Multilevel oblique corpectomy without fusion: our experience in 48 patients

Cervical Oblique Corpectomy: Revitalizing the Underused Surgical Approach With Step-By-Step Simulation in Cadavers

ABSTRACT

Recently, the World Federation of Neurosurgical Societies Spine committee recommended that additional research on cost-benefit analysis of various surgical approaches for cervical spondylotic myelopathy be carried out and their efficacy with long-term outcomes be compared. Unfortunately, it is highly probable that the oblique corpectomy (OC) will not be included in cost-benefit investigations due to its infrequent application by neurosurgeons dealing with the spine. In this cadaveric study, head and necks of 5 adult human cadavers stained with colored latex and preserved in 70% alcohol solution were dissected under a table-mounted surgical microscope using 3× to 40× magnifications. The OC approach was performed to simulate real surgery, and the neurovascular structures encountered during the procedure and their relations with each other were examined. Oblique corpectomy was performed unilaterally, although neck dissections were performed bilaterally on 10 sides in all 5 cadavers. At each stage of the dissection, multiple three-dimensional photographs were obtained from different angles and distances. For an optimal OC, both the anterior spinal cord must be sufficiently decompressed and sufficient bone must be left in place to prevent instability in the cervical spine. Oblique corpectomy is a valid and potentially low cost alternative to other anterior and posterior approaches in the surgical treatment of cervical spondylotic myelopathy. However, meticulous cadaver studies are essential before starting real surgical practice on patients in order to perform it effectively and to avoid the risks of the technique.

Anterior Surgical Techniques for Cervical Spondylotic Myelopathy: WFNS Spine Committee Recommendations

Objective

This study was performed to review the literature and to present the most up-to-date information and recommendations on the indications, complications, and success rate of anterior surgical techniques for cervical spondylotic myelopathy (CSM). The commonly performed anterior surgical procedures are multiple-level anterior cervical discectomy and fusion, anterior cervical corpectomy and fusion and its variants (skip corpectomy and hybrid surgery), and oblique corpectomy without fusion.

Methods

A comprehensive literature search and analysis were performed using MEDLINE (PubMed), the Cochrane Register of Controlled Trials, and the Web of Science for peer-reviewed articles published in English during the last 10 years.

Results

Corpectomy is mandated for ventral compression of fewer than 3 vertebral segments where single-level disc and osteophyte excision is inadequate to decompress the cord. Endoscopic or oblique partial corpectomy improves the sagittal canal diameter by 67% and obviates the need for an additional bone graft procedure.

Conclusion

The indications of anterior surgery in patients with CSM include a straightened or kyphotic spine with a compression level lower than 3. With an appropriate choice of implants and meticulous surgical technique, surgical complications can be seen only rarely. Improvements after anterior surgery for CSM have been reported in 70% to 80% of patients.

Oblique corpectomy in the cervical spine

STUDY DESIGN

A narrative review.

OBJECTIVES

A literature review of studies reporting on the application of oblique corpectomy (OC) in various pathologies of the cervical spine.

SETTING

UK.

METHODS

A search was carried out using the PubMed and Google Scholar up to 18 March 2017. Finally, 26 studies met the inclusion criteria.

RESULTS

A multilevel OC shows good clinical outcomes in various pathologies in the cervical spine. The clinical improvement in cervical spondylotic myelopathy (CSM) and ossification of the posterior longitudinal ligament was found to be over 70%. OC allows wide anterior decompression of the spinal cord and complete unilateral nerve root decompression. The approach carries a risk of Horner's syndrome, vertebral artery and accessory nerve injury. OC does not compromise spine stability and osteoarthrodesis with bone grafting is not necessary. Spinal motions are preserved and appear close to normal. OC can be applied in patients with a low fusion rate such as the elderly, diabetics, and heavy smokers. Furthermore, OC was found to be an optimal approach for exta-intradural tumors of the cervical spine.

CONCLUSIONS

OC seems to be a valid alternative for the management of multisegmental CSM in selected cases. It should not be considered a first-line treatment strategy due to the relatively high morbidity. There are no studies comparing OC without fusion to other treatment options in CSM. Therefore, rigorous prospective studies using validated outcome measures with long-term follow-up are required.

Rare Complications of Cervical Spine Surgery: Horner's Syndrome

STUDY DESIGN

A multicenter retrospective case series.

OBJECTIVE

Horner's syndrome is a known complication of anterior cervical spinal surgery, but it is rarely encountered in clinical practice. To better understand the incidence, risks, and neurologic outcomes associated with Horner's syndrome, a multicenter study was performed to review a large collective experience with this rare complication.

METHODS

We conducted a retrospective multicenter case series study involving 21 high-volume surgical centers from the AOSpine North America Clinical Research Network. Medical records for 17 625 patients who received subaxial cervical spine surgery from 2005 to 2011 were reviewed to identify occurrence of 21 predefined treatment complications. Descriptive statistics were provided for baseline patient characteristics. Paired t test was used to analyze changes in clinical outcomes at follow-up compared to preoperative status.

RESULTS

In total, 8887 patients who underwent anterior cervical spine surgery at the participating institutions were screened. Postoperative Horner's syndrome was identified in 5 (0.06%) patients. All patients experienced the complication following anterior cervical discectomy and fusion. The sympathetic trunk appeared to be more vulnerable when operating on midcervical levels (C5, C6), and most patients experienced at least a partial recovery without further treatment.

CONCLUSIONS

This collective experience suggests that Horner's syndrome is an exceedingly rare complication following anterior cervical spine surgery. Injury to the sympathetic trunk may be limited by maintaining a midline surgical trajectory when possible, and performing careful dissection and retraction of the longus colli muscle when lateral exposure is necessary, especially at caudal cervical levels.

Prognosis of posterior osteophyte after anterior cervical decompression and fusion in patients with cervical spondylotic myelopathy using three-dimensional computed tomography study

BACKGROUND

Inadequacy of posterior osteophyte resection in anterior cervical decompression and fusion (ACDF) surgery has long been a clinical concern as it may influence surgical outcome. There has been no agreement on the prognosis in the presence of remnant posterior osteophytes.

METHODS

This study retrospectively investigated 26 cervical spondylotic myelopathy patients after ACDF in whom a remnant posterior osteophyte was identified by long-term follow-up CT scans (minimum of 2 years). Remnant posterior osteophytes and osseous spinal canal were measured and compared between pre-operation CT and long-term post-operation CT. The post-operative clinical outcomes were also studied.

RESULTS

The remnant osteophytes did not obviously decrease in size in any patient and significantly enlarged in 10 patients, with a new posterior osteophyte developing in one patient. In patients whose remnant osteophyte is enlarged, the incidence of pseudoarthrosis, as well as clinical deterioration during follow-up was significantly higher than patients with stable osteophytes.

CONCLUSION

Contrary to previous reports, none of the remnant posterior osteophytes decreased obviously in size during follow up. Despite the persistence of posterior osteophytes, ACDF is still effective in CSM treatment. Posterior osteophyte enlargement at fused segment appears to be associated with symptomatic pseudoarthrosis and clinical deterioration after surgery.

Anterior approaches for cervical spondylotic myelopathy: which? When? How?

Cervical spondylotic myelopathy is a degenerative disorder with an unfavorable natural history. Surgical treatment options have evolved substantially over time, with both anterior and posterior methods proving successful for certain patients with specific characteristics. Anterior decompression of the spinal canal plus fusion techniques for stabilization has several advantages and some disadvantages when compared to posterior options. Understanding the pros and cons of the approaches and techniques is critical for the surgeon to select the best operative treatment strategy for any given patient to achieve the best outcome. Multiple decision-making factors are involved, such as sagittal alignment, number of levels, shape of the pathoanatomy, age and comorbidities, instability, and pre-operative pain levels. Any or all of these factors may be relevant for a given patient, and to varying degrees of importance. Choice of operative approach will therefore be dependent on patient presentation, risks of that approach for a given patient, and to some degree surgeon experience.

The evolution of T2-weighted intramedullary signal changes following ventral decompressive surgery for cervical spondylotic myelopathy

Object

T2-weighted intramedullary increased signal intensity (ISI) on MRI in patients with cervical spondylotic myelopathy (CSM) appears to represent a wide spectrum of pathological changes that determine reversibility of cord damage. Although sharp T2-weighted ISI on preoperative imaging may correlate with poorer surgical outcomes, there are limited data on how these changes progress following surgery. In this study, the authors characterized pre-and postoperative ISI changes in patients undergoing surgery for CSM and studied their postoperative evolution in an attempt to quantify their clinical significance.

Methods

The preoperative and postoperative MR images obtained in 56 patients who underwent oblique cervical corpectomy for CSM were reviewed, and the ISI was classified into 4 subtypes based on margins and intensity: Type 0 (none), Type 1 (“fuzzy”), Type 2 (“sharp”), and Type 3 (“mixed”). The locations of the ISI were further classified as focal if they represented single discrete lesions, multifocal if there were multiple lesions with intervening normal cord, and multisegmental if the lesions were continuous over more than 1 segment. The maximum craniocaudal length of the ISI was measured on each midsagittal MR image. The Nurick grade and Japanese Orthopaedic Association (JOA) score were used to assess clinical status. The mean duration of follow-up was 28 months.

Results

T2-weighted ISI changes were noted preoperatively in 54 patients (96%). Most preoperative ISI changes were Type 1 (41%) or Type 3 (34%), with a significant trend toward Type 2 (71%) changes at follow-up. Multi-segmental and Type 3 lesions tended to regress significantly after surgery (p = 0.000), reducing to Type 2 changes at follow-up. Clinical outcomes did not correlate with ISI subtype; however, there was a statistically significant trend toward improvement in postoperative Nurick Grade in patients with a > 50% regression in ISI size. In addition, patients with more than 18 months of follow-up showed significant regression in ISI size compared with patients imaged earlier. On logistic regression analysis, preoperative Nurick grade and duration of follow-up were the only significant predictors of postoperative improvement in functional status (OR 4.136, p = 0.003, 95% CI 1.623–10.539 and OR 6.402, p = 0.033, 95% CI 1.165–35.176, respectively).

Conclusions

There is a distinct group of patients with multisegmental Type 3 intramedullary changes who show remarkable radiological regression after surgery but demonstrate a residual sharp focal ISI at follow-up. A regression of the ISI by > 50% predicts better functional outcomes. Patients with a good preoperative functional status remain the most likely to show improvement, and the improvement continues to occur even at remote follow-up. The clinical relevance of the quality of the T2-weighted ISI changes in patients with CSM remains uncertain; however, postoperative regression of the ISI change is possibly a more important correlate of patient outcome than the quality of the ISI change alone.

Effect of type II odontoid fracture nonunion on outcome among elderly patients treated without surgery: based on the AOSpine North America geriatric odontoid fracture study

STUDY DESIGN

Subgroup analysis of a prospective multicenter study.

OBJECTIVE

Outcome analysis of nonoperatively treated elderly patients with type II odontoid fractures, including assessment of consequence of a fracture nonunion.

SUMMARY OF BACKGROUND DATA

Odontoid fractures are among the most common fractures in the elderly, and controversy exists regarding treatment.

METHODS

Subgroup analysis of a prospective multicenter study of elderly patients (≥65 yr) with type II odontoid fracture. Neck Disability Index and Short-Form 36 (SF-36) version 2 were collected at baseline and 6 and 12 months. Fifty-eight (36.5%) of the 159 patients were treated nonoperatively.

RESULTS

Of the 58 patients initially treated nonoperatively, 8 died within 90 days and were excluded. Of the remaining 50 patients, 11 (22.0%) developed nonunion, with 7 (63.6%) requiring surgery. Four of the 39 (10.3%) patients classified as having "successful union" required surgery due to late fracture displacement. Thus, 15 (30.0%) patients developed primary or secondary nonunion and 11 (22.0%) required surgery. The overall 12-month mortality was 14.0% (nonunion = 2, union = 5; P= 0.6407). For union and nonunion groups, Neck Disability Index and SF-36 version 2 declined significantly at 12 months compared with preinjury values (P< 0.05), except for SF-36 version 2 Physical Functioning (P= 0.1370). There were no significant differences in outcome parameters based on union status at 12 months (P> 0.05); however, it is important to emphasize that the 12-month outcomes for the nonunion patients reflect the status of the patient after delayed surgical treatment in the majority of these cases.

CONCLUSION

Nonoperative treatment for type II odontoid fracture in the elderly has high rates of nonunion and mortality. Patients with nonunion did not report worse outcomes compared with those who achieved union at 12 months; however, the majority of patients with nonunion required delayed surgical treatment. These findings may prove useful for patients who are not surgical candidates or elect for nonoperative treatment.

LEVEL OF EVIDENCE

2.

Clinical and radiological outcomes in 153 patients undergoing oblique corpectomy for cervical spondylotic myelopathy

OBJECTIVE

To document the clinical and radiological outcomes in a large series of patients undergoing the oblique cervical corpectomy (OCC) for spondylotic myelopathy.

MATERIALS AND METHODS

We retrospectively analyzed our series of 153 patients undergoing OCC for cervical spondylotic myelopathy (CSM) over the last 10 years. A mean clinical follow-up of 3 years was obtained in 125 patients (81.7%), while 117 patients (76.5%) were followed up radiologically. Neurological function was measured by the Nurick grade and the modified Japanese Orthopedic Association score (JOA). Plain radiographs and magnetic resonance images (MRI) were reviewed.

RESULTS

Ninety-two percent were men with a mean age of 51 years and a mean duration of symptoms of 18 months. Sixty-one had a single level corpectomy, 66 had a 2-level, 24 had a 3-level, and two had a 4-level OCC. There was statistically significant improvement (p < 0.05) in both the Nurick grade and the JOA score at mean follow-up of 34.6 ± 25.4 months. Permanent Horner's syndrome was seen in nine patients (5.9%), postoperative C5 radiculopathy in five patients (3.3%), dural tear with CSF leak in one patient (0.7%), and vertebral artery injury in one patient (0.7%). Of the 117 patients who were followed up radiologically, five patients (4.3%) developed an asymptomatic kyphosis of the cervical spine while 22 patients (25.6%) with preoperative lordotic spines had a straightening of the whole spine curvature.

CONCLUSIONS

The OCC is a safe procedure with good outcomes and a low morbidity for treating cervical cord compression due to CSM. This procedure avoids graft-related complications associated with the central corpectomy, but is technically demanding.

Reduction in range of cervical motion on serial long-term follow-up in patients undergoing oblique corpectomy for cervical spondylotic myelopathy

PURPOSE

To determine whether motion preservation following oblique cervical corpectomy (OCC) for cervical spondylotic myelopathy (CSM) persists with serial follow-up.

METHODS

We included 28 patients with preoperative and at least two serial follow-up neutral and dynamic cervical spine radiographs who underwent OCC for CSM. Patients with an ossified posterior longitudinal ligament (OPLL) were excluded. Changes in sagittal curvature, segmental and whole spine range of motion (ROM) were measured. Nathan's system graded anterior osteophyte formation. Neurological function was measured by Nurick's grade and modified Japanese Orthopedic Association (JOA) scores.

RESULTS

The majority (23 patients) had a single or 2-level corpectomy. The average duration of follow-up was 45 months. The Nurick's grade and the JOA scores showed statistically significant improvements after surgery (p < 0.001). 17% of patients with preoperative lordotic spines had a loss of lordosis at last follow-up, but with no clinical worsening. 77% of the whole spine ROM and 62% of segmental ROM was preserved at last follow-up. The whole spine and segmental ROM decreased by 11.2° and 10.9°, respectively (p ≤ 0.001). Patients with a greater range of segmental movement preoperatively had a statistically greater range of movement at follow-up. The analysis of serial radiographs indicated that the range of movement of the whole spine and the range of movement at the segmental spine levels significantly reduced during the follow-up period. Nathan's grade showed increase in osteophytosis in more than two-thirds of the patients (p ≤ 0.01). The whole spine range of movement at follow-up significantly correlated with Nathan's grade.

CONCLUSIONS

Although the OCC preserves segmental and whole spine ROM, serial measurements show a progressive decrease in ROM albeit without clinical worsening. The reduction in this ROM is probably related to degenerative ossification of spinal ligaments.

Segmental anterior decompression and fusion for multilevel ossification of the posterior longitudinal ligament

The purpose of this study was to evaluate the outcome of segmental anterior decompression and fusion for multilevel ossification of the posterior longitudinal ligament. Data were collected from 23 patients with multilevel ossification of the posterior longitudinal ligament. Average operative time and blood loss were 121 minutes and 201.6 mL, respectively. The Nurick score significantly decreased from 2.7±0.9 preoperatively to 1.8±0.9 at last follow-up (P<.01). The preoperative Japanese Orthopaedic Association score was 8.2, which significantly increased to 13.8 points at last follow-up (P<.01), with an improvement rate of 64.5%. The operation also significantly increased cervical lordosis (P<.01) from 7.7° preoperatively to 13.3° postoperatively. The fusion rate was 95.7% at 6 months postoperatively, and 100% at 12 months postoperatively. The loss of cervical lordosis and height of fusion segments were 1.2° and 0.9 mm at last follow-up, respectively. No hardware complications occurred. Cerebrospinal fluid leakage occurred in 2 patients, and hematoma occurred in 1 patient who needed an emergency operation. Segmental anterior decompression and fusion was generally effective and safe in the treatment of multilevel ossification of the posterior longitudinal ligament if indications were well controlled.

Multilevel oblique corpectomy for cervical spondylotic myelopathy preserves segmental motion

PURPOSE

To document the neurological outcome, spinal alignment and segmental range of movement after oblique cervical corpectomy (OCC) for cervical compressive myelopathy.

METHODS

This retrospective study included 109 patients--93 with cervical spondylotic myelopathy and 16 with ossified posterior longitudinal ligament in whom spinal curvature and range of segmental movements were assessed on neutral and dynamic cervical radiographs. Neurological function was measured by Nurick's grade and modified Japanese Orthopedic Association (JOA) scores. Eighty-eight patients (81%) underwent either a single- or two-level corpectomy; the remaining (19%) undergoing three- or four-level corpectomies. The average duration of follow-up was 30.52 months.

RESULTS

The Nurick's grade and the JOA scores showed statistically significant improvements after surgery (p < 0.001). The mean postoperative segmental angle in the neutral position straightened by 4.7 ± 6.5°. The residual segmental range of movement for a single-level corpectomy was 16.7° (59.7% of the preoperative value), for two-level corpectomy it was 20.0° (67.2%) and for three-level corpectomies it was 22.9° (74.3%). 63% of patients with lordotic spines continued to have lordosis postoperatively while only one became kyphotic without clinical worsening. Four patients with preoperative kyphotic spines showed no change in spine curvature. None developed spinal instability.

CONCLUSIONS

The OCC preserves segmental motion in the short-term, however, the tendency towards straightening of the spine, albeit without clinical worsening, warrants serial follow-up imaging to determine whether this motion preservation is long lasting.

Oblique corpectomy to manage cervical myeloradiculopathy

Background. The authors describe a lateral approach to the cervical spine for the management of spondylotic myeloradiculopathy. The rationale for this approach and surgical technique are discussed, as well as the advantages, disadvantages, complications, and pitfalls based on the author's experience over the last two decades. Methods. Spondylotic myelo-radiculopathy may be treated via a lateral approach to the cervical spine when there is predominant anterior compression associated with either spine straightening or kyphosis, but without vertebral instability. Results. By using a lateral approach, the lateral aspect of the cervical spine and the vertebral artery are easily reached and visualized. Furthermore, the lateral part of the affected intervertebral disc(s), uncovertebral joint(s), vertebral body(ies), and posterior longitudinal ligament can be removed as needed to decompress nerve root(s) and/or the spinal cord. Conclusion. Multilevel cervical oblique corpectomy and/or lateral foraminotomy allow wide decompression of nervous structures, while maintaining optimal stability and physiological motion of the cervical spine.

The value of intraoperative ultrasound in oblique corpectomy for cervical spondylotic myelopathy and ossified posterior longitudinal ligament

Intraoperative ultrasound (IOUS) has been described to be useful during central corpectomy for compressive cervical myelopathy. This study aimed at documenting the utility of IOUS in oblique cervical corpectomy (OCC). Prospective data from 24 patients undergoing OCC for cervical spondylotic myelopathy and ossified posterior longitudinal ligament (OPLL) were collected. Patients had a preoperative cervical spine magnetic resonance (MR) image, IOUS and a postoperative cervical CT scan. Retrospective data from 16 historical controls that underwent OCC without IOUS were analysed to compare the incidence of residual compression between the two groups. IOUS identified the vertebral artery in all cases, detected residual cord compression in six (27%) and missed compression in two cases (9%). In another two cases with OPLL, IOUS was sub-optimal due to shadowing. IOUS measurement of the corpectomy width correlated well with these measurements on the postoperative CT. The extent of cord expansion noted on IOUS after decompression showed no correlation with immediate or 6-month postoperative neurological recovery. No significant difference in residual compression was noted in the retrospective and prospective groups of the study. Craniocaudal spinal cord motion was noted after the completion of the corpectomy. IOUS is an inexpensive and simple real-time imaging modality that may be used during OCC for cervical spondylotic myelopathy. It is helpful in identifying the vertebral artery and determining the trajectory of approach, however, it has limited utility in patients with OPLL due to artifacts from residual ossification.

Midline trough corpectomies for the evacuation of an extensive ventral cervical and upper thoracic spinal epidural abscess

The author reports on a 59-year-old woman with a history of a chronic, nonhealing skin ulcer who presented with sepsis, neck pain, and rapidly progressive quadriparesis. Precontrast and postcontrast MR imaging studies revealed a multifocal ventral cervical and upper thoracic spinal epidural abscess. Compression of the spinal cord from the abscess was greatest behind the disc space of C2–3 and C7–T1. Because of the patient's tenuous medical status, the author elected to apply a technique that would allow expeditious decompression without necessitating concomitant fusion and instrumentation. Multilevel, contiguous trough corpectomies were performed for evacuation of the compressive lesions. A high-speed matchstick bur was used to create a 5- to 7-mm midline trough in the vertebrae and intervening disc spaces from C-2 to T-3. Rapid and successful decompression of the entire ventral cervical and upper thoracic epidural space was achieved using this technique. Understanding that the surgical treatment of discitis or osteomyelitis can often result in a kyphotic deformity or frank instability, the patient was immobilized in a cervical collar following surgery and underwent vigilant monitoring with serial plain radiographs, CT scans, and MR images. These neuroimaging studies confirmed complete resolution of the abscess and the slow development of a mild, stable kyphotic deformity. At the 1-year follow-up, the patient was ambulating and had returned to work. A trough corpectomy is a viable surgical approach that allows for rapid decompression of ventral cervical and upper thoracic epidural abscesses while obviating the need for same-setting fusion and fixation.

Noncontiguous anterior decompression and fusion for multilevel cervical spondylotic myelopathy: a prospective randomized control clinical study

Anterior decompression and fusion is an established procedure in surgical treatment for multilevel cervical spondylotic myelopathy (MCSM). However, contiguous corpectomies and fusion (CCF) often induce postoperative complications such as nonunion, graft subsidence, and loss of lordotic alignment. As an alternative, noncontiguous corpectomies or one-level corpectomy plus adjacent-level discectomy with retention of an intervening body has been developed recently. In this study, we prospectively compared noncontiguous anterior decompression and fusion (NADF) and CCF for MCSM in terms of surgical invasiveness, clinical and radiographic outcomes, and complications. From January 2005 to June 2007, 105 patients with MCSM were randomized to NADF group (n = 55) and CCF group (n = 50), and followed up for average 31.5 months (range 24-48 months). Average operative time and blood loss decreased significantly in the NADF group as compared with those in the CCF group (p < 0.05 and <0.001, respectively). For VAS, within 3 months postoperatively, there was no significant difference between the two groups. But at 6 months after surgery and final follow-up, VAS improved significantly in NADF group than that in CCF group (p < 0.05). No significant difference of JOA score was observed between the two groups at every collection time. In NADF group, all 55 cases obtained fusion at 1 year after operation (average 5.1 months). In CCF group, 48 cases achieved fusion 1 year postoperatively, but the other 2 cases were performed posterior stabilization and achieved fusion 6 months later. The differences of cervical lordosis between two groups were insignificant at the same follow-up time. But the loss of lordosis and height of fusion segments in 6 months postoperatively and final follow-up were significantly more in CFF group than in NADF group (p < 0.001). Complications were similar in both groups. But in CCF group three cases needed reoperation, one case with extradural hematoma was immediately re-operated after anterior decompression and two cases mentioned above were performed posterior stabilization at 1 year postoperatively. In conclusion, in the patients with MCSM, without developmental stenosis and continuous or combined ossification of posterior longitudinal ligaments, NADF and CCF showed an identical effect of decompression. In terms of surgical time, blood loss, VAS, fusion rate and cervical alignment, NADF was superior compared with CCF.

Cervical spine lateral approach for myeloradiculopathy: technique and pitfalls

BACKGROUND

The authors describe the rationale of cervical spine lateral approach technique to manage spondylotic myeloradiculopathy with its advantages, disadvantages, complications, and pitfalls.

METHODS

The cervical lateral approach could be indicated to treat spondylotic myeloradiculopathy where anterior compression is predominant and the spine is straight or kyphotic without instability.

RESULTS

Using the present approach the lateral aspect of the cervical spine is easily reached and the vertebral artery is well controlled. The lateral part of the pathological intervertebral discs, uncovertebral joints, vertebral bodies and posterior longitudinal ligament are removed as necessary and decompression tailored to each patient to completely free the nerve roots and/or spinal cord.

CONCLUSION

The cervical lateral multilevel corpectomy/foraminotomy technique allows wide anterior decompression of the spinal cord and complete unilateral nerve root decompression preserving spinal stability and physiological spinal motion.

Multilevel oblique corpectomy without fusion in managing cervical myelopathy: long-term outcome and stability evaluation in 268 patients

Object

The multilevel oblique corpectomy (MOC) allows widening of the spinal canal and foramen trough via an anterolateral access to the cervical spine with control of the vertebral artery and does not require vertebral stabilization or fusion. In the present study, the authors' goal was to demonstrate the long-term efficacy and safety of MOC in the treatment of selected cases of spondylotic myelopathy.

Methods

The authors conducted a prospective study in a series of 268 patients who underwent MOC for cervical spondylotic myelopathy over a 14-year period. Preoperative and postoperative neurological functioning were evaluated with the modified Japanese Orthopaedic Association scale. Spinal stability was assessed in all patients on serial plain and dynamic cervical radiographs at the last follow-up. The degree of canal expansion after MOC was also measured using the spinal canal/vertebral body ratio, and directly by measuring the diameter of osseous canal on pre- and postoperative CT scans and high-resolution MR images.

Results

At a mean follow-up of 96 months, clinical improvement was recorded in 86.6% of patients with a global recovery rate of 87.6%, clinical stability in 8%, and worsening in 5%. Long-term spinal stability was demonstrated in 98% of patients.

Conclusions

Multilevel oblique corpectomy was demonstrated to be a safe procedure that provided good results in terms of improved functional status and long-term spinal stability.

Cervical spondylotic myelopathy treated by oblique corpectomy: a prospective study

OBJECTIVE

Anterolateral partial oblique corpectomy (OC) aims to decompress the cervical spinal cord without subsequent fusion and saves the patient from graft-, instrument-, and fusion-related complications. Although it is a promising technique, there are few studies dealing with its efficacy and safety.

METHODS

In this prospective study, 40 consecutive patients underwent an OC (one to four levels from C3 to C7) for cervical spondylotic myelopathy; they ranged in age from 43 to 78 years (mean, 55 yr). The average follow-up period was 59 months (range, 24-98 mo). Clinical and radiological data were analyzed to assess the results and find possible factors related to outcomes.

RESULTS

Thirty-seven (92.5%) of the 40 patients improved by the 6-month follow-up examination according to the Japanese Orthopedic Association score. The improvement was the most prominent in lower extremity dysfunction. Recovery was positively correlated with the preoperative Japanese Orthopedic Association score (r = 0.37, P = 0.018). Permanent Horner's syndrome developed in four patients (10%). During the long-term follow-up period, neurological improvement was maintained and there were no signs of postoperative instability, posture change, or axial pain.

CONCLUSION

OC for treating multilevel cervical spondylotic myelopathy achieved good results with a low morbidity rate. The results of the current study suggest that OC is a good alternative to conventional median corpectomy and fusion techniques in selected cases.

Multilevel cervical oblique corpectomy in the treatment of ossified posterior longitudinal ligament in the presence of ossified anterior longitudinal ligament

STUDY DESIGN

Clinical study.

OBJECTIVE

To highlight the value of the oblique corpectomy in managing patients with cervical myelopathy caused by extensive ossified posterior longitudinal ligament (OPLL) who also have a coexisting ossified anterior longitudinal ligament (OALL).

SUMMARY OF BACKGROUND DATA

OPLL, OALL, and diffuse idiopathic skeletal hyperostosis (DISH) may coexist, and the surgical treatment is varied. Patients with cervical myelopathy who are asymptomatic for the OALL may be managed by either anterior or posterior approaches, while those with dysphagia are best managed by an anterior approach that can deal with both pathologies simultaneously. The OALL resection is indicated only if symptomatic. The central corpectomy, while a good option for anterior decompression, requires complex reconstruction procedures. The oblique corpectomy preserves the ventral half of the vertebral body and does not require stabilization.

METHODS

In a series of 135 patients undergoing multilevel oblique corpectomy for cervical myelopathy, 3 had OPLL with massive OALL that was asymptomatic. The OPLL was removed using microdrills while preserving the OALL. Preoperative and postoperative MR imaging assessed cord compression and spinal alignment, whereas dynamic plain roentgenography assessed stability. Patients were assessed clinically for signs of dysphagia and dysphonia.

RESULTS

The cervical myelopathy improved in all 3 patients at a follow-up of 3 years, 1 year, and 6 months, respectively, with no development of dysphagia. One patient had a Horner's syndrome that improved by 6 months and another had a C5 radiculopathy that was improving by 6 months. Imaging showed good decompression of the spinal cord, with no kyphosis or instability.

CONCLUSION

The oblique corpectomy is a surgical option in patients with asymptomatic OALL in the setting of progressive myelopathy due to OPLL with intrinsic stability as a result of their OALL. This technique avoids a multilevel central corpectomy that is associated with significant instability often requiring reconstructive procedures.

Multilevel Oblique Corpectomies: Surgical Indications and Technique

Objective:

We describe extensively the multilevel oblique corpectomy technique with its advantages, disadvantages, indications, and biomechanical effects. This procedure is an alternative to the anterior corpectomy.

Methods:

Multilevel oblique corpectomy can be indicated in spondylotic myelopathy, whether or not it is associated with unilateral radiculopathy. Certain conditions must be fulfilled: anterior compression must be predominant, the spine must be kyphotic or straight, preoperative instability has to be excluded, and intervertebral discs have to be dehydrated and collapsed.

Results:

The lateral aspect of the cervical spine is reached and the vertebral artery is controlled through a lateral approach. The lateral part of the pathological intervertebral discs is removed. Then, the lateral portion of the vertebral body is drilled to create an 8-mm wide vertical trench. When the posterior cortical bone as well as the superior and inferior end plates are reached, the microscope is moved obliquely to extend the drilling horizontally as long as required, up to the contralateral pedicle if necessary. Next, the posterior cortical bone and the posterior longitudinal ligament are removed to completely decompress the spinal cord. In the case of radiculopathy, the ipsilateral foramen can be completely opened by taking away the uncovertebral joint after its lateral aspect has been separated from the vertebral artery.

Conclusion:

The multilevel oblique corpectomy technique allows wide anterior decompression of the spinal cord and complete unilateral nerve root decompression. Using this technique, the spinal stability is preserved and osteoarthrodesis is not required. Spinal motions are preserved and appear close to normal.