Outcome in patients with cervical radiculopathy. Prospective, multicenter study with independent clinical review

STUDY DESIGN: The Cervical Spine Research Society study is a prospective, nonrandomized, multicenter investigation of patients with cervical spondylosis and disc disease. In this analysis, only patients who had radiculopathy without myelopathy as the predominant symptom were considered. OBJECTIVES: To determine demographics, surgeon treatment practices, and outcomes in patients with symptomatic radiculopathy. SUMMARY OF BACKGROUND DATA: Current data on patient demographics and treatment practices of surgeons do not exist. There are no published prospective studies in which outcomes, including pain, function, neurologic symptoms, and ability to perform activities of daily living, are systematically quantified. METHODS: Patients were recruited by participating Cervical Spine Research Society surgeons. Demographic, symptomologic, and functional patient data were compiled from surveys of patients and physicians completed at the time of initial examination, and outcomes were assessed from surveys of patients completed after treatment. Data were compiled and statistically analyzed by a blinded third party. RESULTS: Of the 503 patients enrolled by 41 CSRS surgeons, 246 (49%) had radiculopathy. Patients had a mean duration of symptoms of 26.7 months (range, 8 weeks to > 352 months) and a mean age of 48.1 +/- 12.42 years; 44.7% were female. Surgery was recommended for 86 (35%) of these patients. Of the 155 patients on whom there were follow-up data, 51 (33%) underwent surgery, whereas 104 (67%) received medical treatment. Surgically treated patients had a significant improvement in pain, neurologic symptoms, functional status, and ability to perform activities of daily living. A significant number of patients who underwent surgery reported persistent excruciating or horrible pain on follow-up (26%). Patients treated medically also had significant improvement in pain and overall functional status. CONCLUSIONS: In summary, this study represents the first in-depth, prospective outcome analysis of patients with cervical spondylotic and discogenic radiculopathy.     

Vertebral artery injuries in cervical spine surgery

Background contextVertebral artery injuries (VAIs) are rare but serious complications of cervical spine surgery, with the potential to cause catastrophic bleeding, permanent neurologic impairment, and even death. The present literature regarding incidence of this complication largely comprises a single surgeon or small multicenter case series.PurposeWe sought to gather a large sample of high-volume surgeons to adequately characterize the incidence and risk factors for VAI, management strategies used, and patient outcomes after VAI.Study designThe study was constructed as a cross-sectional study comprising all cervical spine patients operated on by the members of the international Cervical Spine Research Society (CSRS).Patient sampleAll patients who have undergone cervical spine surgery by a current member of CSRS as of the spring of 2012.Outcome measuresFor each surgeon surveyed, we collected self-reported measures to include the number of cervical cases performed in the surgeon's career, the number of VAIs encountered, the stage of the case during which the injury occurred, the management strategies used, and the overall patient outcome after injury.MethodsAn anonymous 10-question web-based survey was distributed to the members of the CSRS. Statistical analysis was performed using Student t tests for numerical outcomes and chi-squared analysis for categorical variables.ResultsOne hundred forty-one CSRS members (of 195 total, 72%) responded to the survey, accounting for a total of 163,324 cervical spine surgeries performed. The overall incidence of VAI was 0.07% (111/163,324). Posterior instrumentation of the upper cervical spine (32.4%), anterior corpectomy (23.4%), and posterior exposure of the cervical spine (11.7%) were the most common stages of the case to result in an injury to the vertebral artery. Discectomy (9%) and anterior exposure of the spine (7.2%) were also common time points for an arterial injury. One-fifth (22/111) of all VAI involved an anomalous course of the vertebral artery. The most common management of VAI was by direct tamponade. The outcomes of VAIs included no permanent sequelae in 90% of patients, permanent neurologic sequelae in 5.5%, and death in 4.5%. Surgeons at academic and private centers had nearly identical rates of VAIs. However, surgeons who had performed 300 or fewer cervical spine surgeries in their career had a VAI incidence of 0.33% compared with 0.06% in those with greater than 300 lifetime cases (p=.028).ConclusionsThe overall incidence of VAI during cervical spine surgery reported from this survey was 0.07%. Less experienced surgeons had a higher rate of VAI compared with their more experienced peers. The results of VAI are highly variable, resulting in no permanent harm most of the time; however, permanent neurologic injury or death occur in 10% of cases.     

Voiding dysfunction associated with cervical spondylotic myelopathy

Patients with cervical spondylotic myelopathy who were neurosurgical candidates were prospectively evaluated for voiding abnormalities. The patients had relatively advanced neurologic disease because of delays in presentation and in diagnosis. The 22 consecutive patients included 20 males and 2 females with average age of 57 years. Sixteen patients had voiding symptoms with 12 noting a change in voiding pattern following the onset of their neurologic symptoms. Detrusor hyperreflexia was present in 16 (73%) of the patients and external sphincter dyssynergia in 8 (36%) of the patients. Neurologically mediated voiding dysfunction was common in patients with myelopathy secondary to cervical spondylosis.     

Surgery for cervical spinal cord compression in patients with multiple sclerosis

OBJECTIVE: The goal of this study was to investigate the clinical and paraclinical features, treatment, and outcomes of patients with multiple sclerosis (MS) and coexisting spinal cord compression secondary to either cervical spondylosis or cervical disc disease. Patients with MS commonly experience neurological disabilities that present as myelopathy associated with bladder dysfunction. For some patients with MS, however, this neurological deterioration may result from coexisting spinal cord compression attributable to either spondylosis or a herniated disc. Overlapping symptoms of the two conditions do not allow clear clinical determination of the underlying cause of worsening. METHODS: Patients with MS who underwent cervical decompression surgery were selected. Medical records were retrospectively reviewed, to collect data on their pre- and postoperative clinical courses. RESULTS: Nine women and five men with definite MS were selected for cervical decompression surgery to treat neurological deterioration considered to be at least partially attributable to spinal cord compression. The most common symptoms were progressive myelopathy (n = 13), neck pain (n = 11), and cervical radiculopathy (n = 10). Bladder dysfunction was notably absent among these patients with MS with moderate disabilities. Surgical intervention was frequently delayed because the neurological deterioration was initially thought to be attributable to MS. The majority of patients experienced either improvement or stabilization of their preoperative symptoms in the immediate postoperative period; three subjects (21%) maintained this improvement after a mean follow-up period of 3.8 years. No MS relapses, permanent neurological worsening, or serious complications resulting from surgery or general anesthesia were noted. CONCLUSION: Carefully selected patients with MS and cervical spinal cord compression secondary to either spondylosis or disc disease may benefit from surgical decompression, with minimal associated morbidity. Clinical features (especially neck pain and cervical radiculopathy) and magnetic resonance imaging may assist clinicians in differentiating between the two conditions and may guide appropriate treatment without undue delay.     

Cervical spondylotic myelopathy: diagnosis and treatment.

The delineation of cervical spondylotic myelopathy as a clinical entity has improved with the development of high-quality cross-sectional neuroradiologic imaging. The natural history of this disorder is usually slow deterioration in a stepwise fashion, with worsening symptoms of gait abnormalities, weakness, sensory changes, and often pain. The diagnosis can usually be made on the basis of findings from the history, physical examination, and plain radiographs, but confirmation by magnetic resonance imaging or computed tomography and myelography is necessary. Minimal symptoms without hard evidence of gait disturbance or pathologic reflexes warrant nonoperative treatment, but patients with demonstrable myelopathy and spinal cord compression are candidates for operative intervention. Both anterior and posterior approaches have been utilized for surgical treatment of cervical myelopathy. Anterior decompression frequently requires corpectomy at one or more levels and strut grafting with bone from the ilium or fibula. Multilevel laminectomies were initially used for posterior decompression but now are either combined with fusion or replaced by laminoplasty. Any operative technique requires proper patient selection and demands adequate decompression of the canal to effect neurologic improvement. Perioperative complications can be devastating in this group of high-risk patients with cervical spondylotic myelopathy, but careful attention to detail, meticulous technique, and experience can result in excellent outcomes.     

Preoperative instability does not influence the clinical outcome in patients with cervical spondylotic myelopathy treated with expansive laminoplasty

Sixty-seven patients with cervical spondylotic myelopathy treated with expansive laminoplasty were retrospectively reviewed at a minimum 2-year follow-up. This study was designed to evaluate whether preoperative instability influences the clinical outcome in patients with cervical spondylotic myelopathy treated with laminoplasty without spinal fusion. Patients with preoperative instability were older and had shorter durations of symptoms prior to surgery than those without the instability. There were no significant differences in prevalence of axial symptoms, neurologic recovery, or radiologic findings between patients with and without preoperative cervical instability. At follow-up, the cervical range of motion was limited to 43.5% of the preoperative range, and no cervical instability was observed in any patients. Preoperative instability does not influence the clinical outcome and can be ignored if expansive laminoplasty is indicated for patients with cervical spondylotic myelopathy.     

Central corpectomy for cervical spondylotic myelopathy: a consecutive series with long-term follow-up evaluation

Since 1984, a consecutive series of patients with cervical spondylotic myelopathy has been treated by central corpectomy and strut grafting. This report focuses on 40 cases operated on between 1984 and 1987 and followed from 2 to 5 years. The perioperative complication rate was 47.5%, with a 7.5% incidence of persistent sequelae: severe C-5 radiculopathy in one patient, swallowing dysfunction in one, and hypoglossal nerve palsy in one. No single factor (age, duration of symptoms, or severity of myelopathy) was absolutely predictive of outcome; however, syndromes of short duration had the best likelihood of cure. Similar outcomes were associated, individually, with long duration of symptoms, age over 70 years, and severe myelopathy. After factoring a 5% regression of improvement, the long-term cure rate was 57.5% and the failure rate was 15%. Myelopathy worsening was not documented.     

脊髓型颈椎病患者的排尿功能障碍及术后近期效果

目的:探讨脊髓型颈椎病患者产生排尿障碍的影响因素及其术后近期的改善情况。方法:对51例脊髓型颈椎病患者的病程、首发症状、合并症进行分析,并按术前脊髓功能状况评分分组观察术前、术后排尿功能和尿流率改变。结果:51例中术前有排尿障碍者27例（529％）,术后近期症状改善19例（70.4％）;术前尿流率异常者29例（56.9％）,术后最大尿流率较术前显著增加。病程超过1年、以下肢症状起病、合并颈椎OPLL及脊髓功能评分低的患者易出现排尿障碍和尿流率异常。结论:上述因素易造成脊髓型颈椎病患者发生排尿功能障碍;术后近期其排尿功能障碍可获得显著改善。     

Acquired atlantoaxial instability in children with spastic cerebral palsy

The development of nontraumatic atlantoaxial instability in children with spastic cerebral palsy has not been reported. The authors present three patients with severe spastic quadriplegia who developed C1-C2 instability and cervical myelopathy at mean age 12.6 years. These patients demonstrated a similar clinical picture with symptoms attributed to cervical myelopathy in varied severity including apneic episodes, opisthotonus, alteration in muscle tone, torticollis, respiratory problems, hyperreflexia, and bradycardia. Patient 1 was scheduled for surgery but died due to an apneic episode. Patient 2 refused surgery and has been followed for 3 years while his neurologic condition remains unchanged. Patient 3 underwent occipitocervical decompression and fusion, recovered neurologically, and resumed his previous functional skills. Patients demonstrating considerable functional deterioration or insidious change in their established neurologic status should undergo detailed screening to rule out developing upper cervical instability. Early surgical intervention consisting of spinal decompression and fusion may prevent the development of myelopathy.     

Relationships between outcomes of conservative treatment and magnetic resonance imaging findings in patients with mild cervical myelopathy caused by soft disc herniations.

STUDY DESIGN: A retrospective follow-up study of conservatively treated patients with mild cervical myelopathy caused by cervical soft disc herniation. OBJECTIVE: To investigate the outcome of conservative treatment for patients with mild myelopathy caused by cervical soft disc herniation and to evaluate usefulness of magnetic resonance findings in the prediction of the outcomes. SUMMARY OF BACKGROUND DATA: Recent studies on conservative treatment for cervical soft disc herniation have focused mainly on radiculopathy, and not on myelopathy. METHODS: Twenty-seven patients with mild cervical myelopathy secondary to cervical soft disc herniation were treated conservatively for more than 6 months by cervical bracing and restriction of daily activities. Of the 27 patients, 17 patients (Group A) underwent conservative treatment only and it was associated with improvement in their neurologic deficits, while the other 10 patients (Group B) ultimately underwent decompression surgery because of neurologic deterioration. Comparisons between the two groups were made in regard to JOA scores, patient satisfaction, and magnetic resonance findings, including location of the disc herniation (focal or diffuse in the sagittal plane, median or paramedian in the axial plane). RESULTS: The JOA scores were 13.6 +/- 1.6 in Group A and 14.1 +/- 1.6 in Group B before treatment, 14.9 +/- 1.0 and 12.9 +/- 2.1, respectively, at 3 months, and 16.2 +/- 0.8 and 16.0 +/- 1.2, respectively, at the final follow-up. The JOA scores at 3 months were significantly lower in Group B than in Group A. Satisfaction with the results of treatment at the final follow-up was reported by 77% of the patients in Group A and 90% in Group B. Focal-type herniation was present in 47% of the patients in Group A and 70% in Group B, while median-type herniation was diagnosed in 77% in Group A and 30% in Group B. Follow-up magnetic resonance imaging of the patients in Group A showed spontaneous regression of a herniated mass in 10 patients (59%). Diffuse-type herniations were more likely to regress spontaneously than focal-type herniations (78% vs. 37%). CONCLUSIONS: Conservative treatment is an effective treatment option for mild cervical myelopathy caused by cervical soft disc herniation. A good outcome can be expected in patients with a median-type and/or diffuse-type herniation on magnetic resonance imaging.     

Clinical evidence for cervical myelopathy due to Chiari malformation and spinal stenosis in a non-randomized group of patients with the diagnosis of fibromyalgia

Objective While patients with fibromyalgia report symptoms consistent with cervical myelopathy, a detailed neurological evaluation is not routine. We sought to determine if patients with fibromyalgia manifest objective neurological signs of cervical myelopathy.Methods Two hundred and seventy patients, 18 years and older, who carried the diagnosis of fibromyalgia but who had no previously recognized neurological disease underwent detailed clinical neurological and neuroradiological evaluation for the prevalence of objective evidence of cervical myelopathy and radiological evidence of cerebellar tonsillar herniation (Chiari 1 malformation) or cervical spinal canal stenosis.Results Patients were primarily women (87%), of mean age 44 years, who had been symptomatic for 8 years (standard deviation, 6.3 years). The predominant complaints were neck/back pain (95%), fatigue (95%), exertional fatigue (96%), cognitive impairment (92%), instability of gait (85%), grip weakness (83%), paresthesiae (80%), dizziness (71%) and numbness (69%). Eighty-eight percent of patients reported worsening symptoms with neck extension. The neurological examination was consistent with cervical myelopathy: upper thoracic spinothalamic sensory level (83%), hyperreflexia (64%), inversion of the radial periosteal reflex (57%), positive Romberg sign (28%), ankle clonus (25%), positive Hoffman sign (26%), impaired tandem walk (23%), dysmetria (15%) and dysdiadochokinesia (13%). MRI and contrast-enhanced CT imaging of the cervical spine revealed stenosis. The mean antero-posterior (AP) spinal canal diameter at C2/3, C3/4, C4/5, C5/6, C6/7 and C7/T1 was 13.5 mm, 11.8 mm, 11.5 mm, 10.4 mm, 11.3 mm and 14.5 mm respectively, (CT images). In 46% of patients, the AP spinal diameter at C5/6 measured 10 mm, or less, with the neck positioned in mild extension, i.e., clinically significant spinal canal stenosis. MRI of the brain revealed tonsillar ectopia >5 mm in 20% of patients (mean=7.1±1.8 mm), i.e., Chiari 1 malformation.Conclusion Our findings indicate that some patients who carry the diagnosis of fibromyalgia have both signs and symptoms consistent with cervical myelopathy, most likely resulting from spinal cord compression. We recommend detailed neurological evaluation of patients with fibromyalgia in order to exclude cervical myelopathy, a potentially treatable condition.     

Outcomes of surgical treatment for cervical myelopathy in patients more than 75 years of age

STUDY DESIGN: Retrospective study on the results of surgical treatment of compressive cervical myelopathy in patients more than 75 years of age. OBJECTIVES: To investigate clinical features and surgical outcomes of compressive cervical myelopathy in aged patients and to discuss the role of surgical treatment. SUMMARY OF BACKGROUND DATA: There are few data focused on the outcomes of surgery in patients with cervical myelopathy who are more than 75 years of age. METHODS: Seventeen patients with compressive cervical myelopathy who underwent surgery were reviewed. The average age at the time of surgery was 77.2 years. Posterior decompression in 15 patients and anterior decompression in 2 patients were performed. Neurologic deficits before and after surgery were assessed using a scoring system proposed by the Japanese Orthopaedic Association (JOA score). Independence of daily living was evaluated. Radiologic features were examined with radiographs and magnetic resonance imaging. Clinical results were compared with those of patients less than 65 years old as a control. RESULTS: The preoperative mean JOA score was 6.1, the postoperative maximum JOA scores averaged 11.4, and the recovery rate was 48.4%. These were significantly inferior to scores in those less than 65 years of age. All seven of the patients who could not walk even with aids before surgery became independent in daily activities after surgery. At the final follow-up, the mean JOA score had decreased to 10.7 and the recovery rate to 39.1%. Five of nine patients whose follow-up periods were more than 5 years showed decreases in JOA score, although all patients were still ambulatory. CONCLUSIONS: Surgical decompression for cervical myelopathy appears to be beneficial, even in patients more than 75 years of age, in improving neurologic function and ability to engage in activities of daily living.     

A comparative study of surgical approaches for cervical compressive myelopathy

Since 1986, the authors have used anterior decompression and fusion to treat patients with one- or two-level lesions without spinal canal stenosis (Group A) and laminoplasty for patients with more than three-level lesions or spinal canal stenosis (Group P). The aim of this study was to compare surgical outcomes of anterior and posterior approaches for patients with cervical myelopathy because of spondylosis and disc herniation and to determine the cause of poor neurologic recovery after surgery. One hundred thirty-six patients were followed up for an average of 5.6 years. There were no significant differences in gender, preoperative neurologic deficits, axial symptoms, or duration of symptoms before surgery between the two groups. Mean recovery rates for disc herniations were 71.1% and 71.9% in Groups A and P, respectively. For spondylosis, mean recovery rates were 49.0% and 58.6% in Groups A and P, respectively. There were no differences in recovery rate for patients with either spinal disorder between Groups A and P. The neurologic recovery of patients with kyphotic spinal cord was inferior to that of patients with lordotic or straight spinal cord. It is possible that acquisition and maintenance of lordosis result in improvement of clinical outcomes after surgery for patients with myelopathy.     

Nonoperative management of dens fracture nonunion in elderly patients without myelopathy

STUDY DESIGN: A retrospective review of elderly patients treated without surgery for chronic mobile nonunions of the odontoid process. Patients were observed on an annual basis with clinical examinations and flexion/extensions plain film radiographs. OBJECTIVES: To evaluate the clinical and radiographic results of elderly patients without myelopathy treated without surgery for dens fracture nonunion. SUMMARY OF BACKGROUND DATA: Because of the risk of progressive myelopathy or sudden neurologic injury, many surgeons recommend operative stabilization for patients with mobile dens nonunions who are able to withstand an operation. There is, however, a lack of information about the radiographic and neurologic progression of dens nonunions. Although a less aggressive surgical approach has been recommended by some authors for elderly or medically compromised patients with acute fractures, long-term follow-up evaluation of patients with resulting nonunions has not been reported. METHODS: A series of elderly patients with chronic, unstable, dens nonunions without myelopathy were treated with a nonoperative treatment protocol. Patients were informed of the nature of their lesion, including the risk of acute or chronic spinal cord injury and the options for operative treatment. Patients were evaluated yearly for clinical and radiographic progression. No intervention to slow progression of atlantoaxial instability was undertaken. RESULTS: None of the patients developed myelopathic symptoms during the follow-up period, and no patient experienced more than a 1 mm radiographic increase in atlantoaxial excursion. None of the reported patients had less than 14 mm available for the spinal cord in either flexion or extension at the start of clinical monitoring. CONCLUSIONS: Although further follow-up evaluation is needed, the authors believe on the basis of this review that this treatment protocol may be considered for patients who are poor candidates for surgical fusion.     

Ossification of the posterior longitudinal ligament. Results of anterior cervical decompression and arthrodesis in sixty-one North American patients

BACKGROUND: Ossification of the posterior longitudinal ligament is commonly associated with cervical myelopathy. Surgical treatment is a matter of controversy. We report on a series of patients who were managed with anterior cervical decompression and arthrodesis for the treatment of cervical myelopathy associated with ossification of the posterior longitudinal ligament. METHODS: We retrospectively reviewed the records for all sixty-five patients who had been managed with anterior decompression and arthrodesis for the treatment of cervical ossification of the posterior longitudinal ligament and associated neurologic compression from 1982 to 2001. Sixty-one patients (thirty-nine men and twenty-two women) were followed for at least two years (or until the time of death). The average number of vertebrae resected was 2.2. The average duration of follow-up for the sixty surviving patients was four years (range, two years to fifteen years and four months). The preoperative, six-week postoperative, and final follow-up clinical status (including neurological function as assessed with the Nurick grading system) was recorded for each patient. RESULTS: Fifty-six of the sixty-one patients had neurological improvement, with an average improvement of 1.5 Nurick grades at the time of the final follow-up. Eight patients had absent dura at the time of surgery and, of these, five had development of a cerebrospinal fluid fistula. Eight patients had development of new neurological signs and/or symptoms in the upper extremity postoperatively. Eight patients required reoperation because of a painful pseudarthrosis (one patient), strut-graft dislodgment (three), cerebrospinal fluid leakage (three), or compression of a nerve root caudad to the area of the original procedure (one). One patient died as the result of cardiac arrest on the third postoperative day. Fifty-eight patients had an osseous fusion, one had an asymptomatic nonunion, and one had a symptomatic pseudarthrosis that was treated with revision surgery. CONCLUSIONS: Anterior decompression and arthrodesis is an effective way to achieve pain relief and neurological improvement in North American patients of non-Asian descent who have cervical myelopathy associated with ossification of the posterior longitudinal ligament. The risk of durocutaneous fistula, graft dislodgment, and postoperative neurological symptoms appears to be high in patients with cervical myelopathy associated with this condition.     

Subtotal corpectomy versus laminoplasty for multilevel cervical spondylotic myelopathy: a long-term follow-up study over 10 years.

STUDY DESIGN: A retrospective study was conducted. OBJECTIVE: To compare the long-term outcomes of subtotal corpectomy and laminoplasty for multilevel cervical spondylotic myelopathy. SUMMARY OF BACKGROUND DATA: No study has compared the long-term outcomes between subtotal corpectomy and laminoplasty for multilevel cervical spondylotic myelopathy. METHODS: In this study, 23 patients treated with subtotal corpectomy and 24 patients treated with laminoplasty were followed up for 10 to 14 years after surgery. Neurologic recovery, late deterioration, axial pain, radiographic results (degenerative changes at adjacent levels, alignment, and range of motion of the cervical spine), and surgical complications were compared between the two groups. RESULTS: No significant difference in neurologic recovery was found between the two groups 1 and 5 years after surgery, or at the latest follow-up assessment. Neurologic status deteriorated in one patient of the subtotal corpectomy group because of adjacent degeneration, and in one patient of the laminoplasty group because of hyperextension injury. Axial pain was observed in 15% of the corpectomy group and in 40% of the laminoplasty group (P < 0.05). In the corpectomy group, listhesis exceeding 2 mm developed at 38% of the upper adjacent levels, and osteophyte formation at 54% of the lower adjacent levels. In the laminoplasty group, kyphotic deformity developed in one patient (6%) after surgery. In the corpectomy group, the mean vertebral range of motion had decreased from 39.4 degrees to 19.2 degrees (49%) by the final follow-up assessment. In the laminoplasty group, the mean vertebral range of motion had decreased from 40.2 degrees to 11.6 degrees (29%) by the final follow-up assessment. Neurologic complications related to the surgery occurred in two patients (one myelopathy from bone graft dislodgement and one C5 root palsy from bone graft fracture) of the corpectomy group and four patients (C5 root palsy) of the laminoplasty group. All of these patients recovered over time. The corpectomy group needed longer operative time (P < 0.001) and tended to have more blood loss (P = 0.24). Six patients in the corpectomy group needed posterior interspinous wiring because of pseudarthrosis. CONCLUSIONS: Subtotal corpectomy and laminoplasty showed an identical effect from a surgical treatment for multilevel cervical spondylotic myelopathy. These neurologic recoveries usually last more than 10 years. In the subtotal corpectomy group, the disadvantages were longer surgical time, more blood loss, and pseudarthrosis. In the laminoplasty group, axial pain occurred frequently, and the range of motion was reduced severely.     

Cervical posterior fusion with wave-shaped rod under local anesthesia for cervical spondylotic myelopathy: review of 12 patients.

STUDY DESIGN: Clinical evaluation of cervical interspinous fusion under local anesthesia in elderly patients with cervical spondylotic myelopathy. OBJECTIVES: To evaluate the effectiveness of cervical posterior fusion with wave-shaped rods inserted under local anesthesia for elderly high-risk patients with cervical spondylotic myelopathy. SUMMARY OF BACKGROUND DATA: A substantial number of patients cannot undergo surgical interventions under general anesthesia because of their general medical complications. Although such patients would become unable to walk, which might induce a worsening of their general condition, conservative treatments had been adopted as the only treatment for these patients. The authors have obtained satisfactory results by means of posterior interspinous fusion under local anesthesia even in the high-risk patients with severe cervical spondylotic myelopathy. The aims of this surgical technique were to adjust cervical alignment and to stabilize the motion segment(s) without decompression. PATIENTS AND METHODS: Between May 1989 and August 1998, 12 elderly patients (3 men and 9 women) with cervical spondylotic myelopathy were treated with posterior interspinous fusion using wave-shaped rods inserted under local anesthesia. The average age at the surgery was 76.9 years. The average follow-up period was 5 years 6 months. All patients were unable to walk without any assistance because of their advanced myelopathy. It was felt that all of them would be unable to accept general anesthesia because of their generally poor medical conditions. Preoperative severity of the clinical symptoms and postoperative recovery were evaluated by a scoring system proposed by the Japanese Orthopaedic Association, which had 17 points at full mark. RESULTS: The average duration of the surgical procedure was 122.8 minutes. The average total blood loss was 118.6 g. No instrument failures were denoted. Neither neural deterioration nor major complication was observed relating to the surgery. Radiographic bony union of the grafted bone was achieved in all patients. Progression of myelopathy was arrested in all 12 patients, and clinical symptoms were improved in 10 patients. The mean Japanese Orthopaedic Association scores had increased from 5.0 to 10.2 points. CONCLUSIONS: Twelve high-risk patients with cervical spondylotic myelopathy were treated with posterior interspinous fusion using wave-shaped rods inserted under local anesthesia. This method was evaluated as an effective surgical salvage without any mortal complications even in the elderly high-risk patients.     

颈椎人工椎间盘置换术治疗颈椎间盘疾患的早期临床观察

目的：探讨应用颈椎人工椎间盘置换术治疗颈椎间盘疾患的效果.方法：对45例颈椎间盘疾病患者（脊髓型颈椎病35例、神经根型颈椎病5例、急性颈椎间盘突出症5例）实施前路减压、Bryan人工椎间盘置换术.其中单节段置换35例,双节段9例,3节段1例.结果：所有患者随访1～12个月,平均8个月.脊髓型颈椎病患者术前JOA评分平均8.5分,术后平均15.5分,平均改善率为88%.神经根型颈椎病和急性颈椎间盘突出症患者的临床症状均消失.平均术后住院时间为4.8d（2～6d）,38例术后4周内恢复正常生活和工作,7例在术后2个月内恢复工作.所有病例未见假体移位及神经系统症状加重.有2例分别在术后3个月和11个月时出现假体周围骨桥形成无活动,其余43例在最终随访时各置换节段均保留了活动度.结论：应用Bryan人工椎间盘系统置换治疗颈椎间盘疾患早期效果良好.     

Intermittent cervical traction and thoracic manipulation for management of mild cervical compressive myelopathy attributed to cervical herniated disc: a case series

STUDY DESIGN: Case series. OBJECTIVE: To describe the management of 7 patients with grade 1 cervical compressive myelopathy attributed to herniated disc using intermittent cervical traction and manipulation of the thoracic spine. BACKGROUND: Intermittent cervical traction has been indicated for the treatment of patients with herniated disc and has been suggested to be helpful for patients with cervical compressive myelopathy. Manipulation of the thoracic spine has been utilized to safely improve active range of motion and decrease pain in patients with neck pain. METHODS AND MEASURES: Seven women with neck pain, 35 to 45 years of age, were identified as having signs and symptoms consistent with grade 1 cervical compressive myelopathy. Symptom duration ranged from less than 1 week to 52 weeks. All patients were treated with intermittent cervical traction and thoracic manipulation for a median of 9 sessions (range, 2-12 sessions) over a median of 56 days (range, 14-146 days). Numeric Pain Rating Scale and Functional Rating Index scores served as the primary outcome measures. RESULTS: The median decrease in pain scores was 5 (range, 2-8) from a baseline of 6 (range, 4-8), and median improvement in Functional Rating Index scores was 26% (range, 10%-50%) from a baseline of 44% (range, 35%-71%). Dizziness was eliminated in 3 out of 4 patients and chronic headache symptoms were improved in 3 out of 3 patients. There were no adverse events or outcomes. CONCLUSIONS: Intermittent cervical traction and manipulation of the thoracic spine seem useful for the reduction of pain scores and level of disability in patients with mild cervical compressive myelopathy attributed to herniated disc. A thorough neurological screening exam is recommended prior to mechanical treatment of the cervical spine.