51
|
Donk RD, Fehlings MG, Verhagen WIM, Arnts H, Groenewoud H, Verbeek ALM, Bartels RHMA. An assessment of the most reliable method to estimate the sagittal alignment of the cervical spine: analysis of a prospective cohort of 138 cases. J Neurosurg Spine 2017; 26:572-576. [DOI: 10.3171/2016.10.spine16632] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEAlthough there is increasing recognition of the importance of cervical spinal sagittal balance, there is a lack of consensus as to the optimal method to accurately assess the cervical sagittal alignment. Cervical alignment is important for surgical decision making. Sagittal balance of the cervical spine is generally assessed using one of two methods; namely, measuring the angle between C-2 and C-7, and drawing a line between C-2 and C-7. Here, the best method to assess sagittal alignment of the cervical spine is investigated.METHODSData from 138 patients enrolled in a randomized controlled trial (Procon) were analyzed. Two investigators independently measured the angle between C-2 and C-7 by using Harrison's posterior tangent method, and also estimated the shape of the sagittal curve by using a modified Toyama method. The mean angles of each quantitative assessment of the sagittal alignment were calculated and the results were compared. The interrater reliability for both methods was estimated using Cronbach's alpha.RESULTSFor both methods the interrater reliability was high: for the posterior tangent method it was 0.907 and for the modified Toyama technique it was 0.984. For a lordotic cervical spine, defined by the modified Toyama method, the mean angle (defined by Harrison's posterior tangent method) was 23.4° ± 9.9° (range 0.4°–52.4°), for a kyphotic cervical spine it was −2.2° ± 9.2° (range −16.1° to 16.9°), and for a straight cervical spine it was 10.5° ± 8.2° (range −11° to 36°).CONCLUSIONSAn absolute measurement of the angle between C-2 and C-7 does not unequivocally define the sagittal cervical alignment. As can be seen from the minimum and maximum values, even a positive angle between C-2 and C-7 could be present in a kyphotic spine. For this purpose, the modified Toyama method (drawing a line from the posterior inferior part of the vertebral body of C-2 to the posterior upper part of the vertebral body of C-7 without any measurements) is a better tool for a global assessment of cervical sagittal alignment.Clinical trial registration no.: ISRCTN41681847 (https://www.isrctn.com)
Collapse
Affiliation(s)
- Roland D. Donk
- 1Department of Orthopedic Surgery, Via Sana Clinics, Mill
| | - Michael G. Fehlings
- 2Division of Neurosurgery and Spinal Program, Department of Surgery, University of Toronto, Ontario, Canada
| | | | | | - Hans Groenewoud
- 5Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands; and
| | - André L. M. Verbeek
- 5Health Evidence, Radboud University Medical Center, Nijmegen, The Netherlands; and
| | | |
Collapse
|
52
|
Koeppen D, Piepenbrock C, Kroppenstedt S, Čabraja M. The influence of sagittal profile alteration and final lordosis on the clinical outcome of cervical spondylotic myelopathy. A Delta-Omega-analysis. PLoS One 2017; 12:e0174527. [PMID: 28430792 PMCID: PMC5400234 DOI: 10.1371/journal.pone.0174527] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Accepted: 03/05/2017] [Indexed: 11/18/2022] Open
Abstract
Purpose Decompression and maintaining or restoring a cervical lordosis are major goals in the surgical treatment of cervical spondylotic myelopathy (CSM). Numerous studies support the assumption that cervical lordosis is a key factor for neurological recovery and pain reduction. However, even kyphotic patients can be asymptomatic. The balance of the spine is subject of an increasing number of publications. The main purpose of the study was to evaluate the validity of lordotic alignment on the course of CSM and to set this parameter in context with well-validated tools, namely the modified Japanese Orthopaedic Association scoring system (mJOAS) and the visual analogue scale (VAS), to predict and measure the clinical outcome after surgery. Methods This is a retrospective study with prospectively collected data of a heterogeneous cohort. The authors analyzed the records of 102 patients suffering from CSM that underwent decompressive surgery and instrumentation. Clinical outcome was assessed by using the mJOAS, VAS and Odom’s criteria. The radiological analysis involved comparison of pre- and postoperative radiographs. The patients were divided into subgroups to be able to compare the influence of various amounts of correction (3 Delta-groups: <0°, 1–7° and ≥8°) and final lordosis (4 Omega-groups: 0–7°, 8–14°, 15–21°, ≥22°). Results 219 levels were fused in 102 patients. Surgery improved the clinical outcome of all groups significantly. A lordotic profile was achieved in all analyzed groups. Patients that showed small lordosis after surgery (<8°) did not have an inferior clinical outcome compared to patients with larger cervical lordosis (>14°). The comparison of Odom’s criteria showed that preoperatively kyphotic patients benefitted more from surgery than lordotic patients (p = 0.029), but no differences could be seen comparing neck pain and neurological improvement. The improvement of pain and neurological impairment measured by VAS and mJOAS supports the statistical impact and validity of the data despite comparatively small numbers of patients. The lack of postoperative kyphosis is a major limitation of the study to encompass the impact of sagittal alignment on clinical outcome. Conclusions Decompression and stabilization appear to be key elements of surgical treatment of CSM. While the achievement of cervical lordosis remains a major goal of surgery, clinical improvement is not hindered in patients who show small lordosis. However, kyphosis should be eliminated in symptomatic patients. The terms “balance” and “physiologic lordosis” remain complex entities without clear definition. To check the results of our study controlled randomized trials to validate and determine the exact role of cervical balance on the course of CSM would be helpful.
Collapse
Affiliation(s)
- Daniel Koeppen
- Department of Orthopedic Surgery and Traumatology, Bundeswehrkrankenhaus Berlin, Berlin, Germany
| | | | - Stefan Kroppenstedt
- Department of Orthopedic Surgery, Sana Kliniken Sommerfeld, Kremmen, Germany
| | - Mario Čabraja
- Joint Spine Centre, Vivantes Auguste Viktoria Klinikum, Berlin, Germany
- * E-mail:
| |
Collapse
|
53
|
Role of Atlantoaxial and Subaxial Spinal Instability in Pathogenesis of Spinal "Degeneration"-Related Cervical Kyphosis. World Neurosurg 2017; 101:702-709. [PMID: 28254542 DOI: 10.1016/j.wneu.2017.02.063] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 02/10/2017] [Accepted: 02/11/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUNDS The role of subaxial and atlantoaxial instability in the pathogenesis of "degeneration"-related cervical kyphosis is evaluated. MATERIAL AND METHODS During the period 2013-2016, the authors treated 21 patients having cervical kyphosis that was related to degenerative spinal disease. The patients presented with symptoms related to cervical myelopathy. Kyphosis was diagnosed on the basis of described radiologic parameters. The patients were divided into 3 groups. Group A (10 patients) had manifest radiologic evidence of atlantoaxial dislocation, type 1 facetal instability, abnormal increase in atlantodental interval, and evidence of cord compression by the odontoid process. Group B (5 patients) had axial or central atlantoaxial facetal instability (type 2 or 3 atlantoaxial facetal instability) and subaxial spinal instability. Group C (6 patients) had subaxial spinal instability. The patients were treated by only stabilization. Group A patients underwent atlantoaxial fixation, group B patients underwent atlantoaxial and subaxial fixation, and group C patients underwent only subaxial spinal fixation. The operation was aimed at arthrodesis of the spinal segments. No bone or soft tissue decompression was done. RESULTS During the minimum follow-up period of 6 months, all patients improved in their neurologic symptoms and demonstrated evidence of spinal arthrodesis. There were no major surgical complications. CONCLUSIONS Spinal instability plays a major role in the generation of cervical spinal kyphosis. Atlantoaxial instability may form the primary and nodal site of development of the process of spinal degeneration in general and kyphosis in particular.
Collapse
|
54
|
Smith JS, Shaffrey CI, Bess S, Shamji MF, Brodke D, Lenke LG, Fehlings MG, Lafage V, Schwab F, Vaccaro AR, Ames CP. Recent and Emerging Advances in Spinal Deformity. Neurosurgery 2017; 80:S70-S85. [DOI: 10.1093/neuros/nyw048] [Citation(s) in RCA: 65] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Accepted: 10/14/2016] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND: Over the last several decades, significant advances have occurred in the assessment and management of spinal deformity.
OBJECTIVE: The primary focus of this narrative review is on recent advances in adult thoracic, thoracolumbar, and lumbar deformities, with additional discussions of advances in cervical deformity and pediatric deformity.
METHODS: A review of recent literature was conducted.
RESULTS: Advances in adult thoracic, thoracolumbar, and lumbar deformities reviewed include the growing applications of stereoradiography, development of new radiographic measures and improved understanding of radiographic alignment objectives, increasingly sophisticated tools for radiographic analysis, strategies to reduce the occurrence of common complications, and advances in minimally invasive techniques. In addition, discussion is provided on the rapidly advancing applications of predictive analytics and outcomes assessments that are intended to improve the ability to predict risk and outcomes. Advances in the rapidly evolving field of cervical deformity focus on better understanding of how cervical alignment is impacted by thoracolumbar regional alignment and global alignment and how this can affect surgical planning. Discussion is also provided on initial progress toward development of a comprehensive cervical deformity classification system. Pediatric deformity assessment has been substantially improved with low radiation-based 3-D imaging, and promising clinical outcomes data are beginning to emerge on the use of growth-friendly implants.
CONCLUSION: It is ultimately through the reviewed and other recent and ongoing advances that care for patients with spinal deformity will continue to evolve, enabling better informed treatment decisions, more meaningful patient counseling, reduced complications, and achievement of desired clinical outcomes.
Collapse
Affiliation(s)
- Justin S. Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia
| | - Christopher I. Shaffrey
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia
| | - Shay Bess
- Rocky Mountain Scoliosis and Spine Center, Denver, Colorado
| | - Mohammed F. Shamji
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Darrel Brodke
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Lawrence G. Lenke
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Michael G. Fehlings
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Virginie Lafage
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Frank Schwab
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, New York
| | - Alexander R. Vaccaro
- Department of Orthopaedics, Thomas Jefferson Univer-sity, Philadelphia, Pennsylvania
| | - Christopher P. Ames
- Depart-ment of Neurosurgery, University of California San Francisco, San Francisco, California
| |
Collapse
|
55
|
A prospective randomized trial comparing anterior cervical discectomy and fusion versus plate-only open-door laminoplasty for the treatment of spinal stenosis in degenerative diseases. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2016; 26:1162-1172. [DOI: 10.1007/s00586-016-4878-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 09/28/2016] [Accepted: 11/11/2016] [Indexed: 12/18/2022]
|
56
|
Shi S, Li XF, Zhao QT, Yang LL, Liu ZD, Yuan W. Risk Factors for Dysphagia After Single-Level Anterior Cervical Decompression with Arthroplasty or Fusion: A Prospective Study Comparing 2 Zero-Profile Implants. World Neurosurg 2016; 95:148-155. [DOI: 10.1016/j.wneu.2016.07.100] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2016] [Revised: 07/25/2016] [Accepted: 07/27/2016] [Indexed: 12/15/2022]
|
57
|
Kim TH, Ha Y, Shin JJ, Cho YE, Lee JH, Cho WH. Signal intensity ratio on magnetic resonance imaging as a prognostic factor in patients with cervical compressive myelopathy. Medicine (Baltimore) 2016; 95:e4649. [PMID: 27684796 PMCID: PMC5265889 DOI: 10.1097/md.0000000000004649] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
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.
Collapse
Affiliation(s)
- Tae Hyun Kim
- Department of Neurosurgery, Sanggye Paik Hospital, Inje University College of Medicine
| | - Yoon Ha
- Department of Neurosurgery, Yonsei University College of Medicine
| | - Jun Jae Shin
- Department of Neurosurgery, Sanggye Paik Hospital, Inje University College of Medicine
- Correspondence: Jun Jae Shin, Department of Neurosurgery, Sanggye Paik Hospital, Inje University College of Medicine, Dongil-ro 1342, Nowon-gu, Seoul 01757, Korea (e-mail: )
| | - Yong Eun Cho
- Department of Neurosurgery, Yonsei University College of Medicine
| | - Ji Hae Lee
- Department of Radiology, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Woo Ho Cho
- Department of Radiology, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| |
Collapse
|
58
|
Sakai K, Yoshii T, Hirai T, Arai Y, Shinomiya K, Okawa A. Impact of the surgical treatment for degenerative cervical myelopathy on the preoperative cervical sagittal balance: a review of prospective comparative cohort between anterior decompression with fusion and laminoplasty. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2016; 26:104-112. [DOI: 10.1007/s00586-016-4717-8] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Revised: 07/25/2016] [Accepted: 07/25/2016] [Indexed: 10/21/2022]
|
59
|
Smith JS, Klineberg E, Shaffrey CI, Lafage V, Schwab FJ, Protopsaltis T, Scheer JK, Ailon T, Ramachandran S, Daniels A, Mundis G, Gupta M, Hostin R, Deviren V, Eastlack R, Passias P, Hamilton DK, Hart R, Burton DC, Bess S, Ames CP. Assessment of Surgical Treatment Strategies for Moderate to Severe Cervical Spinal Deformity Reveals Marked Variation in Approaches, Osteotomies, and Fusion Levels. World Neurosurg 2016; 91:228-37. [DOI: 10.1016/j.wneu.2016.04.020] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Revised: 04/05/2016] [Accepted: 04/05/2016] [Indexed: 11/29/2022]
|
60
|
My Crooked and Aching Neck-Surgical Management of Cervical Deformity. World Neurosurg 2016; 91:644-6. [PMID: 27188641 DOI: 10.1016/j.wneu.2016.05.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2016] [Accepted: 05/09/2016] [Indexed: 11/21/2022]
|
61
|
Shi S, Zheng S, Li XF, Yang LL, Liu ZD, Yuan W. Comparison of a Stand-Alone Anchored Spacer Versus Plate-Cage Construct in the Treatment of Two Noncontiguous Levels of Cervical Spondylosis: A Preliminary Investigation. World Neurosurg 2016; 89:285-92. [DOI: 10.1016/j.wneu.2016.02.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Revised: 02/01/2016] [Accepted: 02/02/2016] [Indexed: 11/16/2022]
|