Daniel J. Hoh

BACKGROUND AND OBJECTIVES: There is global variation and uncertainty regarding the utilization of laminoplasty in the treatment of patients with degenerative cervical spondylotic myelopathy. We asked whether clinical equipoise can be established among cervical spine surgeon experts for a possible trial comparing laminoplasty with fusion. METHODS: Fifty randomly selected cases from a cervical spondylotic myelopathy trial [NCT-02076113] were presented to 26 cervical spine experts to determine the suitability of randomization to laminoplasty vs fusion surgery. A brief clinical vignette, sagittal T2-weighted MRI, and appropriate axial images were reviewed by the experts. Each expert assessed the randomizability of each case and then stated the choice of approach: laminoplasty, fusion (anterior or posterior), arthroplasty, or no surgery. After 6 months, the same 50 cases were reviewed by all experts. RESULTS: Among 50 cases, 46 (92%) were deemed suitable for randomization by a simple majority at both time points. The response rate of the expert panel members was 100% at both time points. Among 2600 surgeon responses over 2 time points, experts stated their choice of approach as laminoplasty in 40% of instances and selected fusion (anterior or posterior) in 57% of cases. Temporal stability of decision-making was high with mean stability = 0.85 (SD = 0.09), indicating that surgeons generally maintained similar treatment decisions over 6 months. A subset (12 experts) of the expert panel who reviewed these 50 cases over 10 years ago demonstrated a significant increase in the preference for laminoplasty from 18% to 40% ( P < .001). CONCLUSION: Among cervical spine experts, laminoplasty utilization has increased over 10 years. Global cervical spine experts demonstrate equipoise for comparing laminoplasty with fusion. The results suggest that a significant proportion of patients with cervical myelopathy would be eligible for a future trial and the results would be likely to affect global practice.

Metal hypersensitivity in spinal surgery is an immune-mediated reaction to metal ions released from implants like pedicle screws and rods, presenting a notable clinical challenge. Common allergens such as nickel, cobalt, and chromium can trigger delayed-type IV hypersensitivity, resulting in pain, inflammation, implant loosening, and the need for revision surgery. Risk factors include prior metal exposure through jewelry or implants, as well as comorbidities like diabetes and behaviors like smoking. Diagnosis is complex, as symptoms often resemble infection or mechanical failure, necessitating the use of tools like patch testing, lymphocyte transformation testing, and histopathological analysis. Management strategies focus on preoperative risk assessment, selection of hypoallergenic materials like PEEK or titanium, and revision surgery when hypersensitivity is confirmed. Multidisciplinary collaboration involving spine surgeons, allergists, and dermatologists is crucial for accurate diagnosis, effective treatment, and improved patient outcomes, emphasizing the importance of tailored implant choices and vigilant postoperative care.

Spinal cord gliomas are rare entities that often have limited surgical options. Immunotherapy has shown promise in intracranial gliomas with some research suggesting benefit for spinal cord gliomas. A focused review of immunotherapies that have been investigated in spinal cord gliomas was performed. The primary methods of immunotherapy investigated in spinal cord gliomas include immune checkpoint inhibitors, adoptive T-cell therapies, and vaccine strategies. There are innumerable challenges that must be overcome to effectively apply immunotherapeutic strategies to the spinal cord gliomas including low incidence, few antigenic targets, the blood spinal cord barrier, the immunosuppressive tumor microenvironment and neurotoxic treatment effects. Nonetheless, research has suggested ways to overcome these challenges and treatments have been effective in case reports for metastatic non-small cell lung cancer, melanoma, midline glioma and glioblastoma. Current therapies for spinal cord gliomas are markedly limited. Further research is needed to determine if the success of immunotherapy for intracranial gliomas can be effectively applied to these unique tumors.

Transforaminal lumbar interbody fusion (TLIF) is a common approach and results in varying degrees of lordosis correction. The purpose of this study is to determine preoperative radiographic spinopelvic parameters that predict change in postoperative segmental and lumbar lordosis after TLIF. This study is a single surgeon retrospective review of one-level and two-level TLIFs from L3-S1. All patients underwent bilateral facetectomies, 10 mm TLIF cage (non-lordotic) insertions, and bilateral pedicle screw-rod construct placements. Pre- and post-operative X-rays were assessed for preoperative segmental lordosis (SL), lumbar lordosis (LL), and pelvic incidence (PI). Univariate and multi-predictor linear regression analyses were performed to determine the relationships between preoperative radiographic findings and change in early postoperative segmental and lumbar lordosis. Ninety-seven patients contributing 128 intervertebral segments were examined. The mean change in SL after TLIF was 7.3 (range: 0.10-28.9°, SD 6.39°). The mean change in LL after TLIF was 5.5˚ (range: -14.8-39.2°, standard deviation (SD) 7.16°). Greater preoperative LL predicted less postoperative LL correction, while greater preoperative PI predicted more postoperative SL and LL correction. Greater anterior disk height was noted to be associated with a decreased change in SL (∆SL). An annular tear on preoperative magnetic resonance imaging (MRI) predicted a 2.7° decrease in ∆SL. A Schmorl's node on preoperative MRI predicted a 4.0° decrease in change in LL (∆LL). A greater preoperative lordosis and a lower spinopelvic mismatch lessen the potential for an increase in the postoperative SL and LL after a TLIF, which is likely due to a ‘ceiling’ effect of an otherwise optimized spinal alignment. A greater anterior disk height and the presence of an annular tear are associated with decreased ∆SL.