How common is repeat surgery and multi-level treatment in Degenerative Cervical Myelopathy? Findings from a patient perspective survey

Degenerative Cervical Myelopathy (DCM) is a common condition which causes significant disability and reduces health-related quality of life. The only evidence-based treatment and current management guidance is surgery to decompress the spinal cord and stop further damage in moderate to severe cases. However, this guidance is mainly informed by studies that only include first time surgery and/or single level disease, but DCM can reoccur after primary surgery and affect multiple levels of the spine. It is unclear whether patients in these subgroups; repeat surgery and multi-level DCM, differ significantly in their baseline and disease characteristics from those with single-level, single-operation disease. To investigate this, we conducted an online survey of people with DCM looking at key demographic, disease (e.g. mJOA) and treatment characteristics. We received a total of 778 respondents, of which 159 (20%) had undergone surgery for DCM. Around 75% of these respondents had a single operation and 65% at a single level. We found no statistically significant difference in key participant and disease characteristics between respondents with single-level or single-operation and those with multi-level DCM or multiple operations. These data support generalisability of research to these subgroups but also warrants further investigations as these subgroups are underrepresented in current research.     

椎动脉型颈椎病经颈夹脊穴温针灸+手法治疗的临床效果研究

目的:评价椎动脉型颈椎病经颈夹脊穴温针灸+手法治疗的临床效果。方法:选取2016年5月~2018年6月在我院进行治疗的116例椎动脉型颈椎病患者,按随机数表法分为两组,各58例。对照组采用颈夹脊穴温针灸治疗,观察组采用颈夹脊穴温针灸+手法治疗。对比两组治疗前后眩晕问卷调查表评分(DHI)、各临床症状评分以及椎动脉血管相关指数。结果:观察组治疗后DHI评分为(50.97±3.21)分,明显低于对照组的(62.24±4.53)分,差异有统计学意义(P<0.05)。观察组头痛、眩晕、耳鸣、颈痛、视物模糊及旋颈试验评分均明显高于对照组,差异有统计学意义(P<0.05)。观察组双侧椎动脉PI、RI指数均明显低于对照组,差异有统计学意义(P<0.05)。结论:椎动脉型颈椎病经颈夹脊穴温针灸+手法治疗的效果较明显,不仅可改善双椎动脉血流状态,缓解头痛、眩晕、耳鸣、颈痛及视物模糊等临床症状,还有利于颈部动力平衡的恢复。     

Interrater and intrarater agreements of magnetic resonance imaging findings in the lumbar spine: significant variability across degenerative conditions

Background context

Magnetic resonance imaging (MRI) is frequently used in the evaluation of degenerative conditions in the lumbar spine. The relative interrater and intrarater agreements of MRI findings across different pathologic conditions are underexplored, as most studies are focused on specific findings.

Purpose

The purpose of this study was to characterize the interrater and intrarater agreements of MRI findings used to assess the degenerative lumbar spine.

Study design

A retrospective diagnostic study at a large academic medical center was undertaken with a panel of orthopedic surgeons and musculoskeletal radiologists to assess lumbar MRIs using standardized criteria.

Patient sample

Seventy-five subjects who underwent routine lumbar spine MRI at our institution were included.

Outcome measures

Each MRI study was assessed for 10 lumbar degenerative findings using standardized criteria. Lumbar vertebral levels were assessed independently, where applicable, for a total of 52 data points collected per study.

Methods

T2-weighted axial and sagittal MRI sequences were presented in random order to the four reviewers (two orthopedic spine surgeons and two musculoskeletal radiologists) independently to determine interrater agreement. The first 10 studies were reevaluated at the end to determine intrarater agreement. Images were assessed using standardized and pilot-tested criteria to assess disc degeneration, stenosis, and other degenerative changes. Interrater and intrarater absolute percent agreements were calculated. To highlight the most clinically important MRI disagreements, a modified agreement analysis was also performed (in which disagreements between the lowest two severity grades for applicable conditions were ignored). Fleiss kappa coefficients for interrater agreement were determined.

Results

The overall absolute and modified interrater agreements were 76.9% and 93.5%, respectively. The absolute and modified intrarater agreements were 81.3% and 92.7%, respectively. Average Fleiss kappa coefficient was 0.431, suggesting moderate overall agreement. However, when stratified by condition, absolute interrater agreement ranged from 65.1% to 92.0%. Disc hydration, disc space height, and bone marrow changes exhibited the lowest absolute interrater agreements. The absolute intrarater agreement had a narrower range, from 74.5% to 91.5%. Fleiss kappa coefficients ranged from fair-to-substantial agreement (0.282–0.618).

Conclusions

Even in a study using standardized evaluation criteria, there was significant variability in the interrater and intrarater agreements of MRI in assessing different degenerative conditions of the lumbar spine. Clinicians should be aware of the condition-specific diagnostic limitations of MRI interpretation.     

从五脏辨证施针论治颈椎病

颈椎病是常见病、多发病,临床治疗多从心肾施针,然笔者通过查阅文献,结合多年临床经验,认为其与五脏皆有关,故从心、肝、脾、肺、肾五脏进行辨证施针论治,取得了较好的治疗效果。现将其总结归纳如下,供广大学者参考。     

Abstracts from the 43rd Annual Scientific Conference of the American Paraplegia Society—September 2-4, 1997, Las Vegas,Nevada

Abstract

Background: Diagnosing patients with cervical cord compressive myelopathy in a timely manner can be challenging due to varying clinical presentations, the absence of pathognomonic findings, and symptoms that are usually insidious in nature.

Objective: To describe the clinical course of a patient with primary complaint of left medial knee pain that was nonresponsive to surgical and conservative measures; the patient was subsequently diagnosed with cervical cord compressive myelopathy.

Design: Case report.

Subject: A 63-year-old man with a primary complaint of left medial knee pain.

Findings: Physical examination of the left knee was normal except for slight palpable tenderness over the medial joint line. During treatment, he noted loss of balance during activities of daily living. Reassessment revealed bilateral upper extremity hyperreflexia, bilateral Babinski reflex, and positive bilateral Hoffman reflex. Magnetic resonance imaging of the cervical spine demonstrated moderately severe spinal stenosis at the C3-C4, C5-C6, and C6-C7 levels. After C3-C7 laminoplasty for cervical cord compressive myelopathy, he reported substantial improvement of his left medial knee. Three years later, he had no complaint of knee pain.

Conclusion: Appropriate diagnosis and treatment of cervical cord compressive myelopathy may avoid unnecessary diagnostic imaging, medical evaluations, invasive procedures, and potential neurologic complications.     

中医误诊误治举隅

年轻医生初入临床,误诊误治难免发生,总结3则误诊误治医案,于自己,希望将来能少出差错;于广大年轻医生,亦可引以为鉴。     

针刺治疗颈性眩晕60例疗效分析

目的观察针剌治疗颈性眩晕的疗效。方法将120例颈性眩晕患者随机分为针刺组与对照组。针剌组给予针剌治疗,每天1次。7天1个疗程．共治疗2个疗程;对照组给予舒血宁20mL／d静脉滴注,治疗14天。观察2组疗效及随访3个月后的复发率。结果针刺组痊愈率为66．67％,对照组痊愈率为36．67％,2组差异有统计学意义（P〈0．01）;针刺组和对照组总有效率分别为95．00％和88．33％,痊愈3个月后复发率分别为9．09％和22．92％,针刺组好于对照组。但2组差异均无统计学意义（P〉0．05）。结论针刺组的近期疗效及远期疗效均优于对照组。     

Influence of hinge position on the effectiveness of open-door expansive laminoplasty for cervical spondylotic myelopathy

Objective: To assess the influence of different hinge positions on clinical results of expansive open-door laminoplasty (EOLP) for cervical spondylotic myelopathy (CSM).Methods: A total of 102 CSM patients who underwent EOLP from February 2006 to February 2007 were enrolled in this randomized controlled trial. Using a random digits table,57 patients with the hinge located at the inner margin of the lateral mass were classified as wide-open group, while 45 patients with the hinge positioned at the lamina margin served as narrow-open group. All patients were observed over 24 months, and the clinical and radiological results were analyzed statistically.Results: There were no significant differences in operation duration, intraoperative bleeding volume, Japanese Orthopaedic Association (JOA) scores, cervical curvature index, range of motion and neural function recovery rate.The neural functions were satisfactorily improved after surgery in both groups, while the severity of axial symptoms was significantly lower in the narrow-open group than in the wide-open group (P=0.003). The incidence of C5 palsy in the wide-open group was higher than that in the narrowopen group (5.3% vs 0), even though the difference did not reach statistical significance (one tailed Fisher's exact test,P=0.17).Conclusions: Proper inward shift of the hinge can ensure effectiveness of surgical decompression, avoid an excessive backward shift of the spinal cord, decrease the incidence of C5 palsy and alleviate the severity of axial symptoms.     

养子时刻开穴法治疗椎动脉型颈椎病40例疗效观察

方法：将78例椎动脉型颈椎病患者，随机分为养子时刻开穴组和对照组，进行针刺疗效观察。结果：养子时刻开穴组总有效率明显高于对照组，经X^2检验，P＜0．01，两组总有效率在统计学上差异有显著意义。结论：养子时刻开穴法是治疗椎动脉型颈椎病的有效方法。