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array:23 [ "pii" => "S252984962300028X" "issn" => "25298496" "doi" => "10.1016/j.neucie.2023.07.005" "estado" => "S300" "fechaPublicacion" => "2023-09-01" "aid" => "583" "copyright" => "Sociedad Española de Neurocirugía" "copyrightAnyo" => "2023" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "edi" "cita" => "Neurocirugia. 2023;34:217-20" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S1130147323003718" "issn" => "11301473" "doi" => "10.1016/j.neucir.2023.07.001" "estado" => "S300" "fechaPublicacion" => "2023-09-01" "aid" => "583" "copyright" => "Sociedad Española de Neurocirugía" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "edi" "cita" => "Neurocirugia. 2023;34:217-20" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "es" => array:10 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial</span>" "titulo" => "Catastrofismo en cirugía de columna e impacto de los informes radiológicos" "tienePdf" => "es" "tieneTextoCompleto" => "es" "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "217" "paginaFinal" => "220" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "Catastrophism in spine surgery and the impact of radiological reports" ] ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Pedro David Delgado-López, Carlos Fernández Carballal, Igor Paredes, Héctor Roldán Delgado, David Suárez Fernández, Alfonso Vázquez Míguez" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Pedro David" "apellidos" => "Delgado-López" ] 1 => array:2 [ "nombre" => "Carlos" "apellidos" => "Fernández Carballal" ] 2 => array:2 [ "nombre" => "Igor" "apellidos" => "Paredes" ] 3 => array:2 [ "nombre" => "Héctor" "apellidos" => "Roldán Delgado" ] 4 => array:2 [ "nombre" => "David" "apellidos" => "Suárez Fernández" ] 5 => array:2 [ "nombre" => "Alfonso" "apellidos" => "Vázquez Míguez" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S252984962300028X" "doi" => "10.1016/j.neucie.2023.07.005" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S252984962300028X?idApp=UINPBA00004B" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1130147323003718?idApp=UINPBA00004B" "url" => "/11301473/0000003400000005/v1_202309041031/S1130147323003718/v1_202309041031/es/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S2529849622001022" "issn" => "25298496" "doi" => "10.1016/j.neucie.2022.08.002" "estado" => "S300" "fechaPublicacion" => "2023-09-01" "aid" => "564" "copyright" => "Sociedad Española de Neurocirugía" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Neurocirugia. 2023;34:221-7" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Clinical research</span>" "titulo" => "Long insular artery damage might be a key sign for predicting functional prognosis of putaminal hemorrhage" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "221" "paginaFinal" => "227" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "El daño de la arteria insular larga podría ser un signo clave para predecir el pronóstico funcional de la hemorragia putaminal" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 925 "Ancho" => 1672 "Tamanyo" => 137837 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Definition of initial long insular artery damage. The vascular territories of subcortical white matter and the basal ganglia on coronal images are schematically shown. These areas are supplied by three individual arteries branching from the middle cerebral artery, namely the lenticulostriate artery (LSA: bold line) from the M1 segment, the long insular artery (LIA: dashed line) from the M2 segment, and the white matter medullary arteries (WMMAs: dotted lines) from the M3 or M4 segment (A). To standardize radiologic interpretation, the radiologists drew a virtual line from the tip of the anterior horn to the top of the superior limb of the insular cleft (the A–I line). We defined initial LIA damage based on the presence of a hematoma reaching the highest level of the temporal ventricle on coronal or axial CT slices (B).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Yuki Amano, Yohei Yamaguchi, Toshiaki Osato, Toshiichi Watanabe, Kenji Kamiyama, Hirohiko Nakamura" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Yuki" "apellidos" => "Amano" ] 1 => array:2 [ "nombre" => "Yohei" "apellidos" => "Yamaguchi" ] 2 => array:2 [ "nombre" => "Toshiaki" "apellidos" => "Osato" ] 3 => array:2 [ "nombre" => "Toshiichi" "apellidos" => "Watanabe" ] 4 => array:2 [ "nombre" => "Kenji" "apellidos" => "Kamiyama" ] 5 => array:2 [ "nombre" => "Hirohiko" "apellidos" => "Nakamura" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S1130147322000793" "doi" => "10.1016/j.neucir.2022.08.003" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S1130147322000793?idApp=UINPBA00004B" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2529849622001022?idApp=UINPBA00004B" "url" => "/25298496/0000003400000005/v1_202309042000/S2529849622001022/v1_202309042000/en/main.assets" ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Editorial</span>" "titulo" => "Catastrophising in spinal surgery and the impact of radiology reports" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "217" "paginaFinal" => "220" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Pedro David Delgado-López, Carlos Fernández Carballal, Igor Paredes, Héctor Roldan Delgado, David Suárez Fernández, Alfonso Vázquez Míguez" "autores" => array:6 [ 0 => array:4 [ "nombre" => "Pedro David" "apellidos" => "Delgado-López" "email" => array:1 [ 0 => "pedrodl@yahoo.com" ] "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">g</span>" "identificador" => "aff0035" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Carlos" "apellidos" => "Fernández Carballal" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">g</span>" "identificador" => "aff0035" ] ] ] 2 => array:3 [ "nombre" => "Igor" "apellidos" => "Paredes" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">g</span>" "identificador" => "aff0035" ] ] ] 3 => array:3 [ "nombre" => "Héctor" "apellidos" => "Roldan Delgado" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">g</span>" "identificador" => "aff0035" ] ] ] 4 => array:3 [ "nombre" => "David" "apellidos" => "Suárez Fernández" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "aff0025" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">g</span>" "identificador" => "aff0035" ] ] ] 5 => array:3 [ "nombre" => "Alfonso" "apellidos" => "Vázquez Míguez" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">f</span>" "identificador" => "aff0030" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">g</span>" "identificador" => "aff0035" ] ] ] ] "afiliaciones" => array:7 [ 0 => array:3 [ "entidad" => "Servicio de Neurocirugía, Hospital Universitario de Burgos, Burgos, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Neurocirugía, Hospital General Universitario Gregorio Marañón, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Neurocirugía, Hospital Universitario 12 de Octubre, Madrid, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Neurocirugía, Complejo Hospitalario universitario de Canarias, La Laguna, Santa Cruz de Tenerife, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Servicio de Neurocirugía, Complejo Hospitalario Universitario A Coruña, A Coruña, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Servicio de Neurocirugía, Hospital Universitario de Pamplona, Pamplona, Navarra, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] 6 => array:3 [ "entidad" => "Sociedad Española de Cirugía Vertebral y Medular – Neurorraquis, Spain" "etiqueta" => "g" "identificador" => "aff0035" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Catastrofismo en cirugía de columna e impacto de los informes radiológicos" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The vast majority of surgical procedures performed on the spine today are for the purpose of treating various osteodiscal degenerative conditions. These patients usually present with axial pain with or without radicular pain and/or neurological deficits that have usually been previously assessed and treated by general practitioners, rehabilitation medicine physicians and specialists in chronic pain therapy. Broadly speaking, an overwhelming majority of patients with non-specific low back or neck pain and no warning signs improve spontaneously within weeks and months of symptom onset. The relatively benign natural history of degenerative spine disease is well known and well described in the literature.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–7</span></a> However, this fact contrasts sharply with the viewpoint expressed by many fellow doctors and, of course, by patients, who are often unfamiliar with the usual course of these diseases and sometimes confused by overly pessimistic opinions.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Radiology bias and natural history of degenerative spine disease</span><p id="par0010" class="elsevierStylePara elsevierViewall">There is a growing body of literature indicating that performing spinal neuroimaging tests (computed tomography [CT] and/or magnetic resonance imaging [MRI]) too early has a negative impact on the management of patients with low back pain.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8–10</span></a> Attributing too much significance to spinal neuroimaging findings leads to further medical and surgical intervention and may initiate a spiral of iatrogenesis such as that currently seen in certain regions in relation to the over-prescription of, and ensuing addiction to opioid drugs, originally prescribed for chronic pain.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">This <span class="elsevierStyleItalic">radiology bias</span> is explained in part by the high sensitivity, but low specificity, of MRI in identifying the causal origin of pain.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> In fact, it is not uncommon to find patients presenting with severe pain who have little or no MRI findings and, conversely, completely asymptomatic patients with multiple incidental pathological findings.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> Spinal surgery specialists generally use MRI not as a test to confirm the origin of the pain, but as a test to rule out warning signs (trauma, infection, neoplasia or compression of the cauda equina), although, of course, a pathological finding coinciding in both laterality and level and concordant with the patient's symptomatology supports the aetiological diagnosis. On the other hand, neither physicians who are not spinal specialists nor the patient are able to differentiate between relevant and irrelevant findings and may be influenced by other professionals or patients with an alarmist and/or pessimistic perspective, sometimes not free of conflicts of interest, which may result in inappropriate or unnecessary treatment.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Several studies link depressive symptoms and <span class="elsevierStyleItalic">catastrophic thinking</span> with a worse prognosis in patients with low back pain.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">15,16</span></a> This catastrophising is not an irreversible psychological condition but rather a dynamic perception influenced by treatment outcome and patient expectations.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17,18</span></a> Such catastrophising can now be quantified using the Pain Catastrophizing Scale (PCS),<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> a numerical scale of up to 52 points comprising 13 questions that quantify the state of helplessness, magnification and rumination on the problem, with a score in excess of 30 points indicating significant catastrophic thinking. This perception could be related to factors such as the overuse of MRI for non-alarming symptoms, often motivated by the pressure exerted by the patient on the treating physician, and the proliferation of manifold units and clinics specialising in the treatment of acute or chronic pain. In fact, excessive diagnostic effort that is not strictly indicated predisposes to over-utilisation of resources and over-indication of surgical and non-surgical procedures.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> It is recognised that of all the surgical procedures performed in humans, the one whose indication varies the most from one geographical region to another is spinal fusion surgery, with this indication varying by up to a factor of twenty between certain areas and centres.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> The reality is that many spinal procedures that were widely used in the past have been abandoned over time or are in decline, not generally because of the risk they entail but rather because of their ineffectiveness.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">The impact of radiology reports</span><p id="par0025" class="elsevierStylePara elsevierViewall">Nowadays, most patients with spinal conditions have the opportunity to access their radiology test reports via remote applications, and even from their smartphones. This fact, which in principle should be positive in terms of patients having access to their medical data, has not translated into an improvement in patients' health status, but rather the opposite.<a class="elsevierStyleCrossRefs" href="#bib0110"><span class="elsevierStyleSup">22–24</span></a> There is growing evidence in the literature that patients with chronic low back pain who remain <span class="elsevierStyleItalic">blind</span> to these reports do better in terms of pain and function than those who have access to such information.<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">24–26</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">The causes seem to be varied. Firstly, the exhaustive radiological descriptions that can be read in the reports are not easily interpreted by physicians who are not specialists in spinal surgery, and even less so by the patient. Adequate contextualisation of this information is necessary based on the clinical course and especially the age of the patient.<a class="elsevierStyleCrossRef" href="#bib0135"><span class="elsevierStyleSup">27</span></a> The systematic review by Brinjikji et al.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> shows that from a person's forties or fifties onwards, the prevalence of pathological findings in vertebral discs and facet joints in completely asymptomatic individuals exceeds 70–80%.</p><p id="par0035" class="elsevierStylePara elsevierViewall">Moreover, purely factual radiological descriptions negatively influence patients' perception of their pain and lead to poorer functional outcomes, as has recently been demonstrated by Rajasekaran et al.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> in a randomised controlled trial. These authors studied a sample of 44 patients with onset of low back pain at least 12 weeks prior without warning signs or surgical indication at the outset. They randomly divided the patients into two groups: patients in the first group were told the result of their MRI in the usual descriptive way, while those in the second group were told the result of their MRI with emphasis on the low significance of incidental findings. After six weeks of follow-up, pain, illness perception and functional status were assessed using validated scales. The differences were statistically highly significant in favour of the second group. They then identified a number of potentially confusing radiological medical terms and replaced them with simpler or more neutral ones and produced an alternative description called the <span class="elsevierStyleItalic">Clinical MRI Report</span> (as opposed to the <span class="elsevierStyleItalic">Routine MRI Report</span>), which emphasised positive reinforcement, contextualised pathological and incidental findings and de-dramatised their significance in the light of the natural history of the disease. This Clinical Report significantly minimised the negative psychological impact and the perception by the various specialists that the patient would eventually undergo surgery. These authors recommended that radiologists avoid <span class="elsevierStyleItalic">catalogue-type</span> descriptions (based on templates describing all findings, however minimal, level by level), and avoid terms referring to structural damage (e.g. substituting <span class="elsevierStyleItalic">disc degeneration</span> for the appropriate Pfirrmann grade, or replacing <span class="elsevierStyleItalic">annular tear</span> with area of high signal intensity, etc.) that provoke catastrophic thinking.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Several studies suggest that patients' free access to radiology reports is of absolutely no benefit to them and often leads to anxiety and what is known as <span class="elsevierStyleItalic">cyberchondria</span>; an obsessive tendency to search the Internet for information about medical terms and their own disease.<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">26,28,29</span></a> These searches do not seem to alleviate anxiety and they contribute to misinformation and confusion, as well as being a channel for the distribution of pseudo-scientific or outright fraudulent content.<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> It is very important to choose the right words to use in radiology reports so as not to cause unnecessary alarm, but also not to disregard relevant information.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> According to the study by Regev et al.,<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> the terms that most concern patients, generally speaking all those referring to disc abnormalities, are not necessarily those that most concern their doctors, who are more interested in terms referring to nerve root compressions or spinal cord signal changes.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Finally, so-called <span class="elsevierStyleItalic">Remote Reporting</span>, also referred to in the literature as <span class="elsevierStyleItalic">Remote Radiology Readouts</span>, warrants some reflection, fostered by the need to maintain social distancing after the COVID-19 pandemic.<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a> The reality is that an increasing number of centres employ radiologists who produce spinal radiology reports in a location other than the site of the imaging test (sometimes even from other centres, regions or countries) without any access to the patient's clinical information with which to contextualise the findings. This is particularly worrying when it comes to assessing postoperative changes and the evolution of infectious or tumoural processes, where the clinical course and the results of other tests performed (laboratory tests, bone scintigraphy, nuclear, etc.) strongly influence the interpretation of radiological findings.<a class="elsevierStyleCrossRefs" href="#bib0160"><span class="elsevierStyleSup">32,33</span></a> Issuing a radiology report remotely and without clinical information could be equated to writing a report on a surgical procedure without having been present at the surgery. In our view, neuroradiologists need the feedback provided by knowledge of the patient's clinical course and to be part of a team, so that they can interpret neuroimaging findings accurately, without unnecessarily alarming the patient or confusing other specialists involved in the treatment of these patients.<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> One suggested way in which this experience could be gained would be through a specific clinical training programme, for example, through rotations in neurosurgical departments or in established spine surgery units.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Radiology bias and natural history of degenerative spine disease" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "The impact of radiology reports" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:34 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The course and prognostic factors of symptomatic cervical disc herniation with radiculopathy: a systematic review of the literature" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "J.J. Wong" 1 => "P. Côté" 2 => "J.J. Quesnele" 3 => "P.J. Stern" 4 => "S.A. Mior" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.spinee.2014.02.032" "Revista" => array:7 [ "tituloSerie" => "Spine J" "fecha" => "2014" "volumen" => "14" "numero" => "8" "paginaInicial" => "1781" "paginaFinal" => "1789" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24614255" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Natural history of radiculopathy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "E. 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