Anterior direct decompression significantly relieves spinal cord high signal in patients with ossification of the posterior longitudinal ligament: a case-control study

BACKGROUND

In patients with cervical spondylotic myelopathy caused by ossification of the posterior longitudinal ligament, high cord signal (HCS) is frequently observed. However, limited research has investigated the variations in HCS improvement resulting from different surgical approaches. This study aims to explore the potential relationship between the choice of surgical approach and the postoperative improvement of intramedullary high signal in ossification of the posterior longitudinal ligament (OPLL) patients.

METHODS

We extensively reviewed the patients' medical records, based on which demographic information such as gender, age, and body mass index (BMI) were recorded, and assessed the severity of the patients' neurological status preoperatively and postoperatively by using the Japanese Orthopedic Association score (JOAs), focusing on consecutive preoperative and postoperative Magnetic resonance imaging (MRI) T2WI measurements, to study the statistical correlation between the improvement of HCS and the choice of surgical approach.

RESULTS

There were no significant differences in demographic, imaging parameters, and clinical symptoms between patients undergoing anterior and posterior surgery (p > 0.05, Table 1). However, both improvement in JOAs (Recovery2) and improvement in HCS (CR2) were significantly better in the anterior surgery group two years after surgery (p < 0.05, Table 1). Multifactorial logistic regression analysis revealed that posterior surgery and higher preoperative signal change ratio (SCR) were identified as risk factors for poor HCS improvement at the two-year postoperative period (p < 0.05, Table 2). Table 1 Differences in demographic, imaging parameters, and clinical symptoms in patients with anterior and posterior approach Anterior approach Posterior approach P-Values Demographic data  Sex (male/female) 10/12 6/17 0.175  Age 58.59 ± 5.68 61.43 ± 9.04 0.215  Hypertension 14/8 14/9 0.848  Diabetes 16/6 19/4 0.425  BMI 25.58 ± 4.72 26.95 ± 4.58 0.331  Smoking history 19/3 16/7 0.175 Preoperative measured imaging parameters  Preoperative SCR 1.615 ± 0.369 1.668 ± 0.356 0.623  CR1 0.106 ± 0.125 0.011 ± 0.246 0.08  CNR 0.33 ± 0.073 0.368 ± 0.096 0.15  C2-7 Cobb angle 8.977 ± 10.818 13.862 ± 13.191 0.182  SVA 15.212 ± 8.024 17.46 ± 8.91 0.38  mK-line INT 3.694 ± 3.291 4.527 ± 2.227 0.323 Imaging follow-up  6 months postoperative SCR 1.45 ± 0.44 1.63 ± 0.397 0.149  2 years postoperative SCR 1.26 ± 0.19 1.65 ± 0.35 0.000**  CR2 0.219 ± 0.14 - 0.012 ± 0.237 0.000** Clinical symptoms  Preoperative JOAs 10.64 ± 1.59 10.83 ± 1.47 0.679  6 months postoperative JOAs 11.82 ± 1.37 11.65 ± 1.4 0.69  2 years postoperative JOAs 14.18 ± 1.01 12.52 ± 2.06 0.001**  Recovery1 0.181 ± 0.109 0.128 ± 0.154 0.189  Recovery2 0.536 ± 0.178 0.278 ± 0.307 0.001** *, statistical significance (p < 0.05). **, statistical significance (p < 0.01) BMI = body mass index. SCR = the signal change ratio between the localized high signal and normal spinal cord signal at the C7-T1 levels. CR1 = the regression of high cord signals at 6 months postoperatively (i.e., CR1 = (Preoperative SCR-SCR at 6 months postoperatively)/ Preoperative SCR). CR2 = the regression of high cord signal at 2 years postoperatively (i.e., CR2 = (Preoperative SCR-SCR at 2 years postoperatively)/ Preoperative SCR). CNR = canal narrowing ratio. SVA = sagittal vertical axis. mK-line INT = modified K-line interval. JOAs = Japanese Orthopedic Association score. Recovery1 = degree of JOAs recovery at 6 months postoperatively (i.e., Recover1 = (JOAs at 6 months postoperatively-Preoperative JOAs)/ (17- Preoperative JOAs)). Recovery2 = degree of JOAs recovery at 2 years postoperatively (i.e., Recover2 = (JOAs at 2 years postoperatively-Preoperative JOAs)/ (17-Preoperative JOAs)) Table 2 Linear regression analyses for lower CR2 values 95% CI P value Uni-variable analyses Demographic data  Sex (male/female) - 0.01 0.221 0.924  Age - 0.015 0.003 0.195  Hypertension - 0.071 0.204 0.334  Diabetes - 0.195 0.135 0.716  BMI - 0.375 0.422 0.905  Smoking history - 0.249 0.077 0.295  Surgical approach - 0.349 - 0.113 0.000# Preoperative measured imaging parameters  C2-7 Cobb angle - 0.009 0.002 0.185  SVA - 0.008 0.008 0.995  mK-line INT - 0.043 0.005 0.122  Preoperative SCR 0.092 0.445 0.004#  CR1 0.156 0.784 0.004#  CNR - 0.76 0.844 0.918 Multi-variable analyses  Surgical approach - 0.321 - 0.118 0.000**  Preoperative SCR 0.127 0.41 0.000**  CR1 - 0.018 0.501 0.067 #, variables that achieved a significance level of p < 0.1 in the univariate analysis *statistical significance (p < 0.05). **statistical significance (p < 0.01) BMI = body mass index. SCR = the signal change ratio between the localized high signal and normal spinal cord signal at the C7-T1 levels. CR1 = the regression of high cord signals at 6 months postoperatively (i.e., CR1 = (Preoperative SCR-SCR at 6 months postoperatively)/ Preoperative SCR). CR2 = the regression of high cord signal at 2 years postoperatively (i.e., CR2 = (Preoperative SCR-SCR at 2 years postoperatively)/ Preoperative SCR). CNR = canal narrowing ratio. SVA = sagittal vertical axis. mK-line INT = modified K-line interval CONCLUSIONS: For patients with OPLL-induced cervical spondylotic myelopathy and intramedullary high signal, anterior removal of the ossified posterior longitudinal ligament and direct decompression offer a greater potential for regression of intramedullary high signal. At the same time, this anterior surgical strategy improves clinical neurologic function better than indirect decompression in the posterior approach.

Posterior Surgical Ligation and Cyst Decompression -via Needle Puncture- of a Large Anterior Sacral Pelvic Meningocele Through Posterior Sacral Laminectomy

The first documented description of an anterior sacral meningocele was Bryant's in 1823. Anterior sacral meningocele patients have constipation as a universal symptom; urinary incontinence is also common. All the symptoms are directly related to the pressure from a pelvic mass on adjacent structures. When the patient stands, a headache often develops because the spinal fluid pressure decreases as the meningocele sac fills. Finally, a scimitar-shaped sacrum on a neuroradiological anteroposterior plain assessment is pathognomonic. The coccyx may be absent, and the lower sacral laminae may be absent or incomplete. The surgical options for this rare clinical condition are still matter of debate.Anterior sacral meningocele is a pathology that lacks a current classification and neurosurgical therapeutic standards, even though a similar dynamic has been shown by the related traumatic pseudomeningocele. Anterior approaches (retro- and transperitoneal meningocele neck occlusion with internal cerebrospinal fluid (CSF) cyst drainage) and posterior approaches (posterior sacral laminectomy, dural sac ligation, and CSF cyst drainage) are the available surgical strategies.We now report the case of an adult patient for whom a posterior approach was suggested and performed and report her postoperative surgical follow-up. The surgical rationale is also discussed.

Surgical approaches to the petrous apex

The petrous apex is a difficult to reach surgical area due to its deep position in the skull base and many vital surrounding structures. Petrous apex pathology ranges from extradural cholesterol granulomas, cholesteatomas, asymmetric pneumatization, and osteomyelitis to intradural meningiomas and schwannomas. Certain lesions, such as cholesterol granulomas, can be managed with drainage while neoplastic lesions must be completely resected. Surgical options use open, endoscopic, and combined techniques and are categorized into anterior, lateral, and posterior approaches. The choice of approach is determined by the nature of the pathology and location relative to vital structures and extension into surrounding structures and requires thorough preoperative evaluation and discussion of surgical goals with the patient. The purpose of this state-of-the-art review is to discuss the most commonly used surgical approaches to the petrous apex, and the anatomy on which these approaches are based.

Anterior surgical approaches to the cervicothoracic junction: when to use the manubriotomy?

BACKGROUND CONTEXT

The cervicothoracic junction (CTJ) is always a difficult area for anterior approaches. Among them, low anterior cervical approach alone or combined with manubriotomy is the most frequently used.

PURPOSE

To study the need of manubriotomy.

STUDY DESIGN/SETTING

Comparison of last guidelines proposed in literature.

PATIENT SAMPLE

Seven patients treated between March 2010 and March 2011.

METHODS

All the patients were scanned on with computed tomography and magnetic resonance of the spinal column before surgery. Measurements by Teng and Karikari were applied in all the cases. An illustrative case is showed.

RESULTS

The anterior approaches to the CTJ are reviewed. The most recent guidelines by Teng and Karikari are easy to apply and careful. The results obtained were the same in all the cases with good outcome.

CONCLUSIONS

Manubriotomy permits a good exposure of the CTJ area with a low rate of complications. Either Teng and Karikari's guidelines can be used to estabilish the need of manubriotomy.