Research Appraisals
Evidence-based critical appraisals of the latest medical research, systematically evaluated using Oxford CEBM methodology.
Showing 8 appraisals
Child's nervous system : ChNS : official journal of the International Society for Pediatric Neurosurgery
Non-operative management of traumatic occipitocervical distraction injuries in children: a systematic review
PURPOSE: Existing guidelines for the management of atlanto-occipital dislocation (AOD) recommend occipitocervical fusion (OCF) for these low frequency, high-consequence injuries. Recent literature has questioned this guidance and provided case examples of successful non-operative management of a more inclusive and broadly defined spectrum of injuries to the occipitocervical junction (OCJ) termed occipitocervical distraction injuries (OCDI). A systematic review of existing literature on this topic would inform efforts to investigate the safety and efficacy of non-operative management of these injuries. METHODS: We performed a systematic review based on preferred reporting items for systematic reviews (PRISMA) guidelines of English language publications to define and map literature related to non-operative management of pediatric traumatic OCDI. RESULTS: We identified 40 patients in 21 manuscripts meeting defined inclusion and exclusion criteria. 82.5% of patients were successfully managed with non-operative management alone. No patient declined neurologically during orthotic treatment or in relation to crossover to surgical management through a minimum of 3-month follow-up. CONCLUSIONS: This review supports the contention that non-operative management is both safe and effective in the management of OCDI. Further research to develop standardized diagnostic and treatment protocols for non-operative management of OCDI through registries and multi-center research efforts is needed.
31 July 2026
Read appraisal →Spine
Differentiating Spinal Deformity Versus Leg Length Discrepancy in Patients With Pelvic Obliquity : Systematic Review of Diagnostic Methods, Imaging, and Clinical Management
STUDY DESIGN: Systematic review, PROSPERO ID: (CRD42023112392). OBJECTIVE: We aim to provide physicians with an evidence-based stepwise approach to distinguishing the primary cause of plane pelvic obliquity (PO) to guide treatment. SUMMARY OF BACKGROUND DATA: PO is a frequent clinical finding in both spinal deformity (SD) and leg length discrepancy (LLD) but distinguishing between these etiologies remains challenging due to overlapping clinical and radiographic features and potential multifactorial origins. Misdiagnosis may delay care and worsen patient outcomes. MATERIALS AND METHODS: PubMed, Embase, Scopus, and Web of Science were searched from inception to July 2025 for English-language studies evaluating coronal PO in the context of LLD and/or SD that explicitly compared or differentiated limb-origin from spine-origin obliquity using radiographic, advanced imaging, or validated clinical assessments and reported diagnostic accuracy, discriminative features, or management impact. Two reviewers independently screened studies, extracted data, and performed ROBINS-I risk assessment and Newcastle-Ottawa Scale quality assessment. Owing to marked heterogeneity in populations, measurement protocols, and thresholds, findings were synthesized qualitatively with stratification by age group where possible. RESULTS: Of 436 records, 24 cohort studies met the inclusion criteria. Standing anteroposterior (AP) radiographs reliably quantified both LLD and PO, while advanced imaging provided high reproducibility for subtle or ambiguous cases. Radiographic block or shoe lift correction tests distinguished limb-origin and spine-origin PO through immediate postural correction. Key discriminators included a lumbar curve or PO resolving with block/lift correction suggesting LLD, versus persistent deformity despite correction suggesting spinal etiology. Difficulty remains in diagnosing and treating mixed etiology patients. CONCLUSION: Accurate differentiation of spinal versus limb-driven PO begins with a structured diagnostic approach. AP radiographs, followed by functional block tests, and advanced imaging, may increase diagnostic confidence and decrease unnecessary interventions. Particularly in patients with both LLD and coronal plane SD, prospective studies are required to standardize measurement protocols and improve long-term outcomes. LEVEL OF EVIDENCE: Level IV.
16 June 2026
Read appraisal →Journal of neuro-oncology
Intramedullary or invasive characteristics of spinal melanocytomas: a PRISMA compliant systematic review and pooled case analysis
PURPOSE: Primary meningeal melanocytomas (MMs) of the spinal cord are rare lesions. Even rarer are intramedullary and invasive variants. These intramedullary lesions may exhibit more aggressive behavior than their "benign" classification appreciates. The role of adjuvant radiotherapy (aRT) in this context remains uncertain. METHODS: This study is a PRISMA-compliant systematic review with a pooled-case analysis, including two recent institutional cases included as illustrative examples. RESULTS: Sixty-three reports were identified of primary intramedullary or invasive MMs. Among 56 patients with available recurrence data, 8 of 30 patients (26.7%) experienced recurrence after gross-total resection (GTR) and in 8 of 22 (36.4%) after near-total or subtotal resection (NTR/STR), with no significant difference between groups (two-sided Fisher's exact, P = 0.548). No recurrence was observed among three patients who received aRT upfront post GTR, compared with 8 of 27 (29.6%) who did not receive radiation (two-sided Fisher's exact, P = 0.545); however, this subgroup was markedly underpowered and should be interpreted as hypothesis-generating only. Nine patients developed metastatic disease or progression, including one post biopsy. Of the eight who underwent resection at index surgery, 2 (25%) had undergone GTR and 6 (75%) STR. CONCLUSIONS: These findings suggest that the designation of MMs as benign lesions may underestimate the oncologic potential of intramedullary or invasive disease. Consideration of aRT on an individualized basis for patients with intramedullary or invasive disease is reasonable, regardless of extent of resection.
30 May 2026
Read appraisal →The New England journal of medicine
Decompression with or without Duraplasty for Chiari I and Syringomyelia
BACKGROUND: In children with Chiari type I malformation and syringomyelia, neurosurgical posterior fossa decompression (PFD) provides clinical improvement, but whether duraplasty (incising the dura and placing a dural graft) improves outcomes is unclear. METHODS: We conducted a multicenter, cluster-randomized, controlled trial of PFD with duraplasty (PFD-D) as compared with PFD alone. Persons 21 years of age or younger with cerebellar tonsillar ectopia of at least 5 mm and a maximum syrinx diameter of 3.0 to 9.9 mm were enrolled at 38 centers. Centers were cluster-randomized: all the participants within each center underwent the same intervention. The primary outcome was surgical complications within 6 months. Secondary outcomes were clinical improvement, syrinx reduction, and repeat decompression at 10 to 24 months and the change in overall health-related quality of life at 6 to 24 months. RESULTS: A total of 162 participants were included in the trial, of whom 78 were assigned to undergo PFD-D and 84 to undergo PFD alone. The percentage of participants with complications within 6 months was 14% with PFD-D and 6% with PFD (adjusted odds ratio, 2.59; 95% confidence interval [CI], 0.86 to 7.84; P = 0.11). At 24 months, the percentage of participants with clinical improvement was 58% with PFD-D and 46% with PFD; the mean (±SD) syrinx reduction was 3.08±2.33 mm and 1.22±1.79 mm, respectively; and the percentage of participants with repeat decompression was 3% and 14%. Changes in health-related quality of life were similar in the two groups. CONCLUSIONS: The percentage of participants with surgical complications did not differ significantly between those who underwent PFD-D and and those who underwent PFD alone. Larger trials are needed to determine the relative benefits and risks of these two procedures. (Funded by the Patient-Centered Outcomes Research Institute and others; ClinicalTrials.gov number, NCT02669836.).
29 May 2026
Read appraisal →Biomedical physics & engineering express
Enhancing CNN regressors with contour encoding and self-supervision for improved 3D/2D x-ray to CT registration in spinal surgery navigation
With advances in deep learning, regression-based methods have shown promising results in 3D/2D medical image registration. However, strict intraoperative radiation dose constraints produce low-dose x-ray images with severe blur and reduced contrast, significantly degrading registration accuracy and limiting precise image-guided spinal interventions. We propose the Contour Encoding Regressor (CER), a novel end-to-end CNN framework that extracts highly discriminative features directly from binary contour masks of intraoperative x-rays without any restrictions on contour length, shape, or morphology. These contour features are efficiently encoded by a dedicated module and seamlessly fused into the regression pipeline to improve robustness against image degradation. To further enhance pose estimation, CER employs a dual-branch architecture that explicitly decouples rotational and translational parameters, thereby reducing mutual interference and improving overall accuracy. In addition, a self-supervised fine-tuning strategy with a tailored multi-component loss function is introduced to adapt the model to blurred low-dose conditions and minimize residual errors. On low-dose x-ray images, CER achieves a mean target registration error of 1.39 mm-a clinically acceptable threshold-while outperforming state-of-the-art methods in accuracy and enabling real-time performance (0.03-0.06 s per frame on clinically accessible GPUs). These improvements meet the stringent precision and speed requirements of intraoperative navigation, offering strong potential to enhance surgical safety and outcomes in minimally invasive spinal procedures.
10 May 2026
Read appraisal →Physics in medicine and biology
Confounding factors in the generalisation of synthetic CT to diagnostic spine MRI
Objective. Generalisation of synthetic CT (sCT) generation to diagnostic MRI data in the spine faces many challenges, particularly when aiming at accurate visualisation of pathologies for orthopaedic treatment management. In this study we assessed the effect of potential confounding factors on the performance of sCT generation from diagnostic MR images.Approach. Paired spinal diagnostic MR and CT scans from two centres (51 patients) were collected retrospectively, spanning multiple spinal pathologies and regions. Each patient's dataset contained 3D T1-/T2-weighted and 2D T1- and T2-weighted scans. 3D U-Nets were trained per centre on the 3D MR data and CT using a mean absolute error (MAE) loss. The performance was assessed on sCTs derived from original 2D and 3D data and from simulated 2D data with varying orientation (axial/coronal/sagittal) and slice spacing (1.1-6.6 mm). The sCTs were compared to the CTs using MAE, peak signal-to-noise ratio, and dice similarity coefficient.Main results. We identified MR resolution, orientation and contrast as confounding factors for sCT generation from diagnostic MR. Additionally, CT noise and CT-to-MR registration were identified to influence the performance evaluation. Performance degraded with larger slice spacings and significant differences between orientations occurred more often at larger slice spacings. The effect of slice spacing and orientation was stronger inside the vertebrae than outside. While the networks performed better overall on contrasts more similar to the training contrasts, they demonstrated promising performance when trained on 3D T2w images and tested on 2D T1w images. Finally, higher CT noise levels resulted in worse sCT performance metrics, reflected in a significant correlation between noise and MAE.Significance. This work demonstrates that generalisation of sCT generation to diagnostic spine MRI data is hampered primarily by MRI acquisition related aspects including MR resolution, orientation and contrast, which provides guidance for future work on generalisable sCT from diagnostic MR.
27 Apr 2026
Read appraisal →Child's nervous system : ChNS : official journal of the International Society for Pediatric Neurosurgery
Surgical management of anterior sacral meningoceles: a case series and systematic review
PURPOSE: Anterior sacral meningoceles (ASMs) are rare forms of spinal dysraphism caused by anterior herniation of meninges through a sacral defect. Surgical management is the treatment of choice, yet the optimal approach remains debated. This study compares outcomes of three main surgical approaches-anterior transabdominal, posterior transsacral, posterior sagittal (PSARP-type)-focusing on the efficacy and safety of the PSARP-type. METHODS: A retrospective single-center analysis was conducted on eight patients treated for ASM between 2008 and 2025. Demographic, clinical, radiological, functional data were reviewed. Outcomes included recurrence, reoperation, sac size reduction, bladder function; complications were categorized as early or late. A systematic literature review was performed according to PRISMA guidelines. RESULTS: Eight patients (6 females, 2 males; mean age 19.4 years) underwent surgery (five anterior Pfannenstiel incision, two posterior sagittal, one posterior transsacral). All were symptomatic, 87.5% had associated malformations. Sac reduction was achieved in 87.5% of cases, with no new neurological deficits. Complications were mild and self-limiting, including transient urinary retention and cerebrospinal fluid fistula managed with lumboperitoneal shunt. The literature review (49 studies, 68 patients) confirmed female predominance (81%), association with Marfan and Currarino syndromes (35%), preference for posterior approaches (70%), which showed lower morbidity and recurrence rates. One postoperative death (1.4%) was reported. CONCLUSIONS: Posterior approaches-particularly the PSARP-type-provide safe, effective, and functionally favorable alternatives to anterior surgery for ASM, offering optimal exposure, precise dural closure, superior cosmetic outcomes with minimal morbidity. The anterior route should be reserved for large or high-lying lesions. Further multicenter studies with longer follow-up are warranted.
17 Apr 2026
Read appraisal →European journal of orthopaedic surgery & traumatology : orthopedie traumatologie
Radiological and surgical outcomes after graduation to posterior spinal fusion surgery following magnetically controlled growing rod treatment for early-onset scoliosis: a systematic review and single-arm meta-analysis
PURPOSE: Early-onset scoliosis (EOS) is a challenging condition for spinal surgeons. Growing rods represent the standard treatment for patients requiring surgery, and magnetically controlled growing rods (MCGR) are increasingly adopted. Many patients ultimately transition to posterior spinal fusion (PSF), although the necessity of definitive fusion remains debated. This systematic review and single-arm meta-analysis aimed to evaluate radiographic and surgical outcomes of PSF following MCGR treatment. METHODS: A systematic literature search was conducted in PubMed, Google Scholar, Medline, Scopus, Embase, and the Cochrane Library up to April 2025, following PRISMA guidelines. Eligible studies were identified using a PIO (Population, Intervention, Outcome) framework. Extracted data included demographic, radiographic, and surgical outcomes, including complications. A single-arm meta-analysis compared pre- and post-PSF radiographic parameters (main curve magnitude, thoracic kyphosis (TK), T1-T12 and T1-S1 lengths). Risk of bias was assessed using the MINORS tool. RESULTS: Eight retrospective studies were included (370 patients), of which six were eligible for quantitative synthesis. The meta-analysis demonstrated significant improvements in all radiographic parameters (main curve magnitude, TK, T1-T12 and T1-S1 lengths, p < 0.05). The pooled overall postoperative complication rate after PSF was 17.2%. CONCLUSIONS: PSF appears to be a viable treatment option following MCGR, providing significant deformity correction with a relatively acceptable complication rate. Nevertheless, the current evidence is limited by small, retrospective cohorts. Larger, prospective studies with standardized reporting of surgical variables and clinical outcomes are needed to better define the role of final fusion and to optimize treatment protocols.
4 Apr 2026
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