], p < 0.001). Ninety (16.2%) patients underwent a cervical vertebra MRI, which showed that 86 (95.6%) patients had cervical root disorders including 21 (23.3%) cases of bulging, 9 (10%) of annular tear, and 56 (62.2%) of central disc protrusion; 4 (4.4%) patients had normal findings. The multivariate logistic regression analysis revealed that age was the only significant predictor of neurologic findings in patients with breast pain (p < 0.05, OR: 1.02, CI: 1.002–1.053). Conclusions: Cervical root disorders should be considered as a cause of extramammary breast pain.

Cervical muscle diseases are associated with indefinite and various symptoms in the whole body.

Patients with various and indefinite symptoms in the whole body occasionally have coincident with stiffness or tenderness of the cervical muscles. This prospective case series examined the effect of local modulation of the cervical muscles in patients with cervical disorders reporting indefinite whole-body symptoms. A total of 1863 hospitalized patients with cervical disorders accompanying three or more indefinite whole-body symptoms, who were resistant to outpatient care, were enrolled in this study for 12years. All patients underwent daily physical therapies to the cervical muscles during hospitalization. Self-rated records on the medical interview sheets documenting 30 representative symptoms including cervical/shoulder pain or stiffness and 28 representative indefinite whole-body symptoms at admission and discharge were compared across the population. The number of symptoms decreased significantly with the local modulation of the cervical muscles during hospitalization. All of the 28 indefinite whole-body symptoms at admission showed recovery rates greater than 50% at discharge. The mean number of symptoms decreased significantly from 17.8 at admission to 7.4 at discharge (p < 0.0001). The percentages of patients reporting 10 or more symptoms were 91.1% and 29.3% at admission and discharge, respectively. Moreover, 8.2% of patients reported no residual symptoms at discharge. Cervical muscle lesions may contribute to indefinite whole-body symptoms, possibly through dysfunction of the parasympathetic nervous system in the muscles. Local modulation of cervical muscles could lead to a breakthrough in the management of patients with indefinite whole-body symptoms. UMIN000035445. These slides can be retrieved under Electronic Supplementary Material.

Diaphragmatic dysfunction in dogs with cervical spinal disorders before and after surgery using fluoroscopy, motion-mode ultrasound and radiography was not different than a group of control dogs.

Cervical spinal disorders can lead to life-threatening respiratory complications. Diaphragmatic dysfunction is attributed to spinal cord morbidity secondary to cervical myelopathy or decompressive surgical intervention. The purpose of this observational case-control study was to determine the frequency of diaphragmatic dysfunction in dogs with cervical spinal disorders and a control group, the strength of association between cervical myelopathies and decompressive surgery with diaphragm paresis, and the agreement between and clinical usefulness of fluoroscopy, motion-mode ultrasonography, and radiography for diagnosing diaphragmatic dysfunction. Thirty-five client-owned dogs were recruited with 14 control dogs and 21 test dogs. Dogs were evaluated for the presence of diaphragmatic dysfunction using radiography, M-mode ultrasonography, and fluoroscopy before and after an anesthetic or surgical event. Diaphragmatic dysfunction was observed more frequently in dogs with cervical spinal disease prior to surgery (8/21; 38.1%) compared to control dogs (3/14; 21.4%) but was not statistically significant (P=.30). The occurrence of diaphragmatic dysfunction did not significantly increase following surgical decompression in either group. There was no to slight agreement between all imaging modalities. Most dogs with diaphragmatic dysfunction were asymptomatic. Diaphragmatic dysfunction was not statistically associated with cervical myelopathy or decompressive surgery. Ultrasonography and radiography were not useful diagnostic tests for determining diaphragmatic dysfunction in asymptomatic dogs when compared to fluoroscopy.

Эффективность элиминации вируса папилломы человека при лечении патологии шейки матки

Study Objective: To assess the efficacy of antiviral medications, using the apoptotic markers caspase-3 and caspase-9, in the treatment of cervical disorders accompanied by papillomavirus infection. Study Design: This was a prospective study. Materials and Methods: One hundred and seventy women with a positive human papillomavirus (HPV) test, aged 18 to 45, participated in the study. Group I consisted of 60 women with histologically confirmed cervical leukoplakia; Group II was made up of 55 patients with cervical intraepithelial neoplasia (CIN) I; and Group III comprised 55 women with CIN II. The control group consisted of 40 healthy women. All participants underwent a standard examination and had measurements taken for levels of caspase-1, caspase-3, and caspase-9, which were used to assess changes in their apoptotic programs. During the study, the patients with HPV were divided into subgroups. In the cervical leukoplakia group, 34 women (subgroup Ia) were only monitored and 26 women (subgroup Ib) received antiviral treatment. Similarly, in the CIN I group, 27 patients (subgroup IIa) were only monitored and 28 women (subgroup IIb) received antiviral drugs. In the CIN II group, all patients underwent excision of their lesions. According to the study design, 28 women who had undergone excision had monitoring alone (subgroup IIIa) and for 27 participants the surgical treatment was combined with an antiviral medication (subgroup IIIb). The efficacy of the treatment regimens was assessed three and six later by cytology and colposcopy data and levels of caspase-3 and caspase-9. Treatment efficacy was assessed chiefly by the presence or absence of HPV or reduction in viral load below significant levels. Study Results: After three and six months, viral load reduction in all subgroups of women who received antiviral treatment was greater and more of these women had a negative HPV test (after three and six months the overall efficacy was 11.7% vs. 30.7% and 20.5% vs. 42.3% in subgroups Ia and Ib, respectively; 7.4% vs. 21.4% and 22.2% vs. 35.7% in subgroups IIa and IIb, respectively; and 75% vs. 85.2% and 64.2% vs. 92.6% in subgroups IIIa and IIIb, respectively). Caspase-3 and caspase-9 levels decreased in both the subgroups that had monitoring alone and the subgroups that received combination treatment, but in the latter case they were closer to the control group’s levels. Correlation analysis revealed a strong direct relationship between clinically significant viral load and caspase-3 levels (rху = 0.79) and a moderate direct relationship between caspase-9 levels and high viral load (rху = 0.58). Conclusion: The proposed comprehensive approach, including antiviral therapy, to the treatment of HPV-associated cervical disorders such as leukoplakia, CIN I and CIN II, has higher clinical efficacy than monitoring over time alone or only the excision of lesions (in patients with CIN II). This is because of its effects on the system of natural killers and stimulation of the ability of cytotoxic lymphocytes to identify and destroy defective cells. Keywords: human papillomavirus, apoptosis, caspases, dysplasia, leukoplakia.

From incidence to strategy: a systematic review in playing-related musculoskeletal disorders

The intense performance and repetitive movements for a long period of time contribute to the developing of musculoskeletal disorders in instrumental musicians. This study aims to identify the major musculoskeletal disorders in the practice of the musical instrument and reflect on strategies to be used in the music teaching and learning process to reduce the risk factors for future musculoskeletal disorders. A systematic review of English and non-English articles using PubMed, Web of Science, and Scopus from 2015-2019. Additional studies were identified by searching abstracts presented at Medical Problems of Performing Artists (2015-2019) and Psychology of Music (2015-2019). Search terms included a combination of the keyword's musculoskeletal disorders, instrumental musicians, and music (n=187). From the systematic analysis pain, disabilities of the arm, shoulder, hand, neck, back and shoulders and temporomandibular, cervical muscle disorders and postural asymmetries are the major musculoskeletal disorders in the practice of the musical instrument. It is important to define preventive strategies to prevent and reduce the development of PRMDs in practitioners and performers.