Specificity of CT myelographic findings in cervical nerve root symptoms

Summary In a series of 62 patients with cervical nerve root symptoms CT myelography of the cervical spine revealed specific radiological signs in 24 patients. These signs are: stenosis of the spinal canal, nerve root swelling and/or soft disc herniation. Disc bulging or spondylotic encroachment with only partial narrowing of the myelographically visible part of the foramen, and often unilateral flattening of the cord is considered clinically insignificant. A normal appearance of cord and nerve roots was seen in 22 patients.     

Magnetic resonance imaging of diseased cervical and lumbar intervertebral discs

Magnetic resonance images (MRI) of diseased cervical and lumbar intervertebral discs involving both intrinsic and extrinsic cord lesions were examined using either a 0.15 T resistive or a 0.5 T superconductive magnetic imaging system. High resolution images were obtained by means of a surface coil in most cases. The vertebrae, intervertebral discs, and spinal cord were delineated in greatest detail on spin-echo (SE) images with a long repetition time (TR) and a short echo time (proton density-weighted image), on which the spinal cord was appreciated without overshadowing by the cerebrospinal fluid-filled subarachnoid space. Protrusion of degenerated intervertebral discs into the spinal canal was clearly demonstrated not only on sagittal but also on parasagittal and transverse views. The location of protruded discs and compression of the spinal cord, caudal sac, and nerve roots were well visualized three-dimensionally. Pathological features of intervertebral discs were better appreciated on T2-weighted images with long TR and SE pulse sequences. Degeneration of intervertebral discs resulted in decreased signal intensity in cases involving lumbar disc lesions but not those involving cervical disc lesions. In a case of suspected myelomalacia, the intrinsic cord lesion resulting from traumatic disc protrusion appeared as focal low signal intensity on T1-weighted images and as somewhat high intensity on T2-weighted images. The inversion recovery sequence with median inversion time displayed an inferior image of low contrast and was judged uninformative in comparison to SE images. The authors' observations demonstrate that MRI is an essential diagnostic technique for spinal cord disorders.(ABSTRACT TRUNCATED AT 250 WORDS)     

Myelography in the late postoperative period in patients subjected to anterior cervical decompression and fusion

Summary During a 13 year period, 286 patients with cervical disc herniation and/or spondylotic spurs, were subjected to anterior decompression and vertebral interbody fusion with autologous bone.Twenty patients were re-admitted in the late postoperative period due to recurrent radicular symptoms and/or signs of myelopathy. In these patients myelography was performed again. In 14 patients spinal cord compression and/or nerve root involvement at a new level was visualized. At the operated level, however, the myelograms demonstrated a smooth anterior wall in the spinal canal.The series confirms the safety, effectiveness and reliability of the Cloward procedure in achieving long term spinal cord and nerve root decompression, and a solid vertebral interbody fusion.     

Soft cervical disc herniation. Influence of cervical spinal canal measurements on development of neurologic symptoms.

STUDY DESIGN: In 100 consecutive patients who underwent surgery because of soft cervical disc herniation, the sagittal and transverse diameters, the area of the bony cervical spinal canal, the sagittal diameter of the hernia, and the minimal bony intervertebral foramen diameter were measured by computed tomography. The data were compared with measurements from a control group of 35 matched healthy individuals. OBJECTIVES: To evaluate the relation between the severity of concurrent neurologic symptoms and the sagittal and transverse diameters, the cross-sectional area of the bony spinal canal, the sagittal diameter of the hernia, and diameter of the minimal bony intervertebral foramen in patients with soft cervical disc herniation. SUMMARY OF BACKGROUND DATA: Traumatic injury and spondylotic changes have a far greater impact on the spinal cord and nerve roots if the sagittal diameter of the bony cervical spinal canal is small. However, in the case of soft cervical disc herniation, no computer tomographic measurements are available for sagittal and transverse diameters, cross-sectional area of the bony spinal canal, sagittal diameter of the hernia, and diameter of the minimal bony intervertebral foramen in relation to the severity of concurrent neurologic symptoms. METHODS: Computed tomography was used to measure sagittal and transverse diameters, cross-sectional area of the bony cervical spinal canal, sagittal diameter of the hernia, and diameter of the minimal bony intervertebral foramen in 100 patients with symptomatic monosegmental cervical soft disc herniation. All patients had undergone an anterior discectomy with removal of the hernia and subsequent interbody fusion using an autologous bone graft taken from the iliac crest. RESULTS: A mean sagittal diameter of the bony cervical spinal canal of 12.9 mm was found, indicating a certain degree of developmental stenosis. Patients with motor disturbances had a significantly smaller sagittal diameter of the bony spinal canal than did patients without motor disturbances. There was a linear correlation between the sagittal diameter of the bony cervical spinal canal and that of the hernia. The sagittal diameter, the area of the bony spinal canal, and diameter of the minimal bony intervertebral foramen were significantly smaller in patients with soft cervical disc herniation than in the control group. CONCLUSIONS: Results from this study strongly suggest that the degree and severity of neurologic symptoms accompanying cervical soft disc herniation are inversely related to the sagittal diameter and the area of the bony cervical spinal canal. The latter area is reduced in cases of developmental stenosis or because of soft disc herniation. Moreover, patients with soft cervical disc herniation have a significantly smaller sagittal diameter of the bony spinal canal, a significantly smaller minimal bony intervertebral foramen diameter, and a significantly smaller cross-sectional area of the bony cervical canal than do healthy matched individuals.     

非手术治疗无骨折脱位型颈脊髓损伤预后的多因素分析

目的 :探讨影响非手术治疗无骨折脱位型颈脊髓损伤预后的因素。方法 :回顾性分析2009年1月至2012年12月接受非手术治疗的122例无骨折脱位型颈脊髓损伤患者的临床资料,其中男84例,女38例;平均年龄(52.37±13.27)岁(18~83岁)。选择年龄、性别、受伤原因、受伤至治疗时间、脊髓损伤ASIA分级、MRI脊髓损伤类型、脊髓损伤范围、有效颈椎管率、椎间盘突出Pfirrmann分级、椎间盘突出节段、椎间盘韧带复合体损伤、大剂量甲基强的松龙冲击治疗12个可能对非手术治疗预后产生影响的因素,应用单因素和多因素Logistic回归分析,研究其对预后的影响。结果:单因素分析显示MRI脊髓损伤类型、脊髓损伤范围、有效颈椎管率、椎间盘突出Pfirrmann分级、椎间盘突出节段及脊髓损伤ASIA分级均对预后有显著影响(P均0.05)。进一步行多因素分析,按照其作用强度,影响预后的主要因素依次为:MRI脊髓损伤类型、脊髓损伤范围、有效颈椎管率、椎间盘突出Pfirrmann分级、脊髓损伤ASIA分级(P均0.05)。结论 :影响非手术治疗无骨折脱位型颈脊髓损伤预后的主要因素是MRI脊髓损伤类型及范围,同时与有效椎管率、椎间盘突出程度及脊髓损伤ASIA分级相关。对于选择非手术治疗需谨慎,仅适用MRI检查提示脊髓信号无改变或水肿程度轻且范围局限者,其余则建议积极手术治疗。     

The relationship between the cervical spinal canal diameter and the pathological changes in the cervical spine

A congenitally narrow cervical spinal canal has been established as an important risk factor for the development of cervical spondylotic myelopathy. However, few reports have described the mechanism underlying this risk. In this study, we investigate the relationship between cervical spinal canal narrowing and pathological changes in the cervical spine using positional magnetic resonance imaging (MRI). Two hundred and ninety-five symptomatic patients underwent cervical MRI in the weight-bearing position with dynamic motion (flexion, neutral, and extension) of the cervical spine. The sagittal cervical spinal canal diameter and cervical segmental angular motion were measured and calculated. Each segment was assessed for the extent of intervertebral disc degeneration and cervical cord compression. Based on the sagittal canal diameter, the subjects were classified into three groups: A, subjects with a congenitally narrow canal, diameter of less than 13 mm; B, subjects with a normal canal, diameter of 13–15 mm; C, subjects with a wide canal, diameter of more than 15 mm. When compared with Groups A and B, the disc degeneration grades at the C3-4, C5-6, and C6-7 segments and the cervical cord compression scores at the C3-4 and C5-6 segments showed significant differences. Additionally, when compare with Groups A and C, the disc degeneration grades at all segments, except C2-3, and the cervical cord compression scores at all segments, except C2-3, showed significant differences. With respect to the cervical kinematics, few differences in the kinematics were observed between Groups B and C, however, the kinematics in Group A was different with other two groups. In Group A, the segmental mobility at the C4-5 and C6-7 segments were significantly higher than those observed in Group B, and the segmental mobility at the C3-4 segment was significantly lower than that observed in Groups B or C. We demonstrated the unique pathological and kinematic traits of cervical spine that exist in a congenitally narrow canal. We hypothesize that kinematic trait associated with a congenitally narrow canal may greatly contribute to pathological changes in the cervical spine. Our results suggest that cervical spinal canal diameter of less than 13 mm may be associated with an increased risk for development of pathological changes in cervical intervertebral discs. Subsequently, the presence of a congenitally narrow canal can expose individuals to a greater risk of developing cervical spinal stenosis.     

无骨折脱位型颈髓损伤的临床研究

目的：探讨颈椎在无骨折脱位情况下出现颈髓损伤的临床机制。方法：观察２４例无骨折脱位型颈髓损伤，重点分析其影像学检查特点。结果：２７％病例合并椎管狭窄，８３％的病例存在椎间盘突出，不同程度压迫脊髓。结论：无骨折脱位型颈脊髓损伤机制中，存在外伤致颈椎间盘损伤，突出的间盘向后压迫损伤颈髓。颈椎间盘损伤受力机制为屈曲→压缩→过伸。颈椎管狭窄、椎间盘退变等是此类脊髓损伤的病理解剖基础     

压迫脊髓的儿童颈椎间盘炎（附5例报告）

目的　报告 5例压迫脊髓的儿童颈椎间盘炎。方法　 5例中男 3例 ,女 2例 ,年龄 4～ 14岁 ,平均 10岁。 5例X线片均发现有颈椎间盘钙化 ,并可见钙化间盘组织突入椎管。 3例为C3、4 ,2例在C6、7。 5例均有反复发作的颈痛 ,2例有神经根刺激症状 ,5例均无脊髓受损表现。结果　症状在治疗后 1周～ 2个月缓解。 5例病人均进行了随访 ,随访时间 5周～ 15个月 ,钙化影消失的时间 3周～ 8个月 ,平均 3 6个月。结论　颈椎X线平片是主要诊断方法 ,椎间隙正常而间盘钙化为重要的诊断与鉴别诊断依据 ,突入椎管内的实性团块 ,可经保守治疗而消失     

细胞因子IL-1a、IL -6、TNF-a、MMP3与颈椎间盘退变机制的相关性研究

[目的]探讨细胞因子在颈椎间盘退变机制中的作用及其与神经功能的相关性.[方法]实验组椎间盘组织取自46例颈椎病患者,根据术前颈椎MRI及术中椎间盘突出情况分为两组:退变组(24例)和突出组(22例).对照组椎间盘组织取自15例无颈椎病病史的颈椎外伤患者.根据颈椎病患者术前JOA评分分为三组:轻度组(17例),中度组(15例)和重度组(14例).采用酶联免疫吸附法(ELISA法)分别检测不同退变程度颈椎间盘中IL-1a、IL -6、TNF -a和MMP3的表达水平.[结果]对照组、退变组和突出组三组之间比较,IL -1a、IL -6、TNF-a和MMP3的表达有统计学意义(P＜0.05),其表达水平与颈椎间盘退变呈正相关趋势;轻度组、中度组和重度组三组之间比较,MMP3、TNF -a的表达有统计学意义(P＜0.05),其表达水平与JOA评分呈负相关趋势.[结论]IL -1、IL -6、TNF -a和MMP3与颈椎间盘退变密切相关,其表达水平与椎间盘退变呈正相关趋势;TNF -a与神经功能有关,可能在神经损伤中起主导作用;MMP3与椎间盘突出有关,对TNF -a的神经功能损伤可能起促进作用.     

无骨折脱位型颈髓损伤(附17例报告)

17例无骨折脱位型颈髓损伤患者均为颈椎过伸性损伤,X线片示颈椎无骨折、脱位。受伤前患有颈椎病6例;强直性脊柱炎2例。17例中12例行脊髓造影、CT检查,4例椎间盘退变,3例后纵韧带骨化,1例椎体后缘骨刺,3例存在发育性椎管狭窄,2例MRI检查可见脊髓病理改变。发现伤前存在发育性或退行性颈椎管狭窄者,虽受伤外力轻,但脊髓损伤重、脊髓功能也恢复差。     

Histopathologic effects of discitis on neural tissues: an experimental study

To determine the cause of neurologic symptoms and signs seen in discitis, the neural histopathologic effects of discitis were investigated in an experimental study carried out on rats. Groups of seven rats each had their intervertebral discs inoculated with either Staphylococcus aureus, Klebsiella pneumoniae, Pseudomonas aeruginosa, or a control solution. Histopathologic examinations of the spinal cord and nerve roots were performed after 3 weeks. On histopathologic examination, vacuolar myelopathy in the spinal cord and vacuolar neuropathy within the nerve roots near the junction with the spinal cord were found. The severity and form of vacuolar myelopathy varied according to the bacteria used for inoculation. The myelopathy and neuropathy seen in this rat model of bacterial discitis might be the result of an immunologic mechanism and could be responsible for the neurologic signs and symptoms of discitis in patients.     

下腰部神经根管的解剖学观察及临床意义

目的 探讨腰骶神经根管的形态、结构、走行及比邻组织病理改变的特点,提高对病因的认识和临床诊疗水平.方法 选择5具无脊柱疾患的成人腰骶椎段标本,依照后路椎管及神经根管手术探查的习惯入路,分别对下腰部椎管和神经根管后方冠状面、神经根管后壁、前壁及椎间盘横断面进行解剖及观察.结合临床78例腰骶椎手术患者的椎管和神经根管探查所见,相互印证.结果 下腰部神经根自硬膜囊穿出后,随着序列的下降,与硬膜囊的夹角也随之减小,而出发点则随之升高;在途径椎管内及椎间管内两个阶层中,前段一般不受退变及异常应力作用产生形变,增厚的黄韧带多为致病因,后段为纤维管道,不越过间盘组织,可能与骨退变及增生有更大的相关性.结论 神经根自硬膜囊发出后,因序列不同,出发点及角度均不同,与椎间盘关系亦不同,在作髓核摘除时应避免损伤;在整个神经根行走径路中,均可由自身的增生退变或以合并存在的形式导致途径的神经根发生嵌压引发临床症状和体症,由于病变部位和病变组织性质不同,手术方法也不同.     

Redundant nerve roots of the cauda equina: clinical aspects and consideration of pathogenesis

In order to investigate the clinical significance of redundant nerve roots of the cauda equina (RNR) and their pathogenesis, the following studies were performed: 1) examination of 1,256 myelograms of patients with lumbar disease; 2) clinical analysis of 55 patients with RNR and 75 without RNR; 3) electrophysiological examination of 9 patients with RNR; and 4) anatomical and histopathological examination of 6 autopsy cases. RNR were found in 42% of patients with severely constricted spinal canals. In comparing patients with RNR and those without RNR, RNR were found in older patients, these patients exhibited a longer period from the onset of the symptoms to the time of myelographic manifestation, and they caused more severe signs and symptoms. The spatial distribution of redundant nerve roots and the extent of degeneration of nerve fibers in redundant nerve roots indicated the close causal relationship between RNR and constriction of the spinal canal. As the pathogenesis of RNR, the authors suggest a squeezing force from the constricted spinal canal acting on the nerve roots.     

MRI对颈椎病的诊断价值

96例混合型颈椎病的MRI主要表现为椎间盘髓核失水、变性、椎间隙变窄，椎间盘膨出、突出和脱出，椎体后缘骨赘形成、黄韧带肥厚内招、椎管狭窄；脊髓受压移位、变形，脊髓水肿、变性、软化和囊肿形成，其横截面积缩小；椎间孔处颈神经根周围脂肪高信号减少或消失。不用对比剂的推动脉MR显影（MRA）可立即显示颈部双侧推动脉粗细、迂曲、受阻及动态状况。其中32例以脊髓型为主老同时作脊髓造影和CTM检查，并经手术证实。脊髓造影、CTM、MRI与手术所见符合率分别为60％、85％、96％。作者认为，MRI诊断颈椎病简捷准确，定位精确度高，可优化缩短诊疗全过程。     

Cervical spine in diastrophic dysplasia: an MRI analysis

In this cross-sectional study, we evaluated the cervical spine in patients with diastrophic dysplasia (DD) by using magnetic resonance imaging (MRI). From 90 (57 female, 33 male) patients of different ages (0.3-56.0 years), T1- and T2-weighted images were obtained. The craniocervical junction and status of the medulla were examined, and the transverse areas of dural tube and medulla were measured. Alignment of the cervical spine, vertebral abnormalities, and disc changes also were evaluated. The cervical spinal canal was moderately narrowed, particularly in adults. The transverse areas of the medulla and especially of the dural tube were smaller compared with a normal population (p < 0.0001). There was no stenosis of the foramen magnum in patients with DD, but the spinal canal was narrowed. Degenerative changes were common. In all age groups, intervertebral discs were dark and disc heights were narrowed. Three (3%) patients (two children, one adult) had cervical kyphosis. Compression of the medulla was noted in association with severe cervical kyphosis in one child and one adult. Typical findings of the cervical spine in DD were exceptionally wide foramen magnum, narrowed spinal canal and early degenerative changes, and in older age groups, especially midcervically narrowed spinal canal. Severe cervical kyphosis caused medullar compression. The intervertebral discs developed abnormally. Abnormal disc structure may be one etiologic factor in the development of cervical kyphosis. Early and rapid progression of the degenerative changes is a normal finding in patients with DD, regardless of their age, and this also explains the stiffness of the cervical spine in clinical examination.     

The anatomic relation among the nerve roots, intervertebral foramina, and intervertebral discs of the cervical spine

STUDY DESIGN: An anatomic study of the cervical intervertebral foramina, nerve roots, and intradural rootlets performed using a surgical microscope. OBJECTIVES: To investigate the anatomy of cervical root compression, and to obtain the anatomic findings related to cervical foraminotomy for the treatment of cervical radiculopathy. SUMMARY OF BACKGROUND DATA: Cervical foraminotomy is a procedure performed frequently for the management of cervical radiculopathy. However, anatomic studies of cervical foraminotomy have not been fully elucidated. METHODS: In this study, 18 cadavers were obtained for the study of the cervical spine. All the soft tissues were dissected from the cervical spine. Thereafter, laminectomy and facetectomy were performed on C4 through T1 using a surgical microscope. The nerve roots and surrounding anatomic structures, including intervertebral discs and foramina, were exposed. In addition, the intradural rootlets and their intersegmental connections were observed. RESULTS: The shape of the intervertebral foramina approximated a funnel, the entrance zone being the most narrow part and the root sleeves conical, with their takeoff points from the central dural sac being the largest part. Therefore, compression of the nerve roots occurred at the entrance zone of the intervertebral foramina. Anteriorly, compression of the nerve roots was caused by protruding discs and osteophytes of the uncovertebral region, whereas the superior articular process, the ligamentum flavum, and the periradicular fibrous tissues affected the nerve posteriorly. The C5 nerve roots were found to exit over the middle aspect of the intervertebral disc, whereas the C6 and C7 nerve roots were found to traverse the proximal part of the disc. The C8 nerve roots had little overlap with the C7-T1 disc in the intervertebral foramen. The C6 and C7 rootlets passed two disc levels in the dural sac. Also, a high incidence of the intradural connections between the dorsal rootlets of C5, C6, and C7 segments was found. CONCLUSIONS: This study demonstrated the anatomy of the nerve roots, rootlets, and intervertebral foramina, and may aid in understanding the pathology of cervical radiculopathy. The presence of intradural connections between dorsal nerve roots and the relation between the course of the nerve root and the intervertebral disc may explain the clinical variation of symptoms resulting from-nerve root compression in the cervical spine. To perform cervical foraminotomy for cervical radiculopathy, it is necessary to understand the detailed anatomy of the intervertebral foramina thoroughly.     

Cervical spinal cord compression attributable to a calcified intervertebral disc in a patient with X-linked hypophosphatemic rickets: case report and review of the literature

OBJECTIVE AND IMPORTANCE: X-linked hypophosphatemic rickets is a common inherited phosphate-wasting disorder, but it is a rare cause of spinal cord compression. We present the first reported case of a calcified intervertebral disc causing spinal canal stenosis in X-linked hypophosphatemic rickets. CLINICAL PRESENTATION: A 44-year-old woman presented with paresthesia of her left arm and a loss of grip in both hands. Magnetic resonance imaging revealed a calcified intervertebral disc, as well as a posterior osteophytic bar causing marked cervical cord compression at C6/C7. INTERVENTION: An anterior cervical discectomy at C6/C7 and fusion with autologous bone graft were performed. The patient then exhibited significant improvement. CONCLUSION: A review of the 16 published cases demonstrates that thickening of the vertebral laminae, facet joint hypertrophy, and ossification of the intervertebral discs, posterior longitudinal ligament, and/or ligamentum flavum contribute to spinal canal stenosis in X-linked hypophosphatemic rickets. Those changes are caused by the disease itself and are unlikely to be related to long-term vitamin D treatment. Eleven of 16 patients were reported to have experienced favorable outcomes after surgery.     

颈椎病及其相关疾病的解剖学研究

目的探讨颈椎病和颈源性疾病的发病原因及脊椎错位的解剖学因素。方法应用16具成人尸体,在椎间联结完整和人工破坏椎周软组织的情况下,分别观察颈椎各向运动时的错位情况及错位对相关组织的影响。结果椎间联结破坏后,颈椎伸屈大于40°时可致前后滑脱式错位;旋转运动大于30°时可使椎间孔变形变窄,椎间孔变窄1/3时,神经根受到刺激,变窄到1/2时,神经根受到压迫。颈椎侧屈大于30°时,钩椎关节发生侧摆式错位,使椎动脉和交感神经受到影响。椎体前后滑脱式错位超过2～3mm时,可使已有椎管狭窄的脊髓受到压迫。结论在已有损伤、退变的脊椎运动时可引起错位,错位是引起脊椎病发病的主要原因之一,这为临床治疗脊椎相关疾病提供了解剖学基础。     

强直性脊柱炎合并颈椎无骨折脱位型脊髓损伤

目的 总结强直性脊柱炎合并颈椎无骨折脱位型脊髓损伤的临床特征、诊断和手术治疗。方法 1986～2004年，笔者手术治疗累及颈椎的强直性脊柱炎合并无骨折脱位型脊髓损伤27例。结果 本组27例中椎管内韧带骨化18例，脊髓损伤的原因依次为韧带骨化所致的椎管狭窄，椎间盘损伤和椎体后骨刺及椎间不稳定。术前均为不完全性损伤，非手术治疗不提高脊髓功能。术后脊髓ASIA分级平均改善1级。后路手术椎板切除率、出血量、手术时间、术后引流量明显高于不合并强直性脊柱炎的患者。前路手术可达到骨性融合。结论 强直性脊柱炎合并颈椎无骨折脱位型脊髓损伤一般为不完全性损伤，损伤的内因依次为椎管内韧带骨化所致的椎管狭窄、椎间盘损伤、椎间骨赘和椎间不稳定。适当的手术可改善脊髓功能。手术难度大，风险高。     

认识颈腰椎间盘病

目的　探讨颈腰椎间盘病的特点和诊断。方法　对近 6年中的颈腰椎盘突出症伴退变性椎管狭窄症和颈椎病并施行手术的 5 6例进行分析。结果　发现颈腰椎间盘突出症是本病的重要原因。结论　根据临床症状、体征和影像学检查 ,颈椎MRI和腰椎CT检查 ,是防范混淆和误诊的必要条件