Cervicothoracic Junction Research Articles

Effectiveness of Thoracic Manipulation and Cervicothoracic Mobilisation in Decreasing Pain and Increasing Rom in Nonspecific Neck Pain

BACKGROUND: Hypomobility of the cervicothoracic (CT) junction has been suggested neck discomfort as one of its causes.There are, however, few trials that have contrasted the impact of CT junction mobilisation against a successful neck pain intervention. The treatment of distant spinal segments using thoracic spine manipulation is non-specific and is founded on the notion of interregional reliance.Recent studies have examined the usefulness of segment-specific spinal mobilisation in the cervical spine, although no firm findings could be drawn from earlier research. The aforementioned factors call for research into the effectiveness of a particular CT junction mobilisation vs a general thoracic manipulation intervention in neck discomfort. MATERIAL AND METHODS: Participants in a randomised clinical trial with mechanical neck soreness and Cervicothoracic junction dysfunction were randomly assigned to the mid-thoracic (T3-T6) manipulation group or the C7-T1 stage Maitland mobilisation group. The results of the cervical flexion, extension, facet flexion, and rotation degrees of movement (ROM) before and after the intervention have been measured the use of a cervical range of motion (CROM) device. The severity of self-stated ache become measured using the numerical pain score scale (NPRS). After the intervention, a one-way ANCOVA was used to evaluate the outcomes. RESULTS: For the study, 48 individuals have been enrolled, with a median age of 36.Forty eight±12.Forty eight for the thoracic manipulation organization and 34.25± 12.24 for the CT junction organization. After treatment, there were no discernible differences in cervical variety of movement (ROM) or self-said ache depth among thegroups (p-value = 0.07, 0.96, 003, 0.Forty, 0.30, 0.31 for flexion, extension, bilateralside bending, and rotation, respectively), nor in neck pain depth (p = 0.67). The cervical ROM and pain, however, extensively stepped forward in both businesses whilst in comparison within-institution, pre- and post. CONCLUSION: This preliminary investigation showed that thoracic manipulation had the same effects on the outcomes of cervical range of motion and neck discomfort as level-specific Cervicothoracic mobilisation in patients with non-specific neck pain when it was compared to remote mid-thoracic manipulation. KEYWORDS: Cervicothoracic Mobilization, Thoracic manipulation, Non-specific neck pain, ROM, mechanical neck pain

Global Sagittal Spinal Compensation for Dropped Head Alignment.

This is a retrospective radiographic study of a consecutive series of cases in patients with dropped head syndrome (DHS) at a single tertiary referral center. The aim was to clarify the compensation among parameters of spinal sagittal alignment in patients with DHS. The treatment strategy for DHS should vary according to the types of global sagittal spinal alignment. However, theoretical evidence in consideration of spinal sagittal compensation against the dropped head condition is lacking. One hundred sixteen patients diagnosed with isolated neck extensor myopathy were enrolled. Radiographic measurements were made, including parameters of spinal sagittal alignment. The patients were divided into three groups according to sagittal spinal balance: C7SVA (sagittal vertical axis) ≥ +50mm (P-DHS; positive imbalanced DHS), -50mm ≤C7SVA <+50mm (B-DHS; balanced DHS), and C7SVA <-50mm (N-DHS; negative imbalanced DHS). Correlations among the various spinal parameters were analyzed. Among all types of DHS, there was no correlation between C2-C7 angle (C2-C7A) and T1 slope. In B-DHS, other correlations among the adjacent spinal segments were maintained. In N-DHS, there was no correlation between C2-C7A and TK, and in P-DHS, there was also no correlation between TK and lumbar lordosis. The loss of compensation at the cervicothoracic junction was observed in all DHS types. B-DHS showed decompensation only at the cervicothoracic junction. N-DHS presented additional decompensation of the thoracic spine, and P-DHS showed decompensation between the thoracic and lumbar spine. Evaluation of global sagittal spinal balance is important for determining global spinal compensation associated with DHS and when considering treatment strategy.

Immediate Effect of Thoracic Spine and Shoulder Joint Manipulation and Thermotherapy on Glenohumeral Range of Motions in Patients with Adhesive Capsulitis

Adhesive capsulitis (AC) is a common shoulder condition that leads to progressive loss of shoulder joint mobility leading to functional limitations. Many treatment protocols are in practice however there is no consensus on which is the best. Much literature reflects clinicians using thoracic spine and shoulder joint manipulations in different studies but a lack of evidence was found studying their effect when applied together and their immediate effect, for the management of patients with AC. Therefore, the objective of this study was to statistically analyse and report the immediate effect of thoracic spine and shoulder joint manipulations on subjects with AC assessing their pain and joint Range of motion. In this study, purposive sampling of 20 pre diagnosed subjects of AC were included and VAS conducted a pre-intervention assessment for assessing pain, and a goniometer for assessing the glenohumeral active Range of motion. All the subjects received a single session of high-velocity thrust manipulative therapy to the cervicothoracic junction, upper/mid-thoracic spine, and the glenohumeral joint of the affected shoulder. Everyone received thermotherapy (moist heat) before and after the manual therapy session, after which the data were documented and analyzed statistically. It was observed that there was a significant difference between pre and post-VAS and pre and post-range of motion scores in the samples (p&lt;0.001). It is essential to mention that compared to VAS, goniometry results were more promising. To conclude, it can be stated that thoracic spine and shoulder joint manipulation adjunct with thermotherapy, in general, has an immediate positive effect on the management of patients with adhesive capsulitis.

Does extending a posterior cervical fusion construct into the upper thoracic spine impact patient-reported outcomes as long as 2 years after surgery in patients with degenerative cervical myelopathy?

In multilevel posterior cervical instrumented fusion, extension of fusion across the cervicothoracic junction (CTJ) at T1 or T2 has been associated with decreased rates of reoperation and pseudarthrosis but with longer surgical time and increased blood loss. The impact on patient-reported outcomes (PROs) remains unclear. The primary objective was to determine whether extension of fusion through the CTJ influenced PROs at 3, 12, and 24 months after surgery. The secondary objective was to compare the number of patients who reached the minimal clinically important differences (MCIDs) for the PROs, modified Japanese Orthopaedic Association (mJOA) score, operative time, intraoperative blood loss, length of stay, discharge disposition, adverse events (AEs), reoperation within 24 months of surgery, and patient satisfaction. This was a retrospective observational cohort study of prospectively collected multicenter data of patients with degenerative cervical myelopathy. Patients who underwent posterior instrumented fusion of 4 levels or greater (between C2 and T2) between January 2015 and October 2020 and received 24 months of follow-up were included. PROs (scores on the Neck Disability Index [NDI], EQ-5D, physical component summary and mental component summary of SF-12, and numeric rating scale for arm and neck pain) and mJOA scores were compared using ANCOVA and adjusted for baseline differences. Patient demographic characteristics, comorbidities, and surgical details were abstracted. The proportions of patients who reached the MCIDs for these outcomes were compared with the chi-square test. Operative duration, intraoperative blood loss, AEs, reoperation, discharge disposition, length of stay, and satisfaction was compared by using the chi-square test for categorical variables and the independent-samples t-test for continuous variables. A total of 198 patients were included in this study (101 patients with fusion not crossing the CTJ and 97 with fusion crossing the CTJ). Patients with a construct extending through the CTJ were more likely to be female and have worse baseline NDI scores (p > 0.05). When adjusted for baseline differences, there were no statistically significant differences between the two groups in terms of the PROs and mJOA scores at 3, 12, and 24 months. Surgical duration was longer (p < 0.001) and intraoperative blood loss was greater in the group with fusion extending to the upper thoracic spine (p = 0.013). There were no significant differences between groups in terms of AEs (p > 0.05). Fusion with a construct crossing the CTJ was associated with reoperation (p = 0.04). Satisfaction with surgery was not significantly different between groups. The proportions of patients who reached the MCIDs for the PROs were not statistically different at any time point. There were no statistically significant differences in PROs between patients with a posterior construct extending to the upper thoracic spine and those without such extension for as long as 24 months after surgery. The AE profiles were not significantly different, but longer surgical time and increased blood loss were associated with constructs extending across the CTJ.

The Improvement of Balance, Coordination &amp; Proprioception Following an MPI Cervico-Thoracic Junction Seated Adjustment: A Case Report

Abstract: Further enquiries into how spinal manipulation directly impacts proprioception, balance and coordination are required to support the current body of evidence. The leading question of this study was “Does a Motion Palpation Institute cervico-thoracic junction high velocity, low amplitude adjustment impact proprioception, balance and coordination?”. A 32- year-old female with no prior gymnastic experience was recruited for this case-study. The participant was blind folded and given two attempts to maintain a static tandem Romberg stance on a 46cm high, 20cm wide gymnastic balancing beam for as long as possible. During the first attempt the participant lost her balance immediately. The participant then received a seated Motion Palpation Institute cervico-thoracic junction adjustment. Following the adjustment, an immediate improvement in balance, proprioception and coordination was observed. During attempt two, the participant could maintain her balance exponentially. The findings of this study suggest that spinal manipulation may have a potential benefit on proprioception, balance and coordination in a healthy patient. This further illustrates the importance of spinal manipulation as a non-invasive, low cost and low risk treatment. Further research to expand the findings of this study are needed to reach a stronger conclusion.

Should cervicothoracic junctions be avoided in long cervical posterior fusion surgery? Analysis of clinical and radiologic outcomes over two years.

This study aimed to confirm the usefulness of surgery that avoids the cervicothoracic junction (CTJ) by comparing the clinical and radiographic outcomes after posterior cervical fusion at C5/6 with those at C7/T1. Patients who underwent laminectomy and posterior cervical instrument fusion for cervical spondylotic myelopathy (CSM) from 2012 to 2019 were retrospectively reviewed and divided according to whether the end level was at C5/6 (group 1) or C7/T1 (group 2). Demographic variables and incidence of distal junctional kyphosis (DJK) were compared between the groups. Clinical outcomes (visual analog scale [VAS] score for arm and neck pain and the Neck Disability Index value) and radiologic outcomes (T1 slope, cervical lordosis, segmental lordosis, C2-7 sagittal vertical axis, T1 slope-cervical lordosis mismatch) were compared over time. Sixty-seven patients were included. There were 32 patients in group 1 and 35 in group 2. The VAS score for neck pain was significantly lower in group 1 than in group 2 at 2years after surgery (p = 0.03). The C2-7 sagittal vertical axis was significantly larger in group 2 than in group 1 at 1year and 2years postoperatively (p = 0.04). The incidence of DJK was higher in group 2 than in group 1 (28.57% vs 9.37%, p = 0.04). This study found that when CTJs are included in the posterior cervical long fusion surgery, although it would be better than preoperation, postoperative kyphosis and consequent neck pain may progress. The results of this study advocate the concept of avoiding CTJ fusion if possible.

Modified harvesting technique for pedicled pectoralis major muscle flap after extended manubrial resection in case of recurrent cervicothoracic junction tumors.

The problem of the replacement after manubrial resection can be solved standardly through apedicled pectoralis major muscle flap (PMMF) defect coverage, harvested thought an accessory incision. We recently established an alternative and easier harvesting technique, also in critical cases (patients with recurrent tumor and after radio-chemotherapy), that improves aesthetic outcome and allows harvesting an adequate muscle flap for an optimal chest wall coverage. Asingle center retrospective analysis between 2017 and 2020 was performed. Flap harvest was performed subcutaneously using the same incision resections line, thereby sparing the clavicular and upper sternocostal aspects of the pectoralis muscle. Fifteen patients with recurrent tumors after radio-chemotherapy and involving the upper thoracic inlet underwent manubrial resection with associated extended upper mediastinal dissection and replacement using apectoralis major island flap following our harvesting technique. The majority (70%) of patients had an uneventful course of recovery and showed satisfying aesthetic results and low donor site morbidity. Four (26%) patients had major complications that required surgical revision. All patients had early postoperative shoulder mobilization without functional deficit or aesthetic deformity. Pedicled pectoralis major muscle flap (modified harvesting) provides an adequate replacement of the upper thoracic inlet, with excellent aesthetic and functional results, also in high risk patients.

68Ga-DOTA PET for Diagnosis of Spinal Cerebrospinal Fluid Leaks.

Spontaneous intracranial hypotension due to spinal cerebrospinal fluid (CSF) leakage causes substantial disease burden. In many patients, the course is protracted and refractory to conservative treatment, requiring targeted therapy. We propose PET of the CSF space with 68Ga-DOTA as a state-of-the-art approach to radionuclide cisternography (RC) and validate its diagnostic value. Methods: This study is a retrospective analysis of patients with suspected intracranial hypotension due to spinal CSF leaks and who underwent whole-body PET/CT at 1, 3, and 5 h after intrathecal lumbar injection of 68Ga-DOTA. Two independent raters unaware of the clinical data analyzed all scans for direct and indirect RC signs of CSF leakage. Volume-of-interest analysis was performed to assess the biologic half-life of the tracer in the CSF space and the ratio of decay-corrected activity in the CSF space at 5 and 3 h (simplified marker of tracer clearance). Comprehensive stepwise neuroradiologic work-up served as a reference; additional validation was provided by surgical findings and follow-up. Results: Of 40 consecutive patients, 39 patients with a working diagnosis of intracranial hypotension due to a spinal CSF leak (spontaneous, n = 31; postintervention, n = 8) could be analyzed. A spinal CSF leak was verified by the neuroradiologic reference method in 18 of 39 patients. As the only direct and indirect diagnostic signs, extrathecal tracer accumulation at the cervicothoracic junction (67% sensitivity and 90% specificity) and lack of activity over the cerebral convexities (5 h; 94% sensitivity and 67% specificity) revealed a high diagnostic value for spinal CSF leaks. Their combination provided little improvement (71% sensitivity and 95% specificity). Additional quantitative analyses yielded no benefit (94% sensitivity and 53% specificity for biological half-life; 94% sensitivity and 58% specificity for the ratio of total radioactivity within the CSF space at 5 and 3 h). The location of direct signs (extrathecal tracer accumulation) did not correlate with verified sites of spinal CSF leakage. Conclusion: We propose CSF PET with 68Ga-DOTA as a novel, fast, and convenient approach to RC for verification but not localization of spinal CSF leaks with high sensitivity and specificity. CSF PET may fulfill an important gatekeeper function for stratifying patients toward escalation (ruling in) or deescalation (ruling out) of diagnostic and therapeutic measures. Further prospective studies are needed to validate the present results and determine the potential of the methods to reduce the burden to patients.

Should we bridge the cervicothoracic junction in long cervical fusions? A meta-analysis and systematic review of the literature.

Long posterior cervical decompression and fusion (PCF) is commonly performed to surgically treat patients with multilevel cervical pathology. In cases in which constructs may necessitate crossing the cervicothoracic junction (CTJ), recommendations for appropriate caudal fusion level vary in the literature. The aim of this study was to report the clinical and radiological outcomes of multilevel PCFs ending at C7 versus those crossing the CTJ. A systematic search of PubMed, CINAHL Plus, and Scopus was conducted to identify articles that evaluated clinical and radiological outcomes of long PCFs that ended at C7 (cervical group) or crossed the CTJ (thoracic group). Based on heterogeneity, random-effects models of a meta-analysis were used to estimate the pooled estimates and the 95% confidence intervals. PCF outcome data of 1120 patients from 10 published studies were included. Compared with the cervical group, the thoracic group experienced greater mean blood loss (453.0 ml [95% CI 333.6-572.5 ml] vs 303.5 ml [95% CI 203.4-403.6 ml]), longer operative times (235.5 minutes [95% CI 187.7-283.3 minutes] vs 198.5 minutes [95% CI 157.9-239.0 minutes]), and a longer length of stay (6.7 days [95% CI 3.3-10.2 days] vs 6.2 days [95% CI 3.8-8.7 days]); however, these differences were not statistically significant. None of the included studies specifically investigated factors that led to the decision of whether to cross the CTJ. The cervical group had a mean fusion rate of 86% (95% CI 71%-94%) compared with the thoracic group with a rate of 90% (95% CI 81%-95%). Of patients in the cervical group, 17% (95% CI 10%-28%) required revision surgery compared with 7% (95% CI 4%-13%) of those in the thoracic group, but this difference was not statistically significant. The proportion of patients who experienced complications in the cervical group was found to be 28% (95% CI 12%-52%) versus 14% (95% CI 7%-26%) in the thoracic group; however, this difference was not statistically significant. There was no significant difference (no overlap of 95% CIs) in the incidence of adjacent-segment disease, pseudarthrosis, or wound-related complications between groups. This meta-analysis suggests similar clinical and radiographic outcomes in multilevel PCF, regardless of inclusion of the CTJ. The lowest instrumented level did not significantly affect revision rates or complications. The ideal stopping point must be tailored to each patient on an individualized basis.

Is C7-T1 cervical disc replacement a viable technique: A case series.

IntroductionCervical disc replacement (CDR) surgery is well established for the treatment of disc degeneration from C3-C7, but there is little data regarding the safety and efficacy of CDR at the cervicothoracic junction, C7-T1. CDR is an appealing option, in terms of range of motion preservation, symptom relief, and absence of risk for nonunion. Currently, C7-T1 CDR is not approved by the Food and Drug Administration, and the existing literature is limited to two case reports that describe the results of a combined two patients. This series explores whether C7-T1 CDR is a reasonable treatment and alternative to fusion.MethodsWe present a case series of seven consecutive patients who underwent CDR at C7-T1 by a single surgeon from January to December of 2019. There were five females and two males with an average age of 61.3 ± 6.4 years.ResultsAverage follow up was 18.9 ± 2.5 months. The average postoperative NDI score was 22.6 % ± 14.0. We also recorded qualitative data regarding patient satisfaction and revision surgery status. There was one complication of disc subsidence following three months of complete pain resolution. The six other patients reported being very satisfied with their surgical outcome.ConclusionThese seven cases dramatically increase the volume of data in the literature on clinical outcomes and patient satisfaction following CDR at the cervicothoracic junction. Additionally, the heterogeneity of cases shows the effectiveness of this treatment in many real-world cases. A greater volume of cases with longer follow up will be necessary to better establish long-term clinical success.

Surgical strategy for metastatic spinal tumor patients with surgically challenging situation.

The incidence of spinal metastasis is increasing as cancer patients live longer owing to the improvement of cancer treatments. However, traditional surgery (TS) which fixates at least 2 levels above and 2 levels below the affected vertebrae is sometimes difficult to perform as it is burdensome to the patients. In this article, we introduce our experience and strategy in treating spinal metastasis, focusing particularly on challenging cases.We retrospectively reviewed the data of 110 patients who underwent spinal surgery for metastatic spinal tumors from April 2018 to March 2020. Among them, 5 patients who received anterior approach surgery were excluded. The remaining 105 patients were enrolled. In addition to TS, we also performed cervical pedicle screw, cervicothoracic junction fixation, thoracolumbar short fixation, and decompression surgery, depending on the characteristics of the tumor. The overall survival was analyzed, and the local tumor control rate was evaluated using magnetic resonance imaging. Perioperative clinical characteristics including Spine Oncology Study Group Outcomes Questionnaire, visual analog scale, Eastern Cooperative Oncology Group performance score, and Karnofsky Performance Score were also investigated.The overall survival rate was 57.9% at 1 year, and the local tumor control rate was 81.1% after surgery. There was a statistically significant difference according to the type of the tumor in the survival analysis: the overall survival rates were 72.7% for favorable tumors and 48.6% for unfavorable tumors at 12 months after surgery (P = .04). Spine Oncology Study Group Outcomes Questionnaire, visual analog scale, Eastern Cooperative Oncology Group performance score, and Karnofsky Performance Score was improved after surgery. All surgical methods, including TS, cervical pedicle screw, cervicothoracic junction fixation, thoracolumbar short fixation, and decompression surgery, showed good clinical and radiological outcomes.Optimized surgical methods show similarly good clinical outcomes in managing spinal metastasis as TS.

Correlation between neurologic status and spinal injury at the Cervicothoracic Junction.

With limited studies on spinal injuries occurring at the cervicothoracic junction, there is currently a knowledge gap regarding the correlation between morphology of injury and neurology and whether surgery provides a favorable neurological outcome. The primary objective was to determine whether the neurological deficit correlated with the severity of injury at this region of the spine. All patients with injuries at the cervicothoracic junction from December 2015 to December 2020 in a government trauma hospital were included. Patient demographics, characteristics of the injury, neurological score, imaging findings, surgery details and neurological outcomes were analyzed. All patients had a minimum follow up of 2 years. Of the total 30 patients, 23 were male and 7 female with mean age 42.4 years. 90% had fall injuries with 76.7% sustaining AO type C injury and 10% with AO B2 injury.73.4% had injury at C6-C7 level followed by 13.3% , C7-T1. Only 16.7% patients presented with intact neurology. Plain x-rays failed to detect cervicothoracic junction, injuries in 63.3% patients. Posterior stabilization was performed in 56.7%. Neurological improvement was observed in 9 patients. Though cervicothoracic junction injuries are uncommon, they are highly unstable injuries and difficult to diagnose by plain x-rays. These injuries also result in profound neurological deficit. Surgical stabilization of these injuries should be considered for a favorable neurological and functional outcome.

No difference in reoperation rates for nonunions (operative nonunions) in posterior cervical fusions stopping at C7 versus T1/2: a cohort of 875 patients.

The challenges of posterior cervical fusions (PCFs) at the cervicothoracic junction (CTJ) are widely known, including the development of adjacent-segment disease by stopping fusions at C7. One solution has been to cross the CTJ (T1/T2) rather than stopping at C7. This approach may have undue consequences, including increased reoperations for symptomatic nonunion (operative nonunion). The authors sought to investigate if there is a difference in operative nonunion in PCFs that stop at C7 versus T1/T2. A retrospective analysis identified patients from the authors' spine registry (Kaiser Permanente) who underwent PCFs with caudal fusion levels at C7 and T1/T2. Demographics, diagnoses, operative times, lengths of stay, and reoperations were extracted from the registry. Operative nonunion was adjudicated via chart review. Patients were followed until validated operative nonunion, membership termination, death, or end of study (March 31, 2020). Descriptive statistics and 2-year crude incidence rates and 95% confidence intervals for operative nonunion for PCFs stopping at C7 or T1/T2 were reported. Time-dependent crude and adjusted multivariable Cox proportional hazards models were used to evaluate operative nonunion rates. The authors identified 875 patients with PCFs (beginning at C3, C4, C5, or C6) stopping at either C7 (n = 470) or T1/T2 (n = 405) with a mean follow-up time of 4.6 ± 3.3 years and a mean time to operative nonunion of 0.9 ± 0.6 years. There were 17 operative nonunions, and, after adjustment for age at surgery and smoking status, the cumulative incidence rates were similar between constructs stopping at C7 and those that extended to T1/T2 (C7: 1.91% [95% CI 0.88%-3.60%]; T1/T2: 1.98% [95% CI 0.86%-3.85%]). In the crude model and model adjusted for age at surgery and smoking status, no difference in risk for constructs extended to T1/T2 compared to those stopping at C7 was found (adjusted HR 1.09 [95% CI 0.42-2.84], p = 0.86). In one of the largest cohort of patients with PCFs stopping at C7 or T1/T2 with an average follow-up of > 4 years, the authors found no statistically significant difference in reoperation rates for symptomatic nonunion (operative nonunion). This finding shows that there is no added risk of operative nonunion by extending PCFs to T1/T2 or stopping at C7.

P.166 Subcutaneous intrathecal catheter and port implants for administration of Nusinersen in patients with Spinal Muscular Atrophy

Background: Until recently, no effective treatment was available for spinal muscular atrophy (SMA). In 2017, Health Canada approved intrathecal Nusinersen a medication that prevents degeneration of the motor neurons in the spinal cord. The administration is intrathecally most commonly via lumbar puncture (LP) to have a direct effect on the motor neurons of the spinal cord.Many older patients with SMA and concomitant spinal deformities present technical challenges to access the thecal sac. Different routes have been described for delivery of the medication. These techniques may require sedation, are associated with radiation exposure, and demand experience personnel. Methods: A new surgical technique has been proposed to overcome these obstacles by combining two Health Canada approved devices: 1) an intrathecal catheter designed for intrathecal baclofen pumps and 2) an implantable subcutaneous port designed for intravascular medication administration Results: We describe the technical nuances and outline the clinical outcomes of six patients with complex spine deformities who have undergone such an implant for administration of Nusinersen. Conclusions: We discuss the benefits of the procedure which includes: 1) administration in the outpatient setting without sedation, 2) avoidance of costly imaging and experienced personnel, and 3) placement of the catheter in the cervicothoracic junction.

Intercostobrachial neuralgia—a case of bizzare diagnosis?

BackgroundIntercostobrachial neuralgia is a rare and bizarre diagnosis usually missed by many clinicians. The rare occurrence and absence of clear diagnostic criteria could be a result of this missed diagnosis. The symptoms could range from debilitating pain in the axilla, medial arm, and forearm at rest and with specific shoulder movements. The symptoms are very distinct from axillary web syndrome in which the patient could have thickening of subcutaneous tissue of axilla with affected shoulder mobility but absence of neural symptoms. The diagnostic and treatment procedure involving breast cancer may cause injury or lesion of the intercostobrachial nerve and is of particular interest to the surgeons, pain physicians, and physical therapists. The diagnosis is reached after excluding all the other possible diagnoses. The treatment of this post-surgical intercostobrachial neuralgia can range from cryoneurolysis, ultrasound-guided nerve block, steroid injection, and paravertebral nerve block. Lidocaine injection and avoiding certain positions like flexion and abduction are helpful in certain patients. Unfortunately, there is not much literature available on possible manual therapy treatments of this diagnosis. Therefore, this case report focuses on potential manual therapies to address this intricate diagnosis.Case presentationThe patient is a 38-year-old Asian female reported to an outpatient orthopedic physical therapy clinic with left medial arm and forearm pain for the past 5 years. Medical history included left breast lump removal surgery 9 years ago and cervical laminectomy C6–C7 with little success. The quick disability arm and hand scale showed a 36% disability score of function. The manual therapy approach targeted the cervicothoracic junction, second and third costovertebral joint, thoracic spine (T1–T8), and atlantooccipital joint (C0–C1). The patient showed significant improvement in function with a DASH score falling to 0% disability with a hands-on approach.ConclusionThe intercostobrachial neuralgia is usually undiagnosed by various practitioners, physicians, and surgeons. The clinicians must consider manual treatments to the second and third rib and soft tissue mobilizations around the axillary region. The patient demonstrated significant improvement in symptoms with this approach.

Functional outcomes in the management of cervicothoracic junction tuberculosis.

Background: We analyzed the clinical and radiological parameters influencing functional outcomes and neurological recovery in patients with cervicothoracic junctional tuberculosis (TB).Methods: This was a retrospective analysis of 16 cases of cervicothoracic junction (CTJ) spinal TB; 11 patients were managed operatively, while five were managed conservatively. Patients’ outcomes were assessed at 1 month, 1 year, and yearly thereafter and included an analysis of multiple outcome scores, various radiographic parameters, and sensitivity or resistance to anti-tubercular therapy.Results: Patients averaged 25.94 years of age, and typically had three-level vertebral involvement. They were followed for a mean duration of 24 months, and the duration of anti-tubercular therapy averaged 17 months. Patients demonstrated clinical improvement on Japanese Orthopedic Association score and Neck disability index (P < 0.005) starting from 1 month following initiation of treatment which continued in subsequent follow-up, along with change in radiological parameters consisting of mean segmental kyphotic angle from 18.98° to 15.13°, C2–C7 SVA from 16.13 mm to 22.61 mm, T1 slope from 22.80° to 14.66°, thoracic inlet angle from 75.35° to 63.25°, neck tilt from 51.81° to 48.33°, and cervical lordosis from 4.66° to −0.44° (P > 0.05) at the end of 1 year.Conclusion: Tuberculous affection of the dynamic CTJ is a challenging scenario in clinical practice and its management involves consideration of disease extent, neurological status, and effort toward restoration of normal alignment of spine in sagittal and coronal plane to get favorable clinical outcomes.

Bridging the cervicothoracic junction during posterior cervical laminectomy and fusion for the treatment of multilevel cervical ossification of the posterior longitudinal ligament: a retrospective case series

BackgroundThe purpose of this study was to investigate the surgical efficacy of crossing the cervicothoracic junction during posterior cervical laminectomy and fusion for the treatment of multilevel cervical ossification of the posterior longitudinal ligament (OPLL).MethodsFrom October 2009 to October 2017, 46 consecutive patients with multilevel cervical OPLL underwent posterior cervical laminectomy and crossing the cervicothoracic junction fusion were obtained in the study. Their medical records were retrospectively collected. Cervical lordosis and cervical sagittal balance were used to assess radiographic outcomes. Japanese Orthopedic Association (JOA), axial symptom, C5 root palsy, blood loss, and operation time were used to assess clinical outcomes. The mean follow-up period was 20.7 ± 8.3 months.ResultsThe operation time was 205.2 ± 39.8 min and the intraoperative blood loss was 352.2 ± 143.7 ml. Analysis of the final follow-up data showed significant differences in JOA score (P < 0.01), C2-C7 lordosis angle (P < 0.01), and C2-C7 SVA (P < 0.01). CT confirmed that grafted bone was completely fused in all patients and progression of OPLL was observed in two patients (4.3%) at final follow-up. No adjacent segment disease (ASD) or instrument failure occurred in any patients.ConclusionsCervical laminectomy and crossing the cervicothoracic junction fusion are effective and safe methods to treat multilevel cervical OPLL. Randomized controlled studies compared constructs ending at cervical vertebrae or thoracic vertebrae are needed to confirm these results.

Surgical treatment approach of cervicothoracic junction spinal tuberculosis in pediatric: A case report.

Introduction and importanceThe cervicothoracic junction is prone to infection by tuberculosis bacteria, which leads to spinal instability. Meanwhile, cervicothoracic junction spinal tuberculosis is a disease that affects the C7 to T3 vertebral, and it accounts for 5% of all spinal tuberculosis cases. Surgical procedures of treating this disease vary, and the most commonly used method is the combined anterior and posterior approach. This case report presents the disease with uncommon location in pediatric, which is rarely reported, and performed with the single-stage posterior approach to treat the patient, which showed a good clinical and radiological result.Case presentationA 15-years old girl with one-month history of progressive inferior paraplegia (within a month, her muscle strength went from score 5 to 0) initially complained of neck pain, gradual weakness of the lower extremities, and hypoesthesia below T4. The spine's MRI also showed a tuberculous spondylitis in the T1 to T3 vertebral and a huge paravertebral abscess at the C5 to T3 level. Subsequently, an adequate decompression, debridement, maintenance and reinforcement of stability as well as deformity correction were carried out using the single-stage posterior approach.ConclusionsThe cervicothoracic junction spinal tuberculosis with huge paravertebral abscess makes surgical procedures difficult, specifically in pediatric patients. However, the single stage posterior approach produced a better clinical and radiological result with a short operation time. The selection of appropriate surgical approach management with good perioperative planning as well as effective medical management improved the patient's condition.

MISDIAGNOSIS OF SPONTANEOUS SPINAL EPIDURAL HEMATOMA IN A PARTURIENT: A CASE REPORT

Background: Spontaneous spinal epidural hematomais a rare clinical entity. The symptoms can be similar to Guillain Barre Syndrome, especially if it occurs at the cervicothoracic junction. Its pathophysiology is still unknown and seems to be multifactorial, which makes it a challenging situation in terms of diagnosis and treatment, mainly during pregnancy. Case report:a 22-year-old female at 31 weeks of pregnancy presented to the emergencies complaining of the sudden onset of a neurogenic syndrome with the history of influenza like symptoms six days before. Although cerebrospinal fluid analysis showed no abnormalities, the diagnosis of Guillain Barre Syndrome was suspected on the basis of a series of arguments.The next day, her case worsened as she started exhibiting tetraparesis with genital disorders. Emergency Magnetic Resonance Imaging showed a spinal epidural hematoma extending from C5 to C7. The patient underwent an emergency decompressive laminectomy with evacuation of the hematoma. No apparent vascular malformation was objectified. Despite rehabilitation, she still experienced motor sequelae. Conclusion:Each case requires individual and repetitive evaluation with the establishment of a dated diagram in order to minimize the risk of delayed diagnosis and treatment in spontaneous spinal epidural hematoma, mainly during pregnancy.

What's New in Spine Surgery.

What's New in Spine Surgery.