Anterior cingulate cortex functions

Anterior cingulate cortex functions

see also dorsal anterior cingulate cortex.

The anterior cingulate cortex, appears to play a role in a wide variety of autonomic functions, such as regulating blood pressure and heart rate.

It is also involved in rational cognitive functions, such as reward anticipation, decision-makingempathyimpulse control and emotion.


From January to December 2016, eighteen participants with opiate drug addiction during physical detoxification who completed a Drug Rehabilitation Center of Anhui Province, and eighteen healthy controls recruited performed a cue-elicited craving task in a MRI scanner while signal data were collected. Two regions of interest were the right anterior cingulate and the left anterior cingulate, then the linear correlation between the whole brain and the anterior cingulates was calculated to find out the abnormal functional connectivity of the anterior cingulates.

Contrasted experimental group with the healthy controls, the functional connectivity of bilateral fusiform gyruscaudate nucleus, and the anterior cingulates was increased in the opiate drug addicts during physical detoxification group (P<0.05),and the functional connectivity between anterior cingulates and polus temporalis, hippocampi, Middle frontal gyrus of orbit, Supplementary motor area, dorsolateral superior frontal gyrus was decreased (P<0.05).

The anterior cingulates dysfunction of functional connectivity in a cue-elicited craving task may play a important role in the relapse of opiate drug addicts during physical detoxification 1).


Pica is most often reported in the presence of iron deficiency or gastrointestinal disturbance. The mechanism that underlies the behavior is poorly understood. Lesions to the anterior cingulate gyrus (ACG) can present in many ways, with signs and symptoms including motor and sensory changes, autonomic dysfunction, seizures, and behavioral alterations.

To date, no reports of pica, or eating disturbances, have been tied to anterior cingulate cortex lesions. In a article, Rangwala et al., describe the case of an 8-year-old boy presenting with pica consumption of paper who was shown to have a mass in the left ACG. After surgical resection of the lesion, all of the patient’s symptoms resolved and he returned to his normal life 2).


The somatosensory cortex encodes incoming sensory information from receptors all over the body. Affective touch is a type of sensory information that elicits an emotional reaction and is usually social in nature, such as a physical human touch. This type of information actually coded differently than other sensory information. Intensity of affective touch is still encoded in the primary somatosensory cortex, but the feeling of pleasantness associated with affective touch activates the anterior cingulate cortex more than the primary somatosensory cortex. Functional magnetic resonance imaging (fMRI) data shows that increased blood oxygen level contrast (BOLD) signal in the anterior cingulate cortex as well as the prefrontal cortex is highly correlated with pleasantness scores of an affective touch. Inhibitory transcranial magnetic stimulation (TMS) of the primary somatosensory cortex inhibits the perception of affective touch intensity, but not affective touch pleasantness. Therefore, the S1 is not directly involved in processing socially affective touch pleasantness, but still plays a role in discriminating touch location and intensity.


Qiao et al. reported a case of refractory epilepsy characterized by aura of extreme fear and hypermotor seizures, in which the left (dominant hemisphere) anterior cingulate gyrus (ACG) was determined to be the epileptogenic zone (EZ) through multiple modalities of presurgical evaluation including analysis of high frequency oscillation on intracranial EEG. Tailored resection of EZ was thus performed and pathological examination revealed focal cortical dysplasia (FCD) type IIb. The patient has been seizure free during an 18-month follow-up. The report has provided novel anatomical, electrophysiological and surgical evidences suggesting the critical role of ACG in ictal fear and possibility of surgical management of fear-manifesting refractory epilepsy 3).


Impaired wakefulness (IW) in normal pressure hydrocephalus (NPH) is associated with reduced relative regional cerebral blood flow (rrCBF) in the anterior cingulate cortex. Improved wakefulness following surgery corresponds to rrCBF increments in the frontal association cortex 4).

References

1)

Han Y, Sun T, Zheng XL, Jiang ZQ, Lou FY, Zhang SJ. [Task-related functional connectivity of anterior cingulate in opiate drug addicts during physical detoxification: a task fMRI study]. Zhonghua Yi Xue Za Zhi. 2019 Mar 5;99(9):700-703. doi: 10.3760/cma.j.issn.0376-2491.2019.09.013. Chinese. PubMed PMID: 30831621.
2)

Rangwala SD, Tobin MK, Birk DM, Butts JT, Nikas DC, Hahn YS. Pica in a Child with Anterior Cingulate Gyrus Oligodendroglioma: Case Report. Pediatr Neurosurg. 2017;52(4):279-283. doi: 10.1159/000477816. Epub 2017 Jul 14. PubMed PMID: 28704833.
3)

Qiao L, Yu T, Ni D, Wang X, Xu C, Liu C, Zhang G, Li Y. Correlation between extreme fear and focal cortical dysplasia in anterior cingulate gyrus: Evidence from a surgical case of refractory epilepsy. Clin Neurol Neurosurg. 2017 Oct 31;163:121-123. doi: 10.1016/j.clineuro.2017.10.025. [Epub ahead of print] PubMed PMID: 29101860.
4)

Tullberg M, Hellström P, Piechnik SK, Starmark JE, Wikkelsö C. Impaired wakefulness is associated with reduced anterior cingulate CBF in patients with normal pressure hydrocephalus. Acta Neurol Scand. 2004 Nov;110(5):322-30. PubMed PMID: 15476461.

Anterior cervical disc arthroplasty versus anterior cervical discectomy and fusion

Anterior cervical disc arthroplasty versus anterior cervical discectomy and fusion

Anterior cervical disc arthroplasty has been shown in a number of prospective clinical studies to be a viable treatment alternative to anterior cervical discectomy and fusion (ACDF) for symptomatic cervical degenerative disc disease. In addition to preserving motion, some evidence suggests that this technique may result in a lower incidence of subsequent surgical intervention than treatment with fusion.

One reason for this trend is the observation that in clinical studies, patients with a history of cervical arthrodesis seem to have a higher incidence of adjacent segment degeneration 1)2) 3).

Furthermore, in biomechanical investigations, most authors have reported an increase in the segmental range of motion (ROM) and the intradiscal pressure (IDP) in the levels proximal and distal to a simulated mono- or bisegmental arthrodesis 4) 5) 6) 7) 8) 9) 10) 11) 12) 13).


MacDowall et al., from Sweden performed a randomized controlled trial with 153 patients (mean age 47 years) undergoing surgery for cervical radiculopathy. Eighty-three patients received an Artificial disc replacement (ADR) and 70 patients underwent fusion surgery. Outcomes after 5 years were assessed using patient-reported outcome measures using the Neck Disability Index (NDI) score as the primary outcomemotion preservation and heterotopic ossification by radiographyadjacent segment pathology (ASP) by MRI; and secondary surgical procedures.

Scores on the NDI were approximately halved in both groups: the mean score after 5 years was 36 (95% confidence interval [CI] 31-41) in the ADR group and 32 (95% CI 27-38) in the fusion group (p = 0.48). There were no other significant differences between the groups in six other patient-related outcome measures. Fifty-four percent of the patients in the ADR group preserved motion at the operated cervical level and 25% of the ADRs were spontaneously fused. Seventeen ADR patients (21%) and 7 fusion patients (10%) underwent secondary surgery (p = 0.11), with 5 patients in each group due to clinical ASP.

In patients with cervical degenerative disc disease and radiculopathy decompression as well as Artificial disc replacement, surgery did not result in better clinical or radiological outcomes after 5 years compared with anterior cervical discectomy and fusion. Clinical trial registration no.: 44347115 (ISRCTN) 14).


One hundred-nine patients with one level cervical disc herniation, were randomized to one of the following treatments: Anterior cervical disc arthroplasty (ACDA), Anterior cervical discectomy and fusion (ACDF) with intervertebral cageAnterior cervical discectomy (ACD) without fusion. Clinical and radiological outcome was measured by NDIVisual Analogue Scale (VAS) neck pain, VAS arm painSF-36EQ-5D, patients’ self-reported perceived recovery, radiographic cervical curvature, and adjacent segment degeneration (ASD) parameters at baseline and until two years after surgery. BBraun Medical paid €298.837 to cover the costs for research nurses.

The NDI declined from 41 to 47 points at baseline to 19±15 in the ACD group, 19± 18 in the ACDF group, and 20±22 in the ACDA group after surgery (p=0.929). VAS arm and neck pain declined to half its baseline value and decreased below the critical value of 40 mm. Quality of life, measured by the EQ-5D, increased in all three groups. ASD parameters were comparable in all three groups as well. No statistical differences were demonstrated between the treatment groups.

The hypothesis that ACDA would lead to superior clinical outcome in comparison to ACDF or ACD could not be confirmed during a two-year follow-up time period. Single level ACD without implanting an intervertebral device may be a reasonable alternative to ACDF or ACDA 15).


Findlay et al., from London and Edinburgh, researched for cervical total disc replacement versus anterior cervical discectomy and fusion.

Databases including MedlineEmbase, and Scopus were searched. Inclusion criteria involved prospective randomized control trials (RCTs) reporting the surgical treatment of patients with symptomatic degenerative cervical disc disease. Two independent investigators extracted the data. The strength of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria. The primary outcome measures were overall and neurological success, and these were included in the meta-analysis. Standardized patient-reported outcomes, including the incidence of further surgery and adjacent segment disease, were summarized and discussed.

A total of 22 papers published from 14 randomized control trials (RCTs) were included, representing 3160 patients with follow-up of up to ten years. Meta-analysis indicated that TDR is superior to ACDF at two years and between four and seven years. In the short-term, patients who underwent TDR had better patient-reported outcomes than those who underwent ACDF, but at two years this was typically not significant. Results between four and seven years showed significant differences in Neck Disability Index (NDI), 36-Item Short-Form Health Survey (SF-36) physical component scores, dysphagia, and satisfaction, all favouring TDR. Most trials found significantly less adjacent segment disease after TDR at both two years (short-term) and between four and seven years (medium- to long-term).

TDR is as effective as ACDF and superior for some outcomes. Disc replacement reduces the risk of adjacent segment disease. Continued uncertainty remains about degeneration of the prosthesis. Long-term surveillance of patients who undergo TDR may allow its routine use 16).


Although cervical disc arthroplasty (CDA) at C3-4 was infrequent, the improved clinical outcomes of CDA were similar at C3-4 to that in the other subaxial levels of the cervical spine at the approximately 5-year follow-ups. In this Asian population, who had a propensity to have ossification of the posterior longitudinal ligament, there was more heterotopic ossification (HO) formation in patients who received CDA at the C3-4 level than in other subaxial levels of the cervical spine. While the type of artificial discs could have confounded the issue, future studies with more patients are required to corroborate the phenomenon 17).


The hypothesis that ACDA would lead to superior clinical outcome in comparison to ACDF or anterior cervical discectomy (ACD) could not be confirmed during a two-year follow-up time period. Single level ACD without implanting an intervertebral device may be a reasonable alternative to ACDF or ACDA 18).

Cost-effectiveness

A study is the first to report the comparative cost-effectiveness of cervical total disc replacement (cTDR) vs anterior cervical discectomy and fusion(ACDF) for 2-level degenerative disc disease at 5 years. Ament et al conclude that, because of the negative incremental cost-effective ratio (ICER), cTDR is the dominant modality 19)

Patients who underwent CTDR for single-level degenerative disease had lower readmission rates, lower reoperation rates, and reduced index and total costs than those treated with ACDF. Cervical disc arthroplasty (CDA) was effective in reducing the monthly cost of care compared with ACDF20).

Based on a modeling evaluation, CTDR was found to be more effective and less costly over a 7-year time horizon for patients with single-level symptomatic degenerative disc disease. These results are robust across a range of scenarios and perspectives and are intended to support value-based decision making 21).

The incremental cost-effectiveness ratio of CTDR compared with traditional ACDF is lower than the commonly accepted threshold of $50,000 per QALY. This remains true with varying input parameters in a robust sensitivity analysis, reaffirming the stability of the model and the sustainability of this intervention 22).

At the same time, while generating clinical results comparable to spinal fusion, TDR incurred significantly lower costs. Therefore, both from the medical and from the financial point of view, TDR is a viable choice in the treatment of DDP 23).

Results of the sensitivity analysis indicated that CDR must remain functional for at least 14 years to establish greater cost-effectiveness than ACDF. Since the current literature has yet to demonstrate with certainty the actual durability and long-term functionality of CDR, future long-term studies are required to validate the present analysis 24).


Although cervical total disc replacement (TDR) has shown equivalence or superiority to anterior cervical discectomy and fusion (ACDF), potential problems include nonphysiological motion (hypermobility), accelerated degeneration of the facet joints, particulate wear, and compromise of the mechanical integrity of the endplate during device fixation.

There is no definitive evidence that TDR has better intermediate-term results than anterior cervical discectomy and fusion (ACDF) 25).


3D motion analysis data comparing patients after ACDF and AD replacement in ten patients who underwent C5-6 ACDF and 7 who underwent C5-6 AD replacement were enrolled. Using biplanar fluoroscopy and a model-based track technique (accurate up to 0.6 mm and 0.6°), motion analysis of axial rotation and flexion-extension of the neck was performed. Three nonoperative segments (C3-4, C4-5, and C6-7) were assessed for both intervertebral rotation (coronal, sagittal, and axial planes) and facet shear (anteroposterior and mediolateral). Results There was no difference in total neck motion comparing ACDF and AD replacement for neck extension (43.3° ± 10.2° vs 44.3° ± 12.6°, p = 0.866) and rotation (36.0° ± 6.5° vs 38.2° ± 9.3°, p = 0.576). For extension, when measured as a percentage of total neck motion, there was a greater amount of rotation at the nonoperated segments in the ACDF group than in the AD group (p = 0.003). When comparing specific motion segments, greater normalized rotation was seen in the ACDF group at C3-4 (33.2% ± 4.9% vs 26.8% ± 6.6%, p = 0.036) and C6-7 (28.5% ± 6.7% vs 20.5% ± 5.5%, p = 0.009) but not at C4-5 (33.5% ± 6.4% vs 31.8% ± 4.0%, p = 0.562). For neck rotation, greater rotation was observed at the nonoperative segments in the ACDF group than in the AD group (p = 0.024), but the differences between individual segments did not reach significance (p ≥ 0.146). Increased mediolateral facet shear was seen on neck extension with ACDF versus AD replacement (p = 0.008). Comparing each segment, C3-4 (0.9 ± 0.5 mm vs 0.4 ± 0.1 mm, p = 0.039) and C4-5 (1.0 ± 0.4 mm vs 0.5 ± 0.2 mm, p = 0.022) showed increased shear while C6-7 (1.0 ± 0.4 mm vs 1.0 ± 0.5 mm, p = 0.767) did not.

This study illustrates increased motion at nonoperative segments in patients who have undergone ACDF compared with those who have undergone AD replacement. Further studies will be required to examine whether these changes contribute to adjacent-segment disease 26).

The data from a investigational device exemption (IDE) study through 48 months signify a number of clinically relevant benefits for total disc replacement (TDR) over anterior cervical discectomy and fusion (ACDF). Patients experienced improved clinical outcomes with TDR—including improvement in pain and function outcomes and superiority in overall primary endpoint success. Additionally, incidences of adjacent segment degeneration and subsequent surgeries were reduced with TDR. Perhaps future studies and also longer-term followup of this patient cohort may continue to establish 2-level cervical TDR as a superior surgical option for symptomatic degenerative disc disease 27).

References

1)

Goffin J, Geusens E, Vantomme N, Quintens E, Waerzeggers Y, Depreitere B, et al. Long-term follow-up after interbody fusion of the cervical spine. J Spinal Disord Tech. 2004;17:79–85. doi: 10.1097/00024720-200404000-00001.
2)

Gore DR, Sepic SB. Anterior discectomy and fusion for painful cervical disc disease: a report of 50 patients with an average follow-up of 21 years. Spine. 1998;23:2047–2051. doi: 10.1097/00007632-199810010-00002.
3)

Hilibrand AS, Carlson GD, Palumbo MA, Jones PK, Bohlman H. Radiculopathy and myelopathy at segments adjacent to the site of a previous anterior cervical arthrodesis. J Bone Joint Surg. 1999;81-A:519–528.
4)

Chang U-K, Kim DH, Lee MC, Willenberg R, Kim S-H, Lim J. Changes in adjacent-level disc pressure and facet joint force after cervical arthroplasty compared with cervical discectomy and fusion. J Neurosurg Spine. 2007;7:33–39. doi: 10.3171/SPI-07/07/033.
5)

Chang U-K, Kim DH, Lee MC, Willenberg R, Kim S-H, Lim J. Range of motion change after cervical arthroplasty with ProDisc-C and Prestige artificial discs compared with anterior cervical discectomy and fusion. J Neurosurg Spine. 2007;7:40–46. doi: 10.3171/SPI-07/07/040.
6)

DiAngelo DJ, Foley KT, Morrow BR, Schwab JS, Song J, German JW, et al. In vitro biomechanics of cervical disc arthroplasty with the ProDisc-C total disc implant. Neurosurg Focus. 2004;17(E7):44–54. doi: 10.3171/foc.2004.17.3.7.
7)

DiAngelo DJ, Robertson JT, Metcalf NH, McVay BJ, Davis RC. Biomechanical testing of an artificial cervical joint and an anterior plate. J Spinal Disord Tech. 2003;16:314–323. doi: 10.1097/00024720-200308000-00002.
8)

Dmitriev AE, Cunningham BW, Hu N, Sell G, Vigna F, McAfee PC. Adjacent level intradiscal pressure and segmental kinematics following a cervical total disc arthroplasty. An in vitro human cadaveric model. Spine. 2005;30:1165–1172. doi: 10.1097/01.brs.0000162441.23824.95.
9)

Eck JC, Humphreys SC, Lim T-H, Jeong ST, Kim JG, Hodges SD, et al. Biomechanical study on the effect of cervical spine fusion on adjacent-level intradiscal pressure and segmental motion. Spine. 2002;27:2431–2434. doi: 10.1097/00007632-200211150-00003.
10)

Fuller DA, Kirkpatrick JS, Emery SE. A kinematic study of the cervical spine before and after segmental arthrodesis. Spine. 1998;23:1649–1656. doi: 10.1097/00007632-199808010-00006.
11)

Park D-H, Ramakrishnan P, Cho T-H, Lorenz E, Eck JC, Humphreys SC, et al. Effect of lower two-level anterior cervical fusion on the superior adjacent level. J Neurosurg Spine. 2007;7:336–340. doi: 10.3171/SPI-07/09/336.
12)

Pospiech J, Stolke D, Wilke HJ, Claes LE. Intradiscal pressure recordings in the cervical spine. Neurosurgery. 1999;44:379–384. doi: 10.1097/00006123-199902000-00078.
13)

Ragab AA, Escarcega AJ, Zdeblick TA. A quantitative analysis of strain at adjacent segments after segmental immobilization of the cervical spine. J Spinal Disord Tech. 2006;19:407–410. doi: 10.1097/00024720-200608000-00006.
14)

MacDowall A, Canto Moreira N, Marques C, Skeppholm M, Lindhagen L, Robinson Y, Löfgren H, Michaëlsson K, Olerud C. Artificial disc replacement versus fusion in patients with cervical degenerative disc disease and radiculopathy: a randomized controlled trial with 5-year outcomes. J Neurosurg Spine. 2019 Jan 11:1-9. doi: 10.3171/2018.9.SPINE18659. [Epub ahead of print] PubMed PMID: 30641852.
15) , 18)

Vleggeert-Lankamp CLA, Janssen TMH, van Zwet E, Goedmakers CMW, Bosscher L, Peul W, Arts MP. The NECK trial: Effectiveness of anterior cervical discectomy with or without interbody fusion and arthroplasty in the treatment of cervical disc herniation; a double-blinded randomised controlled trial. Spine J. 2018 Dec 21. pii: S1529-9430(18)31322-6. doi: 10.1016/j.spinee.2018.12.013. [Epub ahead of print] PubMed PMID: 30583108.
16)

Findlay C, Ayis S, Demetriades AK. Total disc replacement versus anterior cervical discectomy and fusion. Bone Joint J. 2018 Aug;100-B(8):991-1001. doi: 10.1302/0301-620X.100B8.BJJ-2018-0120.R1. PubMed PMID: 30062947.
17)

Chang PY, Chang HK, Wu JC, Huang WC, Fay LY, Tu TH, Wu CL, Cheng H. Differences between C3-4 and other subaxial levels of cervical disc arthroplasty: more heterotopic ossification at the 5-year follow-up. J Neurosurg Spine. 2016 May;24(5):752-9. doi: 10.3171/2015.10.SPINE141217. Epub 2016 Jan 29. PubMed PMID: 26824584.
19)

Ament JD, Yang Z, Nunley P, Stone MB, Lee D, Kim KD. Cost Utility Analysis of the Cervical Artificial Disc vs Fusion for the Treatment of 2-Level Symptomatic Degenerative Disc Disease: 5-Year Follow-up. Neurosurgery. 2016 Jul;79(1):135-45. doi: 10.1227/NEU.0000000000001208. PubMed PMID: 26855020; PubMed Central PMCID: PMC4900425.
20)

Radcliff K, Zigler J, Zigler J. Costs of Cervical Disc Replacement Versus Anterior Cervical Discectomy and Fusion for Treatment of Single-Level Cervical Disc Disease: An Analysis of the Blue Health Intelligence Database for Acute and Long-term Costs and Complications. Spine (Phila Pa 1976). 2015 Apr 15;40(8):521-9. doi: 10.1097/BRS.0000000000000822. PubMed PMID: 25868092.
21)

Radcliff K, Lerner J, Yang C, Bernard T, Zigler JE. Seven-year cost-effectiveness of ProDisc-C total disc replacement: results from investigational device exemption and post-approval studies. J Neurosurg Spine. 2016 May;24(5):760-8. doi: 10.3171/2015.10.SPINE15505. Epub 2016 Jan 29. PubMed PMID: 26824587.
22)

Ament JD, Yang Z, Nunley P, Stone MB, Kim KD. Cost-effectiveness of cervical total disc replacement vs fusion for the treatment of 2-level symptomatic degenerative disc disease. JAMA Surg. 2014 Dec;149(12):1231-9. doi: 10.1001/jamasurg.2014.716. Erratum in: JAMA Surg. 2014 Dec;149(12):1295. PubMed PMID: 25321869.
23)

Wiedenhöfer B, Nacke J, Stephan M, Richter W, Carstens C, Eichler M. Is Total Disc Replacement a Cost Effective Treatment for Cervical Degenerative Disc Disease? J Spinal Disord Tech. 2014 Oct 10. [Epub ahead of print] PubMed PMID: 25310395.
24)

Qureshi SA, McAnany S, Goz V, Koehler SM, Hecht AC. Cost-effectiveness analysis: comparing single-level cervical disc replacement and single-level anterior cervical discectomy and fusion: clinical article. J Neurosurg Spine. 2013 Nov;19(5):546-54. doi: 10.3171/2013.8.SPINE12623. Epub 2013 Sep 6. PubMed PMID: 24010896.
25)

Li Z, Yu S, Zhao Y, Hou S, Fu Q, Li F, Hou T, Zhong H. Clinical and radiologic comparison of dynamic cervical implant arthroplasty versus anterior cervical discectomy and fusion for the treatment of cervical degenerative disc disease. J Clin Neurosci. 2013 Nov 4. pii: S0967-5868(13)00585-7. doi:10.1016/j.jocn.2013.09.007. [Epub ahead of print] PubMed PMID: 24411326.
26)

McDonald CP, Chang V, McDonald M, Ramo N, Bey MJ, Bartol S. Three-dimensional motion analysis of the cervical spine for comparison of anterior cervical decompression and fusion versus artificial disc replacement in 17 patients. J Neurosurg Spine. 2013 Dec 20. [Epub ahead of print] PubMed PMID: 24359000.
27)

Davis RJ, Nunley PD, Kim KD, Hisey MS, Jackson RJ, Bae HW, Hoffman GA, Gaede SE, Danielson GO 3rd, Gordon C, Stone MB. Two-level total disc replacement with Mobi-C cervical artificial disc versus anterior discectomy and fusion: a prospective, randomized, controlled multicenter clinical trial with 4-year follow-up results. J Neurosurg Spine. 2015 Jan;22(1):15-25. doi: 10.3171/2014.7.SPINE13953. PubMed PMID: 25380538.
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