Surgical Treatment of Cervical Myeloradiculopathy Associated with Movement Disorders

Deep Brain Stimulation Before Anterior Cervical Discectomy and Fusion for a Patient With Cervical Dystonia and Cervical Myelopathy: A Case Report

Cervical dystonia with concurrent cervical myelopathy is a challenging pathology that requires thoughtful management. A 46-year-old female was referred to our center with this presentation. We elected to perform bilateral globus pallidus internus deep brain stimulation (DBS-GPi) prior to C5 to C7 anterior cervical discectomy and fusion (ACDF) to avoid the potential for dystonic movements to negatively impact cervical fusion. The patient was followed up at three months post C5 to C7 ACDF and nine months post DBS-GPi with complete control of tremor and no radiographic evidence of hardware loosening or malalignment. Though this strategy was successful in treating both our patient's cervical myelopathy and cervical dystonia, larger studies need to be conducted to optimize the treatment of patients presenting with these concurrent pathologies.

Combined Anterior-Posterior Fusion Versus Posterior Alone Fusion for Cervical Myelopathy in Athetoid-Cerebral Palsy

STUDY DESIGN

Retrospective comparative study.

OBJECTIVES

Although some studies have discussed the use of lateral mass screws (LMSs) in patients with cerebral palsy (CP), it is unclear whether posterior LMS fixation alone is a suitable method. We aimed to compare the clinical, radiological, and surgical outcomes of 2 surgical modalities, namely, combined anterior-posterior (A-P) instrumented fusion and posterior fusion alone, in athetoid-type CP patients with cervical myelopathy (CM).

METHODS

We analyzed 63 patients with athetoid-CP and CM who underwent posterior fusion only with LMS (group A, 35 patients) and A-P fusion (group B, 28 patients). The primary outcome was the 1- and 3-year fusion rates for the surgical segments. The secondary outcomes included the clinical outcomes based on pain intensity determined using the visual analog scale score, neck disability index, and 17-point Japanese Orthopedic Association score, radiological, and surgical outcomes.

RESULTS

Fusion was achieved at 3 years postoperatively in 22 of 35 patients (63%) in group A and in 26 of 28 patients (93%) in group B (P = 0.02). The posterior neck pain intensity was also significantly lower in group B than in group A 2 and 3 years postoperatively (P = 0.02 and 0.01, respectively). The incidence of screw loosening and implant-related problems was higher in group A (60%) than in group B (21%) (P = 0.01). The other clinical and radiological parameters were similar between the groups.

CONCLUSIONS

For athetoid CP-induced CM, combined A-P fusion would result in superior clinical and radiological outcomes compared to posterior fusion alone.

Factors Affecting Postoperative Complications and Outcomes of Cervical Spondylotic Myelopathy with Cerebral Palsy : A Retrospective Analysis

Objective

Cervical surgery in patients with cervical spondylotic myelopathy (CSM) and cerebral palsy (CP) is challenging owing to the complexities of the deformity. We assessed factors affecting postoperative complications and outcomes after CSM surgery in patients with CP.

Methods

Thirty-five consecutive patients with CP and CSM who underwent cervical operations between January 2006 and January 2014 were matched to 35 non-cerebral palsy (NCP) control patients. Postoperative complications and radiologic outcomes were compared between the groups. In the CP group, the Japanese Orthopaedic Association score; Oswestry neck disability index; modified Barthel index; and values for the grip and pinch, Box and Block, and Jebsen-Taylor hand function tests were obtained preand postoperatively and compared between those with and without postoperative complications.

Results

Sixteen patients (16/35%) in the CP group and seven (7/35%) in the NCP group (p=0.021) had postoperative complications. Adjacent segment degeneration (p=0.021), postoperative motor weakness (p=0.037), and revisions (p=0.003) were significantly more frequent in the CP group than in the NCP group; however, instrument-related complications were not significantly higher in the CP group (7/35 vs. 5/35, p=0.280). The number of preoperative fixed cervical deformities were significantly higher in CP with postoperative complications (5/16 vs. 1/19, p=0.037). In the CP group, clinical outcomes were almost similar between those with and without postoperative complications.

Conclusion

The occurrence of complications during the follow-up period was high in patients with CP. However, postoperative complications did not significantly affect clinical outcomes.

Surgical Strategies for Cervical Deformities Associated With Neuromuscular Disorders

Neuromuscular disorders (NMDs) are diseases involving the upper and lower motor neurons and muscles. In patients with NMDs, cervical spinal deformities are a very common issue; however, unlike thoracolumbar spinal deformities, few studies have investigated these disorders. The patients with NMDs have irregular spinal curvature caused by poor balance and poor coordination of their head, neck, and trunk. Particularly, cervical deformity occurs at younger age, and is known to show more rigid and severe curvature at high cervical levels. Muscular physiologic dynamic characteristics such as spasticity or dystonia combined with static structural factors such as curvature flexibility can result in deformity and often lead to traumatic spinal cord injury. In addition, postoperative complication rate is higher due to abnormal involuntary movement and muscle tone. Therefore, it is important to control abnormal involuntary movement perioperatively along with strong instrumentation for correction of deformity. Various methods such as botulinum toxin injection, physical therapy, muscle division technique, or intrathecal baclofen pump implant may help control abnormal involuntary movements and improve spinal stability. Surgical management for cervical deformities associated with NMDs requires a multidisciplinary effort and a customized strategy.

More Than 10-year Follow-up After Laminoplasty and Pedicle Screw Fixation for Cervical Myelopathy Associated With Athetoid Cerebral Palsy

STUDY DESIGN

Retrospective case series.

OBJECTIVE

The aim of this study was to investigate the clinical outcomes >10 years following laminoplasty and pedicle screw fixation for cervical myelopathy associated with athetoid cerebral palsy (CP).

SUMMARY OF BACKGROUND DATA

Surgery for cervical myelopathy associated with CP remains a challenge because of perioperative instrumentation failure and adjacent segment problems due to patients' repetitive involuntary neck movements with deformity of the cervical spine.

METHODS

A single-center series of 14 patients were reviewed. The patients comprised seven women and seven men with a mean age of 52 years at the time of surgery. The mean follow-up period was 12.5 years. The Barthel index (BI), which shows independence in activities of daily life, and Japanese Orthopaedic Association (JOA) score were assessed. Radiographic evaluation included changes of the C2-C7 angle in the sagittal plane, fusion rate, adjacent segment degeneration, and instrument failure.

RESULTS

The 10-year BI and JOA score significantly improved at 36% and 31%, respectively. The preoperative Cobb angle of the sagittal plane from C2-C7 measured 11.9° of kyphosis, which improved to 0.8° of lordosis. In the radiographic analysis, 35% (proximal) and 21% (distal) of the adjacent segment showed progression in degeneration of more than one grade after 10 years. More than 90% of the patients who underwent magnetic resonance imaging showed progressive disc degeneration on either side after 10 years. Autofusion inside the disc or anterior vertebral bony bridging was observed in 86% of intervertebral levels without anterior procedures.

CONCLUSION

The procedure showed favorable initial stability and maintained favorable clinical outcomes in patients with CP. More than 90% of the patients showed disc degeneration on either side. The rate of proximal adjacent segment degeneration was higher than that of distal segments with or without symptoms at the >10-year follow-up.

LEVEL OF EVIDENCE

4.

Spinal Fusion in Parkinson's Disease Patients: A Propensity Score-Matched Analysis With Minimum 2-Year Surveillance

STUDY DESIGN

Retrospective analysis.

OBJECTIVE

To compare outcomes and complication rates between patients with and without Parkinson's disease (PD) patients undergoing surgery for adult spinal deformity (ASD).

SUMMARY OF BACKGROUND DATA

There is limited literature evaluating the impact of PD on long-term outcomes after thoracolumbar fusion surgery for ASD.

METHODS

Patients admitted from 2009 to 2011 with diagnoses of ASD who underwent any thoracolumbar fusion procedure with a minimum 2-year follow-up surveillance were retrospectively reviewed using New York State's Statewide Planning and Research Cooperative System. A 1:1 propensity score-match by age, Deyo score, and number of fused vertebral levels was conducted before comparing surgical outcomes of patients with ASD with and without PD. Univariate analysis compared demographics, complications, and subsequent revision. Multivariate binary stepwise logistic regression models identified independent predictors of these outcomes (covariates: age, sex, Deyo Index score, and PD diagnosis).

RESULTS

A total of 576 propensity score-matched patients were identified (PD: n = 288; no-PD: n = 288), with a mean age of 69.7 years (PD) and 70.2 years (no-PD). Each cohort had comparable distributions of age, sex, race, insurance provider, Deyo score, and number of levels fused (all P > 0.05). Patients with PD incurred higher total charges across ASD surgery-related visits ($187,807 vs. $126,610, P < 0.001), yet rates of medical complications (35.8% PD vs. 34.0% no-PD, P = 0.662) and revision surgery (12.2% vs. 10.8%, P > 0.05) were comparable. Postoperative mortality rates were comparable between PD and no-PD cohorts (2.8% vs. 1.4%, P = 0.243). Logistic regression identified nine-level or higher spinal fusion as a significant predictor for an increase in total complications (odds ratio = 5.64); PD was not associated with increased odds of any adverse outcomes.

CONCLUSION

Aside from higher hospital charges incurred, patients with PD experienced comparable overall complication and revision rates to a propensity score-matched patient cohort without PD from the general population undergoing thoracolumbar fusion surgery. These results can support management of concerns and postoperative expectations in this patient cohort.

LEVEL OF EVIDENCE

3.

Botulinum Toxin Type A Injection for Cervical Dystonia in Adults with Dyskinetic Cerebral Palsy

We aimed to evaluate the efficacy and safety of injecting botulinum toxin A (BoNT-A) into the neck muscles to treat cervical dystonia (CD) in patients with dyskinetic cerebral palsy (CP). This was a randomized, double-blinded, placebo-controlled trial with cross-over design. We prospectively enrolled adults with dyskinetic CP who were over 20 years old and had been clinically diagnosed with CD for more than one year. The primary outcome measure was the change in Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS) at four weeks from the baseline TWSTRS. Seventeen patients were initially enrolled, but one patient was excluded after the final evaluation because of a violation of the study protocol. At four weeks, the BoNT-A injections showed significant improvement in TWSTRS total scores compared to the saline injections (p = 0.0286 for ANCOVA). At 12 weeks, the BoNT-A injections resulted in greater improvements in TWSTRS total scores than the saline injections without statistical significance (p = 0.0783 for ANCOVA). Dysphagia occurred in three out of 16 patients: two after BoNT-A and one after saline. The dysphagia was transient and improved naturally within two weeks without any special treatment. BoNT-A injection for CD in adults with dyskinetic CP is relatively safe and improves pain and disability.

Comparison of Morphological Characteristics of the Subaxial Cervical Spine between Athetoid Cerebral Palsy and Normal Control

Objective

To compare the morphometry of subaxial cervical spine between cerebral palsy (CP) and normal control.

Methods

We retrospectively analyzed 72 patients with CP, as well as 72 patients from normal population. The two groups were matched for age, sex, and body mass index. Pedicle, lateral mass (LM), and vertebral foramen were evaluated using computed tomography (CT) imaging. Pedicle diameter, LM height, thickness, width and vertebral foramen asymmetry (VFA) were measured and compared between the two groups. Cervical dynamic motion, disc and facet joint degeneration were investigated. Additionally, we compared the morphology of LM between convex side and concave side with cervical scoliotic CP patients.

Results

LM height was smaller in CP group. LM thickness and width were larger in CP group at mid-cervical level. In 40 CP patients with cervical scoliosis, there were no height and width differences between convex and concave side. Pedicle outer diameter was not statistically different between two groups. Pedicle inner diameter was significantly smaller in CP group. Pedicle sclerosis was more frequent in CP patients. VFA was larger in CP group at C3, C4, and C5. Disc/facet degeneration grade was higher in the CP group. Cervical motion of CP group was smaller than those of the control group.

Conclusion

LM morphology of CP patients was different from normal population. Sclerotic pedicles and vertebral foramen asymmetry were more commonly identified in CP patients. CP patients were more likely to demonstrate progressive disc/facet degeneration. This data may provide useful information on cervical posterior instrumentation in CP patients.

Surgical Outcomes of Posterior Spinal Fusion Alone Using Cervical Pedicle Screw Constructs for Cervical Disorders Associated With Athetoid Cerebral Palsy

STUDY DESIGN

Retrospective case series.

OBJECTIVE

The aim of this study was to investigate clinical outcomes after posterior spinal fusion (PSF) using cervical pedicle screw (CPS) constructs for cervical disorders associated with athetoid cerebral palsy (CP).

SUMMARY OF BACKGROUND DATA

Traditionally, most patients with cervical myelopathy associated with CP have required combined anterior and posterior fusion to achieve solid stability against severe involuntary movement.

METHODS

Thirty-one CP patients with cervical disorders who underwent PSF alone with a minimum 2-year follow-up (mean 58 months) were analyzed. All patients were treated with PSF using CPS constructs with or without decompression procedures. The average number of fused segments was 5.1 (range, 1-10 segments), and a halo jacket was applied in 16 patients for at least 2 months after surgery. Clinical outcomes using the Japanese Orthoedic Association scoring system (JOA score) and walking ability, radiographic sagittal alignment, fusion status, and surgery-related complications were evaluated.

RESULTS

The JOA score improved from 8.3 points preoperatively to 10.9 points at the final follow-up (P < 0.05). Although no patients experienced deterioration in their walking ability postoperatively, 10 patients were unable to walk at the final follow-up. Sagittal alignment, including C0-2 angle, C2-7 angle, and local alignment in fused segments, was maintained postoperatively. Twenty-five patients achieved fusion at the final follow-up (fusion rate: 81%), and fivepatients with nonunion required additional surgery. With regard to complications, 5 patients encountered postoperative upper extremity palsy.

CONCLUSION

The CPS construct is amenable to achieve a relatively high fusion rate without correction loss, and good clinical outcomes can be achieved with a posterior single approach for CP patients. In the future, efforts should be made to make appropriate decisions regarding the fusion area, take preventative measures against postoperative upper extremity palsy, and simplify external orthoses after surgery, especially with the use of a halo jacket.

LEVEL OF EVIDENCE

4.

Clinical Outcomes of Correcting Cervical Deformity in Cerebral Palsy Patients

OBJECTIVE

To assess several different cervical alignment parameters to determine the clinical relationship between cerebral palsy (CP) with cervical spondylotic myelopathy (CSM) and cervical deformity.

METHODS

This study included consecutive patients (N = 31) with CP CSM who underwent cervical operation between January 2006 and January 2014 and who had cervical deformities, such as angular and translational deformities. Cervical spine alignment was assessed with the following parameters: C2-7 Cobb angle, C2-7 sagittal vertical axis (SVA), and T1 slope minus C2-7 Cobb angle. Other clinical values were the manual muscle test, spasticity, grip and pinch test, Box and Block test, and Jebsen-Taylor Hand Function Test. Outcome assessments (Oswestry Neck Disability Index [NDI] and modified Barthel Index) were obtained for all patients pre- and postoperatively.

RESULTS

Mean follow-up duration was 3.5 years. There were 13 patients in the corrected group and 18 in the not corrected group. Angular and translational correction were 19.0° (C2-7 Cobb angle), 19.8° (T1 slope minus C2-7 Cobb angle), and 16 mm (C2-7 SVA). Postoperative NDI scores showed greater improvement in the corrected group than the uncorrected group (P = 0.049). In the corrected group, grip power increased postoperatively (8.9 ± 8.9 vs 15.5 ± 8.3; P = 0.021).

CONCLUSIONS

Surgical treatment for patients with CP CSM deformity helped alleviate symptoms. Postoperative NDI scores and hand function improved in patients with CP CSM deformity, especially those in the corrected group. Clinicians should consider correcting the deformity in patients with CP CSM.

Severe Neurological Complications Associated With Tourette Syndrome

BACKGROUND

Tics and Tourette syndrome are common problems evaluated by both the general pediatrician and pediatric neurologist. The common comorbidities of tics are well known, but the severe neurological complications are rare and may not be appreciated.

METHODS

This is a retrospective case series and literature review.

RESULTS

We present here four adolescents with Tourette syndrome who had severe neurological complications secondary to motor tics. We provide the history, neurological examination, and radiological findings in addition to a review of previously reported cases of vascular and cervical cord complications associated with violent motor tics.

CONCLUSIONS

We highlight the importance of recognizing the presenting signs of these complications early and the need to vigorously treat violent motor tics to prevent significant neurological complications.

Clinical Findings and Natural History in Ten Unrelated Families with Juvenile and Adult GM1 Gangliosidosis

We describe 12 subjects of ten unrelated families from the region of Campinas and the southern state of Minas Gerais, Brazil, who presented with juvenile (n = 4) and adult (n = 8) GM1 gangliosidosis. Data includes clinical history, physical examination, and ancillary exam findings. Six subjects presented initially with skeletal deformities, while the remaining six had neurological manifestations at onset. Over time, all exhibited a combination of osteoarticular and neurologic degeneration with varying degrees of severity. Corneal clouding, angiokeratomas, and inguinal hernia were seen in one individual each. Other features commonly described in lysosomal storage disorders were not found in this series, such as coarse faces, gingival hypertrophy, visceromegaly, and cherry red spot. All subjects presented with short stature, dysostosis multiplex, dysarthria, and impairment of activities of daily living, 10/12 had extrapyramidal signs, 8/12 had pyramidal signs, 8/12 had oculomotor abnormalities, 4/12 had behavioral alterations, and 2/12 had ataxia. None had seizures or Parkinsonism. All female subjects developed severe hip dysplasia and underwent arthroplasty due to chronic pain. A vertebral bone bar and os odontoideum, not previously described in this condition, were found in one patient each. There was no clear genotype-phenotype correlation regarding enzyme residual activity and clinical findings, since all subjects were compound heterozygous, but the p.T500A was the most frequent allele in eight families and was associated to Morquio B phenotype. Two sets of siblings allowed intrafamilial comparison revealing consistent features among the families. Interfamilial correlation among unrelated families presenting the same mutations was less consistent.

Degenerative Cervical Myelopathy: Epidemiology, Genetics, and Pathogenesis

STUDY DESIGN

Review.

OBJECTIVE

To formally introduce "degenerative cervical myelopathy" (DCM) as the overarching term to describe the various degenerative conditions of the cervical spine that cause myelopathy. Herein, the epidemiology, pathogenesis, and genetics of conditions falling under this hypernym are carefully described.

SUMMARY OF BACKGROUND DATA

Nontraumatic, degenerative forms of cervical myelopathy represent the commonest cause of spinal cord impairment in adults and include cervical spondylotic myelopathy, ossification of the posterior longitudinal ligament, ossification of the ligamentum flavum, and degenerative disc disease. Unfortunately, there is neither a specific term nor a specific diagnostic International Classification of Diseases, Tenth Revision code to describe this collection of clinical entities. This has resulted in the inconsistent use of diagnostic terms when referring to patients with myelopathy due to degenerative disease of the cervical spine.

METHODS

Narrative review.

RESULTS

The incidence and prevalence of myelopathy due to degeneration of the spine are estimated at a minimum of 41 and 605 per million in North America, respectively. Incidence of cervical spondylotic myelopathy-related hospitalizations has been estimated at 4.04/100,000 person-years, and surgical rates seem to be rising. Pathophysiologically, myelopathy results from static compression, spinal malalignment leading to altered cord tension and vascular supply, and dynamic injury mechanisms. Occupational hazards, including transportation of goods by weight bearing on top of the head, and other risk factors may accelerate DCM development. Potential genetic factors include those related to MMP-2 and collagen IX for degenerative disc disease, and collagen VI and XI for ossification of the posterior longitudinal ligament. In addition, congenital anomalies including spinal stenosis, Down syndrome, and Klippel-Feil syndrome may predispose to the development of DCM.

CONCLUSION

Although DCMs can present as separate diagnostic entities, they are highly interrelated, frequently manifest concomitantly, present similarly from a clinical standpoint, and seem to be in part a response to compensate and improve stability due to progressive age and wear of the cervical spine. The use of the term "degenerative cervical myelopathy" is advocated.

LEVEL OF EVIDENCE

5.

Morphological characteristics of cervical spine in patients with athetoid cerebral palsy and the accuracy of pedicle screw placement

STUDY DESIGN

A retrospective study.

OBJECTIVE

To investigate the morphology of the cervical spine in patients with athetoid cerebral palsy (CP), and to evaluate its relationship with the breach of cervical pedicle screws.

SUMMARY OF BACKGROUND DATA

Cervical pedicle screws have been increasingly used in surgery for patients with CP, but screw misplacement is not uncommon. Although the altered morphology of the cervical spine in patients with CP may result in this high breach rate, few studies have examined the cervical pedicle profile.

METHODS

We retrospectively analyzed 31 patients with cervical myelopathy with CP, as well as 30 patients with cervical spondylotic myelopathy (CSM), who underwent posterior decompression surgery. The pedicle outer diameter, inner diameter, transverse angle and lateral mass deformity were investigated by obtaining preoperative computed tomographic scans. The accuracy of the placement of 56 pedicle screws used in fusion surgery for 12 patients with CP was also analyzed using postoperative computed tomographic scans.

RESULTS

The outer diameter of the pedicle in CP was in the range from 3.3 to 9.6 mm, and was larger than that in CSM at all cervical levels except for C7. Pedicle sclerosis was more frequently observed in CP than in CSM (23% vs. 7.3%, P < 0.001). The transverse angle at C3 and C4 was larger, and lateral mass deformity was more frequently observed in CP than in CSM. The critical breach of pedicle screws in CP was found in 29%. A multivariate analysis revealed that pedicle sclerosis was associated with an increased risk of breach (odds ratio: 6.3; 95% confidence interval: 1.03-39.0; P = 0.047).

CONCLUSION

The pedicle diameter in patients with CP was relatively large, but pedicle sclerosis, a wide transverse angle and lateral mass deformity were frequently observed. Sclerotic pedicles were associated with a higher risk of critical breach.

LEVEL OF EVIDENCE

N/A.

Long-term surgical outcomes of cervical myelopathy with athetoid cerebral palsy

PURPOSE

To understand the long-term surgical outcomes and prognostic factors for the operative treatment of cervical myelopathy (CM) in patients with athetoid cerebral palsy (ACP).

METHODS

We retrospectively reviewed 24 patients with ACP who underwent surgery for CM at our hospital between March 2002 and June 2008. All patients had more than 5 years follow-up. Anterior fusion (11 patients), posterior fusion (1 patient), or combined anterior and posterior (AP) fusion (7 patients) and C1-2 fusion (5 patients) surgeries were performed. Surgical outcomes (average follow-up 102 months), as assessed using modified JOA (mJOA) scores, the Neck Disability Index (NDI), and a visual analog scale (VAS) were compared between the preoperative and postoperative states.

RESULTS

Preoperatvie cervical kyphosis decreased mJOA scores significantly. Long-term follow-up clinical outcomes demonstrated that 10 patients showed favorable (excellent and good) outcomes and 11 patients had non-favorable (fair and worse) outcomes. According to the mJOA scores, patients showed postoperative improvement (7.10-10.45). NDI decreased from 68.46 to 31.66. A second operation was done in seven cases due to instrument failure, progressive kyphotic deformities and adjacent segment degeneration. A preoperative botulinum toxin injection significantly decreased (p < 0.05) the incidence of a second operation.

CONCLUSIONS

Patients with ACP have high incidence of instrument failure. Strong surgical fixation, bone fusion and perioperative immobilizations using botulinum toxin injection should be carefully planned preoperatively.

Laminoplasty and pedicle screw fixation for cervical myelopathy associated with athetoid cerebral palsy: minimum 5-year follow-up

STUDY DESIGN

Retrospective case series.

OBJECTIVE

To evaluate the outcomes after laminoplasty and posterior spinal fusion using pedicle screws for cervical myelopathy associated with athetoid cerebral palsy.

SUMMARY OF BACKGROUND DATA

A variety of surgical procedures have been reported including decompression without fusion, spinal fusion by anterior, posterior, or circumferential approach in this population. However, involuntary neck movements bring risk of postoperative neurological deterioration due to progression of kyphosis, pseudoarthrosis, or adjacent segmental degeneration.

METHODS

A consecutive series of 17 patients who underwent midline T-saw laminoplasty and posterior spinal fusion using pedicle screws were retrospectively reviewed. The mean age was 52 years (8 females and 9 males) at the time of surgery. The mean follow-up was 71 months. Radiographical measures were made in change of Cobb angle of sagittal plane from C2 to C7 and accuracy of pedicle screws. Barthel Index that shows independence in activities of daily life and the Japanese Orthopaedic Association score were also evaluated.

RESULTS

Preoperative Cobb angle of sagittal plane from C2 to C7 measured 11.0°± 14.5° of kyphosis, which improved to 1.5°± 12.7° postoperatively (P < 0.05). Solid posterior bony fusion was achieved in all cases without rigid orthosis such as halo vest. There were 2 cases of adjacent segmental instability, which required additional surgery. Nineteen (13%) out of the 138 screws showed deviation from the pedicle with postoperative computed tomography. However, there were no neurovascular complications during or after the surgery in any cases. Postoperative Japanese Orthopaedic Association score and Barthel Index significantly improved in 32% ± 16%, and 48% ± 26%, respectively.

CONCLUSION

Laminoplasty and pedicle screw fixation provided strong internal fixation and improved neurological function and activities of daily living for cervical myelopathy associated with athetoid cerebral palsy.

LEVEL OF EVIDENCE

4.

Multiple neck operations in a patient with severe motor tics because of Tourette's syndrome: a case report

INTRODUCTION

In patients with Tourette's syndrome who have severe motor tics, involuntary neck movements can enhance degenerative changes in the cervical spine, occasionally causing myelopathy. There have been a limited number of reports on surgical treatment for cervical myelopathy caused by Tourette's syndrome, and a consensus for surgical treatment has not been fully established. To the best of our knowledge, this is the first report that describes a case of cervical myelopathy in a patient with Tourette's syndrome with severe motor tics who has undergone multiple surgeries of the cervical spine.

CASE PRESENTATION

A 44-year-old Asian man with severe motor tics due to Tourette's syndrome presented with cervical myelopathy. Previously, he had undergone an anterior discectomy and spinal fusion with ceramics at the C3-C4 and C5-C6 levels, but required further surgery because of displacement of the ceramics. After the second operation, he developed compression myelopathy at the sandwiched (C4-C5) disc level, and had to undergo a C4-C5 anterior discectomy and spinal fusion, which was unsuccessful.As a salvage operation, we performed a C3-C7 decompression and spinal fusion from both the anterior and posterior approaches. By thorough postoperative external immobilization of his neck, our patient's spinal fusion was successful and his neurological improvements were maintained for more than 10 years.

CONCLUSIONS

Patients with Tourette's syndrome with cervical myelopathy are at risk of having multiple neck operations to correct their symptoms. Postoperative immobilization and the correct selection of surgical procedure are quite important for successful spinal fusion and for avoiding complications at adjacent levels in these patients.

Current and future medical treatment in primary dystonia

Dystonia is a hyperkinetic movement disorder, characterized by involuntary and sustained contractions of opposing muscles causing twisting movements and abnormal postures. It is often a disabling disorder that has a significant impact on physical and psychosocial wellbeing. The medical therapeutic armamentarium used in practice is quite extensive, but for many of these interventions formal proof of efficacy is lacking. Exceptions are the use of botulinum toxin in patients with cervical dystonia, some forms of cranial dystonia (in particular, blepharospasm) and writer's cramp; deep brain stimulation of the pallidum in generalized and segmental dystonia; and high-dose trihexyphenidyl in young patients with segmental and generalized dystonia. In order to move this field forward, we not only need better trials that examine the effect of current treatment interventions, but also a further understanding of the pathophysiology of dystonia as a first step to design and test new therapies that are targeted at the underlying biologic and neurophysiologic mechanisms.

Botulinum toxin assessment, intervention and aftercare for paediatric and adult niche indications including pain: international consensus statement

Evidence is emerging for the use of botulinum neurotoxin type-A (BoNT-A) for niche indications including pain independent of spasticity. Pain indications such as chronic nociceptive back pain, piriformis syndrome, chronic myofascial pain, pelvic pain, complex regional pain syndrome, facial pain and neuropathic pain are outlined in this paper. Of these, class I evidence is available for the treatment of chronic nociceptive low back pain, piriformis syndrome, myofascial pain, facial pain, neuropathic pain and plantar fasciitis. Peri-operative use of BoNT-A is emerging, with indications including planning for surgery and facilitating surgery, as well as healing and improving analgesia post-operatively. Evidence is limited, although there are some reports that clinicians are successfully using BoNT-A peri-operatively. There is class I evidence showing pre-operative use of BoNT-A has a beneficial effect on outcomes following adductor-release surgery. The use of BoNT for treatment of tremor, other than neck tremor in the setting of cervical dystonia, including evidence for upper limb tremor, cranial tremor and non-dystonic neck tremor is reviewed. The evidence is variable at this stage, and further study is required to develop definitive recommendations for the clinical utility of BoNT-A for these indications.

Long-term surgical outcome and risk factors in patients with cervical myelopathy and a change in signal intensity of intramedullary spinal cord on Magnetic Resonance imaging

OBJECT

The goal of this study was to determine the long-term clinical significance of and the risk factors for intramedullary signal intensity change on MR images in patients with cervical compression myelopathy (CCM), an entity most commonly seen with cervical spondylotic myelopathy and ossification of the posterior longitudinal ligament (OPLL).

METHODS

One hundred seventy-four patients with CCM but without cervical disc herniation, severe OPLL (in which the cervical canal is < 10 mm due to OPLL), or severe kyphotic deformity (> 15 degrees of cervical kyphosis) who underwent surgery were initially selected. One hundred eight of these patients were followed for > 36 months, and the 71 patients who agreed to MR imaging examinations both pre- and postsurgery were enrolled in the study (the mean follow-up duration was 60.6 months). All patients underwent cervical laminoplasty. The authors used the Japanese Orthopaedic Association (JOA) score and recovery ratio for evaluation of pre- and postoperative outcomes. The multifactorial effects of variables such as age, sex, a history of smoking, diabetes mellitus, duration of symptoms, postoperative expansion of the high signal intensity area of the spinal cord on MR imaging, sagittal arrangement of the cervical spine, presence of ventral spinal cord compression, and presence of an unstable cervical spine were studied.

RESULTS

Change in intramedullary signal intensity was observed in 50 of the 71 patients preoperatively. The pre- and postoperative JOA scores and the recovery ratio were significantly lower in the patients with signal intensity change. The mean JOA score of the upper extremities was also significantly lower in these patients. Twenty-one patients showed hypointensity in their T1-weighted images, and a nonsignificant correlation was observed between intensity in the T1-weighted image and the mean JOA score and recovery ratio. The risk factors for signal intensity change were instability of the cervical spine (OR 8.255, p = 0.037) and ventral spinal cord compression (OR 5.502, p < 0.01). Among these patients, 16 had postoperative expansion of the high signal intensity area of the spinal cord. The mean JOA score and the recovery ratio at the final follow-up were significantly lower in these patients. The risk factor for postoperative expansion of the high signal intensity area was instability of the cervical spine (OR 5.509, p = 0.022). No significant correlation was observed between signal intensity on T1-weighted MR images and postoperative expansion of the intramedullary high signal intensity area on T2-weighted MR images.

CONCLUSIONS

Long-term clinical outcome was significantly worse in patients with intramedullary signal intensity changes on MR images. The risk factors were instability of the cervical spine and severe ventral spinal compression. The long-term clinical outcome was also significantly worse in patients with postoperative expansion of the high signal intensity area. The fact that cervical instability was a risk factor for the postoperative expansion of the high signal intensity indicates that this high signal intensity area occurred, not only from necrosis secondary to ischemia of the anterior spinal artery, but also from the repeated minor traumas inflicted on the spinal cord from an unstable cervical spine. The long-term neurological outcome found in the preliminary study of patients with CCM who had cervical instability and intramedullary signal intensity changes on MR images suggests that surgical treatment should include posterior fixation along with cervical laminoplasty or anterior spinal fusion.

Cervical myelopathy in athetoid and dystonic cerebral palsy: retrospective study and literature review

The early onset of degenerative cervical lesions has been well described in patients suffering from athetoid or dystonic cerebral palsy. Myelopathy can occur and aggravate of their unstable neurological status. Diagnosis and treatment are delayed and disrupted by the abnormal movements. This retrospective study was implemented to evaluate the symptoms, the anatomical findings, and the surgical management of seven patients from 20 to 56 years old suffering from cervical myelopathy and athetoid or dystonic cerebral palsy. The mean delay in diagnosis was 15 months and the mean follow-up was 33 months. The initial symptoms were spasticity, limbs weakness, paresthesias and vesico-sphinteric dysfunction. In addition to abnormal movements, imaging demonstrated disc herniation, spinal stenosis and instability. All patients were managed surgically by performing simultaneous spinal cord decompression and fusion. Two patients benefited from preoperative botulinum toxin injections, which facilitated postoperative care and immobilization. Strict postoperative immobilization was achieved for 3 months by a Philadelphia collar or a cervico-thoracic orthosis. All patients improved functionally with a mean Japanese Orthopaedic Association score gain of 1.5 points, in spite of the permanent disabilities of the myelopathy. Complications occurred with wound infection, metal failure and relapse of cervical myelopathy at an adjacent level in one case each. All the previous authors advised against isolated laminectomy but no consensus emerged from the literature analysis. Spinal fusion is usually recommended but can be complicated by degenerative adjacent deterioration. Surgical management provides good outcomes but requires a long-term follow-up.

Surgical treatments for cervical spondylotic myelopathy associated with athetoid cerebral palsy

OBJECTIVE

To evaluate the clinical characteristics and surgical outcomes of the patients with cervical spondylotic myelopathy associated with athetoid cerebral palsy.

METHODS

The authors reviewed the clinical and neurodiagnostic findings, surgical managements and outcomes in six consecutive patients with cervical spondylotic myelopathy associated with athetoid cerebral palsy who had been treated with surgical decompression and fusion procedures between January 1999 and December 2005. The mean age of the 6 patients (four women and two men) at the time of surgery was 42.8 years (range, 31-55 years). The mean follow-up period was 56.5 months (range, 17-112 months). The neurological outcome was evaluated before and after operations (immediately, 6 months after and final follow-up) using grading systems of the walking ability, brachialgia and deltoid power.

RESULTS

At immediate postoperative period, after 6 months, and at final follow-up, all patients showed apparent clinical improvements in walking ability, upper extremity pain and deltoid muscle strength. Late neurological deterioration was not seen during follow-up periods. There were no serious complications related to surgery.

CONCLUSION

Surgical decompression and stabilization in patients with cervical spondylotic myelopathy associated with athetoid cerebral palsy have been challenging procedure up to now. Our results indicate that early diagnosis and appropriate surgical procedure can effectively improve the clinical symptoms and neurological function in patients with cervical spondylotic myelopathy and athetoid cerebral palsy, even in those with severe involuntary movements.

Malignant Tourette syndrome

The aim of this work was to draw attention to potentially life-threatening symptoms associated with Tourette syndrome (TS) and to explore their relationship to TS comorbidities. Medical records of all patients with TS evaluated at our Movement Disorders Clinic between July 2003 and July 2006 were reviewed. Data on patients with malignant TS, defined as >or=2 emergency room (ER) visits or >or=1 hospitalizations for TS symptoms or its associated behavioral comorbidities, were entered into a dataset and analyzed. Five illustrative cases are described. Of 333 TS patients evaluated during the 3-year period, 17 (5.1%) met the criteria for malignant TS. Hospital admission or ER visits were for tic-related injuries, self-injurious behavior (SIB), uncontrollable violence and temper, and suicidal ideation/attempts. Compared with patients with nonmalignant TS, those with malignant TS were significantly more likely to have a personal history of obsessive compulsive behavior/disorder (OCB/OCD), complex phonic tics, coprolalia, copropraxia, SIB, mood disorder, suicidal ideation, and poor response to medications. Although TS is rarely a disabling disorder, about 5% of patients referred to a specialty clinic have life-threatening symptoms. Malignant TS is associated with greater severity of motor symptoms and the presence of >or=2 behavioral comorbidities. OCD/OCB in particular may play a central role in malignant TS; obsessive compulsive qualities were associated with life-threatening tics, SIB, and suicidal ideation. Malignant TS is more refractory to medical treatment than nonmalignant TS.

Tourette's syndrome with cervical disc herniation

Tourette's syndrome is manifested in a broad spectrum of motor, vocal, and behavioral disturbances. Movement disorders, such as tics, may contribute to the development of cervical myelopathy owing to the effects of involuntary movements on the neck. However, the association of cervical myelopathy with motor tics of the head and neck is rare. We report here a case of a violent, repetitive neck extension due to Tourette's syndrome that developed cervical myelopathy caused by cervical disc herniation.

Quadriparesis due to intraspinal cyst after failed posterior occipitocervical fusion in a patient with athetoid cerebral palsy

STUDY DESIGN

A case report and review of the literature are presented.

OBJECTIVES

To describe the clinical course and treatment of a patient with athetoid cerebral palsy who had quadriparesis due to an intraspinal cyst, following a failed occipitocervical fusion using sublaminar wires and rods.

SUMMARY OF BACKGROUND DATA

Intraspinal cyst as a cause of quadriparesis in a patient with athetoid cerebral palsy is extremely rare. To our knowledge, there have been no publications on this issue.

METHODS

A 60-year-old man with athetoid cerebral palsy and a history of posterior occipitocervical fusion presented with quadriparesis. Salvage surgery for cervical myelopathy and pseudarthrosis was performed with laminectomy and rearthrodesis using the pedicle screw system. An intraspinal cyst was identified as the main cause of the paraparesis.

RESULTS

Solid bony fusion and the improvement of paraparesis were achieved 2 years and 1 month after the surgery. He is now able to feed himself and to walk with a cane, both without assistance.

CONCLUSION

A physician managing patients with athetoid cerebral palsy should always be aware that an intraspinal cyst in the cervical spine may be the cause of cervical myelopathy.

Surgical management of cervical myelopathy: indications and techniques for laminectomy and fusion

BACKGROUND

Cervical spondylotic myelopathy (CSM) is a commonly encountered surgical disease that may be approached through a variety of operative techniques. Operative goals in the treatment of CSM include effective neural element decompression and maintaining spinal stability to avoid delayed deformity progression and neurologic compromise. Determining the most appropriate operative approach requires careful consideration of the patient's clinical presentation and radiographic imaging.

PURPOSE

To review the indications and techniques for multilevel laminectomy and fusion in the treatment of CSM.

CONCLUSIONS

When indications permit, a multilevel laminectomy is an effective and safe method of neural element decompression. Recognizing the potential for spinal instability is essential to prevent neurologic compromise and intractable axial neck pain caused by deformity progression. A variety of techniques have been described to supplement the posterior tension band after laminectomy; however, lateral mass fixation has evolved into the preferred stabilization technique. Although clinical success is well documented, a successful outcome is dependent on a comprehensive, individualized evaluation of each patient presenting with CSM.

Unilateral atlantal lateral mass hypertrophy

✓ The authors report the cases of four patients in whom they diagnosed an extremely rare and hitherto unreported clinical condition—unilateral hypertrophy of the C-1 lateral mass causing symptomatic cord compression. All patients presented with long-standing torticollis and progressive myelopathy. Three patients underwent posterior decompressive surgery and one underwent resection of the part of the lateral mass invading into the spinal canal and subsequent atlantoaxial plate and screw fixation. Clinical improvement of varying degrees occurred in all cases following surgery. The clinical recovery, however, was most remarkable in the patient who underwent resection of the bone portion indenting the cord. The follow-up periods ranged from 2 to 14 years.

The remarkable similarity in the presenting clinical and radiological/neuroimaging features in all four patients suggests that unilateral hypertrophy of the lateral mass of atlas may be a defined clinical entity. The treatment strategy needs to be evaluated; however, resection of the compression-causing portion of the hypertrophic bone appears to be the best treatment option.