Cervical spondylotic myelopathy: is a combined approach necessary? / Mielopatia cervical espondilótica: a abordagem combinada é necessária? / Mielopatía cervical espondilótica: ¿el abordaje combinado es necesario?

ABSTRACT Objective: Cervical spondylotic myelopathy (CSM) is the main cause of spinal dysfunction in adults. The type of surgical approach to treatment is not well defined in the literature. The objective is to report the results obtained through isolated posterior decompression in patients with a previous indication of the combined approach for the treatment of cervical spondylotic myelopathy. Methods: This is a therapeutic study with level of evidence II, according to the Oxford classification table. Ten patients who underwent isolated posterior approach surgery for the treatment of cervical spondylotic myelopathy were evaluated through imaging and questionnaires (visual analog scale, mJOA-Br scale - Brazilian Portuguese version of the Modified Japanese Orthopedic Association Scale, and Neck Disability Index (NDI)), comparing pre- and postoperative results. Results: Late evaluation of the 10 patients was performed in the period ranging from 24 to 36 months (mean of 30.3 months ± 7.25) following surgery. The comparison of the clinical and radiological parameters in all patients showed a statistical difference in relation to the preoperative scales applied and to the degree of cervical lordosis (p <0.05), evidencing improvement after decompression and posterior fixation of the cervical spine. Conclusions: The isolated posterior approach (decompression, fixation and arthrodesis) allowed the clinical and radiological improvement of patients with cervical spondylotic myelopathy and who had an indication of the complementary anterior approach. Level of evidence II; Retrospective study.

RESUMO Objetivo: A mielopatia cervical espondilótica (MCE) é a principal causa de disfunção medular nos adultos. O tipo de abordagem cirúrgica para o tratamento não é bem definido na literatura. O objetivo é relatar os resultados obtidos por meio da descompressão posterior isolada nos pacientes com indicação prévia da abordagem combinada para o tratamento da mielopatia cervical espondilótica. Métodos: Trata-se de um estudo terapêutico com nível de evidência II, conforme a tabela de classificação Oxford. Dez pacientes submetidos apenas à abordagem cirúrgica posterior para tratamento de mielopatia cervical espondilótica foram avaliados por meio de exames de imagem e de questionários (escala visual analógica, escala mJOA-Br - Versão em Português da Escala Modificada da Sociedade Japonesa de Ortopedia e escala de incapacidade cervical - Neck Disability Index - NDI), comparando os resultados pré e pós-operatórios. Resultados: A avaliação tardia dos 10 pacientes foi realizada no período que variou de 24 a 36 meses (média de 30,3 meses ± 7,25) de pós-operatório. A comparação dos parâmetros clínicos e radiológicos em todos os pacientes mostrou diferença estatística com relação ao pré-operatório para as escalas aplicadas e para o grau de lordose cervical (p < 0,05), evidenciando a melhora depois da descompressão e da fixação posterior da coluna cervical. Conclusões: A abordagem posterior isolada (descompressão, fixação e artrodese) permitiu a melhora clínica e radiológica de pacientes com mielopatia cervical espondilótica e que tinham indicação da abordagem anterior complementar. Nível de evidência II; Estudo retrospectivo.

RESUMEN Objetivo: La mielopatía cervical espondilótica (MCE) es la principal causa de disfunción medular en los adultos. El tipo de abordaje quirúrgico para el tratamiento no está bien definido en la literatura. El objetivo es relatar los resultados obtenidos por medio de la descompresión posterior aislada en los pacientes con indicación previa del abordaje combinado para el tratamiento de la mielopatía cervical espondilótica. Métodos: Se trata de un estudio terapéutico con nivel de evidencia II, conforme a la tabla de clasificación Oxford. Diez pacientes sometidos únicamente al abordaje quirúrgico posterior para el tratamiento de la mielopatía cervical espondilótica fueron evaluados mediante exámenes de imagen y cuestionarios (escala analógica visual, escala mJOA-Br - versión en portugués de la escala modificada de la Sociedad Japonesa de Ortopedia y escala de incapacidad cervical - Neck Disability Index - NDI), comparando los resultados pre y postoperatorios. Resultados: La evaluación tardía de los 10 pacientes fue realizada en el período que varió de 24 a 36 meses (promedio de 30,3 meses ± 7,25) de postoperatorio. La comparación de los parámetros clínicos y radiológicos en todos los pacientes mostró diferencia estadística con relación al preoperatorio para las escalas aplicadas y para el grado de lordosis cervical (p <0,05), evidenciando la mejora después de la descompresión y de la fijación posterior de la columna cervical. Conclusiones: El abordaje posterior aislado (descompresión, fijación y artrodesis) permitió la mejora clínica y radiológica de pacientes con mielopatía cervical espondilótica y que tenían indicación del abordaje anterior complementario. Nivel de evidencia II; Estudio retrospectivo.

Disfagia devido a osteoitose cervical: relato de caso / Dysphagia due to cervical osteophytosis: case report

Doenças degenerativas na coluna cervical são comuns nos pacientes idosos. Os autores apresentam caso de paciente do sexo feminino, 44 anos, com quadro de disfagia progressiva relacionada à osteofitose cervical anterior em (C5-C6 e C6-C7). Esofagograma mostrou a compreensão esofágica pelos osteófitos anteriores. O tratamento realizado foi brocagem dos osteófitos, discectomia cervical em dois níveis e artrodese cervical, resultando na remissão completa do sintoma. Embora seja uma causa de disfagia, osteófito deve ser incluído como diagnóstico diferencial pois é uma causa tratável e reversível do sintoma.

Degenerative diseases of the cervical spine are common in elderly patients. The authors present a case report of female, 44 years old, with progressive dysphagia due to anterior cervical osteophytes (C5-C6 and C6-C7). Esophagogram showed esophageal compression by anterior osteophytes. The treatment was removal of osteophytes by drill, cervical discectomy on two levels and cervical arthrodesis, resulting in complete remission of symptoms. Although it is an un-common cause of dysphagia, osteophytes should be included in the differential diagnosis because it is a reatable and reversible cause of the symptom.

Dysphagia due to anterior cervical osteophytosis: case report / Disfagia por osteofitose cervical anterior: relato de caso clínico / Disfagia por osteofitosis cervical anterior: relato de caso clínico

The objective of this study is to highlight the possibility of dysphagia induced by anterior cervical osteophytes. When not diagnosed early this condition may be responsible for complications such as severe dysphagia and potential lung aspiration, especially in elderly patients. Analysis of a case report of a 72-year old woman who presented cervical pain and progressive dysphagia. Imaging studies have shown anterior cervical osteophytosis and multilevel degenerative changes in the cervical spine. The patient underwent surgical excision of the cervical anterior osteophytes (C4, C5 and C6) and C5/C6 arthrodesis through anterior approach. The postoperative period was uneventful and symptoms resolved within 2 weeks. Early diagnosis and treatment led to complete resolution, avoiding late and serious complications associated with this pathology in the geriatric population, especially severe and progressive dysphagia and risk of pulmonary aspiration, and the consequent morbidity and mortality associated. A multidisciplinary approach is essential for the correct assessment of this condition.

O objetivo do trabalho é salientar a possibilidade de disfagia induzida por osteofitose cervical anterior. Quando não diagnosticada precocemente essa afecção pode ser responsável por complicações como disfagia grave e aspiração pulmonar, sobretudo nos doentes idosos. Análise de caso clínico de doente do sexo feminino com 72 anos de idade que apresentava dor cervical e disfagia progressiva. Foram realizados exames de imagem que revelaram osteofitose cervical anterior e alterações degenerativas em diversos níveis. A paciente foi submetida à excisão cirúrgica dos osteófitos cervicais anteriores (C4, C5 e C6) e à artrodese de C5-C6 por acesso cervical anterior. O período pós-operatório decorreu sem complicações com remissão dos sintomas em duas semanas. O diagnóstico e tratamento precoces permitiram a resolução completa, evitando as complicações tardias e graves associadas a essa patologia na população geriátrica, sobretudo disfagia grave e progressiva e risco de aspiração pulmonar, com a consequente morbimortalidade a elas associada. A abordagem multidisciplinar é fundamental para a avaliação correta desse quadro.

El objetivo de este trabajo es salientar la posibilidad de disfagia inducida por osteofitosis cervical anterior. Cuando no es diagnosticada precozmente esta afección puede ser responsable por complicaciones como disfagia grave y aspiración pulmonar, sobre todo en los enfermos ancianos. Análisis de caso clínico de enfermo del sexo femenino con 72 años de edad que presentaba dolor cervical y disfagia progresiva. Fueron realizados exámenes de imagen que revelaron osteofitosis cervical anterior y alteraciones degenerativas en diversos niveles. La paciente fue sometida a escisión quirúrgica de los osteófitos cervicales anteriores (C4, C5 e C6) y a la artrodesis de C5-C6 por acceso cervical anterior. El período postoperatorio transcurrió sin complicaciones con remisión de los síntomas en dos semanas. El diagnóstico y tratamiento precoces permitieron la resolución completa, evitando las complicaciones tardías y graves asociadas a esa patología en la población geriátrica, sobre todo disfagia grave y progresiva y riesgo de aspiración pulmonar, con la consiguiente morbimortalidad a ellas asociada. El abordaje multidisciplinario es fundamental para la evaluación correcta de ese cuadro.

Is the Cross-sectional Area after Unilateral Open Door Laminoplasty Wider than that after Midline Splitting Laminoplasty ? : Mathematical Approach

OBJECTIVE: The aim of this study was to compare geometrically cross-sectional areas of two different laminoplasty techniques in same opening size. Some investigators have studied the expanded areas of the two different techniques using imaging study. Although it is unclear that postoperative spinal canal is correlated with the surgical outcome we just focused on mathematical and geometrical correlation of the expandable area with surgical opening size in different laminoplasty techniques. METHODS: To predict the expandable area by a midline splitting technique and a unilateral open door technique, we placed an imaginary isosceles triangle in the spinal canal and drew graphs for the equation of the expandable areas in same opening size using the Pythagorean theorem and mathematical program. To substitute the constant figures of mathematical formula we estimated the normal cervical spine CT scans of 50 Korean adults. RESULTS: We subtracted the imaginary triangle from the spinal canal and were left with the remaining area of the spinal canal that was not changed before and after surgery. In same opening size the expandable area by the midline splitting technique was same but slightly wider than the unilateral open door technique, irrespective of the triangular shape. For a normal isosceles triangle the results were the same. CONCLUSION: Using mathematical proof, the expandable area after the midline splitting technique was same but slightly larger than that after the unilateral open door technique, irrespective of the size of the lamina opening.

Outcome of microsurgical decompression combined with cervical artificial disc replacement / 中华外科杂志

<p><b>OBJECTIVE</b>To study the microsurgical decompression combined with cervical artificial disc replacement clinical efficacy for the treatment of cervical spondylosis.</p><p><b>METHODS</b>From January 2006 to November 2011, 21 cases of cervical spondylosis, totally 23 intervertebral spaces, were under the microscope disc decompression and cervical artificial disc replacement. There were 11 male and 10 female patients; aged from 28 to 60 years, with an average of 46.3 years. The diagnosis included 5 cases of nerve root type cervical spondylosis and 16 cases of cervical spondylotic myelopathy. Application of Bryan prosthesis treatment of 9 patients, a total of 10 intervertebral spaces; ProDisc-C prosthesis to treat 12 patients, a total of 13 intervertebral space. Following-up Japanese Orthopedic Association (JOA), neck disability index (NDI) and visual analogue scale (VAS) scores were recorded and compared with pre-operative scores by the paired t-test.</p><p><b>RESULTS</b>The patients were followed up for 6 to 74 months, with an average of 27.7 months. Although a patient with spinal bony stenosis symptom improved, but not satisfied, and after the posterior decompression, who had a better prognosis. The remaining patients during follow-up symptoms were obvious improved, and the replacement segments were stable. There was no prosthesis subsidence and significantly offset. In 1 month post-operation and last follow-up compared with pre-operative scores, JOA (t = 9.195 and 17.070), NDI (t = 7.193 and 14.062) and VAS (t = 14.851 and 16.133) scores were significantly different (P < 0.05); and 1 month post-operation compared with last follow-up, JOA (t = 5.916), NDI (t = 7.722) and VAS (t = 4.564) scores were significantly different (P < 0.05).</p><p><b>CONCLUSIONS</b>Cervical artificial disc replacement combined with microscopic decompression surgery can completely remove the oppression of nerve tissue caused by pressure, and the efficacy is more secure.</p>

Comparative study of Kurokawa's double door laminoplasty and modified Kurokawa's double door laminoplasty for the treatment of cervical disorders / 中华外科杂志

<p><b>OBJECTIVE</b>To observe and compare the medium-long-term efficacy of Kurokawa's and modified Kurokawa's double door laminoplasty for the treatment of cervical disorders.</p><p><b>METHODS</b>A retrospective analysis was performed to compare the outcomes and complications between two kinds of operations on 172 cases from January 2002 to December 2010, including 106 cases of cervical spondylotic myelopathy, 52 cases of cervical stenosis, 21 cases of cervical ossification of the posterior longitudinal ligament. Patients were divided into two groups according to two surgical methods: traditional group, including 51 male and 18 female patients, with mean age of (56 ± 18) years (35-76 years); modified group, including 75 male and 28 female patients, with mean age of (58 ± 20)years (35-80 years). The two groups were comparable and compared according to different data using t test, χ(2) test and rank sum test.</p><p><b>RESULTS</b>All patients were followed up continuously for (52 ± 33)months, 123 patients were followed up ≥ 2 years, 71 patients ≥ 5 years. All patients' Japanese Orthopaedic Association (JOA) score improved significantly at the latest follow-up(t = 3.420, P < 0.01); no significant difference between the patients' JOA score improvement rate of two groups. The postoperative incidence rate of axial symptoms in patients of modified group (3.9%) was significantly lower than the traditional group (14.5%) (χ(2) = 7.548, P < 0.05), and cervical intervertebral activity decreased in the modified group was better than the traditional group in the first 3 months postoperatively (27% ± 6% vs. 19% ± 4%,Z = 6.34, P < 0.05), but during the medium-long-term follow-up, no significant difference in the cervical intervertebral activity decreased between two groups.</p><p><b>CONCLUSIONS</b>Medium-long-term efficacy of Kurokawa's and modified Kurokawa's double door laminoplasty is satisfied and reliable. Avoiding damaging of semispinalis cervicis insertion in spinous process of C2, the modified operation method can protect the extensor group of the neck muscle and reduce the incidence of postoperative axial symptoms better.</p>

Radiographic outcome analysis of three different fusion methods in maintenance of intervertebral height after cervical anterior corpectomy / 中华外科杂志

<p><b>OBJECTIVE</b>To compare the radiographic outcome of three different fusion methods in maintenance of intervertebral height after cervical anterior corpectomy.</p><p><b>METHODS</b>From May 2005 to November 2009, a total of 77 patients with cervical spondylotic myelopathy who underwent anterior cervical corpectomy and fusion were reviewed in the study. Fusion methods included autogenous iliac bone grafting in 22 patients (group 1), titanium mesh cages without end caps in 21 patients (group 2) and titanium mesh cages with modular end caps in 34 patients (group 3). No significant differences were found in age, gender or level of corpectomy among the three groups (P > 0.05). The height of anterior border (HAB) and the height of posterior border (HPB) of the fused segment were measured on lateral radiographs pre-operatively, post-operatively and at final follow-up to evaluate the outcome. The incidence of subsidence of titanium mesh cage and iliac bone was also reviewed retrospectively. The statistical analysis included One-way variation analysis and chi-square test.</p><p><b>RESULTS</b>All cases obtained the follow-up with an average of (30 ± 5) months (range 24 to 46 months). At final follow-up, the loss of the height of anterior border (HAB) of the fused segment in group 3 ((0.4 ± 0.4) mm) was less than that in the other two groups ((0.9 ± 0.6) mm in group 1 and (1.1 ± 0.8) mm in group 2) (mean difference = -0.45 mm and -0.70 mm, P < 0.05), but the difference was not statistically significant between group 1 and group 2 (P > 0.05); the loss of HPB of the fused segment in group 3((0.6 ± 0.5) mm) was less than that in the other two groups ((1.1 ± 0.7) mm in group 1 and (1.6 ± 0.8) mm in group 2) (mean difference = -0.52 mm and -0.98 mm, P < 0.05), but the difference was not statistically significant between group 1 and group 2 (P > 0.05). Iliac bone subsidence occurred in 10 cases (45.5%) in group 1, including mild subsidence (1 - 3 mm) in 9 cases (40.9%) and severe subsidence (> 3 mm) in 1 case (4.5%), and titanium mesh cage subsidence occurred in 11 cases (52.4%) in group 2, including mild subsidence in 9 cases (42.9%) and severe subsidence in 2 cases (9.5%), and 2 cases (5.9%) in group 3 showed mild subsidence of titanium mesh cages. The incidence of titanium mesh cage subsidence in group 3 was less than that in the other two groups (χ(2) = 12.423 and 15.551, P < 0.05), but the difference was not statistically significant between group 1 and 2 (P > 0.05).</p><p><b>CONCLUSIONS</b>Titanium mesh cage with modular end cap is superior to both titanium mesh cage without end cap and auto iliac bone graft in maintenance of the cervical intervertebral height postoperatively. The usage of modular end cap can efficiently reduce postoperative subsidence rate of titanium mesh cage.</p>

The mid-term effects of Bryan cervical disc prosthesis on sagittal alignment of overall cervical spine and the functional spinal unit / 中华外科杂志

<p><b>OBJECTIVE</b>To investigate the mid-term radiological outcome of sagittal alignment of overall cervical spine and the functional spinal unit after replacement surgery with Bryan cervical disc prosthesis.</p><p><b>METHODS</b>Eighteen patients with cervical disc disorder were performed cervical disc replacement with 20 Bryan discs from November 2005 to May 2010, including single-level 16 cases and bi-level 2 cases. The patient consisted of 13 males and 5 females with age ranging from 38 to 59 years (average, (47 ± 6) years). Fourteen cases with overall cervical lordotic alignment and segmental lordotic alignment per-operatively (group 1) and 4 others with segmental kyphotic alignment and overall cervical kyphotic alignment per-operatively (group 2). The overall sagittal alignment (C(2-7)) and segmental sagittal alignment were measured pre-operatively, post-operatively and at final follow-up to evaluate the outcome.</p><p><b>RESULTS</b>All cases obtained the follow-up with an average of (24 ± 5) months (range 12 to 53 months). To the mean overall cervical alignment, there were 9.9° ± 1.9° per-operatively, 12.8° ± 2.1° post-operatively and 11.6° ± 1.8° at final follow-up in group 1 and -1.8° ± 0.8° per-operatively, 7.3° ± 1.3° post-operatively and 5.0° ± 2.1° at final follow-up in group 2. There were statistical significance between per-operatively and post-operatively (t = -2.987 and -5.058, P < 0.05) and no statistical significance between post-operatively and final follow-up (P > 0.05) in both groups. To the mean segmental alignment there were 2.6° ± 0.8° per-operatively, 5.4° ± 1.0° post-operatively and 4.3° ± 0.9° at final follow-up in group 1 and -3.0° ± 0.8° per-operatively, 3.8° ± 1.3° post-operatively and 0.3° ± 2.8° at final follow-up in group 2. There were statistical significance between per-operatively and post-operatively in both groups (t = -3.829 and -4.086, P < 0.05) and between post-operatively and final follow-up in group 1 (t = 2.630, P < 0.05)but not in group 2 (P > 0.05).</p><p><b>CONCLUSIONS</b>The Bryan cervical disc prosthesis has a good mid-term outcome for maintaining sagittal alignment of overall cervical spine and the functional spinal unit. Long-term follow-up should be needed to assess the long-term functionality of the prosthesis.</p>

Young adult and giant cervical exostosis

Degenerative changes in the spine can result in the formation of osteophytes on the anterior surface of the cervical spine. Depending on their site, osteophytes can bring on clinical manifestations such as dysphagia, hoarseness, and stridor. We discuss an interesting case of a young adult patient who presented with dysphagia along with neck discomfort, and on investigation was found to be suffering from diffuse idiopathic skeletal hyperostosis. Here, we briefly portray the presenting features, radiographic findings, and management options

Terapia manual no tratamento da espondilólise e espondilolistese: revisão de literatura / Manual therapy for treating spondylolysis and spondylolisthesis: a literature review

A espondilólise é um defeito na pars interarticularis da vértebra com descontinuidade óssea do segmento intervertebral; a progressão do defeito resulta em deslizamento de uma vértebra sobre a outra, chamado espondilolistese, o que pode provocar dor. O tratamento não-cirúrgico é a escolha inicial na maioria dos casos de espondilolistese, mas poucos estudos verificam a eficácia dos tratamentos conservadores. O objetivo deste estudo foi realizar uma revisão da literatura sobre esses tratamentos, sobretudo no que concerne à terapia manual, a fim de ajudar os terapeutas na prescrição de intervenções eficazes. Os resultados mostram que tanto a terapia manual como a fisioterapia convencional apresentam efeitos benéficos na redução da dor lombar e na melhora funcional do paciente. As terapias manuais envolvem manipulação da coluna vertebral e articulação sacroilíaca, músculo-energia e alongamento dos músculos afetados. Exercícios de estabilização lombopélvica, fortalecimento dos músculos posturais e alongamento dos isquiotibiais e psoas também foram considerados importantes. O paciente deve ser avaliado individualmente em seu quadro clínico e radiográfico para determinação do plano de tratamento. Dentre as opções conservadoras de tratamento encontradas, nenhuma se mostrou conclusivamente superior às outras e todas podem ser incluídas no tratamento sintomático de pacientes com espondilólise/listese.

Spondylolysis is a defect in the pars interarticularis of a vertebra with a disruption in the intervertebral segment. Progression of the defect leads to one vertebra slipping over another - which is called spondylolisthesis - which may cause low-back pain. Non-surgical treatment is the initial course of action in most cases of spondylolisthesis. However, few studies have assessed the efficacy of conservative treatment. The purpose of the present study is to review literature on conservative treatment for spondylolysis/listhesis, especially manual therapy, in order to guide practitioners for effective intervention. Results show that both manual therapy and conventional physiotherapy were effective in relieving low-back pain and beneficial for patient's functional outcome. Manual therapy involved spine manipulation, sacroiliac joint manipulation, muscle-energy techniques and stretching affected muscles. Stabilizing lombopelvic exercises, postural muscles strengthening, and hamstring and psoas stretching were also considered important in treating spondylolysis/listhesis. Each case's clinical and radiological features must be individually considered in order to determinate therapeutic strategy. Among non-surgical options, none has proved better than others and all may be included in symptomatic treatment of patients with spondylolysis/listhesis.

Clinical validity of hinge position to expansive semi open-door laminoplasty / 中华外科杂志

<p><b>OBJECTIVE</b>To evaluate and compare the efficacy and clinical results of cervical expansive open door laminoplasty (EOLP) with different hinge position.</p><p><b>METHODS</b>From February 2006 to February 2007, a total of 102 cases with cervical spondylotic myelopathy were assessed in this randomized controlled trial. Fifty-seven patients underwent EOLP with the hinge located at the inner margin of the lateral mass classified as wide-open group. Forty-five cases who underwent EOLP with the hinge positioned at the lamina margin served as narrow-open group. The clinical results and radiological examinations of both groups were evaluated 24 months after surgery.</p><p><b>RESULTS</b>There were no significant differences in operation time, bleeding quantity and recovery rate of Japanese Orthopaedic Association (JOA) scores. The incidence of C(5) palsy and severity of axial symptoms in the wide-open group were significantly lower than those in the narrow-open group (P < 0.05). There were no significant differences in cervical curvature index and range of motion between the two groups.</p><p><b>CONCLUSIONS</b>Well-suited and appropriated inwardly shift the hinge could promote clinical outcomes after EOLP, especially decrease the incidence of the C(5) palsy and the severity of axial symptom, but it is contraindication for patients with ossification of posterior longitudinal ligament, ossification of ligament flavum and fluorosis cervical stenosis.</p>

Combined posterior and anterior approaches for the treatment of cervical spondylotic myelopathy / 中国骨伤

<p><b>OBJECTIVE</b>To explore the efficacy of one stage or staging treatment of cervical spondylotic myelopathy through combined posterior and anterior approaches.</p><p><b>METHODS</b>From June 2001 to October 2008, 45 patients with pinching cervical spondylotic myelopathy and developmental stenosis of cervical spinal canal were decompressed through combined posterior and anterior approaches in one stage or staging operation. Among the patients, 35 patients were male and 10 patients were female, ranging in age from 45 to 72 years, with an average of 53 years. Five patients were decompressed through combined posterior and anterior approaches in one-stage operation, and other 40 patients were treated in staging operation. All the patients were treated with open-door posterior cervical expansive laminoplasty and anterior decompression, bone graft and titanium plate internal fixation. JOA scores were used to evaluate the therapeutic effects at the 3rd month and one year after operation.</p><p><b>RESULTS</b>After the treatment, 44 patients were followed up from 13 to 62 months, with an average of 30 months. One patient was dead of lung infection at the 21th day after operation. The nerve root palsy of C5 was found in 3 cases. One patient had postoperative hoarseness. Axial symptoms were found in 14 cases. Two patients had donor site complications. There were no screws broken or back out, no screw loosening, no moving or sinking of bone block or Ti-net, no door re-closer and cervical deformity. Forty-four patients got spinal fusion. According to JOA score criteria: the average preoperative JOA score was (9.36 +/- 2.24) points, JOA score was (12.34 +/- 2.64) points in 3 months after operation, (12.77 +/- 2.61) points in one year after operation. Among 44 cases, 16 got an excellent result, 19 good, 6 fair, 3 invalid. There were statistically differences between preoperative score and 3 months or one year after operation.</p><p><b>CONCLUSION</b>Decompression through combined posterior and anterior approaches for the treatment of pinching cervical spondyoltic myelopathy and developmental stenosis of cervical spinal canal has good efficacy, as well as a safety operation method. The operation method with one or staging decompression through combined anterior and posterior approach should be chosen according to the conditions of the patients and the operations. Anterior decompression, bone graft and titanium plate internal fixation could restore the height of vertebral body effectively and prevent fusion complication.</p>

Análise radiológica da degeneração discal experimental em coelhos / Radiological analysis of experimental disc degeneration in rabbits

OBJETIVO: Validar a avaliação radiográfica da degeneração discal experimental em coelhos. MÉTODOS: Os discos intervertebrais lombares de coelhos New Zealand foram puncionados três vezes com uma agulha 18G com profundidade limitada de 5mm, através de abordagem lateral. Foram realizadas radiografias seriadas pré e pós-operatórias imediatas, e depois de quatro, oito e 12 semanas do procedimento, com posterior análise da altura discal, formação de osteófito, esclerose da placa vertebral e presença de degeneração discal. A análise estatística dos dados foi validada pelo coeficiente de concordância Kappa, com intervalo de confiança (IC) de 95 por cento. RESULTADOS: Observou-se diminuição significativa do espaço discal nas radiografias em AP após 12 semanas de pós-operatório, com Kappa = 0,489 para IC 95 por cento (0,25-0,72) com p < 0,001. Os sinais radiográficos de degeneração discal também apresentaram valor de Kappa = 0,63 para IC 95 por cento (0,39-0,86) com p < 0,001. Os demais critérios avaliados tiveram resultados positivos, porém, com menor valor de Kappa. CONCLUSÃO: O modelo de degeneração discal em coelhos proposto neste estudo mostrou-se factível, com correlação radiológica positiva entre as imagens pré e pós-operatórias, validando a possibilidade de indução de degeneração discal nesse modelo animal para futuros estudos.

OBJECTIVE: To validate radiographic evaluation of a rabbit model for disc degeneration. METHODS: Lumbar intervertebral discs of New Zealand rabbits were stabbed three times with a 18G needle at a limited depth of 5mm, through lateral approach. Serial radiographic images were taken on the early pre-and postoperative periods, and after four, eight and 12 weeks of the procedure, with subsequent analysis of disc height, osteophyte formation, endplate sclerosis, and presence of disc degeneration. The statistical analysis of data was validated by the Kappa coefficient, with a confidence interval (CI) of 95 percent. RESULTS: A significant reduction of disc space was found on AP X-ray images after 12 postoperative weeks, with Kappa = 0.489 for CI 95 percent (0.25-0.72) with p < 0.001. X-ray signs of disc degeneration also presented Kappa = 0.63 for CI 95 percent (0.39-0.86) with p < 0.001. The remaining assessed criteria showed positive results, but with a lower Kappa value. CONCLUSION: The disc degeneration model using rabbits as proposed in this study was shown to be feasible, with positive X-ray correlation between pre- and postoperative images, validating the potential to induce disc degeneration in this animal model for future studies.

Anterior decompression for the treatment of cervical spondylotic myelopathy associated with ossification of posterior longitudinal ligament / 中华外科杂志

<p><b>OBJECTIVE</b>To study the technique and effect of anterior decompression for the treatment of cervical spondylotic myelopathy associated with ossification of posterior longitudinal ligament (OPLL).</p><p><b>METHOD</b>Sixty-one patients (42 male and 19 female, 45 - 74 years with mean age of 57 years old) underwent anterior decompression for the treatment of cervical spondylotic myelopathy associated with OPLL. Among them, OPLL was definitely diagnosed in 49 patients preoperatively, and was found during the operation in the other 12 patients. The occupying rate of OPLL ranged 32%-70% with an average of 52%. The preoperative JOA scores ranged 4 - 14 points with an average of 9.6 points. In additional to conventional decompression, the ossification was removed completely after discectomy and corpectomy.</p><p><b>RESULTS</b>Corpectomy was performed in 41 cases, discectomy in 6 cases and combination of corpectomy and discectomy in 14 cases. The follow-up of all patients ranged from 6 to 36 months (mean 16 months). The postoperative JOA scores ranged 8-16 points with an average of 12.8 points. The neurological improvement rate ranged from 25.0% to 87.5% with an average of 65.2%. The transient leakage of cerebrospinal fluid (CSF) occurred in 5 cases, and stopped after conservational treatment. No neurological deterioration developed.</p><p><b>CONCLUSIONS</b>The difficulty and risk of anterior decompression are significantly increased in the patients with cervical spondylotic myelopathy associated with OPLL. Remove of ossification after corpectomy and discectomy could provide complete decompression and better results.</p>

Correlation between increased spinal cord signal intensity on T2-weighted MRI and clinical prognosis of compressive cervical myelopathy / 南方医科大学学报

<p><b>OBJECTIVE</b>To analyze the correlations between increased spinal cord signal intensity on magnetic resonance images (MRI) and the clinical prognosis of compressive cervical myelopathy.</p><p><b>METHODS</b>Sixty-six patients with cervical spondylotic myelopathy underwent surgeries through the anterior approach. In all the patients, the diagnoses were established on the basis of both neurological examination and MRI findings that showed spinal cord compression. The patients were divided into two groups according to preoperative MRI, namely isointense MRI T1/T2 signal group and iso/hyperintense MRI T1/T2 group. The JOA scores of the patients were evaluated before and at 6 and 12 months after the operation.</p><p><b>RESULTS</b>The patients were followed up for 12 to 38 months after the operation (mean 21 months), and no statistically significant difference were found in the pre- and postoperative JOA scores between the two groups (P>0.05).</p><p><b>CONCLUSION</b>The peoperative hyperintense signals on T2 weighted MRI does not correlate to the prognosis of patients with compressive cervical myelopathy, who may also have favorable clinical outcomes after the operation.</p>

Incidência de osteófitos na coluna vertebral / Osteophyte incidence on vertebral column

Ao longo do processo de evolução o homem adquiriu a postura ereta. Devido à ação da gravidade surgiram algumas complicações decorrentes dessa postura; entre elas o aparecimento de osteófitos. O objetivo do presente estudo foi verificar a incidência de osteófitos em exames laudados da coluna vertebral e qual a região da coluna mais acometida. Para isso foram utilizados 1089 laudos de 636 indivíduos, sendo 55,5% mulheres e 44,5% homens, atendidos em um intervalo de 6 meses, de janeiro a junho de 2006 em uma Clínica de Radiologia particular do Alto Tietê. Os resultados encontrados foram que dos laudos,26,9% foram considerados anormais. Das três regiões da coluna vertebral, foram encontrados osteófitos respectivamente para mulheres e homens: 15,4% e 5,7% região cervical; 13,6% e 12,4% região torácica e 17,9% e 13,7% região lombar. O grau de osteófito mais encontrado foiosteófito marginal para as regiões cervical e lombar e labiação marginal predominou na região torácica. Concluiu-se que a incidência de osteófitos do total de laudos analisados foi 26,9% ea região da coluna mais acometida foi a lombar. Além disso, as mulheres apresentaram mais casos de osteófitos que homens.

With the evolution of mankind appeared the erect posture. Due to gravity actioncomplications appeared because of this posture, like the osteophytes. The aim of this study was to investigate osteophyte incidence on vertebral column and the most affected column region. For this were used 1089 reports of 636 patients: 55.5% women and 44.5% men, attended between january and june of 2006 in a privet Clinic on Alto do Tietê, region of São Paulo. Resultsrevealed that 26.9% of reports had alterations. Region’s analysis revealed osteophytes in men and women, respectively: 15.4% and 5.7% on cervical region; 13.6% and 12.4% on thoracic region and 17.9% and 13.7% on lumbar region. The most common kind of osteophyte was marginal osteophyte on cervical and lumbar regions and marginal labium was predominant on thoracic region. The incidence of osteophytes on vertebral column was 26.9% and lumbar region was the most affected. Besides, women have more osteophytes cases than men.

Surgery for cervical spondylotic myelopathy: anterior versus posterior approaches

Surgical treatment of cervical spondylotic myelopathy [CSM] remains controversial. Several approaches have been advocated to treat cervical spondylotic myelopathy including anterior, posterior and combined approaches. The aim of this study was to review the clinical and imaging varieties of cervical spondylotic myelopathy and their influence on choosing the appropriate surgical approach. Fifty five cases with cervical spondylotic myelopathy operated upon at the neurosurgery department, Alexandria University were reviewed. The different clinical and imaging features were analyzed, and parameters for choice of surgical approach were addressed. Among all patients with CSM, neck pain was present in 49%, brachialgia in 67%, mild myelopathy in 44% and moderate myelopathy in 56%. Following cervical laminectomy, neck pain improved in 50% and remained stationary in 50%; brachialgia recovered in 33%, improved in 50% and remained stationary in 17%; mild myelopathy showed good outcome in 80% and fair outcome in 20%; whereas moderate myelopathy showed good outcome in 20%, fair outcome in 60% and poor outcome in 20%. Following anterior discectomy with fusion, neck pain recovered in 28.5%, improved in 38% and remained stationary in 28.5%; brachialgia recovered in 58.5%, improved in 31% and remained stationary in 10.5%; mild myelopathy showed excellent outcome in 17%, good outcome in 58% and fair outcome in 25%; whereas moderate myelopathy showed good outcome in 35%, fair outcome in 30% and poor outcome in 35%. Following cervical laminoplasty, neck pain improved in 100%; brachialgia remained stationary in 100%; mild myelopathy showed good outcome in 100%; whereas moderate myelopathy showed fair outcome in 50% and poor outcome in 50%. Early surgical intervention for CSM is associated with higher recovery rate. Selection of surgical approach depends on age, cord morphology, and spine geometry mostly spinal curve and canal diameter. The presense of cervical spine instability necessitates complementation of spine decompression with spine fixation

Clinical outcomes of single level Bryan cervical disc arthroplasty: a prospective controlled study / 中华外科杂志

<p><b>OBJECTIVE</b>To compare the clinical outcomes of single level Bryan cervical disc replacement with traditional anterior cervical discectomy and fusion (ACDF).</p><p><b>METHODS</b>From Dec 2003 to May 2005, 59 patients with primary, single-level cervical radiculopathy and/or myelopathy were prospectively randomized into 2 groups: Bryan group with artificial disc replacement and ACDF group with traditional anterior cervical discectomy and fusion. Operation time, blood loss and hospitalization duration were compared between the 2 groups. Follow-up was taken at six weeks, 3, 6, 12 and 24 months after operation, and each case in both groups was evaluated with serial radiographic studies, neck disability indices (NDI), visual analog scale scores (VAS) for arm and neck pain.</p><p><b>RESULTS</b>No difference was found in the operation time, intraoperative blood loss and hospital stay between the 2 groups. But at the follow-up of 6 weeks and 3 months after operation, significant difference in NDI and VAS of neck pain existed. All replaced segments remained normal range of motion in sagittal rotation, while no motion occurred in any of the fusion segments. In ACDF group movement of the whole cervical spine decreased but gradually recovered to preoperative level in 6 months after operation. In Bryan group, pre- and postoperative motion of the whole cervical spine remained unchanged at any of the follow-up time.</p><p><b>CONCLUSIONS</b>Bryan disc replacement can achieve similar clinical improvement compared with traditional ACDF. Arthroplasty has the advantages of motion maintenance for the cervical spine and short recovery time after operation.</p>

The application of cervical spine arthroplasty with Bryan disc and mid-term clinical and radiological follow-up results / 中华外科杂志

<p><b>OBJECTIVE</b>To study the clinical and radiological outcome of Bryan cervical disc replacement and the degenerative status on adjacent segments.</p><p><b>METHODS</b>The data of 26 cases of single level disc replacement with minimal 2 years follow-up were reviewed. CLINICAL OUTCOME was assessed with the JOA 17 score scale and Odom's score. Radiological assessment including range of motion and heterotopic ossification of operated level were recorded. Adjacent level degeneration on X-ray and MRI scan at baseline and at follow-up were compared.</p><p><b>RESULTS</b>(1) CLINICAL OUTCOME: the average JOA score was 16 with 84% improvement ratio at final follow-up in 18 cases of cervical myelopathy. Eight cases of radiculopathy were fully recovered. According to the Odom's criteria 15 cases had an excellent outcome, 7 good, 4 fair, and no case of poor result. (2) On X-ray: The range of motion (ROM) at operated level was 6.9 degrees (2 degrees-12 degrees) at baseline and 7.8 degrees (1 degree-14 degrees) at final follow-up. The heterotopic ossification around the prosthesis was observed in 7 cases and only 1 case lost movement. The average ROM was 5.3 degree in other 6 cases. There was no obvious change of disc height at adjacent levels. (3) On MRI: There was no deterioration of disc degeneration at adjacent levels at final follow-up according to Pfirrmann's classification. There was no further ligamentum flavum impingement into spinal canal observed at adjacent levels but the disc movement slightly increased at both upper and lower adjacent level at final follow-up.</p><p><b>CONCLUSIONS</b>The motion at operated level is preserved after minimal 2 years Bryan disc replacement with satisfied clinical outcome. The deterioration of disc degeneration at adjacent levels may be postponed.</p>

Functional evaluation of the cervical spine after Bryan artificial disc replacement / 中华外科杂志

<p><b>OBJECTIVE</b>To assess the effect of Bryan cervical disc replacement on the function of the cervical spine.</p><p><b>METHODS</b>Bryan cervical artificial disc replacement was performed in 164 cases from Dec 2003 to Aug 2007, and all the cases were retrospectively followed up. Among them, 1 disc replacement was done in 132 cases, 2 discs in 28 cases and 3 discs in 4 cases with a total number of 200 artificial discs. There were 102 male patients and 62 female patients. Their age ranged from 25 to 70 years old (with an average of 47 years old). All the cases were operated according to the standard procedure for Bryan artificial disc replacement, and immobilized in a cervical collar for 2 weeks after operation. Motion of the replaced disc in sagittal direction, JOA score and satisfaction rate of the patients were followed up and evaluated.</p><p><b>RESULTS</b>In this group, no acute complications happened during the operation. All patients returned to work 4 to 6 weeks after operation. The postoperative ameliorate rate of JOA score was 56%. Range of motion in sagittal direction of the operated disc was 14.4 degrees before operation, decreased to 5.7 degrees at 1 week after operation , but improved to 14.7 degrees at the time of final follow-up and was not significantly different from preoperative range. Motion in the upper adjacent disc to the replacement level was 10.9 degrees before operation, decreased to 5.5 degrees at 1 week after operation , and improved to 8.2 degrees at the time of final follow-up but was significantly smaller than preoperative range. The satisfaction rate of the patients was 94%. Loosening of the prosthesis happened in 1 case 6 months after operation but remained stable afterwards. Subsidence up to 1 mm occurred in another case 7 months after operation but also remained stable afterwards. Automatic posterior union occurred in 3 cases in which relative small size artificial discs were implanted.</p><p><b>CONCLUSIONS</b>The clinical outcome of Bryan artificial disc replacement was quite good. Pre-operative range of motion of the cervical spine can be maintained.</p>