Cervical radiculopathy and myelopathy: when and what can surgery contribute to treatment?

Conservative Treatment and Surgical Indication of Cervical Ossification of the Posterior Longitudinal Ligament

Ossification of the posterior longitudinal ligament (OPLL) sometimes causes severe myelopathy and requires surgical treatment [...].

Ultrasound-Guided percutaneous laser disc decompression (PLDD) with fluoroscopic validation for the treatment of cervical disc herniation: Technical note

OBJECTIVE

Percutaneous laser disc decompression (PLDD) has been regarded as an effective alternative for the treatment of cervical soft disc herniations. Repeated X-Ray scanning is essential when performing this technique.

DESIGN

Technical note.

METHODS

We present a new method for the treatment of cervical disc herniation using ultrasound to guide the needle entry to the cervical disc, to avoid excess of radiation exposure during the surgical procedure. We evaluated the efficacy of this cervical approach.We retrospectively reviewed the clinical data of 14 cases who underwent a PLDD under ultrasound (US) guidance for the treatment of contained cervical disc herniation using a 1470 Nm diode laser. The lower cervical discs (C5-C6 and C6-C7) were the most affected sites, accounting for 78.6% of surgical discs.A significant NRS reduction between baseline and 1 month (p = 0.0002) and between baseline and 12 months (p = 0.0007) was observed.

CONCLUSIONS

Our results support the conclusion that US guided PLDD with fluoroscopic validation is a minimally invasive technique for patients affected by herniated cervical discs, but proper choice of patients is critical. This approach should not be performed except after adequate training under close supervision of surgeons experienced in this procedure and in interventional US.

Is brace necessary after cervical surgery: A meta-analysis of randomized controlled trials

BACKGROUND

Currently, there are increasing surgical treatments for neck pain. However, whether to use cervical brace after operation remains poorly defined. We aim to clear the clinical efficacy of the use of cervical brace after cervical surgery.

METHODS

We searched for relevant studies in 8 electronic databases up to March 2021. The mean difference and 95% confidence intervals were used for continuous data. Cochrane Collaboration's tool was used to assess the risk of bias. The data were collected and input into the Review Manager 5.3 software (The Cochrane Collaboration, Copenhagen, Denmark).

RESULTS

Four randomized controlled trials were finally included in our study. For pain, the pooled analysis showed that postoperative neck brace compared with no brace can relieve neck pain at all follow-up periods except 6 months. For neck disability index, the result showed that postoperative neck brace compared with no brace can improve neck disability index during the 3 to 12 month follow-up period. However, no significant difference was identified between 2 groups within the follow-up of 6 weeks after surgery. In addition, the result tends to get the opposite at follow-up of 24 months. For 36-Short form health survey Physical Component Summary, there was no significant difference between 2 groups in the early 3 weeks after surgery, but the results were changed after 3 weeks. For 36-short form health survey Mental Component Summary, there appears to be no significant change between 2 groups at all time intervals.

CONCLUSION

Wearing a cervical brace after cervical surgery is conducive to improving symptoms after cervical surgery at different stages. However, there is no relevant evidence indicating it can improve the mental health of postoperative patients. Higher quality, large prospective randomized studies are needed to verify the current conclusions.

Fibrous Connection Between Cervical Nerve and Zygapophysial Joint and Implication of the Cervical Spondylotic Radiculopathy: An Anatomic Cadaveric Study

STUDY DESIGN

Observational, anatomical, cadaveric study.

OBJECTIVE

We anatomically investigated the fibrous connection between the cervical nerves and the zygapophysial joint capsules.

SUMMARY OF BACKGROUND DATA

Cervical spondylotic radiculopathy is caused by the compression of the cervical nerves as the static factor and head and neck movements as the dynamic factor. To understand the dynamic pathology of cervical spondylotic radiculopathy, the anatomic relationship between the cervical nerves and the zygapophysial joints needs to be investigated in detail.

METHODS

In 11 cadavers, we dissected both sides from the C5 to C7. For macroscopic examination, we observed structures connecting the cervical nerves and the zygapophysial joints in 18 cervical nerves from three cadavers. In 14 sides of eight cadavers, we histologically analyzed the fibrous structures and their attachments.

RESULTS

Macroscopically, the fibrous band connected the cranial surface of the cervical nerve to the lateral and inferior aspects of the transverse process. In four of 18 nerves, the fibrous bands were divided into two fascicles by loose connective tissues. In addition, the fibrous bands extended along the dorsal aspect of the posterior tubercle of the transverse process and attached to the zygapophysial joint capsule. Histologically, densely stained fibrous tissues overlaid the zygapophysial joint capsule and extended to the recess between the posterior tubercle and inferior articular process on the cranial vertebral body.

CONCLUSION

We macroscopically and histologically clarified the fibrous bands connecting the cervical nerve to the zygapophysial joint capsule. The fibrous bands may help clarify the pathology of cervical spondylotic radiculopathy associated with the zygapophysial joints as dynamic factors.Level of Evidence: N/A.

From clinic to hypothesis, an innovative operation for the treatment of lumbar spinal stenosis in a minimal invasive way

Concerning the damage to back muscles and posterior ligament complex (PLC) by posterior open approach for lumbar spinal stenosis (LSS), the oblique lateral intervertebral fusion (OLIF) is pretty popular nowadays. However, oblique lateral approach has obvious drawbacks, which are limited vision and operative scope for achieving spinal canal decompression. Herein, we present a hypothesis that lumbar canal decompression can be well achieved by OLIF combined with spinal endoscope operative system. Nerval decompression and spinal reconstruction are achieved in a minimal invasive way, which may play an instructive role for the treatment of serious LSS.

Thunder-Fire Moxibustion for Cervical Spondylosis: A Systematic Review and Meta-Analysis

BACKGROUND

Cervical spondylosis (CS) refers to the degenerative changes in the cervical spinal column, which affect the majority of middle-aged and elderly people. Thunder-fire moxibustion originated from thunder-fire miraculous needle, which has been applied widely for treating pain syndromes for thousands of years. The aim of our research is to provide evidence to assess the efficacy and safety of thunder-fire moxibustion in treating CS. Methods and analysis. Retrieved literature databases included Cochrane Library, MEDLINE, Web of Science, EBSCO, EBASE, Springer, PubMed, WFDP, CNKI, VIP, and CBM. The period of retrieval was from the establishment of the database to December 2018. Randomized controlled trials which compared thunder-fire moxibustion and other therapies in CS were included. The quality of inclusive trials was accessed though a Cochrane risk of bias tool. According to the test results of heterogeneity, a random effect model or fixed effect model was used to analyze the data.

RESULTS

Meta-analysis was conducted for the total effective rate of thunder-fire moxibustion, traditional Chinese medicine syndrome score, pain score, satisfaction score, and score of the symptoms and functional rehabilitation of cervical vertigo. The analysis results were as follows: compared with other therapies, the efficacy of thunder-fire moxibustion was statistically significant, total effective rate increased (OR = 2.48; 95% CI [1.80, 3.41]; P < 0.00001), traditional Chinese medicine syndrome score decreased (SMD = -3.05; 95% CI[-4.18, -1.93]; P < 0.00001), traditional Chinese medicine syndrome score decreased (SMD = -3.05; 95% CI[-4.18, -1.93]; P < 0.00001), traditional Chinese medicine syndrome score decreased (SMD = -3.05; 95% CI[-4.18, -1.93]; P < 0.00001), traditional Chinese medicine syndrome score decreased (SMD = -3.05; 95% CI[-4.18, -1.93]; P < 0.00001), traditional Chinese medicine syndrome score decreased (SMD = -3.05; 95% CI[-4.18, -1.93].

CONCLUSION

Based on the existing evidence, the curative effect and safety of thunder-fire moxibustion on CS were statistically significant. We should interpret the results scrupulously because of the low evidence level. Large-scale, high-quality, rigorous RCTs with long-term follow-up should be performed in the future.

The Odom Criteria: Validated at Last: A Clinimetric Evaluation in Cervical Spine Surgery

BACKGROUND

The Odom criteria, established in 1958, are a widely used, 4-point rating scale for assessing the clinical outcome after cervical spine surgery. Surprisingly, the Odom criteria have never been validated, to our knowledge. The aim of this study was to investigate the reliability and validity of the Odom criteria for the evaluation of surgical procedures of the cervical spine.

METHODS

Patients with degenerative cervical spine disease were included in the study and divided into 2 subgroups on the basis of their most predominant symptom: myelopathy or radiculopathy. Reliability was assessed with interrater and test-retest design using quadratic weighted kappa coefficients. Construct validity was assessed by means of hypotheses testing. To evaluate whether the Odom criteria could act as a global perceived effect (GPE) scale, we assessed concurrent validity by comparing area under the curve (AUC) values of receiver operating characteristic (ROC) curves for the set of questionnaires.

RESULTS

A total of 110 patients were included in the study; 19 were excluded, leaving 91 in our analysis. Reliability assessments showed κ = 0.77 for overall interrater reliability and κ = 0.93 for overall test-retest reliability. Interrater reliability was κ = 0.81 for the radiculopathy subgroup and κ = 0.68 for the myelopathy subgroup. At least 75% of the hypotheses were met. The AUCs showed similar characteristics between the Odom criteria and GPE scale.

CONCLUSIONS

The Odom criteria met the predefined criteria for reliability and validity. Therefore, the Odom criteria may be used to assess surgical outcome after a cervical spine procedure, specifically for patients presenting with radicular symptoms. The results of previous studies that have been deemed less trustworthy because of the use of the Odom criteria should be reconsidered.

Development and Achievement of Cervical Laminoplasty and Related Studies on Cervical Myelopathy

Cervical laminoplasty (CL) is one of the surgical methods via the posterior approach for treating patients with multilevel affected cervical myelopathy (CM). The main purpose of CL is to decompress the cervical spinal cord by widening the narrowed spinal canal, combined with preserving the posterior anatomical structures to the degree possible and preserving the widened space stably. During the development and improvement of spine surgeries including CL, various studies on CM have progressed and useful achievements have been obtained: (1) posterior cervical spine fixation systems that can be used in combination with CL simultaneously have been developed; (2) various materials to stably maintain the enlarged spinal canal have been developed; (3) the main influential factors on the surgical results are the inner factors of the patients, such as the patient's age and the disease duration; (4) various surgical methods to preserve the function of the posterior cervical muscles have been tried to avoid postoperative kyphotic changes of the cervical spine; (5) postoperative complications, such as C5 palsy and axial pain, have been examined, and the countermeasures have been tried; (6) K-line on lateral X-ray films has been applied to evaluate the indication of CL in patients with CM due to ossification of the posterior longitudinal ligament (OPLL) preoperatively; and (7) the method and idea of CL have been adapted to surgeries at the thoracic and lumbar spine. However, some issues remain to be resolved, such as the deterioration of neurological findings, especially in patients with continuous or mixed-type OPLL, the postoperative kyphotic-directional alignment change of the cervical spine, C5 palsy, and axial pain.

Spinal cord MRI signal changes at 1 year after cervical decompression surgery is useful for predicting midterm clinical outcome: an observational study using propensity scores

BACKGROUND CONTEXT

There is little information on the relationship between magnetic resonance imaging (MRI) T2-weighted high signal change (T2HSC) in the spinal cord and surgical outcome for cervical myelopathy. We therefore examined whether T2HSC regression at 1 year postoperatively reflected a 5-year prognosis after adjustment using propensity scores for potential confounding variables, which have been a disadvantage of earlier observational studies.

PURPOSE

The objective of this study was to clarify the usefulness of MRI signal changes for the prediction of midterm surgical outcome in patients with cervical myelopathy.

STUDY DESIGN/SETTING

This is a retrospective cohort study.

PATIENT SAMPLE

We recruited 137 patients with cervical myelopathy who had undergone surgery between 2007 and 2012 at a median age of 69 years (range: 39-87 years).

OUTCOME MEASURES

The outcome measures were the recovery rates of the Japanese Orthopaedic Association (JOA) scores and the visual analog scale (VAS) scores for complaints at several body regions.

MATERIALS AND METHODS

The subjects were divided according to the spinal MRI results at 1 year post surgery into the MRI regression group (Reg+ group, 37 cases) with fading of T2HSC, or the non-regression group (Reg- group, 100 cases) with either no change or an enlargement of T2HSC. The recovery rates of JOA scores from 1 to 5 years postoperatively along with the 5-year postoperative VAS scores were compared between the groups using t test. Outcome scores were adjusted for age, sex, diagnosis, symptom duration, and preoperative JOA score by the inverse probability weighting method using propensity scores.

RESULTS

The mean recovery rates in the Reg- group were 35.1%, 34.6%, 27.6%, 28.0%, and 30.1% from 1 to 5 years post surgery, respectively, whereas those in the Reg+ group were 52.0%, 52.0%, 51.1%, 49.0%, and 50.1%, respectively. The recovery rates in the Reg+ group were significantly higher at all observation points. At 5 years postoperatively, the VAS score for pain or numbnessin the arms or hands of the patients in the Reg+ group (24.7 mm) was significantly milder than that of the patients in the Reg- group (42.2 mm).

CONCLUSIONS

Spinal T2HSC improvement at 1 year postoperatively may predict a favorable recovery until up to 5 years after surgery.

High-resolution diffusion tensor imaging in cervical spondylotic myelopathy: a preliminary follow-up study

Diffusion imaging is a promising technique as it can provide microstructural tissue information and thus potentially show viable changes in spinal cord. However, the traditional single-shot imaging method is limited as a result of various image artifacts. In order to improve measurement accuracy, we used a newly developed, multi-shot, high-resolution, diffusion tensor imaging (DTI) method to investigate diffusion metric changes and compare them with T₂ -weighted (T2W) images before and after decompressive surgery for cervical spondylotic myelopathy (CSM). T2W imaging, single-shot DTI and multi-shot DTI were employed to scan seven patients with CSM before and 3 months after decompressive surgery. High signal intensities were scored using the T2 W images. DTI metrics, including fractional anisotropy (FA), axial diffusivity (AD), radial diffusivity (RD) and mean diffusivity (MD), were quantified and compared pre- and post-surgery. In addition, the relationship between imaging metrics and neurological assessments was examined. The reproducibility of multi-shot DTI was also assessed in 10 healthy volunteers. Post-surgery, the mean grade of cervical canal stenosis was reduced from grade 3 to normal after 3 months. Compared with single-shot DTI, multi-shot DTI provided better images with lower artifact levels, especially following surgery, as a result of reduced artifacts from metal implants. The new method also showed acceptable reproducibility. Both FA and RD values from the new acquisition showed significant differences post-surgery (FA, p = 0.026; RD, p = 0.048). These changes were consistent with neurological assessments. In contrast, T2W images did not show significant changes before and after surgery. Multi-shot diffusion imaging showed improved image quality over single-shot DWI, and presented superior performance in diagnosis and recovery monitoring for patients with CSM compared with T2W imaging. DTI metrics can reflect the pathological conditions of spondylotic spinal cord quantitatively and may serve as a sensitive biomarker for potential CSM management.

Comparison of morphology between patients with and without developmental spinal canal stenosis to inform the feasibility of C1 lateral mass screw insertion in the atlas

BACKGROUND

C1 lateral mass screws are increasingly being used as an effective anchoring system. Insufficient posterior arch height increases difficulty of inserting the screws using the Tan method. The general aim of our retrospective cross-sectional study was to clarify the atlas morphology of patients with developmental spinal canal stenosis to evaluate the usefulness of the Tan method.

METHODS

A computed tomography myelogram was performed in 85 Japanese patients presenting with spinal disorders. The following morphological measures at the level of the atlas were obtained: anterior-posterior length (APL), medial-lateral width (MLW), lateral mass transverse diameter (LMTD), dural sac area (DSA), spinal cord area (SCA), lateral mass height (LMH), lateral mass width (LMW), lateral mass length (LML), posterior arch length (PAL), posterior lamina height (PLH), and posterior vertebral groove height (PVGH). Patients were classified into two groups: patients with developmental spinal canal stenosis (DCS), identified by a longitudinal diameter of the spinal canal <12 mm and patients without developmental spinal canal stenosis (NDCS), identified by a longitudinal diameter of the spinal canal ≥12 mm. Measures obtained on the computed tomography images were compared between the two groups.

RESULTS

Among the 85 patients in our study group, developmental spinal stenosis was identified in 47 patients. The APL, DSA, PAL and PVGH measurements were significantly smaller among the 47 patients in the DCS group, compared to the 38 patients in the NDCS group (p < 0.01). The mean height of the PVGH was <4.0 mm in 63.5% of the total study group.

CONCLUSIONS

The normally inserted C1 lateral mass screws have a diameter of 3.5-4.0 mm, and hence, the Tan method require a posterior arch height that exceeds this value. Our study provides evidence of a narrower posterior arch in Japanese individuals with developmental spinal canal stenosis. Therefore, the safe use of the Tan method to insert C1 lateral mass screws may be limited in Japanese individuals with developmental spinal canal stenosis.

Signal intensity ratio on magnetic resonance imaging as a prognostic factor in patients with cervical compressive myelopathy

Patients with intramedullary signal intensity (SI) changes have a poor prognosis after surgical decompression in cervical compressive myelopathy (CCM); however, some patients show no clear relationship between the SI and postsurgical prognosis. This discrepancy may be because no comprehensive and proper quantitative evaluation exists to assess SI on magnetic resonance imaging (MRI). The purpose of this study was prospectively to evaluate the correlation between the clinical features, neurological outcome of patients with CCM, and the quantitative assessment of SI changes preoperatively and postoperatively, and the correlation with SI severity.A total of 112 patients with CCM at 1 or 2 levels underwent anterior cervical discectomy and fusion. We quantitatively analyzed MR signal changes on T1-weighted MR images (T1WI), gadolinium-diethylenetriaminepentaacetic acid (Gd-DTPA) contrast-enhanced T1WI, and T2-weighted MR images (T2WI) using the signal intensity ratio (SIR). We evaluated the correlations between various variables and neurological outcome using the Japanese Orthopedic Association (JOA) scale, and the severity of SI change by grade (i.e., grade 0 ["none"], grade 1 ["light"], and grade 2 ["bright on T2WI"]).Significant differences between the 3 grades existed in symptom duration, preoperative JOA score, SIR on T2WI, and JOA recovery ratio. The JOA recovery ratio was negatively correlated with symptom duration and the SIR on T2WI, and positively correlated with the preoperative JOA score and cord compression ratio, but not with the SIR on T1WI and contrast-enhanced T1WI. On the postoperative 12-month follow-up MRI, the JOA recovery ratio and SIR on T2WI of the SI reversal patients were better than those of the nonreversal patients. On multiple regression analysis, the SIR on T2WI was the main significant prognostic factor of surgical outcome.The grading system on T2WI provided reliable predictive information for neurological outcome. Quantitative alterations in the SI on preoperative and postoperative T2WI, but not T1WI or contrast-enhanced T1WI, reflected the clinical features, surgical outcomes, and the correlation with SI severity. The patients with a longer duration of symptoms, lower cord compression ratio, severe myelopathy, intense signal change (i.e., grade 2) on the spinal cord, and an SIR greater than 1.55 had a poor recovery after a surgical operation.

The Triangle Model of Congenital Cervical Stenosis

STUDY DESIGN

Retrospective Cross-Sectional Study OBJECTIVE.: Identify the pathoanatomical features of the cervical spine associated with congenital stenosis SUMMARY OF BACKGROUND DATA.: Congenital cervical stenosis (CCS) describes a patient with a decreased spinal canal diameter at multiple levels of the cervical spine in the absence of degenerative changes. Despite recognition of CCS throughout the literature, the anatomical features that lead to this condition have not been established. Knowledge of the pathoanatomy behind CCS may lead to alterations in surgical technique for this patient population that may improve outcomes.

METHODS

From 1000 cervical MRIs between January 2000 and December 2014, CCS was identified in 68 patients using a strict definition of age less than 50 years with mid-sagittal canal diameters (mid-SCD) (<10  mm) at multiple sub-axial cervical levels (C3-C7). A total of 68 patients met the inclusion criteria for this group. Fourteen controls with normal SCDs (>14  mm) at all cervical levels were used for comparison. Anatomic measurements obtained at each level (C3-C7) included: coronal vertebral body, AP vertebral body, pedicle width, pedicle length, laminar length, AP lateral mass, posterior canal distance, lamina-pedicle angle, and lamina-disc angle (LDA). Statistical significance was defined as P < 0.01.

RESULTS

CCS patients demonstrated significantly different anatomical measurements when compared with controls. Significantly smaller lateral masses, lamina lengths, lamina-pedicle angles, and larger LDAs were identified at levels C3 to C7 in the CCS group (P < 0.01). These anatomic components form a right triangle that illustrates the cumulative narrowing effect on space for the spinal cord.

CONCLUSION

The pathoanatomy of CCS is associated with a decrease in the lamina-pedicle angle and an increase in the LDA ultimately leading to a smaller SCD. The global changes in CCS are best illustrated by this triangle model and are driven by the posterior elements of the cervical spine.

LEVEL OF EVIDENCE

4.

The Occupancy of the Components in the Cervical Spine and Their Changes with Extension and Flexion

Study Design Retrospective case series. Objectives The kinematics of the cervical spine has been investigated by many researchers. However, the occupancy of the disk bulges, spinal cord, ligamentum flavum, and the rest of the canal as well as the changes of these structures with motion have not yet been investigated. The goal of this study is to investigate these dynamic changes. Methods The kinetic magnetic resonance images of 248 patients (124 men and 124 women) were evaluated, and the occupancy of each structure for each cervical level at neutral, flexion, and extension were calculated. Results Whole canal anteroposterior (AP) diameters showed significant differences between neutral-extension and flexion-extension at the C4-C5 and C5-C6 levels (p < 0.05). The mean disk bulges showed significant differences between neutral-flexion and flexion-extension at the C4-C5, C5-C6, C6-C7, and C7-T1 levels (p < 0.01). The mean spinal canal AP diameter showed significant differences between flexion-extension and neutral-extension at the C3-C4, C4-C5, C5-C6, and C6-C7 levels (p < 0.05). There were significant differences between neutral-flexion at the C4-C5, C5-C6, and C6-C7 levels (p < 0.05). The mean thickness of the ligamentum flavum showed significant differences between flexion-extension at the C3-C4, C4-C5, C5-C6, and C6-C7 levels (p < 0.001). There were significant differences between neutral-extension at the C3-C4 and C5-C6 levels (p < 0.05). There were significant differences between neutral-flexion at the C5-C6 and C6-C7 levels (p < 0.05). The mean thickness of the spinal cord showed significant differences between neutral-flexion at the C2-C3 and C3-C4 levels (p < 0.05). There were significant differences between flexion-extension at the C3-C4 and C4-C5 levels (p < 0.01). The rest of the canal showed significant differences between neutral-extension and flexion-extension at the C3-C4, C4-C5, C5-C6, and C6-C7 levels (p < 0.005). There were significant differences between neutral-flexion at the C5-C6 and C6-C7 levels (p < 0.01). Conclusions The occupancy of each structure in the cervical spine for each level was revealed by this study. In addition, the dynamic changes in the cervical spine with flexion and extension were seen to have different characteristics for each level.

Prevalence and distribution of thoracic and lumbar compressive lesions in cervical spondylotic myelopathy

Study Design

Retrospective cross-sectional study.

Purpose

This study analyzed the prevalence and distribution of horacic and lumbar compressive lesions in cervical spondylotic myelopathy as well as their relationships with cervical developmental spinal canal stenosis (DCS) by using whole-spine postmyelographic computed tomography.

Overview of Literature

There are few studies on missed compressive lesions of the spinal cord or cauda equina at the thoracolumbar level in cervical spondylotic myelopathy. Furthermore, the relationships between DCS, and the prevalence and distribution of thoracic and lumbar compressive lesions are unknown.

Methods

Eighty patients with symptomatic cervical spondylotic myelopathy were evaluated. Preoperative image data were obtained. Patients were classified as DCS or non-DCS (n=40 each) if their spinal canal longitudinal diameter was <12 mm at any level or ≥12 mm at all levels, respectively. Compressive lesions in the anterior and anteroposterior parts, ligamentum flavum ossification, posterior longitudinal ligament ossification, and spinal cord tumors at the thoracolumbar levels were analyzed.

Results

Compressive lesions in the anterior and anteroposterior parts were observed in 13 (16.3%) and 45 (56.3%) patients, respectively. Ligamentum flavum and posterior longitudinal ligament ossification were observed in 19 (23.8%) and 3 (3.8%) patients, respectively. No spinal cord tumors were observed. Thoracic and lumbar compressive lesions of various causes tended to be more common in DCS patients than non-DCS patients, although the difference was statistically insignificant.

Conclusions

Surveying compressive lesions and considering the thoracic and lumbar level in cervical spondylotic myelopathy in DCS patients are important for preventing unexpected neurological deterioration and predicting accurate neurological condition after cervical surgery.

Clinical Outcomes After Cervical Transcorporeal Microdecompression and Vertebral Body Access Channel Repair

BACKGROUND

Although anterior cervical decompression and fusion (ACDF) can be performed using minimally invasive techniques, the extensive removal of anatomical keystones during decompression requires a segmental fusion to restore biomechanical stability. Treatment with arthrodesis techniques may result in a prolonged recovery time, loss of motion, and the need for further treatment if a pseudarthosis or adjacent segment disease occur. Transcorporeal micro decompression (TCMD) is a newly developed motion sparing, minimally invasive anterior cervical spine decompression procedure that utilizes a small channel through the cervical vertebral body to decompress areas of central or foraminal stenosis while preserving the native disc. Cervical decompression with TCMD can be performed as a stand-alone or hybrid procedure with ACDF at the adjacent levels. This study retrospectively assesses patient based clinical outcome measures in patients treated with TCMD.

METHODS

A retrospective, non-randomized, single-center chart review of single surgeon experience with patients undergoing TCMD both with and without adjacent level ACDF using both a trajectory control guide and access channel repair. Statistical analyses were performed on pre and post-operative data collected using visual analog scale (VAS) and neck disability index (NDI) outcome measures.

RESULTS

Among 62 patients, there were no cases of neurovascular injury, CSF leak, transfusion, or migration of repair implement. Revision surgery was required in 6.4% (n=4) patients. A subanalysis of outcome metrics was performed for patients that underwent standalone TCMD (TCMD group, n=42) and TCMD with concurrent ACDF at one or more levels (TCMD+ACDF group, n=20). TCMD group NDI improved from 20.0 to 2.7 at 1 year (p=0.0001); Axial VAS improved from 5.5 to 0.6 (p=0.0001); and Radiating VAS improved from 7.0 to 0.7 (p=0.0001). TCMD+ACDF group NDI improved from 22.0 to 4.0 at 1 year (p=0.004); Axial VAS improved from 7.1 to 1.2 (p=0.01); and Radiating VAS trended towards significant improvement from 6.4 to 2.3 (p=0.09). Mean return to work was 10 days in the TCMD group and 57 days in the TCMD+ACDF group.

CONCLUSIONS

Within the limits of a retrospective, single-surgeon study, patients did experience both functional improvement and pain relief as measured by NDI and VAS respectively from standalone TCMD or combined ACDF / TCMD procedures. Definitive statements on long-term efficacy, disc space preservation, and motion preservation await further study.

Functional assessment of patients with cervical myelopathy who underwent surgical treatment

OBJECTIVE: Evaluate and correlate the functional response of patients with cervical myelopathy with the current clinical scores in patients who underwent surgical treatment. METHODS: We analyzed medical records of 34 patients with cervical myelopathy who underwent four different types of surgery. All patients were evaluated preoperatively and postoperatively with the application of the JOA and Nurick questionnaires. RESULTS: Functional clinical improvement was statistically significant. The mean preoperative JOA was 8.5 ± 3.06 and 10.7 ± 3.9 in the postoperative; Nurick was 3.2 ± 1.1 preoperatively and 2.8 ± 1.3 postoperatively. CONCLUSION: There is benefit with the surgical procedure in patients with cervical myelopathy. The neurological function after surgery depends on the previous function (the higher the duration of the previous symptoms, the greater the progression of the disease and, therefore, worse the neurological function) and the age is not a relevant factor of improvement, as already shown in other series. The clinical functional improvement of patients is visible with surgical treatment, regardless of surgical technique.

Functional Outcomes of Surgery in Cervical Spondylotic Radiculopathy versus Myelopathy: A Comparative Study

Background. Cervical spondylosis can cause three different categories of symptoms and signs with possible overlap in the affected patients. Aim. We aim to compare functional outcome of surgery in the patients with cervical spondylotic radiculopathy and myelopathy, regardless of their surgical type and approach. Materials and Methods. We retrospectively reviewed 140 patients with cervical spondylotic radiculopathy and myelopathy who had been operated from August 2006 to January 2011, as Group A (68 cases) and Group B (72 cases), respectively. The mean age was 48.2 and 55.7 years, while the mean followup was 38.9 and 37.3 months, respectively. Functional outcome of the patients was assessed by neck disability index (NDI) and patient satisfaction with surgery. Results. Only in Group A, the longer delay caused a worse surgical outcome (NDI). In addition, in Group B, there was no significant relationship between imaging signal change of the spinal cord and our surgical outcomes. Improvement in NDI and final satisfaction rate in both groups are comparable. Conclusions. Surgery was associated with an improvement in NDI in both groups (P < 0.001). The functional results in both groups were similar and comparable, regarding this index and patient's satisfaction score.

The natural history of asymptomatic lumbar canal stenosis in patients undergoing surgery for cervical myelopathy

We retrospectively examined the prevalence and natural history of asymptomatic lumbar canal stenosis in patients treated surgically for cervical compressive myelopathy in order to assess the influence of latent lumbar canal stenosis on the recovery after surgery. Of 214 patients who had undergone cervical laminoplasty for cervical myelopathy, we identified 69 (32%) with myelographically documented lumbar canal stenosis. Of these, 28 (13%) patients with symptomatic lumbar canal stenosis underwent simultaneous cervical and lumbar decompression. Of the remaining 41 (19%) patients with asymptomatic lumbar canal stenosis who underwent only cervical surgery, 39 were followed up for ≥ 1 year (mean 4.9 years (1 to 12)) and were included in the analysis (study group). Patients without myelographic evidence of lumbar canal stenosis, who had been followed up for ≥ 1 year after the cervical surgery, served as controls (135 patients; mean follow-up period 6.5 years (1 to 17)). Among the 39 patients with asymptomatic lumbar canal stenosis, seven had lumbar-related leg symptoms after the cervical surgery.

Kaplan–Meier analysis showed that 89.6% (95% confidence interval (CI) 75.3 to 96.0) and 76.7% (95% CI 53.7 to 90.3) of the patients with asymptomatic lumbar canal stenosis were free from leg symptoms for three and five years, respectively. There were no significant differences between the study and control groups in the recovery rate measured by the Japanese Orthopaedic Association score or improvement in the Nurick score at one year after surgery or at the final follow-up.

These results suggest that latent lumbar canal stenosis does not influence recovery following surgery for cervical myelopathy; moreover, prophylactic lumbar decompression does not appear to be warranted as a routine procedure for coexistent asymptomatic lumbar canal stenosis in patients with cervical myelopathy, when planning cervical surgery.

Prospective cohort study of mild cervical spondylotic myelopathy without surgical treatment

OBJECT

Because the main pathology of cervical spondylotic myelopathy (CSM) is spinal cord damage due to compression, surgical treatment is usually recommended to improve patient symptoms and prevent exacerbation. However, lack of clarity of prognosis in cases that present with insignificant symptoms, particularly those of mild CSM, lead one to question the veracity of this course of action. The purpose of this study was to elucidate the prognosis of mild CSM without surgical intervention by evaluation of clinical symptoms and MR imaging findings.

METHODS

Sixty cases of mild CSM (42 males and 18 females, average age 57.2 years) presenting with scores of 13 or higher on the Japanese Orthopaedic Association (JOA) scale were treated initially by in-bed Good Samaritan cervical traction without surgery. These patients were enrolled between 1995 and 2003 and followed up periodically until the date of myelopathy deterioration or until the end of March 2009. The deterioration of myelopathy was defined as a decline in JOA score to less than 13 with a decrease of at least 2 points. As a prognostic factor, the authors used their classification of spinal cord shapes at their lateral sides on axial T1-weighted MR imaging. "Ovoid deformity" was classified as a situation in which both sides were round and convex, and "angular-edged deformity" where one or both sides exhibited an acute-angled lateral corner. The duration of follow-up was assessed as the tolerance rate of mild CSM using Kaplan-Meier survival analysis and compared between 2 groups classified by MR imaging findings. Furthermore, differences between groups were analyzed by various applications of the log-rank test.

RESULTS

Of the initial 60 cases, follow-up records existed for 55, giving a follow-up rate of 91.7% (38 males and 17 females, average age 56.1 years). The mean JOA score at end point was 14.1, which was not statistically different from the mean of 14.5 at the initial visit. Deterioration in myelopathy was observed in 14 (25.5%) of 55 cases, whereas 41 (74.5%) of 55 cases maintained mild extent myelopathy without deterioration through the follow-up period (mean 94.3 months). The total tolerance rate of mild CSM was 70%. However, there was a significant difference in the tolerance rate between the cases with angular-edged deformity (58%) and cases with ovoid deformity (95%; p = 0.049).

CONCLUSIONS

The tolerance rate of mild CSM was 70% in this study, which proved that the prognosis of mild CSM without surgical treatment was relatively good. However, the tolerance rate of the cases with angular-edged deformity was 58%. Therefore, surgical treatment should be considered when mild CSM cases show angular-edged deformity on axial MR imaging, even if patients lack significant symptoms.

Correlation of magnetic resonance imaging findings and reported symptoms in patients with chronic cervical dysfunction

Information gathered from the patient history, physical examination, and advanced testing augments the decision-making process and is proposed to improve the probability of diagnostic and prognostic accuracy. However, these findings may provide inconsistent results and can lead to errors in decision-making. The purpose of this study was to examine the relationship between common clinical complaints and specific findings on magnetic resonance imaging (MRI) in patients with chronic neck dysfunction. Forty-five English-speaking participants (25 female), with mean age of 52 (SD = 13.4), were evaluated by a neurosurgeon for complaints of symptoms related to the cervical spine. All participants answered a subjective questionnaire and received an MRI of the cervical spine. Cramer's V nominal correlation was performed to explore the relationship between the targeted variables. The correlation matrix calculations captured three significant findings. Evidence of spinal cord compression was significantly correlated to 1) anteroposterior canal diameter of less than or equal to 9 mm (r = .31; p<0.05) and 2) diminished subarachnoid fluid around the cord (r = .48; p<0.01). Report of loss of dexterity was significantly correlated with 3) report of lower extremity clumsiness (r = .33; p<0.05). In this study, no definitive relationships were found between the clinical complaints of neck pain, hand function, or clumsiness and specific MRI findings of spinal cord compression. Further research is needed to investigate the diagnostic utility of subjective complaints and their association with advanced testing.

[Neck pain with and without affection of nerve roots]

BACKGROUND

The prevalence of neck pain is 30-50 %, and those most affected are women and people in working age. Neck pain and other musculoskeletal complaints are among the most common causes for sick leave and disability pension in Norway, which emphasises the need for guidelines on diagnostic assessment and treatment of these patients.

MATERIAL AND METHODS

This paper is based on a review of "The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorder", Cohrane overviews and some additional sources.

RESULTS

A classification of neck pain into grades I-IV is recommended as a tool for daily clinical work. Unspecific neck pain (grades I and II) is still a challenge and the various underlying conditions are not well defined. Diagnostics and assessment of neck pain is mainly directed towards nerve root affection (grade III) or serious neck disease (grade IV).

INTERPRETATION

Treatment of neck pain is not sufficiently evidence-based, as there are few high-quality publications within this field. Research within the field is clearly needed and should be prioritized nationally.

Morphological analysis of the cervical pedicles, lateral masses, and laminae in developmental canal stenosis

STUDY DESIGN

Retrospective cross-sectional study.

OBJECTIVE

This study aimed to elucidate the relationship between developmental spinal canal stenosis (DCS) and morphologic features in the cervical spine by comparing the features between DCS and nondevelopmental spinal canal stenosis (NDCS).

SUMMARY OF BACKGROUND DATA

DCS is an important predisposing factor for cervical myelopathy. Further, various posterior cervical spinal instrumentations have been developed. However, no study has specifically addressed the cervical posterior morphology of DCS.

METHODS

A total of 52 consecutive patients underwent cervical spine computed tomography myelography. Axial images of the largest pedicle diameter were selected from C3 to C7 vertebrae and 260 images were analyzed. The following parameters were measured: spinal canal longitudinal diameter (SCLD), spinal canal transverse diameter, osseous spinal canal area, dural sac area, spinal cord area, pedicle outer width, pedicle axis length, pedicle transverse angulation, lateral mass longitudinal diameter, lateral mass transverse diameter, lamina outer width, and lamina axis length. The participants were classified into 2 groups: DCS group (SCLD <12 mm at any level) and NDCS group (SCLD ≧12 mm at all levels).

RESULTS

The mean osseous spinal canal area and dural sac area at C3-C5 in the DCS group were less than those in the NDCS group. The mean spinal cord area did not differ significantly at C3-C7 between the groups. The mean pedicle outer width at C6 and C7 in the DCS group was less than that in NDCS group. The mean lateral mass transverse diameter at C5 and mean lateral mass longitudinal diameter at C3, C5, and C6 in the DCS group were less than those in the NDCS group.

CONCLUSION

Myelopathy is expected to progress in patients with DSC and these patients with severe neurologic symptoms may need cervical operation. However, posterior screw insertions should be considered more carefully than in NDCS patients.

Degenerative spondylolisthesis does not influence surgical results of laminoplasty in elderly cervical spondylotic myelopathy patients

The objective of the study was to investigate the comorbidity of degenerative spondylolisthesis (DS), in elderly cervical spondylotic myelopathy (CSM) patients in our hospital, and the correlation between surgical results and preoperative DS. There are few studies on the outcome of laminoplasty for CSM with DS. A total of 49 elderly patients (>65 years old) who eventually had surgical treatment for CSM were evaluated. A slippage displacement of more than 2.5 mm at least at one level was classified to have a positive DS on flexion/extension radiographs (DS group). A slippage displacement less than 1.0 mm was considered a negative DS (non-DS group). Seventeen patients who had slippage of 1.0-2.5 mm were excluded from the study. The DS group (n = 15) included cases with DS at preoperation, while the remaining cases (n = 17) belonged to the non-DS group. The flexion/extension radiographs of the two groups were compared for range of motion and clinical results at 3 years after the operation. Of all elderly patients, 30.6% had DS. There was no significant difference between the two groups based on the clinical results. The range of motion of all cervical spines (DS group and non-DS group) was significantly limited. However, there was no significant difference between the two groups. New postoperative DS appeared in four patients, of which two were from the DS group and two from the non-DS group. These data suggest that degenerative spondylolisthesis does not influence surgical results in elderly cervical spondylotic myelopathy patients.

Plasma disc decompression for contained cervical disc herniation: a randomized, controlled trial

Prospective case series studies have shown that plasma disc decompression (PDD) using the COBLATION SpineWand device (ArthroCare Corporation, Austin, TX) is effective for decompressing the disc nucleus in symptomatic contained cervical disc herniations. This prospective, randomized controlled clinical trial was conducted to evaluate the clinical outcomes of percutaneous PDD as compared to conservative care (CC) through 1 year. Patients (n = 115) had neck/arm pain >50 on the visual analog scale (VAS) pain scale and had failed at least 30 days of failed CC. Patients were randomly assigned to receive either PDD (n = 62) or CC (n = 58). Clinical outcome was determined by VAS pain score, neck disability index (NDI) score, and SF-36 health survey, collected at 6 weeks, 3 months, 6 months, and 1 year. The PDD group had significantly lower VAS pain scores at all follow-up time points (PDD vs. CC: 6 weeks, -46.87 +/- 2.71 vs. -15.26 +/- 1.97; 3 months, -53.16 +/- 2.74 vs. -30.45 +/- 2.59; 6 months, -56.22 +/- 2.63 vs. -40.26 +/- 2.56; 1 year, -65.73 +/- 2.24 vs. -36.45 +/- 2.86; GEE, P < 0.0001). PDD patients also had significant NDI score improvement over baseline when compared to CC patients at the 6 weeks (PDD vs. CC: -9.15 +/- 1.06 vs. -4.61 +/- 0.53, P < 0.0001) and 1 year (PDD vs. CC: -16.70 +/- 0.29 vs. -12.40 +/- 1.26, P = 0.005) follow-ups. PDD patients showed statistically significant improvement over baseline in SF-36 physical component summary scores when compared to CC patients at 6 weeks and 1 year (PDD vs. CC: 8.86 + 8.04 vs. 4.24 +/- 3.79, P = 0.0004; 17.64 +/- 10.37 vs. 10.50 +/- 10.6, P = 0.0003, respectively). In patients who had neck/arm pain due to a contained cervical disc herniation, PDD was associated with significantly better clinical outcomes than a CC regimen. At 1 year, CC patients appeared to suffer a "relapse, showing signs of decline in most measurements, whereas PDD patients showed continued stable improvement.

Does developmental canal stenosis influence surgical results of bilateral open-door laminoplasty for cervical spondylotic myelopathy?

OBJECT

The purpose of this study was to investigate the prevalence of developmental canal stenosis in patients with cervical spondylotic myelopathy (CSM), and the correlation between surgical results and degree of developmental canal stenosis.

METHODS

A total of 112 patients who eventually had surgical treatment for CSM were evaluated. Male patients whose sagittal spinal diameter was < 14 mm and females whose sagittal diameter was < 13 mm even at one level were classified as having developmental canal stenosis. Two groups of patients were used in this study; the "positive" group (57 cases) included patients with developmental canal stenosis preoperatively, whereas the "negative" group (55 cases) excluded such patients. Lateral functional radiographs obtained in patients in the 2 groups were compared for range of motion and clinical results.

RESULTS

Developmental canal stenosis was found in 50.9% of all cases. Based on clinical results, there was no significant difference between the 2 groups.

CONCLUSIONS

Patients with CSM showed a high incidence of preoperative developmental canal stenosis. However, there were no significant differences in clinical results between patients with and without this disorder. These results indicate that developmental canal stenosis is not a factor that influences surgical results.

The correlation of diffusion-weighted magnetic resonance imaging in cervical compression myelopathy with neurologic and radiologic severity

STUDY DESIGN

A retrospective evaluation of diffusion-weighted imaging, apparent diffusion coefficient (ADC) maps, and T2-weighted images in patients with cervical compression myelopathy.

OBJECTIVE

To correlate high signal intensity on ADC maps and T2-weighted images to neurologic severity and radiologic spinal cord compression.

SUMMARY OF BACKGROUND DATA

Previous studies indicated that the ADC map was more sensitive in detection of cervical compressive myelopathy than T2-weighted imaging. The relationship to neurologic severity has not been previously published.

METHODS

In 100 patients with or without cervical compressive myelopathy, the magnetic resonance appearance of the spinal cord on ADC maps and T2-weighted images was evaluated independently by 2 readers. On the basis of the presence or absence of abnormality, patients were categorized into 4 groups by type of intramedullary change. The degree of canal compression and the Japanese Orthopedic Association (JOA) score for cervical myelopathy were compared among the 4 types.

RESULTS

The type I group consisted of 32 patients without signal change on either ADC maps or T2-weighted images. The type II group had 33 patients with high signal intensity only on the ADC map. The type III group contained 28 patients with high signal intensity on both the ADC map and the T2-weighted images. The type IV group comprised 7 patients with high signal intensity only on T2-weighted images. The degree of canal compression and the JOA scores were significantly different among the 4 groups (P < 0.005). Most type III (25 of 28) and type IV (7 of 7) patients had severe cord compression. Average JOA scores in each type were (I) 16.0, (II) 14.7, (III) 11.7, and (IV) 8.7.

CONCLUSION

ADC maps demonstrated internal changes in the early stages of chronic spinal cord compression, but had limitations for the detection of intramedullary changes in late-stage myelopathy.

Prognostic factors for deterioration of patients with cervical spondylotic myelopathy after nonsurgical treatment

STUDY DESIGN

A prospective study involving 56 patients with cervical spondylotic myelopathy (CSM) was conducted.

OBJECTIVE

To investigate the outcomes and prognostic factors for CSM after nonsurgical treatment.

SUMMARY OF BACKGROUND DATA

The superiority of surgical treatment over nonsurgical treatment has not been confirmed in mild forms of CSM. Outcomes and prognostic factors for nonsurgical treatment of mild forms of CSM are not well understood.

METHODS

Clinical signs and symptoms of CSM were assessed by Japanese Orthopedic Association (JOA) scores. Nonsurgical treatment was selected for patients with mild forms of CSM (JOA >or=13 patients). Seventy patients with mild forms of CSM were enrolled in the study between 1995 and 2003. The follow-up rate was 80.0%. Prognostic factors that exacerbate clinical symptoms of CSM were examined, such as age, gender, follow-up period, developmental or dynamic factors on plain lateral radiograph, high signal intensity area on T2-weighted sagittal MRI, and the extent of maximum cord compression; partial or circumferential spinal cord compression, on axial MRI. Univariate and multivariate logistic regression analysis were carried out to test for significant prognostic factors.

RESULTS

There was, on average, no statistically significant deterioration in JOA scores after nonsurgical treatment. However, 11 of 56 patients deteriorated after nonsurgical treatment. The only factor that significantly exacerbated clinical symptoms of CSM was circumferential spinal cord compression in the maximum compression segment on axial MRI. Indeed, 10 of 33 CSM patients with circumferential spinal cord compression on axial MRI deteriorated after nonsurgical treatment.

CONCLUSION

Outcomes of mild forms of CSM during nonsurgical treatment were generally good as shown by average JOA scores. The only prognostic factor for mild forms of CSM was circumferential spinal cord compression in the maximum compression segment on axial MRI. Surgical treatment can be considered for patients with this prognostic factor.

Cutaneous silent periods in the evaluation of cord compression in cervical spondylosis

OBJECTIVE

The clinical diagnosis of cervical spondylotic myelopathy (CSM) may be challenging in patients with cervical spondylosis (CS). Routine nerve conduction studies (NCS) may not evaluate cord compression adequately.

METHODS

We obtained cutaneous silent periods (CSP) in 26 consecutive patients presenting with clinical features of CS, in comparison with 30 normal controls. The results were also compared with transcranial magnetic stimulation (TMS) findings, and magnetic resonance imaging of the cervical cord as the gold standard.

RESULTS

CSP findings showed similarly high sensitivity of up to 96% with TMS in evaluating cervical cord dysfunction.

CONCLUSION

In specific clinical settings, CSP is of value for the diagnosis of CSM in CS. CSP measurement is advocated as a simple and rapid diagnostic adjunct to NCS in evaluating CS patients with possible cord compromise.

Transcranial magnetic stimulation screening for cord compression in cervical spondylosis

OBJECTIVE

Cervical spondylosis (CS) often results in various degrees of cord compression, which can be evaluated functionally with transcranial magnetic stimulation (TMS). We investigate the use of TMS as a screening tool for myelopathy in CS.

METHODS

We prospectively studied 231 patients classified into Groups 1 to 4 based on MRI grading of severity of cord compromise. TMS elicited central motor conduction times and motor evoked potential (MEP) amplitudes in all 4 limbs. The results were compared with those from 45 healthy controls.

RESULTS

TMS showed 98% sensitivity and 98% specificity for cord abnormality using MRI as reference standard.

CONCLUSIONS

MEP abnormalities are useful for electrophysiological evaluation of cord compression in CS. While TMS is not a substitute for MRI, it is of value as a rapid, inexpensive and non-invasive technique for screening patients before MRI studies.

Predictors of Outcome of Surgery for Cervical Compressive Myelopathy: Retrospective Analysis and Prospective Study

The outcomes of surgical treatment in 80 patients with cervical compressive myelopathy were retrospectively reviewed to examined the correlations between surgical outcomes and the following seven predictive factors: age at surgery, duration of symptoms, severity of myelopathy, number of compressed segments, intramedullary high intensity segments on T(2)-weighted magnetic resonance (MR) imaging, surgical method, and the type of disease. The recovery rates were evaluated at 3 months after the surgery. Significant correlations were observed between recovery rate and duration of symptoms, severity of myelopathy, and high intensity segments on T(2)-weighted MR imaging. No statistical correlation was observed with the other factors. Multivariate analysis revealed significant correlations between recovery rate and duration of symptoms and number of high intensity segments on T(2)-weighted MR imaging. The multiple regression equation was expressed as follows: recovery rate = 82.981 + 0.101 x (age) - 0.675 x (duration) - 1.452 x (number of compressed segments) - 1.451 x (preoperative Neurosurgical Cervical Spine Scale) - 13.826 x (number of high intensity segments). Based on this predicted formula, we compared the predicted and actual recovery rates for 17 patients treated recently. The two values were similar except in two patients with long duration of symptoms. We conclude that the surgical outcome can be predicted to a certain extent and this information could be provided to patients considering surgery for cervical compressive myelopathy.

Indications for surgical fusion of the cervical and lumbar motion segment

STUDY DESIGN

A literature review and the authors' clinical experience for the indication of fusion in the degenerative lumbar and cervical spine is provided.

OBJECTIVE

To establish absolute and relative criteria for the indication for fusion in the degenerative cervical and lumbar spine.

SUMMARY OF BACKGROUND DATA

Fusion in the cervical and lumbar degenerative spine is indicated under certain strict criteria. However, fusion in circumstances not meeting these criteria is controversial.

METHOD

A review of the literature and the authors' experience concerning indication and criteria of fusion in degenerative, lumbar, and cervical spine is provided.

RESULTS

Fusion for the unstable spine related to trauma, infection, and tumors is relatively accepted. However, indications for fusion for degenerative, cervical, and lumbar spine are more controversial.

CONCLUSION

Lumbar and cervical fusion in the degenerative spine is frequently performed. Certain criteria have been established when a fusion should be considered. However, even these are not universally accepted. Strict prospective studies are needed to determine when a fusion of the degenerative, cervical, and lumbar spine is indicated. Patients with severe radicular pain may be considered for surgery after a comprehensive trial of conservative management. Fusion is usually necessary after a cervical discectomy, especially when spondylosis or osteophytic compression is present. Lumbar fusion is rarely indicated for routine discectomy. In patients with mechanical back or neck pain, surgery should only be considered after conservative measures have been exhausted and a radiographic abnormality is present at the symptomatic level, perhaps with pain concordant with discographic findings. Careful patient selection is the key to obtaining favorable surgical outcomes. In many cases, the goal may be a return to functionality rather than achieving a completely asymptomatic state.

Pectoralis major motor evoked potentials in cervical spondylosis

Myelopathy is a severe complication of cervical spondylosis (CS). We studied 27 consecutive patients with CS referred for evaluation for possible myelopathy using transcranial magnetic stimulation. The findings were compared with those from 20 normal controls. Magnetic resonance imaging was utilized to assess the degree of cord compromise. Central motor conduction time (CMCT) abnormalities showed equivalent diagnostic yield with pectoralis major (PM) recordings, as compared with combined first dorsal interossei and abductor hallucis recordings. Our findings show that CMCT measurement with PM recordings is of value as a diagnostic adjunct in the electrophysiological evaluation of myelopathy in CS.

The Amelioration of Symptoms in Cervical Spinal Stenosis with Spinal Cord Deformation Through Specific Chiropractic Manipulation: A Case Report with Long-Term Follow-Up

OBJECTIVE

To describe the chiropractic management of a patient with paresthesia on the entire left side of her body and magnetic resonance imaging (MRI)-documented cervical spinal cord deformation secondary to cervical spinal stenosis.

CLINICAL FEATURES

A 70-year-old special education teacher had neck pain, headaches, and burning paresthesia on the entire left side of her body. These symptoms developed within hours of being injured in a side-impact motor vehicle accident. Prior to her visit, she had been misdiagnosed with a cerebrovascular accident.

INTERVENTION AND OUTCOMES

Additional diagnostic studies revealed that the patient was suffering from cervical spinal stenosis with spinal cord deformation. Two manipulative technique systems (Advanced Biostructural Therapy and Atlas Coccygeal Technique) unique to the chiropractic profession and based on the theory of relief of adverse mechanical neural tension were administered to the patient. This intervention provided complete relief of the patient's complaints. The patient remained symptom-free at long-term follow-up, 1 year postaccident.

CONCLUSION

There is a paucity of published reports describing the treatment of cervical spinal stenosis through manipulative methods. Existing reports of the manipulative management of cervical spondylosis suggest that traditional manual therapy is ineffective or even contraindicated. This case reports the excellent short-term and long-term response of a 70-year-old patient with MRI-documented cervical spinal stenosis and spinal cord deformation to less traditional, uniquely chiropractic manipulative techniques. This appears to be the first case (reported in the indexed literature) that describes the successful amelioration of the symptoms of cervical spinal stenosis through chiropractic manipulation. More research into the less traditional chiropractic systems of spinal manipulation should be undertaken.

Anterior decompression for cervical spondylotic myelopathy

Cervical spondylotic myelopathy is a clinical entity that manifests itself due to compression and ischemia of the spinal cord. The goal of treatment is to decompress the spinal cord and stabilize the spine in neutral, anatomical position. Since the obstruction and compression of the cord are localized in front of the cord, it is obvious that an anterior surgical approach is the preferred one. The different surgical procedures, complications, and outcome are discussed here.

Cervical myelopathy: clinical and neurophysiological evaluation

The overall frequency of troublesome neck pain is estimated to be about 34%, and it was observed that the frequency of complaints lasting 1 month or longer was higher in women than in men. The prevalence increased with age, with regard to both pain duration and chronic pain. Approximately 14% of a randomly selected population meets the criterion for chronic neck pain: complaints lasting more than 6 months. Epidemiologic data substantiate the importance of morphologic, age-related changes of the cervical spine; however, the incidence and prevalence of cervical myelopathy is not known. It could be that the structural transformation of the intervertebral disc, the uncovertebral processes and the zygapophyseal joints is a process accompanied by disturbed function that ultimately not only induces pain, but can lead to narrowing of spinal canal, with symptoms and signs of cervical myelopathy. For a diagnosis of radicular and myelopathic syndromes, the functional and neurological examination is enhanced by neurophysiological assessment. Electromyography (EMG) performed with needle electrodes is the oldest method for diagnosing nerve root compression and anterior horn cell syndromes, and is claimed to have no false-positive results. For cervical myelopathy, as a routine examination sensory evoked potentials (SEPs) by stimulation of tibial nerve and motor evoked potentials (MEPs) from the upper and lower extremities are recommended.

Diffusion-weighted MR Imaging with Apparent Diffusion Coefficient and Apparent Diffusion Tensor Maps in Cervical Spondylotic Myelopathy

PURPOSE

To evaluate diffusion-weighted magnetic resonance (MR) imaging in patients with cervical spondylosis and/or myelopathy.

MATERIALS AND METHODS

A multishot echo-planar imaging sequence with calculation of apparent diffusion coefficient (ADC) and apparent diffusion tensor (ADT) was applied in 36 patients with symptomatic cervical spondylosis. Diffusion-weighted images read by two neuroradiologists were compared with T2-weighted fast spin-echo images read independently by three neuroradiologists with regard to clinical status (n = 36). MR findings in a selected subgroup of 20 patients whose clinical status was confirmed by electrophysiologic examination also were compared. Sensitivity, specificity, positive predictive value, and negative predictive value of both T2-weighted imaging and diffusion-weighted imaging (ADC and ADT) were calculated and compared.

RESULTS

Patients with myelopathy had abnormal ADC (17 of 21) and ADT (15 of 19) maps with increased ADC and ADT values and decreased anisotropy. For the detection of myelopathy, diffusion-weighted ADC maps had a sensitivity of 80% (17 of 21), while T2-weighted images had a sensitivity of 61% (13 of 21). The negative predictive value was 63% (seven of 11) and 60% (12 of 20) for ADC maps and T2-weighted images, respectively. Conversely, the specificity of diffusion-weighted images (53%; seven of 13) was lower than that of T2-weighted images (92%; 12 of 13). In patients with myelopathy confirmed at electrophysiologic examination, the sensitivity of diffusion-weighted images increased to 92% (12 of 13) and the negative predictive value increased to 75% (three of four), while T2-weighted images had a 53% (seven of 13) sensitivity and a 50% (six of 12) negative predictive value.

CONCLUSION

Diffusion weighting improved the sensitivity of imaging in cervical spondylotic myelopathy.