European Spine Journal Research Articles

The Michel Benoist and Robert Mulholland yearly European Spine Journal Review: a survey of the “surgical and research” articles in the European Spine Journal, 2010

The Michel Benoist and Robert Mulholland yearly European Spine Journal Review: a survey of the “surgical and research” articles in the European Spine Journal, 2010

The Michel Benoist and Robert Mulholland yearly European Spine Journal Review: a survey of the “medical” articles in the European Spine Journal, 2010

From the wealth of information provided in the European Spine Journal in 2010, I have tried to extract the most “medically oriented” papers. As usual, there are fewer “medical” than “surgical” articles. During my selection, I realized that the distinction between surgical and non-surgical papers was an arbitrary one. Articles dealing with pure surgical techniques are obviously of little interest to the medical readers, yet the numerous non-surgical spinal specialists must be aware of the development of new surgical procedures. Confirmation with the passage of time of the validity of less recent surgical therapies, with their risk of complications, is also essential to a proper counseling of the patient. It is equally important for the spinal surgeon, who is frequently the first-line consultant, to have a clear estimation of the therapeutic value of the various conservative treatment modalities. In addition, care of patients with spinal diseases often calls for a multi-disciplinary approach. This emphasizes the need for all of us to be informed of the progress of basic research, and of the ever-evolving technologies, such as, for example imaging and electrophysiological techniques. I therefore invite the reader to have a look at both reviews, medical and surgical. He may well find that the same papers have occasionally been reviewed by both Bob Mulholland and myself.

Education program of EuroSpine/The Spine Society of Europe

Dear Reader, Dear member and friend of EuroSpine, the Spine Society of Europe (SSE), In the name of the European Spine Journal, the official journal of the EuroSpine, the Spine Society of Europe, and the associated national and specialist spine societies, I recommend to you and your residents, fellows and co-workers to attend the below announced educational events Fig. 1. Fig. 1 European education plan for spine specialists These programs have been developed by the Educational Committee of EuroSpine in close consultation with national societies and have been implemented by the EuroSpine Foundation. They represent a landmark in the efforts to offer independent educational programs on the way to a spine specialist recognition in Europe. Only through a broad support from the European Spinal Community we will reach this goal.

The Michel Benoist and Robert Mulholland yearly European Spine Journal Review: a survey of the “surgical and research” articles in the European Spine Journal, 2009

This has been an exciting year in the Journal with some important innovations. Reporting single interesting cases has always been popular with readers though not with editors, often considered to have too little science, and too much anecdote. The series of Grand Rounds published this year [13, 21, 41] meet these criticisms, and whilst improving the readers diagnostic and management skills, have an attractive immediacy about them, and are well worth reading. The Editorial by Aebi [1] emphasises the educational and teaching value of what in the UK we often refer to as “bedside teaching” of which Grand Rounds is an example, hallowed by many years of use in medical training. The other two innovations, the creation of a Chinese Section Editorial Board [2] and the translation and publication of papers in the Italian literature during the year, both expand in a valuable way the range of intellectual content in the Journal. The Supplements have been of great interest and will be referred to below, but Supplement 2 is unique as it is available electronically only, and contains single case reports. It makes very interesting internet browsing, instructing us in some difficult diagnostic and management problems.

The Michel Benoist and Robert Mulholland yearly European Spine Journal Review: a survey of the “medical” articles in the European Spine Journal, 2009

The year 2009 has been one of innovations in the European Spine Journal. Three important new projects have been presented by M. Aebi, Editor in Chief of the journal in three editorials published in the March, May and August issues. They consist of the formation of a Chinese Section Editorial Board, the creation of an Open Operating Theater, and of Grand Rounds. The two latter innovations strongly reinforce the educational role of the journal. Since 2004, at the end of each year Bob Mulholland and I have worked together to make a “readers’ digest” of the articles published throughout the year. As usual there are more surgical than medical papers. However, we hope that our selection for this year is as exhaustive and complementary as possible. Among the medical articles I have selected those which appear to have the best clinical relevance. There are of course many other papers, which are just as good.

The quality of quality of life publications in the spinal literature: are we getting any better?

Criteria for methodological quality have been widely accepted in many fields of surgical practice. These criteria include those of Velanovich and Gill and Feinstein. No such analysis of the spine surgery literature has ever been reported. This study is a systematic review of the quality of life (QOL) publications to determine if the recent interest in QOL measurements following spinal surgery has been accompanied by an improvement in the quality of the papers published. The archives of the journals Journal of Neurosurgery: Spine, Spine, Journal of Spinal Disorders & Techniques, European Spine Journal, and The Spine Journal, for the years 2000-2004 inclusive, were examined, and all publications reporting QOL outcomes were analyzed. Each paper was scored according to the criteria of Velanovich and Gill and Feinstein, and the methodological quality of these manuscripts-and any time-dependent changes-were determined. During the study period, the total number of articles published increased by 36%, while the number of QOL articles increased by 102%. According to the criteria of Velanovich, there was a statistically significant improvement in the quality of the publications over the study period (p = 0.0394). In 2000, only 27% of outcome measures were disease specific, 77% were valid, and 77% were appropriate for the study design. In 2004, 43% were disease specific, 88% were valid, and 89% were appropriate. In 2000, 53% of studies used appropriate statistical analysis compared with 100 and 96% for 2003 and 2004, respectively. There was no demonstrable improvement in the fulfillment of the more rigorous Gill and Feinstein criteria for any of the 5 journals over the period of the study. The authors' study illustrates a moderate improvement in the quality of these publications over the study period but much methodological improvement is required.

Meta-analysis of lumbar posterolateral fusion versus circumferential fusion in the treatment of the lumbar disease

To evaluate the efficacy of lumbar posterolateral fusion versus circumferential fusion in the treatment of the lumbar disease. Searched MEDLINE (January, 1966 to December, 2007), EMBASE (January, 1984 to December, 2007), Cochrane Central Register of Controlled Trial (4th Quarter 2007), The China Biological Medicine Database (1984 to December, 2007), and hand searched several related journals, such as Spine, European Spine Journal, The Journal of Bone and Joint Surgery, Chinese Journal of Surgery, Chinese Journal of Orthopaedics, Chinese Journal of Spine and Spinal Cord, and so on. Searched the reviews, the clinical results and some other related studies on the two fusion techniques, and the quality of included trials was evaluated. Data were extracted by two reviewers independently with a designed extraction form. RevMan 5.0.5.0 software was used for data analysis of the fusion rate, the complication rate, the re-operation rate, the operative blood loss, the clinical outcome, and the operation time. Four randomized clinical trials (RCTs) involving 437 patients were included. The results of Meta-analysis indicated that in the fusion rate [OR 0.47, 95%CI (0.24, 0.94), P = 0.030], the complication rate [OR 0.53, 95%CI (0.32, 0.87), P = 0.010], and the operative blood loss [weighted mean difference (WMD) = -349.95, 95%CI (-561.64, -138.26), P = 0.001], the circumferential fusion group was significantly higher than the posterolateral fusion group. And in the re-operation rate [OR 2.28, 95%CI (1.30, 3.98), P = 0.004] the posterolateral fusion group was significantly higher than the circumferential fusion group. There were no statistically significant differences in the clinical outcome [OR 1.04, 95%CI (0.64, 1.68), P = 0.870] and the operation time [WMD = -90.24, 95%CI (-190.20, 9.71), P = 0.080]. To compare with the posterolateral fusion, the circumferential fusion can increase the fusion rate and reduce the re-operation rate, but it can also increase the complication rate and the blood loss. More high quality large-scale randomized controlled trials are required.

2009: the year of innovations—third innovation

After having introduced into the European Spine Journal a Chinese Section with its own small sub-editorial board and the concept of “Grand Rounds” (see issues 3, 5, and 7, Vol. 18, 2009) it is my pleasure to introduce the newest product of the European Spine Journal and EuroSpine—The Spine Society of Europe: the Open Operating Theatre (OOT). The European Spine Journal is used as a platform, where films of surgical techniques and procedures are available. These are films for the subscribers of the European Spine Journal, which are available online. These surgical films are all edited according to the same script and shall be considered as standardized teaching and learning material for surgeons in training and for established surgeons as refresher. The films are presented in the European Spine Journal in the form of structured printed abstracts, which will be indexed like any other article in the journal, and provide to the authors the impact factor (IF) of the journal and to the subscribers ultimately CME points (in preparation). All the classical procedures in spine surgery shall finally be available in a video library in the OOT, and shall all be free for subscribers. The structured script shall guarantee the educational value of the material. The plan is that at least three to four times per year an issue contains 4 abstracts for corresponding films in the OOT. In the abstract it is indicated on which web address the film can be accessed with the subscribers user name and password. It is the goal of the video library to present all the regular classical surgical techniques not only from one surgeon, but also ultimately from different surgeons just like we can listen to a classical piece of music with different conductors and soloists. In addition to those regular surgical videos of the OOT, the European Spine Journal is also creating films according to the same principles about new technologies and techniques arising in the spinal market. New techniques and technologies may be presented once or twice a year in the form of a special OOT video supplement, which is sponsored by the MedTech Industry. The idea is to teach new techniques and technologies according to the same standardized rules like the regular films in order to make them free from industry influence and bias. This will give to the industrial partner the opportunity to offer to the spinal community and their clients European Spine Journal-accredited teaching and learning material and not just advertisement material. This will definitely add value to the OOT on one side and to the industrial partner on the other side by acquiring a generally accredited teaching portfolio. The films, which are available and shown on the video web-platform of the European Spine Journal (Springer Publisher) may ultimately also be acquired in the free market. The echo of surgeons, who are willing to contribute with their expertise and accept the extra work of producing such films has been overwhelming, and the European Spine Journal is now going to tap on this resource in the next years to build up a complete audio-visual learning and teaching platform. If anybody of the subscribers and readers of the European Spine Journal has ideas how to improve the quality or expand the initiative or to contribute themselves, do not hesitate to contact me. In this issue we will have the first series of four video films of the OOT. As these first products may not yet be the full quality of what is intended, the films in the next issues will certainly be. Starting with the next issue all the films will specifically be produced for the OOT, whereas the first series has been produced from existing films. I hope you appreciate and enjoy this new service and product of the European Spine Journal. M. Aebi Editor-in-Chief

Letter to the Editor concerning “A less invasive surgical approach in the lumbar lateral recess stenosis: direct approach to the medial wall of the pedicle” (A. Colak et al., Eur Spine J (2008) 17:1745–1751)

Dear Sir, I have read the paper of Dr. Simsek which was published in European Spine Journal (2008) 17:1745–1751 and compliment the authors on preparing this publication. In the discussion on p 1750 the problem is addressed of determining the degree of facetectomy required for relief of the lateral spinal stenosis, and it is stated that no satisfactory guideline has been established. However, when responding to the question “How do you know that decompression is complete?” I submit that there are two clinical observations that can be made during surgery. The first is that in the early stages of its exposure in the stenotic canal, the nerve root is extremely sensitive and, when touched with a blunt probe, it will cause the leg on the affected side to go into a vigorous spasm. The second observation is that, as the stenosis is finally relieved, the collapsed perineural veins refill rapidly, and within minutes of this perineural vein refilling, manipulation of the nerve root no longer elicits vigorous muscular contractions in the leg. To the question as to how one knows that the decompression is complete, the answer is that when the surgeon observes the dramatic rapid refilling of the perineural veins on the posterior surface of the exposed nerve root and the nerve root loses its extreme sensitivity [1]. In addition, I will mail you a copy of a CD film I prepared on Techniques of Lumbar Canal Decompression, which complements this current paper in the European Spine Journal and deals with the surgical techniques for the relief of lumbar spinal canal stenosis [2]. I hope you will find it of interest.

Complications of surgical treatment for lumbar spinal stenosis

The paper presents analytical literature review of complications of surgical treatment for lumbar spinal stenosis. The study was based on paper abstracts identified on the MEDLINE database, on publications from Russian and Ukrainian periodicals, Spine, European Spine Journal, and other sources of scientific and medical information for recent 15 years.

The Michel Benoist and Robert Mulholland yearly European Spine Journal Review: a survey of the “medical” articles in the European Spine Journal, 2008

Many high-quality papers were published in the European Spine Journal in 2008. They came from all parts of the world, not only from European countries, but also Australia, China, Japan, North and South America and India. This worldwide important contribution reflects the vitality of the Journal as well as the efficacy of the editors. The high quality of the papers stems also from the hard work of the editorial and advisory board, responsible for reviewing and evaluating the articles. As in the past years, Robert Mulholland and I have selected the papers whose basic and clinical aspects seemed particularly important to us. I have undertaken to review the “medical” papers with the aim of suggesting reading—or rereading—the selected papers, without, of course, neglecting the many other excellent papers. As usual the selection has been difficult and is most probably imperfect.

World Forum for Spine Research: The intervertebral disc

World Forum for Spine Research: The intervertebral disc

A survey of the "surgical and research" articles in the European Spine Journal, 2007.

Over the last couple of years the European Spine Journal has become truly international with papers from all over the world, and at the same time it has increased its size. Professor Mulholland has selected and reviewed some 40 papers from over 200 published in 2007 and that he felt were of particular interest to practicing surgeons and would influence their management of patients, or papers that challenged established beliefs. Papers dealing with back pain, spondylolysis, tumors, spinal stenosis, spinal infection, clinical examination, lumbar disc herniation, spinal fractures, etc. are reviewed and their significance assessed. The aim of the review is to encourage readers to read the papers themselves, hopefully stimulated by the trenchant comments of the reviewer, both critical and laudatory.

A survey of the “medical” articles in the European Spine Journal, 2007

A wealth of informative studies appeared in the European Spine Journal in 2007. As usual, most of them are surgically oriented. They will be covered by my friend and colleague, Robert Mulholland. I have selected the articles which primarily interest the non surgically-oriented reader as well as researchers in the field of spinal pathology. It is also evident that all practitioners involved in the care of patients with spinal diseases must be aware of the surgical news and vice versa.

Increased secretion of salivary glands produced by facial vibrotactile stimulation

Patients with low-back pain can be evaluated immediately by means of an electrical tool that produces bony vibration to the lumbar spinal processes (Yrjama M, Vanharanta H. Bony vibrotactile stimulation: A new, non-invasive method for examining intradiscal pain. European Spine Journal 1994;3:233–235). In the rehabilitation of masticatory disturbance and dysphagia, an electric toothbrush is commonly used as an oral motor exercise tool for the facilitation of blood flow and metabolism in the orofacial region in Japanese hospitals. However, subjects receiving vibration in the facial regions reported increased salivary secretion. We attempted to develop an oral motor exercise apparatus modified by a headphone headset that was fixed and could be used for extended periods. The vibration apparatus of the heating conductor is protected by the polyethyle methacrylate (dental mucosa protective material), and electric motors for vibration control of the PWM circuit. We examined the amount of salivation during vibration stimuli on the bilateral masseter muscle belly, using a cotton roll positioned at the opening of the secretory duct for 3 min. Although the quantity of salivation in each subject showed various and large fluctuations in the right and left sides of the parotid and submandibular and sublingual glands, one or more of the salivary glands were effectively stimulated by 89 Hz vibration. The reported apparatus will be useful as an additional method in orofacial rehabilitation.

Current opinions and recommendations on multimodal intraoperative monitoring during spine surgeries

With the rapid development of imaging techniques and better understanding of structural and functional pathology of the spine and spinal cord there has been a worldwide increase in the number of spine surgeries performed, particularly in specialized interdisciplinary spine centers. In addition to the congenital and acquired deformities of the spine and relatively rare spinal cord tumors, common degenerative spine disease within the aging general population contributes to a growing number of pathologies with myelopathies. This is important because antecedent myelopathy increases spinal cord risk during surgical treatment. The possibility of having functional neurophysiological assessment during spine and spinal cord surgery was introduced in 1970s by applying somatosensory evoked potentials (SEPs) as well as spinal evoked potentials [15, 21, 32, 33]. Meanwhile these modalities and continuous EMG recording have been enhanced by the addition of corticospinal motor pathway monitoring through the use of motor evoked potentials (MEPs) elicited by transcranial electrical stimulation [3]. The application of multimodal intraoperative monitoring (MIOM) became routine in several spine centers, being documented by publications about the specificity and sensitivity as well as clinical experience and outcome measurements during different spinal surgical procedures [6, 9, 13, 14, 17, 22, 24, 26, 27]. In this supplement on intraoperative monitoring the Spine Center of the Schulthess Clinic presents their experience with the application of MIOM during spine surgery analyzing 1,017 operations in the years 2000–2005. The patients for monitoring were selected out of 11,356 who received spine surgery at the institution during the study period. The indication for each monitoring procedure was discussed and established within the monitoring and surgical team. The detailed analysis of this large patient population resulted in a sensitivity of 89% and specificity of 99%. Sutter et al. [31] conclude that MIOM is an effective method of monitoring the spinal cord functional integrity during spine surgery and therefore can lead to reduction of neurological deficits and consequently improve postoperative results. An independent series of 206 thoracolumbar surgeries also presented in this supplement supports this conclusion [19]. Sala et al. [27] discussed in their recent publication of a historical control study the ethical limitation for performing prospective randomized studies to assess the efficacy of MIOM while clearly documenting that monitoring improves outcome after surgery for intramedullary spinal tumors. The Spine Society of Europe (SSE) supported the development of MIOM by presentations of the results at its annual meetings and organized workshops to stimulate discussion and communication between the spine surgeons and clinical neuroscientists. The SSE has also introduced quality control management in spine surgeries by establishing Spine Tango, a web-based international registry that includes MIOM documentation (http://www.eurospine.org). Other international spine societies such as Scoliosis Research Society presented several original papers on MIOM at the 41st annual meeting in 2006 [2, 5, 23] illustrating its advantages for surgery of adolescent idiopathic and infantile scoliosis. Recently, the International Society of Intraoperative Neurophysiology (ISIN) was founded to stimulate interdisciplinary communication and collaboration between surgeons, neurologists, neurophysiologists and anesthetists (http://www.ptsroma.it/isin). The aim of a first consensus meeting on intraoperative monitoring during spine surgeries in Verona (28 September 2006) was to provide recommendations for the improvement and appropriate application of monitoring techniques during spine surgeries. Experts in the field were invited for a meeting with the support of the European Spine Journal (Max Aebi, MD, Editor-in-chief, Marek Szpalski, MD, Supplement Editor) to summarize the current state-of-the-art and prepare current opinions and recommendations. This consensus statement represents a work in progress and as with all other recommendations or proposals, it must be updated as new information is gained.

Health care technology assessment and transfer

Health care technology assessment and transfer

Multimodal intraoperative monitoring: towards a routine use in surgical treatment of severe spinal disorders

With the rapid development of imaging techniques and better understanding of structural and functional pathology of the spine and spinal cord there has been a worldwide increase in the number of spine surgeries performed, particularly in specialized interdisciplinary spine centers. In addition to congenital and acquired deformities of the spine and relatively rare spinal cord tumors, common degenerative spine disease within the aging general population contributes to a growing number of pathologies with myelopathies. This is important because antecedent myelopathy increases spinal cord risk during surgical treatment. The possibility of having functional neurophysiological assessment during spine and spinal cord surgery was introduced in the 1970s by applying somatosensory evoked potentials (SEPs) as well as spinal evoked potentials. Meanwhile these modalities and continuous EMG recording have been enhanced by the addition of cortico–spinal motor pathway monitoring through the use of motor evoked potentials (MEPs) elicited by transcranial electrical stimulation. The application of multimodal intraoperative monitoring (MIOM) became routine in several spine centers, being documented by publications about the specificity and sensitivity as well as clinical experience and outcome measurements during different spinal surgical procedures. In this supplement on intraoperative monitoring the Spine Center of the Schulthess Clinic presents their experience with the application of MIOM during spine surgery analyzing 1,017 surgeries in the years 2000–2005, as well as pioneers of MIOM such as Profs T.Tamaki, V.Deletis, D.McDonnald and F.Sala contributed with their experience to the supplement. The Spine Society of Europe (SSE) supported the development of MIOM by presentations of the results at its annual meetings and organized workshops to stimulate discussion and communication between spine surgeons and clinical neuroscientists. The SSE has also introduced quality control management in spine surgeries by establishing Spine Tango, a web-based international registry that includes MIOM documentation (http://www.eurospine.org). Recently, the International Society of Intraoperative Neurophysiology (ISIN) was founded to stimulate interdisciplinary communication and collaboration between surgeons, neurologists, neurophysiologists and anesthetists (http://www.ptsroma.it/isin). The aim of a first consensus meeting on intraoperative monitoring during spine surgeries in Verona (28 September 2006) was to provide recommendations for the improvement and appropriate application of monitoring techniques during spine surgeries. Experts in the field were invited for a meeting with the support of the European Spine Journal (Max Aebi, MD, Editor-in-chief, Marek Szpalski, MD, Deputy Editor in charge of Supplements) to summarize the current state-of-the-art and prepare current opinions and recommendations. This consensus statement represents a work in progress and as with all other recommendations or proposals, it must be updated as new information is gained. The consensus group is however, of the opinion and recommends the establishment of a MIOM as a routine procedure in spine centers dealing with severe spinal disorders, in which surgical procedures could lead to damage of neural structures. The current body of knowledge makes the wake-up test to monitor the correction of spinal deformities of exceptional application. Nevertheless, its use might still be justified in the event of technical failure of neuromonitoring setup. Close collaboration of the different international scientific societies such as the Spine Society of Europe, the International Society of Intraoperative Neurophysiology, the Scoliosis Research Society, the International Society for Study of the Lumbar Spine and the Cervical Spine Research Society could facilitate interdisciplinary communication as well as the establishment of the monitoring units in spine centers. It is also recommended that the International Society of Intraoperative Neurophysiology takes this paper as a “study in progress” and elaborates on the development of quality management and standards for intraoperative monitoring as well as educational standards and accreditation. As the specificity and sensitivity of MIOM is well established, the design of historical studies as presented by Sala should be initiated to gain more sound information on the efficacy of monitoring procedures to reduce neurological complications (as obviously performance of prospective randomized trials is limited by ethical considerations). The authors would like to specially thank Charles McCammon, research Assistant at Schulthess Clinic for his editorial support, corrections of the manuscripts and coordination among the different research groups.

A survey of the “medical” articles in the European Spine Journal, 2006

It has been a pleasure to do this overview of the 2006 issues of European Spine Journal (ESJ). ESJ is obviously in good health, considering the number of excellent papers coming from all parts of the world. Thanks to the remarkable and professional efforts of the Editors, much has been accomplished since the founding of the Journal, fifteen years ago by M. Aebi. At that time, and as is the case for most new publications, the immediate future of the Journal was not assured. Very rapidly, however, ESJ became the official publication of the original European Spine Society, created in Brussels at approximately the same time. This association has proven to be successful. Because of the multiplicity of high-quality papers, the “readers’ digest” task assigned to Bob Mulholland and me was not easy; moreover, this past year, in addition to an abundance of original papers and case reports, three excellent supplements were published. Two of them concern the evidence-based effectiveness and cost effectiveness of various treatments of spinal disorders. Efforts in this direction tend to lead to the development of appropriate guidelines. This clearly indicates the wishes of the Editors to take a leading role in this important matter. Among the wealth of information, I have tried to select the most medically oriented papers which would primarily interest non-surgical readers of ESJ. I am convinced that ESJ will continue to be the expression of the multi-disciplinary commitment of all of us to the care of patients with spinal diseases.

A survey of the “surgical and research” articles in the European Spine Journal, 2006

With the greatly increased size of the Journal it is of course very difficult to draw attention to all the papers of great merit. My hope is that by alluding briefly to some, with a brief account of what I feel is important about them, readers will be encouraged to read them. Some papers I am critical of and in these cases it is perhaps even more important that the reader examines them and makes their own judgement.