Alignment Of Cervical Spine Research Articles

Les céphalées cervicogéniques

To investigate the feasibility and effect of a multimodal program for improving chronic cervicogenic headache (CGH) via the addition of sagittal cervical spine alignment correction.Pilot, parallel-group, randomized controlled trial.60 patients with CGH, straightening of the cervical lordosis, and forward head posture (FHP) were randomly assigned using permuted-block randomization either to a control (n = 30) or an experimental group (n = 30).Subjects in both groups received a multimodal program where the denneroll cervical spine extension traction orthotic was added to the experimental group only. Feasibility was assessed through recruitment rate, compliance rate, adherence rate, safety, and global satisfaction in addition to clinical outcome measures: FHP distance, cervical lordosis, headache frequency, headache disability inventory (HDI), headache impact test-6 (HIT-6), and daily defined dose (DDD). Evaluations were performed at: baseline, 10 weeks, 1 year follow up, and 2-year follow up. The assessor was blind to group allocation for all measured outcomes.The recruitment rate was 60%, 78 % out of them completed the entire study. The recruited participants complied with 98% of the required visits. No adverse events were recorded and greater overall satisfaction with the interventions was reported. Greater improvements were found for the experimental group's cervical lordosis (f = 259.9, P< < .001) and FHP (f = 142.5, P< < .001). At 10 weeks, both groups showed equal improvements in CGH outcomes: headache frequency (P = 0.07), HDI (P = 0.07), HIT-6 (P = .2), and DDD (P = .3). In contrast, at the 1-year and 2-year follow up, between group differences were found for all CGH outcomes, P < .00, indicating greater improvement in the experimental group.The results indicated feasibility for recruitment rate, compliance rate, exercise session adherence, safety, and global satisfaction. At 1-year and 2-year follow-up, the addition of the denneroll orthotic device revealed positive influence on CGH management outcomes.The trial was retrospectively registered with the Pan African Clinical Trial Registry (PACTR201605001650300).

Comparison of 3 Fusion Techniques in the Treatment of the Degenerative Cervical Spine Disease. Is Stand-Alone Autograft Really the “Gold Standard?”

A prospective study. The aim of this study was to compare the 3 different methods of interbody fusion of the cervical spine-autograft in stand-alone technique, autograft with anterior plate, and polyetheretherketone cage supported by anterior plate. The clinical and radiological data obtained were analyzed and discussed. Although degenerative cervical spine disease has been treated by an anterior approach for more than 50 years, there is not one generally accepted operative approach. There is a very low-quality evidence of little or no difference in pain relief between each of the techniques. Iliac crest autograft still seems to be the "gold standard" for interbody fusion. Prospective study collecting clinical and radiological data of 81 patients undergoing anterior cervical interbody fusion, in which the interbody fusion of 1 or 2 motion segments from C3 to C7 was done by any of the 3 techniques--stand-alone insertion of autograft (group 1: 28 patients), autograft and anterior plate (group 2: 18 patients), and polyetheretherketone cage filled with beta-tricalcium phosphate and plate (group 3: 29 patients). Patients were followed for 2 years after surgery. Significant interaction of relative height in the segment and time was found (P < 0.001). The values of the relative height of stand-alone autograft dropped below 95% of initial height and the values of the other 2 groups remained above 105%. Significant interaction of time and group was found for Cobb S angles (P < 0.001). Values of group 1 decreased substantially and remained significantly lower than values of other 2 groups. Fusion rate was 100% in all groups. Neck Disability Index group and time interaction was found (P = 0.023). During postoperative follow-up, group 1 scored in all controls higher than the other 2 groups, but differences were not significant. Visual analogue scale showed effect of time (P < 0.001). This was due to a smaller improvement of patients in group 1 during the whole follow-up in comparison with the other 2 groups. Highest proportion of unsatisfied patients was in group 1 compared with the other 2 groups after 2 years (P = 0.034). Significantly worse radiological and clinical results after 2 years of follow-up were achieved using stand-alone autograft technique in comparison with autograft supported by anterior plating similarly as in comparison with cage implant and anterior plating. Using artificial fusion substrate together with plate and cage can offer the same clinical and radiological results such as iliac autograft and plating. Anterior plating seems to be an important factor influencing the postoperative cervical spine alignment and also the clinical outcome.

Impact of lateral mass anatomic variation on ideal polyaxial screw head mobility: technical considerations

Objective. To assess optimal angulation characteristics of lateral mass screws for subaxial (C3 to C6) fixation of the cervical spine in the neutral position. Background. In the typical Magerl or Anderson placement technique, the screw trajectory is ideally parallel to the facet joint. For the rod and screw to align properly, the screw head must rotate enough to become perpendicular to the rod. If the optimal angle for the screw head is limited by the screw design, abnormal torsional forces will be generated at the rod/screw interface inducing kyphosis. In this paper, we examined the spinal anatomy in patients with normal CTs to determine the necessary range of motion between tulip head and screw to prevent forced persuasion and abnormal cervical spine alignment. Methods. We examined subaxial radiographs of 292 vertebrae from C3 to C6 in 73 normal subjects. Computed tomography (CT) scans of the cervical spine with multiplanar reconstructions were evaluated in the axial and sagittal planes. A planned screw entry angle of 30° based upon the midpoint of the lateral mass was used in the axial plane, and parallel to the facet joint in the sagittal plane. The screw head angle (SHA) was then calculated from this 3D measured angle. Results. The measured SHA ranged from 27 to 60°. The average SHA was 43.8°. The average SHA was not significantly different between the levels measured with consistent range and standard deviation. Seventy-six percent (223/292) of levels measured required a SHA >40°, and 12% (36/292) required a SHA >50°. Conclusion. The authors recommend using cervical instrumentation systems that allow for at least 55° of freedom of the polyaxial head to prevent abnormal segmental forces. In systems with lesser angulation, technique modifications must be applied to prevent translational forces.

Use sagittal reconstruction CT for making decisions regarding the surgical strategy for cervical ossification of the posterior longitudinal ligament

Use sagittal reconstruction CT to verify the surgical strategy for cervical ossification of the posterior longitudinal ligament (OPLL). A retrospective study of 161 patients (106 males and 55 females) who had undergone surgery for OPLL from July 2007 to November 2010 was performed. The mean age at surgery was 54.5 years (range from 26 to 77 years). The mean follow-up period was 28 months (12 - 54 months). There were 40 patients accept anterior approach surgeries (anterior group) which include 14 cases of anterior cervical corpectomy and fusion and 26 cases of anterior cervical discectomy and fusion. There were 120 patients accept posterior approach surgeries (posterior group) which was spinous process-splitting laminoplasty for cervical myelopathy using coralline hydroxyapatite. One patient accepted combined anterior and posterior approach. According to the sagittal reconstruction CT, the main reason for spinal cord compression was cervical disc herniation in anterior group, and OPLL in posterior group. The level of spinal cord compression was 1 to 2 levels in anterior group, and 1 to 5 levels in posterior group with a major of 2 to 4 levels. As the classification of OPLL, segmental type and circumscribed type were major of segmental type in anterior group and all of the four types were in posterior group, the distribution of each type was average. The patients of posterior group were classified into two groups according to the modified K-line classification, and clinical results were compared between the two groups. The modified K-line was defined as a line that connects the midpoints of the spinal canal at C(2) and C(7) on sagittal CT myelography. Compression to the spinal cord did not exceed the K-line in the modified K-line(+) group and did exceed it in the modified K-line(-) group. Clinical data were compared using t-test or χ(2) test. Correlation analysis was used to determine the relationships of C(2)-C(7) angulation between sagittal reconstruction CT and neutral position X-ray. The patient of anterior group had better recovery rate of the JOA score (72% ± 27%) than the posterior group (59% ± 35%) at the latest follow-up (t = 2.238, P = 0.027). In posterior group, the patients of modified K-line(+) group had better recovery rate of the JOA score (63% ± 37%) than the K-line(-) group (49% ± 30%) at the latest follow up (t = 2.150, P = 0.034). The C(2)-C(7) angulation on sagittal reconstruction CT was 11° ± 9° which has significantly correlated with the C(2)-C(7) angulation on neutral position X-ray which was 10° ± 10° (r = 0.947, P < 0.01). Considering the selection of surgical approach, it should be combined with the main clinical diagnosis for spinal cord compression, the level of compression, the classification of OPLL and the kyphotic alignment of the cervical spine. The modified K-line is a simple and practical tool for making decisions regarding the surgical strategy for cervical OPLL patients.

Long Term Results of Anterior Corpectomy and Fusion for Cervical Spondylotic Myelopathy

BackgroundResults showed good clinical outcomes of anterior corpectomy and fusion (ACCF) for patients with cervical spondylotic myelopathy (CSM) during a short term follow-up; however, studies assessing long term results are relatively scarce. In this study we intended to assess the long term clinical and radiographic outcomes, find out the factors that may affect the long term clinical outcome and evaluate the incidence of adjacent segment disease (ASD).MethodsThis is a retrospective study of 145 consecutive CSM patients on ACCF treatment with a minimum follow-up of 5 years. Clinical data were collected from medical and operative records. Patients were evaluated by using the Japanese Orthopedic Association (JOA) scoring system preoperatively and during the follow-up. X-rays results of cervical spine were obtained from all patients. Correlations between the long term clinical outcome and various factors were also analyzed.FindingsNinety-three males and fifty-two females completed the follow-up. The mean age at operation was 51.0 years, and the mean follow-up period was 102.1 months. Both postoperative sagittal segmental alignment (SSA) and the sagittal alignment of the whole cervical spine (SACS) increased significantly in terms of cervical lordosis. The mean increase of JOA was 3.8±1.3 postoperatively, and the overall recovery rate was 62.5%. Logistic regression analysis showed that preoperative duration of symptoms >12 months, high-intensity signal in spinal cord and preoperative JOA score ≤9 were important predictors of the fair recovery rate (≤50%). Repeated surgery due to ASD was performed in 7 (4.8%) cases.ConclusionsACCF with anterior plate fixation is a reliable and effective method for treating CSM in terms of JOA score and the recovery rate. The correction of cervical alignment and the repeated surgery rate for ASD are also considered to be satisfactory.

Maintaining Neutral Sagittal Cervical Alignment After Football Helmet Removal During Emergency Spine Injury Management

Descriptive laboratory study. To determine whether the placement of padding beneath the occiput after helmet removal is an effective intervention to maintain neutral sagittal cervical spine alignment in a position comparable with the helmeted condition. Current on-field recommendations for managing football athletes with suspected cervical spine injuries call for face mask removal, rather than helmet removal, because the combination of helmet and shoulder pads has been shown to maintain neutral cervical alignment. Therefore, in cases when helmet removal is required, recommendations also call for shoulder pad removal. Because removal of equipment causes motion, any technique that postpones the need to remove the shoulder pads would reduce prehospital motion. Four lateral radiographs of 20 male participants were obtained (age = 23.6 ± 2.7 years). Radiographs of participants wearing shoulder pads and helmet were first obtained. The helmet was removed and radiographs of participants with occipital padding were obtained immediately and 20 minutes later and finally without occipital padding. Cobb angle measurements for C2-C6 vertebral segments were determined by an orthopedic spine surgeon blinded to the study's purpose. Intraobserver reliability was determined using intraclass coefficient analysis. Measurements were analyzed using a 1×4 repeated-measures analysis of variance and post hoc pairwise comparisons with Bonferroni correction. Intraobserver analysis showed excellent reliability (intraclass correlation = 1.0; 95% confidence interval [CI], 0.999-1.0). Repeated-measures analysis of variance detected significant differences (F(3,17) = 13.34; P < 0.001). Pairwise comparisons revealed no differences in cervical alignment (all measurements reported reflect lordosis) when comparing the baseline helmeted condition (10.1° ± 8.7°; 95% CI, 6.0-14.1) with the padded conditions. Measurements taken after removal of occipital padding (14.4° ± 8.1°; 95% CI, 10.6-18.2) demonstrated a significant increase in cervical lordosis compared with the immediate padded measurement (9.5° ± 6.9°; 95% CI, 6.3-12.7; P = 0.011) and the 20-minute padded measurement (6.5° ± 6.8°; 95% CI, 3.4-9.7; P < 0.001). Although face mask removal remains the standard, if it becomes necessary to remove the football helmet in the field, occipital padding (along with full body/head immobilization techniques) may be used to limit cervical lordosis, allowing safe delay of shoulder pad removal.

The mid-term effects of Bryan cervical disc prosthesis on sagittal alignment of overall cervical spine and the functional spinal unit

To investigate the mid-term radiological outcome of sagittal alignment of overall cervical spine and the functional spinal unit after replacement surgery with Bryan cervical disc prosthesis. Eighteen patients with cervical disc disorder were performed cervical disc replacement with 20 Bryan discs from November 2005 to May 2010, including single-level 16 cases and bi-level 2 cases. The patient consisted of 13 males and 5 females with age ranging from 38 to 59 years (average, (47 ± 6) years). Fourteen cases with overall cervical lordotic alignment and segmental lordotic alignment per-operatively (group 1) and 4 others with segmental kyphotic alignment and overall cervical kyphotic alignment per-operatively (group 2). The overall sagittal alignment (C(2-7)) and segmental sagittal alignment were measured pre-operatively, post-operatively and at final follow-up to evaluate the outcome. All cases obtained the follow-up with an average of (24 ± 5) months (range 12 to 53 months). To the mean overall cervical alignment, there were 9.9° ± 1.9° per-operatively, 12.8° ± 2.1° post-operatively and 11.6° ± 1.8° at final follow-up in group 1 and -1.8° ± 0.8° per-operatively, 7.3° ± 1.3° post-operatively and 5.0° ± 2.1° at final follow-up in group 2. There were statistical significance between per-operatively and post-operatively (t = -2.987 and -5.058, P < 0.05) and no statistical significance between post-operatively and final follow-up (P > 0.05) in both groups. To the mean segmental alignment there were 2.6° ± 0.8° per-operatively, 5.4° ± 1.0° post-operatively and 4.3° ± 0.9° at final follow-up in group 1 and -3.0° ± 0.8° per-operatively, 3.8° ± 1.3° post-operatively and 0.3° ± 2.8° at final follow-up in group 2. There were statistical significance between per-operatively and post-operatively in both groups (t = -3.829 and -4.086, P < 0.05) and between post-operatively and final follow-up in group 1 (t = 2.630, P < 0.05)but not in group 2 (P > 0.05). The Bryan cervical disc prosthesis has a good mid-term outcome for maintaining sagittal alignment of overall cervical spine and the functional spinal unit. Long-term follow-up should be needed to assess the long-term functionality of the prosthesis.

Comparison of 4 Airway Devices on Cervical Spine Alignment in a Cadaver Model With Global Ligamentous Instability at C5–C6

Human cadaveric study using various intubation devices in a cervical spine instability model. We sought to evaluate various intubation techniques and determine which device results in the least cervical motion in the setting of a global ligamentous instability model. Many patients presenting with a cervical spine injury have other injuries that may require rapid airway management with endotracheal intubation. Secondary neurologic injuries may occur in these patients because of further displacement at the level of injury, vascular insult, or systemic decrease in oxygen delivery. The most appropriate technique for achieving endotracheal intubation in the patient with a cervical spine injury remains controversial. A global ligamentous instability at the C5-C6 vertebral level was created in lightly embalmed cadavers. An electromagnetic motion analysis device (Liberty; Polhemus, Colchester, VT) was used to assess the amount of angular and linear translation in 3 planes during intubation trials with each of 4 devices (Airtraq laryngoscope, lighted stylet, intubating LMA, and Macintosh laryngoscope). The angular motions measured were flexion-extension, axial rotation, and lateral bending. Linear translation was measured in the medial-lateral (ML), axial, and anteroposterior planes. Intubation was performed by either an emergency medical technician or by a board-certified attending anesthesiologist. Both time to intubate as well as failure to intubate (after 3 attempts) were recorded. There was no significant difference shown with regards to time to successfully intubate using the various devices. It was shown that the highest failure-to-intubate rate occurred with use of the intubating LMA (ILMA) (23%) versus 0% for the others. In flexion/extension, we were able to demonstrate that the Lightwand (P = 0.005) and Airtraq (P = 0.019) resulted in significantly less angular motion than the Macintosh blade. In anterior/posterior translation, the Lightwand (P = 0.005), Airtraq (P = 0.024), and ILMA (P = 0.021) all caused significantly less linear motion than the Macintosh blade. In axial rotation, the Lightwand (P = 0.017) and Airtraq (P = 0.022) resulted in significantly less angular motion than the Macintosh blade. In axial translation (P = 0.037) and lateral bending (P = 0.003), the Lightwand caused significantly less motion than the Macintosh blade. In a cadaver model of C5-C6 instability, the greatest amount of motion was caused by the most commonly used intubation device, the Macintosh blade. Intubation with the Lightwand resulted in significantly less motion in all tested parameters (other than ML translation) as compared with the Macintosh blade. It should also be noted that the Airtraq caused less motion than the Macintoshblade in 3 of the 6 tested planes. There were no significant differences in failure rate or the amount of time it took to successfully intubate in comparing these techniques. We therefore recommend the use of the Lightwand, followed by the Airtraq, in the setting of a presumed unstable cervical spine injury over the Macintosh laryngoscope.

Age-related changes in osseous anatomy, alignment, and range of motion of the cervical spine. Part I: Radiographic data from over 1,200 asymptomatic subjects

This study aimed to establish radiographic standard values for cervical spine morphometry, alignment, and range of motion (ROM) in both male and female in each decade of life between the 3rd and 8th and to elucidate these age-related changes. A total of 1,230 asymptomatic volunteers underwent anteroposterior (AP), lateral, flexion, and extension radiography of the cervical spine. There were at least 100 men and 100 women in each decade of life between the 3rd and 8th. AP diameter of the spinal canal, vertebral body, and disc were measured at each level from the 2nd to 7th cervical vertebra (C2-C7). C2-C7 sagittal alignment and ROM during flexion and extension were calculated using a computer digitizer. The AP diameter of the spinal canal was 15.8 ± 1.5 [mean ± standard deviation (SD)] mm at the mid-C5 level, and 15.5 ± 2.0 mm at the C5/6 disc level. The disc height was 5.8 ± 1.3 mm at the C5/6 level, which was the minimum height, and the maximum height was at the C6/7 level. Both the AP diameter of the spinal canal and disc height decreased gradually with increasing age. The C2-C7 sagittal alignment and total ROM were 13.9 ± 12.3° in lordosis and 55.3 ± 16.0°, respectively. The C2-C7 lordotic angle was 8.0 ± 11.8° in the 3rd decade and increased to 19.7 ± 11.3 in the 8th decade, whereas the C2-C7 ROM was 67.7 ± 17.0° in the 3rd decade and decreased to 45.0 ± 12.5 in the 8th decade. The extension ROM decreased more than the flexion ROM, and lordotic alignment progressed with increasing age. There was a significant difference in C2-C7 alignment and ROM between men and women. The standard values and age-related changes in cervical anatomy, alignment, and ROM for males and females in each decade between the 3rd and 8th were established. Cervical lordosis in the neutral position develops with aging, while extension ROM decreases gradually. These data will be useful as normal values for the sake of comparison in clinical practice.

Detailed Study of Graft Sinking and Worsening of the Fused Segment Angle in Patients With Cervical Disease Treated With the Williams-Isu Method

Detailed changes involved in the worsening of the fused segment angle were assessed after application of the Williams-Isu method using autologous bone grafts from cervical vertebral bodies in 30 patients with cervical disease treated by single-level anterior fusion. The mean follow-up duration was 25.4 months. The fused segment angle was measured on serial radiographs. Whole cervical spine alignment changed from 12.8° to 9.9°. The alignment of the fused segment worsened by mean 3.3°. To elucidate the characteristics of worsening of the fused segment, the 30 patients were divided into 2 groups: Group I (n = 20) without and Group II (n = 10) with postoperative worsening of the fused segment. The loss in the fused segment angle was significantly greater in Group II (8.0°) than Group I (0.9°). Preoperative range of motion and disc height were significantly greater in Group II than Group I. Worsening of the fused segment angle occurred within 1 month in Group I, whereas stabilization was observed after 3 months in Group II. Graft subsidence was primarily posterior and inferior. Our results indicate that the preoperative range of motion and disc height of the fused segment must be considered to prevent worsening in that segment after anterior fusion. Such detailed information is useful for the selection and postoperative monitoring of patients eligible for treatment by the Williams-Isu method.

The Influence of Cervical Spine Alignment on the Quality of Life after Cervical Discectomy and Interbody Fusion Using Peek Cages in Patients with Cervical Disc Disease

Though Anterior Cervical Discectomy and Fusion ACDF procedure with peek cages is a well accepted treatment for cervical radiculopathy, the exact relationship between cervical spine alignment CSA and the clinical outcome after ACDF is not well recognized. Considering the biomechanics of the cervical spine, one of the main goals of anterior cervical discectomy and fusion is to maintain or to restore normal CSA. Progression of the degenerative changes in the cervical spine alters the proper CSA and may indirectly decreases the effect of our treatment.

Correlation between Cervical Spine Sagittal Alignment and Clinical Outcomes after ACDF

Cervical and global sagittal spine alignment has received amplified attention in recent literature. Studies have shown that maintenance of lordosis and decreased subsidence with the use of anterior cervical plates improves clinical outcomes after anterior cervical discectomy and fusion (ACDF). However, the relationship between maintenance or restoration of cervical lordosis after ACDF and patient-reported health-related quality of life measures (HRQOLs) has not been evaluated.

Occipitocervical dissociative injuries: common in blunt trauma fatalities and better detected with objective computed tomography-based measurements

Background context Occipitocervical injuries (OCIs) are generally not common in blunt trauma victims, but autopsy studies of blunt trauma fatalities consistently report a high prevalence of these injuries. New computed tomography (CT)-based quantitative criteria have recently been developed for use in assessing the occipitocervical spine. The efficacy of these new criteria for detecting OCI would be supported if the high prevalence of OCI in blunt trauma fatalities can also be detected using these objective CT-based criteria. Purpose To test the hypothesis that the prevalence of OCI in blunt trauma fatalities, determined using objective CT-based measurements and reliable reference data, will be similar to the prevalence reported in prior autopsy studies. Study design/setting Retrospective assessment of the CT examinations of blunt trauma fatalities at a Level 1 trauma center. Patient sample Seventy-four consecutive patients who died within 21 days of blunt trauma and had a CT examination of the cervical spine. Outcome measures Quantitative measurements from CT examinations of the occiput–C1 and C1–C2 levels. Methods Measurements were made on a Picture Archiving and Communication System (PACS) from the CT images that were originally used for diagnosis and also using imaging software that allowed for precisely reoriented slices that correct for variations in the alignment of the upper cervical spine. The prevalence of abnormal measurements found by each method and the interobserver reliability of the measurements were assessed. Results At least one abnormal measurement was found in 50% of cases based on measurements made on the PACS, and in 34% of cases using measurements from carefully reoriented images. At least three abnormal measurements were found in 22% and 14% of patients, respectively. Only one of the patients had been diagnosed as having an OCI before death. Interobserver reliability measurements of more than 80% were found for most measurements. Conclusions Using precise CT-based measurements and reliable reference data for diagnosis of occipitocervical dissociative injuries, the prevalence of injuries in severely injured blunt trauma patients was close to the levels reported in prior autopsy studies (approximately 30%). This supports that with careful measurements, both soft- and hard-tissue OCI can be detected by CT. This study is limited by the fact that a gold standard was not available to confirm the injuries.

Radiographic Analysis of Atlantoaxial Fusion for Atlantoaxial Instability -Comparison of Posterior wiring, Transarticular screw, Posterior screw-rod fixation-

Study Design: This is a retrospective study. Objectives: We wanted to clarify the association between the position of the atlantoaxial fusion angle and the change of the subaxial cervical spine alignment (SCA) and the reduction loss after atlantoaxial fusion (AAF) using the posterior wiring technique (PWT), transarticular screw fixation (TAF) and posterior screw-rod fixation (PSR) for treating atlantoaxial instability (AAI). Summary of the Literature Review: There are not many studies on the change of the SCA and the reduction loss after AAF. Material and Methods: Thirty five patients underwent AAF for AAI from 1986 to 2008. The mean follow-up period was 59.5 months. The surgical techniques were divided into three groups, that is, PWT: 17 patients, TAS: 10 and PSR: 8. The causes of instability were transverse ligament rupture in 12 patients, rheumatoid arthritis in 11, Os odontoideum in 6 and nonunion of an odontoid fracture in 6. Plain radiographs were used to assess the atlanto-dental interval, the posterior arch-lamina angle, the change of the SCA and the time of fusion. Results: Fusion was achieved in all the patients within 3.5 months (range: 3-5 months). The radiologic findings in the 5 PWT patients showed a reduction loss and 3 patients showed subaxial cervical kyphosis (SCK). The TAS group had no reduction loss or SCK. The PSR group had no reduction loss and one patient showed SCK. A statistically significant reduction loss and SCK occurred in the group in which there was a posterior arch-laminar angle greater than 10 degrees before and after surgery. Conclusions: For the treatment of AAI, the position of the AAF is associated with the change of the postoperative SCA. The preoperative lodortic position of C1-2 should be maintained to prevent the change of the SCA.

Lacrosse Equipment and Cervical Spinal Cord Space During Immobilization: Preliminary Analysis

Removal of the lacrosse helmet to achieve airway access has been discouraged based only on research in which cervical alignment was examined. No researchers have examined the effect of lacrosse equipment on the cervical space available for the spinal cord (SAC). To determine the effect of lacrosse equipment on the cervical SAC and cervical-thoracic angle (CTA) in the immobilized athlete. Observational study. Outpatient imaging center. Ten volunteer lacrosse athletes (age = 20.7 +/- 1.87 years, height = 180.3 +/- 8.3 cm, mass = 91 +/- 12.8 kg) with no history of cervical spine injury or disease and no contraindications to magnetic resonance imaging (MRI). The lacrosse players were positioned supine on a spine board for all test conditions. An MRI scan was completed for each condition. The independent variables were condition (no equipment, shoulder pads only [SP], and full gear that included helmet and shoulder pads [FG]), and cervical spine level (C3-C7). The dependent variables were the SAC and CTA. The MRI scans were evaluated midsagittally. The average of 3 measures was used as the criterion variable. The SAC data were analyzed using a 3 x 5 analysis of variance (ANOVA) with repeated measures. The CTA data were analyzed with a 1-way repeated-measures ANOVA. We found no equipment x level interaction effect (F(3.7,72) = 1.34, P = .279) or equipment main effect (F(2,18) = 1.20, P = .325) for the SAC (no equipment = 5.04 +/- 1.44 mm, SP = 4.69 +/- 1.36 mm, FG = 4.62 +/- 1.38 mm). The CTA was greater (ie, more extension; critical P = .0167) during the SP (32.64 degrees +/- 3.9 degrees) condition than during the no-equipment (25.34 degrees +/- 2.3 degrees ; t(9) = 7.67, P = .001) or FG (26.81 degrees +/- 5.1 degrees; t(9) = 4.80, P = .001) condition. Immobilizing healthy lacrosse athletes with shoulder pads and no helmets affected cervical spine alignment but did not affect SAC. Further research is needed to determine and identify appropriate care of the lacrosse athlete with a spine injury.

Changes in cervical range of motion and sagittal alignment in early and late phases after total disc replacement: radiographic follow-up exceeding 2 years

This was a retrospective clinical study in which the follow-up period exceeded 2 years. The authors investigated the time course of radiographic changes in the cervical range of motion (ROM) and sagittal alignment after cervical total disc replacement involving the ProDisc-C artificial disc. Eighteen patients who underwent C5-6 total disc replacement were followed for an average of 27 months. Cervical neutral and flexion-extension lateral radiographs were obtained before and at 1 and 3 months after surgery for early-phase observations and at the last follow-up for late-phase observation. Segmental ROM values in the treated, superior, and inferior adjacent segments were measured. For whole-neck motion, C2-7 ROM was also measured. The percentage contributions of ROM at functional and adjacent segments to whole-neck motion were calculated. For evaluating sagittal alignment, C2-7 and C5-6 Cobb angles were measured. All data from ProDisc-C arthroplasty were compared with the results obtained in 22 patients who underwent C5-6 interbody fusion in which a Solis cage was used and who were followed for an average of 25 months. In the ProDisc-C group, C2-7 and C5-6 ROM significantly decreased in the early phase after surgery and returned to preoperative levels in the late phase. Both superior and inferior adjacent segments showed significantly decreased ROM in the acute phase after surgery and returned to the preoperative values in the late phase. In terms of contributions to whole-neck motion, the ROM of the functional and adjacent segments did not change significantly compared with the preoperative ROM. In the cage group, C2-7 ROM was also significantly decreased in the early phase after surgery and returned to preoperative levels at the late phase. Both superior and inferior adjacent segments exhibited significantly increased ROM and percentage contributions to whole-neck motion in the early and late phases. Sagittal alignment of the whole cervical spine became significantly more lordotic in the late phase in the ProDisc-C group. The C5-6 Cobb angle became significantly lordotic in the ProDisc-C group, whereas there was no significant change in C5-6 Cobb angle in the cage group. In the early phase after ProDisc-C replacement, the ROM of the entire neck as well as functional and adjacent segments decreased but, at the late phase, they returned to the preoperative state. Contributions of functional and adjacent segments to whole-neck motion were not changed after ProDisc-C replacement. Adjacent-segmental motion could be saved by ProDisc-C replacement instead of interbody cage fusion. Segmental degenerative kyphosis was significantly corrected in patients who underwent ProDisc-C replacement.

Effective lordosis: analysis of sagittal spinal canal alignment in cervical spondylotic myelopathy

Analysis of cervical sagittal deformity in patients with cervical spondylotic myelopathy (CSM) requires a thorough clinical and radiographic evaluation to select the most appropriate surgical approach. Angular radiographic measurements, which are commonly used to define sagittal deformity, may not be the most appropriate to use for surgical planning. The authors present a simple straight-line method to measure effective spinal canal lordosis and analyze its reliability. Furthermore, comparisons of this measurement to traditional angular measurements of sagittal cervical alignment are made in regards to surgical planning in patients with CSM. Twenty preoperative lateral cervical digital radiographs of patients with CSM were analyzed by 3 independent observers on 3 separate occasions using a software measurement program. Sagittal measurements included C2-7 angles utilizing the Cobb and posterior tangent methods, as well as a straight-line method to measure effective spinal canal lordosis from the dorsal-caudal aspect of the C2-7 vertebral bodies. Analysis of variance for repeated measures or Cohen 3-way (kappa) correlation coefficient analysis was performed as appropriate to calculate the intra- and interobserver reliability for each parameter. Discrepancies in angular and effective lordosis measurements were analyzed. Intra- and interobserver reliability was excellent (intraclass coefficient > 0.75, kappa > 0.90) utilizing all 3 techniques. Four discrepancies between angular and effective lordotic measurements occurred in which images with a lordotic angular measurement did not have lordosis within the ventral spinal canal. These discrepancies were caused by either spondylolisthesis or dorsally projecting osteophytes in all cases. Although they are reliable, traditional methods used to make angular measurements of sagittal cervical spine alignment do not take into account ventral obstructions to the spinal cord. The effective lordosis measurement method provides a simple and reliable means of determining clinically significant lordosis because it accounts for both overall alignment of the cervical spine as well as impinging structures ventral to the spinal cord. This method should be considered for use in the treatment of patients with CSM.

Circumferential fixation with craniofacial miniplates for a cervical spine injury in a child

Unstable pediatric cervical spine injuries present significant challenges in terms of fixation. Given the smaller cervical vertebral bodies in the preschool-aged population, commercially available pediatric cervical fixation instrumentation may be unsuitable because of the inappropriately large size of the screws and plates. The authors describe a 2-year-old girl who sustained an unstable C6-7 distraction injury during a motor vehicle accident. Because of the small size of her vertebral bodies, standard cervical spine instrumentation was not feasible, and posterior wiring alone was believed to be insufficient because of the complete distraction of all 3 spinal columns. The patient was taken to the operating room where craniofacial plates with an inherent locking mechanism were used to circumferentially stabilize the cervical spine. Follow-up examination 6 months postoperatively demonstrated stable cervical spine alignment and fusion with no evidence of the failure of either the anterior or posterior hardware. The use of craniofacial miniplates with an intrinsic locking mechanism represents a superior alternative for both anterior and posterior cervical fixations when spinal instrumentation is needed in the pediatric age group.

Anterior Cervical Discectomy and Titanium Cage Fusion – 7-year Follow-up

The purpose of this study was to prospectively evaluate long-term results after anterior cervical discectomy and titanium cage fusion (ACDF) and titanium cage fusion. Special focus was on the adjacent levels. 54 patients (age: 48+/-10 years; one level operation in 44 patients and two level operation in 10 patients) entered the study. Re-evaluation consisted of a clinical out patient investigation and was possible in 33 patients. VAS, PROLO and Oswestry scores were used. Lateral radiographs were taken and changes in the operated and adjacent segments were measured and compared to radiographs directly after surgery. Clinical patient data was compared with the data prior to surgery. The mean follow-up time of the 33 patients was 7.26 +/- 0.22 years. One patient needed re-surgery of the cervical spine above the fused segment. PROLO results showed a significant improvement (PROLO F 1.52+/-0.67 to 3.79+/-1.17 p<0.01; PROLO E 1.52+/-0.5 to 3.55+/-1.42 p<0.01). Mean VAS at the time of investigation was 3.2+/-2.5. Oswestry score was 16.4+/-9.5. The alignment of the whole cervical spine was stable lordotic (Katsuura 10.9+/-9.0 degrees to 11.5+/-7.8 degrees ; p=0.76). Total segmental height had reduced from 36.6+/-4.6 mm to 34.6+/-3.9 mm (p=0.04). No significant reduction of disc space height of adjacent levels was detectable (superior: 5.8+/-1.6 mm to 5.2+/-1.6 mm; inferior: 6.0+/-1.7 mm to 5.3+/-1.9 mm). One adjacent superior level showed spontaneous fusion. Ventral and dorsal osteophytes in the superior and inferior adjacent levels increased in number and increased significantly in degree. Patients with bi-segmental fusion (n=7) showed similar results. ACDF with titanium cages has good clinical long-term results. A significant progression of degenerative changes can be observed on radiographs without clinical consequences for the patients. A comparison with patients without surgery and conservative therapy is needed to allow a better interpretation of the radiological results.

Cervical Spine Alignment During On-Field Management of Potential Catastrophic Spine Injuries

Context:When cervical spine injuries are suspected, the cervical spine should be immobilized in a neutral position and neck motion controlled in preparation for transport to an emergency facility. Protocols for emergency transport utilizing common devices (cervical collars) and methods (transfer techniques) during these procedures are not entirely evidence based.Evidence Acquisition:The medical literature search covered the time period of January 1966 to June 2008 using the following keywords, either alone or in combination: extrication collars, cervical collars, spine orthoses, spinal immobilization, spine board, spinal board, transfer techniques, and back board. Biomedical databases searched included Medline, Web of Science, and Cumulative Index to Nursing and Allied Health Literature (CINAHL [1982 to 2008]). The reference lists of all trials identified were also searched for additional trials.Methods:Only trials that directly compared the efficacy or safety of transfer methods and/or immobilization devices were included. Studies that measured voluntary head movement after the fitting of the cervical orthoses and those that did not evaluate motion across individual spinal segments were not included.Results:A lift-and-slide transfer method with a full body immobilization device creates less motion than a log-roll maneuver. Extrication-type cervical immobilization collars are limited in their ability to control neck motion in the injured cadaveric model.Conclusion:Allied health professionals responsible for the management of the cervical spine–injured patient should become familiar with and employ a lift-and-slide transfer technique in appropriate situations and should not rely exclusively on extrication-type collars to immobilize the neck.