Degenerative cervical spondylosis: clinical syndromes, pathogenesis, and management

Ten-Year Outcomes of Cervical Disc Arthroplasty Versus Anterior Cervical Discectomy and Fusion : A Systematic Review With Meta-Analysis

STUDY DESIGN

A systematic review with meta-analysis of randomized controlled trials and comparative retrospective cohort studies.

OBJECTIVE

The purpose of this study is to compare the 10-year outcomes of cervical disc arthroplasty (CDA) with those of anterior cervical discectomy and fusion (ACDF) for the treatment of cervical degenerative disc disease (CDDD).

SUMMARY OF BACKGROUND DATA

ACDF is the gold standard for the treatment of CDDD. However, the loss of motion at the operative level may accelerate adjacent segment disease (ASD). The preservation of motion with CDA attempts to prevent this complication of cervical fusion. Short-term and mid-term data reveal comparable results for CDA versus ACDF; however, long-term results are unknown.

MATERIALS AND METHODS

A systematic review with meta-analysis was performed to determine if CDA had improved outcomes compared with ACDF at 10-year follow-up. PubMed and Web of Science database searches through 2023 were performed to identify randomized controlled trials and comparative retrospective cohort studies involving treatment of one-level or two-level CDDD.

RESULTS

Six studies were eligible for analysis. CDA had significantly improved neck disability index and visual analog scale scores but lower Japanese Orthopaedic Association scores compared to ACDF at 10-year follow-up ( P < 0.05). None of these results met minimal clinically important differences. CDA had significantly fewer secondary surgeries and adverse events compared to ACDF ( P <0.05). There were no significant differences in neurological success.

CONCLUSIONS

The authors found that significantly fewer secondary surgeries and adverse events were seen after CDA than after ACDF at 10-year follow-up. CDA had statistically, but not clinically, improved neck disability index and visual analog scale scores but lower Japanese Orthopaedic Association scores in comparison to ACDF. CDA was not significantly different from ACDF in terms of a successful neurological outcome.

Novel Cervical Endoscopic Unilateral Laminoforaminotomy for Bilateral Decompression in Cervical Spondylosis Myeloradiculopathy: A Technical Note and Clinical Results

Background: This study investigates the efficacy of the Cervical Endoscopic Unilateral Laminoforaminotomy for Bilateral Decompression (CE-ULFBD) technique in treating cervical myeloradiculopathy, primarily caused by degenerative spondylosis. Traditionally managed through multisegmental anterior cervical discectomy and fusion (ACDF) or laminoplasty combined with foraminotomy, this condition has recently experienced a promising shift towards minimally invasive approaches, particularly endoscopic spinal decompression. While empirical evidence is still emerging, these techniques show potential for effective treatment. Method: The objective was to evaluate the outcomes of CE-ULFBD in achieving single or multilevel bilateral foraminal and central decompression, emphasizing the reduction of injury to posterior cervical muscles and the associated postoperative neck soreness common in conventional procedures. This paper delineates the surgical procedures involved in CE-ULFBD and presents the clinical outcomes of nine patients diagnosed with myeloradiculopathy due to severe cervical stenosis. Result: Assessments were conducted using the Visual Analogue Scale (VAS) for neck and arm pain and the Modified Japanese Orthopaedic Association scale (mJOA) for the activity measurement of daily living. Results indicated a considerable decrease in pain levels according to the VAS, coupled with significant improvements in functional capacities as measured by the mJOA scale. Additionally, no major postoperative complications were noted during the follow-up period. Conclusion: The study concludes that CE-ULFBD is a safe and effective approach for the treatment of cervical myeloradiculopathy resulting from severe cervical stenosis, offering a viable and less invasive alternative to traditional decompressive surgeries.

Do key measurement parameters derived from specific cervical vertebral segments differ between lordotic and non-lordotic cervical spine alignments? A study of asymptomatic young adults

BACKGROUND

Measurement parameters derived from specific cervical vertebral segments (e.g., C2 slope) can provide clinicians with important information on cervical sagittal balance and guide pre- and post-surgical decision-making processes. It is unclear however, what constitutes typical values for these types of measurements in an asymptomatic population of young adults, whether values change depending upon the classification of the cervical spine's global alignment, and if any non-lordotic cervical subtypes display values that are comparable to those reported for pre-surgery patients.

METHODS

Neutral lateral cervical radiographs of 150 asymptomatic participants (18-30 years) were taken. Global cervical alignment was classified as lordotic or one of four non-lordotic subtypes using a multi-method subtyping protocol. Four key measurement parameters - the anterior translation of the head measure (ATHM), C0-C2 angle, C2 slope, and C7 slope - were derived from specific cervical segments. Independent samples t-tests were used to compare lordotic and non-lordotic groups.

RESULTS

There was considerable variation in the four key measurement parameters amongst this asymptomatic population of young adults. Thirty-four percent of the sample were classified as lordotic and 66% were classified as non-lordotic. There was a significant difference (p ≤ 0.0125) between lordotic and non-lordotic groups for the C0-C2 angle, C2 slope and C7 slope. There was no difference between groups for the ATHM (p ≥ 0.0125). Within the non-lordotic group, the global-kyphotic (GK) subtype had the largest mean C2 slope, largest mean C0-C2 angle, and smallest mean C7 slope.

CONCLUSIONS

Long term prospective investigations are required to determine whether possible biomarkers (alignment parameters/radiological measurements) for spinal degenerative changes can be identified so that early interventions can be put in place to try and reduce the impact of neck pain on society.

Ultrasound-guided injection acupotomy as a minimally invasive intervention therapy for cervical spondylotic radiculopathy: a randomized control trial

OBJECTIVE

To explore the efficacy and safety of ultrasound-guided injection acupotomy as a minimally invasive intervention treatment of cervical spondylotic radiculopathy (CSR).

METHODS

160 CSR subjects were recruited who met the inclusion criteria in our hospital from October 2019 to December 2021. The subjects were randomly divided into the experimental and control group, with 80 cases in each. The experimental group received ultrasound-guided injection acupotomy as a minimally invasive intervention therapy. The control group received ultrasound-guided selective nerve root block (SNRB). The Odom's criteria clinical curative effect, visual analogue scale (VAS), neck disability index (NDI), and 36-Item Short Form Health Survey questionnaire (SF-36) were used to evaluate the outcome of subjects at several different points in time.

RESULTS

At 30 min and 1 month after the end of treatment, there was no significant difference in any scores. However, after six months, the excellent and good rate was better in the experimental group compared to the control (RD = 0.175; 95% CI, 0.044-0.300, p = 0.009). The total effective rate was also better in the experimental group (RD = 0.126; 95% CI, 0.021-0.232, p = 0.018). In contrast, the VAS score (MD = -0.500; 95% CI, -1.000-0.000, p = 0.030) and NDI score (MD = -6.460; 95% CI, -11.067 to -1.852, p = 0.006) were lower in the experimental group compared to the control. The total SF-36 score was higher in the experimental group (MD = 7.568; 95% CI, 2.459-12.677, p = 0.004).

CONCLUSION

Ultrasound-guided injection acupotomy minimally invasive interventional treatment of CSR has no significant difference in short-term curative effect compared with ultrasound-guided SNRB, but the data indicators are significantly better than the latter at 6 months after the end of the course of treatment, showing better long-term efficacy.

Predicting surgical outcome and sagittal alignment change in patients with cervical spondylosis and degenerative kyphosis after anterior cervical discectomy and fusion

The aim of this study was to forecast the risk factors of poor outcomes and postoperative loss of lordosis or recurrence of kyphosis. In this retrospective study, 101 patients with cervical spondylosis and preoperative kyphosis who underwent anterior cervical discectomy and fusion (ACDF) were enrolled, between June 2015 and June 2019. Patients were grouped according to the recovery rate of Japanese Orthopaedic Association (JOA) score whether more than 50%, and the change of postoperative cervical Cobb angle. There were 22 cases with less than 50% of recovery rate and 35 cases with the worsening of postoperative sagittal alignment (WPSA). Multivariate linear-regression analysis was conducted with the data. Advanced age (p = 0.019), longer duration of symptoms (p = 0.003) and loss of local Cobb angle (LCA) after surgery (p = 0.031) was significantly associated with a poor clinical outcome. A whole kyphosis (p = 0.009), aggravated neck pain after surgery (p = 0.012), preoperative lower thoracic 1 (T1) (p < 0.001), bigger change of C2-7 sagittal vertical axis (SVA) (p = 0.008) and adjacent segment degeneration (ASD) (p = 0.024) was significantly associated with the WPSA. Preoperative health education, nutritional support and early postoperative rehabilitation intervention, in perioperative period, were recommended for patients with advance age, longer duration of symptoms, whole cervical kyphosis and lower T1. Postoperative sagittal malalignment was related to neck pain and ASD after surgery.

Incidence of complications associated with cervical spine surgery and post-operative physical therapy and implications for timing of initiation of post-operative physical therapy: a retrospective database study

PURPOSE

To describe the incidence of complications associated with cervical spine surgery and post-operative physical therapy (PT), and to identify if the timing of initiation of post-operative PT impacts the incidence rates.

METHODS

MOrtho PearlDiver database was queried using billing codes to identify patients who had undergone Anterior Cervical Discectomy and Fusion (ACDF), Posterior Cervical Fusion (PCF), or Cervical Foraminotomy and post-operative PT from 2010-2019. For each surgical procedure, patients were divided into three 12-week increments for post-operative PT (starting at post-operative weeks 2, 8, 12) and then matched based upon age, gender, and Charlson Comorbidity Index score. Each group was queried to determine complication rates and chi-square analysis with adjusted odds ratios, 95% confidence intervals, and p-values were used.

RESULTS

Following matching, 3,609 patients who underwent cervical spine surgery at one or more levels and had post-operative PT (ACDF:1784, PCF:1593, and cervical foraminotomy:232). The most frequent complications were new onset cervicalgia (2-14 weeks, 8-20 weeks, 12-24 weeks): ACDF (15.0%, 14.0%, 13.0%), PCF (18.8%, 18.0%, 19.9%), cervical foraminotomy (16.8%, 16.4%, 19.4%); revision: ADCF (7.9%, 8.2%, 7.4%), PCF (9.3%, 10.6%, 10.2%), cervical foraminotomy (11.6%, 10.8% and 13.4%); wound infection: ACDF (3.3%, 3.4%, 3.1%), PCF (8.3%, 8.0%,7.7%), cervical foraminotomy (5.2%, 6.5%, < 4.7%). None of the comparisons were statistically significant.

CONCLUSION

The most common post-operative complications included new onset cervicalgia, revision and wound infection. Complications rates were not impacted by the timing of initiation of PT whether at 2, 8, or 12 weeks post-operatively.

Comparison of Two Anterior Reconstructive Techniques in the Treatment of 3-Level and 4 Level Cervical Spondylotic Myelopathy: A Meta-analysis of Last Decade

Study Design

A meta-analysis.

Objective

Anterior cervical discectomy and fusion (ACDF) and anterior cervical corpectomy and fusion (ACCF) are widely used in the treatment of cervical spondylotic myelopathy (CSM). However, the clinical outcomes and complications between ACDF and ACCF treating multi-level CSM remain poorly understood. Thus, we performed a meta-analysis to compare the clinical outcomes and complications of the two procedures in the treatment of 3-level and 4-level CSM.

Methods

An extensive search of the literature was performed in the English databases of PubMed, Embase, and Cochrane Library and the Chinese databases of CNKI and WANFANG. We collected factors, including demographic data, surgical factors, and complications. Data analysis was conducted with RevMan 5.3 and STATA 12.0.

Results

Finally, 14 articles (5429 patients) were included in our study. No significant difference was found in preoperative and 3-month follow-up Japanese Orthopedic Association (JOA) scores, neck disability index, preoperative C2-C7, segmental angle, operation time, as well as the number of dysphagia, hoarseness, cerebral fluid leakage, infection, epidural hematoma, axial pain, hardware breakage, and pseudarthrosis between ACDF and ACCF. However, our findings showed that blood loss (P < 0.00001), the number of total complications (P < 0 .00001), C5 palsy (P = 0.0004), graft dislodgement (P = 0.02), graft subsidence (P = 0.0003), and revision surgery (P = 0.0008) in ACDF were significantly less than in ACCF. Additionally, postoperative and change of C2-C7 (P < 0.00001), segment angle (P < 0.00001), and fusion rate (P = 0.001) in ACDF were significantly higher than in ACCF. Post-operative JOA in ACDF was significantly higher than in ACCF (P = 0.02).

Conclusions

Although the clinical efficacy of both surgeries was similar, ACDF was superior to ACCF in the reconstruction of cervical lordosis and the number of complications in the treatment of 3-level and 4-level CSM.

Clinical efficacy and safety of posterior minimally invasive surgery in cervical spondylosis: a systematic review

Background

Posterior minimally invasive surgery has been increasingly used in in recent years for the clinical treatment of cervical spondylosis. However, this treatment remains challenging and has not been comprehensively reported. The aim of this study was to provide a systematic review of posterior minimally invasive treatment for cervical spondylosis to demonstrate the clinical efficacy and safety of this procedure.

Method

We collected information from patients with myelopathy or radiculopathy cervical spondylosis who underwent posterior minimally invasive surgery and verified the clinical efficacy and safety of these surgeries with different measurement indicators from five electronic databases: the Nurick, visual analog scale score, Japanese Orthopaedic Association (JOA) score, Neck Disability Index (NDI), EuroQol Five Dimensions Questionnaire (EQ-5D) score, Short-Form Health Survey Physical Component Summary (SF12-PCS) questionnaire score, Short-Form Health Survey Mental Component Summary (SF12-MCS) questionnaire score, and the MOS item short form health survey (HF-36) score. The decompression effect, cervical spine stability, average surgery time, surgical blood loss volume, length of hospital stay, and related complications were included in the descriptive analysis. Reporting of this protocol followed the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines checklist.

Results

We identified 14 observational studies of cervical spondylosis with 479 patients, mainly including 197 cases of myelopathy and 207 cases of radiculopathy. Channel and endoscopic techniques were used. This study was certified by PROSPERO: CRD42021290074. Significant improvements in the quantitative indicators (Neck-VAS in 9 studies, JOA in 7 studies, NDIs in 5 studies, Nurick, ARM-VAS, and EQ-5D in 2 studies each, and the SF12-PCS, SF12-MCS, and HF-36 in 1 study each) were observed between pre- and postoperation (P < 0.05), and satisfactory clinical significance was acquired in the descriptive indicators [average surgery time (94.56 ± 37.26 min), blood loss volume (68.78 ± 103.31 ml), average length of stay (2.39 ± 1.20 d), and cervical spine stability after surgery]. Additionally, we showed that there was a 4.9% postoperative complication rate and the types of complications that may occur.

Conclusion

Posterior minimally invasive surgery is an effective and safe method for the treatment of cervical spondylosis and is a recommended optional surgical procedure for single-segment myelopathy and radiculopathy.

Patients With Preoperative Cervical Deformity Experience Similar Clinical Outcomes to Those Without Deformity Following 1-3 Level Anterior Cervical Decompression and Fusion

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

The aim was to compare the outcomes of patients with incompletely corrected cervical deformity against those without deformity following short-segment anterior cervical decompression and fusion for clinically significant radiculopathy or myelopathy.

SUMMARY OF BACKGROUND DATA

Cervical deformity has increasingly been recognized as a driver of disability and has been linked to worse patient-reported outcomes measures (PROMs) after surgery.

METHODS

Patients 18 years or above who underwent 1-3 level anterior cervical decompression and fusion to address radiculopathy and/or myelopathy at a single institution between 2014 and 2018 with at least 1 year of PROMs were reviewed. Patients were categorized based on cervical deformity into 2 groups: sagittal vertebral axis (cSVA) ≥40 mm as the deformity group, and cSVA <40 mm as the nondeformity group. Patient demographics, surgical parameters, preoperative and postoperative radiographs, and minimum 1-year PROMs were compared.

RESULTS

Of the 230 patients, 191 (83%) were in the nondeformity group and 39 (17%) in the deformity group. Patients with deformity were more likely to be male (69.2% vs. 40.3%, P<0.001) and have a greater body mass index (32.8 vs. 29.7, P=0.028). The deformity group had significantly greater postoperative cSVA (44.2 vs. 25.1 mm, P<0.001) but also had significantly greater ∆cSVA (-4.87 vs. 0.25 mm, P=0.007) than the nondeformity group. Both groups had significant improvements in visual analog scale arm, visual analog scale neck, Short-Form 12 Physical Component Score, and neck disability index (NDI) (P<0.001). However, the deformity group experienced significantly greater ∆NDI and ∆mental component score (MCS)-12 scores (-19.45 vs. -11.11, P=0.027 and 7.68 vs. 1.32, P=0.009).

CONCLUSIONS

Patients with preoperative cervical sagittal deformity experienced relatively greater improvements in NDI and MCS-12 scores than those without preoperative deformity. These results suggest that complete correction of sagittal alignment is not required for patients to achieve significant clinical improvement.

LEVEL OF EVIDENCE

III.

Should Somatosensory and Motor Evoked Potential Monitoring Be Used Routinely in All Posterior Cervical Operations for Degenerative Conditions of the Cervical Spine?

OBJECTIVE

Intraoperative neuromonitoring (IONM) is useful during spinal cord operations, but whether IONM is necessary for posterior cervical surgeries for degenerative conditions is unknown. We evaluated the utility of somatosensory evoked potential (SSEP) and motor evoked potential (MEP) monitoring as a tool for predicting new postoperative neurologic deficits during posterior decompression and fusion for degenerative cervical spine conditions.

METHODS

We retrospectively reviewed posterior cervical operations performed at our institute over a 4-year period. Patients with postoperative neurologic deficits were identified, and a detailed analysis performed to ascertain whether SSEP or MEP monitoring accurately predicted the onset of new postoperative deficits.

RESULTS

Overall, 498 patients were included in the analysis (median age 66 years; range: 22-93 years). SSEP monitoring was performed in all patients, and both SSEP and MEP monitoring were performed in 121 patients (24%). Twenty-one patients (4.2%) had new postoperative neurologic deficits. SSEP had significantly higher specificity (90%) but lower sensitivity (33%) than MEP (74% specificity [P = 0.008], 50% sensitivity [P = 0.01]) for detecting neurologic compromise intraoperatively. For SSEP, the positive predictive value (PPV) and negative predictive value (NPV) in detecting intraoperative changes that translated to new postoperative neurological deficits were 12% and 97%, respectively, whereas for MEP, the PPV and NPV were 6% (P = 0.009) and 98% (P = 0.20), respectively.

CONCLUSIONS

IONM during posterior cervical operations for degenerative conditions of the spine is not reliable at predicting new postoperative neurologic deficits in patients treated for degenerative conditions, but may provide peace of mind to the surgeon intraoperatively when no abnormalities are detected.

Cervical disc degeneration: important considerations for the manual therapist

Cervical disc degeneration (CDD) is a progressive, age-related occurrence that is frequently associated with neck pain and radiculopathy. Consistent with the majority of published clinical practice guidelines (CPG) for neck pain, the 2017 American Physical Therapy Association Neck Pain CPG recommends cervical manipulation as an intervention to address acute, subacute, and chronic symptoms in the 'Neck Pain With Mobility Deficits' category as well for individuals with 'Chronic Neck Pain With Radiating Pain'. While CPGs are evidence-informed statements intended to help optimize care while considering the relative risks and benefits, these guidelines generally do not discuss the mechanical consequences of underlying cervical pathology nor do they recommend specific manipulation techniques, with selection left to the practitioner's discretion. From a biomechanical perspective, disc degeneration represents the loss of structural integrity/failure of the intervertebral disc. The sequelae of CDD include posterior neck pain, segmental hypermobility/instability, radicular symptoms, myelopathic disturbance, and potential vascular compromise. In this narrative review, we consider the mechanical, neurological, and vascular consequences of CDD, including information on the anatomy of the cervical disc and the mechanics of discogenic instability, the anatomic and mechanical basis of radiculitis, radiculopathy, changes to the intervertebral foramen, the importance of Modic changes, and the effect of spondylotic hypertrophy on the central spinal canal, spinal cord, and vertebral artery. The pathoanatomical and biomechanical consequences of CDD are discussed, along with suggestions which may enhance patient safety.

The Impact of Physical Therapy Following Cervical Spine Surgery for Degenerative Spine Disorders: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVE

To characterize the effects of postoperative physical therapy (PT) after surgery for cervical spondylosis on patient-reported outcomes and impairments. Secondarily, to identify associated complications, adverse effects, and health care costs with postoperative PT, and to describe the content, timing, and duration of the PT.

SUMMARY OF BACKGROUND DATA

Cervical spine surgery is common; however, it is unclear if the addition of postoperative PT leads to improved patient outcomes and decreased health care costs.

MATERIALS AND METHODS

PubMed, Embase, Cochrane Central Register of Controlled Trials, Physiotherapy Evidence Database, and Web of Science were searched until July 2019. All peer-reviewed articles involving cervical spine surgery with postoperative PT for cervical spondylosis were considered for inclusion. Risk of bias was assessed using the Revised Cochrane risk-of-bias tool for randomized trials. Findings were described narratively, and GRADE approach was used to define the quality of evidence.

RESULTS

A total of 10,743 studies were screened. Six studies met inclusion criteria; 2 randomized controlled trials and 4 subsequent follow-up studies containing study arms that included postoperative PT after cervical spine surgery. Meta-analysis was not performed due to study heterogeneity and no study compared PT+surgery to surgery alone. PT treatment included exercise therapy, cognitive behavioral therapy, and optional vestibular rehabilitation. Included studies indicated PT appeared to have positive effects on patient outcomes, however, there were no treatment control groups and the quality of evidence was very low to low. Timing, duration, and content of PT programs varied. No studies reported complications, adverse effects, or cost-effectiveness relating to PT after surgery.

CONCLUSIONS

Current literature prevents a definitive conclusion regarding the impact of postoperative PT, given the lack of treatment control groups. PT treatment was limited to exercise therapy, cognitive behavioral therapy, and optional vestibular rehabilitation in the included studies. PT treatment varied, limiting consistent recommendations for content, timing, and treatment duration. Controlled trials are needed to determine the effectiveness of the addition of postoperative PT following cervical spine surgery for cervical spondylosis.

LEVEL OF EVIDENCE

Level II.

The efficacy and safety of fire needle for cervical spondylotic radiculopathy: A protocol for systematic review and meta-analysis

BACKGROUND

Cervical spondylotic radiculopathy (CSR) is one of the most common types of cervical spondylosis, and its treatments are mainly for relieving radicular pain and improving dysfunction. The existing randomized controlled trials (RCTs) suggest that fire needle may be a potential therapy in the treatment of CSR, but there is no evidence-based medical evidence to date. Therefore, this study will systematically evaluate the efficacy and safety of fire needle in the treatment of CSR.

METHODS

We will search for 7 electronic databases (PubMed, EMBASE, Cochrane library, China National Knowledge Infrastructure, Chinese Scientific Journals Database, Sinomed, and Wanfang Database) and 2 trial registration platforms (ClinicalTrials.gov and Chinese Clinic Trials.gov) to collect eligible studies. The RCTs related to fire needle for CSR and published up to June 30, 2021 will be included, regardless of language. We will consider the visual analogue scale as the primary outcome and the secondary outcome will include cervical range of motion, assessment of muscle strength, neck disability index, the MOS item short from health survey, activities of daily living, total efficiency, and adverse reactions. We will use the standard proposed in Cochrane Handbook 5.1.0 to assess the quality and bias risk of every RCT, and all analyses will be conducted through RevMan software V5.3 (Copenhagen: Nordic Cochrane Center, Cochrane, Collaborative Organization, 2014).

RESULTS

This systematic review and meta-analysis will provide a convincing synthesis of existing evidences on the efficacy and safety of fire needle for CSR, and the results will be submitted to a peer-reviewed journal for publication.

CONCLUSION

The results of this study will provide high-quality evidence of fire needle in the treatment of CSR for clinical decision-making.

INPLASY REGISTRATION NUMBER

INPLASY202170041.

Effects of different severities of disc degeneration on the range of motion of cervical spine

Aims and Objectives:

The human spine degenerates with age. Intervertebral disc degeneration occurs in the cervical spine. The objective of this study is to determine the effects of degenerative disc diseases on the range of motion (ROM) of the human cervical spinal column using a validated finite-element model.

Materials and Methods:

The validated intact and healthy C2–T1 finite-element model simulated the cortical shell, cancellous core, posterior elements of the vertebrae, and spinal ligaments (longitudinal, capsular, spinous and ligamentum flava, and nucleus and annulus of the discs). Three different stages of the disc disease, that is, mild, moderate, and severe, were simulated at the C5–C6, C6–C7, and C5–C6–C7 discs, respectively, and they were termed as upper single level, lower single level, and bi-level (BL) models, respectively. The material properties and geometry of the disc(s) were altered to simulate the different stages of degeneration. The external mechanical loading was applied in the sagittal mode, via flexion–extension motions and the magnitude was 2.0 Nm for each mode. They were applied to each of the healthy and disc degeneration models, and for each of the three severities of degeneration. The ROM at adjacent and index levels was extracted and normalized with respect to the healthy (baseline) spine.

Results:

A nonuniform distribution in the ROM was found for different disc degeneration states, segmental levels, and flexion–extension loading modes. The specific results for each and level are reported in the results section of the paper.

Conclusion:

Closer follow-up times may be necessary in symptomatic patients with progressive disease, especially with BL involvements.

Multiple level anterior cervical discectomy and fusion versus posterior laminectomy for the management of multilevel cervical spondylotic myelopathy: clinical and radiological outcome

Background

Though both anterior and posterior approach are used for the management of multilevel cervical spondylotic myelopathy (CSM), the choice between both approaches remains to be of considerable debate.

Aim of the work

The aim of the study was to evaluate the clinical and radiographic outcomes of patients with multiple level CSM who underwent posterior laminectomy (PL) versus anterior cervical discectomy and fusion (ACDF).

Methods

This is a retrospective comparative study of 30 patients, with multiple level CSM managed by the authors, either by PL (n = 15) or ACDF (n = 15). Clinical outcome was assessed at 1, 3, 6, and 12 months postoperatively using the modified Japanese Orthopedic Association scale (mJOA) while the postoperative radiographic changes represented by the Cobb’s angle variation was recorded at 12 months postoperatively and compared with preoperative values. Also, the incidence of postoperative complications and neurological deterioration was recorded and studied between the two groups. Study duration was for 2 years from December 2014 to December 2016.

Results

Both the ACDF and PL groups showed an improvement in the mJOA score mean value at 1 year after surgery in comparison with the preoperative evaluation data; however, on comparing between both groups at 1 year postoperatively, the median percent of increase in mJOA score was significantly higher in the ACDF group compared with the PL group (33.3% vs 22.2% respectively). On the other hand, the Cobb’s angle percent of change 1 year after surgery showed a median percent of increase of 18.7% in the ACDF group in contrast to a median decrease of − 11.1% in the PL group which was statistically significant. Minimal complications were reported in both groups.

Conclusion

Both PL and ACDF are effective modalities for the surgical management of multilevel CSM showing good clinical outcome; however, when compared with the posterior approach, there was a statistical significant difference favoring ACDF regarding the median percent of increase in mJOA score and the postoperative Cobb’s angle improvement.

Histologic Observation and Significance of Sympathetic Nerve Fiber Distribution on Human Cervical Ligamentum Flavum

Objective

To study the distribution of sympathetic nerves of the ligamentum flavum (LF), confirm its existence by histological observation and nuclear magnetic resonance spectroscopy, and analyze the relationship between sympathetic nerve fibers and the biomechanical structure of the LF.

Methods

Randomly controlled scientific research selected 15 cases of posterior surgery in the affiliated hospital of Qingdao University from January 2013 to December 2019. The average age was 67.5 ± 14.5 years old, eight males and seven females. The LF specimens (completely separated fresh tissue) of different segments (C_3‐7) were taken during the operation. Two pages of LF specimens on the left and right sides of the same segment are randomly allocated by the pairing method for formalin fixation and cryopreservation in liquid nitrogen. LF specimens extracted from seven other adult cadaver specimens (average age at death of about 56.8 ± 4.0 years, three males and four females) were used as a control group; together with formalin‐ fixed specimens obtained during surgery, 3D slices were given layer by layer. The distribution of sympathetic nerves in different parts of the LF was analyzed by glyoxylic acid‐induced biological monoamine fluorescent technique (SPG) and hematoxylin–eosin (HE) staining. Fifteen liquid nitrogen storage specimens were divided into the back of the LF and the spinal canal through frozen sections, and were analyzed by nuclear magnetic resonance spectroscopy‐hydrogen spectrum (¹H ‐NMR) for neurotransmitters and neurometabolites.

Results

There were type C sympathetic nerve fibers in the LF, which were divided into linear shape (α) and wave shape (β). Experimental group (χ² = 1.705, P > 0.05) and control group (χ² = 0.879, P > 0.05) can detect no difference in fluorescence units. Nerve fiber transmitter metabolites choline (Cho), creator (Cr), γ‐aminobutyric acid (GABA) also indicate that the sympathetic nerve is present in the LF. LF sympathetic nerve fibers were mainly distributed in the proximal spinal canal surface, nerve fibers on the medial belt (area II) were fewer than the lateral belt (area I) (W = 210, P < 0.05). The ¹HNMR spectrum of LF spinal canal PG / Cho (t = 8.721, P < 0.05), GABA (t = 16.01, P < 0.05) value increased, lactic acid (Lac) / Cr (t = 4.213, P < 0.05), Cho / Cr (t = 2.402, P < 0.05) value decreased, indicating that nerve fibers are actively metabolized on the surface of the spinal canal, mainly distributed in tube surface. βtype fibers were more often distributed around microvessels. A small amount of α type fibers went next to the vascular structures, while α type fibers and β type fibers go cross within LF. Two patients with vertebral artery dissection had no recurrence of sympathetic symptoms within a total of 12 follow‐ups 2 years after discharge.

Conclusions

There are many sympathetic nerve fibers distributed on LF, and their distribution may be correlated with histological and mechanical characteristics of LF. It may also be the anatomical basis of cervical vertigo.

Early Implant Failure of a 2-Level M6-Cervical Total Disc Replacement: A Case Report

CASE

We report a case of implant failure after primary 2-level M6-cervical disc replacement (M6-C; Spinal Kinetics) at C4-5 and C5-6. At revision surgery, a full-thickness tear was identified in the sheath of the C5-6 implant. Histology from periprosthetic tissue demonstrated polyethylene particles without acute inflammation. Tissue cultures were positive for Propionibacterium acnes, but ultrasonicate cultures were negative for both prostheses. An independent laboratory test confirmed mechanical failure of the C5-6 prosthesis.

CONCLUSION

This is the first report of mechanical failure associated with wear-debris osteolysis after M6-C disc arthroplasty. Therefore, continued surveillance after CTDR is necessary.

Lateral Position versus Prone Position for Cervical Laminoplasty: A Retrospective Comparative Study

Purpose

To examine the safety of lateral decubitus positions for cervical laminoplasty.

Patients and Methods

A retrospective comparative study was conducted on the safety between the lateral and prone positions in cervical laminoplasty. After screening, 466 patients who underwent cervical laminoplasty at a single medical center were enrolled and categorized into the lateral (n=229) and prone (n=237) groups. Data on positioning time, surgical time, blood loss, complication rates, and surgical outcomes were collected and compared between the two groups. The patients were further divided into underweight, normal weight, overweight, and obesity subgroups according to their body mass index, and the collected data were compared between the lateral and prone groups.

Results

The lateral group had a lower incidence of facial pressure ulcers (2.18%) than the prone group (11.39%). However, positioning time, surgical time, blood loss, and surgical outcomes were not significantly different between the two groups. In the subgroup analysis, no significant difference in positioning time, operative time, and blood loss was observed in the underweight, normal weight, and overweight patients between the two groups, but in the obesity subgroup, the lateral group had a significantly shorter positioning time (15.23±6.44 vs 21.63±9.43 min, P=0.045) and operative time (140.16±40.48 vs 178.62±51.82 min, P=0.037) and lesser blood loss (285.31±171.75 vs 430.46±189.84 mL, P=0.044) than the prone group.

Conclusion

The lateral position is as safe as the prone position for cervical laminoplasty, but it has advantages over the prone position for patients with obesity.

A National Snapshot Detailing the Impact of Parkinson's Disease on the Cost and Outcome Profiles of Fusion Procedures for Cervical Myelopathy

BACKGROUND

Studies suggest a higher prevalence of cervical deformities in Parkinson's Disease (PD) patients who predispose to cervical myelopathy (CM). Despite the profound effect of CM on function and quality of life, no study has assessed the influence of PD on costs and outcomes of fusion procedures for CM.

OBJECTIVE

To conduct the first national-level study that provides a snapshot of the current outcome and cost profiles for different fusion procedures for CM in PD and non-PD populations.

METHODS

Patients with or without PD who underwent cervical decompression and fusion anteriorly (ACDF), posteriorly (PCDF), or both (Frontback), for CM were identified from the 2013 to 2014 National Inpatient Sample using International Classification of Disease codes.

RESULTS

A total of 75 870 CM patients were identified, with 535 patients (0.71%) also having PD. Although no difference existed between in-hospital mortality rates, overall complication rates were higher in PD patients (38.32% vs 22.05%; P < .001). PD patients had higher odds of pulmonary (P = .002), circulatory (P = .020), and hematological complications (P = .035). Following ACDFs, PD patients had higher odds of complications (P = .035), extended hospitalization (P = .026), greater total charges (P = .003), and nonhome discharge (P = .006). Although PCDFs and Frontbacks produced higher overall complication rates for both populations than ACDFs, PD status did not affect complication odds for these procedures.

CONCLUSION

PD may increase risk for certain adverse outcomes depending on procedure type. This study provides data with implications in healthcare delivery, policy, and research regarding a patient population that will grow as our population ages and justifies further investigation in future prospective studies.

Clinical significance of microsurgical excision of the posterior longitudinal ligament using a high-frequency electrosurgical excision procedure in anterior cervical discectomy and fusion

Introduction

Anterior cervical decompression and fusion surgery using traditional methods to remove the posterior longitudinal ligament often causes massive bleeding, increasing the risk of surgery. However, the use of a high-frequency electrotome under the microscope can significantly reduce bleeding and reduce the risk of surgery.

Aim

To explore the clinical significance of electrosurgical excision of the posterior longitudinal ligament in the cervical anterior approach under the microscope.

Material and methods

From December 2015 to December 2017, patients who underwent anterior cervical discectomy and fusion at our hospital were followed up. We enrolled 73 men and 50 women who were 30 to 74 years old (mean, 49.96 years). Among 67 patients in group A treated with a high-frequency electrosurgical knife under the microscope, 58 were followed up; among 73 patients in group B treated with a traditional cervical hook knife under the microscope, 65 were followed up. Clinical data, operative time, intraoperative bleeding volume, VAS score, and Japanese Orthopaedic Association (JOA) improvement rate were retrospectively analyzed.

Results

There were significant differences in the mean operative time and intraoperative bleeding volume between the two groups (p < 0.05); however, no significant differences were found in the incidence of cerebrospinal fluid leakage, JOA improvement rate at 3 months postoperatively, and VAS score at 3 months postoperatively between the two groups (p > 0.05).

Conclusions

Electrosurgical resection of the posterior longitudinal ligament of the cervical vertebrae under the microscope can significantly reduce intraoperative bleeding and shorten the operative time and has obvious advantages compared with traditional methods.

Clinical efficacy of laminectomy with instrumented fixation in treatment of adjacent segmental disease following ACCF surgery: a retrospective observational study of 48 patients

This study was designed to investigate the clinical efficacy of laminectomy with instrumented fixation in treatment of adjacent segmental diseases following anterior cervical corpectomy and fusion (ACCF) surgery. Between January 2008 and December 2015, 48 patients who underwent laminectomy with instrumented fixation to treat adjacent segmental diseases following ACCF surgery, were enrolled into this study. The patients were followed up at least 2 years. Pain assessment was determined by visual analogue scale (VAS) score and Neck Disability Index (NDI) score; neurological impairment was evaluated by Japanese Orthopaedic Association (JOA) score; and radiographic parameters were also compared. All comparisons were determined by paired t test with appropriate Bonferronni correction. VAS score preoperatively and at last follow-up was 5.28 ± 2.35 vs 1.90 ± 1.06 (P < 0.001). JOA score preoperatively and at last follow-up was 8.2 ± 3.6 vs 14.5 ± 1.1 (P < 0.001). NDI score preoperatively and at last follow-up was 30.5 ± 12.2 vs 10.6 ± 5.8 (P < 0.001). Moreover, the losses of cervical lordosis and C2-C7 range of motion after laminectomy were significant (both P < 0.005), but not sagittal vertical axis distance. Postoperative complications were few or mild. In conclusion, clinical effectiveness and safety can be guaranteed when the patients undergo laminectomy with instrumented fixation to treat adjacent segmental diseases following ACCF surgery.

Reoperation and complications after anterior cervical discectomy and fusion and cervical disc arthroplasty: a study of 52,395 cases

PURPOSE

The aim of this study was to analyze rates of perioperative complications and subsequent cervical surgeries in patients treated for cervical degenerative disc disease with anterior cervical discectomy and fusion (ACDF) and those treated with artificial cervical disc arthroplasty (ACDA) for up to 5-year follow-up.

METHODS

California's Office of Statewide Health Planning and Development discharge database was analyzed for patients aged 18-65 years undergoing single-level ACDF or ACDA between 2003 and 2010. Medical comorbidities were identified with CMS-Condition Categories. Readmissions for short-term complications of the procedure were identified and rates of subsequent cervical surgeries were calculated at 90-day and 1-, 3-, and 5-year follow-up. Multivariate regression modeling was used to identify associations with complications and subsequent cervical surgeries correcting for patient and provider characteristics.

RESULTS

A total of 52,395 eligible cases were identified: 50,926 ACDF and 1469 ACDA. Readmission was less common in the ACDA group (OR: 0.69, 95% CI: 0.48-1.0, p = 0.048). Subsequent cervical spine surgery was more common in the ACDF group in the immediate perioperative period (within 90 days of surgery) (ACDF 3.35% vs. ACDA 2.04%, OR: 0.63, 95% CI: 0.44-0.92, p = 0.015). At 1-, 3-, and 5-year postoperatively, rates of subsequent cervical surgeries were similar between the two cohorts.

CONCLUSIONS

We found no protective benefit for ACDA versus ACDF for single-level disease at up to 5-year follow-up in the largest cohort of patients examined to date. Early complications were rare in both cohorts stressing the value of large cohort studies to study risk factors for rare events. These slides can be retrieved under Electronic Supplementary Material.

Expression of miR-625 and Fas in cervical vertebral cartilage endplate

The aim of the present study was to assess miR-625 and Fas expression in normal and degenerative cervical cartilage endplate (CEP) tissues. Following biof-informatics analysis, the Fas gene was predicted to be one of the targets of miR-625. Quantitative PCR (qPCR) and western blotting were used to detect miR-625 and Fas expression in normal and degenerative CEP. A luciferase reporter assay was used to identify whether miR-625 could directly target the 3' untranslated region (3'-UTR) of Fas. Lentiviral overexpression and/or inhibition vectors of miR-625 (pre-miR-625)/antigomiR-625 were constructed to determine whether overexpression or inhibition of miR-625 could affect Fas and B-cell lymphoma 2 (Bcl-2) expression in cartilaginous endplate cells (CECs) and tissues. qPCR analysis demonstrated that miR-625 expression in degenerative CEP was significantly lower than in normal CEP tissue, while the production of Fas in degenerated CEP was significantly higher. Results from western blotting also showed a significant increase in Fas expression in degenerative CEP. miR-625 can bind directly to the 3'-UTR of the Fas gene. However, this inhibition was attenuated by a target mutation in the miR-625-binding site of the 3'-UTR of Fas mRNA. In addition, following transfection of CECs with pre-miR-625 and antigomiR-625, expression of Fas significantly decreased and increased, respectively, and Bcl-2 expression was upregulated and downregulated, respectively. Upregulation of miR-625 can inhibit Fas expression and further affect Bcl-2 expression in CEP degeneration, suggesting that miR-625-mediated inhibition of the Fas gene is important in cervical degeneration.

A novel index for quantifying the risk of early complications for patients undergoing cervical spine surgeries

OBJECTIVE It is becoming increasingly necessary for surgeons to provide evidence supporting cost-effectiveness of surgical treatment for cervical spine pathology. Anticipating surgical risk is critical in accurately evaluating the risk/benefit balance of such treatment. Determining the risk and cost-effectiveness of surgery, complications, revision procedures, and mortality rates are the most significant limitations. The purpose of this study was to determine independent risk factors for medical complications (MCs), surgical complications (SCs), revisions, and mortality rates following surgery for patients with cervical spine pathology. The most relevant risk factors were used to structure an index that will help quantify risk and anticipate failure for such procedures. METHODS The authors of this study performed a retrospective review of the National Inpatient Sample (NIS) database for patients treated surgically for cervical spine pathology between 2001 and 2010. Multivariate models were performed to calculate the odds ratio (OR) of the independent risk factors that led to MCs and repeated for SCs, revisions, and mortality. The models controlled for age (< and > 65 years old), sex, race, revision status (except for revision analysis), surgical approach, number of levels fused/re-fused (2-3, 4-8, ≥ 9), and osteotomy utilization. ORs were weighted based on their predictive category: 2 times for revision surgery predictors and 4 times for mortality predictors. Fifty points were distributed among the predictors based on their cumulative OR to establish a risk index. RESULTS Discharges for 362,989 patients with cervical spine pathology were identified. The mean age was 52.65 years, and 49.47% of patients were women. Independent risk factors included medical comorbidities, surgical parameters, and demographic factors. Medical comorbidities included the following: pulmonary circulation disorder, coagulopathy, metastatic cancer, renal failure, congestive heart failure, alcohol abuse, neurological disorder, nonmetastatic cancer, liver disease, rheumatoid arthritis/collagen vascular diseases, and chronic blood loss/anemia. Surgical parameters included posterior approach to fusion/re-fusion, ≥ 9 levels fused/re-fused, corpectomy, 4-8 levels fused/re-fused, and osteotomy; demographic variables included age ≥ 65 years. These factors increased the risk of at least 1 of MC, SC, revision, or mortality (risk of death). A total of 50 points were distributed among the factors based on the cumulative risk ratio of every factor in proportion to the total risk ratios. CONCLUSIONS This study proposed an index to quantify the potential risk of morbidity and mortality prior to surgical intervention for patients with cervical spine pathology. This index may be useful for surgeons in patient counseling efforts as well as for health insurance companies and future socioeconomics studies in assessing surgical risks and benefits for patients undergoing surgical treatment of the cervical spine.

An in vivo comparison study in goats for a novel motion-preserving cervical joint system

Cervical degenerative disease is one of the most common spinal disorders worldwide, especially in older people. Anterior cervical corpectomy and fusion (ACCF) is a useful method for the surgical treatment of multi-level cervical degenerative disease. Anterior cervical disc replacement (ACDR) is considered as an alternative surgical method. However, both methods have drawbacks, particularly the neck motion decrease observed after arthrodesis, and arthroplasty should only be performed on patients presenting with cervical disc disease but without any vertebral body disease. Therefore, we designed a non-fusion cervical joint system, namely an artificial cervical vertebra and intervertebral complex (ACVC), to provide a novel treatment for multi-level cervical degenerative disease. To enhance the long-term stability of ACVC, we applied a hydroxyapatite (HA) biocoating on the surface of the artificial joint. Thirty-two goats were randomly divided into four groups: a sham control group, an ACVC group, an ACVC-HA group, and an ACCF group (titanium and plate fixation group). We performed the prosthesis implantation in our previously established goat model. We compared the clinical, radiological, biomechanical, and histological outcomes among these four different groups for 24 weeks post surgery. The goats successfully tolerated the entire experimental procedure. The kinematics data for the ACVC and ACVC-HA groups were similar. The range of motion (ROM) in adjacent level increased after ACCF but was not altered after ACVC or ACVC-HA implantation. Compared with the control group, no significant difference was found in ROM and neutral zone (NZ) in flexion-extension or lateral bending for the ACVC and ACVC-HA groups, whereas the ROM and NZ in rotation were significantly greater. Compared with the ACCF group, the ROM and NZ significantly increased in all directions. Overall, stiffness was significantly decreased in the ACVC and ACVC-HA groups compared with the control group and the ACCF group. Similar results were found after a fatigue test of 5,000 repetitions of axial rotation. The histological results showed more new bone formation and better bone implant contact in the ACVC-HA group than the ACVC group. Goat is an excellent animal model for cervical spine biomechanical study. Compared with the intact state and the ACCF group, ACVC could provide immediate stability and preserve segmental movement after discectomy and corpectomy. Besides, HA biocoating provide a better bone ingrowth, which is essential for long-term stability. In conclusion, ACVC-HA brings new insight to treat cervical degenerative disease.

The effect of an integrated education model on anxiety and uncertainty in patients undergoing cervical disc herniation surgery

BACKGROUND

Educating patients about receiving surgical procedures is becoming an important issue, as it can reduce anxiety and uncertainty while helping to hasten decisions for undergoing time sensitive surgeries. We evaluated a new integrated education model for patients undergoing cervical disc herniation surgery using a quasi-experimental design.

METHODS

The participants were grouped into either the new integrated educational model (n = 32) or the standard group (n = 32) on the basis of their ward numbers assigned at admission. Anxiety, uncertainty, and patient satisfaction were measured before (pre-test) and after the educational intervention (post-test-1) and post-surgery (post-test-2) to assess the effectiveness of the model in this intervention.

RESULTS

We found that the generalized estimating equation modeling demonstrated this new integrated education model was more effective than the conventional model in reducing patients' anxiety and uncertainty (p <0.05). Patients were also more satisfied with our newly developed model as it takes a more holistic approach to individual health.

CONCLUSION

This novel systemic educational model enhances patient's understanding of the medical condition and surgery while promoting patient-caregiver interaction for optimal patient health outcomes. We present a comprehensive and consistent platform for educational purposes in patients undergoing surgery as well as reducing the psychological burden from anxiety and uncertainty. Integrating medicine, nursing, and new technologies into an e-practice and e-learning platform offers the potential of easier understanding and usage. It could revolutionize patient education in the future.

C5 palsy after cervical laminectomy and fusion: does width of laminectomy matter?

BACKGROUND CONTEXT

A common complication of cervical laminectomy and fusion with instrumentation (CLFI) is development of postoperative C5 nerve palsy. A proposed etiology is excess nerve tension from posterior drift of the spinal cord after decompression. We hypothesize that laminectomy width will be significantly increased in patients with C5 palsy and will correlate with palsy severity.

PURPOSE

The purposes of this study were to evaluate laminectomy width as a risk factor for C5 palsy and to assess correlation with palsy severity.

STUDY DESIGN/SETTING

This is a retrospective, single-institution clinical study.

PATIENT SAMPLE

Patient population included all patients with cervical spondylotic myelopathy who underwent CLFI between 2007 and 2014 by a single surgeon. Patients who underwent CLFI for trauma, infection, or tumor or had previous or circumferential cervical surgery were excluded. All patients with a new C5 palsy received a postoperative magnetic resonance imaging. An additional computed tomography (CT) scan was ordered to assess hardware. All control patients received a CT scan at 6 months postoperatively to evaluate fusion.

OUTCOME MEASURES

The association between width of laminectomy and development of postopeative C5 palsy was measured.

METHODS

Patient comorbidities including obesity, smoking history, and diabetes were recorded in addition to preopertaive and postoperative deltoid and biceps motor strength. Sagittal alignment was measured with C2-C7 Cobb angle preopertaive and postoperative radiographs. The width of laminectomy was measured in a blinded fashion on the postoperative CT scan by two observers.

RESULTS

Seventeen patients with C5 nerve palsy and 12 controls were identified. There were no baseline differences in age, sex, diabetes, smoking history, number of surgical levels, or sagittal alignment. Body mass index was significantly higher in the control cohort. There was no significant increase in the C3-C7 laminectomy width in patients with postoperative C5 palsy. The width of laminectomy measurments were highly similar between the two observers. There was no correlation between laminectomy width and palsy severity.

CONCLUSIONS

This is the largest series of C5 palsies after laminectomy documented with CT imaging. Laminectomy width was not associated with an increased risk of postoperative C5 palsy at any level. Reduction in laminectomy width may not reduce rate of postoperative nerve palsy.

Clinical outcome of anterior vs posterior approach for cervical spondylotic myelopathy

OBJECTIVE

The aim is to demonstrate whether there is clinical difference between posterior vs anterior decompression in cervical spondylotic myelopathy.

METHODS

Forty-two patient database was obtained from the Centro Medico Nacional de Occidente in Mexico, those who underwent surgical treatment for cervical myelopathy with a mean 1.4 year follow-up.

RESULTS

Patients were divided; group A (45%) anterior approach and group B (55%) posterior approach, for mJOA, group A had a lower score compare with group B. While in the Nurick score group B got a higher score compare with group A.

CONCLUSIONS

Posterior decompression resulted in better functional outcomes (p < 0.05).

Mid- to Long-Term Outcomes of Cervical Disc Arthroplasty versus Anterior Cervical Discectomy and Fusion for Treatment of Symptomatic Cervical Disc Disease: A Systematic Review and Meta-Analysis of Eight Prospective Randomized Controlled Trials

PURPOSE

This study aimed to investigate the mid- to long-term outcomes of cervical disc arthroplasty (CDA) versus anterior cervical discectomy and fusion (ACDF) for the treatment of 1-level or 2-level symptomatic cervical disc disease.

METHODS

Medline, Embase, and the Cochrane Central Register of Controlled Trials databases were searched to identify relevant randomized controlled trials that reported mid- to long-term outcomes (at least 48 months) of CDA versus ACDF. All data were analyzed by Review Manager 5.3 software. The relative risk (RR) and 95% confidence intervals (CIs) were calculated for dichotomous variables. The weighted mean difference (WMD) and 95%CIs were calculated for continuous variables. A random effect model was used for heterogeneous data; otherwise, a fixed effect model was used.

RESULTS

Eight prospective randomized controlled trials (RCTs) were retrieved in this meta-analysis, including 1317 and 1051 patients in CDA and ACDF groups, respectively. Patients after an ACDF had a significantly lower rate of follow-up than that after CDA. Pooled analysis showed patients in CDA group achieved significantly higher rates of overall success, Neck Disability Index (NDI) success, neurological success and significantly lower rates of implant/surgery-related serious adverse events and secondary procedure compared with that in ACDF group. The long-term functional outcomes (NDI, Visual Analog Scale (VAS) neck and arm pain scores, the Short Form 36 Health Survey physical component score (SF-36 PCS)), patient satisfaction and recommendation, and the incidence of superior adjacent segment degeneration also favored patients in CDA group with statistical difference. Regarding inferior adjacent segment degeneration, patients in CDA group had a lower rate without statistical significance.

CONCLUSIONS

This meta-analysis showed that cervical disc arthroplasty was superior over anterior discectomy and fusion for the treatment of symptomatic cervical disc disease in terms of overall success, NDI success, neurological success, implant/surgery-related serious adverse events, secondary procedure, functional outcomes, patient satisfaction and recommendation, and superior adjacent segment degeneration.

Gait and balance disorders

This chapter focuses on one of the most common types of neurologic disorders: altered walking. Walking impairment often reflects disease of the neurologic structures mediating gait, balance or, most often, both. These structures are distributed along the neuraxis. For this reason, this chapter is introduced by a brief description of the neurobiologic underpinning of walking, stressing information that is critical for imaging, namely, the anatomic representation of gait and balance mechanisms. This background is essential not only in order to direct the relevant imaging tools to the regions more likely to be affected but also to interpret correctly imaging findings that may not be related to the walking deficit object of clinical study. The chapter closes with a discussion on how to image some of the most frequent etiologies causing gait or balance impairment. However, it focuses on syndromes not already discussed in other chapters of this volume, such as Parkinson's disease and other movement disorders, already discussed in Chapter 48, or cerebellar ataxia, in Chapter 23, in the previous volume. As regards vascular disease, the spastic hemiplegia most characteristic of brain disease needs little discussion, while the less well-understood effects of microvascular disease are extensively reviewed here, together with the imaging approach.

Effectiveness of Riluzole as a pharmacotherapeutic treatment option for early cervical myelopathy: a double-blinded, placebo-controlled randomised controlled trial

PURPOSE

To evaluate the effectiveness of Riluzole as a pharmacotherapeutic treatment option for early cervical myelopathy using clinical parameters and DTI analysis.

METHODS

Early cervical myelopathy cases with MJOA scores ≥13, were recruited for the double-blinded, placebo-controlled randomised control trial. Thirty cases with fifteen cases each in the test and placebo group were studied. Analysis was done using diffusion tensor imaging (DTI) and clinical evaluation, pre- and post-institution of sodium channel blocker Riluzole for a period of 1 month (50 mg twice daily). Placebo group was treated with Vitamin B complex tablets. Diffusion co-efficient fractional anisotrophy (FA), apparent diffusion co-efficient (ADC), volume ratio (VR), relative anisotrophy (RA) and Eigen vectors were calculated. Outcomes analysis was based on clinical scores of MJOA, Nurick grading, SF-12, NDI, and statistical analysis of DTI datametrics.

RESULTS

The mean MJOA score was 15.6 (13-17) with no significant change in the test and control groups. The mean ADC, FA values were 1533.36 (1238-1779) and 494.36 (364-628) and changed to 1531.57 (1312-2091) and 484.86 (294-597), respectively, in the Riluzole group. However, the changes in the values of ADC, FA, and other co-efficients including VR, RA and eigenvectors in the two groups were not statistically significant. The functional scores in the SF-12 and NDI questionnaires did not change significantly.

CONCLUSIONS

Our study did not show a significant change in the clinical outcome and DTI Indices with the use of Riluzole as a standalone pharmacotherapeutic agent for early cervical myelopathy. More studies may be needed to confirm the usefulness of Riluzole as a treatment option for cervical myelopathy.

The role of iatrogenic foraminal stenosis from lordotic correction in the development of C5 palsy after posterior laminectomy and fusion

Background

Post-operative C5 nerve root palsy is a known complication following cervical spine surgery. Although several theories have been proposed, there remains no consensus as to the etiology of the palsies. Multiple pre-operative radiographic measures have been assessed for utility in predicting palsy. The purpose of this study is to evaluate published radiographic parameters as well as specifically evaluate the effect of cervical lordosis in the development of C5 palsy to establish thresholds that reliably predict the incidence.

Methods

This study is a retrospective review of 54 consecutive multilevel cervical laminectomy and fusion surgeries performed by a single spine surgeon between June 2007 and February 2014. Pre-operative MRI and pre- and post-operative plain films were assessed to measure anteroposterior diameter (APD) of the spinal cord, cervical laminar angles, anteroposterior foraminal diameters (FD), cervical curvature index (Ishihara), cervical spine angle (C2-7), and C4-5 angle. Univariate analysis through independent t tests was used to compare differences between groups. Stepwise logistic regression was performed to identify pre-operative variables associated with C5 palsy. Receiver operating characteristic curves were created for significant variables to assess predictive accuracy through determining the area under the curve.

Results

There were 13 (24 %) palsies in the 54 patients in the study. All palsies completely resolved within 6 months. Among pre-operative measures, FD and APD were significantly different between the palsy and non-palsy groups. The average post-operative C4-5 angle was significantly different between the groups, though the cervical spine angle and curvature index, as well as the change in these measures from pre-operative measurements, did not differ significantly between groups.

Conclusions

Post-operative palsy is likely a result of iatrogenic nerve root compression from a decreased in cross-sectional area of the neuroforamen in a patient with pre-operative narrowing of the foramen. However, spinal cord drift back may also play a role from the combined effect of posterior decompression from laminectomy and relative slack afforded by increased lordosis. Accordingly, increased post-operative lordosis would increase the likelihood of effect from both of these mechanisms. We recommended limited conservative lordotic correction in patients with pre-operative foraminal narrowing.

Cervical total disc replacement is superior to anterior cervical decompression and fusion: a meta-analysis of prospective randomized controlled trials

BACKGROUND

Despite being considered the standard surgical procedure for symptomatic cervical disc disease, anterior cervical decompression and fusion invariably accelerates adjacent segment degeneration. Cervical total disc replacement is a motion-preserving procedure developed as a substitute to fusion. Whether cervical total disc replacement is superior to fusion remains unclear.

METHODS

We comprehensively searched PubMed, EMBASE, Medline, and the Cochrane Library in accordance with the inclusion criteria to identify possible studies. The retrieved results were last updated on December 12, 2014. We classified the studies as short-term and midterm follow-up.

RESULTS

Nineteen randomized controlled trials involving 4516 cases were identified. Compared with anterior cervical decompression and fusion, cervical total disc replacement had better functional outcomes (neck disability index [NDI], NDI success, neurological success, neck pain scores reported on a numerical rating scale [NRS], visual analog scales scores and overall success), greater segmental motion at the index level, fewer adverse events and fewer secondary surgical procedures at the index and adjacent levels in short-term follow-up (P < 0.05). With midterm follow-up, the cervical total disc replacement group indicated superiority in the NDI, neurological success, pain assessment (NRS), and secondary surgical procedures at the index level (P < 0.05). The Short Form 36 (SF-36) and segmental motion at the adjacent level in the short-term follow-up showed no significant difference between the two procedures, as did the secondary surgical procedure rates at the adjacent level with midterm follow-up (P > 0.05).

CONCLUSIONS

Cervical total disc replacement presented favorable functional outcomes, fewer adverse events, and fewer secondary surgical procedures. The efficacy and safety of cervical total disc replacement are superior to those of fusion. Longer-term, multicenter studies are required for a better evaluation of the long-term efficacy and safety of the two procedures.

The Effect of the PEEK Cage on the Cervical Lordosis in Patients Undergoing Anterior Cervical Discectomy

BACKGROUND:

Loss of cervical lordosis is a significant factor in the development of degeneration of the spine with aging. This degenerative changings of the cervical spine would cause pressure effect on the cervical root and/or medulla spinalis.

AIM:

Our goal is to understand the effect of the PEEK cage on cervical lordosis in the early postoperative period. Also, to interpret the effects of one- level, two- level, three-level and four- level disc pathologies on cervical lordosis.

MATERIAL AND METHODS:

We retrospectively investigated our archive, and we selected thirty-four patients undergoing anterior cervical discectomy and fusion with PEEK cage filled with demineralized bone matrix (ACDFP).

RESULTS:

We determined that ACDFP provides improvement in the cervical lordosis angle in both groups. Also, we found statistically significant difference between group 1 and 2 regarding causes of radiculomyelopathy statistically.

CONCLUSION:

We achieved better cervical lordotic angles at the postoperative period by implanting one-level, two-level, three-level or four-level PEEK cage filled with demineralized bone matrix. Also, the causes of cervical root and or medulla spinalis impingement were different in group1 and 2. While extruded cervical disc impingement was the first pathology in group 1, osteophyte formation was the first pathology in group 2.

Anterior surgical treatment of cervical spondylotic myelopathy: review article

BACKGROUND

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

QUESTIONS/PURPOSES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Anterior cervical discectomy and fusion with "mini-invasive" harvesting of iliac crest graft versus polyetheretherketone (PEEK) cages: a retrospective outcome analysis

BACKGROUND

Limited outcome data suggested a minimal evidence for better clinical and radiographic outcome of polyetheretherketone cages compared with bone grafts in the anterior cervical discectomy and fusion. We proposed a "mini-invasive" surgical technique for harvesting iliac crest grafts that provides bicortical autografts of sufficient size to be used in multilevel cervical procedures and is not associated with long-term significant donor site pain.

METHODS

All patients undergoing discectomy and fusion during a three years period were consecutively extracted from computer database and retrospectively evaluated by means of telephonic interview, independently from surgical procedure (iliac crest autograph or prosthesis). Two procedure-blinded neurologists retrieved baseline clinical-demographic data and pre-surgical scores of routinely performed scales for pain and functional abilities. Afterwards, a third blinded neurologist performed clinical follow up by a semi-structured interview including Verbal Analog Scale for pain and Neck Disability Scale for discomfort.

RESULTS

80 patients out of 115 selected cases completed the follow up. 40 patients had been treated by mini-invasive bone graft harvesting and 40 with PEEK cages for cervical fusion. VAS for both neck and arm pain were significantly reduced within groups. Patients did not complaint any significant pain and/or paraesthesias at donor site from the first week after intervention. Neck Disability Scale was significantly lower at the end of follow up in both groups.

CONCLUSIONS

"Miniinvasive" bicortical autografts is a less invasive, inexpensive technique to harvest iliac graft that may produce a reduced amount of general and local donor-site complications without outcome differences with prosthetic cages.

Impact of Age and Duration of Symptoms on Surgical Outcome of Single-Level Microscopic Anterior Cervical Discectomy and Fusion in the Patients with Cervical Spondylotic Radiculopathy

We aim to evaluate the impact of age and duration of symptoms on surgical outcome of the patients with cervical spondylotic radiculopathy (CSR) who had been treated by single-level microscopic anterior cervical discectomy and fusion (ACDF). We retrospectively evaluated 68 patients (48 female and 20 male) with a mean age of 41.2 ± 4.3 (ranged from 24 to 72 years old) in our Orthopedic Department, Imam Reza Hospital. They were followed up for 31.25 ± 4.1 months (ranged from 25 to 65 months). Pain and disability were assessed by Visual Analogue Scale (VAS) and Neck Disability Index (NDI) questionnaires in preoperative and last follow-up visits. Functional outcome was eventually evaluated by Odom's criteria. Surgery could significantly improve pain and disability from preoperative 6.2 ± 1.4 and 22.2 ± 6.2 to 3.5 ± 2.0 and 8.7 ± 5.2 (1–21) at the last follow-up visit, respectively. Satisfactory outcomes were observed in 89.7%. Symptom duration of more and less than six months had no effect on surgical outcome, but the results showed a statistically significant difference in NDI improvement in favor of the patients aged more than 45 years (P = 0.032), although pain improvement was similar in the two groups.

Outcomes following cervical disc arthroplasty: a retrospective review

Cervical disc arthroplasty has emerged as a viable technique for the treatment of cervical radiculopathy and myelopathy, with the proposed benefit of maintenance of segmental range of motion. There are relatively few, non-industry sponsored studies examining the outcomes and complications of cervical disc arthroplasty. Therefore, we set out to perform a single center evaluation of the outcomes and complications of cervical disc arthroplasty. We performed a retrospective review of all patients from a single military tertiary medical center undergoing cervical disc arthroplasty from August 2008 to August 2012. The clinical outcomes and complications associated with the procedure were evaluated. A total of 219 consecutive patients were included in the review, with an average follow-up of 11.2 (±11.0)months. Relief of pre-operative symptoms was noted in 88.7% of patients, and 92.2% of patients were able to return to full pre-operative activity. There was a low rate of complications related to the anterior cervical approach (3.2% with recurrent laryngeal nerve injury, 8.9% with dysphagia), with no device/implant related complications. Symptomatic cervical radiculopathy is a common problem in both the civilian and active duty military populations and can cause significant disability leading to loss of work and decreased operational readiness. There exist several surgical treatment options for appropriately indicated patients. Based on our findings, cervical disc arthroplasty is a safe and effective treatment for symptomatic cervical radiculopathy and myelopathy, with a low incidence of complications and high rate of symptom relief.