Surgical results of anterior corpectomy in the aged patients with cervical myelopathy

Anterior cervical discectomy fusion versus posterior decompression and fusion in octogenarians with cervical myelopathy: Clinical outcomes and complications with a 3-year follow-up

Introduction

Cervical stenosis and concurrent Cervical Spondylotic Myelopathy (CSM) are prevalent in the elderly. Treatment options include Anterior Cervical Discectomy Fusion (ACDF) and Posterior Decompression and Fusion (PDF).

Research question

This study aims to compare clinical outcomes and complications between ACDF and PDF in patients aged 80 and above.

Material and methods

Data from electronic medical records between 2005 and 2021 at a single institution were analyzed. Logistic and linear regression analyses were performed to explore risk factors and the relationship between comorbidities and neurological conditions.

Results

21 patients with ACDF and 26 with PDF were studied over 16 years. PDF patients had more operated levels, higher blood loss, and longer hospital stays, but mortality rates and mJOA improvements were similar in both groups. The presence of comorbidities was a unique risk factor for postoperative complications.

Discussion and conclusion

ACDF and PDF led to neurological improvements in elderly CSM patients. However, the decision of surgical procedure should carefully consider the potential for postoperative complications, particularly in patients with comorbidities.

Anterior cervical corpectomy for the treatment of spondylotic myelopathy: results of a prospective double-armed study with a three-year follow-up

BACKGROUND

Since the first description in the 1950s, cervical spondylotic myelopathy (CSM) has posed many challenges to neurosurgeons and spine surgeons. Direct comparison among different operative approaches has failed to produce valuable results due to either an insufficient number of enrolled patients or a lack of standardization of baseline conditions. This prospective double-armed non-randomized study with a 3-year follow-up involved 80 patients with degenerative cervical myelopathy surgically and conservatively treated. The primary aim was to determine the efficacy of corpectomy in mild-moderate and severe CSM and to compare the outcomes of conservative and surgical treatment.

METHODS

Eighty patients were stratified into two arms, on the basis of the mJOA score: mild-moderate (mJOA ≥12) and severe myelopathy (mJOA score <12). Each arm was subdivided into two treatment groups (operative or conservative): A1, mild-moderate myelopathy treated with corpectomy; A2, mild-moderate myelopathy treated conservatively; B1, severe myelopathy treated with corpectomy; B2, severe cervical myelopathy treated conservatively. The clinical outcome was evaluated with the modified JOA score, timed 10-meter walk, Mehalic grade, motor evoked potentials, the SF-12, and further assessed by external observers blinded to the type of treatment.

RESULTS

No significant differences in the recovery rates were found between the A1 and A2 groups at 6 months, although better results were recorded in the surgical groups (A1 and B1) at 12 months and at the final follow-up, as suggested by the significantly higher recovery rates. Multivariate analysis showed an inverse correlation between the duration of symptoms and the recovery rate (P<0.0001). Moreover, the preoperative timed 10-meter walk (P<0.004), the preoperative hypointensity on T1-weighted MR images (P<0.001), a higher Mehalic grade (P<0.02), the pre-treatment MEP (P<0.002), and the preoperative spinal canal diameter (P<0.004) significantly influenced the recovery rate.

CONCLUSIONS

This prospective double-armed non-randomized study demonstrates that corpectomy is an effective and safe treatment, especially for severe forms of myelopathy. In mild-moderate conditions, a discrepancy between neurological improvement and expressed level of satisfaction was found. The present results also show that a multiparametric evaluation is crucial for proper patient selection for corpectomy.

Outcomes of cervical spinal stenosis surgery in patients aged ≥ 65 years based on insurance status: a single-center cohort study from a tertiary center in Germany

OBJECTIVE

The prevalence of degenerative disorders of the spine, such as cervical spinal stenosis with cervical spine myelopathy (CSM) in the geriatric population, has rapidly increased worldwide. To date, there has been no systematic analysis comparing outcomes in older patients suffering from progressive CSM and undergoing surgery depending on their health insurance status. We sought to compare the clinical outcomes and complications after anterior cervical discectomy and fusion (ACDF) or posterior decompression with fusion in patients aged ≥ 65 years with multilevel cervical spinal canal stenosis and concomitant CSM with special focus on their insurance status.

METHODS

Clinical and imaging data were retrieved from patients' electronic medical records at a single institution between September 2005 and December 2021. Patients were allocated into two groups with respect to their health insurance status: statutory health insurance (SHI) vs. private insurance (PI).

RESULTS

A total of 236 patients were included in the SHI group and 100 patients in the privately insured group (PI) group. The overall mean age was 71.7 ± 5.2 years. Regarding comorbidities, as defined with the age-adjusted CCI, SHI patients presented with higher rates of comorbidities as defined by a CCI of 6.7 ± 2.3 and higher prevalence of previous malignancies (9.3%) when compared to the PI group (CCI 5.4 ± 2.5, p = 0.051; 7.0%, p = 0.048). Both groups underwent ACDF (SHI: 58.5% vs. PI: 61.4%; p = 0.618), and the surgical duration was similar between both groups. Concerning the intraoperative blood transfusion rates, no significant differences were observed. The hospital stay (12.5 ± 1.1 days vs. 8.6 ± 6.3 days; p = 0.042) and intenisve care unit stay (1.5 ± 0.2 days vs. 0.4 ± 0.1 days; p = 0.049) were significantly longer in the PI group than in the SHI group. Similar in-hospital and 90-day mortality rates were noted across the groups. The presence of comorbidities, as defined with the age-adjusted CCI, poor neurological status at baseline, and SHI status, was significant predictor for the presence of adverse events, while the type of surgical technique, operated levels, duration of surgery, or blood loss was not.

CONCLUSIONS

Herein, we found that surgeons make decisions independent of health insurance status and aim to provide the most optimal therapeutic option for each individual; hence, outcomes were similar between the groups. However, longer hospitalization stays were present in privately insured patients, while SHI patients presented on admission with poorer baseline status.

The Effect of Vocal Intonation Therapy on Vocal Dysfunction in Patients With Cervical Spinal Cord Injury: A Randomized Control Trial

In this study, the vocal intonation therapy (VIT) was compared with the standard respiratory therapy for people suffering from respiratory dysfunction as a result of cervical spinal cord injury (CSCI) to observe its effect on vocal quality. Thirty patients with vocal dysfunction after CSCI with the injury time of more than 3 months were screened for inclusion in the trial, and 18 patients completed the 12-weeks, each participant had 60 sessions in total in the clinical trial. All patients were allocated to the intervention group or the control group. The intervention group received VIT training and the control group received respiratory phonation therapy. Both groups were trained by professional therapists, and the training time was 30 min/day, 5 days/week, for 60 sessions for each group in a total of 12 weeks. In the Baseline (T0), mid-intervention period (after 6 weeks, T1), and after intervention (after 12 weeks, T2), the vocal quality of the two groups of patients was tested with a computer-aided real-time audio analyzer 2.1.6 (Adobe Systems, United States) for Sing-SPL (p &lt; 0.0001), Speech-SPL (p &lt; 0.0001), SNL (p &lt; 0.0001), and F0 (p &lt; 0.0001) of the intervention group were significantly improved compared with the control group. In comparing the spectrometry analysis of vocal quality for the 2 groups of participants, there was a significant difference in the results of Sing-SPL and Speech-SPL acoustic analysis in the intervention group of patients at T2 (after 12 weeks) compared to the control group. Vocal intonation therapy—music therapy can improve the speech sound quality of cervical CSCI patients and provide CSCI patients with a practical, highly operable treatment that has both functional training effects and can bring a pleasant experience that can be promoted in the medical field. This study was approved by the Ethics Committee of China Rehabilitation Research Center (CRRC) (approval No. 2019-83-1) on May 20th, 2019. It was registered with the National Health Security Information Platform, medical research registration, and filing information system (Registration No. MR-11-21-011802) on January 28th, 2021.

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.

Spinal cord compression is associated with brain plasticity in degenerative cervical myelopathy

The impact of spinal cord compression severity on brain plasticity and prognostic determinates is not yet fully understood. We investigated the association between the severity of spinal cord compression in patients with degenerative cervical myelopathy, a progressive disease of the spine, and functional plasticity in the motor cortex and subcortical areas using functional magnetic resonance imaging. A 3.0 T MRI scanner was used to acquire functional images of the brain in 23 degenerative cervical myelopathy patients. Patients were instructed to perform a structured finger-tapping task to activate the motor cortex to assess the extent of cortical activation. T₂-weighted images of the brain and spine were also acquired to quantify the severity of spinal cord compression. The observed blood oxygen level-dependent signal increase in the contralateral primary motor cortex was associated with spinal cord compression severity when patients tapped with their left hand (r = 0.49, P = 0.02) and right hand (r = 0.56, P = 0.005). The volume of activation in the contralateral primary motor cortex also increased with spinal cord compression severity when patients tapped with their left hand (r = 0.55, P = 0.006) and right hand (r = 0.45, P = 0.03). The subcortical areas (cerebellum, putamen, caudate and thalamus) also demonstrated a significant relationship with compression severity. It was concluded that degenerative cervical myelopathy patients with severe spinal cord compression recruit larger regions of the motor cortex to perform finger-tapping tasks, which suggests that this adaptation is a compensatory response to neurological injury and tissue damage in the spinal cord.

Determining the Difference in Clinical and Radiologic Outcomes Between Expandable and Nonexpandable Titanium Cages in Cervical Fusion Procedures: A Systematic Review and Meta-Analysis

BACKGROUND

Expandable cages have been increasingly used in cervical and lumbar reconstructions; however, there is a paucity in the literature on how they compare with traditional nonexpandable cages in the cervical spine. We present a systematic review and meta-analysis, comparing the clinical and radiologic outcomes of expandable versus nonexpandable corpectomy cage use in the cervical spine.

METHODS

A database search identified studies detailing the outcomes of expandable and nonexpandable titanium cage use in the cervical spine. These studies were screened using the PRISMA protocol. Fixed-effects and random-effects models were used with a 95% confidence interval. Two analyses were carried out for each outcome: one including all studies and the other including only studies reporting on exclusively 1-level and 2-level cases.

RESULTS

Forty-one studies were included. The mean change in segmental lordosis was significantly greater in expandable cages (all, 6.72 vs. 3.69°, P < 0.001; 1-level and 2-level, 6.81° vs. 4.31°, P < 0.001). The mean change in cervical lordosis was also significantly greater in expandable cages (all, 5.71° vs. 3.11°, P = 0.027; 1-level and 2-level, 5.71° vs. 2.07°, P = 0.002). No significant difference was found between the complication rates (all, P = 0.43; 1-level and 2-level, P = 0.94); however, the proportion of revisions was significantly greater in expandable cages (all, 0.06 vs. 0.02, P = 0.03; 1-level and 2-level, 0.08 vs. 0.01, P = 0.017).

CONCLUSIONS

The use of expandable cages may carry a modest improvement in radiologic outcomes compared with nonexpandable cages in the cervical spine; however, they may also lead to a higher rate of revisions based on our analyses.

Cervical Spondylotic Myelopathy: When and Why the Cervical Corpectomy?

BACKGROUND

Cervical spondylotic myelopathy (CSM) is a degenerative disease that represents the most common spinal cord disorder in adults. The best treatment option has remained controversial. We performed a prospective study to evaluate the clinical, radiographic, and neurophysiologic outcomes for anterior cervical corpectomy in the treatment of CSM.

METHODS

From January 2011 to January 2017, 60 patients with CSM were prospectively enrolled in the present study. The patients were divided according to the modified Japanese Orthopaedic Association scale (mJOA) score into 2 groups: group A, patients with mild to moderate CSM (mJOA score ≥13); and group B, patients with severe myelopathy (mJOA score <13). Data were collected for each participating subject, including demographic information, symptoms, medical history, radiologic and neurophysiologic features, and functional impairment.

RESULTS

Of the 60 patients, 35 were men (58.3%) and 25 were women (41.7%). Their average age was 57.48 ± 10.60 years. The mean symptom duration was 25.33 ± 16.00 months; range, 3-57 months). Of the 60 patients, 22 had undergone single-level corpectomy and 36 multilevel corpectomy. A significant improvement in the motor evoked potentials was observed in both groups.

CONCLUSIONS

Single- and multilevel corpectomy are valid and safe options in the treatment of CSM. In the present prospective study, a statistically significant improvement in the mJOA score and neurophysiologic parameters was observed for both moderate and severe forms of CSM.

Intervertebral Disc Disease of the Lumbar Spine in Health Personnel with Occupational Exposure to Patient Handling-A Systematic Literature Review and Meta-Analysis

Lifting or carrying loads or working while the trunk is in a bent position are well established risk factors for the development of disc disease of the lumbar spine (LDD). Patient handling is associated with certain hazardous activities, which can result in exposure to heavy loads and high pressure for the discs of the lumbar spine of the nurses performing these tasks. The purpose of this review was to examine the occurrence of work-related LDD among health personnel (HP) with occupational exposure to patient handling activities in comparison to un-exposed workers. A systematic literature search was conducted using the following databases: PubMed, CINAHL, Scopus, and Web of Science. A meta-analysis of odds ratios (OR) was conducted by stratifying for various factors. Five studies reported a higher prevalence for LDD among nurses and geriatric nurses (11.3-96.3%) compared to all controls (3.78-76.47%). Results of the meta-analysis showed a significantly increased OR for LDD among HP compared to all controls (OR 2.45; 95% confidence interval (CI) 1.41, 4.26). In particular, the results of this review suggest that nurses have a higher probability of developing disc herniation than office workers.

Compression-induced senescence of nucleus pulposus cells by promoting mitophagy activation via the PINK1/PARKIN pathway

The current research aimed to explore the possible relationship between PINK1/PARKIN-mediated mitophagy and the compression-induced senescence of nucleus pulposus cells (NPCs). Therefore, the stages of senescence in NPCs were measured under compression lasting 0, 24 and 48 hours. The mitophagy-related markers, autophagosomes and mitochondrial membrane potential were tested to determine the levels of PINK1/PARKIN-mediated mitophagy under compression. The PINK1 and PARKIN levels were also measured by immunohistochemistry of human and rat intervertebral disc (IVD) tissues taken at different degenerative stages. A specific mitophagy inhibitor, cyclosporine A (CSA) and a constructed PINK1-shRNA were used to explore the relationship between mitophagy and senescence by down-regulating the PINK1/PARKIN-mediated mitophagy levels. Our results indicated that compression significantly enhanced the senescence of NPCs in a time-dependent manner. Also, PINK1/PARKIN-mediated mitophagy was found to be activated by the extended duration of compression on NPCs as well as the increased degenerative stages of IVD tissues. After inhibition of PINK1/PARKIN-mediated mitophagy by CSA and PINK1-shRNA, the senescence of NPCs induced by compression was strongly rescued. Hence, the excessive degradation of mitochondria in NPCs by mitophagy under continuous compression may accelerate the senescence of NPCs. Regulating PINK1/PARKIN-mediated mitophagy might be a potential therapeutic treatment for IVD degeneration.

Degenerative Cervical Myelopathy: A Brief Review of Past Perspectives, Present Developments, and Future Directions

Degenerative cervical myelopathy (DCM) is the most common cause of spinal cord injury in developed countries; its prevalence is increasing due to the ageing of the population. DCM causes neurological dysfunction and is a significant cause of disability in the elderly. It has important negative impacts on the quality of life of those affected, as well as on their caregivers. DCM is triggered by a variety of degenerative changes in the neck, which affect one or more anatomical structures, including intervertebral discs, vertebrae, and spinal canal ligaments. These changes can also lead to structural abnormalities, leading to alterations in alignment, mobility, and stability. The principle unifying problem in this disease, regardless of the types of changes present, is injury to the spinal cord due to compression by static and/or dynamic forces. This review is partitioned into three segments that focus on key elements of the past, the present, and the future in the field, which serve to introduce the focus issue on "Degenerative Cervical Myelopathy and the Aging Spine". Emerging from this review is that tremendous progress has been made in the field, particularly in recent years, and that there are exciting possibilities for further advancements of patient care.

Outcome Measures and Variables Affecting Prognosis of Cervical Spondylotic Myelopathy: WFNS Spine Committee Recommendations

This study is conducted to review the literature systematically to determine most reliable outcome measures, important clinical and radiological variables affecting the prognosis in cervical spondylotic myelopathy patients. A literature search was performed for articles published during the last 10 years. As functional outcome measures we recommend to use modified Japanese Orthopaedic Association scale, Nurick’s grade, and Myelopathy Disability Index. Three clinical variables that affect the outcomes are age, duration of symptoms, and severity of the myelopathy. Examination findings require more detailed study to validate their effect on the outcomes. The predictive variables affecting the outcomes are hand atrophy, leg spasticity, clonus, and Babinski’s sign. Among the radiological variables, the curvature of the cervical spine is the most important predictor of prognosis. Patients with instability are expected to have a poor surgical outcome. Spinal cord compression ratio is a critical factor for prognosis. High signal intensity on T2-weighted magnetic resonance images is a negative predictor for prognosis. The most important predictors of outcome are preoperative severity and duration of symptoms. T2 hyperintensity and cord compression ratio can also predict outcomes. New radiological tests may give promising results in the future.

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.

Surgical Treatment of Cervical Spondylotic Myelopathy in the Elderly: Outcomes in Patients Aged 80 Years or Older

STUDY DESIGN

Retrospective multicenter study.

OBJECTIVE

We aimed to assess the outcomes following posterior cervical decompression for cervical spondylotic myelopathy (CSM) in a large sample of patients older than 80 years.

SUMMARY OF BACKGROUND DATA

Although age is a predictor of surgical outcomes for CSM, most previous studies have only investigated the effect of age for patients aged 65 to 75 years, and surgical outcomes remain unclear for older patients.

METHODS

Patients older than 50 years who underwent posterior cervical decompression for CSM were enrolled from 17 institutions. The patients were grouped into a young-old group (<80 yrs old) and an old-old group (≥80 yrs). Clinical information, comorbidities, perioperative complications, Japanese Orthopaedic Association (JOA) scores, Japanese Orthopaedic Association Cervical Myelopathy Evaluation Questionnaire (JOACMEQ), visual analog scale (VAS) scores, and radiographic parameters were compared between the two groups. All patients were followed for at least 1 year after surgery.

RESULTS

The young-old and old-old groups included 491 and 77 patients, respectively. The JOA score and quality of life measured by JOACMEQ improved significantly after surgery in both groups. Compared with the young-old group, the old-old group had lower preoperative JOA scores (9.6 vs. 11.0), lower final JOA scores (12.6 vs. 14.0), and lower recovery rates (42% vs. 50%). However, there were no significant differences in perioperative complications or in the VAS scores at the final assessments. The old-old group had a higher mean preoperative sagittal Cobb angle at C2-C5, though this was not statistically significant postoperatively.

CONCLUSION

Posterior decompression surgery is safe and beneficial for patients older than 80 years with CSM, despite having a more limited neurological recovery compared with younger patients.

LEVEL OF EVIDENCE

3.

Anterior Cervical Corpectomy and Fusion and Anterior Cervical Discectomy and Fusion Using Titanium Mesh Cages for Treatment of Degenerative Cervical Pathologies: A Literature Review

Anterior cervical corpectomy and fusion (ACCF) and anterior cervical discectomy and fusion (ACDF) are 2 effective and safe surgical treatments of degenerative cervical pathologies and are associated with a high percentage of excellent clinical outcomes when a graft or device must be used during the surgery, such as an allograft, autograft, nano-hydroxyapatite/polyamide cages, poly-ether-ether-ketone (PEEK) cages, and titanium mesh cages (TMCs). Although TMCs have been used in cervical surgeries for almost 2 decades, no specific reviews have been performed introducing the state of this material. Thus, in the present review, we discuss the status of using TMCs in anterior cervical surgeries.

Studies that tested the usage of TMCs in treating degenerative cervical pathologies were included in this review. The development and progress of TMCs, the biomechanical analysis of TMCs, the radiological and clinical assessment of TMCs, the advantages and disadvantages of using TMCs, and their prospects for future applications as a device of ACCF and ACDF in treating degenerative cervical pathologies are discussed.

Studies included in this review showed that TMCs can provide sufficient biomechanical stability. Furthermore, the TMCs used in anterior cervical fusion avoid the donor-site morbidity and achieve a solid bony fusion. However, there are some shortcomings. The structural characteristics and the design of TMCs cause the TMC subsidence rate to remain high, thus resulting in multiple related complications.

We believe that due to the virtues of TMCs, they are worthy of application and promotion. However, the structure of TMCs should be further optimized to reduce the TMC subsidence rate and subsidence-related complications, ultimately achieving excellent clinical results.

Trends in the Treatment of Single and Multilevel Cervical Stenosis: A Review of the American Board of Orthopaedic Surgery Database

BACKGROUND

In order to identify any changes in the utilization of new and old techniques, we investigated trends in the operative management of cervical stenosis by orthopaedic surgeons applying for board certification.

METHODS

We queried the American Board of Orthopaedic Surgery database from 1998 to 2013 to identify all of the cervical spine procedures for stenosis that had been performed by candidates taking Part II of the licensing examination. Longitudinal trends were determined for the utilized approach, the individual procedures that had been performed, and whether a motion-preserving technique had been employed.

RESULTS

There were 5,068 cervical spine procedures performed by 1,025 candidates. Procedure totals remained relatively constant until 2011, when a sudden increase of 280% (202 to 768 procedures) was noted. This trend continued, reaching a 460% increase (202 to 1,131 procedures) compared with 2010. The number of candidates only rose by 150% (42 to 105) over the entire study period. The proportion of procedures performed via an anterior approach saw a bimodal distribution; early on, this approach predominated over posterior procedures and was largely driven by the number of corpectomies that were performed. From 2004 to 2011, posterior procedures became more prevalent, but there was a sharp decline in 2011, driven by the large number of anterior cervical discectomies and fusions that were performed. This remained constant through 2013. Lastly, motion-preserving techniques, which included total disc replacement and laminoplasty, had modest increases in utilization from 2005 to 2007. This increased prevalence was short-lived, and it steadily declined through 2014 to <5% utilization.

CONCLUSIONS

The number of candidates performing cervical spine procedures increased more than twofold over a 16-year period. This reflects a larger proportion of the orthopaedic graduates who subspecialize in spine surgery. While the number of surgeons performing spine surgery has increased, the sheer number of procedures that each surgeon performed greatly outpaced the increased number of surgeons. Motion-preserving techniques had their peak utilization in 2007, and have since decreased to <5%, in contrast to fusion techniques, which predominate, comprising >90% of the performed procedures.

Does age affect surgical outcomes in patients with degenerative cervical myelopathy? Results from the prospective multicenter AOSpine International study on 479 patients

BACKGROUND

In general, older patients with degenerative cervical myelopathy (DCM) are felt to have lower recovery potential following surgery due to increased degenerative pathology, comorbidities, reduced physiological reserves and age-related changes to the spinal cord. This study aims to determine whether age truly is an independent predictor of surgical outcome and to provide evidence to guide practice and decision-making.

METHODS

A total of 479 patients with DCM were prospectively enrolled in the CSM-International study at 16 centres. Our sample was divided into a younger group (<65 years) and an elderly (≥65 years) group. A mixed model analytic approach was used to evaluate differences in the modified Japanese Orthopaedic Association (mJOA), Nurick, Short Form-36 (SF-36) and Neck Disability Index (NDI) scores between groups. We first created an unadjusted model between age and surgical outcome and then developed two adjusted models that accounted for variations in (1) baseline characteristics and (2) both baseline and surgical factors.

RESULTS

Of the 479 patients, 360 (75.16%) were <65 years and 119 (24.84%) were ≥65 years. Elderly patients had a worse preoperative health status (p<0.0001) and were functionally more severe (p<0.0001). The majority of younger patients (64.96%) underwent anterior surgery, whereas the preferred approach in the elderly group was posterior (58.62%, p<0.0001). Elderly patients had a greater number of decompressed levels than younger patients (p<0.0001). At 24 months after surgery, younger patients achieved a higher postoperative mJOA (p<0.0001) and a lower Nurick score (p<0.0001) than elderly patients. After adjustments for patient and surgical characteristics, these differences in postoperative outcome scores decreased but remained significant.

CONCLUSIONS

Older age is an independent predictor of functional status in patients with DCM. However, patients over 65 with DCM still achieve functionally significant improvement after surgical decompression.

Surgical outcomes of elderly patients with cervical spondylotic myelopathy: a meta-analysis of studies reporting on 2868 patients

OBJECTIVE

Cervical spondylotic myelopathy usually presents in the 5th decade of life or later but can also present earlier in patients with congenital spinal stenosis. As life expectancy continues to increase in the United States, the preconceived reluctance toward operating on the elderly population based on older publications must be rethought. It is a known fact that outcomes in the elderly cannot be as robust as those in the younger population. There are no publications with detailed meta-analyses to determine an acceptable level of outcome in this population. In this review, the authors compare elderly patients older than 75 years to a nonelderly population, and they discuss some of the relevant strategies to minimize complications.

METHODS

In accordance with PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, the authors performed a PubMed database search to identify English-language literature published between 1995 and 2015. Combinations of the following phrases that describe the age group (“elderly,” “non-elderly,” “old,” “age”) and the disease of interest as well as management (“surgical outcome,” “surgery,” “cervical spondylotic myelopathy,” “cervical degenerative myelopathy”) were constructed when searching for relevant articles. Two reviewers independently assessed the outcomes, and any disagreement was discussed with the first author until it was resolved. A random-effects model was applied to assess pooled data due to high heterogeneity between studies. The mean difference (MD) and odds ratio were calculated for continuous and dichromatic parameters, respectively.

RESULTS

Eighteen studies comprising elderly (n = 1169) and nonelderly (n = 1699) patients who received surgical treatment for cervical spondylotic myelopathy were included in this meta-analysis. Of these studies, 5 were prospective and 13 were retrospective. Intraoperatively, both groups required a similar amount of operation time (p = 0.35). The elderly group had lower Japanese Orthopaedic Association (JOA) scores (MD −1.36, 95% CI −1.62 to −1.09; p < 0.00001) to begin with compared with the nonelderly group. The nonelderly group also had a higher postoperative JOA score (MD −1.11, 95% CI −1.44 to −0.79; p < 0.00001), therefore demonstrating a higher recovery rate from surgeries (MD −11.98, 95% CI −16.16 to −7.79; p < 0.00001). The length of stay (MD 4.14, 95% CI 3.54–4.73; p < 0.00001) was slightly longer in the elderly group. In terms of radiological outcomes, the elderly group had a smaller postoperative Cobb angle but a greater increase in spinal canal diameter compared with the nonelderly group. The complication rates were not significant.

CONCLUSIONS

Cervical myelopathy is a disease of the elderly, and age is an independent factor for recovery from surgery. Postoperative and long-term outcomes have been remarkable in terms of improvement in mobility and independence requiring reduced nursing care. There is definitely a higher potential risk while operating on the elderly population, but no significant difference in the incidence of postoperative complications was noted. Withholding surgery from the elderly population can lead to increased morbidity due to rapid progression of symptoms in addition to deconditioning from lack of mobility and independence. Reduction in operative time under anesthesia, lower blood loss, and perioperative fluid management have been shown to minimize the complication rate. The authors request that neurosurgeons weigh the potential benefit against the risks for every patient before withholding surgery from elderly patients.

Kinematic analysis of cervical spine canal diameter and its association with grade of degeneration

OBJECTIVES

To investigate the cervical spinal canal diameters variance under positional MRI, and also the relationship between cervical canal diameter variance rate and grade of degeneration.

METHODS

From January 2013 to January 2015, a consecutive of 273 symptomatic patients (166 males and 207 females) with an average age of 44.6 years (range 21-89 years) underwent positional cervical MRI. T2-weighted sagittal images of 1638 cervical intervertebral discs from 273 subjects were classified into five grades. The canal diameter and canal diameter variance rate at three positions and their comparison among five grade of degeneration were evaluated. The measurements were tabulated and analyzed using SPSS. 13.0. p values less than 0.05 were considered to indicate a statistically significant difference.

RESULTS

The sagittal cervical canal diameter at the C5/6 level were the smallest compared with the other levels regardless of neutral, flexion or extension positions, C5/6 level had the largest canal diameter variance rate in both flexion and extension (8.14 ∓ 0.38 and 7.81 ∓ 0.31 %, respectively), second was C4/5 level (7.65 ∓ 0.39 and 7.67 ∓ 0.32 %, respectively). A total of 1638 discs were classified into 5 groups, each level showed the similar tendency that no matter what position, with the increasing grade of degenerative disc degree, spine canal diameter decreased gradually. For C5/6 under extension and flexion position, significant difference was also noted between grade 2 and 3; For C4/5 under extension position, significant difference existed between grade 1 and 2, grade 1 and 3, while under flexion position, significant difference existed between grade 2 and 4, and the results also showed no significant difference at the same degree of degeneration on both levels between extension and flexion position.

CONCLUSIONS

C5/6 and C4/5 is of higher risk of suffering SCI than other levels, C4/5 level predispose SCI at earlier stage than C5/6, patients presenting with intermediate signal and slight decreased disc height on T2 weighted MRI at C4/5 level should be paid attention.

Aging and age related stresses: a senescence mechanism of intervertebral disc degeneration

Intervertebral disc (IVD) degeneration is a complicated process that involves both age-related change and tissue damage caused by multiple stresses. In a degenerative IVD, cellular senescence accumulates and is associated with reduced proliferation, compromised self-repair, increased inflammatory response, and enhanced catabolic metabolism. In this review, we decipher the senescence mechanism of IVD degeneration (IVDD) by interpreting how aging coordinates with age-related, microenvironment-derived stresses in promoting disc cell senescence and accelerating IVDD. After chronic and prolonged replication, cell senescence may occur as a natural part of the disc aging process, but can potentially be accelerated by growth factor deficiency, oxidative accumulation, and inflammatory irritation. While acute disc injury, excessive mechanical overloading, diabetes, and chronic tobacco smoking contribute to the amplification of senescence-inducing stresses, the avascular nature of IVD impairs the immune-clearance of the senescent disc cells, which accumulate in cell clusters, demonstrate inflammatory and catabolic phenotypes, deteriorate disc microenvironment, and accelerate IVDD. Anti-senescence strategies, including telomerase transduction, supply of growth factors, and blocking cell cycle inhibitors, have been shown to be feasible in rescuing disc cells from early senescence, but their efficiency for disc regeneration requires more in vivo validations. Guidelines dedicated to avoiding or alleviating senescence-inducing stresses might decelerate cellular senescence and benefit patients with IVD degenerative diseases.

A systematic review of clinical and surgical predictors of complications following surgery for degenerative cervical myelopathy

OBJECTIVE

Although generally safe and effective, surgery for the treatment of cervical spondylotic myelopathy (CSM) is associated with complications in 11%-38% of patients. Several predictors of postoperative complications have been proposed but few are used to detect high-risk patients. A standard approach to identifying "at-risk" patients would improve surgeons' ability to prevent and manage these complications. The authors aimed to compare the complication rates between various surgical procedures used to treat CSM and to identify patient-specific, clinical, imaging, and surgical predictors of complications.

METHODS

The authors conducted a systematic review of the literature and searched MEDLINE, MEDLINE in Process, EMBASE, and Cochrane Central Register of Controlled Trials from 1948 to September 2013. Cohort studies designed to evaluate predictors of complications and intervention studies conducted to compare different surgical approaches were included. Each article was critically appraised independently by 2 reviewers, and the evidence was synthesized according to the principles outlined by the Grading of Recommendation Assessment, Development and Evaluation (GRADE) Working Group.

RESULTS

A total of 5472 citations were retrieved. Of those, 60 studies met the inclusion criteria and were included in the review. These studies included 36 prognostic cohort studies and 28 comparative intervention studies. High evidence suggests that older patients are at a greater risk of perioperative complications. Based on low evidence, other clinical factors such as body mass index, smoking status, duration of symptoms, and baseline severity score, are not predictive of complications. With respect to surgical factors, low to moderate evidence suggests that estimated blood loss, surgical approach, and number of levels do not affect rates of complications. A longer operative duration (moderate evidence), however, is predictive of perioperative complications and a 2-stage surgery is related to an increased risk of major complications (high evidence). In terms of surgical techniques, higher rates of neck pain were found in patients undergoing laminoplasty compared with anterior spinal fusion (moderate evidence). In addition, with respect to laminoplasty techniques, there was a lower incidence of C-5 palsy in laminoplasty with concurrent foraminotomy compared with nonforaminotomy (low evidence).

CONCLUSIONS

The current review suggests that older patients are at a higher risk of perioperative complications. A longer operative duration and a 2-stage surgery both reflect increased case complexity and can indirectly predict perioperative complications.

One stage laminoplasty and posterior herniotomy for the treatment of myelopathy caused by cervical stenosis with cervical disc herniation

The aim of the study was to introduce a method of one stage laminoplasty and posterior herniotomy for myelopathy caused by cervical stenosis with cervical disc herniation and to evaluate the clinical efficacy of this surgery. From 1999 to 2008, 18 patients with myelopathy caused by cervical stenosis with cervical disc herniation who underwent this procedure were included. The average age was 63 years (range 48-74 years), and the average follow-up period was 46 months (range 3-108 months). Neurologic status was evaluated using the JOA scoring system. Neurological symptoms improvement was seen in all patients after surgery. The average JOA score was 14.22±1.86 by final follow-up, which was higher than preoperative values (P<0.01), and the average improvement in neurological function was 76.63%. Neurologic examination showed that excellent results had been obtained by 10 patients, good results by 8 patients, with no fair or poor results. 2 patients developed cerebrospinal fluid leakage after surgery and recovered during the follow-up period. One patient with cervical disc herniation developed postoperative C5 palsy on the axle side on the third day after surgery. She completely recovered by 1 month after surgery. No other patients experienced postoperative neurologic complications. Complete anterior and posterior decompression of the spinal cord was achieved after surgery. We concluded that one stage laminoplasty and posterior herniotomy is an effective, reliable, and safe procedure for the treatment of myelopathy caused by cervical stenosis with cervical disc herniation.

Anterior surgical treatment of cervical spondylotic myelopathy: review article

BACKGROUND

Cervical spondylotic myelopathy (CSM) is a common indication for cervical spine surgery. Surgical options include anterior, posterior, or combined procedures each with specific advantages and disadvantages.

QUESTIONS/PURPOSES

This article will provide a description of the various anterior alternatives and discuss the available evidence used in guiding the surgical decision making process with the aim of answering the following questions: (1) What anatomical/disease related factors favor anterior over posterior surgeries? (2) What are the common anterior procedures and how safe and effective are they? (3) What are the most effective options for multilevel CSM? (4) Is there a role for motion preservation? An additional objective is to discuss technical advances that have improved success rates for anterior procedures.

METHODS

The PubMed database was searched. Keywords were CSM and anterior surgery. Three hundred eighty two articles were found one hundred three were reviewed. Articles describing anterior cervical techniques were selected along with studies describing the various anterior techniques or comparisons of anterior to posterior techniques.

RESULTS

Anterior decompression and fusion procedures are more effective than posterior procedures for patients with primarily ventrally located compression especially in the presence of cervical kyphosis. ACDF, ACCF, and hybrid combinations are safe and effective treatment options for multilevel CSM. Anterior procedures may be more cost effective and result in significantly improved postoperative quality of life and health-related quality of life measures compared to posterior procedures.

CONCLUSION

Anterior cervical decompression techniques are safe and effective in the treatment of CSM. Anterior surgeries may be preferable to posterior approaches, when considering health-related quality of life measures and cost effectiveness.

Anterior cervical discectomy versus corpectomy for multilevel cervical spondylotic myelopathy: a meta-analysis

PURPOSE

This is a meta-analysis to compare the results between anterior cervical discectomy fusion (ACDF) and anterior cervical corpectomy fusion (ACCF) for the patients with multilevel cervical spondylotic myelopathy (MCSM).

METHODS

Systematic review and meta-analysis of cohort studies between ACDF with plate fixation and ACCF with plate fixation for the treatment of MCSM. An extensive search of literature was performed in PubMed, Mediline, Embase and the Cochrane library. The following outcome measures were extracted: JOA scores, fusion rate, cervical lordosis (C2-7), complications, blood loss and operation time. Data analysis was conducted with RevMan 5.0.

RESULTS

Four cohorts (six studies) involving 258 patients were included in this study. The pooled analysis showed that there was no significant difference in the postoperative JOA score [WMD = -0.14 (-1.37, 1.10), P = 0.83], fusion rate [OR = 0.84 (0.15, 4.86), P = 0.85] between two group. However, there was significant difference in the cervical lordosis [WMD = 3.38 (2.52, 4.23), P < 0.00001], surgical complication rate and instrument related complication rate (P = 0.01, 0.005 respectively), blood loss [WMD = -52.53 (-73.53, -31.52), P < 0.00001], and operation time [WMD = -14.10 (-20.27, -7.93), P < 0.00001].

CONCLUSIONS

As compared with ACCF with plate fixation, ACDF with plate fixation showed no significant differences in terms of postoperative JOA score, fusion rate, but better improved cervical lordosis, lower complication and smaller surgical trauma. As the limitations of small sample and short follow-up in this study, it still could not be identified whether ACDF with plate fixation is more effective and safer than ACCF with plate fixation.

Comparison of two anterior fusion methods in two-level cervical spondylosis myelopathy: a meta-analysis

OBJECTIVE

The aim of this study was to evaluate the efficacy and safety of anterior cervical corpectomy and fusion (ACCF) and anterior cervical discectomy and fusion (ACDF) for treating two-adjacent-level cervical spondylosis myelopathy (CSM).

DESIGN

A meta-analysis of the two anterior fusion methods was conducted. The electronic databases of PubMed, the Cochrane Central Register of Controlled Trials, ScienceDirect, CNKI, WANFANG DATA and CQVIP were searched. Quality assessment of the included studies was evaluated using the Cochrane Risk of Bias Tool and the Methodological Index for Non-Randomised Studies criteria. Pooled risk ratios of dichotomous outcomes and standardised mean differences (SMDs) of continuous outcomes were generated. Using the χ(2) and I(2) tests, the statistical heterogeneity was assessed. Subgroup and sensitivity analyses were also performed.

PARTICIPANTS

Nine eligible trials with a total of 631 patients and a male-to-female ratio of 1.38:1 were included in this meta-analysis.

INCLUSION CRITERIA

Randomised controlled trials (RCTs) and non-randomised controlled trials that adopted ACCF and ACDF to treat two-adjacent-level CSM were included.

RESULTS

No significant differences were identified between the two groups regarding hospital stay, the Japanese Orthopaedic Association (JOA) score, visual analogue scale (VAS) scores for neck and arm pain, total cervical range of motion (ROM), fusion ROM, fusion rate, adjacent-level ossification and complications, while ACDF had significantly less bleeding (SMD=1.14, 95% CI (0.74 to 1.53)); a shorter operation time (SMD=1.13, 95% CI (0.82 to 1.45)); greater cervical lordosis, total cervical (SMD=-2.95, 95% CI (-4.79 to -1.12)) and fused segment (SMD=-2.24, 95% CI (-3.31 to -1.17)); higher segmental height (SMD=-0.68, 95% CI (-1.03 to -0.34)) and less graft subsidence (SMD=0.40, 95% CI (0.06 to 0.75)) compared to ACCF.

CONCLUSIONS

The results suggested that ACDF has more advantages compared to ACCF. However, additional high-quality RCTs and a longer follow-up duration are needed.

Evaluation of anterior cervical reconstruction with titanium mesh cages versus nano-hydroxyapatite/polyamide66 cages after 1- or 2-level corpectomy for multilevel cervical spondylotic myelopathy: a retrospective study of 117 patients

Objective

To retrospectively compare the efficacy of the titanium mesh cage (TMC) and the nano-hydroxyapatite/polyamide66 cage (n-HA/PA66 cage) for 1- or 2-level anterior cervical corpectomy and fusion (ACCF) to treat multilevel cervical spondylotic myelopathy (MCSM).

Methods

A total of 117 consecutive patients with MCSM who underwent 1- or 2-level ACCF using a TMC or an n-HA/PA66 cage were studied retrospectively at a mean follow-up of 45.28±12.83 months. The patients were divided into four groups according to the level of corpectomy (1- or 2-level corpectomy) and cage type used (TMC or n-HA/PA66 cage). Clinical and radiological parameters were used to evaluate outcomes.

Results

At the one-year follow-up, the fusion rate in the n-HA/PA66 group was higher, albeit non-significantly, than that in the TMC group for both 1- and 2-level ACCF, but the fusion rates of the procedures were almost equal at the final follow-up. The incidence of cage subsidence at the final follow-up was significantly higher in the TMC group than in the n-HA/PA66 group for the 1-level ACCF (24% vs. 4%, p = 0.01), and the difference was greater for the 2-level ACCF between the TMC group and the n-HA/PA66 group (38% vs. 5%, p = 0.01). Meanwhile, a much greater loss of fused height was observed in the TMC group compared with the n-HA/PA66 group for both the 1- and 2-level ACCF. All four groups demonstrated increases in C2-C7 Cobb angle and JOA scores and decreases in VAS at the final follow-up compared with preoperative values.

Conclusion

The lower incidence of cage subsidence, better maintenance of the height of the fused segment and similar excellent bony fusion indicate that the n-HA/PA66 cage may be a superior alternative to the TMC for cervical reconstruction after cervical corpectomy, in particular for 2-level ACCF.

Vertebral artery anomaly and injury in spinal surgery

STUDY DESIGN

Systematic review.

STUDY RATIONALE

The purpose of this review is to further define the published literature with respect to vertebral artery (VA) anomaly and injury in patients with degenerative cervical spinal conditions.

OBJECTIVES

In adult patients with cervical spine or degenerative cervical spine disorders receiving cervical spine surgery, what is the incidence of VA injury, and among resulting VA injuries, which treatments result in a successful outcome and what percent are successfully repaired?

MATERIALS AND METHODS

A systematic review of pertinent articles published up to April 2013. Studies involving traumatic onset, fracture, infection, deformity or congenital abnormality, instability, inflammatory spinal diseases, or neoplasms were excluded. Two independent reviewers assessed the level of evidence quality using the Grades of Recommendation Assessment, Development and Evaluation criteria; disagreements were resolved by consensus.

RESULTS

From a total of 72 possible citations, the following met our inclusion criteria and formed the basis for this report. Incidence of VA injuries ranged from 0.20 to 1.96%. None of the studies reported using preoperative imaging to identify anomalous or tortuous VA. Primary repair and ligation were the most effective in treating VA injuries.

CONCLUSION

The incidence of VA injuries in degenerative cervical spinal surgery might be as high as 1.96% and is likely underreported. Direct surgical repair is the most effective treatment option. The most important preventative technique for VA injuries is preoperative magnetic resonance imaging or computed tomography angiographic imaging to detect VA anomalies. The overall strength of evidence for the conclusions is low.

Predictors of outcome in patients with degenerative cervical spondylotic myelopathy undergoing surgical treatment: results of a systematic review

PURPOSE

To conduct a systematic review of the literature to determine important clinical predictors of surgical outcome in patients with cervical spondylotic myelopathy (CSM).

METHODS

A literature search was performed using MEDLINE, MEDLINE in Process, EMBASE and Cochrane Database of Systematic Reviews. Selected articles were evaluated using a 14-point modified SIGN scale and classified as either poor (<7), good (7-9) or excellent (10-14) quality of evidence. For each study, the association between various clinical factors and surgical outcome, evaluated by the (modified) Japanese Orthopaedic Association scale (mJOA/JOA), Nurick score or other measures, was defined. The results from the EXCELLENT studies were compared to the combined results from the EXCELLENT and GOOD studies which were compared to the results from all the studies.

RESULTS

The initial search yielded 1,677 citations. Ninety-one of these articles, including three translated from Japanese, met the inclusion and exclusion criteria and were graded. Of these, 16 were excellent, 38 were good and 37 were poor quality. Based on the excellent studies alone, a longer duration of symptoms was associated with a poorer outcome evaluated on both the mJOA/JOA scale and Nurick score. A more severe baseline score was related with a worse outcome only on the mJOA/JOA scale. Based on the GOOD and EXCELLENT studies, duration of symptoms and baseline severity score were consistent predictors of mJOA/JOA, but not Nurick. Age was an insignificant predictor of outcome on any of the functional outcomes considered.

CONCLUSION

The most important predictors of outcome were preoperative severity and duration of symptoms. This review also identified many other valuable predictors including signs, symptoms, comorbidities and smoking status.

Morphological character of cervical spine for anterior transpedicular screw fixation

BACKGROUND

Anterior cervical interbody grafts/cages combined with a plate were frequently used in multilevel discectomies/corpectomies. In order to avoid additional posterior stabilization in patients who undergo anterior reconstructive surgery, an anterior cervical transpedicular screw fixation, which offers higher stability is desirable. We investigated in this study the anatomical (morphologic) characters for cervical anterior transpedicular screw fixation.

MATERIALS AND METHODS

Left pedicle parameters were measured on computed tomography (CT) images based on 36 cervical spine CT scans from healthy subjects. The parameters included outer pedicle width (Distance from lateral to medial pedicle surface in the coronal plane), outer pedicle height (OPH) (Distance from upper to lower pedicle surface in the sagittal plane), maximal pedicle axis length (MPAL), distance transverse insertion point (DIP), distance of the insertion point to the upper end plate (DIUP), pedicle sagittal transverse angle (PSTA) and pedicle transverse angle (PTA) at C3 to C7.

RESULTS

The values of outer pedicle width and MPAL in males were larger than in females from C3 to C7. The OPH in males was larger than in females at C3 to C6, but there was no difference at C7. The DIP and PTA were significantly greater in males than in females at C3, but there was no difference in the angle at C4-7. The PSTA was not statistically different between genders at C3, 4, 7, but this value in males was larger than females at C5, 6. The DIUP was significantly greater in males at C3, 4, 6, 7 but was non significant at C5.

CONCLUSIONS

The placement of cervical anterior transpedicular screws should be individualized for each patient and based on a detailed preoperative planning.

Anterior cervical discectomy and fusion versus anterior cervical corpectomy and fusion for multilevel cervical spondylosis: a systematic review

INTRODUCTION

There is considerable controversy as to which technique is best option for reconstruction after multilevel anterior decompression for cervical spondylosis. The aim of this study was to compare the clinical and radiographic results and complications of anterior cervical discectomy fusion (ACDF) and anterior cervical corpectomy fusion (ACCF) in the treatment of multi-level cervical spondylosis.

METHOD

We reviewed and analyzed papers published from Jan 1969 to Dec 2010 regarding the comparison of ACDF and ACCF for multilevel cervical spondylosis. Statistical comparisons were made when appropriate.

RESULTS

Twelve studies were included in this systematic review. Blood loss was greater for ACCF compared with ACDF. Similarly, the rate of graft dislodgement in ACCF was higher than that in ACDF. Nonunion rates were 18.4% for 2-level ACDF and 37.3% for 3-level ACDF, whereas nonfusion rates were 5.1% for single-level ACCF and 15.2% for 2-level ACCF. In addition, nonunion rates for three disc levels fused were much higher than that for two disc levels fused, regardless of discectomy or corpectomy. Clinical outcome was compared between ACDF and ACCF in nine studies. Of these, similar outcome was found between ACDF and ACCF in six studies, whereas three studies reported better outcome in ACCF compared with ACDF.

CONCLUSION

Nonunion rates of ACDF are higher than those of ACCF for multilevel cervical spondylosis. Sometimes, clinical outcome of ACCF was better than ACDF for multilevel cervical spondylosis.

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.

Anterior approach for complex cervical spondylotic myelopathy

Cervical spondylotic myelopathy (CSM) is a slowly progressive disease resulting from age-related degenerative changes in the spine that can lead to spinal cord dysfunction and significant functional disability. The degenerative changes and abnormal motion lead to vertebral body subluxation, osteophyte formation, ligamentum flavum hypertrophy, and spinal canal narrowing. Repetitive movement during normal cervical motion may result in microtrauma to the spinal cord. Disease extent and location dictate the choice of surgical approach. Anterior spinal decompression and instrumented fusion is successful in preventing CSM progression and has been shown to result in functional improvement in most patients.

Epidemiological characteristics of adult SCIWORA in Tianjin, China: a preliminary study

INTRODUCTION

The epidemiology of spinal cord injury without radiographic abnormality (SCIWORA) is less frequently reported in adults as compared with children. The annual incidence of SCIWORA was approximately 5.74% per million in Tianjin from 2004 to 2008. Importantly, the epidemiological characteristics of adult SCIWORA may be different from that in children. The aim of this study was to evaluate the radiological-clinical data of patients with adult SCIWORA, and to relatively analyze the epidemiological features.

MATERIALS AND METHODS

Inpatients with cervical SCIWORA who were 16 and above in Tianjin were admitted in municipal hospitals in Tianjin from 2004 to 2008; all the patients received MRI scanning in sagittal and axial views. Epidemiological characteristics, such as injury origin, injury level or severity, neurological scale and MRI feature were acquired.

RESULTS

In total, 203 patients were enrolled. The average age among the adult groups was 55.9 years (men 55.8 years, women 53.6 years). SCIWORA occurred more commonly in adults in the 46-60 age group, and falls were the leading cause of injury (52.2%), followed by vehicular injury (28.6%). The most predominantly affected level was C4/5 (48.7%), followed by C5/6 (30.5%) and C3/4 (12.8%), respectively. The occurrence of central cord syndrome (50.2%) with posterior longitudinal ligament tear (43.8%) was relatively higher than other injury patterns.

CONCLUSION

It is clear that adult cervical SCIWORA is different from that in the pediatric group. Our study highlights the epidemiological properties of adult SCIWORA in Tianjin, China. Differing from other reports, particularly epidemiology study, we represent the first report regarding adult SCIWORA from China. As the geriatric population increases, it is very important to set up an individualized evaluation system based on a nationally scaled epidemiological database. The results from our study will be useful in assisting in the creation of such a database.

Long-term follow-up of cervical radiographic sagittal spinal alignment after 1- and 2-level cervical corpectomy for the treatment of spondylosis of the subaxial cervical spine causing radiculomyelopathy or myelopathy: a retrospective study

Object

Few data exist regarding long-term outcomes after cervical corpectomy for spondylotic cervical myelopathy and radiculomyelopathy. In this retrospective review, long-term radiographic outcomes are reported for 130 patients after 1- or 2-level cervical corpectomy for spondylotic myelopathy or radiculomyelopathy.

Methods

Electronic medical records including clinical data and radiographic images during a 15-year period (1993–2008) were reviewed at the Cincinnati Department of Veterans Affairs Medical Center. All patients underwent radiographic follow-up for at least 12 months (range 12–156, mean 45 ± 39.3 months), as well as clinical follow-up performed by neurosurgery staff for a mean of 29.3 ± 39.6 months (range 4–156 months). Clinical parameters at surgery and last examination included the Chiles modified Japanese Orthopaedic Association (mJOA) Myelopathy Scale. Measurements included cervical spine sagittal alignment on lateral radiographs preoperatively and postoperatively, focal Cobb angles at operated levels, and C2–7 regional alignment. Statistical analysis included the Student t-test and chi-square test. Perioperative complications and additional surgery in the cervical spine were recorded.

Results

The mJOA scores improved from a mean of 11.91 ± 2.4 preoperatively to 14.9 ± 2.33 postoperatively. The mean sagittal lordosis of the C2–7 spine increased from −16.2° ± 9.2° preoperatively to −18.5° ± 11.9° at last follow-up. Focal Cobb angles averaged a slight kyphotic angulation of 4.1° ± 2.3° at latest radiographic follow-up; of note, 7 patients (5.4%), all who had cylindrical titanium mesh cages (CTMCs), showed severe kyphotic angulation (+8.4° ± 2.4°). Patients with preoperative myelopathy showed clinical improvement at follow-up. The fusion rate was 96.2%; 3 of the 5 patients with radiographic evidence of nonfusion were smokers. Patients with postoperative kyphosis had significantly more chronic neck pain (visual analog scale score >4 lasting more than 6 months) and visits related to pain (p <0.01). Those with CTMCs had higher rates of postoperative kyphosis, chronic neck pain, and visits related to pain, irrespective of the number of levels fused (p <001). At latest follow-up, although a kyphotic increase occurred in the focal cervical sagittal Cobb angles, lordosis increased in C2–7 sagittal Gore angles. Two patients (1.5%) underwent revision of the implanted graft and/or hardware, and 5 patients (3.8%) had another procedure for adjacent-level pathologies 1–9 years later (mean 4.4 ± 2.7 years).

Conclusions

Long-term follow-up data in our veteran population support cervical corpectomy as an effective, long-lasting treatment for spondylotic myelopathy of the cervical spine. Use of CTMCs without end caps was associated with statistically significant increased postoperative kyphotic angulation and chronic pain. Despite an increase in focal kyphosis over time, regional cervical sagittal lordotic alignment had increased at the latest follow-up. Further investigation will include the association of chronic neck pain and postoperative kyphosis, and high fusion rates among a veteran population of heavy smokers.

Functional and clinical outcomes following surgical treatment in patients with cervical spondylotic myelopathy: a prospective study of 81 cases

Object

Cervical spondylotic myelopathy (CSM) is the most common cause of spinal dysfunction in the elderly. Operative management is beneficial for most patients with moderate/severe myelopathy. This study examines the potential confounding effects of age, sex, duration of symptoms, and comorbidities on the functional outcomes and postoperative complications in patients who underwent cervical decompressive surgery.

Methods

We included consecutive patients who underwent surgery from December 2005 to October 2007. Functional outcomes were assessed using the Nurick grading system and the modified Japanese Orthopaedic Association and Berg Balance scales. Comorbidity indices included the Charlson Comorbidity Index and the number of ICD-9 codes.

Results

There were 57 men and 24 women with a mean age of 57 years (range 32–88 years). The mean duration of symptoms was 25.2 months (range 1–120 months). There was a significant functional recovery from baseline to 6 months after surgery (p < 0.01). Postoperative complications occurred in 18.5% of cases. Although the occurrence of complications was not significantly associated with sex (p = 0.188), number of ICD-9 codes (p = 0.113), duration of symptoms (p = 0.309), surgical approach (p = 0.248), or number of spine levels treated (p = 0.454), logistic regression analysis showed that patients who developed complications were significantly older than patients who had no complications (p = 0.018). Only older age (p < 0.002) and greater number of ICD-9 codes (p < 0.01) were significantly associated with poorer functional recovery after surgical treatment. However, none of the studied factors were significantly associated with clinically relevant functional recovery after surgical treatment for CSM (p > 0.05).

Conclusions

Our results indicate that surgery for CSM is associated with significant functional recovery, which appears to reach a plateau at 6 months after surgery. Age is a potential predictor of complications after decompressive surgery for CSM. Whereas older patients with a greater number of preexisting medical comorbidities had less favorable functional outcomes after surgery for CSM in the multivariate regression analysis, none of the studied factors were associated with clinically relevant functional recovery after surgery in the logistic regression analysis. Therefore, age-matched protocols based on preexisting medical comorbidities may reduce the risk for postoperative complications and improve functional outcomes after surgical treatment for CSM.

The stabilizing potential of anterior, posterior and combined techniques for the reconstruction of a 2-level cervical corpectomy model: biomechanical study and first results of ATPS prototyping

Clinical studies reported frequent failure with anterior instrumented multilevel cervical corpectomies. Hence, posterior augmentation was recommended but necessitates a second approach. Thus, an author group evaluated the feasibility, pull-out characteristics, and accuracy of anterior transpedicular screw (ATPS) fixation. Although first success with clinical application of ATPS has already been reported, no data exist on biomechanical characteristics of an ATPS-plate system enabling transpedicular end-level fixation in advanced instabilities. Therefore, we evaluated biomechanical qualities of an ATPS prototype C4-C7 for reduction of range of motion (ROM) and primary stability in a non-destructive setup among five constructs: anterior plate, posterior all-lateral mass screw construct, posterior construct with lateral mass screws C5 + C6 and end-level fixation using pedicle screws unilaterally or bilaterally, and a 360° construct. 12 human spines C3-T1 were divided into two groups. Four constructs were tested in group 1 and three in group 2; the ATPS prototypes were tested in both groups. Specimens were subjected to flexibility test in a spine motion tester at intact state and after 2-level corpectomy C5-C6 with subsequent reconstruction using a distractable cage and one of the osteosynthesis mentioned above. ROM in flexion-extension, axial rotation, and lateral bending was reported as normalized values. All instrumentations but the anterior plate showed significant reduction of ROM for all directions compared to the intact state. The 360° construct outperformed all others in terms of reducing ROM. While there were no significant differences between the 360° and posterior constructs in flexion-extension and lateral bending, the 360° constructs were significantly more stable in axial rotation. Concerning primary stability of ATPS prototypes, there were no significant differences compared to posterior-only constructs in flexion-extension and axial rotation. The 360° construct showed significant differences to the ATPS prototypes in flexion-extension, while no significant differences existed in axial rotation. But in lateral bending, the ATPS prototype and the anterior plate performed significantly worse than the posterior constructs. ATPS was shown to confer increased primary stability compared to the anterior plate in flexion-extension and axial rotation with the latter yielding significance. We showed that primary stability after 2-level corpectomy reconstruction using ATPS prototypes compared favorably to posterior systems and superior to anterior plates. From the biomechanical point, the 360° instrumentation was shown the most efficient for reconstruction of 2-level corpectomies. Further studies will elucidate whether fatigue testing will enhance the benefit of transpedicular anchorage with posterior constructs and ATPS.

Surgical results and complications in a series of 71 consecutive cervical spondylotic corpectomies

BACKGROUND

Cervical corpectomy is a common procedure in spondylosis. It is normally a well-tolerated surgery and clinical improvement is widely described. However, it is associated with potential risky complications (subsidence, clinical deterioration, vertebral artery injury...); thus, a judicious surgical indication and a good technique are required.

METHODS

We revised retrospectively the clinical evolution and complications of 71 spondylotic corpectomies in a series of 100 consecutive patients operated on due to different ethiological causes from January 2001 to September 2007 at our hospital.

RESULTS

Among the 71 cases, a single-level corpectomy was performed in 46 cases and a two level in 25. The graft we used was a titanium mesh filled with bone from the removed vertebra in 69 cases and a telescopic cage in two additional cases. We stabilized the construction with a locking plate. The presurgical clinical status of patients, according to the Nurick grading scale was as follows: 30 patients were grade 0, 12 were grade 1, eight were grade 2, 14 were grade 3, five were grade 4 and two were grade 5. After decompression, 41 patients were considered cured, three were grade 1, seven were grade 2, 11 were grade 3, seven were grade 4 and one was grade 5. One patient died in the postoperative period. Globally, 44 (62%) patients achieved good or excellent results (grades 0-1), 15 (21%) remained as previously (grade >1), six (8%) improved partially and five (7%) worsened. Forty (95%) grades 0 and 1 patients became cured, and four (50%), four (31%) and two (28%) grades 2, 3 and 4-5, respectively, experienced a postsurgical improvement. Significant complications occurred in 18 (25%) patients. The most significant were: hardware failure (n = 7), subsidence in five cases (one required intervention) and incorrect screw placement in two (one required intervention); permanent dysphagia (n = 4) and dysphonia (n = 1); postsurgical neurological worsening in three cases (two improved and one remained grade 4); vertebral artery injury in one case; and an urgent evacuation of a prevertebral hematoma. One patient died due to respiratory disturbances.

CONCLUSIONS

Cervical corpectomy is efficient for spinal cord decompression, especially when anterior components (disk osteophyte, OPLL...) bulge in the spinal cord. A three or more level corpectomy was not considered in this series since they may be associated to high rate morbidity. We found that this decompression led to better clinical results in patient grades 0 and 1 and to poorer results as myelopathy progressed. Among complications, subsidence was the most frequent specific one, but since it was rarely associated with symptoms, the majority of patients were successfully treated conservatively.

National trends in anterior cervical fusion procedures

STUDY DESIGN

Population-based database analysis.

OBJECTIVE

To analyze trends in patient- and healthcare-system-related characteristics, utilization and outcomes associated with anterior cervical spine fusions.

SUMMARY OF BACKGROUND DATA

Anterior cervical decompression and spine fusion (ACDF) is one of the most commonly performed surgical procedures of the spine. However, few data analyzing trends in patient- and healthcare-system-related characteristics, utilization and outcomes exist.

METHODS

Data from 1990 to 2004 collected in the National Hospital Discharge Survey were accessed. ACDF procedures were identified. Five-year periods of interest (POI) were created for temporal analysis and changes in the prevalence and utilization of this procedure as well as in patient- and healthcare-system-related variables were examined. The changes in the occurrence of procedure-related complications were evaluated.

RESULTS

An estimated total of 771,932 discharges after ACDF were identified. Temporally, an almost 8-fold increase in total prevalence was accompanied by a similar increase in utilization (23/100.000 civilians/POI to 157/100.000/civilians/POI). The highest increase in utilization was observed in those > or =65 years (28-fold). Average age increased from 47.2 years to 50.5 years over time. Length of hospital stay decreased from 5.17 days to 2.38 days. Overall procedure-related complication rates decreased from 4.6% to 3.03%. The prevalence of hypertension, diabetes mellitus, hypercholesterolemia, obesity, pulmonary, and coronary artery increased over time among patients undergoing ACDF.

CONCLUSION

Despite limitations inherent to secondary analysis of large databases, we identified a number of significant changes in the utilization, demographics, and outcomes associated with ACDF, which can be used to assess the effect of changes in medical care, direct health care resources, and future research. The effect of the increased prevalence of comorbidities on medical practice remains to be evaluated. Further studies are necessary to evaluate causal relationships.

In vitro study of accuracy of cervical pedicle screw insertion using an electronic conductivity device (ATPS part III)

Reconstruction of the highly unstable, anteriorly decompressed cervical spine poses biomechanical challenges to current stabilization strategies, including circumferential instrumented fusion, to prevent failure. To avoid secondary posterior surgery, particularly in the elderly population, while increasing primary construct rigidity of anterior-only reconstructions, the authors introduced the concept of anterior transpedicular screw (ATPS) fixation and plating. We demonstrated its morphological feasibility, its superior biomechanical pull-out characteristics compared with vertebral body screws and the accuracy of inserting ATPS using a manual fluoroscopically assisted technique. Although accuracy was high, showing non-critical breaches in the axial and sagittal plane in 78 and 96%, further research was indicated refining technique and increasing accuracy. In light of first clinical case series, the authors analyzed the impact of using an electronic conductivity device (ECD, PediGuard) on the accuracy of ATPS insertion. As there exist only experiences in thoracolumbar surgery the versatility of the ECD was also assessed for posterior cervical pedicle screw fixation (pCPS). 30 ATPS and 30 pCPS were inserted alternately into the C3-T1 vertebra of five fresh-frozen specimen. Fluoroscopic assistance was only used for the entry point selection, pedicle tract preparation was done using the ECD. Preoperative CT scans were assessed for sclerosis at the pedicle entrance or core, and vertebrae with dense pedicles were excluded. Pre- and postoperative reconstructed CT scans were analyzed for pedicle screw positions according to a previously established grading system. Statistical analysis revealed an astonishingly high accuracy for the ATPS group with no critical screw position (0%) in axial or sagittal plane. In the pCPS group, 88.9% of screws inserted showed non-critical screw position, while 11.1% showed critical pedicle perforations. The usage of an ECD for posterior and anterior pedicle screw tract preparation with the exclusion of dense cortical pedicles was shown to be a successful and clinically sound concept with high-accuracy rates for ATPS and pCPS. In concert with fluoroscopic guidance and pedicle axis views, application of an ECD and exclusion of dense cortical pedicles might increase comfort and safety with the clinical use of pCPS. In addition, we presented a reasonable laboratory setting for the clinical introduction of an ATPS-plate system.

Single level cervical disc herniation: A questionnaire based study on current surgical practices

BACKGROUND

Operative procedures like simple discectomy, with or without fusion and with or without instrumentation, for single level cervical disc herniation causing neck pain or neurological compromise have been described and are largely successful. However, there is a debate on definitive criteria to perform fusion (with or without instrumentation) for single level cervical disc herniation. Hence, we conducted a questionnaire based study to elicit the opinions of practicing neurosurgeons.

MATERIALS AND METHODS

About 148 neurosurgeons with atleast 12 years of operative experience on single level cervical disc herniation, utilizing the anterior approach, were enrolled in our study. All participating neurosurgeons were asked to complete a practice based questionnaire. The responses of 120 neurosurgeons were analysed.

RESULTS

The mean age of enrolled surgeons was 51 yrs (range 45-73) with mean surgical experience of 16.9 yrs (range 12-40 yrs) on single level cervical disc herniation. Out of 120 surgeons 10(8%) had 15-25 years experience and always preferred fusion with or without instrumentation and six (five per cent with 17-27 yrs experience had never used fusion techniques. However, 104 (87%) surgeons with 12-40 yrs experience had their own criteria based on their experiences for performing fusion with graft and instrumentation (FGI), while. 85 (75%) preferred auto graft with cage.

CONCLUSIONS

Most of surgeons performed FGI before the age of 40, but for others, patient criteria such as job (heavier job), physical examination (especially myelopathy) and imaging findings (mild degenerative changes on X-ray and signal change in the spinal cord on MRI) were considered significant for performing FGI.