C1-2 Level Research Articles

Trial data of the anti-obesity potential of a high resistant starch diet for canines using Dodamssal rice and the identification of discriminating markers in feces for metabolic profiling.

Dodamssal rice (Oryza sativa L.) includes high levels of resistant starch (RS), which is a source of dietary fiber. Recently, there has been an increase in the prevalence of obesity in canines; however, the information regarding diet treatments for such a condition is inadequate. Targeted metabolic profiles in canine feces were performed to identify potential biomarkers of RS and demonstrate the effect and potential use of Dodamssal rice as an anti-obesity treatment. Study canines were divided into three groups and fed either a regular diet, high-fat diet (HFD), or high-fat diet with Dodamssal rice (DoHFD). Fecal metabolites were analyzed using gas chromatography time-of-flight mass spectrometry and a gas chromatography-flame ionization detector. Multivariate analyses were used to analyze and visualize the obtained data. A total of 52 metabolites were detected in the canine feces. In addition, HFD group feces contained a significantly low level of C12:0. The DoHFD group feces had higher levels of 4-aminobutyric acid, glucose, and 3-hydroxybutyric acid compared to the other groups (p < 0.05). For the first time, targeted metabolic profiling in the canine feces in response to three diets was performed. This metabolic profiling approach should be a useful tool to detect discriminating markers as well as assess the effect of diet compositions for anti-obesity treatment of canines. Furthermore, Dodamssal rice may possibly be used not only for canines, but also to treat obesity in other animals and humans.

Microsurgical Treatment of Bowhunter's Syndrome: 3-Dimensional Operative Video.

We present the case of a 56-yr-old previously healthy male who presented with an approximately 1-yr history of intermittent dizziness, near syncope, and holocephalic headaches when turning his head to the left side for a prolonged period of time. He had a distant history of a previous anterior cervical discectomy and fusion at the C6-7 level. He was neurologically intact. Static, dynamic, and vascular imaging confirmed hypoplasia of the right vertebral artery and dominance of the left vertebral artery that completely filled the posterior circulation. Dynamic imaging confirmed compression of the left vertebral artery just above the C5-6 disc space on full head rotation to the left. After an anterior cervical exposure, we dissected lateral to the C5-6 disc space to the transverse process. The anterior tubercle was identified, and a Doppler ultrasound was used to insonate the vertebral artery above the level of compression. The anterior wall of the transverse foramen was thinned with a high-speed drill under constant irrigation and Kerrison rongeurs used to expose the vertebral artery at the site of compression. Importantly, the fibrotic band at, above, and below the level of compression was also dissected and removed. The patient tolerated the procedure well, and was discharged from the hospital 2 d after surgery with no neurological deficits and with complete relief of his preoperative symptoms. Because his symptoms completely resolved and have not recurred, no postoperative imaging was performed. The etiology, presentation, and microsurgical treatment of this rare disease are discussed.All appropriate patient consents were obtained for this submission.© 2017 Department of Neurosurgery, Emory University Hospital. Used with permission.All Figures used with permission as above.

Teaching NeuroImages: Vertebral artery compression by head tilt around the roll axis diagnosed by transcranial Doppler.

A 59-year-old man reported transient vertigo and diplopia during leftward head tilt around the roll axis. Neurologic examination was unremarkable with the head erect or tilted. Magnetic resonance angiography of the head and neck showed hypoplasia of the right vertebral artery (figure 1). Transcranial Doppler waveform was monitored during leftward head tilt. The left vertebral artery flow velocity decreased with tilt, and abruptly increased after returning to erect posture (figure 2). Vertebral artery can be stretched or kinked by head rotation or tilt,1,2 typically at the C1-2 level.1 Transcranial Doppler could be helpful in diagnosis of such cases.

Benefits and pitfalls of iterative decomposition of water and fat with echo asymmetry and least-squares estimation (IDEAL) imaging in clinical application of the cervical spine MR

To evaluate efficacy of T2-weighted (T2W) iterative decomposition of water and fat with echo asymmetry and least-squares estimation (IDEAL)-fast spin echo (FSE) imaging of the cervical spine. The cervical spine of 100 symptomatic patients was imaged using routine magnetic resonance imaging (MRI) versus IDEAL-FSE imaging. The signal-to-noise ratios (SNRs), contrast-to-noise ratios (CNRs), and image quality were analysed. To compare the diagnostic efficiency of degenerative spondylopathy, evaluations of spondylolisthesis, retrolisthesis, disc herniation, myelopathy, disc degeneration, and bone marrow oedema were also performed. IDEAL-FSE showed significantly higher SNRs and CNRs (all p<0.001) than fat-suppressed (FS) T2W-FSE. Sixteen of 100 patients had cervical spine instrumentation; in those patients, IDEAL-FSE provided significantly better uniformity of fat suppression (p<0.001) and fewer metallic artefacts (p<0.001). For patients without instrumentation, FS T2W-FSE showed significantly better overall image quality (p<0.001) and homogeneity of the cerebrospinal fluid (CSF; p<0.001) with fewer motion artefacts (p<0.001). IDEAL-FSE, however, provided significantly better uniformity of fat suppression (p<0.001). There were no significant differences in the diagnoses of spondylolisthesis, retrolisthesis, disc herniation, or myelopathy between IDEAL and FS T2W images. The only significant differences between the IDEAL and FS T2W images were noted when diagnosing degenerative disc disease at the C2-3 and C5-6 disc levels (p=0.019, p=0.002, respectively) and bone marrow oedema at C3 vertebral body (p=0.029). T2W IDEAL-FSE imaging should only be considered as an additional sequence to conventional FS T2W images in patients with poor fat suppression or severe metallic artefacts.

Extruding Cervical Screw: A Rare Cause of Dysphagia

Complications from instrumentation of the cervical spine may affect the esophagus, as it directly overlies the cervical vertebrae; there have been reported cases of perforation, abscess, stricture, and diverticulum formation. While orthopedic surgeons and neurosurgeons are aware of these rare complications, gastroenterologists may not be familiar with them and may not consider these diagnoses when evaluating patients with oropharyngeal issues. We present a case of cervical screw extrusion leading to dysphagia and hoarseness, that underscores the importance of careful endoscopic inspection of the retropharynx during endoscopy and the early use of imaging in evaluation of patients with a history of cervical instrumentation. A 49 year old woman presented with a 4 month history of increasing difficulty and pain swallowing (right side of the throat), and significant hoarseness. Past history was significant for a motor vehicle accident 17 years prior, with cervical spine injury leading to refractory radiculopathy. She subsequently underwent anterior cervical decompression, fusion, and insertion of an integrated cage and plate system. Upper endoscopy showed a normal esophagus. Careful inspection identified a prominent bulge in the right posterior oropharynx, proximal to the piriform sinus with a superficial mucosal erosion, but no perforation (Fig. 1). A follow-up cervical CT scan confirmed a screw extending from the C4-5 level into the posterior esophagus to the right of midline at the level of the piriform sinus (Fig. 2); there was also evidence of instrumented fusion at C4-5 and C4-6 using integrated cage and plate system. The patient was then referred to neurosurgery for urgent operative removal of the screws.1742_A Figure 1. Endoscopic examination identifying a prominent bulge in the right posterior oropharynx, proximal to the piriform sinus.1742_B Figure 2. CT scan confirming a screw extending from the C4-5 level into the posterior esophagus to the right of midline at the level of the piriform sinus.Esophageal complications related to cervical fusion hardware are rare, and may present in the immediate post-operative period or years later. Slow anterior migration of the screw or cage system over time may cause extrinsic compression of the pharyngoesophageal wall leading to pressure necrosis and ultimately erosion or perforation. Gastroenterologists should have a high index of suspicion for this diagnosis when evaluating patients with history of cervical instrumentation presenting with oropharyngeal dysphagia. Endoscopic exam should focus on careful inspection of the oropharynx, as the pertinent findings may be subtle. Follow-up imaging with CT or MRI should be considered in the appropriate setting to confirm the diagnosis.

Wednesday, September 26, 2018 1:00 PM – 2:00 PM Interventional Pain Management: 29. The use of high dose cervical spinal cord stimulation in the treatment of chronic upper extremity and neck pain

BACKGROUND CONTEXT Within the last few decades, the use of dorsal column stimulation has increased as an alternative method for the long-term treatment of chronic neuropathic pain of the axial spine and extremities. The explicit purpose of this therapy has been to replace pain in the affected area with a more favorable paresthesia. However, the electrical stimulation may elicit paresthesias which are unfavorable to a subset of patients making the therapy untenable despite adequate pain control. To address this issue, an innovative form of high-dose (HD) programming that utilizes a range of frequencies which provide paresthesia-free pain control has been clinically successful in thoracic dorsal column stimulation. To date, no such use of HD programming has been reported in cervical dorsal column stimulation. PURPOSE The purpose of this study is to evaluate the utility of high-dose stimulation in the cervical spine for the paresthesia-free treatment of upper extremity and neck pain. STUDY DESIGN/SETTING The study design follows a retrospective analysis to evaluate the history, treatment conditions and results of three patients with chronic upper extremity and neck pain treated with high-dose cervical spinal cord stimulation. A review of the literature regarding cervical spinal cord stimulation and the current state of high-dose stimulation was also undertaken. PATIENT SAMPLE Three patients, two male and one female, were included in the case series. The first patient, a 43 year old male, suffered from post-traumatic neck and right upper extremity neuropathic pain as a result of ballistic cervical spinal cord injury. The second patient, a 68 year male, presented with cervical degenerative foraminal and central moderate stenosis from C2 through C7 with neck pain and bilateral radiculopathy. The third patient, a 32 year old female, was referred for left upper extremity chronic regional pain syndrome after a work related injury, without significant cervical pathology. OUTCOME MEASURES Outcome measures in this case series were evaluated through the typical method of identifying candidacy for permanent dorsal column stimulator implantation, specifically relative percent pain relief with and without stimulation. METHODS Patients were evaluated preoperatively both clinically and radiographically to determine candidacy for a stimulator trial. Adequate patency of the cervical spinal canal on MRI and pain locations amenable to cervical spinal cord stimulation were found to be present in all patients. Each patient then underwent a stage 1 cervical spinal cord stimulator placement with externalized extension leads. Specifically, two 1 × 8 percutaneous Medtronic epidural arrays were advanced to the level of C2-3 bilaterally or eccentric to the affected side. A five-day trial of both low-dose paresthesia and high-dose paresthesia-free therapy was applied. All patients experienced greater than 50% pain relief (range 70%–90%) without paresthesias and requested permanent implantation. Stage 2 extension lead removal with generator connection and implantation was performed in all three cases using the Medtronic Intellis rechargeable generator without complication and with persistent and current paresthesia-free pain control since implantation (range 6-12 months). RESULTS During the trial period, all patients experienced greater than 50% pain relief (range 70%–90%) without paresthesias utilizing high-dose programming. Pain returned to baseline levels with the device off. Low-dose therapy was applied during the trial period as well, resulting in all cases with similar pain relief, but with the presence of paresthesias, which in all cases was less favorable to the paresthesia-free high-dose programming. After permanent implantation, all three patients continue to experience persistent and current paresthesia-free pain control (range 6-12 months). CONCLUSIONS This retrospective case series first reports and demonstrates the effectiveness of high-dose cervical spinal cord stimulation in the paresthesia-free treatment of a variety of upper extremity chronic pain generators. This suggests a potential benefit to a subset of patients who may benefit from cervical spinal cord stimulation but defer therapy due to unfavorable paresthesias. In the future, a larger study should be conducted in order to fully understand the use of high-dose cervical spinal cord stimulation. Medtronic Spinal Cord Stimulator (Approved for this indication) FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Friday, September 28, 2018 4:05 PM–5:05 PM abstracts: new concepts: cervical spine: 246. C5 palsy after single- and multilevel anterior cervical discectomy and fusion

BACKGROUND CONTEXT Postoperative C5 nerve root palsy is a known complication after decompressive cervical surgery, most commonly reported after posterior cervical decompression and fusion (PCDF). However, while the rate of C5 palsy after anterior cervical decompression and fusion (ACDF) is lower, the effect of increasing number of levels fused on the prevalence of C5 palsy is unclear. PURPOSE To examine the rate of C5 palsy after one-, two-, three- and four-level ACDF including the C4-5 level, without corpectomy, and without posterior decompression. STUDY DESIGN/SETTING Retrospective cohort. PATIENT SAMPLE Retrospective review of all anterior cervical discectomy and fusion patients at one institution over a 1 year period. OUTCOME MEASURES Manual motor testing grade. METHODS We performed a retrospective review of ACDFs performed at one institution by multiple surgeons between September 2015 and June 2016. Patient demographic and surgical information was reviewed, including postoperative motor examination results in the immediate postoperative period. C5 palsy was defined as motor decline of the deltoid muscle function by at least one level on standard manual muscle testing. Patients were excluded if undergoing concurrent posterior surgery or corpectomy, or if no postoperative motor strength was documented. Fisher's exact test was used to compare categorical variables between groups, and analysis of variance used to compare continuous variables. RESULTS We identified 226 patients undergoing single- or multilevel ACDF over the study time period, with a total of 196 meeting our inclusion criteria. Average age of all patients was 59.0 years and 49% were male, with no significant differences noted between groups undergoing single- or multilevel ACDF. Average follow up was 7 months. Ten patients developed postoperative C5 palsy, with an overall rate of 5.1%. There were no statistically significant differences in age, patient sex or numbers of levels fused between the palsy and no-palsy groups. We identified two C5 palsies in the single-level group (8.7%), two in the two-level group (3.1%), five in the three-level group (5.6%) and one in the four-level group (5.6%). These rates were not statistically significant between groups (p>.05). Six of the 10 patients with C5 palsy had complete recovery of final deltoid and/or biceps strength, while two patients had at least some level of strength recovery. Two patients had no measured improvement in C5 motor function by final follow up. CONCLUSIONS To our knowledge, no prior study has specifically compared the risk of C5 palsy between single- and multilevel ACDF when excluding corpectomy and posterior cervical cases. We found an overall C5 palsy rate of 5.1% for all patients undergoing one-, two-, three-, and four-level ACDF that included the C4-5 level at our institution. The rate of postoperative deltoid and/or biceps motor strength decline was lowest in the patients undergoing two-level ACDF and highest in the single-level group, but this finding did not reach statistical significance. Our rate of C5 palsy appears comparable to published literature.

Simple presurgical method of predicting C5 palsy after cervical laminoplasty using C5 nerve root ultrasonography.

The incidence of C5 palsy after cervical laminoplasty is approximately 5%. Because C5 palsy is related to cervical foraminal stenosis at the C4-5 level, the authors hypothesized that cervical foraminal stenosis can be diagnosed by examining the C5 nerve root (NR) using ultrasonography. The purpose of this study was to investigate whether postoperative C5 palsy could be predicted using ultrasonography. This study used a prospective diagnosis design. In total, 140 patients undergoing cervical laminoplasty were examined with ultrasound. The cross-sectional area (CSA) of the C5 NR was measured on both sides before surgery, and the incidence of postoperative C5 palsy was examined. The difference between the CSA of the patients with and without C5 palsy and the lateral differences in the C5 palsy group were determined. The incidence of C5 palsy was 5% (7 cases). Symptoms manifested at a median of 5 days after surgery (range 1-29 days). The CSA of the C5 NR on the affected side was significantly enlarged in the C5 palsy group compared with that in the no-C5 palsy group (p = 0.001). In addition, in the patients who had C5 palsy, the CSA of the C5 NR was significantly enlarged on the affected side compared with that on the unaffected side (p = 0.02). Receiver operating characteristic analysis indicated that the best threshold value for the CSA of the C5 NR was 10.4 mm2, which provided 91% sensitivity and 71% specificity. C5 palsy may be predicted preoperatively using ultrasound. The authors recommend the ultrasonographic measurement of the CSA of the C5 NR prior to cervical laminoplasty.

Percutaneous Endoscopic Cervical Discectomy and Osteophytes Removal Via an Anterior Transforaminal Approach for Radiculopathy: Technical Notes and Review

BACKGROUND: Cervical radiculopathy can be treated by anterior endoscopic approach to access its target pathology decompressing spinal nerve roots without fusion. The transforaminal anterior percutaneous endoscopic cervical discectomy approach is easy way to transverse process and decompress and remove osteophytes. It preserves spinal motion, stability and reduces risk of vertebral injury. METHODS: A case selected had neck pain radiating toward right arm for 2 month but severe pain from 20 days, neck deformities, head tilted toward right side. Neurological examination showed decreased sensation, weakness over right sided trapezius, biceps and triceps muscles. Eaton sign and Spurling sign were positive. Preoperative dynamic X-ray showed degenerative changes, osteophtyes at C3-4, C5-6, CT -intervertebral foraminal stenosis at C3-4 and C5-6 level, MRI -disc protrusion severely compressing spinal cord at C3/4 level. We operated at most significant level as first successful newer approach for cervical radiculopathy with osteophytes removal, decompression and discectomy by PECD anterolateral (transforaminal approach) under general anesthesia. RESULTS: Blood loss 100 mL. Hospital Stay 3 days. Operative time was 80 minute. There was marked improvement of preoperative VAS score from 7/10 to 3/10. After surgery drain was fixed for 24 hour to collect some residual fluids and avoid hematomas. There were no significant post operative events or surgery-related complication. CONCLUSION: Under percutaneous endoscopic system is easy to visualize proper minute structure, drill, dissect and lessen the chance of iatrogenic injury, decrease risk of vertebral arteries. Anterior transformaminal endoscopic surgical approach can be further developed and trained for treatment of cervical radiculopathy in large population.

Endoscopic Anterior Approach for Cervical Disc Disease (Disc Preserving Surgery)

To report our experience of endoscopic disc removal by anterior approach for management of cervical myelopathy in 210 patients. A retrospective study of 187 cases of single- and 23 cases of double-level disc disease was performed. Cases of myelopathy with or without unilateral or bilateral radiculopathy and unilateral radiculopathy with either soft or hard disc prolapse were included. Patients with ≥3 disc levels, unstable spine, infections, trauma, significant posterior compression, congenital canal stenosis, disc extending more than half the vertebral body height, and prior surgery at the same level were excluded. C5-6 (n= 119 patients), C6-7 (n= 58 patients), C4-5 (n= 49 patients), C3-4 (n= 6 patients), and C2-3 (n= 1 patient) levels were represented. Visual analog scale and Nurick grading system were used to assess severity of neck and arm pain and functional outcomes, respectively. Preoperative mean visual analog scale scores for arm and neck pain were 6.7 and 3.2, respectively, which improved to 1.7 and 1.1 at 3 months after surgery. The average preoperative Nurick grade improved from 2.64 to0.81 at 6 months postoperatively. Follow-up was 6-54months. Endoscopic anterior discectomy (disc preserving surgery) is an effective and safe alternative in cervical disc disease. Although there was reduction in disc height, clinical outcome was good at an average 29 months of follow-up. Long-term follow-up is required to assess any progressive disc degeneration and clinical results.

Dorsal and ventral horn atrophy is associated with clinical outcome after spinal cord injury.

ObjectiveTo investigate whether gray matter pathology above the level of injury, alongside white matter changes, also contributes to sensorimotor impairments after spinal cord injury.MethodsA 3T MRI protocol was acquired in 17 tetraplegic patients and 21 controls. A sagittal T2-weighted sequence was used to characterize lesion severity. At the C2-3 level, a high-resolution T2*-weighted sequence was used to assess cross-sectional areas of gray and white matter, including their subcompartments; a diffusion-weighted sequence was used to compute voxel-based diffusion indices. Regression models determined associations between lesion severity and tissue-specific neurodegeneration and associations between the latter with neurophysiologic and clinical outcome.ResultsNeurodegeneration was evident within the dorsal and ventral horns and white matter above the level of injury. Tract-specific neurodegeneration was associated with prolonged conduction of appropriate electrophysiologic recordings. Dorsal horn atrophy was associated with sensory outcome, while ventral horn atrophy was associated with motor outcome. White matter integrity of dorsal columns and corticospinal tracts was associated with daily-life independence.ConclusionOur results suggest that, next to anterograde and retrograde degeneration of white matter tracts, neuronal circuits within the spinal cord far above the level of injury undergo transsynaptic neurodegeneration, resulting in specific gray matter changes. Such improved understanding of tissue-specific cord pathology offers potential biomarkers with more efficient targeting and monitoring of neuroregenerative (i.e., white matter) and neuroprotective (i.e., gray matter) agents.

Outcome of Anterior Cervical Discectomy and Fusion In Degenerative Compressive Myelorediculopathy With Stand-Alone Titanium Cage

Background : Anterior Cervical Discectomy and Fusion (ACDF) is widely performed for cervical degenerative disease with autograft or allograft with long term satisfactory outcome. But the complications of autogenous bone grafting cause the spinal surgeons to seek alternative method. This prospective study was conducted to observe the outcome of using stand-alone titanium cage in ACDF. Materials and methods : Total 50 patients (68 levels) with degenerative compressive cervical myelorediculopathy were operated using stand-alone titanium cage from July 2013 to June 2015 in the Department of Neurosurgery, Chittagong Medical College Hospital. All patients were examined and evaluated preoperatively by plain X-ray and MRI and postoperatively by plain X-ray at one, three and 12 months. Clinical and neurological outcome was assessed by Japanese Orthopedic Association (JOA) score. Results: The mean age was 42.04±7.94 years ranged from 30 to 66 years. Maximum patients were in 41-50 years age group. Quadriparesis was found most common symptom (60%) followed by brachialgia (20%). Out of 50 patients, 32 (64%) suffered from single level compression while 18 (36%) patients suffered from two level compression. Among all operated levels, C5-6 (n-30, 44.2%) was most common level followed by C6-7 (n- 20,29.4%) and C4-5 (n-12, 17.6%) level. All patients improved in terms of their neck pain, redicular arm pain, clumsy hand movement and quadriparesis after surgery. Subsidence was observed in 15 (30%) patients and kyphosis was observed in 10 (20%) patients. All patients with subsidence and kyphosis were neurologically stable and no revision was required. Mean preoperative JOA score was 8.38±3.71 and mean post operative JOA score was 12.92±3.39. Among all patients in post operative follow up, 22 (44%) patients showed excellent recovery and 15 (30%) patients showed good recovery. Conclusion: Anterior cervical fusion using a stand-alone titanium cage is a safe and effective procedure allowing excellent to good functional recovery and avoiding donor site morbidity. Titanium cage can be an effective alternative to iliac bone autograft.&#x0D; JCMCTA 2017 ; 28 (2) : 34-38

Cervical Myelopathy Secondary to Combined Ossification of Ligamentum Flavum and Posterior Longitudinal Ligament-A Case Report.

In the cervical spine, the combined ossification of the ligamentum flavum (OLF) and posterior longitudinal ligament is rarely seen. Patients are usually treated with cervical laminectomy or laminoplasty with OLF resection. In most of the cases, OLF is adhered to the dura and there is a risk of dural tear or cerebrospinal fluid (CSF) leakage during its resection. In this case report, the authors present results of laminectomy with debulking instead of complete excision of OLF for spinal cord decompression in a cervical myelopathy case in which OLF was adhered to the dura. A 69-year-old man presented with insidious onset weakness in bilateral lower limbs and unsteady gait, which he had experienced 1 month. He has a history of neck pain with left upper limb radiation for the last 2 years. Magnetic resonance imaging showed C5-6 severe central canal stenosis with underlying myelomalacia. Computed tomography showed ossification posterior longitudinal ligament and OLF contributing to severe central canal stenosis at the C5-6 level. The patient underwent C4-C6 laminectomy, debulking of OLF, posterior instrumentation, and fusion with autogenous bone graft from C3 to C6. A histological specimen showed osseous tissue within the ligamentum flavum. After surgery the patient's symptoms improved and no recurrence was observed at 4 years after surgery. The symptoms of myelopathy were successfully treated with debulking instead of complete excision of OLF, thus reducing the risk of dural tear or CSF leakage.

Percutaneous Endoscopic Cervical Discectomy and Osteophytes Removal Via an Anterior Transforaminal Approach for Radiculopathy: Technical Notes and Review

BACKGROUND: Cervical radiculopathy can be treated by anterior endoscopic approach to access its target pathology decompressing spinal nerve roots without fusion. The transforaminal anterior percutaneous endoscopic cervical discectomy approach is easy way to transverse process and decompress and remove osteophytes. It preserves spinal motion, stability and reduces risk of vertebral injury. METHODS: A case selected had neck pain radiating toward right arm for 2 month but severe pain from 20 days, neck deformities, head tilted toward right side. Neurological examination showed decreased sensation, weakness over right sided trapezius, biceps and triceps muscles. Eaton sign and Spurling sign were positive. Preoperative dynamic X-ray showed degenerative changes, osteophtyes at C3-4, C5-6, CT -intervertebral foraminal stenosis at C3-4 and C5-6 level, MRI -disc protrusion severely compressing spinal cord at C3/4 level. We operated at most significant level as first successful newer approach for cervical radiculopathy with osteophytes removal, decompression and discectomy by PECD anterolateral (transforaminal approach) under general anesthesia. RESULTS: Blood loss 100 mL. Hospital Stay 3 days. Operative time was 80 minute. There was marked improvement of preoperative VAS score from 7/10 to 3/10. After surgery drain was fixed for 24 hour to collect some residual fluids and avoid hematomas. There were no significant post operative events or surgery-related complication. CONCLUSION: Under percutaneous endoscopic system is easy to visualize proper minute structure, drill, dissect and lessen the chance of iatrogenic injury, decrease risk of vertebral arteries. Anterior transformaminal endoscopic surgical approach can be further developed and trained for treatment of cervical radiculopathy in large population.

Early ventral surgical treatment without traction of acute traumatic subaxial cervical spine injuries.

Background:Spinal cord decompression after cervical spinal cord injury (SCI) is the standard of care. However, there is a lack of consensus regarding the optimal management of these injuries, including the role of traction and timing of surgery. Here, we report the safety/efficacy of ventral surgery without preoperative traction for intraoperative fracture reduction following acute cervical SCI.Methods:We prospectively collected a series of patients who sustained acute traumatic subaxial cervical (C3–7) spine fractures between 2004 and 2016. Patients underwent anterior cervical decompression and fusion within 24 h of injury without the utilization of preoperative traction.Results:Thirty-six patients (27 male, 9 female), averaging 35 years of age, sustained 25 motor-vehicle accidents, 4 sports-related injuries, and 7 falls. Fracture dislocations were seen in 26 patients, whereas burst fractures were seen in 10. The majority of injuries occurred at the C4–5 (13 patients) and C5–6 (13 patients) levels. Complete SCI occurred in 10 patients, and incomplete SCI in 26 patients. All patients underwent anterior surgery only; 16 required vertebrectomy in addition to anterior cervical discectomy and fusion. Intraoperative reduction was achieved in all patients using a Cobb elevator or distraction pins without the use of preanesthesia traction. There were no intraoperative complications. Postoperatively, there were one postoperative hematoma, two wound/hardware revisions, one subsequent posterior fusion, and one reoperation anteriorly after screw pullout. The average hospital length of stay was 10.6 days (range 1–39).Conclusion:Early direct surgical stabilization/fusion for acute SCI because of subaxial cervical spine fractures is both safe and effective in selected cases when performed anteriorly without preoperative traction in select cases.

Modified high cervical approach for C3-4 anterior pathology in difficult neck patients

Introduction:The anterior approach to cervical pathologies is a time-tested versatile approach. It is, however, associated with a number of pharyngo-tracheo-laryngeal complications (PTL complications) such as dysphonia, dysphagia, and aspiration, more commonly in high cervical C3-4 inclusive pathologies and even more so in patients with “difficult neck.” The modified high cervical approach was devised and employed to address these issues at our institution.Materials and Methods:Patients who underwent surgery for anterior cervical C3-4 inclusive pathologies between January 2015 and April 2018 were included in the study. Parameters for considering difficult neck were defined. Patient subgroup with difficult neck underwent surgery through a modified high cervical approach, whereas others underwent surgery through a standard approach. The incidence of pharyngo-tracheo-laryngeal complications in both subgroups of this patient set was compared among itself as well with a similar patient set with the same two subgroups, both of which underwent surgery through standard approach alone from May 2010 to December 2014 – before the introduction of modified high cervical approach.Results:A total of 280 patients underwent surgery for C3-4 level pathology between May 2010 and April 2018. There were 197 males and 93 females in this population. Mean age was 45.8 ± 6.3 years. Incidence of pharyngo-tracheo-laryngeal complications was 20.3% in patients who underwent surgery before the employment of modified high cervical approach – 32.4% of difficult neck and 16.6% of others developed features of pharyngo-tracheo-laryngeal complications. After employment of modified high cervical approach, 16.67% of difficult neck and 16.2% of other patients developed features of pharyngo-tracheo-laryngeal complications.Conclusion:The modified high cervical technique is a good surgical option to prevent pharyngo-tracheo-laryngeal complications in cases of anterior C3-4 pathology when operating of patients with difficult neck.

Rigid Occipitocervical Instrumented Fusion for Atlantoaxial Instability in an 18-Month-Old Toddler With Brachytelephalangic Chondrodysplasia Punctata

Case report. We report here on an 18-month-old boy with brachytelephalangic chondrodysplasia punctata (BCDP), whose atlantoaxial instability was successfully managed with occipitocervical instrumented fusion (OCF) using screw and rod instrumentations. Recently, there have been a number of reports on BCDP with early onset of cervical myelopathy. Surgical OCF is a vital intervention to salvage affected individuals from the life-threatening morbidity. Despite recent advancement of instrumentation techniques, however, rigid OCF is technically demanding in very young children with small and fragile osseous elements. To our best knowledge, this is the first report on application of the instrumentation technique to a toddler patient with BCDP. A 16-month-old boy with BCDP presented with tetraplegia and swallow obstacle. Hypoplasia of the odontoid process and atlantoaxial instability were present in lateral radiographs. T2-weighted magnetic resonance (MR) images revealed a high signal region in the spinal cord at the C1-2 and C7-T1 levels. Cervical computed tomography (CT) showed that the pedicles and lateral masses in the cervical spine were small and immature, but the laminae were comparatively thick. One week before surgery, the patient was fitted with a Halo-body jacket. We performed plate-rod placement with occipital cortical screws and C2/C3 interlaminar screws, and added an autogenous bone graft using the right 8 and 9 ribs. Rigid fixation of the occipito-cervical spine was completed successfully without major complications. Postoperative halo-body jacket immobilization was continued for 3 months, after which Aspen collar was fitted. CT confirmed occipitocervical bone fusion at 6 months after surgery. Mild clinical improvements in motor power of the affected muscles and swallowing were witnessed at 1 year postoperatively. Rigid fixation using screw, rod, and occipital plate instrumentation was successful in an 18-month-old toddler with BCDP and atlantoaxial instability. Bone fusion was achieved at postoperative 6 months. 5.

Rapid Progression of Ossification of the Posterior Longitudinal Ligament After Anterior Cervical Discectomy and Fusion

Ossification of the posterior longitudinal ligament (OPLL) has a reported incidence of 1.9%-4.3%. Disease progression is associated with surgery, with most studies focusing on OPLL progression after laminoplasty. The continued range of motion following surgery is believed to place strain on adjacent levels, driving calcification of the ligament. We present a case of marked progression of OPLL at levels adjacent to a previous anterior cervical discectomy and fusion. A 59-year-old man initially presented for progressive loss of balance and dexterity and underwent a C4-6 anterior cervical discectomy and fusion procedure. Computed tomography performed 1 year postoperatively showed fusion across C4-6 with no evidence of OPLL at any level. Two years following index surgery, the patient reported right-side arm pain. Computed tomography revealed new minimal OPLL opposite the C3-4 level that was not causing cord compression. A sparing midline bilateral C3-7 laminotomy was performed to correct stenosis seen on magnetic resonance imaging. At 7 years after the index procedure, the patient presented with myelopathic symptoms exceeding symptoms at his index presentation. Computed tomography revealed marked progression of OPLL. The patient underwent C2-T2 posterior fusion with laminectomy from C2-C7 and responded well with gradual improvements in balance and arm pain after surgery. Our report demonstrates that OPLL progression, which is largely reported following laminoplasty, may similarly occur following anterior cervical discectomy and fusion and supports the concept of motion-related OPLL progression.

Daha önce tanı konulmamış servikal dar kanal olgusunda manyetik rezonans görüntüleme sırasında ani gelişen tetraparezi: Olgu sunumu

Objective: To report a case with sudden-onset tetraparesis during taking magnetic resonance imaging (MRI). Case report: A 73-year-old man was referred with complaints of paresis of his arms and legs. His tetraparesis had developed suddenly while an MRI was performed 10 days before. He had a severe tetraparesis with 0/5 motor strength in his legs and 2/5 motor strength in his arms. On the MRI, a serious spinal stenosis at C3-4 and C4-5 levels and a faint myleopathic signal of the spinal cord at the level of the C4-5 disc space were seen. After posterior decompression, the patient’s tetraparesis improved gradually and he could walk independently and perform his daily activities with mild spasticity after 13 months. Conclusion: It is known that sudden neurological deficits may be seen in cervical trauma in patients with cervical spinal stenosis due to spondylosis. However, this case who did not have a trauma history showed us that a long period of positioning the neck beyond the patient’s control, even during the execution of MRI, may cause sudden deterioration.

17 yo Football Player with Central Cord Syndrome after Negative Initial Neck Exam

HISTORY: A 17 year old HS football receiver was injured when he sustained a hit from the opposing safety. Reported mechanism by opposing player was shoulder to head impact. He fell to the ground in the prone position. He was immediately evaluated on the field by the nearby opposing athletic trainers. He had no LOC, no neck pain on the field, and he denied tenderness to palpation. He complained of having the wind knocked out of him. He reported that he got hit in the back of the leg and it felt odd. He had an ACL brace on his right knee. Care was transitioned to his team athletic trainers. He was turned supine and his helmet was removed. Afterwards, his right arm was noted to be in an awkward position. He could not move his arms or his legs. He had good sensation but had tingling in his upper and lower extremities. He had no prior history of weakness, neck pain, or concussion. His neck was immobilized. He regained motion in the upper extremity, but continued to demonstrate weakness in grip strength. He could not move his lower extremity. On EMS arrival he was spine boarded, and then taken to the ED for further management. PHYSICAL EXAMINATION: He was AO x 3. He had no tenderness over the cervical spinous processes and paraspinal muscles. He had normal sensation of his bilateral extremities. After being turned supine and having his helmet removed, he developed weakness of his upper and lower extremities, but no sensory deficit. Respiratory and Cardiovascular exams were normal. DIFFERENTIAL DIAGNOSIS: 1. Central Cord Syndrome 2. Anterior Cord Syndrome 3. Posterior Cord Syndrome 4. Brown-Sequard Syndrome 5. Concussion 6. Intracranial Hemorrhage 7. Acute disk herniation 8. Epidural Hematoma 9. Syringomyelia TEST AND RESULTS:CT Head, XR C, T, L spine: No fracture or bleed MR C-spine: Congenital stenosis of the spinal canal, with endplate osteophytes/protrusions moderately narrowing the spinal canal to 8 mm at C3-4, with expansile T2 signal suggestive of edema within the cervical spinal cord at C3-4 levels. FINAL/WORKING DIAGNOSIS: Traumatic Cervical Myelopathy superimposed on Congenital Stenosis of Spinal Canal TREATMENT AND OUTCOMES: 1. Immobilization with Miami J Collar 2. Admitted to the hospital for observation. 3. Sensory and strength deficits improved during stay. 4. Transferred to an intensive inpatient activity based rehabilitation facility.