Surgical treatment of cervical spondylotic radiculomyelopathy with abnormal involuntary neck movements. Report of three cases

Cervical spondylotic myelopathy usually arises in patients in their late 40s or early 50s, most frequently at the C5/6 and C6/7 levels. Recently, excellent results have been attained with microsurgery in cases of cervical spondylosis. On the other hand, treatment of cervical spondylotic myelopathy in patients with athetoid dystonic cerebral palsy entails several problems. The authors report three cases of such troublesome myelopathy. A 34-year-old male with severe athetoid movement showed cervical spondylotic myelopathy. Myelography and magnetic resonance (MR) imaging demonstrated compression of the spinal cord through the C3-C5 levels. A 47-year-old female with athetoid dystonic cerebral palsy presented myelopathy. Myelography and MR imaging showed instability and spinal cord compression at the C5/6 level. A 34-year-old male with spasmodic torticollis showed C6 radiculopathy due to cervical disc hernia at the C5/6 level. Cervical anterior decompression with interbody fusion brought temporary improvement in all the three patients. However, such problems as slippage of Halo-vest, difficulty in eating during Halo-vest fixation, relapse of neurological deficit, were experienced. Due to postoperative cervical instability, cervical laminectomy is considered to be contraindicated in such patients. Anterior decompression with bone fusion has been reported effective, but, if athetoid dystonia continues, there is a potential for myelopathic deterioration due to spondylotic changes adjacent to the fused vertebrae.     

Unstable cervical spine in athetoid cerebral palsy

The manifestations and pathomechanism of cervical instability of the athetoid neck in cerebral palsy (CP) patients was clarified in this study by means of static and dynamic x-ray analysis. Instability was defined as follows: 1) listhesis indicating anterior or posterior slip of more than 3 mm and/or 2) sagittal rotation between two vertebrae beyond the normal range measured by Penning. Cervical instability fitting this definition mainly took place in the upper and middle cervical disc levels, such as C3-4, C4-5, and/or occasionally C5-6. These coincide with the disc levels adjacent to the apex of the lordotic curve and/or those around the transitional vertebrae between the two reversed curves that render the cervical spine S-shaped in athetoid CP. A large facet angle at the apex vertebra facilitated anterior and/or posterior listhesis of the vertebrae. Conversely, a sudden decrease in the facet angle around the transitional vertebra in S-shaped curves precipitated deflection of the spine and increased sagittal rotation at this level. In addition to these structural abnormalities, rapid and repetitious neck movements seemed to accelerate the progression of cervical instability in athetoid CP patients.     

Cervical myelopathy in athetoid and dystonic cerebral palsy: retrospective study and literature review

The early onset of degenerative cervical lesions has been well described in patients suffering from athetoid or dystonic cerebral palsy. Myelopathy can occur and aggravate of their unstable neurological status. Diagnosis and treatment are delayed and disrupted by the abnormal movements. This retrospective study was implemented to evaluate the symptoms, the anatomical findings, and the surgical management of seven patients from 20 to 56 years old suffering from cervical myelopathy and athetoid or dystonic cerebral palsy. The mean delay in diagnosis was 15 months and the mean follow-up was 33 months. The initial symptoms were spasticity, limbs weakness, paresthesias and vesico-sphinteric dysfunction. In addition to abnormal movements, imaging demonstrated disc herniation, spinal stenosis and instability. All patients were managed surgically by performing simultaneous spinal cord decompression and fusion. Two patients benefited from preoperative botulinum toxin injections, which facilitated postoperative care and immobilization. Strict postoperative immobilization was achieved for 3 months by a Philadelphia collar or a cervico-thoracic orthosis. All patients improved functionally with a mean Japanese Orthopaedic Association score gain of 1.5 points, in spite of the permanent disabilities of the myelopathy. Complications occurred with wound infection, metal failure and relapse of cervical myelopathy at an adjacent level in one case each. All the previous authors advised against isolated laminectomy but no consensus emerged from the literature analysis. Spinal fusion is usually recommended but can be complicated by degenerative adjacent deterioration. Surgical management provides good outcomes but requires a long-term follow-up.     

Surgical outcomes of cervical myelopathy in patients with athetoid cerebral palsy

Purpose

Surgical treatment for cervical myelopathy with athetoid cerebral palsy remains unestablished. Instrumented fusion is reported to have good clinical results; however, there are no data of decompression surgery for this pathology in recent years. This study aimed to assess the surgical outcomes of laminoplasty with or without posterior instrumented fusion for cervical myelopathy in patients with athetoid cerebral palsy.

Methods

A multi-centre surgical series of patients with cervical myelopathy and athetoid cerebral palsy were enrolled in this study. All patients showed symptoms and signs suggestive of cervical myelopathy and underwent laminoplasty with or without instrumented fusion. The Japanese Orthopaedic Association (JOA) score, Barthel index (BI), and changes in the C2–C7 sagittal Cobb angle in the lateral plain radiograph were analysed.

Results

There were 25 patients (16 men and 9 women; mean age, 54.4 ± 10.8 years) with cervical myelopathy and athetoid cerebral palsy who underwent surgical treatment. The mean follow-up period was 41.9 ± 35.6 months. Overall, the BI significantly improved after surgery, whereas the JOA score and C2–C7 angle did not improve postoperatively. The recovery rate of the JOA score in the laminoplasty group was significantly higher than that of the fusion group (P = 0.02).

Conclusions

Cervical laminoplasty with or without instrumented fusion for treating cervical myelopathy due to athetoid cerebral palsy is effective in improving activities of daily living. Cervical laminoplasty may be an effective and less invasive surgical method for selective patients, especially for those with small involuntary movements and no remarkable cervical kyphosis nor instability.

     

Unilateral pallidal stimulation in cervical dystonia

Cervical dystonia (spasmodic torticollis) is a focal dystonia of the cervical region. Various treatment modalities have been performed with variable success rates. We present a 42-year-old woman complaining of involuntary head rotation for the last 3 years. Different medical treatments had been used for 3 years. Botulinum toxin injections resulted in temporary and moderate improvement for periods of 3-4 months. Pallidal stimulation was performed using a quadripolar electrode and a battery-operated programmable pulse generator. We conclude that a unilateral pallidal lesion or stimulation is an effective method of treatment in focal dystonia. The target must be the pallidum contralateral to the contracted sternocloidomastoid muscle. Deep brain stimulation is superior to lesioning because of the capability of manipulating the stimulation parameters which can modify the pallidotomy effect.     

Selective peripheral denervation in patients with spasmodic torticollis.

The results of selective peripheral denervation of the involved muscles in 35 patients with spasmodic torticollis are reported. We modified the operation first described by Bertrand. Follow-up was 3 months to 2.5 years in 34/35 patients. 73% noticed a significant improvement or disappearance of dystonia and pain following surgery and physiotherapy for 3 months postoperatively. Selective peripheral denervation is recommended for patients with spasmodic torticollis of at least 1-2 years duration which is resistant to conservative treatment. It may also be used in patients who do not respond to injection of botulinum A toxin or who develop resistance to this kind of therapy.     

手足徐动症继发颈椎病的手术治疗

【摘要】目的总结报告手足徐动症继发颈椎病的手术治疗结果,分析其发生特点与治疗原则。方法对32例手足徐动症继发颈椎病患者的症状、体征、手术方法及手术并发症等进行分析,并与同期收治的93例颈椎病患者进行比较,不同手术方式的效果之间也进行统计学比较。结果(1)手足徐动症继发颈椎病患者的平均年龄为37.94岁,颈椎病患者的平均年龄为52.48岁,两者比较差异有非常显著性意义(P<0.001)。(2)手术节段与颈椎病对照组比较差异有非常显著性意义(P<0.001)。(3)手术后症状、体征的改善结果与颈椎病对照组比较差异无显著性意义(P=0.068)。(4)29例行颈椎前路手术者中加用钛板固定的植骨愈合时间明显缩短(P=0.041)。结论手足徐动症继发颈椎病的特点为患者年轻且病变严重。颈椎前路减压、植骨融合加钛板内固定为最佳的手术方法。     

Long-term results of double-door laminoplasty for cervical stenotic myelopathy

STUDY DESIGN: A retrospective study of the long-term results from double-door laminoplasty (Kurokawa's method) for patients with myelopathy caused by ossification of the posterior longitudinal ligament and cervical spondylosis was performed. OBJECTIVE: To know whether the short-term results from double-door laminoplasty were maintained over a 10-year period and, if not, the cause of late deterioration. SUMMARY OF BACKGROUND DATA: There are few long-term follow-up studies on the outcome of laminoplasty for cervical stenotic myelopathy. METHODS: In this study, 35 patients with cervical myelopathy caused by ossification of the posterior longitudinal ligament in the cervical spine and 25 patients with cervical spondylotic myelopathy, including 5 patients with athetoid cerebral palsy, underwent double-door laminoplasty from 1980 through 1988 and were followed over the next 10 years. The average follow-up period was 153 months (range, 120-200 months) in patients with ossification of the posterior longitudinal ligament and 156 months (range, 121-218 months) in patients with cervical spondylotic myelopathy. Neurologic deficits before and after surgery were assessed using a scoring system proposed by the Japanese Orthopedic Association (JOA score). Patients who showed late deterioration received further examination including computed tomography scan and magnetic resonance imaging of the cervical spine. RESULTS: In 32 of the patients with ossification of the posterior longitudinal ligament and 23 of the patients with cervical spondylotic myelopathy, myelopathy improved after surgery. The improvement of Japanese Orthopedic Association scores was maintained up to the final follow-up assessment in 26 of the patients with ossification of the posterior longitudinal ligament and 21 of the patients with cervical spondylotic myelopathy. Late neurologic deterioration occurred in 10 of the patients with ossification of the posterior longitudinal ligament an average of 8 years after surgery, and in 4 of the patients with cervical spondylotic myelopathy, including the 3 patients with athetoid cerebral palsy, an average of 11 years after surgery. The main causes of deterioration in patients with ossification of the posterior longitudinal ligament were a minor trauma in patients with residual cervical cord compression caused by ossification of the posterior longitudinal ligament and thoracic myelopathy resulting from ossification of the yellow ligament in the thoracic spine. CONCLUSIONS: The short-term results of laminoplasty for cervical stenotic myelopathy were maintained over 10years in 78% of the patients with ossification of the posterior longitudinal ligament, and in most of the patients with cervical spondylotic myelopathy, except those with athetoid cerebral palsy. Double-door laminoplasty is a reliable procedure for individuals with cervical stenotic myelopathy.     

矩形钛质颈椎椎间融合器在颈椎前路融合术中的应用以及近期效果观察

目的 探讨矩形钛质颈椎椎间融合器(SynCage-C)在颈椎前路椎问盘切除、椎体间植骨融合术中的应用价值。方法应用SynCage-C行颈椎病前路椎间盘切除后椎体间融合19例,平均随访9个月(6～14个月)。结果本组均为颈椎病患者,脊髓型16例、神经根型3例。平均年龄48岁(34～66岁),男性13例,女性6例。单节段融合16例,双节段3例。每节段平均手术时问40min,平均出血60ml。术后平均围领保护8．5周。3个月时颈椎侧位X线片显示融合良好。19例患者中仅有1例因戴围领超过3个月而感颈部僵直,1例有短暂髂骨取骨区疼痛。本组未见融合节段曲度不良、反曲、Cage下沉、融合不良。结论SynCage-C操作简单,可以有效恢复和维持椎间隙高度,植入后即刻稳定,椎间融合良好,取骨区创伤小。     

Circumferential cervical surgery for spondylostenosis with kyphosis in two patients with athetoid cerebral palsy.

BACKGROUND: Patients with athetoid cerebral palsy may develop severe degenerative changes in the cervical spine decades earlier than their normal counterparts due to abnormal cervical motion. METHODS: Two patients, 48 and 52 years of age, presented with moderate to severe myelopathy (Nurick Grades IV and V). MR and 3-dimensional CT studies demonstrated severe spondylostenosis with kyphosis in both patients. This necessitated multilevel anterior corpectomy with fusion (C2-C7, C3-C7) using fibula and iliac crest autograft and Orion plating, followed by posterior wiring, fusion using Songer cables, and halo placement. RESULTS: Postoperatively, both patients improved, demonstrating only mild or mild to moderate (Nurick Grades II and III) residual myelopathy. Although both fused posteriorly within 3.5 months, the patient with the fibula graft developed a fracture of the anterior C7 body with mild anterior graft migration, and inferior plate extrusion into the C7-T1 interspace. However, because he has remained asymptomatic for 9 months postoperatively, without dysphagia, removal of the plate has not yet been necessary. CONCLUSIONS: Patients with athetoid cerebral palsy should undergo early prospective cervical evaluations looking for impending cord compromise. When surgery is indicated, circumferential surgery offers the maximal degree of cord decompression and stabilization with the highest rate of fusion.     

Surgical treatment for cervical spondylotic myelopathy associated with athetoid cerebral palsy

There have been several reports on surgical interventions in patients with adult cervical spondylotic myelopathy associated with athetoid cerebral palsy; however, the long-term effectiveness of these interventions has not been demonstrated. We have performed surgical treatments — posterior fusion with wave-shaped rods and anterior interbody fusion with internal fixators — in 20 patients. The present study included 17 of these patients, 16 men and 1 woman, and their mean follow-up period was 8.6 years (range, 5–15.5 years). One year after surgery, walking ability was improved in 14 patients. Pain in the upper extremities and muscle weakness of the deltoid were alleviated in all patients. One patient showed recurrence of myelopathy after 8.5 years' follow-up. Our surgical technique is effective in patients with cervical spondylotic myelopathy secondary to athetoid cerebral palsy, even in those with severe involuntary movements. Postoperative rigid external fixations are not required. Received: July 27, 1999 / Accepted: March 7, 2000     

颈动脉鞘交感神经网剥离术治疗手足徐动型脑瘫

目的:回顾性总结颈动脉鞘交感神经网剥离术治疗手足徐动型脑瘫的效果,并对其治疗机制进行探讨。方法:自1998年至2006年,对560例手足徐动型脑瘫患者施行了颈动脉鞘交感神经网剥离术,其中男391例,女169例,年龄3～25岁,平均10.7岁。术后1周对患者进行观察评估,术后6个月和1年时进行门诊或电话随访。观察评估内容包括头颈部活动、双手协调能力、站立及步态、肌张力、流涎、斜视、眼球运动、语言清晰度等。效果明显者权重值为1分,有改善但不甚满意者权重值为0.5分,无效为0分。结果:术后1年560例患者中308例头颈部活动改善(占55%),403例双手协调能力改善(占72%),229例站立及步态改善(占41%),185例肌张力改善(占33%),252例流涎改善(占45%),174例斜视、眼球运动改善(占31%),251例语言清晰度改善(占45%),310例家长对手术结果总体满意(占55%)。术后6个月有效率高于术后1年。结论:手足徐动型脑瘫患者接受颈动脉鞘交感神经网剥离术治疗后部分患者在手足徐动症状、手指协调能力、肌张力、流涎以及语言发音方面确有改善。其机制可能与减少交感神经兴奋性,脑组织微循环改变及脑潜能神经元激活有关。仍需要长期随访观察。     

脊髓型颈椎病术后颈椎间盘突出自行消失的原因探讨

目的：了解脊髓型颈椎病颈椎管扩大成型术后，颈椎间盘突出自行消失的原因并由此提出脊髓型颈椎病新的致病学说。方法：自１９９４年６月～１９９８年５月对脊髓型颈椎病行后路单开门椎管扩大成型术患者行临床及ＭＲＩ检查。结果：８例患者，术后４～１３个月，平均５．８个月复查时，颈椎ＭＲＩ检查发现，其术前ＭＲＩ显示的颈椎间盘突出影像消失，相应部位硬膜、脊髓无压迫。结论：（１）颈椎间盘退变突出后，出现颈椎节段性不稳定，刺激突出间盘周围组织，产生炎症性反应；（２）颈椎间盘突出、颈椎退变或颈椎管狭窄，致硬膜外腔压力增高，导致硬膜外静脉回流障碍，出现硬膜外静脉瘀滞、怒张。上述为脊髓型颈椎病发病的又一可能因素     

A case of the myelitis due to Toxocara canis infection complicated with cervical spondylosis

A 59-year-old male had suffered from numbness of the hands for 7 months. With a diagnosis of cervical spondylosis, he had been treated conservatively at a nearby clinic. After he fell off his bicycle, the numbness intensified and limb weakness developed. Cervical MRI revealed spinal cord compression at the C4/5 and C5/6 levels due to cervical spondylosis with prominent edema in the spinal cord spreading from the C4 to C6 level. The edema was very serious. Therefore, we suspected that the traumatic spinal injury underlying the cervical spondylosis was complicated by another disease. Cervical spinal angiography revealed no apparent vascular disorder. Contrast enhanced MRI showed a small enhanced area in the spinal cord at the C5 level. Because of the rapid progression of gait disturbance, expansive laminoplasty was performed without further examination. Although remarkable amelioration of the symptoms was seen just after the surgery, the symptoms worsened again about 1 month later. The patient's clinical history was reconsidered, revealing that he likes raw bovine liver. Serological examination, because of suspicion of parasitic infection showed elevated titers of anti-Toxocara canis antibody in the serum and cerebrospinal fluid. Administration of albendazole improved the clinical symptoms, and normalized the serological and MRI findings. Myelitis due to T canis infection is a rare disease. For an early and accurate diagnosis, it is important to be fully aware of this disease and to include detailed information on food preferences and pet-keeping in the process of compiling a clinical history.     

Long-term surgical outcomes of cervical myelopathy with athetoid cerebral palsy

Purpose

To understand the long-term surgical outcomes and prognostic factors for the operative treatment of cervical myelopathy (CM) in patients with athetoid cerebral palsy (ACP).

Methods

We retrospectively reviewed 24 patients with ACP who underwent surgery for CM at our hospital between March 2002 and June 2008. All patients had more than 5 years follow-up. Anterior fusion (11 patients), posterior fusion (1 patient), or combined anterior and posterior (AP) fusion (7 patients) and C1-2 fusion (5 patients) surgeries were performed. Surgical outcomes (average follow-up 102 months), as assessed using modified JOA (mJOA) scores, the Neck Disability Index (NDI), and a visual analog scale (VAS) were compared between the preoperative and postoperative states.

Results

Preoperatvie cervical kyphosis decreased mJOA scores significantly. Long-term follow-up clinical outcomes demonstrated that 10 patients showed favorable (excellent and good) outcomes and 11 patients had non-favorable (fair and worse) outcomes. According to the mJOA scores, patients showed postoperative improvement (7.10–10.45). NDI decreased from 68.46 to 31.66. A second operation was done in seven cases due to instrument failure, progressive kyphotic deformities and adjacent segment degeneration. A preoperative botulinum toxin injection significantly decreased (p < 0.05) the incidence of a second operation.

Conclusions

Patients with ACP have high incidence of instrument failure. Strong surgical fixation, bone fusion and perioperative immobilizations using botulinum toxin injection should be carefully planned preoperatively.     

Peripheral neurotomy for torticollis: a new approach

Most of spasmodic torticollis is classifical as cervical dystonia and the treatment of choice is chemical or surgical denervation. There are two major procedures for surgical denervation, intradural ventral rhizotomy and extradural peripheral neurotomy (Bertrand procedure). Both have advantages and disadvantages. The authors have modified these procedures to minimize the complications, with unilateral intradural ventral rhizotomy of C1 and C2, extradural denervation of the C3-C6 posterior rami, and contralateral peripheral sectioning of the branches of the spinal accessory nerve to the sternocleidomastoid muscle. 30 patients underwent this modified operation (Group A) and the results were compared with those in a matched control group of 20 patients who underwent the traditional Bertrand procedure (Group B). Only one patient in Group A showed a sensory deficit in the C2 area, while all the patients in Group B had C2 sensory disturbance. Pre- and postoperative rating scores did not differ between the two groups. The intraoperative blood loss was significantly smaller in Group A. Compared with the traditional Bertrand's operation, our procedure involves fewer complications and significantly less intraoperative blood loss.     

A case of postoperative palsy of the brachial plexus and facial nerve caused by use of cervical collar during lung surgery

We report a case of palsy of the brachial plexus and facial nerve manifested after surgery for lung cancer in a 77-year-old female who also had a retroodontoid pseudotumor. Lobectomy was conducted with the patient in a left lateral position. For the purpose of cervical stabilization, the orthopedic surgeon recommended the use of a cervical collar. During the operation, both of her arms were abducted at nearly 80 degrees. On the second postoperative day, the patient complained of sensory disturbances in the lateral area of her left brachium and forearm, which are innervated by the 5th and 6th cervical spinal nerves from the brachial plexus. She also complained that she could not abduct and flex her left shoulder, and could not flex her left elbow at all. Simultaneously, facial nerve palsy was observed in her left lower lip. During the operation, her shoulders were forcibly rotated internally and were extremely abducted, resulting in a narrowed distance between the lower jaw and the shoulder and stretching of the brachial plexus. Under this situation, the cervical collar was pressing strongly upon her neck and lower jaw, which might have produced the brachial plexus complication and facial nerve palsy.     

Dropped head syndrome associated with cervical spondylotic myelopathy

We report a case of an 80-year-old woman with dropped head syndrome associated with cervical spondylotic myelopathy. She could not keep her cervical spine in a neutral position for >1 minute. She had a disturbed gait and severe kyphotic deformity in her thoracic spine. Magnetic resonance imaging revealed severe compression of the spinal cord due to cervical spondylotic change. Laminoplasty from C2 through C6 levels was performed. One year after operation, she could keep her cervical spine in a neutral position easily. Her gait was also improved. The symptoms did not recur during 4 years of follow-up. We surmise that to maintain daily activities, she had to extend her cervical spine owing to the thoracic kyphotic deformity, resulting in compression of the spinal cord. The compression led to weakening of the cervical extensor muscles. Cervical laminoplasty was effective.     

颈椎节段不稳在交感型颈椎病中的作用

目的：探讨颈椎不稳定在交感型颈椎病中的作用及手术治疗的效果。方法：回顾伴有交感型颈椎病表现的混合型颈椎病12例,观察颈椎不稳定、围领制动效果,MRI表现及手术的治疗效果等指标。结果：颈椎X线表现：7例出现颈椎不稳定。围领制动效果：5例经围领制动后症状明显缓解,7例经围领制动后症状轻度缓解。MRI：7例在不稳定节段脊髓可见异常信号。手术效果：7例术后交感神经症状明显缓解,治疗效果为优,7例均为节段不稳的患者;4例术后交感神经症状轻度缓解,治疗效果为良;1例术后交感神经症状稍有缓解,治疗效果为中。结论：颈椎不稳定是交感型颈椎病发病的重要因素,手术治疗颈椎不稳所致的交感型颈椎病有良好的疗效。     

A case of cerevical canal stenosis accompanied with congenital cervical fusion and extracranial occlusion of vertebral artery--a clinical and embryological study (author's transl)

A case of cervical canal stenosis accompanied by congenital cervical fusion and extracerebral occlusive disease of the verebral artery was reported. A 39-year-old male was admitted to our hospital on June 5, 1976, because of his shoulder strain, motor weakness and numbness of his left hand, and gait disturbance for a couple of months. Neurological examination disclosed spastic paraparesis with positive pyramidal signs in the four extremities which was greater on the left side, and the superficial and deep sensations were diminished below C-4 dermatomes bilaterally. Spinal tap revealed crystal clear fluid under an initial pressure equivalent to 120 mm of water with a protein content of 20 mg/dl. Plain X-P and laminogram of the cervical spine showed congenital fusion of C 2-3, cervical canal stenosis and cervical spondylosis. Posterior spurring of C 3-4 was demonstrated only on the laminogram. Myelogram showed incomplete myelographic block at the site of C 3-4-5. The left retrograde brachial angiogram disclosed occlusion of the vertebral artery at the site of C3-4. where the proxymal vertebral artery anastomosed with the well developed muscular branch of the vertebral artery, taking a tortuous course at the leve of the transverse foramen of the atlas, and were opacified the distal vertebral artery and basilar artery. Each collateral flow extending from the deep cervical artery and ascending cervical artery anastomosed with the proxymal and distal portion of the occluded vertebral artery. In spite of conservative treatment for two weeks, the cord compression syndromes rather deteriorated. Posterior decompression, that is, C 2-7 laminectomy and C 3-4 partial facetectomy were performed for relieving the symptoms. The postoperative course was uneventfull and there was progressive improvement of the sensory, motor and gait disturbance. The relationship betwen the cervical canal stenosis and cervical spondylosis and their clinco-radiological problem were discussed. The close embryological relationship was very suggestive of the pathogenesis between the cervical bony lesion and congenital cervical fusion and the occlusive vascular lesion of the vertebral artery.