Long-term follow-up results of the Cloward procedure for cervical spondylotic myelopathy

Effectiveness of nasotracheal intubation in anterior cervical surgery including C3 lesions

OBJECTIVE

Anterior approach cervical surgery is widely used for accessing C3 lesions. When operating with an anterior approach, the surgical field is obstructed by mandible. Neck extension is popular method to secure better surgical field but risk devastating neurological damage. To overcome this limited surgical field without neck extension, we adopted nasotracheal intubation and evaluated its efficiency.

METHODS

We retrospectively analyzed 16 patients who underwent anterior cervical discectomy or corpectomy of C3 lesions via nasotracheal intubation. We enrolled an additional 29 patients who underwent anterior cervical discectomy or corpectomy of C3 lesions via orotracheal intubation as a control group. All patients had been diagnosed with cervical spondylotic myelopathy or ossification of the posterior longitudinal ligament. We measured the mandibular-cervical angle, which is the angle between the lower mandibular line and anterior vertebral line.

RESULTS

The mandibular-cervical angle was increased by 7.3 with nasotracheal intubation compared to orotracheal intubation.

CONCLUSIONS

Nasotracheal intubation is an effective surgical option for securing the surgical field without neck extension in anterior cervical surgery including C3 lesions.

Four-level Anterior Cervical Discectomy and Fusions: Results Following Multilevel Cervical Fusion With a Minimum 1-Year Follow-up

STUDY DESIGN

A retrospective review of prospectively collected case series.

OBJECTIVE

This is a retrospective review of prospectively collected data regarding the clinical outcomes, complications, and fusion rates of patients who underwent a 4-level (C3-C7) anterior cervical discectomy and fusion (ACDF).

SUMMARY OF BACKGROUND

The use of multilevel ACDF for cervical spondylosis has been controversial. The literature regarding fusion rates and outcomes have been variable. This study intends to evaluate the outcomes following multilevel ACDF in a large cohort of patients.

CLINICAL MATERIALS AND METHODS

Between 1994 and 2011, 60 patients underwent a 4-level ACDF by a single surgeon. All patients were followed for a minimum of 12 months, and outcome measures included neurological findings, presence or absence of radiographic fusion, and complication rates. All patients had radiographic documentation of spinal cord stenosis at 4 consecutive cervical levels as well as myelopathy and/or radiculopathy symptoms.

RESULTS

Forty-eight patients underwent a single anterior procedure, only 5 patients underwent concurrent anterior and posterior fusion, and 7 patients required a second posterior surgery due to new-onset or residual symptoms or hardware complications after undergoing ACDF. Patients most commonly presented with paresthesias and were diagnosed with cervical stenosis. Overall, 18.3% reported early postoperative dysphagia; however, only 2 patients continued to have mild dysphagia symptoms on long-term follow-up. Other complications included hardware failure (11), residual neck pain (7), residual paresthesias (6), new-onset weakness (3), neck hematoma (1), cellulitis (1), and C5 radiculopathy (1). Overall, 88.3% of patients reported improvement in initial symptoms. Nurick scores were significantly lower following 4-level ACDF. The radiographic fusion rate for all levels was 95%. No patients required reoperation for pseudarthrosis.

CONCLUSION

In appropriate patients, 4-level ACDF is a safe, efficacious method for treating multilevel cervical spinal cord compression, with acceptable complication rates and the ability to achieve neurological improvement and high fusion rates.

Scarf osteotomy for the treatment of moderate to severe hallux valgus: Analysis of predictors for midterm outcomes and recurrence

BACKGROUND

Controversies remain regarding the predictors for outcomes and recurrence after scarf osteotomy for hallux valgus deformity.

METHODS

Sixty-two patients (70 feet) underwent scarf osteotomy for hallux valgus deformity. The radiological angles, tibial sesamoid position, articular congruence, demographics, comorbidities, AOFAS, VAS and SF-12 scores, and the postoperative compliance were tested as predictors for outcomes and recurrence.

RESULTS

After a mean 38±15.4 months follow-up, all of the radiological angles, the total AOFAS, PCS-12 and VAS scores significantly improved (all P<0.001). Preoperative MCS-12 was directly related to the total postoperative AOFAS score (P=0.003). A higher number of cardiovascular risk factors negatively affected the postoperative total AOFAS score, VAS and PCS-12 (β=-3.42, P=0.030; β=0.262, P=0.022; β=-0.181, P=0.025, respectively). The BMI influenced postoperative PCS-12 (β=-0.244, P=0.002). Preoperative HVA was directly related to postoperative DMAA (P=0.002) and tibial sesamoid position (P=0.005). Preoperative joint incongruence and postoperative noncompliance were associated with recurrence (P=0.043 and P=0.035, respectively).

CONCLUSIONS

Satisfactory results can be expected after scarf osteotomy. Higher BMI and number of cardiovascular risk factors, and low mental status should be carefully considered when counselling patients for this procedure. Adherence to postoperative care instructions influences deformity recurrence.

Comparison of the effect of anterior and posterior neurosurgical treatment for cervical spondylotic myelopathy: a clinical outcome

Cervical degenerative disease is the most common cause of acquired disability in patients over the age of 50. The incidence of cervical spondylotic myelopathy (CSM) is increasing with aging of the population. Surgical decompression is indicated for severe CSM. There is, however, insufficient evidence to prefer anterior over posterior surgical decompression technique for CSM. Our purpose was to identify groups of patients that would benefit from a chosen surgical approach with a better clinical outcome. We conducted a retrospective analysis of patients operated for CSM between 2007 and 2011. Patients were assessed according to the Nurick grading system. Preoperative and postoperative clinical details and MR imaging were analyzed. Treatment consisted of either anterior cervical discectomy with fusion (ACDF) or laminectomy without fusion. Over a period of 4 years, 90 patients were included. The mean age of patients was 64.5 ± 1.3 years. Of 90 included patients, 42 patients were treated with ACDF and 48 with laminectomy. Mean total Nurick grade recovery rate (NGRR) was 29.6% with 31.2% in ACDF and 27.7% in laminectomy. Mid-sagittal diameter of the cervical canal measured on MRI-T2 increased significantly more with laminectomy (4.4 mm) than ACDF (2.2 mm) (p < 0.001). The presence of preoperative spasticity or quadriparesis or a multilevel compression indicated a higher recovery on the Nurick scale. Surgical treatment of CSM leads to a significant improvement of the functional neurological status of the patient as well as an increase in the diameter of the cervical canal. No significant difference in Nurick recovery was found between ACDF and laminectomy indicating that clinical decision-making in our series was adequate. We were able to demonstrate that even severely disabled patients have a good chance of neurologic recovery after surgical treatment for CSM.

Cervical alignment after single-level anterior cervical corpectomy and fusion using autologous bone graft without spinal instrumentation for cervical pyogenic spondylitis

BACKGROUND

Subsidence in anterior cervical corpectomy and fusion (ACCF) for cervical degenerative disease (CDD) are constantly observed during the postoperative course. Although kyphotic change of cervical alignment occurred frequently in cervical pyogenic spondylitis (CPS) postoperatively, studies on the postoperative change in segmental angle for CPS are limited. This study aimed to analyze cervical alignment after single-level ACCF using autologous bone graft without spinal instrumentation for CPS compared with that for CDD.

METHODS

Six patients underwent single-level ACCF using autologous bone graft without spinal instrumentation for CPS. The control group included 18 age-matched patients who underwent single-level ACCF using autologous bone graft for CDD without spinal instrumentation for the same duration. Cervical and lateral plain radiographs and computed tomography scans were taken. The Frankel classification was used to assess the neurological status preoperatively, postoperatively, and at 2-year follow-up for CPS.

RESULTS

At 2-year follow-up, the average segmental angle at the fusion level was - 12.2° ± 6.9° for CPS and - 5.2° ± 7.6° for CDD (p = 0.04). Changes in segmental angle at the fusion level were - 7.2 ± 9.0° for CPS and - 1.1° ± 7.1° for CDD (p = 0.02). At 2-year follow-up, the average anterior segmental fusion height was 23.4 ± 1.7 mm for CPS and 29.1 ± 5.1 mm for CDD (p < 0.001). At 2-year follow-up, bone fusion in the CPS group was classified as grade 5 (complete fusion) in 4 patients (66.7%) and grade 4 (probable fusion) in 2 (33.3%). In the CDD group, it was grade 5 in 13 patients (72.2%) and grade 4 in 5 patients (27.8%). Overall, both groups achieved 100% bone fusion rate. The Frankel classification in all CPS cases improved or leveled off.

CONCLUSION

Progression of segmental kyphosis angle and subsidence of graft bone were observed postoperatively on all CPS cases. However, the neurological recovery and bone union were satisfactory.

Long-term outcome of the Cloward procedure for single-level cervical degenerative spondylosis. Clinical and radiological assessment after a 22-year mean follow-up

PURPOSE

To evaluate the long-term outcomes of the classical Cloward procedure in single-level cervical spondylosis.

METHODS

A retrospective study of 28 patients who were affected by cervical degenerative spondylosis at C4-C7 segments and treated by the Cloward technique at a single level from 1985-1995 was conducted. The average follow-up period was 22 years (range, 17-27 years). Preoperative clinical complaints were recorded and compared to the current clinical status. Preoperative, 3-6 months postoperative and a current radiographic study were analysed by evaluating the segmental and global sagittal alignment of the cervical spine as well as the occurrence of adjacent disc degeneration.

RESULTS

The most frequently operated segment was C5-C6 (57.1 %), followed by C6-C7 (32.1 %) and C4-C5 (7.1 %). Pain relief and symptom recovery experienced 3-6 months following the surgery was maintained at the most recent follow-up in 85 % of patients. Adjacent disc degeneration was detected in a total of 17 cases (60.7 %). Overall, a group of 14 cases (50 %) had increased lordosis at C2-C7 at the most recent follow-up, with a mean gain of 1.5º Cobb. According to Odom's criteria, 17 patients (60.8 %) presented with excellent clinical outcome, 6 (21.4 %) presented with good outcome, 5 had a (17.8 %) fair outcome, and none had a poor outcome.

CONCLUSIONS

The Cloward technique provided excellent long-term clinical outcome in the treatment of single-level cervical degenerative spondylosis. There were no major alterations of the cervical sagittal balance, and the development of adjacent segment disease (ASD) was not specifically associated with the previous surgery.