New methods for diagnosing lumbar foraminal stenosis using dynamic digital tomosynthesis radiculography

The symptoms of lumbar radiculopathy, in particular foraminal stenosis, often exacerbated when the patient is upright. However, it is difficult to detect the compression of nerve roots while the patient is upright using conventional MRI. In this study, we analyzed the compression of lumbar nerve roots using dynamic digital tomosynthesis radiculography (DTRG) in patients diagnosed with lumbar radiculopathy. And we determined the relationship between leg pain and nerve compression while the patients are either prone or upright. We evaluated 30 patients with unilateral leg pain diagnosed as lumbar radiculopathy by physical examination and MRI. The patients were divided in two groups, one with foraminal stenosis (17 patients) and the other with canal stenosis (13 patients), based on MRI findings. All patients underwent DTRG to determine the diameter of their nerve roots in the foramen while prone and upright. Pain while prone or upright was assessed using a 100-point visual analogue scale (VAS) questionnaire. The VAS for leg pain while upright was significantly higher in the foraminal stenosis group (58 ± 24.7) than it was in the canal stenosis group (19.6 ± 13.2; p = 0.0002)). The nerve root diameter while prone or upright was significantly smaller in the foraminal stenosis group (1.2 ± 0.2 mm) than it was in the canal stenosis group (0.2 ± 0.1 mm; p < 0.0001). DTRG has the potential to visualize nerve compression while the patient is upright to reveal the relevance of foraminal stenosis to clinical findings. DTRG is useful for diagnosis of lumbar foraminal stenosis.     

A rare anatomical variation of the C7 pedicle and intraspinal course of the C7 nerve root

We report a 58 year old man who presented with severe C7 radiculopathy which failed to respond to conservative measures. Subsequent CT and MR imaging of his cervical spine demonstrated C6/7 foraminal stenosis as well as unusual low take-off of the C7 nerve root in relation to a congenital low-set C7 pedicle, findings which were subsequently confirmed intra-operatively. The relevance of the bony and neural anatomy is described and its implications for surgical management are discussed. To our knowledge, this anatomical anomaly has not been previously highlighted in the published English literature.     

Prospective study of anterior cervical microforaminotomy for cervical radiculopathy.

Cervical radiculopathy caused by a posterolateral disc herniation or spondylosis is a common pathology. Decompression of a stressed cervical nerve root is a routine neurosurgical procedure. To determine the safety and effectiveness of anterior cervical microforaminotomy (ACM), we prospectively studied patients undergoing this treatment at our institution to determine the efficacy of the approach for the treatment of unilateral cervical spondylotic or discogenic radiculopathy. Twenty-five patients were treated with ACM and were followed up for 15-40 months. Clinical signs, neurological results, and complications were recorded. Radiological imaging studies for measurement of post-operative changes were performed to evaluate spinal stability and effectiveness of the ACM procedure. We used MRI, axial cervical CT and reconstructive sagittal cervical CT to assess foraminal decompression. Eight men and 17 women (mean age 51.8 years) were included in this study. Nineteen patients had a single ACM, and six underwent procedures at adjacent 19 levels. The ACM procedure involves microsurgical removal of the lateral portion of the uncinate process to identify the nerve root. Post-operatively, none of the patients' conditions had worsened symptomatically or neurologically. A positive outcome at last follow-up examination was achieved in all patients. The visual analoge scale pain rating was 6.36 pretreatment and 0.64 after 1 year (p<0.0001). ACM appears to be a good alternative procedure, and a good non-fusion disc-preserving technique. Disc and bone resections are minimal in carefully selected patients with unilateral cervical radiculopathy. This method avoids osteoarthrodesis or arthroplasty with disc prostheses.     

Combined upper cervical canal stenosis and cervical ossification of the posterior longitudinal ligament resulting in myelopathy: A case series and literature review

Combined upper cervical canal stenosis and cervical ossification of the posterior longitudinal ligament (OPLL) is an under-recognized disorder. The objective of the present study was to investigate the radiological manifestations and surgical outcomes of this disease combination. Between May 2011 and July 2014, we studied the radiological manifestations of 18 cases of combined upper cervical canal stenosis and cervical OPLL. Appropriate decompression procedures were performed and the clinical outcomes were evaluated using a visual analog scale (VAS) and the Japanese Orthopedic Association (JOA) scoring system. Radiological outcomes, including the space available for the spinal cord (SAC) at the cephalad-adjacent level, occupying ratio of OPLL, and cervical sagittal alignment, were measured. We found that the etiologies of upper cervical canal stenosis included craniovertebral junction deformity, atlantoaxial subluxation, and OPLL extending to the C2 level. The radiological features of OPLL varied. Postoperatively, all patients showed evidence of improvement in their VAS and JOA scores. The radiological results were satisfactory in terms of the SAC at the cephalad-adjacent level, occupying ratio of OPLL, and cervical alignment. We found that the radiological manifestations of combined upper cervical canal stenosis and cervical OPLL varied among patients. Satisfactory results can be achieved by applying appropriate decompression techniques.     

Bilateral decompression of multilevel lumbar spinal stenosis through a unilateral approach.

Lumbar canal stenosis due to hypertrophy and calcification of the facet joints and/or ligamentum flavum is a common condition in the elderly. Although a large number of individuals are symptom-free, the degenerative process, usually encroaching on both central and lateral pathways, may lead to symptoms of itself or decompensate a preexisting narrow canal. Even at an advanced age, decompression surgery is effective for symptomatic stenosis. Less invasive procedures preserving maximal bony and ligamentous structures have recently been recommended to reduce associated morbidity. This paper introduces a unilateral surgical approach for bilateral decompression by ligamentectomy, partial facetectomy and foraminal unroofing. Using a specially designed, one-side retractor, after the ipsilateral nerve root decompression the contralateral dural sac and nerve roots were approached through an 8 x 15 mm window in the interspinous ligament. The contralateral ligamentum flavum, facet joints and foraminal roof were resected, preserving the supraspinous ligament complex and much of the contralateral musculature. This technique, preserving anatomy and biomechanical function of the lumbar spine, is useful for surgery on multilevel lumbar canal stenoses.     

Microsurgical anterior cervical foraminotomy in spondylogenous cervical radiculopathy

The authors present the results of microsurgical anterior cervical foraminotomy used in unilateral cervical radiculopathy caused by lateral disc herniation or foraminal stenosis. In 2000 to 2006, anterior cervical foraminotomy was performed at one or two adjacent levels in 44 patients (27 males and 17 females aged 18 to 64 years (mean age 43 years)) with cervical radiculopathy and myelopathy. All the patients underwent pre- and postoperative computed tomography, magnetic resonance imaging, and functional X-ray study. The surgical technique permitted anterior decompression of the affected nerve root from the site of its formation to the vertebral artery, by maintaining the stability and mobility of the involved vertebral segments. The immediate postoperative period was marked by excellent results with regression of radicular syndrome in 84% of the patients and by good results in 16%. A late (6-month-to-6-year) follow-up showed excellent (78%) and good (22%) results without additional surgery. The findings indicate that anterior cervical foraminotomy is an effective technique of nerve root decompression in patients with lateral disc herniation or foraminal stenosis.     

Posterior Cervical Inclinatory Foraminotomy for Spondylotic Radiculopathy Preliminary

Posterior cervical foraminotomy is an attractive therapeutic option in selected cases of cervical radiculopathy that maintains cervical range of motion and minimize adjacent-segment degeneration. The focus of this procedure is to preserve as much of the facet as possible with decompression. Posterior cervical inclinatory foraminotomy (PCIF) is a new technique developed to offer excellent results by inclinatory decompression with minimal facet resection. The highlight of our PCIF technique is the use of inclinatory drilling out for preserving more of facet joint. The operative indications are radiculopathy from cervical foraminal stenosis (single or multilevel) with persistent or recurrent root symptoms. The PCIFs were performed between April 2007 and December 2009 on 26 male and 8 female patients with a total of 55 spinal levels. Complete and partial improvement in radiculopathic pain were seen in 26 patients (76%), and 8 patients (24%), respectively, with preserving more of facet joint. We believe that PCIF allows for preserving more of the facet joint and capsule when decompressing cervical foraminal stenosis due to spondylosis. We suggest that our PCIF technique can be an effective alternative surgical approach in the management of cervical spondylotic radiculopathy.     

Three‐tesla magnetic resonance neurography of the brachial plexus in cervical radiculopathy

Introduction: There have been no reports of the use of 3‐Tesla magnetic resonance neurography (3T MRN) to characterize cervical radiculopathy. In particular, there are no reports of MRN of brachial plexus involvement in patients with cervical radiculopathy. Methods: We reviewed retrospectively 12 consecutive patients with cervical radiculopathy who underwent 3T MRN. Results: The median age was 54.5 years. Eleven of 12 patients were men. The distribution of nerve‐root signal abnormality was correlated with intervertebral foraminal stenosis and the presence of muscles that exhibited weakness and/or signs of denervation on electromyography. MRN abnormalities were found to extend into the distal part of the brachial plexus in 10 patients. Conclusion: This study demonstrates that MRN is potentially useful for diagnosis in patients with suspected cervical radiculopathy. Moreover, the finding of brachial plexus involvement on MRN may indicate a possible pathophysiological relationship between cervical radiculopathy and brachial plexopathy. Muscle Nerve 52:392–396, 2015     

Cervical root stimulation in the diagnosis of radiculopathy

Cervical root stimulation (CRS) was compared with conventional EMG, nerve conduction, and late response studies in 34 patients with possible cervical radiculopathy. Cervical roots were stimulated by monopolar needles inserted into paraspinal muscles, recording compound muscle action potentials in biceps, triceps, and abductor digiti minimi muscles. In 18 patients with clinical evidence of radiculopathy, EMG was abnormal in 11 (61%), but CRS was abnormal in all 18. Of 16 patients with symptoms but no signs of radiculopathy, EMG was abnormal in 5 (31%) and CRS was abnormal in 9 (56%).     

经颅硬膜外入路骨纤维发育不良性视神经管狭窄减压术疗效分析

目的 探讨视神经管狭窄减压术治疗累及视神经管的骨纤维发育不良的机制、方法、效果及时机.方法 对18例以每侧眼为单位患者行视力、CT、眼底像、OCT检查,手术组21侧行经颅硬膜外入路,其中19侧切除视神经管上壁、外侧壁和内壁病变,另有2侧切除视神经管眶口病变;非手术组15侧随访,其中1侧视力下降后手术.对不同组的视力变化进行非参数检验.结果 治疗性手术组15侧,视力有效率14/15,预防性手术6侧,视力不变(P=0.012),视神经管再次狭窄5侧,其中视力下降1侧(P=o.080).OCT改变符合筛板压力失衡原理.结论 在筛板压力失衡原理指导下,采取经颅硬膜外入路切除视神经管上壁、外侧壁和内壁病变,预防视神经二次损伤效应,可以改善和稳定视力.     

脊髓型颈椎病合并胸椎管狭窄症的诊断与治疗

目的：探讨脊髓型颈椎病合并胸椎管狭窄症的诊断与治疗。方法：回顾性分析4例脊髓型颈椎病合并胸椎管狭窄症的诊断与治疗。其中2例先行颈椎减压和稳定手术，后行胸椎板切除减压术；1例颈、胸椎同时行减压；1例先行胸椎板切除减压术，后行颈椎板成形术。结果：神经病学损害完全恢复2例，明显改善2例。结论：脊髓型颈椎病合并胸椎管狭窄症手术治疗可取得良好的效果。     

Degenerative cervical radiculopathy: diagnosis and conservative treatment. A review

Degenerative cervical radiculopathy: clinical diagnosis and conservative treatment. A review. To provide a state-of-the-art assessment of diagnosis and non-surgical treatment of degenerative cervical radiculopathy a literature search for studies on epidemiology, diagnosis including electrophysiological examination and imaging studies, and different types of conservative treatment was undertaken. The most common causes of cervical root compression are spondylarthrosis and disc herniation. Diagnosis is made mainly on clinical grounds, although there are no well-defined criteria. Provocative tests like the foraminal compression test are widely used but not properly evaluated. The clinical diagnosis of degenerative cervical radiculopathy can be confirmed by magnetic resonance imaging. The role of electromyography is mainly to rule out other conditions. Cervical radiculopathy is initially treated conservatively, although no treatment modality has been evaluated in a randomized controlled trial. Degenerative cervical radiculopathy: diagnosis and conservative treatment. A review.     

脊髓型颈椎病患者骨密度变化与椎体变形及临床表现的相关性

目的：分析脊髓型颈椎病患者骨密度变化与椎体变形及与临床表现的相关性。 方法：选择2009-01/06在安徽医科大学第一附属医院运动医学科住院的脊髓型颈椎病患者42例,分为骨密度正常组20例,骨密度降低组22例,所有病例测量颈椎侧位片C3~6 的椎管椎体矢状径比、椎体变形指数,并作两组之间临床表现的比较。 结果：两组比较,骨密度降低组颈椎(C3,C4,C5,C6)椎管矢状径比值较骨密度正常组显著降低(P < 0.05或P < 0.01),而颈椎 (C3,C4,C5,C6)椎体变形指数在两组之间则差异无显著性意义(P > 0.05)。骨密度降低组临床症状与体征阳性率显著高于骨密度正常组(P < 0.05)。 结论：脊髓型颈椎病患者骨质疏松会导致椎体骨质增生,椎管狭窄,而骨密度降低患者临床表现更明显。     

Long-Term Outcome of Posterior Cervical Inclinatory Foraminotomy

ObjectiveA modified surgical technique of posterior cervical foramintomy called posterior cervical inclinatory foraminotomy (PCIF) was introduced in previous preliminary article. PCIF allows better preservation of facet joint and capsule than conventional techniques. The authors conducted a study to investigate long-term outcomes of PCIF.MethodsWe retrospectively reviewed demographic, radiologic, and clinical data from the patients who underwent PCIFs at our institution. Criteria included a minimum of 48 month follow-up and PCIFs for patients with radiculopathy from foraminal stenosis (C2–T1; single or multilevel) with persistent or recurrent root symptoms despite conservative treatment for more than 3 months. Patients who had undergone previous cervical operation were excluded. The visual analogue scale (VAS) score was used for clinical follow-up, and radiologic follow-up was performed to compare the changes of cervical sagittal alignment, focal angle and disc-space height of treated segment.ResultsThe PCIFs were performed between April 2007 and March 2011 on 46 patients (32 males and 14 females) with a total of 73 levels affected. The average duration of follow-up was 74.4 months. Improvements in radiculopathic pain were seen in 39 patients (84.7%), and VAS score decreased from 6.82±1.9 to 2.19±1.9. Posterior neck pain also improved in 25 patients (71.4%) among 35 patients, and VAS score decreased from 4.97±2.0 to 2.71±1.9. The mean disc-space heights of treated segment were 5.41±1.03 mm preoperatively and decreased to 5.17±1.12 mm postoperatively. No statistically significant changes in cervical sagittal alignment, focal angle were seen during the follow-up period (Cox proportional hazards analysis and Student t-test, p>0.05).ConclusionThe PCIF is highly effective in treating patients with cervical spondylotic radiculopathy, leading to long-lasting relief in pain. Long-term radiologic follow-up showed no significant spinal angular imbalance.     

枕下远外侧入路骨性结构解剖学研究

目的以枕下远外侧入路探讨枕骨大孔区解剖学特征,为利用该入路手术提供形态学基础。方法在成人干颅骨标本(30个、60侧)上对与远外侧入路相关的重要骨性结构进行观察并测量。结果 1例标本枕骨大孔前缘出现骨赘生物,枕骨大孔前后径距离减少,舌下神经管和矢状面的角度是双侧对称的,1例不对称情况的存在,4例舌下神经管中间出现骨柱。从枕髁后缘中点到舌下神经管后缘平均长度为(10.32±2.08)mm。后髁管大多数双侧存在,出现率左侧80.00%右侧90.00%。结论熟悉远外侧入路相关的重要骨性结构特点及数据有利于术中保护重要的神经和血管。     

Simultaneous MR neurography and apparent T2 mapping of cervical nerve roots before microendoscopic surgery to treat patient with radiculopathy due to cervical disc herniation: Preliminary results

There is no imaging modality to quantitatively evaluate compressed cervical nerve roots in cervical radiculopathy. Here we sought to evaluate the usefulness of simultaneous apparent T2 mapping and neurography with nerve-sheath signal increased with inked rest-tissue rapid acquisition of relaxation-enhancement imaging (SHINKEI-Quant) to evaluate compressed nerves quantitatively in patients with cervical radiculopathy due to cervical disc hernia before microendoscopic surgery.One patient with cervical radiculopathy due to cervical disc hernia before microendoscopic surgery and 5 healthy subjects underwent simultaneous apparent T2 mapping and neurography with SHINKEI-Quant. The patient was a 49-year-old man with severe right upper arm pain and numbness. Based on MRI images, we suspected right C7 radiculopathy due to C6-7 cervical disc hernia. The T2 relaxation times of the cervical dorsal root ganglia of the brachial plexus bilaterally at C5–C8 were measured.We observed no significant differences in T2 relaxation times between the nerve roots on the left and right at each spinal level with values in healthy subjects. In our patient, neurography revealed swelling of the right C7 nerve, and a prolonged T2 relaxation time compared with that of the contralateral, unaffected C7 nerve. We performed microendoscopic surgery and the symptoms improved.We were able to evaluate the injured nerve root quantitatively in a patient with cervical radiculopathy using the SHINKEI-Quant technique, being the first study to our knowledge to show the usefulness of this technique to evaluate cervical radiculopathy quantitatively before microendoscopic surgery.     

椎管内肿瘤术中应用钛板行椎管重建

目的探讨椎管内肿瘤术中应用钛板固定椎板棘突复合体、重建椎管完整性的手术方法。方法回顾性分析总结2005年3月至2007年2月间12例椎管内肿瘤患者术中采用椎管后路开窗,钛板固定游离的椎板棘突复合体,重建椎管后部结构的手术方法的可行性和安全性。结果所有患者均未出现因铣刀椎管开窗、钛板置入所致的硬脊膜破损、脊髓和脊神经根损伤、局部异常积液等并发症。随访2-13个月,未见置入材料脱落、移位;无重建的椎板棘突复合体向椎管内塌陷、椎管后凸畸形、医源性椎管狭窄症。9例X线检查显示截骨断面完全或部分骨性融合,骨枷形成。结论椎管内肿瘤术中采用钛板固定重建椎管后柱骨性结构的方法简便、安全、可靠,可实现理想的解剖复位,避免椎板切除相关并发症的发生。     

SENSORY MANIFESTATIONS IN CHARCOT-MARIE-TOOTH DISEASE

We followed up a woman, aged 58, presenting with difficulty in fine finger movements, moderate-to-severe strength deficit at right thumb opposition, and ipsilateral thenar and hypothenar atrophy, but no pain or loss of sensibility. A series of electromyograms performed between November 1996 and June 1997 pointed to motor polyneuropathy with conduction block. Lumbar puncture was negative and routine blood chemistry showed erythrosedimentation rate to oscillate between normal and increased values. Antinuclear and antiendomysium autoantibodies were present, but anti-GM1 autoantibodies were negative. Cervical CT scan showed right C5-C6 and C6-C7 foraminal stenosis supported by joint hypertrophy.
The patient was subjected to intravenous immunoglobulin infusion and gluten-free diet with no improvement. Subsequent clinical follow up and electromyograms showed no conduction block or multiple motor involvement. A suspected diagnosis of round pronator syndrome was ruled out by neurophysiological data, clinical examination, and history. X-ray with oblique projections and magnetic resonance imaging confirmed CT data. Currently, the same localised deficits persist, with no extension to other districts; a mild improvement was seen after kinesiotherapy.
This case was complicated by initial misdiagnosis of neuropathy of immunological origin, due to overestimation of nonspecific or isolated laboratory data. In this case, simply focusing on X-ray data and greater attention to clinical examination and reported symptoms allowed a correct diagnosis of "simple" cervical radiculopathy.     

Acute cervical cord injuries in patients with epilepsy.

Seven cases with acute cervical cord lesions associated with a fit and fall, were found in approximately 500 patients with epilepsy over a period of 7 years. In all patients the epilepsy was refractory to drug therapy and six suffered tonic fits which resulted in falls and frequent head injuries. Notable radiological changes were found in the cervical spine; there was ankylosis in five, hyperostosis in four and the minimum sagittal diameter of the bony canal was less than 11mm in three cases. The findings indicate that repetitive trauma may be a factor in producing bony changes in the cervical spine which put the patient at risk of cervical cord injury, especially when the spinal canal is developmentally narrow.     

A case of neurolymphomatosis diagnosed with FDG-PET]

A 38-year-old man with non-Hodgkin's lymphoma presented with hypesthesia and muscle weakness in the left upper limb. A lack of F-waves in left median and ulnar nerve conduction studies suggested a lesion at the proximal segments of the peripheral nerves, such as the left brachial plexus or nerve roots. Cervical magnetic resonance imaging revealed no lesions compressing nerve roots or peripheral nerves. Small and obscure uptake on the left side of the cervical nerve roots on 67Ga-scintigraphy was indistinguishable from artifact. Positron emission tomography-computed tomography (PET/CT) revealed a region of high glucose uptake in a left cervical intervertebral foramen, leading to a diagnosis of neurolymphomatosis. Neurological symptoms improved following additional chemotherapy, and the high glucose-uptake lesion disappeared. FDG-PET/CT is useful for rapid and non-invasive evaluation of neurolymphomatosis.