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Gundamraj S, Devaraj KB, Harinathan B, Banerjee A, Yoganandan N, Vedantam A. Effect of sagittal alignment on spinal cord biomechanics in the stenotic cervical spine during neck flexion and extension. Biomech Model Mechanobiol 2024:10.1007/s10237-024-01866-y. [PMID: 39003653 DOI: 10.1007/s10237-024-01866-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Accepted: 06/05/2024] [Indexed: 07/15/2024]
Abstract
Spinal cord stress and strain contribute to degenerative cervical myelopathy (DCM), while cervical kyphosis is known to negatively impact surgical outcomes. In DCM, the relationship between spinal cord biomechanics, sagittal alignment, and cord compression is not well understood. Quantifying this relationship can guide surgical strategies. A previously validated three-dimensional finite element model of the human cervical spine with spinal cord was used. Three models of cervical alignment were created: lordosis (C2-C7 Cobb angle: 20°), straight (0°), and kyphosis (- 9°). C5-C6 spinal stenosis was simulated with ventral disk protrusions, reducing spinal canal diameters to 10 mm, 8 mm, and 6 mm. Spinal cord pre-stress and pre-strain due to alignment and compression were quantified. Cervical flexion and extension were simulated with a pure moment load of 2 Nm. The Von Mises stress and maximum principal strain of the whole spinal cord were calculated during neck motion and the relationship between spinal cord biomechanics, alignment, and compression was analyzed using linear regression analysis. Spinal cord pre-stress and pre-strain were greatest with kyphosis (7.53 kPa, 5.4%). Progressive kyphosis and stenosis were associated with an increase in spinal cord stress (R2 = 0.99) and strain (R2 = 0.99). Cervical kyphosis was associated with greater spinal cord stress and strain during neck flexion-extension and the magnitude of difference increased with increasing stenosis. Cervical kyphosis increases baseline spinal cord stress and strain. Incorporating sagittal alignment with compression to calculate spinal cord biomechanics is necessary to accurately quantify spinal stress and strain during neck flexion and extension.
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Affiliation(s)
- Shalini Gundamraj
- Chicago College of Osteopathic Medicine, Midwestern University, Downers Grove, IL, USA
| | - Karthik Banurekha Devaraj
- Department of Neurosurgery, Medical College of Wisconsin, Watertown Plank Road, Milwaukee, WI, 870153226, USA
| | - Balaji Harinathan
- Department of Neurosurgery, Medical College of Wisconsin, Watertown Plank Road, Milwaukee, WI, 870153226, USA
- School of Mechanical Engineering, Vellore Institute of Technology, Chennai, Tamil Nadu, India
| | - Anjishnu Banerjee
- Department of Biostatistics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Narayan Yoganandan
- Department of Neurosurgery, Medical College of Wisconsin, Watertown Plank Road, Milwaukee, WI, 870153226, USA
| | - Aditya Vedantam
- Department of Neurosurgery, Medical College of Wisconsin, Watertown Plank Road, Milwaukee, WI, 870153226, USA.
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Hesni S, Baxter D, Saifuddin A. The imaging of cervical spondylotic myeloradiculopathy. Skeletal Radiol 2023; 52:2341-2365. [PMID: 37071191 DOI: 10.1007/s00256-023-04329-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 03/12/2023] [Accepted: 03/20/2023] [Indexed: 04/19/2023]
Abstract
This review provides a detailed description of the imaging features of cervical spondylotic myelopathy and radiculopathy, with a focus on MRI. Where relevant, we will outline grading systems of vertebral central canal and foraminal stenosis. Whilst post-operative appearances of the cervical spine are outside the scope of this paper, we will touch on imaging features recognised as predictors of clinical outcome and neurological recovery. This paper will serve as a reference for both radiologists and clinicians involved in the care of patients with cervical spondylotic myeloradiculopathy.
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Affiliation(s)
- Susan Hesni
- Department of Radiology, Royal National Orthopaedic Hospital (RNOH), Stanmore, UK.
| | - David Baxter
- Department of Surgery, Royal National Orthopaedic Hospital (RNOH), Stanmore, UK
| | - Asif Saifuddin
- Department of Radiology, Royal National Orthopaedic Hospital (RNOH), Stanmore, UK
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de Dios E, Laesser M, Björkman-Burtscher IM, Lindhagen L, MacDowall A. MRI-based measurements of spondylolisthesis and kyphosis in degenerative cervical myelopathy. BMC Med Imaging 2023; 23:180. [PMID: 37946139 PMCID: PMC10634168 DOI: 10.1186/s12880-023-01151-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 11/02/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND To provide normative data and to determine accuracy and reliability of preoperative measurements of spondylolisthesis and kyphosis on supine static magnetic resonance imaging (MRI) of patients with degenerative cervical myelopathy. METHODS T2-weighted midsagittal images of the cervical spine were in 100 cases reviewed twice by one junior observer, with an interval of 3 months, and once by a senior observer. The spondylolisthesis slip (SSlip, mm) and the modified K-line interval (mK-line INT, mm) were assessed for accuracy with the standard error of measurement (SEm) and the minimum detectable change (MDC). Intraobserver and interobserver reliability levels were determined using the intraclass correlation coefficient (ICC). RESULTS The SEm was 0.5 mm (95% CI 0.4-0.6) for spondylolisthesis and 0.6 mm (95% CI 0.5-0.7) for kyphosis. The MDC, i.e., the smallest difference between two examinations that can be detected with statistical certainty, was 1.5 mm (95% CI 1.2-1.8) for spondylolisthesis and 1.6 mm (95% CI 1.3-1.8) for kyphosis. The highest reliability levels were seen between the second observation of the junior examiner and the senior observer (ICC = 0.80 [95% CI 0.70-0.87] and ICC = 0.96 [95% CI 0.94-0.98] for SSlip and mK-line INT, respectively). CONCLUSIONS This study provides normative values of alignment measurements of spondylolisthesis and kyphosis in DCM patients. It further shows the importance of taking measurement errors into account when defining cut-off values for cervical deformity parameters and their potential clinical application in surgical decision-making.
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Affiliation(s)
- Eddie de Dios
- Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
- Department of Radiology, Sahlgrenska University Hospital, Region Västra Götaland, Bruna stråket 11, Gothenburg, 41345, Sweden.
| | - Mats Laesser
- Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Radiology, Sahlgrenska University Hospital, Region Västra Götaland, Bruna stråket 11, Gothenburg, 41345, Sweden
| | - Isabella M Björkman-Burtscher
- Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Radiology, Sahlgrenska University Hospital, Region Västra Götaland, Bruna stråket 11, Gothenburg, 41345, Sweden
| | - Lars Lindhagen
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Anna MacDowall
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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Acharya S, Khanna V, Chahal RS, Kalra KL, Vishwakarma G. Clinicoradiological Risk Factors Associated with Inability to Achieve Minimum Clinically Important Difference in Operated Cases of Cervical Spondylotic Myelopathy. Asian Spine J 2023; 17:904-915. [PMID: 37463661 PMCID: PMC10622822 DOI: 10.31616/asj.2022.0446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 02/23/2023] [Accepted: 05/27/2023] [Indexed: 07/20/2023] Open
Abstract
STUDY DESIGN This is a retrospective cohort study. PURPOSE This study aimed to identify the clinicoradiological risk factors associated with the inability to achieve minimum clinically important difference (MCID) on the modified Japanese Orthopaedic Association (mJOA) Scale in operated cases of cervical spondylotic myelopathy (CSM). OVERVIEW OF LITERATURE Only a few studies have evaluated the outcomes of surgery performed for CSM using MCID on the mJOA scale. METHODS We analyzed 124 operated CSM cases from March 2019 to April 2021 for preoperative clinical features, cervical sagittal radiographic parameters, and magnetic resonance imaging (MRI) signal intensities (SI). The risk factors associated with missing the MCID (poor outcome) on mJOA at the final follow-up were identified using binary logistic regression. Multivariate analysis was used to find significant risk factors, and odds ratios (OR) were computed. RESULTS A total of 110 men (89.2%) and 14 women (10.8%) with an average age of 53.5±13.2 years were included in the analysis. During the last follow-up, 89 cases (72.1%) achieved MCID (meaningful gains following surgery) while 35 (27.9%) could not. The final model identified the following parameters as significant risk factors for poor outcome: increased duration of symptoms (OR, 6.77; p=0.001), lower preoperative mJOA scale (OR, 0.75; p=0.029), the presence of multilevel T2-weighted (T2W) MRI SI (OR, 4.79; p=0.004), and larger change in cervical sagittal vertical axis (ΔcSVA) (OR, 1.06; p=0.013). Also, an increase in cSVA postoperatively correlated with a reduced functional recovery rate (r=-0.4, p<0.001). CONCLUSIONS Surgery for CSM leads to significant functional benefits. However, poorer outcomes are observed in cases of greater duration of symptoms, higher preoperative severity with multilevel T2W MRI SI, and a larger increase in the postoperative cSVA (sagittal imbalance).
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Affiliation(s)
- Shankar Acharya
- Department of Ortho-Spine Surgery, Sir Ganga Ram Hospital, New Delhi,
India
| | - Varun Khanna
- Department of Ortho-Spine Surgery, Sir Ganga Ram Hospital, New Delhi,
India
| | | | - Kashmiri Lal Kalra
- Department of Ortho-Spine Surgery, Sir Ganga Ram Hospital, New Delhi,
India
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Acharya S, Khanna V, Kalra KL, Chahal RS. Influence of Preoperative Sagittal Alignment on Functional Recovery in Operated Cases of Cervical Spondylotic Myelopathy. Asian J Neurosurg 2023; 18:293-300. [PMID: 37397040 PMCID: PMC10310444 DOI: 10.1055/s-0043-1768597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2023] Open
Abstract
Objective We examine the influence of preoperative cervical sagittal curvature (lordotic or nonlordotic) on the functional recovery of surgically managed cases of cervical spondylotic myelopathy (CSM). The impact of sagittal alignment on the functional improvement of operated CSM cases has not been thoroughly investigated. Materials and Methods We did retrospective analysis of consecutively operated cases of CSM from March 2019 to April 2021. Patients were grouped into two categories: lordotic curvature (with Cobb angle > 10 degrees) and nonlordotic curvature (including neutral [Cobb angle 0-10 degrees] and kyphotic [Cobb angle < 0 degrees]). Demographic data, and preoperative and postoperative functional outcome scores (modified Japanese Orthopaedic Association [mJOA] and Nurick grade) were analyzed for dependency on preoperative curvature, and correlations between outcomes and sagittal parameters were assessed. Results In the analysis of 124 cases, 63.1% (78 cases) were lordotic (mean Cobb angle of 23.57 ± 9.1 degrees; 11-50 degrees) and 36.9% (46 cases) were nonlordotic (mean Cobb angle of 0.89 ± 6.5 degrees; -11 to 10 degrees), 32 cases (24.6%) had neutral alignment, and 14 cases (12.3%) had kyphotic alignment. At the final follow-up, the mean change in mJOA score, Nurick grade, and functional recovery rate (mJOArr) were not significantly different between the lordotic and nonlordotic group. In the nonlordotic group, cases with anterior surgery had a significantly better mJOArr than those with posterior surgery ( p = 0.04), whereas there was similar improvement with either approach in lordotic cases. In the nonlordotic group, patients who gained lordosis (78.1%) had better recovery rates than those who had lost lordosis (21.9%). However, this difference was not statistically significant. Conclusion We report noninferiority of the functional outcome in the cases with preoperative nonlordotic alignment when compared with those with lordotic alignment. Further, nonlordotic patients who were approached anteriorly fared better than those approached posteriorly. Although increasing sagittal imbalance in nonlordotic spines portend toward higher preoperative disability, gain in lordosis in such cases may improve results. We recommend further studies with larger nonlordotic subjects to elucidate the impact of sagittal alignment on functional outcome.
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Affiliation(s)
- Shankar Acharya
- Department of Ortho-Spine Surgery, Sir Ganga Ram Hospital, New Delhi, India
| | - Varun Khanna
- Department of Ortho-Spine Surgery, Sir Ganga Ram Hospital, New Delhi, India
| | - Kashmiri Lal Kalra
- Department of Ortho-Spine Surgery, Sir Ganga Ram Hospital, New Delhi, India
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REVISION RECONSTRUCTION OF THE CERVICAL SPINE IN A PATIENT WITH EARLY DEEP SSI COMPLICATED BY ANGULAR KYPHOSIS: clinical case and literature review. TRAUMATOLOGY AND ORTHOPEDICS OF RUSSIA 2023. [DOI: 10.17816/2311-2905-2373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
Background. Deep surgical site infection (DSSI) is one of the most severe complications in spinal surgery. The timing and nature of DSSI are the determining criteria in the choice of treatment tactics. Aim. To present a unique clinical case of early deep SSI after ACDF in a patient with multisegmental degenerative spinal canal stenosis, complicated by epidural abscess and angular kyphotic deformity. Angular kyphosis correction, corpectomy of C4-6 and three-column cervical reconstruction were performed in one surgical session. Case presentation. A 57-year-old patient was admitted to the clinic after staged surgical interventions on the cervical spine for multilevel degenerative stenosis of the spinal canal. The primary surgical interventions were complicated by DSSI in the early period after the second surgery with formation of angular kyphosis of the cervical spine. The patient underwent revision one-stage reconstructive intervention to correct the deformity, decompress the spinal canal, and three-column reconstruction of C3-7 segments. Long-term follow-up showed persistent reduction of pain syndrome, improved quality of life and absence of recurrence of DSSI. Conclusion. The presented case illustrates the possibilities of one-stage revision three-column cervical spine reconstruction for correction of sagittal profile, decompression of intracanal neural structures and ensuring stability of operated segments. Use of DSSI treatment algorithms based on Prinz V. and Vajkoczy P. classification contributes to the selection of the optimal tactics of patient management.
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MacDowall A, Löfgren H, Edström E, Brisby H, Parai C, Elmi-Terander A. Comparison of posterior muscle-preserving selective laminectomy and laminectomy with fusion for treating cervical spondylotic myelopathy: study protocol for a randomized controlled trial. Trials 2023; 24:106. [PMID: 36765352 PMCID: PMC9921403 DOI: 10.1186/s13063-023-07123-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 01/28/2023] [Indexed: 02/12/2023] Open
Abstract
BACKGROUND Cervical spondylotic myelopathy (CSM) is the predominant cause of spinal cord dysfunction in the elderly. The patients are often frail and susceptible to complications. Posterior surgical techniques involving non-fusion are complicated by postlaminectomy kyphosis and instrumented fusion techniques by distal junction kyphosis, pseudarthrosis, or implant failure. The optimal surgical approach is still a matter of controversy. Since anterior and posterior fusion techniques have been compared without presenting any superiority, the objective of this study is to compare stand-alone laminectomy with laminectomy and fusion to determine which treatment has the lowest frequency of reoperations. METHODS This is a multicenter randomized, controlled, parallel-group non-inferiority trial. A total of 300 adult patients are allocated in a ratio of 1:1. The primary endpoint is reoperation for any reason at 5 years of follow-up. Sample size and power calculation were performed by estimating the reoperation rate after laminectomy to 3.5% and after laminectomy with fusion to 7.4% based on the data from the Swedish spine registry (Swespine) on patients with CSM. Secondary outcomes are the patient-derived Japanese Orthopaedic Association (P-mJOA) score, Neck Disability Index (NDI), European Quality of Life Five Dimensions (EQ-5D), Numeric Rating Scale (NRS) for neck and arm pain, Hospital Anxiety and Depression Scale (HADS), development of kyphosis measured as the cervical sagittal vertical axis (cSVA), and death. Clinical and radiological follow-up is performed at 3, 12, 24, and 60 months after surgery. The main inclusion criterium is 1-4 levels of CSM in the subaxial spine, C3-C7. The REDcap software will be used for safe data management. Data will be analyzed according to the modified intention to treat (mITT) population, defined as randomized patients who are still alive without having emigrated or left the study after 2 and 5 years. DISCUSSION This will be the first randomized controlled trial comparing two of the most common surgical treatments for CSM: the posterior muscle-preserving selective laminectomy and posterior laminectomy with instrumented fusion. The results of the myelopathy randomized controlled (MyRanC) study will provide surgical treatment recommendations for CSM. This may result in improvements in surgical treatment and clinical practice regarding CSM. TRIAL REGISTRATION ClinicalTrials.gov NCT04936074 . Registered on 23 June 2021.
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Affiliation(s)
- Anna MacDowall
- Department of Surgical Sciences, Uppsala University, Entrance 61, 6th floor, 75185, Uppsala, Sweden.
| | - Håkan Löfgren
- grid.5640.70000 0001 2162 9922Neuro-Orthopedic Center, Jönköping, Jönköping County, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Erik Edström
- grid.24381.3c0000 0000 9241 5705Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden ,grid.4714.60000 0004 1937 0626Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden ,Capio, Spine Center Stockholm, Upplands-Väsby, Sweden
| | - Helena Brisby
- grid.8761.80000 0000 9919 9582Department of Orthopaedics, Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
| | - Catharina Parai
- grid.8761.80000 0000 9919 9582Department of Orthopaedics, Institute of Clinical Sciences, University of Gothenburg, Gothenburg, Sweden
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Koller H, Stengel FC, Hostettler IC, Koller J, Fekete T, Ferraris L, Hitzl W, Hempfing A. Clinical and surgical results related to anterior-only multilevel cervical decompression and instrumented fusion for degenerative disease. BRAIN & SPINE 2023; 3:101716. [PMID: 37383455 PMCID: PMC10293232 DOI: 10.1016/j.bas.2023.101716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Revised: 11/20/2022] [Accepted: 01/20/2023] [Indexed: 06/30/2023]
Abstract
Introduction Anterior-only multilevel cervical decompression and fusion surgery (AMCS) on 3-5-levels is challenging due to potential complications. Also, outcome predictors after AMCS are poorly understood. Research Question We hypothesize that in patients with at most mild/moderate cervical kyphosis (CK) of the cervical spine, restoration of cervical lordosis (CL) positively influences clinical outcomes. Methods Analysis of consecutive patients presenting with symptomatic degenerative cervical disease or non-union undergoing AMCS. We measured CL from C2 to C7, Cobb angle of fused levels (fusion angle, FA), C7-Slope, and sagittal vertical axis C2-7 (cSVA, stratified into ≤4cm∖>4cm). Patients with excellent outcome were grouped in BEST-outcomes and with moderate/poor outcomes in WORST-outcomes. Results We included 244 patients. Fifty-four percent had 3-, 39% 4-level and 7% had 5-level fusion. At mean follow-up of 26 months, 41% of patients achieved BEST-outcome and 23% WORST-outcome. Complications and reoperation rates did not significantly differ. Non-union significantly influenced outcomes. The number of patients with non-union was significantly higher in patients with a preoperative cSVA>4cm (OR 13.1 (95%CI:1.8-96.8). Our model, based on the multivariable analysis with WORST-outcome as outcome variable showed a high accuracy (NPV=73%, PPV=77%, specificity=79%, sensitivity=71%). Discussion and Conclusion In 3-5-level AMCS, improvement of FA and cSVA were independent predictors of clinical outcome. Improvement of CL positively influenced clinical outcomes and rates of non-union.
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Affiliation(s)
- Heiko Koller
- Department of Neurosurgery, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
- Department for Traumatology and Sports Injuries, Paracelsus Medical University Salzburg, Austria
| | - Felix C. Stengel
- Department of Neurosurgery, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
- Department of Neurosurgery, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Isabel C. Hostettler
- Department of Neurosurgery, Technical University of Munich, Klinikum rechts der Isar, Munich, Germany
- Department of Neurosurgery, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Juliane Koller
- Department for Orthopedic Surgery, Schoen Clinic Vogtareuth, Vogtareuth, Germany
| | - Tamas Fekete
- Department for Spine Surgery, Schulthess Clinic Zurich, Zurich, Switzerland
| | - Luis Ferraris
- Spine Center, Werner-Wicker-Clinic, Bad Wildungen, Germany
| | - Wolfgang Hitzl
- Research Program Experimental Ophthalmology and Glaucoma Research, Paracelsus Medical University, Salzburg, Austria
| | - Axel Hempfing
- Department for Orthopedic Surgery, Schoen Clinic Vogtareuth, Vogtareuth, Germany
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Evaniew N, Charest-Morin R, Jacobs WB, Johnson M, Bailey CS, Christie S, Paquet J, Nataraj A, Cadotte DW, Wilson JR, Craig M, Xu M, Manson N, Hall H, Thomas KC, Rampersaud YR, McIntosh G, Fisher CG, Dea N. Cervical Sagittal Alignment in Patients with Cervical Spondylotic Myelopathy: An Observational Study From the Canadian Spine Outcomes and Research Network. Spine (Phila Pa 1976) 2022; 47:E177-E186. [PMID: 34845179 DOI: 10.1097/brs.0000000000004296] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Prospective cohort study. OBJECTIVE Among patients with CSM, we aimed to evaluate the extent to which: (1) Preoperative cervical sagittal alignment is associated with health-related quality of life, function, and symptoms; (2) Surgery leads to changes in cervical sagittal alignment; and (3) Postoperative cervical sagittal alignment is associated with health-related quality of life, function, and symptoms at 12 months of follow-up. SUMMARY OF BACKGROUND DATA The importance of maintaining or improving cervical sagittal alignment in the surgical management of patients with CSM has not been established. METHODS We measured C2-C7 Cobb angle, T1 slope, and C2-C7 cervical sagittal vertical axis (cSVA). We tested for associations with Neck Disability Index, Pain Scales for neck and arm pain, EuroQol 5D, Short Form 12 Physical and Mental Component Summaries, and modified Japanese Orthopaedic Association scores. We adjusted for potential confounders using multiple linear regression, and we performed various prespecified subgroup (cSVA > 40 mm, surgical approach) and sensitivity analyses. RESULTS Among 250 patients, adjusted analyses yielded significant inverse associations prior to surgery between each of cSVA and T1 slope with SF12 Physical Component Summaries (T1 slope: -0.14, 95% CI -0.26 to -0.01, P = 0.03; C2-C7 cSVA: -0.13, 95% CI --0.21 to -0.05 P < 0.01). Surgery was associated with a small but statistically significant increase in cSVA across the cohort (+5.8 mm [SD 11.7], P < 0.01) but no change in Cobb angle or T1 slope. At 12-months after surgery, there were no significant associations between alignment parameters or change in alignment and any measures of health-related quality of life, function, or symptoms. Results were consistent across subgroup and sensitivity analyses. CONCLUSION Increased cSVA and T1 slope were associated with inferior health-related quality of life at presentation among patients with CSM, but no significant associations were observed following surgical treatment.Level of Evidence: 3.
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Affiliation(s)
- Nathan Evaniew
- University of Calgary Spine Program, University of Calgary, Calgary, Alberta, Canada
- McCaig Institute for Bone and Joint Health, University of Calgary, Calgary, Alberta, Canada
| | - Raphaële Charest-Morin
- Combined Neurosurgery and Orthopaedic Spine Program, University of British Columbia, Vancouver, British Columbia, Canada
| | - W Bradley Jacobs
- University of Calgary Spine Program, University of Calgary, Calgary, Alberta, Canada
| | - Michael Johnson
- Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Sean Christie
- Division of Neurosurgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Jérôme Paquet
- Department of Orthopaedics, Centre Hospitalier Universitaire de Quebec, Quebec, Quebec, Canada
| | - Andrew Nataraj
- Division of Neurosurgery, University of Alberta, Edmonton, Alberta, Canada
| | - David W Cadotte
- University of Calgary Spine Program, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute and Departments of Clinical Neurosciences and Radiology, Division of Neurosurgery, Cumming School of Medicine, University of Calgary
| | | | - Michael Craig
- Combined Neurosurgery and Orthopaedic Spine Program, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mark Xu
- Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Neil Manson
- Canada East Spine Centre, Saint John Regional Hospital, Saint John, New Brunswick, Canada
| | - Hamilton Hall
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Ken C Thomas
- University of Calgary Spine Program, University of Calgary, Calgary, Alberta, Canada
| | - Y Raja Rampersaud
- Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | | | - Charles G Fisher
- Combined Neurosurgery and Orthopaedic Spine Program, University of British Columbia, Vancouver, British Columbia, Canada
| | - Nicolas Dea
- Combined Neurosurgery and Orthopaedic Spine Program, University of British Columbia, Vancouver, British Columbia, Canada
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Yang H, Sun Y, Wang L, Guo Q, Jiang J, Lu X. Anterior Canal Reconstruction and Fusion for Myelopathy Caused by Degenerative Cervical Kyphosis and Stenosis With or Without Ossification of the Posterior Longitudinal Ligament. Clin Spine Surg 2022; 35:E53-E61. [PMID: 34039887 DOI: 10.1097/bsd.0000000000001194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 04/14/2021] [Indexed: 11/25/2022]
Abstract
STUDY DESIGN This was a retrospective study. OBJECTIVE To introduce an anterior surgical technique for myelopathy caused by degenerative cervical kyphosis and stenosis (DCKS) with or without ossification of the posterior longitudinal ligament (OPLL). SUMMARY OF BACKGROUND DATA The optimal approach in the treatment of DCKS remains a controversy because each anterior or posterior route surgery has advantages and disadvantages. MATERIALS AND METHODS In the period from June 2017 through June 2019, a consecutive cohort of adults diagnosed with DCKS underwent anterior canal reconstruction and fusion (ACRF). All patients underwent x-ray, computed tomography, and magnetic resonance imaging of the cervical spine. Radiologic assessment included kyphosis, canal area, canal reconstruction, OPLL, and spinal cord curvature and morphology. The Japanese Orthopaedic Association (JOA) scoring system was used to evaluate the neurological status. Surgery-related and implant-related complications were all recorded. Follow-up was carried out at 3, 6, 12, 24, and 36 months postoperation. RESULTS Fourty-one patients were included in the study, of which 19 presented with OPLL. Postoperatively, the canal area were significantly greater at last follow-up compared with preoperation (208.4 vs. 123.2 mm2; P=0.001). There was significant kyphosis correction (-17.6 vs. 8.5 degrees, P=0.001) at last follow-up. Ninety-six segmental canal reconstruction were performed, 89 (92.7%) reached bone fusion at both grooves with a mean time of 7.9 months. On sagittal magnetic resonance imaging, 33 (80.5%) patients presented with lordosis in the spinal cord curvature, 8 (19.5%) with straight. The mean JOA score at last follow-up was significantly better than preoperation (15.0 vs. 9.3 points; P<0.01). One patient presented with cerebrospinal fluid leakage, 1 with screw displacement and 2 with dysphagia. CONCLUSION ACRF, receiving good correction of kyphosis, amplified canal area, solid instrumented fusion and circumferential decompression, is an effective and safe surgical technique for cervical myelopathy caused by DCKS with or without OPLL. LEVEL OF EVIDENCE Level III-a retrospective analysis.
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Affiliation(s)
- Haisong Yang
- Department of Orthopaedics, Changzheng Hospital, Second Military Medical University, Shanghai, China
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11
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Donnally CJ, Patel PD, Canseco JA, Vaccaro AR, Kepler CK. Current Management of Cervical Spondylotic Myelopathy. Clin Spine Surg 2022; 35:E68-E76. [PMID: 34379614 DOI: 10.1097/bsd.0000000000001113] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Accepted: 11/07/2020] [Indexed: 11/26/2022]
Abstract
Cervical spondylotic myelopathy (CSM) develops insidiously as degenerative changes of the cervical spine impact the spinal cord. Unfortunately, CSM is a form of spinal cord injury in older patients that often experiences delayed treatment. This summary evaluates the pathophysiology, natural history, diagnosis, and current management of CSM. Frequently, patients do not appreciate or correlate their symptomatology with cervical spine disease, and those with radiographic findings may be clinically asymptomatic. Providers should remember the classic symptoms of CSM-poor hand dexterity, new unsteady gait patterns, new onset and progressive difficulty with motor skills. An magnetic resonance imaging is required in patients with suspected CSM, but computerized tomography myelography is an alternative in patients with implants as contraindications to magnetic resonance imaging. The management of those with CSM has continued to be a controversial topic. In general, patients with incidental findings of cervical cord compression that are asymptomatic can be managed conservatively. Those with daily moderate-severe disease that significantly affects activities of daily living should be treated operatively.
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Affiliation(s)
| | - Parthik D Patel
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA
| | - Jose A Canseco
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA
| | - Alexander R Vaccaro
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA
| | - Christopher K Kepler
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA
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12
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Rodrigues-Pinto R, Montenegro TS, Davies BM, Kato S, Kawaguchi Y, Ito M, Zileli M, Kwon BK, Fehlings MG, Koljonen PA, Kurpad SN, Guest JD, Aarabi B, Rahimi-Movaghar V, Wilson JR, Kotter MRN, Harrop JS. Optimizing the Application of Surgery for Degenerative Cervical Myelopathy [AO Spine RECODE-DCM Research Priority Number 10]. Global Spine J 2022; 12:147S-158S. [PMID: 35174733 PMCID: PMC8859702 DOI: 10.1177/21925682211062494] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
STUDY DESIGN Literature Review (Narrative). OBJECTIVE To introduce the number 10 research priority for Degenerative Cervical Myelopathy: Individualizing Surgery. METHODS This article summarizes the current recommendations and indications for surgery, including how known prognostic factors such as injury time, age, disease severity, and associated comorbidities impact surgical outcome. It also considers key areas of uncertainty that should be the focus of future research. RESULTS While a small proportion of conservatively managed patients may remain stable, the majority will deteriorate over time. To date, surgical decompression is the mainstay of treatment, able to halt disease progression and improve neurologic function and quality of life for most patients. Whilst this recognition has led to recommendations on when to offer surgery, there remain many uncertainties including the type of surgery, or timing in milder and/or asymptomatic cases. Their clarification has the potential to transform outcomes, by ensuring surgery offers each individual its maximum benefit. CONCLUSION Developing the evidence to better guide surgical decision-making at the individual patient level is a research priority for Degenerative Cervical Myelopathy.
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Affiliation(s)
- Ricardo Rodrigues-Pinto
- Spinal Unit (UVM), Department of Orthopaedics, Centro Hospitalar Universitário do Porto - Hospital de Santo António, Porto, Portugal
- Instituto de Ciências Biomédicas Abel Salazar, Porto, Portugal
| | - Thiago S. Montenegro
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | | | - So Kato
- Department of Orthopaedic Surgery, The University of Tokyo, Tokyo, Japan
| | | | - Manabu Ito
- Department of Orthopaedic Surgery, National Hospital Organization Hokkaido Medical Center, Sapporo, Japan
| | - Mehmet Zileli
- Neurosurgery Department, Ege University, Bornova, Izmir, Turkey
| | - Brian K. Kwon
- Vancouver Spine Surgery Institute, Department of Orthopedics, The University of British Columbia, Vancouver, BC, Canada
| | - Michael G. Fehlings
- Division of Neurosurgery, Department of Surgery, University of Toronto, ON, Canada
| | - Paul A. Koljonen
- Department of Orthopaedics and Traumatology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Shekar N. Kurpad
- Department of Neurosurgery, Medical College of Wisconsin, Wauwatosa, WI, USA
| | - James D. Guest
- Department of Neurosurgery and The Miami Project to Cure Paralysis, The Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Bizhan Aarabi
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Vafa Rahimi-Movaghar
- Department of Neurosurgery, Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Iran
| | - Jefferson R. Wilson
- Division of Neurosurgery, Department of Surgery, University of Toronto, ON, Canada
| | | | - James S. Harrop
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
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13
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Koeppen D, Stelling H, Goll M, Kroppenstedt S, Cabraja M. Comparison of sagittal vertical axis and decompression on the clinical outcome of cervical spondylotic myelopathy. Clin Neurol Neurosurg 2022; 213:107125. [PMID: 35030419 DOI: 10.1016/j.clineuro.2022.107125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 01/05/2022] [Accepted: 01/08/2022] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Decompression and cervical balance are major goals in the surgical treatment of cervical spondylotic myelopathy (CSM). Cervical balance is assumed to be a key factor for neurological recovery and pain reduction. Surgical reduction of C2-7 sagittal vertical axis (SVA) correlates with clinical improvement. However, it remains unclear, how much or even if correction is necessary for clinical improvement as long as surgery results in successful decompression. We aim to evaluate the role of radiological cervical balance parameter on the short-term course of CSM. METHODS This is a retrospective study with prospectively collected data of 90 patients. The authors identified 45 patients suffering from CSM that underwent decompressive surgery and instrumentation and showed an increased C2-7 sagittal vertical axis (SVA) after surgery. 45 consecutive patients with a decreased C2-7 SVA were selected as a control group. RESULTS Surgery improved the clinical outcome of both groups significantly. No differences could be seen comparing neck pain and neurological improvement between both groups. An increased C2-7 SVA did not correlate with an inferior clinical outcome. T1-slope correlated with the Cobb-angle. CONCLUSIONS Decompression and stabilization appear to be key elements of surgical treatment of CSM. In short terms, clinical improvement does not appear to affect patients negatively who show a larger C2-7 SVA after surgery. Optimal C2-7 SVA and necessity for a specific C2-7 correction is unclear. The term "balance" remains a complex entity without clear definition.
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Affiliation(s)
- Daniel Koeppen
- Department of Orthopedic Surgery and Traumatology, Bundeswehrkrankenhaus Berlin, Berlin, Germany
| | - Henrik Stelling
- Joint Spine Centre, Vivantes Auguste Viktoria Klinikum, Berlin, Germany
| | - Moritz Goll
- Joint Spine Centre, Vivantes Auguste Viktoria Klinikum, Berlin, Germany
| | | | - Mario Cabraja
- Joint Spine Centre, Vivantes Auguste Viktoria Klinikum, Berlin, Germany.
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Toci G, Canseco J, Karamian B, Chang M, Grasso G, Nicholson K, Pflug E, Russo G, Tarazona D, Kaye ID, Kurd M, Hilibrand A, Woods B, Rihn J, Anderson DG, Radcliff K, Kepler C, Vaccaro A, Schroeder G. The impact of preoperative neurological symptom severity on postoperative outcomes in cervical spondylotic myelopathy. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2022; 13:94-100. [PMID: 35386246 PMCID: PMC8978848 DOI: 10.4103/jcvjs.jcvjs_165_21] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 02/03/2022] [Indexed: 11/16/2022] Open
Abstract
Study Design: The study design is a retrospective cohort study. Objective: To compare patient-reported outcomes between patients with mild versus moderate-to-severe myelopathy following surgery for cervical spondylotic myelopathy (CSM). Summary of Background Data: Recent studies have demonstrated that decompression for CSM leads to improved quality of life when measured by patient-reported outcomes. However, it is unknown if preoperative myelopathy classification is predictive of superior postoperative improvements. Materials and Methods: A retrospective review of patients treated surgically for CSM at a single institution from 2014 to 2015 was performed. Preoperative myelopathy severity was classified according to the modified Japanese Orthopaedic Association (mJOA) scale as either mild (≥15) or moderate-to-severe (<15). Other outcomes included neck disability index (NDI), 12-item short-form survey (SF-12), and visual analog scale (VAS) for arm and neck pain. Differences in outcomes were tested by linear mixed-effects models followed by pairwise comparisons using least square means. Multiple linear regression determined whether any baseline outcomes or demographics predicted postoperative mJOA. Results: There were 67 patients with mild and 50 patients with moderate-to-severe myelopathy. Preoperatively, patients with moderate-to-severe myelopathy reported significantly worse outcomes compared to the mild group for NDI, Physical Component Score (PCS-12), and VAS arm (P = 0.031). While both groups experienced improvements in NDI, PCS-12, VAS Arm and Neck after surgery, only the moderate-to-severe patients achieved improved mJOA (+3.1 points, P < 0.001). However, mJOA was significantly worse in the moderate-to-severe when compared to the mild group postoperatively (-1.2 points, P = 0.017). Both younger age (P = 0.017, β-coefficient = −0.05) and higher preoperative mJOA (P < 0.001, β-coefficient = 0.37) predicted higher postoperative mJOA. Conclusions: Although patients with moderate-to-severe myelopathy improved for all outcomes, they did not achieve normal absolute neurological function, indicating potential irreversible spinal cord changes. Early surgical intervention should be considered in patients with mild myelopathy if they seek to prevent progressive neurological decline over time.
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Ogura Y, Dimar JR, Djurasovic M, Carreon LY. Etiology and treatment of cervical kyphosis: state of the art review-a narrative review. JOURNAL OF SPINE SURGERY 2021; 7:422-433. [PMID: 34734146 DOI: 10.21037/jss-21-54] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 08/19/2021] [Indexed: 11/06/2022]
Abstract
Objective To provide state of the art review regarding cervical kyphosis. Background Cervical spine kyphosis has been increasingly common due to the growing elderly population. Clinicians should comprehensively understand its symptoms, biomechanics, etiology, radiographic evaluation, classification, and treatment options and complications of each treatment. Comprehensive review will help clinicians improve the management for patients with cervical kyphosis. Methods The available literature relevant to cervical kyphosis was reviewed. PubMed, Medline, OVID, EMBASE, and Cochrane were used to review the literature. Conclusions This article summarizes current concepts regarding etiology, evaluation, surgical treatment, complications and outcomes of cervical kyphosis. Major etiologies of cervical kyphosis include degenerative, post-laminectomy, and ankylosing spondylitis. Clinical presentations include neck pain, myelopathy, radiculopathy, and problems with horizontal gaze, swallowing and breathing. Cervical lordosis, C2-7 sagittal vertical axis, chin-brow to vertical angle, and T1 slope should be evaluated from upright lateral 36-inch film. The most widely used classification system includes a deformity descriptor and 5 modifiers. A deformity descriptor provides a basic grouping of the deformity consisting of five types, cervical, cervicothoracic, thoracic, coronal cervical deformity, and cranio-vertebral junction deformity. The 5 modifiers include C2-7 sagittal vertical axis, chin-brow to vertical angle, T1 slope minus cervical lordosis, myelopathy based on modified Japanese Orthopaedic Association score, and SRS-Schwab classification for thoracolumbar deformity. Current treatment options include anterior discectomy and fusion, anterior osteotomy, Smith-Peterson osteotomy, pedicle subtraction osteotomy, or a combination of these based on careful preoperative evaluation.
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Affiliation(s)
- Yoji Ogura
- Norton Leatherman Spine Center, Louisville, KY, USA
| | - John R Dimar
- Norton Leatherman Spine Center, Louisville, KY, USA
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16
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Asif H, Tohidi M, Hopman W, Yen D. Association between pre-operative sagittal alignment and radiographic measures of decompression following cervical laminectomy: a retrospective cohort study. JOURNAL OF SPINE SURGERY 2021; 7:376-384. [PMID: 34734142 DOI: 10.21037/jss-21-41] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 08/06/2021] [Indexed: 11/06/2022]
Abstract
Background The primary purpose of this study was to determine the association between pre-operative cervical sagittal alignment and the extent of cord decompression in the form of increased spinal cord width and cerebrospinal fluid (CSF) space in front of and behind the cord in patients undergoing laminectomy for cervical spondylotic myelopathy (CSM). Secondary objectives included an assessment of the correlation between increasing numbers of levels decompressed and the post-operative cervical spine sagittal alignment, the effect of laminectomy on the change in alignment, as well as effect of laminectomy on pre-existing spinal cord signal abnormality. Methods This retrospective cohort study included patients who underwent cervical laminectomies, without fusion, between 2015 and 2020. Chart review was used to collect baseline variables. Cervical sagittal alignment, width of the spinal cord, and the CSF space in-front and behind the cord was measured pre-operatively and post-operatively using magnetic resonance imaging (MRI) scans for each patient. The correlation between change in measured parameters and pre-operative cervical sagittal alignment was assessed using Spearman's correlation. Results Thirty-five patients were included. Average age was 65.29±10.98 years old. The majority of patients (80%) underwent laminectomies at 3-4 levels. Average pre-operative sagittal alignment determined by the Cobb angle was 6.05°±14.17°, while the average post-operative Cobb angle was 3.15°±16.64°. The change in Cobb angle was not statistically significant (P=0.998). Eleven patients (32%) had pre-operative kyphotic sagittal alignment. The average time from surgery to post-operative MRI scan was 20.44±13.18 months (range, 3-39; median, 18.5; IQR, 23.5). There was no statistically significant association between increasing levels of decompression and change in alignment (P=0.546). Cord signal abnormality persisted after decompression. There was a moderate correlation between lordotic pre-operative cervical sagittal alignment and change in space in-front of the cord (correlation coefficient 0.337, P=0.048) and change in cord width (correlation coefficient 0.388, P=0.021). Conclusions Severity of pre-operative kyphotic sagittal alignment is associated with decreased spinal cord drift and extent of decompression. The pre-operative sagittal alignment is not significantly associated with the change in post-operative alignment. Increasing number of levels decompressed does not worsen a kyphotic cervical spine sagittal alignment.
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Affiliation(s)
- Hamza Asif
- Department of Surgery, Queen's University, Kingston, ON, Canada.,School of Medicine, Queen's University, Kingston, ON, Canada
| | - Mina Tohidi
- Department of Surgery, Queen's University, Kingston, ON, Canada.,Kingston Health Sciences Centre, Kingston, ON, Canada
| | - Wilma Hopman
- Department of Surgery, Queen's University, Kingston, ON, Canada.,Kingston Health Sciences Centre, Kingston, ON, Canada
| | - David Yen
- Department of Surgery, Queen's University, Kingston, ON, Canada.,Kingston Health Sciences Centre, Kingston, ON, Canada
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Abstract
Degenerative cervical myelopathy (DCM) is a recently coined term encompassing a variety of age-related and genetically associated pathologies, including cervical spondylotic myelopathy, degenerative disc disease, and ligamentous aberrations such as ossification of the posterior longitudinal ligament. All of these pathologies produce chronic compression of the spinal cord causing a clinical syndrome characterized by decreased hand dexterity, gait imbalance, and potential genitourinary or sensorimotor disturbances. Substantial variability in the underlying etiology of DCM and its natural history has generated heterogeneity in practice patterns. Ongoing debates in DCM management most commonly center around clinical decision-making, timing of intervention, and the ideal surgical approach. Pivotal basic science studies during the past two decades have deepened our understanding of the pathophysiologic mechanisms surrounding DCM. Growing knowledge of the key pathophysiologic processes will help us tailor personalized approaches in an increasingly heterogeneous patient population. This article focuses on summarizing the most exciting approaches in personalizing DCM patient treatments including biomarkers, factors affecting clinical decision-making, and choice of the optimal surgical approach. Throughout we provide a concise review on the conditions encompassing DCM and discuss the underlying pathophysiology of chronic spinal cord compression. We also provide an overview on clinical-radiologic diagnostic modalities as well as operative and nonoperative treatment strategies, thereby addressing knowledge gaps and controversies in the field of DCM.
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18
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TO THE EDITOR. Spine (Phila Pa 1976) 2021; 46:E1067. [PMID: 34310534 DOI: 10.1097/brs.0000000000004179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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19
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Passias PG, Brown AE, Alas H, Pierce KE, Bortz CA, Diebo B, Lafage R, Lafage V, Burton DC, Hart R, Kim HJ, Bess S, Moattari K, Joujon-Roche R, Krol O, Williamson T, Tretiakov P, Imbo B, Protopsaltis TS, Shaffrey C, Schwab F, Eastlack R, Line B, Klineberg E, Smith J, Ames C. The impact of postoperative neurologic complications on recovery kinetics in cervical deformity surgery. JOURNAL OF CRANIOVERTEBRAL JUNCTION AND SPINE 2021; 12:393-400. [PMID: 35068822 PMCID: PMC8740804 DOI: 10.4103/jcvjs.jcvjs_108_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 11/06/2021] [Indexed: 11/17/2022] Open
Abstract
Objective: The objective of the study is to investigate which neurologic complications affect clinical outcomes the most following cervical deformity (CD) surgery. Methods: CD patients (C2-C7 Cobb >10°, CL >10°, cSVA >4 cm or chin-brow vertical angle >25°) >18 years with follow-up surgical and health-related quality of life (HRQL) data were included. Descriptive analyses assessed demographics. Neurologic complications assessed were C5 motor deficit, central neurodeficit, nerve root motor deficits, nerve sensory deficits, radiculopathy, and spinal cord deficits. Neurologic complications were classified as major or minor, then: intraoperative, before discharge, before 30 days, before 90 days, and after 90 days. HRQL outcomes were assessed at 3 months, 6 months, and 1 year. Integrated health state (IHS) for the neck disability index (NDI), EQ5D, and modified Japanese Orthopaedic Association (mJOA) were assessed using all follow-up time points. A subanalysis assessed IHS outcomes for patients with 2Y follow-up. Results: 153 operative CD patients were included. Baseline characteristics: 61 years old, 63% female, body mass index 29.7, operative time 531.6 ± 275.5, estimated blood loss 924.2 ± 729.5, 49% posterior approach, 18% anterior approach, 33% combined. 18% of patients experienced a total of 28 neurologic complications in the postoperative period (15 major). There were 7 radiculopathy, 6 motor deficits, 6 sensory deficits, 5 C5 motor deficits, 2 central neurodeficits, and 2 spinal cord deficits. 11.2% of patients experienced neurologic complications before 30 days (7 major) and 15% before 90 days (12 major). 12% of neurocomplication patients went on to have revision surgery within 6 months and 18% within 2 years. Neurologic complication patients had worse mJOA IHS scores at 1Y but no significant differences between NDI and EQ5D (0.003 vs. 0.873, 0.458). When assessing individual complications, central neurologic deficits and spinal cord deficit patients had the worst outcomes at 1Y (2.6 and 1.8 times worse NDI scores, P = 0.04, no improvement in EQ5D, 8% decrease in EQ5D). Patients with sensory deficits had the best NDI and EQ5D outcomes at 1Y (31% decrease in NDI, 8% increase in EQ5D). In a subanalysis, neurologic patients trended toward worse NDI and mJOA IHS outcomes (P = 0.263, 0.163). Conclusions: 18% of patients undergoing CD surgery experienced a neurologic complication, with 15% within 3 months. Patients who experienced any neurologic complication had worse mJOA recovery kinetics by 1 year and trended toward worse recovery at 2 years. Of the neurologic complications, central neurologic deficits and spinal cord deficits were the most detrimental.
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Affiliation(s)
- Peter Gust Passias
- Department of Orthopaedic and Neurosurgery, Division of Spine Surgery, NYU Langone Medical Center, New York, NY, USA
| | - Avery E Brown
- Department of Orthopaedic and Neurosurgery, Division of Spine Surgery, NYU Langone Medical Center, New York, NY, USA
| | - Haddy Alas
- Department of Orthopaedic and Neurosurgery, Division of Spine Surgery, NYU Langone Medical Center, New York, NY, USA
| | - Katherine E Pierce
- Department of Orthopaedic and Neurosurgery, Division of Spine Surgery, NYU Langone Medical Center, New York, NY, USA
| | - Cole A Bortz
- Department of Orthopaedic and Neurosurgery, Division of Spine Surgery, NYU Langone Medical Center, New York, NY, USA
| | - Bassel Diebo
- Deparment of Orthopaedic Surgery, SUNY Downstate, New York, NY, USA
| | - Renaud Lafage
- Deparment of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Virginie Lafage
- Lenox Hill Hospital, Northwell Health, Department of Orthopaedics, New York, NY, USA
| | - Douglas C Burton
- Department of Orthopaedic Surgery, University of Kansas Medical Center, Kansas City, KS, USA
| | - Robert Hart
- Department of Orthopaedic Surgery, Swedish Neuroscience Institute, Seattle, WA, USA
| | - Han Jo Kim
- Deparment of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Shay Bess
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO, USA
| | - Kevin Moattari
- Department of Orthopaedic and Neurosurgery, Division of Spine Surgery, NYU Langone Medical Center, New York, NY, USA
| | - Rachel Joujon-Roche
- Department of Orthopaedic and Neurosurgery, Division of Spine Surgery, NYU Langone Medical Center, New York, NY, USA
| | - Oscar Krol
- Department of Orthopaedic and Neurosurgery, Division of Spine Surgery, NYU Langone Medical Center, New York, NY, USA
| | - Tyler Williamson
- Department of Orthopaedic and Neurosurgery, Division of Spine Surgery, NYU Langone Medical Center, New York, NY, USA
| | - Peter Tretiakov
- Department of Orthopaedic and Neurosurgery, Division of Spine Surgery, NYU Langone Medical Center, New York, NY, USA
| | - Bailey Imbo
- Department of Orthopaedic and Neurosurgery, Division of Spine Surgery, NYU Langone Medical Center, New York, NY, USA
| | - Themistocles S Protopsaltis
- Department of Orthopaedic and Neurosurgery, Division of Spine Surgery, NYU Langone Medical Center, New York, NY, USA
| | | | - Frank Schwab
- Deparment of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY, USA
| | - Robert Eastlack
- Division of Orthopaedic Surgery, Scripps Clinic, La Jolla, CA, USA
| | - Breton Line
- Department of Spine Surgery, Denver International Spine Clinic, Presbyterian St. Luke's/Rocky Mountain Hospital for Children, Denver, CO, USA
| | - Eric Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, CA, USA
| | - Justin Smith
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, VA, USA
| | - Christopher Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, CA,, USA
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Miyagi M, Takahashi H, Sekiya H, Ebihara S. Role of preoperative cervical alignment on postoperative dysphagia after occipitocervical fusion. Surg Neurol Int 2021; 12:350. [PMID: 34345490 PMCID: PMC8326147 DOI: 10.25259/sni_547_2021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 06/19/2021] [Indexed: 11/16/2022] Open
Abstract
Background: Dysphagia is one of the most serious complications of occipitocervical fusion (OCF). The previous studies have shown that postoperative cervical alignment, documented with occipito (O)-C2 angles, C2-C6 angles, and pharyngeal inlet angles (PIA), impacted the incidence of postoperative dysphagia in patients undergoing OCF. Here, we investigated the relationship of preoperative versus postoperative cervical alignment on the incidence of postoperative dysphagia after OCF. Methods: We retrospectively reviewed the clinical data/medical charts for 22 patients following OCF (2006– 2019). The O-C2 angles, C2-C6 angles, PIA, and narrowest pharyngeal airway spaces (nPAS) were assessed using plain lateral radiographs of the cervical spine before and after the surgery. The severity of dysphagia was assessed with the functional oral intake scale (FOIS) levels as documented in medical charts; based on this, patients were classified into the nondysphagia (FOIS: 7) versus dysphagia (FOIS: 1–6) groups. Results: Seven patients (35%) experienced dysphagia after OCF surgery. Preoperative PIA and nPAS were smaller in the dysphagia group. Spearman rank correlation showed a positive correlation between preoperative PIA and FOIS and between preoperative nPAS and FOIS. Conclusion: This study suggests that preoperative cervical alignment may best predict the incidence of postoperative dysphagia after OCF.
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Affiliation(s)
- Midori Miyagi
- Department of Rehabilitation Medicine, Toho University Graduate School of Medicine, Ota-ku, Tokyo, Japan
| | - Hiroshi Takahashi
- Department of Orthopaedic Surgery, Toho University Graduate School of Medicine, Ota-ku, Tokyo, Japan
| | - Hideki Sekiya
- Department of Oral Surgery, Toho University Omori Medical Center, Ota-ku, Tokyo, Japan
| | - Satoru Ebihara
- Department of Rehabilitation Medicine, Toho University Graduate School of Medicine, Ota-ku, Tokyo, Japan
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21
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Liu H, Li X, Wang J, Li Z, Li Z, Chen S, Wang H, Zheng Z. Comparison study of clinical outcomes and sagittal alignment improvement between anterior and posterior fusion techniques for multilevel cervical spondylotic myelopathy. J Orthop Surg (Hong Kong) 2021; 29:2309499020988177. [PMID: 33626976 DOI: 10.1177/2309499020988177] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE To compare the sagittal alignment of different surgical approaches in patients with multiple levels cervical spondylotic myelopathy and explore the relationship between the cervical sagittal alignment and patient's health relative quality of life. METHOD A total of 97 multiple levels cervical spondylotic myelopathy patients who underwent surgery from January 2013 to January 2019 were collected in this study. Patients were divided into three groups: anterior cervical discectomy with fusion, anterior cervical corpectomy with fusion and laminectomy with fusion groups. Clinical outcomes and sagittal alignment parameters were compared preoperative and postoperative. RESULTS There were no significant differences in the average age and sex ratio among the groups. Sagittal parameters correlated to health relative quality of life were C7 slope, occipito-C2 angle, external auditory meatus tilt and cervical sagittal vertical axis. Both anterior cervical discectomy with fusion and anterior cervical corpectomy with fusion groups exhibited better sagittal alignment and clinical outcomes improvement postoperatively. Anterior cervical discectomy with fusion provided better clinical outcomes and the better improvement of cervical lordosis, C7 slope, occipito-C2 angle and cervical sagittal vertical axis compared with patients with Laminectomy with fusion. CONCLUSION C7 slope, occipito-C2 angle, external auditory meatus tilt and cervical sagittal vertical axis are the most important cervical sagittal parameters correlated to clinical outcomes in patients with multilevels cervical spondylotic myelopathy; anterior cervical discectomy with fusion and anterior cervical corpectomy with fusion provides more efficient to restoration of cervical sagittal alignment.
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Affiliation(s)
- Hui Liu
- Department of Spine Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiang Li
- Department of Spine Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jianru Wang
- Department of Spine Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zemin Li
- Department of Spine Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zihao Li
- Department of Spine Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Siwen Chen
- Department of Spine Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Hua Wang
- Department of Spine Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zhaomin Zheng
- Department of Spine Surgery, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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Teixeira KDO, Moreno LEM, Matos TD, Fleury RBC, Costa HRT, Defino HLA. CERVICAL SPONDYLOTIC MYELOPATHY: IS A COMBINED APPROACH NECESSARY? COLUNA/COLUMNA 2021. [DOI: 10.1590/s1808-185120212002223254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
ABSTRACT Objective: Cervical spondylotic myelopathy (CSM) is the main cause of spinal dysfunction in adults. The type of surgical approach to treatment is not well defined in the literature. The objective is to report the results obtained through isolated posterior decompression in patients with a previous indication of the combined approach for the treatment of cervical spondylotic myelopathy. Methods: This is a therapeutic study with level of evidence II, according to the Oxford classification table. Ten patients who underwent isolated posterior approach surgery for the treatment of cervical spondylotic myelopathy were evaluated through imaging and questionnaires (visual analog scale, mJOA-Br scale – Brazilian Portuguese version of the Modified Japanese Orthopedic Association Scale, and Neck Disability Index (NDI)), comparing pre- and postoperative results. Results: Late evaluation of the 10 patients was performed in the period ranging from 24 to 36 months (mean of 30.3 months ± 7.25) following surgery. The comparison of the clinical and radiological parameters in all patients showed a statistical difference in relation to the preoperative scales applied and to the degree of cervical lordosis (p <0.05), evidencing improvement after decompression and posterior fixation of the cervical spine. Conclusions: The isolated posterior approach (decompression, fixation and arthrodesis) allowed the clinical and radiological improvement of patients with cervical spondylotic myelopathy and who had an indication of the complementary anterior approach. Level of evidence II; Retrospective study.
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Lee HJ, Jeon DG, Park JH. Correlation between kinematic sagittal parameters of the cervical lordosis or head posture and disc degeneration in patients with posterior neck pain. Open Med (Wars) 2021; 16:161-168. [PMID: 33585691 PMCID: PMC7862998 DOI: 10.1515/med-2021-0219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 11/09/2020] [Accepted: 11/14/2020] [Indexed: 01/08/2023] Open
Abstract
The purpose of this retrospective cross-sectional study was to examine the degrees of the cervical disc degeneration and the parameters of cervical sagittal balance in plain radiographs, representing cervical lordosis or head posture in subjects with posterior neck pain. A total of 113 patients with posterior neck pain with or without radiating pain were analyzed. The kinematic sagittal parameters of cervical radiographs were obtained at the occipito-cervical (O-C2) angle, sagittal Cobb's angles of C1-C2, C2-C7, and sagittal vertical axis (SVA) of C1-C7 and C2-C7. Cervical disc degeneration was evaluated using the sum of Pfirrmann grades and total modified Matsumoto scores calculated from MRI of the cervical spine. A significant positive correlation was found for the C2-C7 angle using the sum of the Pfirrmann grades and total modified Matsumoto scores, whereas the O-C2 angle and the C1-C2 angle were negatively correlated. The sagittal cervical parameters representing cervical kyphosis and jaw lifting posture were found to be significantly correlated with the degree of cervical disc degeneration. These findings suggest that the loss of the natural sagittal lordosis of the cervical spine may contribute to the progression of disc degeneration, rather than the forward head posture.
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Affiliation(s)
- Hyo Jeong Lee
- Department of Rehabilitation Medicine, Gangnam Severance Hospital, Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Dae Geun Jeon
- Department of Rehabilitation Medicine, Gangnam Severance Hospital, Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jung Hyun Park
- Department of Rehabilitation Medicine, Gangnam Severance Hospital, Rehabilitation Institute of Neuromuscular Disease, Yonsei University College of Medicine, Seoul, Republic of Korea
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Surgical Outcomes Following Laminectomy With Fusion Versus Laminectomy Alone in Patients With Degenerative Cervical Myelopathy. Spine (Phila Pa 1976) 2020; 45:1696-1703. [PMID: 32890295 DOI: 10.1097/brs.0000000000003677] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN .: Post-hoc analysis of a prospective observational cohort study. OBJECTIVE .: To compare clinical outcomes following laminectomy and fusion versus laminectomy alone in an international series of individuals suffering from degenerative cervical myelopathy (DCM). SUMMARY OF BACKGROUND DATA .: Significant controversy exists regarding the role of instrumented fusion in the context of posterior surgical decompression for DCM. A previous study comparing laminectomy and fusion with laminoplasty showed no differences in outcomes between groups after adjusting for preoperative characteristics. METHODS .: Based on the operation they received, 208 of the 757 patients prospectively enrolled in the AO Spine North America or International studies at 26 global sites were included in the present study. Twenty-two patients were treated with laminectomy alone and 186 received a laminectomy with fusion. Patients were evaluated using the modified Japanese Orthopedic Association scale (mJOA), Nurick score, Neck Disability Index, and SF36 quality of life measure. Baseline and surgical characteristics were compared using a t test for continuous variables and a chi-square test for categorical variables. A mixed model analytic approach was used to evaluate differences in outcomes at 24 months between patients undergoing laminectomy and fusion versus laminectomy alone. RESULTS .: Surgical cohorts were comparable in terms of preoperative patient characteristics. Patients undergoing laminectomy with instrumented fusion had a significantly longer operative duration (P < 0.0001, 231.44 vs. 107.10 min) but a comparable length of hospital stay. In terms of outcomes, patients treated with laminectomy with fusion exhibited clinically meaningful improvements (in functional impairmentΔmJOA = 2.48, ΔNurick = 1.19), whereas those who underwent a laminectomy without fusion did not (ΔmJOA = 0.78; ΔNurick = 0.29). There were significant differences between surgical cohorts in the change in mJOA and Nurick scores from preoperative to 24-months postoperative (mJOA: -1.70, P = 0.0266; Nurick: -0.90, P = 0.0241). The rate of perioperative complications was comparable (P = 0.879). CONCLUSION .: Our findings suggest that cervical laminectomy with instrumented fusion is more effective than laminectomy alone at improving functional impairment in patients with DCM. These results warrant confirmation in larger prospective comparative studies. LEVEL OF EVIDENCE 2.
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PINTO EDUARDOMOREIRA, TEIXEIRA ARTUR, FRADA RICARDO, ATILANO PEDRO, OLIVEIRA FILIPA, MIRANDA ANTÓNIO. DEGENERATIVE CERVICAL MYELOPATHY: A REVIEW OF CURRENT CONCEPTS. COLUNA/COLUMNA 2020. [DOI: 10.1590/s1808-185120201904233163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
ABSTRACT Herbert von Luschka, a German anatomist, was the first to describe the developmental changes in the anatomical structures of the cervical spine. Degenerative cervical myelopathy (DCM) represents a collection of pathological entities that cause compression of the cervical spinal cord, resulting in a clinical syndrome typified by spasticity, hyperreflexia, pathologic reflexes, finger/hand clumsiness, gait disturbance and sphincter dysfunction. In the cervical spine, certain patients are more likely to have myelopathy due to a congenitally narrowed cervical spine canal. Degenerative changes are more common at C5 and C6 or C6 and C7 due to the increased motion at these levels. Additional contributors to canal narrowing are infolding of the ligamentum flavum, olisthesis, osteophytes, and facet hypertrophy. Myelopathy will develop in approximately 100% of patients with canal stenosis greater than 60% (less than 6 mm sagittal disc cord space). Classically it has an insidious onset, progressing in a stepwise manner with functional decline. Without treatment, patients may progress toward significant paralysis and loss of function. Treatment requires surgery with either anterior or posterior decompression of the area of narrowing, and probable fusion. Factors of a poor prognosis include symptoms lasting for more than 18 months, increased range of motion in the cervical spine, and female gender. In this study, we give an overview of the state-of-the-art in DCM, with a focus on the pathophysiology, clinical presentation, differential diagnosis, imaging evaluation, natural history, treatment options and complications. Level of evidence III; Review article.
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26
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Khan I, Archer KR, Wanner JP, Bydon M, Pennings JS, Sivaganesan A, Knightly JJ, Foley KT, Bisson EF, Shaffrey C, McGirt MJ, Asher AL, Devin CJ. Trajectory of Improvement in Myelopathic Symptoms From 3 to 12 Months Following Surgery for Degenerative Cervical Myelopathy. Neurosurgery 2020; 86:763-768. [PMID: 31435676 DOI: 10.1093/neuros/nyz325] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 05/18/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Degenerative cervical myelopathy (DCM) is a progressive disease resulting from cervical cord compression. The modified Japanese Orthopaedic Association (mJOA) is commonly used to grade myelopathic symptoms, but its persistent postoperative improvement has not been previously explored. OBJECTIVE To utilize the Quality Outcomes Database (QOD) to evaluate the trajectory of outcomes in those operatively treated for DCM. METHODS This study is a retrospective analysis of prospectively collected data. The QOD was queried for patients undergoing elective surgery for DCM. Patients were divided into mild (≥14), moderate (9-13), or severe (<9) categories for their baseline severity of myelopathic symptoms (mJOA scores). A parsimonious multivariable logistic regression model was fitted with 2 points improvement on mJOA from 3- to 12-mo follow-up as the outcome of interest. RESULTS A total of 2156 patients who underwent elective surgery for DCM and had complete 3- and 12-mo follow-up were included in our analysis. Patients improved significantly from baseline to 3-mo on their mJOA scores, regardless of their baseline mJOA severity. After adjusting for the relevant preoperative characteristics, the baseline mJOA categories had significant impact on outcome of whether a patient keeps improving in mJOA score from 3 to 12 mo postsurgery. Patient with severe mJOA score at baseline had a higher likelihood of improvement in their myelopathic symptoms, compared to patients with mild mJOA score in. CONCLUSION Most patients achieve improvement on a shorter follow-up; however, patients with severe symptoms keep on improving until after a longer follow-up. Preoperative identification of such patients helps the clinician settling realistic expectations for each follow-up timepoint.
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Affiliation(s)
- Inamullah Khan
- Department of Orthopedic Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee.,Department of Neurological surgery, Vanderbilt University School of Medicine, Nashville, Tennessee.,Vanderbilt Center for Musculoskeletal Research, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Kristin R Archer
- Department of Orthopedic Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee.,Vanderbilt Center for Musculoskeletal Research, Vanderbilt University School of Medicine, Nashville, Tennessee.,Department of Physical Medicine and Rehabilitation, Vanderbilt University Medical Center, Nashville, Tennessee
| | - John Paul Wanner
- Department of Orthopedic Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Mohamad Bydon
- Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota
| | - Jacquelyn S Pennings
- Department of Orthopedic Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee.,Vanderbilt Center for Musculoskeletal Research, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Ahilan Sivaganesan
- Department of Neurological surgery, Vanderbilt University School of Medicine, Nashville, Tennessee
| | | | - Kevin T Foley
- Department of Neurosurgery, University of Tennessee Health Sciences Center, Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee
| | - Erica F Bisson
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Christopher Shaffrey
- Department of Neurosurgery, University of Virginia Medical Center, Charlottesville, Virginia
| | - Matthew J McGirt
- Carolina Neurosurgery and Spine Associates, Carolinas Healthcare System, Charlotte, North Carolina
| | - Anthony L Asher
- Carolina Neurosurgery and Spine Associates, Carolinas Healthcare System, Charlotte, North Carolina
| | - Clinton J Devin
- Department of Orthopedic Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee.,Department of Neurological surgery, Vanderbilt University School of Medicine, Nashville, Tennessee.,Steamboat Orthopaedic and Spine Institute, Steamboat Springs, Colorado
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Analysis of the impact of spinopelvic radiographic parameters on the severity of cervical spondylotic myelopathy. J Orthop Sci 2020; 25:966-974. [PMID: 32063467 DOI: 10.1016/j.jos.2020.01.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 12/14/2019] [Accepted: 01/06/2020] [Indexed: 11/21/2022]
Abstract
BACKGROUND The correlation between spinal radiographic parameters and severity of cervical spondylotic myelopathy (CSM) is controversial. This study aimed to investigate the associations between spinal radiographic parameters and CSM severity, as well as between cervical and other spinopelvic radiographic parameters. METHODS Patients diagnosed with CSM (N = 118; 77 men) at our hospital from March 2013 to February 2017 were included. The patients' demographic data and the following radiographic parameters were investigated: cervical lordosis (CL), C2-C7 sagittal vertical axis (C2-C7 SVA), T1 slope, thoracic kyphosis, lumbar lordosis, pelvic incidence, sacral slope, pelvic tilt, and sagittal vertical axis (SVA). Cervical cord compression ratio (CCCR) was evaluated on sagittal magnetic resonance imaging. The Japanese Orthopaedic Association (JOA) scoring system was used for clinical evaluation. Correlation analyses were performed among the clinical and radiographic parameters. RESULTS The JOA score had the strongest correlation with SVA (r = -0.46, p < 0.01), followed by CCCR (r = -0.33, p < 0.01), CL (r = -0.29, p < 0.01), T1 slope (r = -0.29, p = 0.01), and C2-C7 SVA (r = -0.20, p = 0.03). Multivariate linear regression analysis revealed a model predicting the JOA score; JOA = 13.6 - 0.24 × SVA - 4.2 × CCCR (r = 0.51, p < 0.01). Although there was no significant correlation between the cervical and lumbopelvic radiographic parameters, the sequential correlation among the investigated spinopelvic parameters was identified. CONCLUSIONS CSM severity worsened with spinal malalignment, such as a larger SVA. Though lumbopelvic radiographic parameters did not significantly impact cervical alignment and CSM severity, the sequential correlations among cervical-thoracic-lumbopelvic radiographic parameters were observed. Therefore, SVA is the most relevant radiographic parameter for CSM, but we cannot preclude the possibility that lumbopelvic alignment also affects cervical alignment and CSM severity.
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Shin Y, Han K, Lee YH. Temporal Trends in Cervical Spine Curvature of South Korean Adults Assessed by Deep Learning System Segmentation, 2006-2018. JAMA Netw Open 2020; 3:e2020961. [PMID: 33057644 PMCID: PMC7563081 DOI: 10.1001/jamanetworkopen.2020.20961] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
IMPORTANCE The loss of the physiologic cervical lordotic curve is a common degenerative disorder known to be associated with abnormal spinal alignment. However, the changing trends among sex and age groups has not yet been well established. OBJECTIVE To analyze the temporal trends in cervical curvature across sex and age groups using an automated deep learning system (DLS). DESIGN, SETTING, AND PARTICIPANTS A retrospective cross-sectional study was conducted using lateral cervical radiographs of 13 691 individuals from January 1, 2006, to December 31, 2018. The degree of anterior vertical curvature was approximated by a DLS approach and convexity measurement method. This population-based study used the Yonsei University College of Medicine Severance Hospital, Seoul, South Korea, cohort database to identify 13 691 consecutive adults (≥18 years of age) who underwent standing lateral radiography in inpatient and outpatient settings. MAIN OUTCOMES AND MEASURES The prevalence of kyphotic and straight cervical curve as well as the trends of degree of cervical curvature in 2006 to 2018 among sex and age groups were determined. The DLS performance was validated with quantitative metrics and compared with interobserver and intraobserver variations. RESULTS Automatic cervical spine segmentation was identified from lateral radiographs of 13 691 individuals (mean [SD] age, 49.9 [15.3] years; 8051 women [58.8%]). From 2006 to 2018, the decrease in the lordotic curve was significant across both sexes and age groups younger than 70 years, with the decrease more pronounced in women and successively younger generations (female, -0.05; 95% CI, -0.06 to -0.04; 18-29 years of age, -0.06; 95% CI, -0.08 to -0.04; 30-39 years of age, -0.06; 95% CI, -0.08 to -0.04; and 40-49 years of age, -0.05; 95% CI, -0.06 to -0.03; all P < .001). The prevalence of straight and kyphotic curvature had a significant increasing trend for both sexes and young generations, in which individuals 18 to 29 years of age generally had the highest prevalence rates during the study cycle (in 2018, kyphosis, 16.7%; 95% CI, 10.8%-22.5%; straight, 45.5%; 95% CI, 37.7%-53.3%). Similar trends were observed with longitudinal analysis of repeated measures of individuals, with more pronounced decreases in lordotic curvature observed among women and young adults. CONCLUSIONS AND RELEVANCE This study suggests a significant, increasing loss of normal cervical lordotic curvature for both sexes and young adults that is greater in progressively younger cohorts and women. Further research is necessary to evaluate associations between neck pain and loss of cervical curvature and address the need for active promotion and practical interventions aimed at neck posture correction.
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Affiliation(s)
- YiRang Shin
- Department of Radiology, Research Institute of Radiological Science, Center for Clinical Imaging Data Science, Yonsei University College of Medicine, Seoul, South Korea
| | - Kyunghwa Han
- Department of Radiology, Research Institute of Radiological Science, Center for Clinical Imaging Data Science, Yonsei University College of Medicine, Seoul, South Korea
| | - Young Han Lee
- Department of Radiology, Research Institute of Radiological Science, Center for Clinical Imaging Data Science, Yonsei University College of Medicine, Seoul, South Korea
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McCarthy MH, Weiner JA, Patel AA. Strategies to Achieve Spinal Fusion in Multilevel Anterior Cervical Spine Surgery: An Overview. HSS J 2020; 16:155-161. [PMID: 32523483 PMCID: PMC7253572 DOI: 10.1007/s11420-019-09738-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 10/18/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Anterior cervical fusion offers surgeons a safe and reliable surgical option for single-level and multilevel pathology; however, multilevel fusions pose a higher risk of complications than single-level fusions, including possible pseudoarthrosis, adjacent segment disease, sagittal imbalance, and construct subsidence. Various techniques can be used to mitigate risk in multilevel anterior cervical fusion. QUESTIONS/PURPOSES We reviewed the literature to determine the best surgical strategies in multilevel anterior cervical fusion. METHODS We searched the PubMed database for articles published from January 1980 through July 2019. Two authors identified relevant articles and then manually screened them for others to include in this review. RESULTS We initially identified 1936 articles and included 48 in our review. We found that clinical outcomes of multilevel anterior cervical fusion can be optimized through the use of biologics and graft selection, the evaluation of pre-existing deformity, the assessment of comorbidities, and the selection of fusion levels. Meticulous surgical technique in conjunction with modern surgical tools, such as instrumentation and biologics, allow surgeons to address complex cervical problems while limiting morbidity and enhancing clinical outcomes. CONCLUSIONS Multilevel anterior cervical fusions offer a relatively safe and reliable treatment option for both single-level and multilevel pathology.
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Affiliation(s)
- Michael H. McCarthy
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, 676 N. Saint Clair, Suite 1350, Chicago, IL 60611 USA
| | - Joseph A. Weiner
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, 676 N. Saint Clair, Suite 1350, Chicago, IL 60611 USA
| | - Alpesh A. Patel
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, 676 N. Saint Clair, Suite 1350, Chicago, IL 60611 USA
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Teo AQA, Thomas AC, Hey HWD. Sagittal alignment of the cervical spine: do we know enough for successful surgery? JOURNAL OF SPINE SURGERY 2020; 6:124-135. [PMID: 32309651 DOI: 10.21037/jss.2019.11.18] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Over the past decade, there has been growing interest in the sagittal alignment of the cervical spine and its correlation to clinical outcomes. It is now known that cervical lordosis is not universally physiological and should not be pursued in all patients undergoing surgery. Rather, it is increasingly understood that it is how these angular parameters (lordosis or kyphosis) interact with translational parameters that is reflective of overall cervical spine and whole spine balance, which in turn impacts patient outcomes. This review synthesises currently available evidence relating to the sagittal alignment of the cervical spine. Radiographic assessment of the cervical spine including horizontal gaze is discussed and alignment in physiological and pathological states analysed. The interdependence of spinal segments is reviewed, with cervical alignment correction influencing the adjacent thoracic spine, and similarly lumbar lordosis (LL) and global balance correction changing cervical spine alignment. Cervical kyphosis with associated cervical sagittal imbalance is known to lead to poorer post-operative outcomes, and this dichotomy in outcomes has not been shown to improve even with alignment correction. Further work is required to uncover the extent to which cervical spine alignment correction should be attempted toward improved patient outcomes, in order to plan and deliver patient-specific surgical realignment targets.
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Affiliation(s)
- Alex Quok An Teo
- University Orthopaedics, Hand and Reconstructive Microsurgery Cluster (UOHC), National University Health System, Singapore, Singapore
| | - Andrew Cherian Thomas
- University Orthopaedics, Hand and Reconstructive Microsurgery Cluster (UOHC), National University Health System, Singapore, Singapore
| | - Hwee Weng Dennis Hey
- University Orthopaedics, Hand and Reconstructive Microsurgery Cluster (UOHC), National University Health System, Singapore, Singapore
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Does preoperative inferior endplate morphology influence the outcomes of cervical disc arthroplasty at C5-C6 level: A retrospective study. Clin Neurol Neurosurg 2020; 190:105666. [PMID: 31911321 DOI: 10.1016/j.clineuro.2020.105666] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 12/27/2019] [Accepted: 01/02/2020] [Indexed: 02/05/2023]
Abstract
OBJECTIVES Despite encouraging clinical results, the postoperative segmental kyphosis was observed in many cervical disc arthroplasty (CDA) studies. Most studies discussed technical factors related to kyphosis. However, the cervical endplate, which contacted directly with prostheses and distributed the compressive load across the vertebral body, was seldom investigated. The purpose of the study was to investigate the effects of the inferior endplate morphology on clinical and radiological outcomes after C5/C6-level CDA with Prestige-LP Disc. PATIENTS AND METHODS One hundred and thirty-two patients with C5/C6-level CDA were retrospectively reviewed. Their preoperative inferior endplates on the mid-sagittal plane were visually classified into 3 types: type I with the endplate concavity apex located posteriorly, type II with the apex located in the middle and type III with the apex located anteriorly. Sagittal diameter of endplate, endplate concavity depth and endplate concavity apex location were measured. Japanese Orthopedic Association (JOA), visual analogue scale (VAS) and Neck Disability Index (NDI) scores were used to evaluate clinical outcomes. Range of motion (ROM) and sagittal alignment including C2-7 and C5-6 angle were assessed. RESULTS The type I, type II and type III endplates accounted for 25.00 %, 51.52 % and 23.48 % of 132 individuals. Most patients achieved significant reduction in VAS scores and NDI but the significant increase in JOA scores. No substantial differences in clinical outcomes were found among the 3 endplate types. Compared with preoperative values, the C5-6 ROM, C2-7 ROM and C2-7 angle were preserved, while the C5-6 angle increased significantly from kyphosis to lordosis. At the last follow-up, type I endplate had the least C5-6 angle (2.03°, 3.94° and 4.46° for type I, II and III endplates) and the highest incidence of segmental kyphosis at C5-C6 level (33.30 %, 14.70 % and 9.70 % in the same order, P = 0.028). CONCLUSIONS Patients achieved satisfactory clinical outcomes after C5/C6-level CDA without significant differences among three endplate types. Type I endplate had a high incidence of segmental kyphosis at C5-C6 level.
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Zileli M, Maheshwari S, Kale SS, Garg K, Menon SK, Parthiban J. Outcome Measures and Variables Affecting Prognosis of Cervical Spondylotic Myelopathy: WFNS Spine Committee Recommendations. Neurospine 2019; 16:435-447. [PMID: 31607075 PMCID: PMC6790741 DOI: 10.14245/ns.1938196.098] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 08/16/2018] [Indexed: 12/28/2022] Open
Abstract
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.
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Affiliation(s)
- Mehmet Zileli
- Department of Neurosurgery, Ege University, Izmir, Turkey
| | - Shradha Maheshwari
- Department of Neurosurgery, LTMG Hospital & LTM Medical College, Mumbai, India
| | | | | | | | - Jutty Parthiban
- Department Neurosurgery and Spine Unit, Kovai Medical Center and Hospital, Tamilnadu, India
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Bajamal AH, Kim SH, Arifianto MR, Faris M, Subagio EA, Roitberg B, Udo-Inyang I, Belding J, Zileli M, Parthiban JKBC. Posterior Surgical Techniques for Cervical Spondylotic Myelopathy: WFNS Spine Committee Recommendations. Neurospine 2019; 16:421-434. [PMID: 31607074 PMCID: PMC6790723 DOI: 10.14245/ns.1938274.137] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Accepted: 09/15/2019] [Indexed: 12/11/2022] Open
Abstract
Objective This study was conducted to determine and recommend the most up-to-date information on the indications, complications, and outcomes of posterior surgical treatments for cervical spondylotic myelopathy (CSM) on the basis of a literature review.
Methods A comprehensive literature search was performed, using the MEDLINE (PubMed), the Cochrane Register of Controlled Trials, and Web of Science databases, for peer-reviewed articles published in English during the last 10 years.
Results Posterior techniques, which include laminectomy alone, laminectomy with fusion, and laminoplasty, are often used in patients with involvement of 3 or more levels. Posterior decompression for CSM is effective for improving patients’ neurological function. Complications resulting from posterior cervical spine surgery include injury to the spinal cord and nerve roots, complications related to posterior screw fixation or instrumentation, C5 palsy, spring-back closure of lamina, and postlaminectomy kyphosis.
Conclusion It is necessary to consider multiple factors when deciding on the appropriate operation for a particular patient. Surgeons need to tailor preoperative discussions to ensure that patients are aware of these facts. Further research is needed on the cost-to-benefit analysis of various surgical approaches, the comparative efficacy of surgical approaches using various techniques, and long-term outcomes, as current knowledge is deficient in this regard.
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Affiliation(s)
- Abdul Hafid Bajamal
- Department of Neurosurgery, Dr. Soetomo Academic General Hospital, Airlangga University, Surabaya, Indonesia
| | - Se-Hoon Kim
- Department of Neurosurgery, Korea University Ansan Hospital, Ansan, Korea
| | - Mohammad Reza Arifianto
- Department of Neurosurgery, Dr. Soetomo Academic General Hospital, Airlangga University, Surabaya, Indonesia
| | - Muhammad Faris
- Department of Neurosurgery, Dr. Soetomo Academic General Hospital, Airlangga University, Surabaya, Indonesia
| | - Eko Agus Subagio
- Department of Neurosurgery, Dr. Soetomo Academic General Hospital, Airlangga University, Surabaya, Indonesia
| | - Ben Roitberg
- Department of Neurosurgery, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Inyang Udo-Inyang
- Department of Neurosurgery, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Jonathan Belding
- Department of Neurosurgery, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Mehmet Zileli
- Department of Neurosurgery, Ege University Faculty of Medicine, Izmir, Turkey
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Wilson JR, Badhiwala JH, Moghaddamjou A, Martin AR, Fehlings MG. Degenerative Cervical Myelopathy; A Review of the Latest Advances and Future Directions in Management. Neurospine 2019; 16:494-505. [PMID: 31476852 PMCID: PMC6790745 DOI: 10.14245/ns.1938314.157] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 08/26/2019] [Accepted: 08/26/2019] [Indexed: 01/23/2023] Open
Abstract
The assessment, diagnosis, operative and nonoperative management of degenerative cervical myelopathy (DCM) have evolved rapidly over the last 20 years. A clearer understanding of the pathobiology of DCM has led to attempts to develop objective measurements of the severity of myelopathy, including technology such as multiparametric magnetic resonance imaging, biomarkers, and ancillary clinical testing. New pharmacological treatments have the potential to alter the course of surgical outcomes, and greater innovation in surgical techniques have made surgery safer, more effective and less invasive. Future developments for the treatment of DCM will seek to improve the diagnostic accuracy of imaging, improve the objectivity of clinical assessment, and increase the use of surgical technology to ensure the best outcome is achieved for each individual patient.
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Affiliation(s)
- Jamie R.F. Wilson
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Spinal Program, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
| | - Jetan H. Badhiwala
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Spinal Program, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
| | - Ali Moghaddamjou
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Spinal Program, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
| | - Allan R. Martin
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Spinal Program, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
| | - Michael G. Fehlings
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
- Spinal Program, Toronto Western Hospital, University Health Network, Toronto, ON, Canada
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Li S, Zhang B, Shen Y, Wu Z. Multivariate analysis of poor outcome after anterior surgery in multilevel cervical spondylotic myelopathy patients with heterotopic ossification and preoperative kyphotic alignment. Ther Clin Risk Manag 2019; 15:1053-1060. [PMID: 31695394 PMCID: PMC6717722 DOI: 10.2147/tcrm.s208991] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Accepted: 07/27/2019] [Indexed: 11/23/2022] Open
Abstract
Objective The aim of this study was to evaluate the risk factors for poor outcome in patients who underwent multi-segmental anterior surgery, and analyze postoperative complications. Methods We retrospectively reviewed 158 patients after anterior surgery due to multilevel cervical spondylotic myelopathy (m-CSM) between June 2008 and June 2016. Adjusted ORs and 95% CIs were determined by multivariate logistic regression analysis. Cutoff values and the area under the curve for continuous risk factors were calculated through receiver operating characteristic curve analysis. The chi-squared test was performed for the comparison of complications among the three surgical groups. Results By analyzing 105 patients with good outcome and 53 patients with poor outcome, we established that the risk factors for poor outcome were advanced age (OR =1.12, P=0.003), longer duration of symptoms (OR =1.07, P=0.028), and bigger kyphotic angle at final follow-up (OR =1.29, P< 0.001). The optimal cutoff values for age, duration of symptoms, and kyphotic angle at final follow-up were 63.1 years, 15.5 months, and 5.3 angle. Postoperative complications occurred in 21 patients (13.3%). The incidence of dysphagia and cerebrospinal fluid leakage were higher in multilevel anterior cervical discectomy and fusion (m-ACDF) group than in other groups (P< 0.05). Conclusion Advanced age, longer duration of symptoms, and bigger kyphotic angle at final follow-up were the risk factors for poor postoperative outcome in patients with m-CSM. The complications after hybrid approach and m-ACDF approach were less than after anterior cervical corpectomy and fusion approach.
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Affiliation(s)
- ShaoQing Li
- Department of Orthopedic Surgery, The Orthopedics Hospital of XingTai City, XingTai 054000, People's Republic of China
| | - BaoYang Zhang
- Department of Orthopedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang 050051, People's Republic of China
| | - Yong Shen
- Department of Orthopedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang 050051, People's Republic of China
| | - ZhanYong Wu
- Department of Orthopedic Surgery, The Orthopedics Hospital of XingTai City, XingTai 054000, People's Republic of China
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Tundo F, Avila MJ, Willard L, Fanous S, Curri C, Hussain I, Baaj AA. Spinal alignment, surgery, and outcomes in cervical deformity: A practical guide to aid the spine surgeon. Clin Neurol Neurosurg 2019; 185:105496. [PMID: 31473432 DOI: 10.1016/j.clineuro.2019.105496] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 08/04/2019] [Accepted: 08/17/2019] [Indexed: 12/20/2022]
Abstract
Compared to the thoracolumbar spine, the literature on cervical spine alignment is scarce. While a consistent number of articles have been published, few analyze the ideal surgical approaches for each type of deformity and the optimal amount of correction to achieve. This paper provides a comprehensive review of current literature on cervical spinal deformities (with or without myelopathy) and their surgical management; it is our goal to create a framework on which surgical planning can be made. A general assessment of the actually utilized parameters and correlation between the cervical and thoracolumbar spine alignment is presented. Moreover, we provide an analysis of cervical surgical approaches (anterior, posterior, or combined), techniques (laminoplasty, laminectomy and fusion, anterior cervical discectomy and fusion, corpectomy), and their indications. Finally, a complete evaluation of outcomes and postoperative health-related quality of life (HRQOL) measures based on questionnaires (NDI, VAS, SF-36, mJOA) is discussed. Several prospective studies would be useful in understanding how cervical alignment may be important in the assessment and treatment of cervical deformities with or without myelopathy. In particular, future works should concentrate on the correlation between cervical alignment parameters, disability scores, and myelopathy outcomes. We propose, via comprehensive literature review, a guide of practical key points on surgical techniques, cervical alignment, and symptom improvement goals surgeons should aim to achieve for each patient.
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Affiliation(s)
- Frederico Tundo
- Department of Orthopaedic and Locomotor Diseases, Policlinico Umberto I Hospital, Sapienza University of Rome, Rome, Italy
| | - Mauricio J Avila
- Division of Neurosurgery, University of Arizona, Tucson, AZ, USA
| | - Laura Willard
- Department of Orthopedics, Bambino Gesù Children's Hospital, Rome, Italy
| | - Sandra Fanous
- Department of Orthopedics, Bambino Gesù Children's Hospital, Rome, Italy
| | - Cloe Curri
- University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Ibrahim Hussain
- Department of Neurological Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA
| | - Ali A Baaj
- Department of Neurological Surgery, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, NY, USA.
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Hamdan ARK, Mahmoud RN, Al Mamoun MM, El Khateeb EES. Effect of Sub-axial Cervical Lateral Mass Screw Fixation on Functional Outcome in Patients with Cervical Spondylotic Myelopathy. Asian J Neurosurg 2019; 14:140-147. [PMID: 30937025 PMCID: PMC6417305 DOI: 10.4103/ajns.ajns_303_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background The role of laminectomy alone as an etiology of postoperative cervical instability is well known. Cervical sagittal malalignment of the spine has been linked to unfavorable functional outcome, so the effect of restoration of sagittal spinal alignment on functional outcomes and treatment effectiveness has recently gained attention. Objective This is a prospective observational study aims to observe the possible relation between cervical sagittal alignment and functional outcomes following sub-axial cervical lateral mass screw fixation in patients with cervical spondylotic myelopathy. Patients and Methods Thirty patients were included in this study all suffering from cervical spondylotic mylopathy (CSM) who underwent cervical laminectomy and screw-rod fixation and followed up over 6 months. Functional outcome accessed using Nurick myelopathy score and neck disability index (NDI)?. We also used the Cobb angle method (C2-C7) as a parameter for radiographic assessment of the cervical sagittal alignment which was measured preoperatively and postoperatively on lateral neutral views of cervical X-ray. Results All the patients underwent cervical laminectomy and fixation in a range of 3-5 levels. Two intraoperative facet fractures and four facet joint violations were observed. All the patients were followed-up for at least 6 months. There were significant improvements of the motor power (88.5%), Nurick score (90%), and NDI (90%) postoperatively. The mean preoperative Cobb angle for all patients was -8.51° ± 14.07° standard deviation (SD) which changed to -10.29 ± 12.43 SD at the end of follow-up. Conclusion Combing posterior decompression with lateral mass screw- rod in patients with CSM was effective in improving or at least maintaining cervical alignment with the good functional outcome.
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Koller H, Ames C, Mehdian H, Bartels R, Ferch R, Deriven V, Toyone H, Shaffrey C, Smith J, Hitzl W, Schröder J, Robinson Y. Characteristics of deformity surgery in patients with severe and rigid cervical kyphosis (CK): results of the CSRS-Europe multi-centre study project. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2018; 28:324-344. [PMID: 30483961 DOI: 10.1007/s00586-018-5835-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Revised: 10/25/2018] [Accepted: 11/15/2018] [Indexed: 10/27/2022]
Abstract
INTRODUCTION AND PURPOSE Little information exists on surgical characteristics, complications and outcomes with corrective surgery for rigid cervical kyphosis (CK). To collate the experience of international experts, the CSRS-Europe initiated an international multi-centre retrospective study. METHODS Included were patients at all ages with rigid CK. Surgical and patient specific characteristics, complications and outcomes were studied. Radiographic assessment included global and regional sagittal parameters. Cervical sagittal balance was stratified according to the CSRS-Europe classification of sagittal cervical balance (types A-D). RESULTS Eighty-eight patients with average age of 58 years were included. CK etiology was ankylosing spondlitis (n = 34), iatrogenic (n = 25), degenerative (n = 9), syndromatic (n = 6), neuromuscular (n = 4), traumatic (n = 5), and RA (n = 5). Blood loss averaged 957 ml and the osteotomy grade 4.CK-correction and blood loss increased with osteotomy grade (r = 0.4/0.6, p < .01). Patients with different preop sagittal balance types had different approaches, preop deformity parameters and postop alignment changes (e.g. C7-slope, C2-7 SVA, translation). Correction of the regional kyphosis angle (RKA) was average 34° (p < .01). CK-correction was increased in patients with osteoporosis and osteoporotic vertebrae (POV, p = .006). 22% of patients experienced a major long-term complication and 14% needed revision surgery. Patients with complications had larger preop RKA (p = .01), RKA-change (p = .005), and postop increase in distal junctional kyphosis angle (p = .02). The POV-Group more often experienced postop complications (p < .0001) and revision surgery (p = .02). Patients with revision surgery had a larger RKA-change (p = .003) and postop translation (p = .04). 21% of patients had a postop segmental motor deficit and the risk was elevated in the POV-Group (p = .001). CONCLUSIONS Preop patient specific, radiographic and surgical variables had a significant bearing on alignment changes, outcomes and complication occurrence in the treatment of rigid CK.
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Affiliation(s)
- H Koller
- Spine and Scoliosis Center, Schön Klinik Vogtareuth, Krankenhausstrasse 20, 83569, Vogtareuth, Germany. .,Department for Trauma and Sports Injuries, Paracelsus Medical University, Salzburg, Austria.
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Beloeil H, Sion B, Rousseau C, Albaladejo P, Raux M, Aubrun F, Martinez V. Early postoperative neuropathic pain assessed by the DN4 score predicts an increased risk of persistent postsurgical neuropathic pain. Eur J Anaesthesiol 2018; 34:652-657. [PMID: 28437260 DOI: 10.1097/eja.0000000000000634] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Acute neuropathic pain can occur in the postoperative period but any link with persistent post-surgical neuropathic pain remains unclear. OBJECTIVES The objectives of this study were to prospectively describe the incidence of acute post-surgical neuropathic pain in a large population using the DN4 (clinician administered) questionnaire and to confirm the hypothetical link between acute and persistent neuropathic pain at 2 months after surgery in a large population using the DN2 (self administered) questionnaire. DESIGN A multi-centre, prospective and observational trial. SETTING Two consecutive days in 27 hospitals in France. PATIENTS Six hundred and eight patients undergoing 13 different types of surgery. Fifteen patients were excluded as data were incomplete, and 229 (38.6%) and 260 (43.8%) were not contactable for assessment at 1 and 2 months after surgery, respectively. MAIN OUTCOME MEASURES Pain was evaluated at least 2 h postoperatively on the same day (D0),on the second day (D2) and at 1 and 2 months after surgery (M1 and M2). Pain was assessed using a 10-point Numeric Rating Scale. If the Numeric Rating Scale score was greater than 0, neuropathic pain was assessed using a DN4 (clinician administered) questionnaire or using a DN2 (self-administered) questionnaire. Acute and persistent postsurgical neuropathic pain (PPSNP) were defined respectively by a DN4 score at least 4/10 on day 0 and/or day 2 and a DN2 score at least 3/7 at 2 months after surgery. RESULTS Of the 593 patients included, 41.2% were in pain before surgery and 8.2% described neuropathic pain. Early after surgery, the majority of the 593 patients (72.2% on the day of surgery and 71.3% on day 2) experienced acute pain. It was neuropathic in nature in 5.6% of patients (95% CI, 3.6 to 8.3) on the day of surgery and 12.9% (95% CI, 9.7 to 16.7) on day 2. Two months after surgery, PPSNP was present in 33.3% of the 333 patients assessed. Multivariate analysis showed that a DN4 score at least 4/10 on the day of surgery or on day 2 was a significant risk factor for PPSNP [odds ratios 4.22 (95% CI, 2.19 to 8.12)]. CONCLUSION Our results suggest that early acute postsurgical neuropathic pain significantly increases the risk of persistent post-surgical neuropathic pain. TRIAL REGISTRATION Clinicaltrials.gov identifier: NTC NCT02826317.
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Affiliation(s)
- Helene Beloeil
- From the CHU Rennes, Pôle Anesthésie et Réanimation, Inserm, UMR 991, CIC 1414 and Université de Rennes 1 (HB), CHU Rennes, Pôle Anesthésie et Réanimation (BS), CHU Rennes, Inserm CIC 1414, Rennes (CR), Pôle Anesthésie Réanimation CHU de Grenoble BP217, Grenoble Cedex 9 (PA), Département d'Anesthésie Réanimation, AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Paris (MR), Hospices civils de Lyon, Université Lyon 1, Groupement hospitalier Nord, Hôpital de la Croix Rousse, Lyon (FA), Service d'Anesthésie Réanimation Chirurgicale, Hôpital Raymond Poincaré, AP-HP (VM); and INSERM, U-987, Hôpital Ambroise Paré, Centre d'Evaluation et de Traitement de la Douleur, Paris, France (VM)
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Long-Term Sustainability of Functional Improvement Following Central Corpectomy for Cervical Spondylotic Myelopathy and Ossification of Posterior Longitudinal Ligament. Spine (Phila Pa 1976) 2018; 43:E703-E711. [PMID: 29068879 DOI: 10.1097/brs.0000000000002468] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Retrospective study. OBJECTIVE To examine predictors of long-term outcome and sustainability of initial functional improvement in patients undergoing corpectomy for cervical spondylotic myelopathy (CSM) or ossification of the posterior longitudinal ligament (OPLL). SUMMARY OF BACKGROUND DATA There are limited data on the predictors of outcome and sustainability of initial functional improvement on long-term follow-up after cervical corpectomy. METHODS We studied the functional outcome at more than 1-year follow-up after central corpectomy in 352 patients with CSM or OPLL. Functional status was evaluated with the Nurick grading system. Analysis was directed at identifying factors associated with both improvement in functional status and the achievement of a "cure" (improvement to a follow-up Nurick grade of 0 or 1). A survival analysis was performed to identify factors associated with sustained functional improvement in patients with serial follow-up evaluations. RESULTS Nurick grade improved from 3.2 ± 0.1 to 1.9 ± 0.1 over a mean follow-up period of 57.1 months (range 12-228 mo). On multivariate analysis, age ≥50 years (P = 0.008) and symptom duration ≥1 year (P < 0.001) were negatively associated with functional improvement by ≥1 Nurick grade. Independent factors negatively associated with "cure" after surgery included age 50 years or older (P = 0.005), preoperative Nurick grade of 4 or higher (P < 0.001) and symptom duration of 1 or more years (P < 0.001). Early improvement in functional status was maintained in 90.5% and 76.3% of patients at 5 and 10 years follow-up, respectively. On survival analysis, patients with shorter preoperative symptom duration (<1 yr) were more likely to demonstrate sustained improvement in functional status after surgery (P = 0.022). CONCLUSION Initial gains in functional status after central corpectomy for CSM and OPLL are maintained in more than 75% of patients at 10 years after surgery. Overall, the most favorable long-term outcomes are achieved in younger patients who present early and with good preoperative functional status. LEVEL OF EVIDENCE 4.
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Lee SH, Son DW, Lee JS, Kim DH, Sung SK, Lee SW, Song GS. Differences in Cervical Sagittal Alignment Changes in Patients Undergoing Laminoplasty and Anterior Cervical Discectomy and Fusion. Neurospine 2018; 15:91-100. [PMID: 29656629 PMCID: PMC5944642 DOI: 10.14245/ns.1834864.432] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2017] [Revised: 01/23/2018] [Accepted: 02/01/2018] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Anterior cervical discectomy and fusion (ACDF) and laminoplasty (LP) are the most commonly performed procedures for degenerative cervical spondylosis. Cervical sagittal alignment (CSA) has recently been studied as an important predictor of clinical and radiological outcomes. The data from previous studies are insufficient for analysis using the recently designed CSA parameters, T1 slope (T1s), and T1s minus cervical angle (T1sCA). METHODS We retrospectively collected data from patients who underwent ACDF and LP from January 2013 to May 2016. The CSA parameters included CA, sagittal vertical axis, T1s, and T1sCA. T1sCA values were used to evaluate the preoperative cervical balance (T1sCA>20°: imbalance). Clinical results were evaluated using the neck disability index (NDI) and recovery rate (RR) according to the Japanese Orthopedic Association scoring system. RESULTS We analyzed the data of 72 patients (ACDF, n=39; LP, n=33). Imbalance on ACDF was associated with an increase in CA (balance: preoperative [PRE], 15.64° → follow-up [F/U], 15.74°, p=0.953; imbalance: PRE, -1.14° → F/U, 8.045°, p=0.008), whereas balance on LP was associated with a significant decrease in CA (balance: PRE, 16.26°→ F/U, 11.59°, p=0.009; imbalance: PRE, 5.36°→ F/U, 2.38°, p=0.249). No significant difference was found in the RR and NDI changes in the ACDF group based on balance, but a significant difference was found in RR in the LP group (balance: 61.65%±19.88%, imbalance: 46.90%±15.71%, p=0.046). CONCLUSION We found a significant difference in postoperative alignment in cases of ACDF and LP according to preoperative cervical sagittal balance. The postoperative clinical results of the LP group were more affected by F/U alignment than by the degree of alignment change.
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Affiliation(s)
- Su Hun Lee
- Department of Neurosurgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Dong Wuk Son
- Department of Neurosurgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Jun Seok Lee
- Department of Neurosurgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Dong Ha Kim
- Department of Neurosurgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Soon Ki Sung
- Department of Neurosurgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Sang Weon Lee
- Department of Neurosurgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Geun Sung Song
- Department of Neurosurgery, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
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Impact of Cervical Spine Deformity on Preoperative Disease Severity and Postoperative Outcomes Following Fusion Surgery for Degenerative Cervical Myelopathy: Sub-analysis of AOSpine North America and International Studies. Spine (Phila Pa 1976) 2018; 43:248-254. [PMID: 28658043 DOI: 10.1097/brs.0000000000002307] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN Sub-analysis of the prospective AOSpine CSM North America and International studies. OBJECTIVE The aim of this study was to investigate the impact of cervical spine deformity on pre- and postoperative outcomes in fusion surgeries for degenerative cervical myelopathy. SUMMARY OF BACKGROUND DATA The associations between cervical alignment and patient outcomes have been reported but are not well established in a myelopathy cohort. The impact of deformity correction in this population also needs to be elucidated. METHODS A total of 757 patients were enrolled in two prospective international multicenter AOSpine studies. Among those who underwent anterior or posterior fusion surgeries, pre- and 1-year postoperative upright neutral lateral radiographs of cervical spine were investigated to measure C2-7 Cobb angle and C2-7 sagittal vertical axis (SVA). Patient outcome measures included the modified Japanese Orthopedic Association score for myelopathy severity, Neck Disability Index (NDI), and Short-form 36 (SF-36). These scores were compared between patients with and without cervical deformity, which was defined as C2-7 Cobb >10° kyphosis and/or SVA >40 mm. RESULTS A total of 178 patients were included with complete pre- and postoperative radiographs. SVA significantly increased postoperatively (27.4 vs. 30.7 mm, P = 0.004). All outcome measurement showed significant improvements above minimal clinically important differences. 23.6% of the patients had cervical deformity preoperatively; preoperative deformity was associated with worse preoperative NDI scores (45.7 vs. 38.9, P = 0.04). Postoperatively, those with deformity exhibited significantly lower SF-36 physical component scores (37.2 vs. 41.4, P = 0.048). However, when focusing on the preoperatively deformed cohort, we did not find any significant differences in the postoperative outcome scores between those with and without residual deformity. CONCLUSION There was a significant association between cervical deformity and both preoperative disease severity and postoperative outcomes; however, no impact of deformity correction was shown. LEVEL OF EVIDENCE 2.
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Buell TJ, Buchholz AL, Quinn JC, Shaffrey CI, Smith JS. Importance of Sagittal Alignment of the Cervical Spine in the Management of Degenerative Cervical Myelopathy. Neurosurg Clin N Am 2018; 29:69-82. [DOI: 10.1016/j.nec.2017.09.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Martin AR, Tadokoro N, Tetreault L, Arocho-Quinones EV, Budde MD, Kurpad SN, Fehlings MG. Imaging Evaluation of Degenerative Cervical Myelopathy. Neurosurg Clin N Am 2018; 29:33-45. [DOI: 10.1016/j.nec.2017.09.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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45
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Ailon T, Smith JS, Shaffrey CI, Kim HJ, Mundis G, Gupta M, Klineberg E, Schwab F, Lafage V, Lafage R, Passias P, Protopsaltis T, Neuman B, Daniels A, Scheer JK, Soroceanu A, Hart R, Hostin R, Burton D, Deviren V, Albert TJ, Riew KD, Bess S, Ames CP. Outcomes of Operative Treatment for Adult Cervical Deformity: A Prospective Multicenter Assessment With 1-Year Follow-up. Neurosurgery 2017; 83:1031-1039. [DOI: 10.1093/neuros/nyx574] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 10/31/2017] [Indexed: 11/13/2022] Open
Affiliation(s)
- Tamir Ailon
- Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Justin S Smith
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | | | - Han Jo Kim
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, New York
| | - Gregory Mundis
- Department of Orthopaedic Surgery, San Diego Center for Spinal Disorders, La Jolla, California
| | - Munish Gupta
- Department of Orthopaedic Surgery, Washington University, St Louis, Missouri
| | - Eric Klineberg
- Department of Orthopaedic Surgery, University of California, Davis, Sacramento, California
| | - Frank Schwab
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, New York
| | - Virginie Lafage
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, New York
| | - Renaud Lafage
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, New York
| | - Peter Passias
- Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York
| | | | - Brian Neuman
- Department of Orthopaedic Surgery, Johns Hopkins University, Baltimore, Maryland
| | - Alan Daniels
- Department of Orthopaedic Surgery, Brown University Alpert Medical School, Providence, Rhode Island
| | - Justin K Scheer
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois
| | - Alex Soroceanu
- Department of Orthopaedics, University of Calgary, Calgary, Alberta, Canada
| | - Robert Hart
- Swedish Neuroscience Institute, Seattle, Washington
| | - Rick Hostin
- Department of Orthopaedic Surgery, Baylor Scoliosis Center, Plano, Texas
| | - Douglas Burton
- Department of Orthopaedics, University of Kansas Medical Center, Kansas City, Kansas
| | - Vedat Deviren
- Department of Orthopedic Surgery, University of California, San Francisco, San Francisco, California
| | - Todd J Albert
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York City, New York
| | - K Daniel Riew
- Department of Orthopaedic Surgery, Columbia University Medical Center, New York, New York
| | - Shay Bess
- Department of Orthopaedic Surgery, Denver International Spine Center, Denver, Colorado
| | - Christopher P Ames
- Department of Neurological Surgery, University of California, San Francisco, San Francisco, California
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Patel S, Glivar P, Asgarzadie F, Cheng DJW, Danisa O. The relationship between cervical lordosis and Nurick scores in patients undergoing circumferential vs. posterior alone cervical decompression, instrumentation and fusion for treatment of cervical spondylotic myelopathy. J Clin Neurosci 2017; 45:232-235. [DOI: 10.1016/j.jocn.2017.07.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Revised: 04/24/2017] [Accepted: 07/11/2017] [Indexed: 11/25/2022]
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Wilson JR, Tetreault LA, Kim J, Shamji MF, Harrop JS, Mroz T, Cho S, Fehlings MG. State of the Art in Degenerative Cervical Myelopathy: An Update on Current Clinical Evidence. Neurosurgery 2017; 80:S33-S45. [PMID: 28350949 DOI: 10.1093/neuros/nyw083] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Accepted: 09/22/2016] [Indexed: 01/14/2023] Open
Abstract
Degenerative cervical myelopathy (DCM) is a common cause of spinal cord dysfunction that confronts clinicians on a daily basis. Research performed over the past few decades has provided improved insight into the diagnosis, evaluation, and treatment of this disorder. We aim to provide clinicians with an update regarding the state of the art in DCM, focusing on more recent research pertaining to pathophysiology, natural history, treatment, consideration of the minimally symptomatic patient, surgical outcome prediction, and outcome measurement. Current concepts of pathophysiology focus on the combination of static and dynamic elements leading to breakdown of the blood-spinal cord barrier at the site of compression resulting in local inflammation, cellular dysfunction, and apoptosis. With respect to treatment, although there is a dearth of high-quality studies comparing surgical to nonoperative treatment, several large prospective studies have recently associated surgical management with clinically and statistically significant improvement in functional, disability, and quality of life outcome at long-term follow-up. When selecting the specific surgical intervention for a patient with DCM, anterior (discectomy, corpectomy, hybrid discectomy/corpectomy), posterior (laminectomy and fusion, laminoplasty), and combined approaches may be considered as options depending on the specifics of the patient in question; evidence supporting each of these approaches is reviewed in detail. Recently developed clinical prediction models allow for accurate forecasting of postoperative outcomes, permitting enhanced communication and management of patient expectations in the preoperative setting. Finally, an overview of outcome measures recommended for use in the assessment of DCM patients is provided.
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Affiliation(s)
- Jefferson R Wilson
- Department of Surgery, Division of Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Lindsay A Tetreault
- Department of Surgery, Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Canada
| | - Jun Kim
- Department of Orthopedic Surgery, Icahn School of Medicine, New York, New York
| | - Mohammed F Shamji
- Department of Surgery, Division of Neurosurgery, Toronto Western Hospital, University of Toronto, Toronto, Canada
| | - James S Harrop
- Division of Neurosurgery and Orthopedics, Thomas Jefferson University Hospital, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Thomas Mroz
- Division of Neurosurgery, Cleveland Clinic, Cleveland, Ohio
| | - Samuel Cho
- Department of Orthopedic Surgery, Icahn School of Medicine, New York, New York
| | - Michael G Fehlings
- Department of Surgery, Division of Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, Canada
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Abstract
STUDY DESIGN Review. OBJECTIVES Cervical spondylotic myelopathy (CSM) is a major cause of disability, particular in elderly patients. Awareness and understanding of CSM is imperative to facilitate early diagnosis and management. This review article addresses CSM with regard to its epidemiology, anatomical considerations, pathophysiology, clinical manifestations, imaging characteristics, treatment approaches and outcomes, and the cost-effectiveness of surgical options. METHODS The authors performed an extensive review of the peer-reviewed literature addressing the aforementioned objectives. RESULTS The clinical presentation and natural history of CSM is variable, alternating between quiescent and insidious to stepwise decline or rapid neurological deterioration. For mild CSM, conservative options could be employed with careful observation. However, surgical intervention has shown to be superior for moderate to severe CSM. The success of operative or conservative management of CSM is multifactorial and high-quality studies are lacking. The optimal surgical approach is still under debate, and can vary depending on the number of levels involved, location of the pathology and baseline cervical sagittal alignment. CONCLUSIONS Early recognition and treatment of CSM, before the onset of spinal cord damage, is essential for optimal outcomes. The goal of surgery is to decompress the cord with expansion of the spinal canal, while restoring cervical lordosis, and stabilizing when the risk of cervical kyphosis is high. Further high-quality randomized clinical studies with long-term follow up are still needed to further define the natural history and help predict the ideal surgical strategy.
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Affiliation(s)
| | | | - John C. Liu
- University of Southern California, Los Angeles, CA, USA,John C. Liu, Department of Neurological Surgery, Keck School of Medicine, University of Southern California, 1200 North State Street, Suite 3300, Los Angeles, CA 90033, USA.
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Goel A, Kaswa A, Shah A, Dhar A. Multilevel Spinal Segmental Fixation for Kyphotic Cervical Spinal Deformity in Pediatric Age Group-Report of Management in 2 Cases. World Neurosurg 2017; 106:661-665. [PMID: 28735126 DOI: 10.1016/j.wneu.2017.07.055] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 07/08/2017] [Accepted: 07/11/2017] [Indexed: 11/29/2022]
Abstract
OBJECTIVE We discuss the role of instability of multiple spinal segments including the atlantoaxial joint in the pathogenesis of cervical kyphotic deformity. MATERIAL AND METHODS Two male patients (5 and 17 years old) had severe cervical kyphosis and presented with symptoms related to myelopathy. The patients underwent multisegmental spinal distraction and fixation that included atlantoaxial joint. No bone decompression was done. RESULTS At a follow-up of >30 months, both patients had significant neurologic recovery. Investigations at follow-up showed successful arthrodesis of treated spinal segments. Although incomplete, there was recovery in kyphosis. CONCLUSIONS Multisegmental spinal distraction and fixation can lead to reduction in kyphosis and relief from symptoms related to myelopathy. Role of spinal instability in general and atlantoaxial joint instability in particular in pathogenesis of cervical kyphosis need to be assessed on the basis of studies with a larger number of patients.
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Affiliation(s)
- Atul Goel
- Department of Neurosurgery, K.E.M. Hospital and Seth G.S. Medical College, Parel, Mumbai, India; Department of Neurosurgery, Lilavati Hospital and Research Centre, Bandra (E), Mumbai, India.
| | - Amol Kaswa
- Department of Neurosurgery, K.E.M. Hospital and Seth G.S. Medical College, Parel, Mumbai, India
| | - Abhidha Shah
- Department of Neurosurgery, K.E.M. Hospital and Seth G.S. Medical College, Parel, Mumbai, India
| | - Arjun Dhar
- Department of Neurosurgery, Lilavati Hospital and Research Centre, Bandra (E), Mumbai, India
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Kato S, Nouri A, Wu D, Nori S, Tetreault L, Fehlings MG. Comparison of Anterior and Posterior Surgery for Degenerative Cervical Myelopathy: An MRI-Based Propensity-Score-Matched Analysis Using Data from the Prospective Multicenter AOSpine CSM North America and International Studies. J Bone Joint Surg Am 2017. [PMID: 28632590 DOI: 10.2106/jbjs.16.00882] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Surgeons often choose between 2 different approaches (anterior and posterior) for surgical treatment of degenerative cervical myelopathy on the basis of imaging features of spinal cord compression, the number of levels affected, and the spinal alignment. However, there is a lack of consensus on which approach is preferable. The objective of the present study was to use magnetic resonance imaging (MRI)-based propensity-score-matched analysis to compare postoperative outcomes between the anterior and posterior surgical approaches for degenerative cervical myelopathy. METHODS A total of 757 patients were enrolled in 2 prospective multicenter AOSpine studies, which involved 26 international sites. Preoperative MRIs were reviewed to characterize the causes of the cord compression, including single-level disc disease, multilevel disc disease, ossification of the posterior longitudinal ligament, enlargement of the ligamentum flavum, vertebral subluxation/spondylolisthesis, congenital fusion, number of compressed levels, or kyphosis. The propensity to choose anterior decompression was calculated using demographic data, preoperative MRI findings, and the modified Japanese Orthopaedic Association (mJOA) scores in a logistic regression model. We then performed 1-to-1 matching of patients who had received anterior decompression with those who had the same propensity score but had received posterior decompression to compare 2-year postoperative outcomes and 30-day perioperative complication rates between the 2 groups after adjustment for background characteristics. RESULTS A total of 435 cases were included in the propensity score calculation, and 1-to-1 matching resulted in 80 pairs of anterior and posterior surgical cases; 99% of these matched patients had multilevel compression. The anterior and posterior groups did not differ significantly in terms of the postoperative mJOA score (15.1 versus 15.3, p = 0.53), Neck Disability Index (20.5 versus 24.1, p = 0.44), or Short Form-36 (SF-36) Physical Component Summary (PCS) score (41.9 versus 40.9, p = 0.30). The overall rates of perioperative complications were similar between the 2 groups (16% versus 11%, p = 0.48); however, dysphagia/dysphonia was reported only in the anterior group whereas surgical site infection and C5 radiculopathy were reported only in the posterior group. CONCLUSIONS Anterior and posterior decompression for degenerative cervical myelopathy resulted in similar postoperative outcomes and rates of complications. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- So Kato
- 1Division of Neurosurgery, Toronto Western Hospital, Toronto, Ontario, Canada
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