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Operative Outcomes for Cervical Myelopathy and Radiculopathy  [PDF]
J. G. Galbraith,J. S. Butler,A. M. Dolan,J. M. O'Byrne
Advances in Orthopedics , 2012, DOI: 10.1155/2012/919153
Abstract: Cervical spondylotic myelopathy and radiculopathy are common disorders which can lead to significant clinical morbidity. Conservative management, such as physical therapy, cervical immobilisation, or anti-inflammatory medications, is the preferred and often only required intervention. Surgical intervention is reserved for those patients who have intractable pain or progressive neurological symptoms. The goals of surgical treatment are decompression of the spinal cord and nerve roots and deformity prevention by maintaining or supplementing spinal stability and alleviating pain. Numerous surgical techniques exist to alleviate symptoms, which are achieved through anterior, posterior, or circumferential approaches. Under most circumstances, one approach will produce optimal results. It is important that the surgical plan is tailored to address each individual's unique clinical circumstance. The objective of this paper is to analyse the major surgical treatment options for cervical myelopathy and radiculopathy focusing on outcomes and complications.
Operative Outcomes for Cervical Myelopathy and Radiculopathy  [PDF]
J. G. Galbraith,J. S. Butler,A. M. Dolan,J. M. O'Byrne
Advances in Orthopedics , 2012, DOI: 10.1155/2012/919153
Abstract: Cervical spondylotic myelopathy and radiculopathy are common disorders which can lead to significant clinical morbidity. Conservative management, such as physical therapy, cervical immobilisation, or anti-inflammatory medications, is the preferred and often only required intervention. Surgical intervention is reserved for those patients who have intractable pain or progressive neurological symptoms. The goals of surgical treatment are decompression of the spinal cord and nerve roots and deformity prevention by maintaining or supplementing spinal stability and alleviating pain. Numerous surgical techniques exist to alleviate symptoms, which are achieved through anterior, posterior, or circumferential approaches. Under most circumstances, one approach will produce optimal results. It is important that the surgical plan is tailored to address each individual's unique clinical circumstance. The objective of this paper is to analyse the major surgical treatment options for cervical myelopathy and radiculopathy focusing on outcomes and complications. 1. Introduction Spondylosis is the most common cause of neural dysfunction in the cervical spine and is becoming more prevalent as the average life-expectancy increases [1]. The degenerative changes associated with ageing include disc herniation, osteophyte formation, hypertrophy of osteoarthritic facet joints, and hypertrophy of ligaments. This condition is often asymptomatic, but in 10% to 15% of cases it compresses the cervical spinal cord and roots to present symptomatically as myelopathy or radiculopathy [2, 3]. Conservative management, such as physical therapy, cervical immobilisation, or anti-inflammatory medications are the preferred and often only required intervention [4]. Surgical intervention is reserved for those patients who have intractable pain or progressive neurological symptoms. Herniated cervical discs and spondylosis causing radiculopathy may be treated from an anterior or posterior approach. Likewise, decompression of the spinal cord can be achieved from either approach. The goals of surgical treatment are decompression of the spinal cord and nerve roots and deformity prevention by maintaining or supplementing spinal stability and alleviating pain. Many surgical techniques have been described to decompress the spinal cord and roots which can employ an anterior, posterior, or circumferential approach. Under most circumstances, one approach will produce optimal results [5–10]. Designing the most effective surgical plan is dependent on numerous factors, including the location of the compressive
Nonoperative Modalities to Treat Symptomatic Cervical Spondylosis  [PDF]
Kieran Michael Hirpara,Joseph S. Butler,Roisin T. Dolan,John M. O'Byrne,Ashley R. Poynton
Advances in Orthopedics , 2012, DOI: 10.1155/2012/294857
Abstract: Cervical spondylosis is a common and disabling condition. It is generally felt that the initial management should be nonoperative, and these modalities include physiotherapy, analgesia and selective nerve root injections. Surgery should be reserved for moderate to severe myelopathy patients who have failed a period of conservative treatment and patients whose symptoms are not adequately controlled by nonoperative means. A review of the literature supporting various modalities of conservative management is presented, and it is concluded that although effective, nonoperative treatment is labour intensive, requiring regular review and careful selection of medications and physical therapy on a case by case basis. 1. Introduction Spondylosis refers to age-related degenerative changes within the spinal column [1], which in the cervical spine may be asymptomatic or can present as pure axial neck pain, cervical radiculopathy, cervical myelopathy, or cervical myeloradiculopathy. Radiological evidence of asymptomatic cervical spondylosis is seen frequently [1, 2], with an incidence of 50% over the age of 40 and 85% over the age of sixty [2, 3]. Unfortunately, neck pain and radiculopathy are relatively common, with about two thirds of the UK population having neck pain at some point in their lives [4, 5], and 34% of responders in a Norwegian survey of 10,000 adults having experienced neck pain in the previous year [6]. Nonsurgical treatment is usually the most appropriate course of initial management [7, 8], with operative intervention being reserved for moderate to severe myelopathy, or cases with unremitting and progressive symptoms that have failed medical treatment [7, 9, 10]. Despite the high incidence of symptomatic cervical degeneration and the widespread use of nonoperative techniques to treat this condition, the number of comparative trials in the literature is small and usually of poor quality [11]. In this paper we attempt to summarise the recommendations of the literature with regards to treating symptomatic cervical spondylosis, including cervical radiculopathy and mild myelopathy. 2. Pathophysiology 2.1. Neck Pain In the vast majority of patients axial neck pain is related to muscular and ligamentous factors related to injury, poor posture, stress, or chronic muscle fatigue [12]. The cervical discs and facet joint scan are also sources of pain secondary to degenerative disease. The pathway whereby a degenerate disc causes neck pain is disputed, however the nerve supply to the peripheral portion of the intervertebral disc may be responsible for the
Operative Treatment of Cervical Myelopathy: Cervical Laminoplasty  [PDF]
Brett A. Braly,David Lunardini,Chris Cornett,William F. Donaldson
Advances in Orthopedics , 2012, DOI: 10.1155/2012/508534
Abstract: Cervical spondylotic myelopathy (CSM) is a degenerative process which may result in clinical signs and symptoms which require surgical intervention. Many treatment options have been proposed with various degrees of technical difficulty and technique sensitive benefits. We review laminoplasty as a motion-sparing posterior decompressive method. Current literature supports the use of laminoplasty for indicated decompression. We also decribe our surgical technique for an open-door, or “hinged”, laminoplasty. 1. Introduction Cervical spondylotic myelopathy (CSM) is the natural result of degenerative compression on the cervical spinal cord. The result may be a progressive and stepwise deterioration of neurological function in patients. The chronic debilitating nature of this process justifies surgical decompression. Posterior decompression has been described as a treatment for CSM since the 1940s. Laminectomy was the initial surgical option used. The decompression was performed by rongeurs. However, the insertion of the rongeur in an already limited space available for the cord led often to a decrease in neurological function postoperatively [1–3]. Even with modern approaches to laminectomy using high speed burs, development of postoperative instability has led surgeons to explore more efficacious ways of decompression. In 1977, Hirabayashi and Satomi published their results on multisegment decompression by means of an open-door laminoplasty [4]. This technique allows for adequate posterior decompression of the spinal cord while retaining the posterior elements. This avoids the postoperative instability seen with laminectomy as well as the stiffness and risks of posterior cervical fusion. Additionally, motion is spared due to the absence of a fusion. There have since been multiple techniques for performing a cervical laminoplasty described with supporting literature [4–8]. These techniques include the expansive “open door,” a midline “French Door,” En Bloc resection, spinous process splitting, and Z-Plasty [4, 9]. Outcome studies have supported laminoplasty as a valid treatment for CSM however, no definitive literature shows its superiority to laminectomy in conjunction with a posterior cervical fusion. All surgical strategies appear to be equal in yielding neurologic outcomes, though differences are found in complication reports. Patient selection is crucial prior to proceeding with cervical laminoplasty. Special attention must be paid to sagittal alignment for optimal outcomes. Laminoplasty is ideal for multilevel stenosis (AP canal diameter < 13?mm) due to
Operative Treatment of Cervical Myelopathy: Cervical Laminoplasty  [PDF]
Brett A. Braly,David Lunardini,Chris Cornett,William F. Donaldson
Advances in Orthopedics , 2012, DOI: 10.1155/2012/508534
Abstract: Cervical spondylotic myelopathy (CSM) is a degenerative process which may result in clinical signs and symptoms which require surgical intervention. Many treatment options have been proposed with various degrees of technical difficulty and technique sensitive benefits. We review laminoplasty as a motion-sparing posterior decompressive method. Current literature supports the use of laminoplasty for indicated decompression. We also decribe our surgical technique for an open-door, or “hinged”, laminoplasty.
Functional Outcomes of Surgery in Cervical Spondylotic Radiculopathy versus Myelopathy: A Comparative Study  [PDF]
F. Omidi-Kashani,E. G. Hasankhani,M. F. Vavsari,S. Afsari,F. Golhasani-Keshtan
Neuroscience Journal , 2013, DOI: 10.1155/2013/293806
Abstract: Background. Cervical spondylosis can cause three different categories of symptoms and signs with possible overlap in the affected patients. Aim. We aim to compare functional outcome of surgery in the patients with cervical spondylotic radiculopathy and myelopathy, regardless of their surgical type and approach. Materials and Methods. We retrospectively reviewed 140 patients with cervical spondylotic radiculopathy and myelopathy who had been operated from August 2006 to January 2011, as Group A (68 cases) and Group B (72 cases), respectively. The mean age was 48.2 and 55.7 years, while the mean followup was 38.9 and 37.3 months, respectively. Functional outcome of the patients was assessed by neck disability index (NDI) and patient satisfaction with surgery. Results. Only in Group A, the longer delay caused a worse surgical outcome (NDI). In addition, in Group B, there was no significant relationship between imaging signal change of the spinal cord and our surgical outcomes. Improvement in NDI and final satisfaction rate in both groups are comparable. Conclusions. Surgery was associated with an improvement in NDI in both groups ( ). The functional results in both groups were similar and comparable, regarding this index and patient's satisfaction score. 1. Introduction Spondylosis is the most common cause of neural compression in cervical spine [1]. The disease can cause three different categories of symptoms and signs with possible overlap in the affected patients [2, 3]. These patients may complain of the neck (pain, stiffness, and limited range of motion) or suffer from radiculopathy or even myelopathy [4]. Neurologic symptoms are usually aroused when the space available for the neural elements is reduced by osteophytes, hypertrophied ligamentum flavum, or a herniated disc [4]. In those patients whose main manifestation of the disease is neck complains, conservative treatment is usually recommended, while in some with cervical spondylotic radiculopathy (CSR) or myelopathy (CSM), surgery may be associated with better satisfactory outcomes [5–7]. Although, some authors still have doubts about the long-term results of surgery in these cases [2, 8]. The poor prognostic factors usually quoted in the surgical treatment of the patients include older age, abnormal cervical curvature, multisegmental compression, more duration of symptoms, higher number of comorbidities, decreased signal intensity on T1-weighted images, increased signal intensity on T2-weighted images, and existence of cord atrophy in preoperative magnetic resonance images (MRIs) [1, 5, 6,
Development of a self-administered questionnaire to screen patients for cervical myelopathy
Hiroshi Kobayashi, Shin-ichi Kikuchi, Koji Otani, Miho Sekiguchi, Yasufumi Sekiguchi, Shin-ichi Konno
BMC Musculoskeletal Disorders , 2010, DOI: 10.1186/1471-2474-11-268
Abstract: A case-control study was performed with the following two groups at our university hospital from February 2006 to September 2008. Sixty-two patients (48 men, 14 women) with cervical myelopathy who underwent operative treatment were included in the myelopathy group. In the control group, 49 patients (20 men, 29 women) with symptoms that could be distinguished from those of cervical myelopathy, such as numbness, pain in the upper extremities, and manual clumsiness, were included. The underlying conditions were diagnosed as carpal tunnel syndrome, cubital tunnel syndrome, thoracic outlet syndrome, tarsal tunnel syndrome, diabetes mellitus neuropathy, cervical radiculopathy, and neuralgic amyotrophy. Twenty items for a questionnaire in this study were chosen from the Japanese Orthopaedic Association Cervical Myelopathy Evaluation Questionnaire, which is a new self-administered questionnaire, as an outcome measure for patients with cervical myelopathy. Data were analyzed by univariate analysis using the chi-square test and by multiple logistic regression analysis. According to the resulting odds ratio, β-coefficients, and p value, items were chosen and assigned a score.Eight items were chosen by univariate and multiple logistic regression analyses and assigned a score. The Hosmer-Lemeshow statistic showed p = 0.805. The area under the receiver operation characteristic curve was 0.86. The developed questionnaire had a sensitivity of 93.5% and a specificity of 67.3%.We successfully developed a simple self-administered questionnaire to screen for cervical myelopathy.Cervical myelopathy is caused by mechanical and dynamic compression of the spinal cord and developmental spinal canal stenosis [1]. Patients with cervical myelopathy have various symptoms, such as numbness, pain, hypoesthesia and weakness of the extremities, pain and stiffness of the neck, manual clumsiness, walking disturbance, and urinary disturbance [2-5]. Numbness of the upper extremities is one of the chief
Cervical Spondylotic Myelopathy: Pathophysiology, Diagnosis, and Surgical Techniques  [PDF]
Tobias A. Mattei,Carlos R. Goulart,Jeronimo B. Milano,Luis Paulo F. Dutra,Daniel R. Fasset
ISRN Neurology , 2011, DOI: 10.5402/2011/463729
Abstract: Cervical spondylotic myelopathy is a degenerative spinal disease which may lead to significant clinical morbidity. The onset of symptoms is usually insidious, with long periods of fixed disability and episodic worsening events. Regarding the pathophysiology of CSM, the repeated injuries to the spinal cord are caused by both static and dynamic mechanical factors. The combination of these factors affects the spinal cord basically through both direct trauma and ischemia. Regarding the diagnosis, both static and dynamics X-rays, as well as magnetic resonance imaging are important for preoperative evaluation as well as individualizing surgical planning. The choice of the most appropriate technique is affected by patient's clinical condition radiologic findings, as well as surgeon's experience. In opposition to the old belief that patients presenting mild myelopathy should be treated conservatively, there has progressively been amount of evidence indicating that the clinical course of this disease is progressive deterioration and that early surgical intervention improves long-term functional recovery and neurological prognosis. 1. Introduction Cervical spondylosis is the most common nontraumatic cause of myelopathy in the cervical spine [1]. Different from the majority of the other spinal problems in which the clinical treatment is usually the first option, early surgery is a key point to interfere in the natural history of cervical spondylotic myelopathy (CSM) and improve the neurological prognosis. In fact, there is strong evidence showing that surgery within one year from onset of symptoms strongly improves prognosis in CSM [1–3]. Nevertheless, the diagnosis of CSM can be difficult because the signs and symptoms can vary widely among the population. Besides, onset of symptoms is usually insidious, with long periods of fixed disability and episodic worsening events. Some findings that can commonly appear are gait spasticity, followed by upper extremity numbness and loss of fine motor control in the hands [2, 3]. Although it is generally agreed that surgical intervention positively impacts the prognosis of CSM, the decision algorithm for the selection of the most appropriate surgical technique is complex. In fact, the choice between a ventral or a dorsal approach depends on several factors such as the relative location of the primary compression (dorsal × ventral) and the alignment of the cervical spine (lordosis × kyphosis), as well as patient-specific spinal biomechanics [2–4]. 2. Pathophysiology CSM has been first defined by Brain et al. in 1952 [2]. The
Functional outcome of corpectomy in cervical spondylotic myelopathy  [cached]
Williams Kanishka,Paul Rajesh,Dewan Yashbir
Indian Journal of Orthopaedics , 2009,
Abstract: Background : Cervical spondylotic myelopathy (CSM) is serious consequence of cervical intervertebral disk degeneration. Morbidity ranges from chronic neck pain, radicular pain, headache, myelopathy leading to weakness, and impaired fine motor coordination to quadriparesis and/or sphincter dysfunction. Surgical treatment remains the mainstay of treatment once myelopathy develops. Compared to more conventional surgical techniques for spinal cord decompression, such as anterior cervical discectomy and fusion, laminectomy, and laminoplasty, patients treated with corpectomy have better neurological recovery, less axial neck pain, and lower incidences of postoperative loss of sagittal plane alignment. The objective of this study was to analyze the outcome of corpectomy in cervical spondylotic myelopathy, to assess their improvement of symptoms, and to highlight complications of the procedure. Materials and Methods: Twenty-four patients underwent cervical corpectomy for cervical spondylotic myelopathy during June 1999 to July 2005.The anterior approach was used. Each patient was graded according to the Nuricks Grade (1972) and the modified Japanese Orthopaedic Association (mJOA) Scale (1991), and the recovery rate was calculated. Results: Preoperative patients had a mean Nurick′s grade of 3.83, which was 1.67 postoperatively. Preoperative patients had a mean mJOA score of 9.67, whereas postoperatively it was 14.50. The mean recovery rate of patients postoperatively was 62.35% at a mean follow-up of 1 year (range, 8 months to 5 years).The complications included one case (4.17%) of radiculopathy, two cases (8.33%) of graft displacement, and two cases (8.33%) of screw back out/failure. Conclusions: Cervical corpectomy is a reliable and rewarding procedure for CSM, with functional improvement in most patients.
Anterior Discectomy and Fusion versus Posterior Foraminotomy in Treatment of Cervical Radiculopathy: A Comparative Prospective Study  [PDF]
Ahmad Abdalla, Ali A. Abd Elaleem
Open Journal of Modern Neurosurgery (OJMN) , 2019, DOI: 10.4236/ojmn.2019.94042
Abstract: Introduction: Cervical radiculopathy is caused by either cervical disc herniation or bone spurs due to cervical spine degeneration. It is common in middle aged and elderly patients. Those patients who are refractory to conservative treatment are candidates for surgical management. The surgical approaches for cervical radiculopathy are either anterior cervical discectomy and fusion (ACDF) or posterior cervical foraminotomy (PCF). In spite of many reports on ACDF and PCF, only a few studies directly compare the outcomes of both techniques. Purpose: To compare anterior cervical discectomy and fusion (ACDF) with posterior cervical foraminotomy (PCF) for the treatment of cervical radiculopathy, regarding the surgical, clinical and radiological outcomes. Patient and methods: This is a prospective randomized controlled clinical study carried on 44 patients with unilateral cervical radiculopathy. They are divided into 2 groups; group (A) included 23 patients who underwent ACDF and group (B) included 21 patients who underwent PCF, with 1 year follow up. The patient age, sex, clinical manifestations, surgical outcomes as number of cervical level, operative time, blood loss, complications and length of hospital stay were recorded. Visual analogus scale (VAS) and neck disability index (NDI) were used for evaluation of clinical outcomes. Postoperative imaging was done after 1 year to detect instability or adjacent level degeneration. Chi-square and unpaired T-test were used to compare the mean values of both groups. Results: The mean age was nearly 45 years for both groups. C5-6 ACDF was the most common level in group (A), while C6-7 PCF was the most frequent operated level in group (B). PCF group had less operative time, blood loss and length of hospital stay than ACDF group. Clinical improvement of the mean values of VAS and NDI were more pronounced in PCF group as compared to ACDF group with statistically significant difference. No cases of cervical instability were recorded during the period of follow up. Conclusion: Posterior cervical foraminotomy is a safe and effective technique for the treatment of cervical radiculopathy as compared to anterior cervical discectomy and fusion. PCF has a shorter operative time, less hospital stay and better clinical outcome.
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