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Lambrechts MJ, Issa TZ, Lee Y, Tran KS, Heard J, Purtill C, Fried TB, Oh S, Kim E, Mangan JJ, Canseco JA, Kaye ID, Rihn JA, Hilibrand AS, Vaccaro AR, Kepler CK, Schroeder GD. How Does the Severity of Neuroforaminal Compression in Cervical Radiculopathy Affect Outcomes of Anterior Cervical Discectomy and Fusion. Asian Spine J 2023; 17:1051-1058. [PMID: 37946340 PMCID: PMC10764125 DOI: 10.31616/asj.2023.0066] [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: 02/28/2023] [Revised: 05/07/2023] [Accepted: 05/09/2023] [Indexed: 11/12/2023] Open
Abstract
STUDY DESIGN This study is a retrospective cohort study. PURPOSE This study aims to determine whether preoperative neuroforaminal stenosis (FS) severity is associated with motor function patient-reported outcome measures (PROMs) following anterior cervical discectomy and fusion (ACDF). OVERVIEW OF LITERATURE Cervical FS can significantly contribute to patient symptoms. While magnetic resonance imaging (MRI) has been used to classify FS, there has been limited research into the impact of FS severity on patient outcomes. METHODS Patients undergoing primary, elective 1-3 level ACDF for radiculopathy at a single academic center between 2015 and 2021 were identified retrospectively. Cervical FS was evaluated using axial T2-weighted MRI images via a validated grading scale. The maximum degree of stenosis was used for multilevel disease. Motor symptoms were classified using encounters at their final preoperative and first postoperative visits, with examinations ≤3/5 indicating weakness. PROMs were obtained preoperatively and at 1-year follow-up. Bivariate analysis was used to compare outcomes based on stenosis severity, followed by multivariable analysis. RESULTS This study included 354 patients, 157 with moderate stenosis and 197 with severe stenosis. Overall, 58 patients (16.4%) presented with upper extremity weakness ≤3/5. A similar number of patients in both groups presented with baseline motor weakness (13.5% vs. 16.55, p =0.431). Postoperatively, 97.1% and 87.0% of patients with severe and moderate FS, respectively, experienced full motor recovery (p =0.134). At 1-year, patients with severe neuroforaminal stenosis presented with significantly worse 12-item Short Form Survey Physical Component Score (PCS-12) (33.3 vs. 37.3, p =0.049) but demonstrated a greater magnitude of improvement (Δ PCS-12: 5.43 vs. 0.87, p =0.048). Worse stenosis was independently associated with greater ΔPCS-12 at 1-year (β =5.59, p =0.022). CONCLUSIONS Patients with severe FS presented with worse preoperative physical health. While ACDF improved outcomes and conferred similar motor recovery in all patients, those with severe FS reported much better improvement in physical function.
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Affiliation(s)
- Mark J. Lambrechts
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA,
USA
| | - Tariq Z. Issa
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA,
USA
| | - Yunsoo Lee
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA,
USA
| | - Khoa S. Tran
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA,
USA
| | - Jeremy Heard
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA,
USA
| | - Caroline Purtill
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA,
USA
| | - Tristan B. Fried
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA,
USA
| | - Samuel Oh
- Icahn School of Medicine at Mount Sinai, New York, NY,
USA
| | - Erin Kim
- Boston University School of Medicine, Boston University, Boston, MA,
USA
| | - John J. Mangan
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA,
USA
| | - Jose A. Canseco
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA,
USA
| | - I. David Kaye
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA,
USA
| | - Jeffrey A. Rihn
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA,
USA
| | - Alan S. Hilibrand
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA,
USA
| | - Alexander R. Vaccaro
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA,
USA
| | - Christopher K. Kepler
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA,
USA
| | - Gregory D. Schroeder
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA,
USA
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A systematic review of validated classification systems for cervical and lumbar spinal foraminal stenosis based on magnetic resonance imaging. 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 2022; 31:1358-1369. [PMID: 35347421 DOI: 10.1007/s00586-022-07147-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 01/03/2022] [Accepted: 02/07/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE Foraminal stenosis is commonly investigated with radiological methods in patients with radiating pain in extremities. However, there is a lack of consensus regarding the methodology to assess compression of the nerve roots. This systematic review was performed to identify validated classification systems for foraminal stenosis in the lumbar and cervical spine based on magnetic resonance imaging (MRI). METHODS A systematic search was conducted according to the PRISMA guidelines. The search included Cochrane, Embase, Medline and PubMed databases going back 30 years and up to September 2021. Three categories of words were used in different variations; foraminal stenosis, MRI and scoring. For inclusion, at least one word from each category had to be present. Articles suggesting classification systems or reporting on their validation were selected for inclusion. RESULTS A total of 823 articles were identified and all abstracts were reviewed. Subsequently, a full-text review of 64 articles was performed and finally 14 articles were included. A total of three validated classification systems were found for the cervical and lumbar spine. The remaining 11 articles reported on validation or suggested modifications of the classification systems. CONCLUSION The three classification systems demonstrated moderate to good reliability and have all been shown feasible in the clinical setting. There is however a need for further studies testing the validity of these classifications in relation to both clinical findings and to surgical outcome data.
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Kim J, Kim K, Lee M, Kim S. Correlation Between Intravascular Injection Rate, Pain Intensity, and Degree of Cervical Neural Foraminal Stenosis During a Cervical Transforaminal Epidural Block. J Pain Res 2021; 14:3017-3023. [PMID: 34594132 PMCID: PMC8478482 DOI: 10.2147/jpr.s330858] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 09/19/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose Cervical transforaminal epidural blocks (CTEBs) are useful for the treatment of cervical radicular pain. However, during CTEBs, inadvertent intravascular injection can introduce particulate steroids into the bloodstream, thus leading to serious complications. Moreover, the risk factors associated with intravascular injection during CTEBs have not been identified. Cervical neural foraminal stenosis (CNFS) is a form of neural foraminal narrowing and a common cause of cervical radicular pain. In this study, we aimed to identify whether there is a correlation between the incidence of intravascular injection during CTEB, pain intensity, and the degree of CNFS. Patients and Methods A total of 126 patients were recruited. The patients were classified into two subgroups (group M and group S) based on the routine cervical T2-weighted axial magnetic resonance imaging (MRI) findings. Group M (n = 63) consisted of moderate CNFS patients, while group S (n = 63) consisted of severe CNFS patients. The occurrence of intravascular injection during CTEB was established using real-time fluoroscopy. The intravascular injection was determined by the spreading of the contrast medium through the vascular channel during the injection. Additionally, pain intensity was scored using a Numeric Rating Scale (NRS) before the procedure and 1 month after the procedure. Results There was no significant difference in the incidence of intravascular injection during CTEB between group M and group S (41.3% vs 39.7%, respectively; p = 0.99) and in the NRS scores before and 1 month after CTEB. However, both groups showed a significant decrease in the NRS scores at 1 month after the procedure compared with that before the procedure. Conclusion The degree of CNFS does not affect the incidence of intravascular injection during CTEB. Regardless of whether patients have moderate or severe CNFS, caution should be exercised during CTEB procedures.
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Affiliation(s)
- Jiseob Kim
- Department of Anesthesiology and Pain Medicine, School of Medicine, Keimyung University, Daegu, Republic of Korea
| | - Kilhyun Kim
- Department of Anesthesiology and Pain Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - MinKyu Lee
- Department of Anesthesiology and Pain Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Saeyoung Kim
- Department of Anesthesiology and Pain Medicine, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
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Systematic review of radiological cervical foraminal grading systems. Neuroradiology 2021; 63:305-316. [PMID: 33392737 DOI: 10.1007/s00234-020-02596-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2020] [Accepted: 10/27/2020] [Indexed: 11/26/2022]
Abstract
The study design of this paper is systematic review. The purpose of this review is to evaluate the existing radiological grading systems that are used to assess cervical foraminal stenosis. The importance of imaging the cervical spine using CT or MRI in evaluating cervical foraminal stenosis is widely accepted; however, there is no consensus for standardized methodology to assess the compression of the cervical nerve roots. A systematic search of Ovid Medline databases, Embase 1947 to present, Cinahl, Web of Science, Cochrane Library, ISRCTN and WHO international clinical trials was performed for reports of cervical foraminal stenosis published before 01 February 2020. In collaboration with the University of Leeds, a search strategy was developed. A total of 6952 articles were identified with 59 included. Most of the reports involved multiple imaging modalities with standard axial and sagittal imaging used most. The grading themes that came from this systematic review show that the most mature for cervical foraminal stenosis is described by (Kim et al. Korean J Radiol 16:1294, 2015) and (Park et al. Br J Radiol 86:20120515, 2013). Imaging of the cervical nerve root canals is mostly performed using MRI and is reported using subjective terminology. The Park, Kim and Modified Kim systems for classifying the degree of stenosis of the nerve root canal have been described. Clinical application of these scoring systems is limited by their reliance on nonstandard imaging (Park), limited validation against clinical symptoms and surgical outcome data. Oblique fine cut images derived from three dimensional MRI datasets may yield more consistency, better clinical correlation, enhanced surgical decision-making and outcomes.
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Kim GU, Chang MC, Kim TU, Lee GW. Diagnostic Modality in Spine Disease: A Review. Asian Spine J 2020; 14:910-920. [PMID: 33373514 PMCID: PMC7788365 DOI: 10.31616/asj.2020.0593] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 11/26/2020] [Indexed: 12/12/2022] Open
Abstract
Spine diseases are common and exhibit several causes, including degeneration, trauma, congenital issues, and other specific factors. Most people experience a variety of symptoms of spine diseases during their lifetime that are occasionally managed with conservative or surgical treatments. Accurate diagnosis of the spine pathology is essential for the appropriate management of spine disease, and various imaging modalities can be used for the diagnosis, including radiography, computed tomography (CT), magnetic resonance imaging (MRI), and other studies such as EOS, bone scan, single photon emission CT/CT, and electrophysiologic test. Patient (or case)-specific selection of the diagnostic modality is crucial; thus, we should be aware of basic information and approaches of the diagnostic modalities. In this review, we discuss in detail, about diagnostic modalities (radiography, CT, MRI, electrophysiologic study, and others) that are widely used for spine disease.
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Affiliation(s)
- Gang-Un Kim
- Department of Orthopaedic Surgery, Hanil General Hospital, Seoul, Korea
| | - Min Cheol Chang
- Department of Physical Medicine and Rehabilitation, Yeungnam University College of Medicine, Daegu, Korea
| | - Tae Uk Kim
- Department of Rehabilitation, Dankook University College of Medicine, Cheonan, Korea
| | - Gun Woo Lee
- Department of Orthopaedic Surgery, Yeungnam University Medical Center, Yeungnam University College of Medicine, Daegu, Korea
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Ozaki M, Nishioka K, Kitayama M, Kawaguchi T, Nakao N. Quantitative evaluation for cervical foraminal bony stenosis based on angled sagittal slices along a nerve root on computed tomography. J Clin Neurosci 2020; 71:89-92. [DOI: 10.1016/j.jocn.2019.10.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 08/12/2019] [Accepted: 10/04/2019] [Indexed: 12/20/2022]
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Full Endoscopic Key Hole Technique for Cervical Foraminal Stenosis: Is Mere Dorsal Decompression Enough? World Neurosurg 2019; 126:e16-e26. [PMID: 30685369 DOI: 10.1016/j.wneu.2019.01.045] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 01/09/2019] [Accepted: 01/14/2019] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To study whether and when mere dorsal decompression is enough in the full endoscopic key hole technique for foraminal stenosis. METHODS We retrospectively reviewed a total of 22 patients with cervical foraminal stenosis who underwent full endoscopic key hole mere dorsal decompression in our institute from October 2016 to October 2017. RESULTS Preoperative neck disability index, neck visual analog scale score, and arm visual analog scale score were 25.8 ± 0.8, 4.9 ± 0.6, and 7.5 ± 0.5 in the group. Immediate postoperative scores were 6.9 ± 0.9, 1.3 ± 0.9, and 1.4 ± 0.5. Follow-up scores at 3 months (7.0 ± 0.9, 1.9 ± 0.6, and 2.7 ± 0.9), 6 months (7.3 ± 0.9, 2.1 ± 0.9, and 1.9 ± 0.5), and 12 months (7.6 ± 0.5, 2.5 ± 0.8, and 2.1 ± 0.7). The symptoms had improved significantly (P < 0.05). According to the Macnab criteria, 15 patients reported excellent results, 2 reported good results, and 2 reported fair results at the 12-month follow-up. CONCLUSIONS Stenosis is mainly caused by dorsal structures; mere dorsal decompression is enough. In both cases, the ventral and dorsal structures contributed to the stenosis. When there is no herniated soft fragment contributing to the stenosis, ventral decompression is not always necessary. If intraoperative exploration detects less tension formed by the ventral abnormal structures, mere dorsal decompression is enough to settle the symptoms.
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Engel G, Bender YY, Adams LC, Boker SM, Fahlenkamp UL, Wagner M, Diederichs G, Hamm B, Makowski MR. Evaluation of osseous cervical foraminal stenosis in spinal radiculopathy using susceptibility-weighted magnetic resonance imaging. Eur Radiol 2018; 29:1855-1862. [DOI: 10.1007/s00330-018-5769-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2018] [Revised: 08/23/2018] [Accepted: 09/14/2018] [Indexed: 02/04/2023]
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Kim W, Ahn KS, Kang CH, Kang WY, Yang KS. Comparison of MRI grading for cervical neural foraminal stenosis based on axial and oblique sagittal images: Concordance and reliability study. Clin Imaging 2017; 43:165-169. [DOI: 10.1016/j.clinimag.2017.03.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Revised: 01/27/2017] [Accepted: 03/10/2017] [Indexed: 10/20/2022]
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Interreader Reliability and Clinical Validity of a Magnetic Resonance Imaging Grading System for Cervical Foraminal Stenosis. J Comput Assist Tomogr 2017; 41:926-930. [DOI: 10.1097/rct.0000000000000628] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Lee KH, Park HJ, Lee SY, Chung EC, Rho MH, Shin H, Kwon YJ. Comparison of two MR grading systems for correlation between grade of cervical neural foraminal stenosis and clinical manifestations. Br J Radiol 2016; 89:20150971. [PMID: 27007709 DOI: 10.1259/bjr.20150971] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To compare the reliability of two recently reported MR grading systems of cervical neural foraminal stenosis (CNFS) and their correlation with clinical manifestations. METHODS We evaluated 188 patients (male : female = 80 : 108; mean age of 41 years) who visited our institution and underwent oblique sagittal MRI of the cervical spine. Two radiologists evaluated the MRI findings for the presence and grade of CNFS at the narrowest point, with the grading systems (Park, Kim and mKim systems) suggested by Park et al and Kim et al. More than one positive neurologic sign and more than one neurologic clinical symptom was considered a positive neurologic manifestation of each foraminal stenosis. Interobserver agreement between the two readers was analyzed using kappa statistics. Non-parametric correlation analysis (Spearman's correlation) was used to evaluate the correlation coefficients (R) to assess the relationship between CNFS grade and clinical manifestations. RESULTS Both the Park and mKim systems demonstrated a relatively high correlation (R = 0.714-0.764) between the CNFS grade and clinical manifestation, while the Kim system yielded a moderate correlation (by Reader 2). The Park and mKim systems demonstrated higher correlation values at the level of C6-7 than C4-5, while the Kim system showed no difference in correlation at the cervical spine level. CONCLUSION Both the Park and mKim systems provide a reliable, reproducible CNFS diagnosis, while the Kim system has a slightly inferior reliability. The Park and mKim systems had a similar, relatively high clinical correlation. ADVANCES IN KNOWLEDGE Grades 2 and 3 of the Park system and Grade 2 in the Kim and mKim systems exhibited a similar clinical significance. Patients with a grade of 0 (using each system) consistently exhibit negative neurologic manifestation.
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Affiliation(s)
- Kyu H Lee
- 1 Department of Radiology, Sungkyunkwan University School of Medicine, Kangbuk Samsung Hospital, Seoul, Republic of Korea
| | - Hee J Park
- 1 Department of Radiology, Sungkyunkwan University School of Medicine, Kangbuk Samsung Hospital, Seoul, Republic of Korea
| | - So Y Lee
- 1 Department of Radiology, Sungkyunkwan University School of Medicine, Kangbuk Samsung Hospital, Seoul, Republic of Korea
| | - Eun C Chung
- 1 Department of Radiology, Sungkyunkwan University School of Medicine, Kangbuk Samsung Hospital, Seoul, Republic of Korea
| | - Myung H Rho
- 1 Department of Radiology, Sungkyunkwan University School of Medicine, Kangbuk Samsung Hospital, Seoul, Republic of Korea
| | - Hyunchul Shin
- 2 Department of Neurosurgery, Sungkyunkwan University School of Medicine, Kangbuk Samsung Hospital, Seoul, Republic of Korea
| | - Young J Kwon
- 2 Department of Neurosurgery, Sungkyunkwan University School of Medicine, Kangbuk Samsung Hospital, Seoul, Republic of Korea
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