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

Management Considerations for Cervical Corpectomy: Updated Indications and Future Directions

Together, lower back and neck pain are among the leading causes of acquired disability worldwide and have experienced a marked increase over the past 25 years. Paralleled with the increasing aging population and the rise in chronic disease, this trend is only predicted to contribute to the growing global burden. In the context of cervical neck pain, this symptom is most often a manifestation of cervical degenerative disc disease (DDD). Traditionally, multilevel neck pain related to DDD that is recalcitrant to both physical and medical therapy can be treated with a procedure known as cervical corpectomy. Presently, there are many flavors of cervical corpectomy; however, the overarching goal is the removal of the pain-generating disc via the employment of the modern anterior approach. In this review, we will briefly detail the pathophysiological mechanism behind DDD, overview the development of the anterior approach, and discuss the current state of treatment options for said pathology. Furthermore, this review will also add to the current body of literature surrounding updated indications, surgical techniques, and patient outcomes related to cervical corpectomy. Finally, our discussion ends with highlighting the future direction of cervical corpectomy through the introduction of the "skip corpectomy" and distractable mesh cages.

The value of Clinical signs in the diagnosis of Degenerative Cervical Myelopathy - A Systematic review and Meta-analysis

STUDY DESIGN

Delayed diagnosis of degenerative cervical myelopathy (DCM) is likely due to a combination of its subtle symptoms, incomplete neurological assessments by clinicians and a lack of public and professional awareness. Diagnostic criteria for DCM will likely facilitate earlier referral for definitive management.

OBJECTIVES

This systematic review aims to determine (i) the diagnostic accuracy of various clinical signs and (ii) the association between clinical signs and disease severity in DCM?

METHODS

A search was performed to identify studies on adult patients that evaluated the diagnostic accuracy of a clinical sign used for diagnosing DCM. Studies were also included if they assessed the association between the presence of a clinical sign and disease severity. The QUADAS-2 tool was used to evaluate the risk of bias of individual studies.

RESULTS

This review identified eleven studies that used a control group to evaluate the diagnostic accuracy of various signs. An additional 61 articles reported on the frequency of clinical signs in a cohort of DCM patients. The most sensitive clinical tests for diagnosing DCM were the Tromner and hyperreflexia, whereas the most specific tests were the Babinski, Tromner, clonus and inverted supinator sign. Five studies evaluated the association between the presence of various clinical signs and disease severity. There was no definite association between Hoffmann sign, Babinski sign or hyperreflexia and disease severity.

CONCLUSION

The presence of clinical signs suggesting spinal cord compression should encourage health care professionals to pursue further investigation, such as neuroimaging to either confirm or refute a diagnosis of DCM.

The Frequency of Symptoms in Patients With a Diagnosis of Degenerative Cervical Myelopathy: Results of a Scoping Review

STUDY DESIGN

Delayed diagnosis of degenerative cervical myelopathy (DCM) is associated with reduced quality of life and greater disability. Developing diagnostic criteria for DCM has been identified as a top research priority.

OBJECTIVES

This scoping review aims to address the following questions: What is the diagnostic accuracy and frequency of clinical symptoms in patients with DCM?

METHODS

A scoping review was conducted using a database of all primary DCM studies published between 2005 and 2020. Studies were included if they (i) assessed the diagnostic accuracy of a symptom using an appropriate control group or (ii) reported the frequency of a symptom in a cohort of DCM patients.

RESULTS

This review identified three studies that discussed the diagnostic accuracy of various symptoms and included a control group. An additional 58 reported on the frequency of symptoms in a cohort of patients with DCM. The most frequent and sensitive symptoms in DCM include unspecified paresthesias (86%), hand numbness (82%) and hand paresthesias (79%). Neck and/or shoulder pain was present in 51% of patients with DCM, whereas a minority had back (19%) or lower extremity pain (10%). Bladder dysfunction was uncommon (38%) although more frequent than bowel (23%) and sexual impairment (4%). Gait impairment is also commonly seen in patients with DCM (72%).

CONCLUSION

Patients with DCM present with many different symptoms, most commonly sensorimotor impairment of the upper extremities, pain, bladder dysfunction and gait disturbance. If patients present with a combination of these symptoms, further neuroimaging is indicated to confirm the diagnosis of DCM.

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.

Brown-Séquard syndrome without vascular injury associated with Horner's syndrome after a stab injury to the neck

CASE DESCRIPTION

This case reviews the acute care and rehabilitation course of a 44-year-old right-handed woman after an assault with a pocketknife. She suffered multiple stab wounds including penetrating injury to the left side of her neck. Physical examination revealed left hemiplegia (motor score = 57), impaired pinprick sensation on the right caudal to the C5 dermatome, impaired joint position sense on the left, and left ptosis and miosis. Initially she was unable to stand without maximum assistance. MR imaging revealed transection of the left hemicord at the C5 level without cord hemorrhage. CTA of the neck was negative for vascular injury. She completed 18 days of acute inpatient rehabilitation. She used forearm crutches for ambulation at time of discharge. Prior to discharge the patient provided written permission for a case report.

DISCUSSION

Stab wounds are the most common cause of traumatic Brown-Séquard syndrome. Horner's syndrome is common in spinal cord lesions occurring in the cervical or thoracic region, however the combination of Horner's and Brown-Séquard syndromes is less commonly reported. In this case report, we review recommendations regarding initial imaging following cervical stab wounds, discuss anatomy and associated neurological findings in Brown-Séquard and Horner's syndromes, and review the expected temporal course of motor recovery.

CONCLUSIONS

Facilitating motor recovery and optimizing function after Brown-Séquard spinal cord injury are important roles for the rehabilitation team. Imaging is necessary to rule out cord hemorrhage or vascular injury and to clinically correlate cord damage with physical examination findings and expected functional impairments. Documenting associated anisocoria and explaining this finding to the patient is an important element of spinal cord injury education. Commonly, patients with Brown-Séquard injuries demonstrate remarkable motor recovery and regain voluntary motor strength and functional ambulation.

Cervical cord decompression using extended anterior cervical foraminotomy technique

OBJECTIVE

At present, gold-standard technique of cervical cord decompression is surgical decompression and fusion. But, many complications related cervical fusion have been reported. We adopted an extended anterior cervical foraminotomy (EACF) technique to decompress the anterolateral portion of cervical cord and report clinical results and effectiveness of this procedure.

METHODS

Fifty-three patients were operated consecutively using EACF from 2008 to 2013. All of them were operated by a single surgeon via the unilateral approach. Twenty-two patients who exhibited radicular and/or myelopathic symptoms were enrolled in this study. All of them showed cervical cord compression in their preoperative magnetic resonance scan images.

RESULTS

In surgical outcomes, 14 patients (64%) were classified as excellent and six (27%), as good. The mean difference of cervical cord anterior-posterior diameter after surgery was 0.92 mm (p<0.01) and transverse area was 9.77 mm(2) (p<0.01). The dynamic radiological study showed that the average post-operative translation (retrolisthesis) was 0.36 mm and the disc height loss at the operated level was 0.81 mm. The change in the Cobb angle decreased to 3.46, and showed slight kyphosis. The average vertebral body resection rate was 11.47%. No procedure-related complications occurred. Only one patient who had two-level decompression needed anterior fusion at one level as a secondary surgery due to postoperative instability.

CONCLUSIONS

Cervical cord decompression was successfully performed using EACF technique. This procedure will be an alternative surgical option for treating cord compressing lesions. Long-term follow-up and a further study in larger series will be needed.