Developmental Spinal Canal Stenosis Research Articles

Increased vertebral body area, disc and facet joint degeneration throughout the lumbar spine in patients with lumbosacral transitional vertebrae.

Lumbosacral transitional vertebrae (LSTV), developmental spinal canal stenosis, lumbar disc and facet joint degeneration are all common lumbar spine conditions. This study explores the relationship between these entities. Five hundred and five patients (254 females, 251 males), mean age 57 ± 13 years, who underwent abdominopelvic CT examinations were studied. Vertebral body cross-sectional area (CSA), spinal canal CSA, width and depth were measured from L1 to L5. The presence of LSTV was documented and the severity of disc/facet joint degeneration graded. LSTV was present in 155 (31%) of 505 patients, being twice as common in males than in females. After controlling for age, height and weight, vertebral body CSAs from L1 to L5 in male LSTV patients were, on average, 9.8% larger than those in male non-LSTV patients (p < 0.0001 for all) while vertebral body areas at L3 and L4 were 4.5% larger in female LSTV patients than in non-LSTV female patients. Disc degeneration from L2/3 to L5/S1 and facet joint degeneration from L2/3 to L4/5 were more severe in LSTV patients. LSTV Castellvi Type II patients appear to be most prone to disc and facet degeneration. LSTV patients, and particularly male patients, have an increased vertebral body CSA compared to non-LSTV patients throughout the lumbar spine. LSTV patients also have more severe disc and facet joint degeneration. The increase in vertebral body area may be contributing to the increased lumbar and facet joint degeneration seen in LSTV patients. • LSTV patients have increased vertebral body cross-sectional area throughout their lumbar spine compared to non-LSTV patients. This vertebral body area increase was more pronounced in male patients and also apparent in younger patients with LSTV. • LSTV patients have increased disc and facet joint degeneration affecting most of the lumbar spine than non-LSTV patients. • Increased vertebral body area may contribute to the increased lumbar disc and facet joint degeneration seen in LSTV patients.

Classification and Surgical Treatment of Developmental Spinal Canal Stenosis at Atlas Level: A 15-Case Study.

A retrospective study. Investigate the diagnosis and surgery strategy for treatment of development spinal canal stenosis (DSSA) at atlas plane based on computerized tography (CT) image characters. The occurrence of spinal canal stenosis in the atlas plane is relatively rare compared with lower cervical. Fifteen patients diagnosed with DSSA were included from 2014 to 2018. They are divided into four subgroups based on the character of CT images: group I (small size atlas), group II (hypertrophy of posterior arch of the atlas [PAA]), group III (incurved of PAA), and group IV (hypertrophy odontoid). There are type I 7, type II 3, type III 2, and group IV 3 in the 15 cases. All the patients received different surgery procedures respectively: (1) posterior arch osteotomy were performed for group I/III//IV without atlantoaxial dislocation, (2) posterior arch resect and replantation were performed for group II, (3) occipital cervical fixation and fusion were added to the patients with associated atlantoaxial dislocation (AAD), (4) a new method of odontoid reduce and atlantoaxial fixation by transoral approach were performed for group IV with associated AAD. All cases underwent surgery successfully which included posterior occipitocervical fixation (OCF) + posterior arch resection (PAR) eight cases, PAR four cases, posterior arch remodeling and re-implantation (PARR) two cases, and Dens remodeling + trans-oral anterior reduction and plate fixation (DR+TARP) one case without severe complications. All patients show different improvement in the symptoms. Japanese orthopaedic association score improved from 9.2 to 14.7 in 1 year follow-up. DSSA could be easily diagnosed and divided into four subgroups according to the character of CT image, corresponding surgery strategy could receive a fine clinical result.Level of Evidence: 4.

The strategy selection of surgical approach and decompression and fusion for cervical spondylotic myelopathy

Cervical spondylotic myelopathy is a common and frequently-occurring disease in Orthopaedics, especially with multi-segmental cervical spondylotic myelopathy. There are several pathogenic factors for cervical spondylotic myelopathy. The clinical symptoms are serious, and the imaging manifestations are complex. Most of them are accompanied by serious neurological damage, which seriously affects the quality of life of patients. Furthermore, some patients have serious cervical spinal cord injury symptoms, which endanger their lives after mild trauma. Therefore, early diagnosis, early treatment and surgery are the most effective methods at present, which could effectively eliminate the factors of spinal cord compression and reconstruct the stability of cervical spine function. However, the choice of surgical approach and decompression fusion has always been the focus of debate. The primary purpose of surgery for cervical spondylotic myelopathy is to completely relieve the compression of spinal cord. According to the imaging characteristics of cervical spondylotic myelopathy, it is the key to the success of the operation to determine the decompression and reconstruction of cervical spondylotic myelopathy. Anterior approach can be adopted in patients with the compression factors located in front of the spinal cord, including disc protrusion, mild osteophyte or local ossification posterior longitudinal ligament, less lesion segments, small compression range, cervical kyphosis or local kyphosis deformity, easy resection of compression and sagittal imbalance correction. Decompression fusion can be selected through intervertebral space, subtotal vertebral body resection and mixed decompression for fusion and fixation. In order to retain the active function of cervical vertebrae, artificial disc replacement and fusion can be selected. For patients with the compression factors located in the posterior part of the spinal cord, including ligamentumflavum hypertrophy or ossification, congenital developmental spinal canal stenosis, there are many factors causing compression in front of the spinal cord. The range is larger, the lesion segment is longer. Thus, it is difficult to resect thoroughly in front of the spinal cord with higher risk of anterior surgery. Although the posterior approach is indirect decompression with the help of posterior spinal cord movement, it plays a good role in improving nerve function with fewer complications and relatively higher safety. There are absolute surgical indications and relative indications for two approaches. Combining anterior and posterior surgery has advantages of complete decompression and strong fixation. However, it has the advantages of great trauma and high risk, so it is necessary to apply it in clinical practice. Moreover, no matter how to choose the approach, we should use perfect imaging data combined with clinical symptoms and signs to clarify the pathological factors of spinal cord com pression, the severity of spinal cord injury, the scope of compression and the responsible segment, and formulate an individualized operation plan.

Wednesday, September 26, 2018 7:35 AM–9:00 AM ePosters: P99. Laminoplasty and laminectomy hybrid decompression for the treatment of cervical spondylotic myelopathy with hypertrophic ligamentum flavum: a retrospective study

BACKGROUND CONTEXT Laminoplasty is widely used in patients with cervical spondylotic myelopathy (CSM); however, for CSM patients with hypertrophic ligamentum flavum (HLF), traditional laminoplasty does not include resection of a pathological ligamentum flavum. PURPOSE To report the outcomes of a posterior hybrid decompression protocol for the treatment of CSM)associated withHLF. STUDY DESIGN/SETTING This study retrospectively reviewed 116 CSM patients with HLF who underwent hybrid decompression with a minimum of 12 months of follow-up. The procedure consisted of reconstruction of the C4 and C6 laminae using CENTERPIECE plates with spinous process autografts, and resection of the C3, C5, and C7 laminae. Surgical outcomes were assessed using Japanese Orthopedic Association (JOA) score, recovery rate, cervical lordotic angle, cervical range of motion, spinal canal sagittal diameter, bone healing rates on both the hinge and open sides, dural sac expansion at the level of maximum compression, drift-back distance of the spinal cord, and postoperative neck pain assessed by visual analog scale. PATIENT SAMPLE During a consecutive 3-year period from February 2009 through April 2012, 283 patients underwent hybrid posteriordecompression in our hospital. The current study retrospectively reviewed 116 CSM patients with HLF who underwent thisprocedure. The researchers selected patients with CSM caused only by HLF (dorsal compression of the spinal cord owing to HLF) and patients with CSM caused by the combination of anterior disease plus HLF (dorsal compression of the spinal cord owing to HLF and anterior disease such as ossification of the posterior longitudinal ligament [OPLL], degenerative disk disease [DDD], and congenital pathologies). The inclusion criteria were: (1) a clear diagnosis made by history, physical examination, plain radiographs, computed tomography (CT), and magnetic resonance imaging (MRI); (2) complete pre- and postoperative imaging and clinical data records; (3) a minimum of 12 months’ postoperative follow-up. Exclusion criteria were: (1) CSM patients with multilevel anterior compression only; e.g., consecutive OPLL or DDD, bu without HLF; and (2) patients lost to follow-up. Of the 116 patients (89 men, 27 women [mean age 61.9 years], 55 also had segmental or localized OPLL, 41 also had cervical degenerative disk herniation (DDH), 11 also had developmental spinal canal stenosis (DSCS), and 9 had ossification of ligament flavum (OLF). Thirteen of 116 patients had single-level spinal canal stenosis, 29 had twolevel stenosis, 48 had three-level stenosis, and the remaining 26 patients had four- or five-level stenosis. OUTCOME MEASURES Results were analyzed using PASW Statistics for Windows, Version 18.0 (SPSS Inc., Chicago, IL, USA). Descriptive statisticswere used for demographics, and Student's t-test was used for continuous variables. Significance was set at P METHODS Not applicable. RESULTS No hardware failure or restenosis was noted. Postoperative JOA score improved significantly, with a mean recovery rate of 65.3±15.5%. Mean cervical lordotic angle had decreased 4.9° by 1 year after surgery (P CONCLUSIONS Hybrid laminectomy and autograft laminoplasty decompression using Centerpiece plates may facilitate bone healing and produce a comparatively satisfactory prognosis for CSM patients with HLF.

Torg’s ratio in normal adult nepalese population

Introduction: Acute cervical trauma occasionally leads to cervical canal stenosis in some individuals in spite of minor trauma. The spinal canal-to-vertebral body ratio (Torg-Pavlov ratio) has been proposed for assessing developmental spinal canal stenosis. It is not affected by magnification, and is measured on lateral plain films of cervical vertebrae. The result of this study may help in better understanding of the Torg’s ratio, which is more reliable than direct measuring of the mid-sagittal diameter of the cervical spinal canal in the diagnosis of cervical spinal stenosis or predicting the prognosis of cervical spinal cord injury. If Torg’s ratio is below normal there is risk of cervical cord injury whereas relatively safe in large Torg’s ratio. Torg’s ratio can be accessed even in rural areas where x-rays are easily available and more economical than MRI and CT scan. It can assess the risk of cord injury during sports and outdoor activities and help individuals’ choose safe carrier in sports or others activities.Methods: In order to ascertain the normal values of the Torg’s ratio in adults Nepalese, hundred sets of cervical vertebral columns of hundred adult Nepalese population of age group 20-40 years were examined. Consecutive patients presenting with history of neck pain with normal x-ray findings or history of trauma without cervical spine injury from Orthopaedic OPD (out patients department) and emergency department of Tribhuvan University Teaching Hospital, Maharajgunj, Kathmandu from March 2011 to August 2012 were included in the study.Results: There were 48 males and 52 females with age ranging from 20 yrs to 40 yrs with the mean of 30.34±5.36 years. The normal average canal/body ratio of the cervical spine is 0.99 +/- 0.09 in male and 1.01 +/- 0.07 in female. It was observed that the ratio of the antero-posterior diameters of cervical spinal canal and vertebral bodies showed sexual dimorphism.Conclusion: The Torg’s ratio is the same irrespective of gender and height. The result of this study will help in better understanding of the Torg’s ratio, which is more reliable than direct measuring of the mid-sagittal diameter of the cervical spinal canal in the diagnosis of cervical spinal stenosis or predicting the prognosis of cervical spinal cord injury.JSSN 2015; 18 (1), Page: 5-9

What Is the Most Representative Parameter for Describing the Size of the Atlas? CT Morphometric Analysis of the Atlas with Special Reference to Atlas Hypoplasia.

The spinal canal diameter (SCD) is one of the most studied factors for the assessment of cervical spinal canal stenosis. The inner anteroposterior diameter (IAP), the SCD, and the cross-sectional area (CSA) of the atlas have been used for the evaluation of the size of the atlas in patients with atlas hypoplasia, a rare form of developmental spinal canal stenosis, however, there is little information on their relationship. The aim of this study was to identify the most useful parameter for depicting the size of the atlas. The CSA, the IAP, and the SCD were measured on computed tomography (CT) images at the C1 level of 213 patients and compared in this retrospective study. These three parameters increased with increasing patient height and weight. There was a strong correlation between IAP and SCD (r = 0.853) or CSA (r = 0.822), while correlation between SCD and CSA (r = 0.695) was weaker than between IAP and CSA. Partial correlation analysis showed that IAP was positively correlated with SCD (r = 0.687) and CSA (r = 0.612) when CSA or SCD were controlled. SCD was negatively correlated with CSA when IAP was controlled (r = −0.21). The IAP can serve as the CSA for the evaluation of the size of the atlas ring, while the SCD does not correlate with the CSA. As the patient height and weight affect the size of the atlas, analysis of the spinal canal at the C1 level should take into account physiologic patient data.

Clinical Results of Laminoplasty for Cervical Myelopathy Caused by Disc Herniation with Developmental Canal Stenosis

Introduction Anterior discectomy and spinal fusion have had acceptable surgical results, but many complications have been reported, especially adjacent segment degeneration and bone graft complications. To compare the surgical results of laminoplasty with those of anterior spinal fusion in patients with myelopathy caused by the cervical disc herniation, and to make a treatment strategy for cervical disc herniation depending on these results. Patients and Methods A total of 10 patients with cervical disc herniation were examined in this study, who underwent laminoplasty without resection of the herniated disc. The mean age was 60 years. As a control group, 31 patients (mean age, 53.4 years) who underwent anterior spinal fusion were examined. All patients in the laminoplasty group also had developmental spinal canal stenosis in which the anteroposterior canal diameter was less than 13 mm. The mean follow-up was 2.5 years in the laminoplasty group and 3.2 years in the anterior fusion group. Neurological and radiological results were examined. The severity of myelopathy was evaluated according to the Neurosurgical Cervical Spine Score (NCSS). Surgical outcomes were evaluated by the NCSS for determining the recovery rate. Results The recovery rate averaged 46% in laminoplasty and 48% in anterior spinal fusion. There were no significant differences between the groups. Cervical lordosis angle was diminished postoperatively without a significant difference between the two groups. In the laminoplasty group, one patient with kyphotic deformity after laminoplasty had transient motor weakness, and one patient underwent anterior spinal fusion after laminoplasty according to myelopathy caused by the cervical disc herniation. Follow-up magnetic resonance imaging showed regression of the size of the herniated disc in 5 of the 10 patients in the laminoplasty group. Conclusion Laminoplasty for patients with narrowed spinal canals showed favorable surgical results. Laminoplasty should be employed for cervical myelopathy caused by disc herniation in particular with developmental spinal canal stenosis to avoid secondary myelopathy.

Prevalence and distribution of thoracic and lumbar compressive lesions in cervical spondylotic myelopathy.

Study DesignRetrospective cross-sectional study.PurposeThis study analyzed the prevalence and distribution of horacic and lumbar compressive lesions in cervical spondylotic myelopathy as well as their relationships with cervical developmental spinal canal stenosis (DCS) by using whole-spine postmyelographic computed tomography.Overview of LiteratureThere are few studies on missed compressive lesions of the spinal cord or cauda equina at the thoracolumbar level in cervical spondylotic myelopathy. Furthermore, the relationships between DCS, and the prevalence and distribution of thoracic and lumbar compressive lesions are unknown.MethodsEighty patients with symptomatic cervical spondylotic myelopathy were evaluated. Preoperative image data were obtained. Patients were classified as DCS or non-DCS (n=40 each) if their spinal canal longitudinal diameter was <12 mm at any level or ≥12 mm at all levels, respectively. Compressive lesions in the anterior and anteroposterior parts, ligamentum flavum ossification, posterior longitudinal ligament ossification, and spinal cord tumors at the thoracolumbar levels were analyzed.ResultsCompressive lesions in the anterior and anteroposterior parts were observed in 13 (16.3%) and 45 (56.3%) patients, respectively. Ligamentum flavum and posterior longitudinal ligament ossification were observed in 19 (23.8%) and 3 (3.8%) patients, respectively. No spinal cord tumors were observed. Thoracic and lumbar compressive lesions of various causes tended to be more common in DCS patients than non-DCS patients, although the difference was statistically insignificant.ConclusionsSurveying compressive lesions and considering the thoracic and lumbar level in cervical spondylotic myelopathy in DCS patients are important for preventing unexpected neurological deterioration and predicting accurate neurological condition after cervical surgery.

The Torg-Pavlov ratio for the prediction of acute spinal cord injury after a minor trauma to the cervical spine

Background contextAcute cervical spinal cord injury (SCI) has been observed in some patients after a minor trauma to the cervical spine. The discrepancy between the severity of the trauma and the clinical symptoms has been attributed to spinal canal stenosis. However, to date, there is no universally established radiological parameter for identifying critical spinal stenosis in these patients. The spinal canal–to–vertebral body ratio (Torg-Pavlov ratio) has been proposed for assessing developmental spinal canal stenosis. The relevance of the Torg-Pavlov ratio for predicting the occurrence and severity of acute cervical SCI after a minor trauma to the cervical spine has not yet been established. PurposeTo investigate the Torg-Pavlov ratio values of the cervical spine in patients suffering from acute cervical SCI after a minor trauma to the cervical spine and the use of the Torg-Pavlov ratio for identifying patients at risk of cervical SCI and predicting the severity and course of symptoms. Study design/settingRetrospective radiological study of consecutive patients. Patient sampleForty-five patients suffering from acute cervical SCI and 68 patients showing no neurologic symptoms after a minor trauma to the cervical spine. Outcome measuresMidvertebral sagittal cervical spinal canal diameter and the sagittal vertebral body diameter. Calculation of the Torg-Pavlov ratio values. MethodsConventional lateral radiographs of the cervical spine (C3–C7) were analyzed to determine the Torg-Pavlov ratio values. Receiver operating characteristic curves were calculated for evaluating the classification accuracy of the Torg-Pavlov ratio for predicting SCI. ResultsThe Torg-Pavlov ratio values in the SCI group were significantly (p<.04) smaller compared with that in the control group. A Torg-Pavlov ratio cutoff value of 0.7 yielded the greatest positive likelihood ratio for predicting the occurrence of SCI. However, there were no significant differences in the Torg-Pavlov ratio values between the different American Spinal Injury Association Impairment Score groups and between patients with complete, partial, and no recovery of symptoms. ConclusionsDevelopmental cervical spinal canal stenosis assessed by the Torg-Pavlov ratio was characteristic for patients suffering from acute cervical SCI after a minor trauma to the cervical spine. Patients at risk of SCI after a minor trauma to the cervical spine can be identified by applying a Torg-Pavlov ratio cutoff value of 0.7. Other factors in addition to the spinal canal–to–vertebral body ratio affect the severity and course of symptoms as a result of cervical SCI.

Morphological Analysis of the Cervical Pedicles, Lateral Masses, and Laminae in Developmental Canal Stenosis

Retrospective cross-sectional study. This study aimed to elucidate the relationship between developmental spinal canal stenosis (DCS) and morphologic features in the cervical spine by comparing the features between DCS and nondevelopmental spinal canal stenosis (NDCS). DCS is an important predisposing factor for cervical myelopathy. Further, various posterior cervical spinal instrumentations have been developed. However, no study has specifically addressed the cervical posterior morphology of DCS. A total of 52 consecutive patients underwent cervical spine computed tomography myelography. Axial images of the largest pedicle diameter were selected from C3 to C7 vertebrae and 260 images were analyzed. The following parameters were measured: spinal canal longitudinal diameter (SCLD), spinal canal transverse diameter, osseous spinal canal area, dural sac area, spinal cord area, pedicle outer width, pedicle axis length, pedicle transverse angulation, lateral mass longitudinal diameter, lateral mass transverse diameter, lamina outer width, and lamina axis length. The participants were classified into 2 groups: DCS group (SCLD <12 mm at any level) and NDCS group (SCLD ≧12 mm at all levels). The mean osseous spinal canal area and dural sac area at C3-C5 in the DCS group were less than those in the NDCS group. The mean spinal cord area did not differ significantly at C3-C7 between the groups. The mean pedicle outer width at C6 and C7 in the DCS group was less than that in NDCS group. The mean lateral mass transverse diameter at C5 and mean lateral mass longitudinal diameter at C3, C5, and C6 in the DCS group were less than those in the NDCS group. Myelopathy is expected to progress in patients with DSC and these patients with severe neurologic symptoms may need cervical operation. However, posterior screw insertions should be considered more carefully than in NDCS patients.

First aid and treatment for cervical spinal cord injury with fracture and dislocation

Background:Traumatic cervical spinal cord injury with subaxial fracture and dislocation not only indicates a highly unstable spine but can also induce life-threatening complications. This makes first aid critically important before any definitive operative procedure is undertaken. The present study analyzes the various first aid measures and operative procedures for such injury.Materials and Methods:Two hundred and ninety-five patients suffered from cervical spinal cord injury with fracture and dislocation. The average period between injury and admission was 4.5 days (range 5 h-12 weeks). The injury includes burst fractures (n = 90), compression fractures with herniated discs (n = 50), fractures and dislocation (n = 88) and pure dislocation (n = 36). Other injuries including developmental spinal canal stenosis and/or multi-segment spinal cord compression associated with trauma (n = 12), lamina fractures compressing the spinal cord (n = 6), ligament injuries (n = 7) and hematoma (n = 6) were observed in the present study. The injury level was C4 (n = 17), C5 (n = 29), C6 (n = 39), C7 (n = 35), C4-5 (n = 38), C5-6 (n = 58), C6-7 (n = 49), C4-6 (n = 16) and C5-7 (n = 14). According to the Frankel grading system, grade A was observed in 20 cases, grade B in 91, grade C in 124 and grade D in 60. One hundred and eighteen (40%) patients had a high fever and difficulty in breathing on presentation. First aid measures included early reduction and immobilization of the injured cervical spine, controlling the temperature, breathing support, and administration of high-dose methylprednisolone within eight hours of the injury (n = 12) and administration of dehydration and neurotrophy medicine. Oxygen support was given and tracheotomy was performed for patients with serious difficulty in breathing. Measures were taken to prevent bedsores and infections of the respiratory and urological systems. Two hundred and thirty six patients were treated with anterior decompression, 31 patients were treated by posterior approach surgery and combined anterior and posterior approach surgery was performed in a single sitting on 28 patients.Results:All patients were followed for 0.5-18 years (mean 11.8 years). At least one Frankel grade improvement was observed in 178 (60.3%) patients. In the anterior surgery group, the best results were observed in the cases with slight compressive fracture with disc herniation (44/50 patients, 88.0%). In the posterior surgery group, one Frankel grade improvement was observed in the cases with developmental spinal canal stenosis with trauma, lamina fractures, ligament injuries and hematoma (27/31, 87.1%). Most of the patients in the Frankel D group recovered normal neurological function after surgery. The majority of the patients with Frankel C neurological deficit (102/124) had the ability to walk postoperatively, while most of the seriously injured patients (Frankel A and B) had no improvement in their neurological function. Radiolographic fusion of the operated segments occurred in most patients within three months. Loss of intervertebral height and cervical physiological curvature was observed to varying degrees in 30.1% (71/236) of the cases in the anterior surgery group.Conclusion:First aid measures of early closed reduction or realignment and immobilization of the cervical spine, breathing support and high-dose methylprednisolone were most important in the treatment for traumatic spinal cord injury. Surgery should be performed as soon as the indications of spinal injury appear. The choice of the approach—anterior, posterior or both, should be based on the type of the injury and the surgeon's experience. Any complications should be actively prevented and treated.

頚椎症性筋萎縮症手術例の検討

We retrospectively evaluated the surgical results of cervical spondylotic amyotrophy in 39 patients (34 men and 5 women) who had been managed between 1973 and 1995. The average age at the time of surgery was 51.2 years (range, 33 to 82 years). Subjects showed muscle atrophy at the shoulder girdle (17 patients), at the forearm and hand (12 patients), and throughout the whole upper extremity (10 patients). Activities of daily living were preoperatively impaired by the muscle weakness. Neurological findings revealed 27 myelopathies and 12 radiculopathies. Anterior interbody fusion (Robinson-Smith) was performed in 35 patients (60 intervertebral discs) and expansive laminoplasty (Hirabayashi) was performed in 4 patients.The average duration of follow-up was 64 months (range, 6 to 164 months). The activities of daily living improved in 31 patients (79%), but in eight patients (21%) they were still impaired. The eight patients preoperatively had all showed myelopathy. In cases of developmental spinal canal stenosis (under 12mm of the sagittal diameter), multiple segmental (over three intervertebral discs) lesions, and generally narrow subarachnoid space, anterior interbody fusion gave poor results. In such cases we recommend the expansive laminoplasty.