Loss Of Cervical Lordosis Research Articles

The Effect of the PEEK Cage on the Cervical Lordosis in Patients Undergoing Anterior Cervical Discectomy.

BACKGROUND:Loss of cervical lordosis is a significant factor in the development of degeneration of the spine with aging. This degenerative changings of the cervical spine would cause pressure effect on the cervical root and/or medulla spinalis.AIM:Our goal is to understand the effect of the PEEK cage on cervical lordosis in the early postoperative period. Also, to interpret the effects of one- level, two- level, three-level and four- level disc pathologies on cervical lordosis.MATERIAL AND METHODS:We retrospectively investigated our archive, and we selected thirty-four patients undergoing anterior cervical discectomy and fusion with PEEK cage filled with demineralized bone matrix (ACDFP).RESULTS:We determined that ACDFP provides improvement in the cervical lordosis angle in both groups. Also, we found statistically significant difference between group 1 and 2 regarding causes of radiculomyelopathy statistically.CONCLUSION:We achieved better cervical lordotic angles at the postoperative period by implanting one-level, two-level, three-level or four-level PEEK cage filled with demineralized bone matrix. Also, the causes of cervical root and or medulla spinalis impingement were different in group1 and 2. While extruded cervical disc impingement was the first pathology in group 1, osteophyte formation was the first pathology in group 2.

Cervical interfacet spacers and maintenance of cervical lordosis

OBJECT The cervical interfacet spacer (CIS) is a relatively new technology that can increase foraminal height and area by facet distraction. These offer the potential to provide indirect neuroforaminal decompression while simultaneously enhancing fusion potential due to the relatively large osteoconductive surface area and compressive forces exerted on the grafts. These potential benefits, along with the relative ease of implantation during posterior cervical fusion procedures, make the CIS an attractive adjuvant in the management of cervical pathology. One concern with the use of interfacet spacers is the theoretical risk of inducing iatrogenic kyphosis. This work tests the hypothesis that interfacet spacers are associated with loss of cervical lordosis. METHODS Records from patients undergoing posterior cervical fusion at Rush University Medical Center between March 2011 and December 2012 were reviewed. The FacetLift CISs were used in all patients. Preoperative and postoperative radiographic data were reviewed and the Ishihara indices and cervical lordotic angles were measured and recorded. Statistical analyses were performed using STATA software. RESULTS A total of 64 patients were identified in whom 154 cervical levels were implanted with machined allograft interfacet spacers. Of these, 15 patients underwent anterior-posterior fusions, 4 underwent anterior-posterior-anterior fusions, and the remaining 45 patients underwent posterior-only fusions. In the 45 patients with posterior-only fusions, a total of 110 levels were treated with spacers. There were 14 patients (31%) with a single level treated, 16 patients (36%) with two levels treated, 5 patients (11%) with three levels treated, 5 patients (11%) with four levels treated, 1 patient (2%) with five levels treated, and 4 patients (9%) with six levels treated. Complete radiographic data were available in 38 of 45 patients (84%). On average, radiographic follow-up was obtained at 256.9 days (range 48-524 days). There was no significant difference in the Ishihara index (5.76 preoperatively and 6.17 postoperatively, p = 0.8037). The analysis had 80% power to detect a change of 4.25 in the Ishihara index at p = 0.05. There was no significant difference in the preand postoperative cervical lordotic angles (35.6° preoperatively and 33.6° postoperatively, p = 0.2678). The analysis had 80% power to detect a 7° change in the cervical lordotic angle at p = 0.05. The ANOVA of the Ishihara index and cervical lordotic angle did not show a statistically significant difference in degree of change in cervical lordosis among patients with a different number of levels of CIS insertion (p = 0.25 and p = 0.96, respectively). CONCLUSIONS In the authors' experience of placing CISs in more than 100 levels, they found no evidence of significant loss of cervical lordosis. The long-term impacts of these implants on fusion rates and clinical outcomes (particularly radiculopathy and postoperative C-5 palsies) remain active areas of interest and fertile ground for further studies.

The Causes of Dizziness in Parkinson’s Disease

Patients with Parkinson’s disease complain dizziness frequently. Postural hypotension and postural instablity are suggested to be the reasons of dizziness in elderly people with Parkinson’s disease. The aim of this prospective surveillance study was to characterize the etiology of the dizziness in patients with PD. A total of 47 consecutive patients with idiopathic Parkinson’s disease were enrolled in the prospective surveillance study. Of the 47 patients, 32 (68.1%) had dizziness. All patients underwent neurological and otologic examination. Complete blood count, serum electrolytes, glucose, liver function tests, renal function tests and thyroid function tests, cranial computerized tomography, direct cervical region radiography and vertebral artery doppler ultrasonography were obtained from all patients. Patients were screened for blood pressure changes, drug use, cardiovascular diseases, hypertension and diabetes mellitus. The findings of loss of disk height, with subsequent loss of cervical lordosis were higher in patients with dizziness (p = 0.01). The results of this study show that cervical-vertebral degeneration may be a common cause of dizziness in Parkinson’s disease patients.

Posterior Global Malalignment After Osteotomy for Sagittal Plane Deformity

Multicenter, retrospective analysis of 183 consecutive patients undergoing lumbar osteotomy. To evaluate cause and impact of posterior postoperative alignment. Sagittal malalignment in the setting of adult spinal deformity (ASD) has shown significant correlation with pain and disability. Surgical treatment often entails correction of deformity by pedicle subtraction osteotomies (PSO). Key radiographical spinopelvic objectives to reach improvement in clinical outcomes have been previously reported. Although anterior alignment is a cause of poor outcomes, the impact and cause of posterior spinal alignment by PSO has not been reported. The patient inclusion criteria were age, more than 18 years, with a diagnosis of sagittal plane deformity (C7 plumbline offset >5 cm, a pelvic tilt >20°, or a lumbar lordosis to pelvic incidence mismatch of ≥10°) requiring a surgical procedure involving a lumbar posterior osteotomy and a long fusion. Patients were divided into 3 groups based on postoperative sagittal vertical axis (SVA): neutral alignment (0 < SVA < 50 mm), anterior alignment (SVA > 50 mm), and posterior alignment (SVA < 0 mm). All patients underwent pre- and postoperative full-length sagittal spine radiography. Differences between groups were evaluated using ANOVA and χ² analysis. Seventy-six patients were postoperatively classified in the anterior group: 59 in the neutral group and 48 in the posterior group. These groups were comparable preoperatively in terms of surgical status (revision vs. primary surgery) and regional alignment (lumbar lordosis and thoracic kyphosis). The patients with posterior alignment were younger and had a significantly lower pelvic incidence (53° vs. 62°), preoperative pelvic tilt (30 vs. 36°), SVA (94 vs. 185 mm) and cervical lordosis (16° vs. 25°) than patients in the anterior alignment group. No significant differences were found in terms surgical procedure. Patients in the posterior alignment group demonstrated a significantly greater change in SVA and pelvic tilt correction (P < 0.05) but with a lower gain in thoracic kyphosis (5 vs. 12°) and reduction of cervical lordosis (4° vs. 22°). A significantly lower pelvic incidence and lack of restoration of thoracic kyphosis may lead to sagittal overcorrection with a posterior alignment. Although the clinical significance of posterior malalignment is still unclear, this study showed a compensatory loss of cervical lordosis in these patients. Particular attention must be paid to preoperative planning before sagittal realignment procedures. Further study will be necessary to evaluate long-term clinical outcomes of these patients.

Long-term impacts of different posterior operations on curvature, neurological recovery and axial symptoms for multilevel cervical degenerative myelopathy

PurposeTo investigate the long-term impacts of different posterior operations on curvature, neurological improvement and axial symptoms for multilevel cervical degenerative myelopathy (CDM), and to study the relationship among loss of cervical lordosis, recovery rate and axial symptom severity.MethodsWe retrospectively reviewed 98 patients with multilevel CDM who had undergone laminoplasty (Group LP, 36 patients), laminectomy (Group LC, 30 patients), or laminectomy with lateral mass screw fixation (Group LCS, 32 patients) between January 2000 and January 2005. Loss of curvature index (CI) was measured according to the preoperative and final follow-up radiographic parameters. The recovery rate was calculated based on the Japanese Orthopedic Association (JOA) score. Axial symptom severity was quantified by Neck Disability Index (NDI).ResultsAnalysis of final follow-up data showed significant differences among the three groups regarding loss of CI (F = 41.46, P < 0.001) between preoperative and final follow-up JOA scores (P < 0.001), final follow-up JOA score (F = 7.81, P < 0.001), recovery rate (F = 12.98, P < 0.001) and axial symptom severity (χ 2 = 18.04, P < 0.001). Loss of CI showed negative association with neurological recovery (r = −0.555, P < 0.001) and positive correlation with axial symptom severity (r = 0.696, P < 0.001).ConclusionsExcellent neurological improvement was obtained by LP and LCS for patients with multilevel CDM, while loss of CI in groups LP and LC caused a high incidence of axial symptoms. Loss of CI was correlated with poor neurological recovery and axial symptom severity. Lateral mass screw fixation can effectively prevent loss of postoperative cervical curvature and reduce incidence of axial symptoms.

Loss of Lordosis and Clinical Outcomes after Anterior Cervical Fusion with Dynamic Rotational Plates

PurposeThe cervical dynamic rotational plating system may induce bone graft subsidence, so it may cause loss of cervical lordosis. However there were few studies for alignments of cervical spines influencing the clinical results after using dynamic rotational plates. The purpose is to evaluate the effect of graft subsidence on cervical alignments due to the dynamic rotational cervical plates and correlating it with the clinical outcomes of patients undergoing anterior cervical fusion.Materials and MethodsThirty-three patients with disease or fracture underwent anterior cervical decompression and fusion using a dynamic rotational plate. The presence and extent of implant complications, graft subsidence, loss of lordosis were identified and Visual Analog Scale score (VAS score), Japanese Orthopaedic Association score (JOA score), clinical outcomes based on Odom's criteria were recorded.ResultsFusion was achieved without implant complications in all cases. The mean graft subsidence at 6 months after the surgery was 1.46 mm. The lordotic changes in local cervical angles were 5.85° which was obtained postoperatively. VAS score for radicular pain was improved by 5.19 and the JOA score was improved by 3. Clinical outcomes based on Odom's criteria showed sixteen excellent, ten good and two satisfactory results. There was no significant relationship between clinical outcomes and changes in the cervical angles.ConclusionDynamic rotational anterior cervical plating provides comparable clinical outcomes to that of the reports of former static cervical platings. The loss of lordosis is related to the amount of graft settling but it is not related to the clinical outcomes.

Analysis of Sagittal Spinal Alignment in 181 Asymptomatic Children

A cross-sectional study. To determine the "normal" radiographic parameters of the sagittal profile of the spine in asymptomatic children. There was consensus that cervical kyphosis is pathologic, but we suspected that the cervical kyphosis or loss of cervical lordosis is abnormal in asymptomatic children and adolescents. And we measured the pediatric sagittal profiles including the cervical lordosis for asymptomatic subjects. Analysis of 181 children without spinal pathology was performed. Radiographic measurements consisted of the following: cervical lordosis; thoracic kyphosis; thoracolumbar sagittal angle; thoracic apex; lumbar apex; lumbar lordosis; sacral inclination; sacral slope; pelvic tilt; and sagittal vertebral axis. The mean cervical lordosis was -4.8 ± 12.0 degrees (negative = lordotic), sagittal vertebral axis -2.1 ± 2.4 cm, thoracic kyphosis +33.2 ± 9.0 degrees, thoracolumbar sagittal angle 5.6 ± 8.4 degrees, lumbar lordosis -48.8 ± 9.0 degrees, sacral inclination 43.9 ± 7.6 degrees, sacral slope 34.9 ± 6.6 degrees, and pelvic tilt 9.4 ± 6.1 degrees. One hundred nine (60.2%) patients had hypolordotic cervical spine (≥ -5 degrees). Cervical kyphosis was present in 80 (44.2%) patients. There is significant variability in sagittal profile of the cervical spine in asymptomatic children. Cervical kyphosis was found in approximately 40% of our study cohort.

Cervical Spine MR Imaging Findings of Patients with Hirayama Disease in North America: A Multisite Study

Most studies of HD have been conducted in Asia, particularly Japan. To characterize the MR imaging findings of North American patients with HD, we reviewed neutral and flexion cervical MR imaging examinations performed for possible HD at 3 academic medical centers located in the Southeastern, Southwestern, and Midwestern regions of the United States. Three neuroradiologists assessed the MR imaging examinations in a blinded fashion and reached a consensus rating for LOA of the posterior dura to the spine, lower spinal cord atrophy, spinal cord T2 hyperintensity, loss of cervical lordosis, anterior dural shift with flexion, and confidence of imaging diagnosis. Final reference diagnosis was established separately with a retrospective chart review by a neurologist. Twenty-one patients met the criteria for HD, all were North American males and all who reported their race were white. Seventeen patients did not meet the criteria and served as controls. Four imaging attributes, LOA, dural shift with flexion, consensus diagnosis of neutral images, and consensus diagnosis of combined neutral and flexion images were all able to discriminate the group with HD from the group without HD (P < .05 for each). Findings of HD were often present on neutral images, but the addition of flexion images increased diagnostic confidence. MR imaging findings in white North American patients with HD include LOA on neutral images and forward displacement of the dura with flexion. Findings are often present on neutral MR images and, in the appropriate clinical scenario, should prompt flexion MR imaging to evaluate anterior dural shift.

Analysis of axial symptoms after indirect decompression for ossification of the posterior longitudinal ligament of the cervical spine

To study the etiology and clinical significance of axial symptoms after posterior operative procedures for ossification of the posterior longitudinal ligament (OPLL). From February 2005 to February 2010, 76 patients with OPLL treated were retrospectively experienced. There were 34 male and 42 female with average of 52.1 years (range from 37 to 74 years), the average duration of the disease was 32.1 months (range from 11 to 56 months). Nineteen patients underwent traditional laminectomy in group A, 33 patients received open-door laminoplasty in group B and 24 patients underwent lateral mass screw fixation in group C. All patients underwent X-ray examination pre- and post operative, computed tomography were used for diagnosis of OPLL, the recovery rate was calculated using pre- and postoperative Japanese Orthopedic Association (JOA) scores for each patient. Pre- and postoperative cervical curvature index and axial symptoms were measured and compared. χ(2) test and SNK test were used as statistical methods. All patients were followed up for 14 - 35 months, average (21 ± 5) months. Loss of cervical curvature index was 4.2% ± 1.7% in group A, 2.9% ± 2.2% in group B and 2.3% ± 1.9% in group C. The difference was significant in loss of cervical curvature indice between group A and B (q = 2.94, P < 0.01), group A and C (q = 4.23, P < 0.01). The average JOA recovery rate was 58.3% for group A, 64.3% for group B and 66.7% for group C. There was no significant difference in JOA recovery rate among the three groups (P > 0.05). The rate of early evident axial symptoms was 7/19 in group A, 30.3% in group B and 33.3% in group C and the difference was not statistically significant (P > 0.05). The incidence of late evident axial symptoms was 5/19 in group A, 12.1% in group B and 8.3% in group C, the difference was not significant between group B and C (χ(2) = 13.762, P < 0.01), but of statistical difference between group A and B(χ(2) = 6.368, P < 0.01), group A and C (χ(2) = 11.481, P < 0.01). No kyphotic deformity in the group A, no "Close Door" phenomenon in group B and no internal failure in group C. The incidence of early axial symptoms are of no significant difference among the three groups, but late axial symptoms are higher in the laminectomy than other groups, which may be associated with loss of cervical lordosis.

Case 2: A pain in the neck

A 10-year-old African-Canadian girl experienced a sudden onset of neck stiffness. There was no history of preceding trauma, but she had reported a sore throat and hoarse voice three weeks earlier. Over the next year, she developed progressively worsening torticollis with associated neck pain, daily headaches and intermittent diplopia. She was taking ibuprofen two to three times daily for head and neck pain with partial improvement. She presented to the emergency department 13 months after onset because her head was now locked in position. There was no history of fevers, weight loss, skin rash, joint pain, muscle weakness, sensory deficits or gait abnormalities. On physical examination, the patient’s head was fixed in position with her chin rotated toward the right and her head tilted toward the left. There was minimal tenderness over her left sternocleidomastoid muscle and no palpable neck mass. Her neurological examination, including cranial nerve testing, was normal. She had no active or effused joints, enthesitis or tenosynovitis. An ophthalmological assessment, including visual acuity, was also unremarkable. Laboratory investigations revealed an increased erythrocyte sedimentation rate of 35 mm/h, but her C-reactive protein, complete blood count, creatine kinase and transaminase levels were normal. Plain radiographs showed a loss of cervical lordosis and abnormal alignment of C1–C2. Further imaging revealed the underlying diagnosis.

Expansive Open-door Laminoplasty With Titanium Miniplate Versus Sutures

Expansive laminoplasty is an effective treatment for cervical myelopathy. Since the design of classic open-door laminoplasty with the use of suture, the procedure has been modified to reduce complications such as restenosis, axial symptoms, and segmental motor paralysis. Expansive open-door laminoplasty with the use of titanium miniplate is becoming popular. It is effective in expanding spinal canal dimensions with good clinical efficacy. However, a lack of studies exist comparing titanium miniplate fixation with classical suture fixation.We performed a retrospective study of 54 patients with cervical myelopathy. Twenty-nine patients (4 women and 25 men) receiving expansive open-door laminoplasty by titanium miniplate fixation were classified as the modified group, and 25 patients (5 women and 20 men) fixed with suture served as the control group. Clinical and radiologic outcomes were assessed. No significant differences were observed in Japanese Orthopaedic Association scores and the recovery rate of C5 palsy. The incidence of axial symptoms in the modified group was significantly lower than that in control group. Radiologic examination showed that postoperative C2-C7 lordosis and range of motion of the cervical spine in the modified group were preserved. No significant differences were observed in mean anteroposterior diameter and open angle in the 2 groups. Both surgical protocols were effective in preventing reclosure of open laminae. Furthermore, the modified laminoplasty was superior in reducing the incidence of axial symptoms and loss of cervical lordosis and range of motion.

Sagittal alignment of the cervical spine after neck injury

The normal sagittal alignment of the cervical spine is lordotic and is affected by the posture of the head and neck. The question of whether loss of cervical lordosis is the result of muscle spasm after injury or a normal variation, and the clinical significance of such changes in sagittal profile of the cervical spine has been an issue of several studies. The purpose of this paper is to study the incidence of normal cervical lordosis and its changes after neck injury compared to the healthy population. We studied the lateral radiographs of the cervical spine of 60 patients with neck injury compared to 100 patients without a neck injury. Lateral radiographs were obtained in the standing or sitting position, and the curvature of the cervical spine was measured using the angle formed between the inferior end plates of the C2 and C7 vertebrae. In the patients without neck injury, lordotic and straight cervical spine sagittal alignment was observed in 36.5% each, double curvature in 17%, and kyphotic in 10%. In the patients with neck injury, lordotic sagittal alignment was observed in 36%, straight in 34%, double curvature in 26% and kyphotic in 4%. No significant difference between the two groups regarding all types of sagittal alignment of the cervical spine was found (p > 0.100). The alterations in normal cervical lordosis in patients with neck injury must be considered coincidental. These alterations should not be associated with muscle spasm caused by neck pain.

Segmental Anterior Decompression and Fusion for Multilevel Ossification of the Posterior Longitudinal Ligament

The purpose of this study was to evaluate the outcome of segmental anterior decompression and fusion for multilevel ossification of the posterior longitudinal ligament. Data were collected from 23 patients with multilevel ossification of the posterior longitudinal ligament. Average operative time and blood loss were 121 minutes and 201.6 mL, respectively. The Nurick score significantly decreased from 2.7±0.9 preoperatively to 1.8±0.9 at last follow-up (P<.01). The preoperative Japanese Orthopaedic Association score was 8.2, which significantly increased to 13.8 points at last follow-up (P<.01), with an improvement rate of 64.5%. The operation also significantly increased cervical lordosis (P<.01) from 7.7° preoperatively to 13.3° postoperatively. The fusion rate was 95.7% at 6 months postoperatively, and 100% at 12 months postoperatively. The loss of cervical lordosis and height of fusion segments were 1.2° and 0.9 mm at last follow-up, respectively. No hardware complications occurred. Cerebrospinal fluid leakage occurred in 2 patients, and hematoma occurred in 1 patient who needed an emergency operation. Segmental anterior decompression and fusion was generally effective and safe in the treatment of multilevel ossification of the posterior longitudinal ligament if indications were well controlled.

Upper Thoracic Myelopathy Caused by Delayed Neck Extensor Weakness in Myotonic Dystrophy

Myotonic dystrophy is the most common autosomal dominant myopathy in adults. Our patient, a 41 year-old female suffering from myotonic muscular dystrophy, developed upper thoracic myelopathy due to hypertrophy of the ligamentum flavum and the posterior longitudinal ligament. She had a typical hatchet face and ptosis with "head hanging forward" appearance caused by neck weakness. Motor weakness, sensory changes and severe pain below T4 level, along with urinary incontinence began 3 months ago. Genetic and electrodiagnostic studies revealed myotonic dystrophy type 1. Magnetic resonance imaging of the spine showed loss of cervical lordosis and spinal cord compression due to hypertrophied ligamentum flavum and posterior longitudinal ligament at T1 to T3 level. We concluded that her upper thoracic myelopathy was likely related to the thickness of the ligamentum flavum and posterior longitudinal ligament due to repetitive mechanical stress on her neck caused by neck muscle weakness with myotonic dystrophy.

Clinical and radiological profile of Hirayama disease: A flexion myelopathy due to tight cervical dural canal amenable to collar therapy.

Background:Hirayama disease (HD) is benign focal amyotrophy of the distal upper limbs, often misdiagnosed as motor neuron disease. Routine magnetic resonance imaging (MRI) is often reported normal.Objective:To study the clinicoradiological profile of hand wasting in young males.Materials and Methods:Patients presenting with insidious-onset hand wasting from March 2008 to May 2011 were evaluated electrophysiologically. Cervical MRI in neutral position was done in 11 patients and flexion contrast imaging was done in 10 patients.Results:All patients were males less than 25 years of age, with median age 23 years, except one patient who was 50 years old. Duration of illness was 3 months to 3 years. All (100%) had oblique amyotrophy, four (36%) cold paresis, 10 (91%) minipolymyoclonus and three (27%) had fasciculations. Regional reflexes were variably absent. Two patients (18%) had brisk reflexes of lower limbs with flexor plantars. Electromyography (EMG) showed chronic denervation in the C7-T1 myotomes. Neutral position MRI showed loss of cervical lordosis in 10/11 (91%), localized lower cervical cord atrophy in 9/11 (82%), asymmetric cord flattening in 11/11 (100%) and intramedullary hyperintensity in 2/11 (18%); flexion study showed loss of dural attachment, anterior displacement of dorsal dura, epidural flow voids in 9/10 (90%) and enhancing epidural crescent in 10/10 (100%). Clinical profile, imaging and electrophysiological findings of the patient aged 50 years will be described in detail as presentation at this age is exceptional. Collar therapy slowed progression in most cases.Conclusion:Clinical features of HD corroborated well with electrophysiological diagnosis of anterior horn cell disease of lower cervical cord. While dynamic contrast MRI is characteristic, routine studies have a high predictive value for diagnosis. Prompt diagnosis is important to institute early collar therapy.

Loss of Cervical Lordosis and Foreign Body Ingestion

Objective: In this retrospective study, we look at the sensitivity and specificity of the loss of cervical lordosis as a radiological sign for the presence of a foreign body in the aerodigestive tract. Method: A total of 39 cases of foreign body ingestion, confirmed with positive surgical removal in the emergency department and operating theatre were reviewed. All 39 had lateral neck x-rays performed in the Emergency department. Results: Of the 39 cases, 36 had loss of cervical lordosis on lateral neck x-ray. All had foreign bodies removed that were between C4 and T level. Therefore, the sensitivity of the loss of cervical lordosis as a sign of the presence of a foreign body in the aerodigestive tract in this study is 92.31%. Conclusion: We conclude that the loss of cervical lordosis is a good sign for the presence of a foreign body in the aerodigestive tract, and we should have a high index of suspicion in these cases despite negative clinical examination.

Medium-term outcomes of C3–6 laminoplasty for cervical myelopathy: a prospective study with a minimum 5-year follow-up

C3-6 laminoplasty preserving muscle insertions into the C7 spinous process is reportedly associated with a significantly decreased frequency of postoperative axial neck pain. However, no prospective study has reported medium-term outcomes of C3-6 laminoplasty. The purpose of this study was to elucidate medium-term outcomes after C3-6 laminoplasty. Subjects comprised 31 patients with cervical myelopathy who underwent C3-6 laminoplasty preserving all bilateral muscles attached to the C2 and C7 spinous processes and were followed for ≥5years. Clinical and radiological data were prospectively collected. Neurological status was assessed using Japanese Orthopaedic Association (JOA) score. Axial neck pain was graded as severe, moderate or mild. Sagittal alignment of the cervical spine and progression of ossification of the posterior longitudinal ligament (OPLL) were assessed by comparing serial lateral radiographs. Mean JOA score improved significantly from 10.6 before surgery to 14.7 at the time of maximum recovery, and slightly declined to 14.3 at final follow-up. In six patients who developed late deterioration, these conditions were unrelated to the cervical spine. As of final follow-up, only one patient (3.2%) had complained of axial neck pain persisting for 5years. Although progression of OPLL was found in 63.6% of patients, none had experienced neurological deterioration due to this progression. At final follow-up, sagittal alignment of the cervical spine was more lordotic than before surgery. Medium-term outcomes of C3-6 laminoplasty were satisfactory. Frequencies of persistent axial neck pain and loss of cervical lordosis after surgery remained significantly decreased for ≥5years postoperatively.

Outcomes of Interbody Fusion Cages Used in 1 and 2-levels Anterior Cervical Discectomy and Fusion

A prospective study was performed in case with cervical spondylosis who underwent anterior cervical discectomy and fusion (ACDF) with titanium or polyetheretherketone (PEEK) cages. To find out which fusion cage yielded better clinical and radiographic results. Although use of autogenous iliac-bone grafts in ACDF for cervical disc diseases remain standard surgical procedure, donor site morbidity and graft collapse or breakage are concerns. Cage technology was developed to prevent these complications. However, there is no comparison regarding the efficacy between titanium and PEEK cage. January 2005 to January 2006, 53 patients who had 1 and 2-levels ACDF with titanium or PEEK cages were evaluated. We measured the rate and amount of interspace collapse, segmental sagittal angulations, and the radiographic fusion success rate. Odom criteria were used to assess the clinical results. The fusion rate was higher in the PEEK group (100% vs. 86.5%, P=0.0335). There was no significant difference between both groups in loss of cervical lordosis (3.2 + or - 2.4 vs. 2.8 + or - 3.4, P=0.166). The mean anterior interspace collapse (1.6 + or - 1.0 mm) in the titanium group was significantly higher than the collapse of the PEEK group (0.5 + or - 0.6 mm) (P<0.0001). The mean posterior interspace collapse was also higher in the titanium group (1.6 + or - 0.9 mm vs. 0.5 + or - 0.5 mm, P<0.0001). An interspace collapse of 3 mm or greater was observed in 16.2% of the patients in the titanium group, compared with zero patients in the PEEK group (P<0.0001). The PEEK group achieved an 80% rate of successful clinical outcomes, compared with 75% in the titanium group (P=0.6642). The PEEK cage is superior to the titanium cage in maintaining cervical interspace height and radiographic fusion after 1 and 2-levels anterior cervical decompression procedures.

Risk Factors for Development of Subaxial Subluxations Following Atlantoaxial Arthrodesis for Atlantoaxial Subluxations in Rheumatoid Arthritis

Retrospective radiographic/imaging study. To evaluate preoperative and sequential postoperative radiographs following C1-C2 arthrodesis for atlantoaxial subluxation in patients with rheumatoid arthritis (RA) to determine risk factors for the development of subaxial subluxations (SAS). The development of SAS has often been observed after C1-C2 arthrodesis. However, there have been no previous reports on the correlation between radiographic parameters and the incidence of postoperative SAS. The study group comprised of 58 patients with RA who underwent C1-C2 arthrodesis due to atlantoaxial subluxation. There were 5 men and 53 women with a mean age of 55.8 years. The mean follow-up period was 137 months. Nineteen patients with a postoperative SAS after C1-C2 arthrodesis were classified as the SAS+ group. Other 39 patients without a postoperative SAS were included in the SAS- group. Clinical outcomes and plain radiographs were reviewed retrospectively and compared between the 2 groups. The difference between pre- and postoperative atlantoaxial (AA) angles in the SAS+ group was significantly greater than those in the SAS- group (P = 0.039). The C2-C7 angles changed significantly between pre- and postoperative periods in the SAS+ group (P = 0.039), but not in the SAS- group (P = 0.897). It was suggested that a large AA angle and a small C2-C7 angle observed at the early postoperative period were the risk factors for the development of SAS. We also demonstrated that a high incidence of the C3-C4 SAS resulted from excessive bone fusion at the C2-C3. Excessive correction of AA angle is likely to cause loss of cervical lordosis, resulting in the development of postoperative SAS. In addition, extensive bony union at C2-C3 following C1-C2 arthrodesis frequently leads to the development of extensive SAS at the C3-C4.

Cervical Injury-football

HISTORY: 18 year-old college football player went in head down for a tackle during a game and collapsed on the field. During evaluation, he complained of left arm numbness and tingling. On examination, he had mid-line bony tenderness of the cervical spine. The patient was spine-boarded and sent to the Emergency Department (ER). Cervical radiographs performed in the ER were interpreted no cervical spine fracture. He was treated and released. Three days after initial injury the athlete presented to the athletic training room complaining of mild tenderness in the neck, especially with rotational maneuvers. Further questioning revealed a previously undisclosed history of recurrent left shoulder pain related to "previous stingers" dating back one year. Symptoms were always isolated to the left arm, recurred each game, and completely resolved prior to starting college. He denies persistent paresthesias or weakness and denies previous neck injury. PHYSICAL EXAM: Neck: Flexion 45°, Extension 10°, Bilateral Rotation 35°. Spurling's causes pain in L shoulder. L paraspinal musculature tender to palpation. C4-7 spinous process tenderness. Neurologic: CN II-XII intact. DTRs 2+ throughout. LE strength 5/5. LUE strength 3+/5 deltoid, biceps/triceps, wrist flexors/extensors, finger abductors. RUE strength 5/5. Sensation intact. Negative Hoffman's. DIFFERENTIAL DIAGNOSIS: Herniated Nucleus Pulposus Cervical Fracture not seen on initial radiographs Ligamentous injury Cervical Spinal Stenosis Cervical Strain Cervical Disk Disease Brachial Plexopathy TESTS AND RESULTS: X-Ray: C6-7 vertebral fusion, decreased height C4, 5, subluxation C3 on C4, C4 on C5 in flexion, loss of cervical lordosis, ROM on flexion/extension views normal but reveal limited motion to C4 and above. MRI: C6-7 vertebral fusion, central canal stenosis without evidence of myelopathy FINAL/WORKING DIAGNOSIS: (1) Recurrent Cervical Neuropraxia, left arm, (2) Klippel-Feil Syndrome, (3) Central Cervical Stenosis TREATMENT AND OUTCOMES: The athlete was held from play. Regular evaluation of neurological exam revealed that LUE strength continued to improve and by four weeks his strength had improved to 5-/5. Physical therapy was continued. He was disqualified from any further participation in contact/collision sports.