Neurosurgical Cervical Spine Scale Research Articles

Clinical study of C3–C4 level surgical cases of cervical spondylosis

ObjectiveThe purpose of this study was to elucidate the pathological characteristics of C3–C4 cervical spondylotic myelopathy (CSM). MethodsSingle-level anterior cervical discectomy and fusion (ACDF) was performed at C3–C4 in 53 patients (38 men, 15 women). The mean duration of preoperative symptoms was 6.0 months. Fifty-three non C3–C4 ACDF patients of our random sample of ACDF patients were compared to the C3–C4 ACDF patients. Clinical outcomes were assessed according to the Japanese Orthopedic Association score (JOA score), the Neurosurgical Cervical Spine Scale (NCSS), and the Nurick scale. And radiological findings including C2–C7 lordosis, C3–C4 range of intervertebral motion (ROM), C2–C7 ROM, and C3–C4%ROM in the cervical spine were evaluated in both groups. ResultsThe recovery rates of JOA score and the NCSS in C3–C4 ACDF patients were 62.5% and 62.1%, respectively. The radiological study of C3–C4 ACDF patients showed that they had significant cervical lordosis, and cervical motion was dependent on the C3–C4 segment, which accounted for 39.8% of C2–C7 ROM (total motion). ConclusionIn C3–C4 ACDF patients, not only static factors, but dynamic factors (instability) at the C3–C4 level contributed to the major causes of CSM.

Occiput/C1–C2 fixations using intra-laminar screw of axis – A long-term follow-up

Background. The surgical management of the craniocervical junction is challenging. Rigid posterior fixation of occiput/C1–C2 can be performed using a variety of surgical techniques including C2 pedicle/pars interarticularis, transarticular and intralaminar screw fixations. Methods. Forty-one patients were treated with occipital plate/C1 lateral mass and C2 intra-laminar screw fixations for basilar invagination and congenital atlantoaxial subluxation, post-traumatic instability, tuberculous and rheumatoid arthritis-associated atlantoaxial dislocation. Out of forty-one, thirty-six patients had bilateral crossing intra-laminar screws and five had ipsilateral laminar screw fixation bilaterally. Results. Follow-up was done in thirty-nine patients from 6 months to 8 years (mean: 21 months) and solid osseous fusion could be achieved in all (100%). One patient was lost to follow-up and another patient died of a cause unrelated to surgical technique. Pre-operative and post-operative Neurosurgical Cervical Spine Scale showed improvement in all patients having features of myelopathy. There were no neurological or vascular complications. However, nine patients had posterior laminar breach, eight had anterior laminar penetrations and three had wound infections. One patient had transient bulbar palsy and one patient had hardware failure in the form of avulsion of the midline occipital plate. Conclusions. Intra-laminar screw fixation is a safe alternative to transarticular and transpedicular/pars interarticularis fixation of C2 with advantage of having no risk of injury to vertebral artery and comparable biomechanical and pull-out strength.

Outcomes of contemporary use of rectangular titanium stand-alone cages in anterior cervical discectomy and fusion: Cage subsidence and cervical alignment

Cervical intervertebral disc replacement using a rectangular titanium stand-alone cage has become a standard procedure for anterior cervical discectomy and fusion (ACDF). We examined outcomes resulting from the contemporary use of rectangular titanium stand-alone cages for ACDF, particularly focusing on cage subsidence and subsequent kyphotic malalignment. Patient data were collected prospectively, and a total of 47 consecutive patients who underwent periodic follow-up of at least 1year’s duration after ACDF were studied retrospectively. Sixty-three rectangular titanium cages were implanted during 31 1-level and 16 2-level procedures. None of the patients developed surgery-related complications (including cage displacement or extrusion). Mean Neurosurgical Cervical Spine Scale scores were significantly improved at 1year after surgery. Twelve of the 63 inserted cages (19.0%) were found to have cage subsidence, occurring in 11 of 47 patients (23.4%). There was no significant difference in functional recovery between patients with and without cage subsidence. Logistic regression analysis indicated that fusion level, cage size and cage position were significantly related to cage subsidence. The distraction ratio among patients with cage subsidence was significantly higher than that among patients without cage subsidence. Cage subsidence resulted in early deterioration of local angle and total alignment of the cervical spine. Although a longer follow-up is warranted, a good surgical outcome with negligible complications appears to justify the use of rectangular titanium stand-alone cages in 1- and 2-level ACDF. Excessive distraction at the fusion level should be avoided, and cage position should be adjusted to the anterior vertical line.

Prediction of Neurological Recovery Using Apparent Diffusion Coefficient in Cases of Incomplete Spinal Cord Injury

Magnetic resonance imaging is useful in evaluating acute spinal cord injury. Apparent diffusion coefficient (ADC) values obtained by diffusion-weighted imaging can differentiate cytotoxic edema from vasogenic edema through microscopic motion of water protons. To determine whether ADC values in the cervical spinal cord match neurological grades and thus predict functional recovery in patients suffering from cervical spinal cord injury. Diffusion-weighted images were obtained using 15 axial slices covering the cervical spinal cord from 16 consecutive patients. ADC values were determined for both gray and white matter. All patients were treated surgically. Patient neurological status was evaluated preoperatively and postoperatively with the Frankel classification and neurosurgical cervical spine scale. One patient had complete spinal cord injury and showed no recovery. Using 15 patients with incomplete injury, we analyzed correlations between preoperative ADC values and neurological grading, degree of postoperative recovery, or cavity formation in follow-up magnetic resonance images. For comparison, ADC values of 11 healthy volunteers were also calculated. There was significant correlation between ADC values and degree of postoperative recovery (P = .02). ADC values of patients showing cavity formation were significantly lower than those of patients without cavity formation (0.70 vs 0.96 × 10⁻³ mm²/s; P = .01). The cutoff ADC value of 0.80 × 10⁻³ mm²/s resulted in 75% sensitivity and 81.8% specificity for predicting cavity formation. Low ADC values in acute spinal cord injury may indicate postoperative cavity formation in the injured spinal cord and predict poor functional recovery.

Bilateral open-door expansive laminoplasty using unilateral posterior midline approach with preservation of posterior supporting elements for management of cervical myelopathy and radiculomyelopathy—analysis of clinical and radiological outcome and surgical technique

The purpose of this study was to evaluate bilateral open-door cervical laminoplasty for management of cervical canal stenosis secondary to multisegmental cervical spondylosis and ossified posterior longitudinal ligament. The importance of unilateral posterior approach with preservation of posterior supporting element is emphasized. Thirty-four patients had expansive laminoplasty. Posterior tension band consisting of nuchal ligaments and supraspinous and interspinous ligaments was secured. Paraspinal deep extensor muscles attached to one side of spinous process were also preserved. Hydroxyapatite-collagen spacers were positioned between split laminae in midline and secured with Ethibond. All patients had features of myelopathy with weakness, hypertonia, clonus, and hyperreflexia in both upper and lower limbs. Bladder and bowel involvement was seen in 11.7% and sexual dysfunction in 5.8%. Preoperative dynamic study of cervical spine, MRI, and/or CT were done in all patients and compared with postoperative studies to see the efficacy of the surgical procedure. Preoperative and postoperative neurosurgical cervical spine scale was used to compare results in relation to age, sex, duration of symptoms, neurosurgical cervical spine score, bladder, bowel, and sexual abnormalities. Elderly patients, lower neurosurgical score, signs and symptoms of more than 2years, and bladder, bowel, and sexual dysfunction had poorer outcome. Complications were few. All patients had adequate diameter of spinal canal postoperatively. Cervical alignment and range of motion of segment subjected to laminoplasty were preserved satisfactorily in follow-up. Bilateral open-door expansive laminoplasty using unilateral posterior midline approach provides preservation of posterior supporting tension band and excellent reconstruction of spinal canal. This technique also does not compromise contralateral paraspinal muscles attached to spinous process.

Surgical Treatment of Cervical Spondylosis in the Elderly: Surgical Outcomes, Risk Factors, and Complications

The incidence of cervical spondylosis in the elderly is increasing with the higher proportion of elderly individuals among the Japanese population. The present study retrospectively analyzed the clinical and radiological features of this clinical entity in 107 patients with cervical spondylosis aged 70 years or older surgically treated between 1995 and 2005. The patients were divided into Group 1 (n = 60) aged between 70 and 74 years, and Group 2 (n = 47) 75 years or older. Patients with localized compression within 2 levels responsible for the neurological symptoms underwent anterior fusion, and patients with a narrow spinal canal were treated by laminoplasty. The pre- and postoperative neurological status (Neurosurgical Cervical Spine Scale) and postoperative complications were compared. More patients in Group 2 required laminoplasty but most patients underwent single-level anterior fusion. There was no statistically significant difference in the surgical results. Group 2 had a much higher ratio of anterior fusion at the C3-4 level. Many of the aged patients had multiple risk factors. Surgical decompression for cervical spondylosis is beneficial even in elderly patients. Single-level anterior fusion to treat the lesion most responsible for the symptoms is the least invasive choice. Elderly patients tend to present with multiple risk factors so require careful perioperative management.

Long-Term Follow-Up Results in Patients With Cervical Disk Disease Treated by Cervical Anterior Fusion Using Titanium Cage Implants

This study is a retrospective analysis of 146 patients, 85 males and 61 females aged 21-80 years (mean 52 years), with cervical disk disease who underwent anterior fusion and titanium cage implantation with follow-up periods of no less than 72 months after surgery. All patients underwent the conventional anterior cervical approach. After removing the protruded disk and osteophyte, cylindrical titanium cages were placed. Single, two, and three level fusion was performed in 76 (52%), 64 (44%), and 6 (4%) patients, respectively. Functional assessment used the Neurosurgical Cervical Spine Scale (NCSS). The curvature index and range of motion were evaluated pre- and postoperatively. The clinical outcomes were satisfactory and there were no significant complications. The mean NCSS was 9.7 before and 12.7 at 1 year after the operation, and 12.1 at final examination. No postoperative cage extrusion or pseudoarthrosis occurred, but the cages descended in 10 patients (7%) although alignment was satisfactory. At 5 years after the operation, 140 of the 146 patients (96%) had solid fusion. The long-term results of anterior fusion with titanium cage implantation in patients with cervical disk disease were satisfactory. Titanium cage placement is a highly useful alternative to the conventional treatment method in these patients.

Complications and Long-Term Follow-Up Results in Titanium Mesh Cage Reconstruction After Cervical Corpectomy

The incidence of the complications and long-term outcome with a minimum 2-year follow-up of anterior cervical reconstruction using titanium mesh cage is evaluated. Relevant literature was also reviewed to discuss the potential risk factors of the complications of this procedure. From 1999 to 2003, 26 patients with cervical spine disorders, (12 patients with OPLL, 7 with cervical spondylosis, 3 with vertebral tumors, 2 with osteomyelitis, and 2 with traumatic lesions) were operated on by this procedure. The series included 14 males and 12 females with a mean age of 60.9 years. Corpectomy was performed on 1 (14 cases), 2 (12 cases). Autologous bone fragments were taken from the excised vertebra. The average improvement rate as scored on the neurosurgical cervical spine scale was 67.4%. The average follow-up period was 54.3 months (range, 24 to 72 months) in 21 who were followed up, and bone union was observed in all cases (22/22 cases) that could be followed up for more than 6 months postoperatively. The average time required for fusion was 6.7 months. Postoperative complications included dyspnea (1 case) and cerebrospinal fluid leakage (2 cases), which was treated by lumbar drainage, without any additional repair operation. No hardware-related complications or adjacent segment degenerative changes were encountered during the follow-up periods. This reconstruction technique yielded good clinical results and helped to avoid complications associated with harvesting bone from the iliac crest donor site. However, risk factors related to the method should be carefully considered.

Perfusion-Weighted Magnetic Resonance Imaging of the Spinal Cord in Cervical Spondylotic Myelopathy

Principles of echo shifting with a train of observations was used to perform magnetic susceptibility-weighted magnetic resonance imaging with bolus-tracking in 14 patients with spondylotic myelopathy to assess changes in perfusion parameters of the spinal cord before and after decompression surgery for cervical spondylotic myelopathy. The mean transit time (MTT), bolus arrival time (T0), and time to peak (TTP) were obtained from regions of interest (ROIs) and assessed as the ratio between the spinal cord and the pons (MTT index = MTT(ROI)/MTT(pons), T0 index = T0(ROI)/T0(pons), TTP index = TTP(ROI)/TTP(pons)). The patients were divided into two groups according to percentage improvement on the Neurosurgical Cervical Spine Scale. The MTT index in patients with good recovery (> or =50%) was significantly reduced. The T0 index and TTP index showed no significant change in both groups. Reduction of MTT index may indicate improved perfusion of the spinal cord following surgery for cervical spondylotic myelopathy.

Predictors of Outcome of Surgery for Cervical Compressive Myelopathy: Retrospective Analysis and Prospective Study

The outcomes of surgical treatment in 80 patients with cervical compressive myelopathy were retrospectively reviewed to examined the correlations between surgical outcomes and the following seven predictive factors: age at surgery, duration of symptoms, severity of myelopathy, number of compressed segments, intramedullary high intensity segments on T(2)-weighted magnetic resonance (MR) imaging, surgical method, and the type of disease. The recovery rates were evaluated at 3 months after the surgery. Significant correlations were observed between recovery rate and duration of symptoms, severity of myelopathy, and high intensity segments on T(2)-weighted MR imaging. No statistical correlation was observed with the other factors. Multivariate analysis revealed significant correlations between recovery rate and duration of symptoms and number of high intensity segments on T(2)-weighted MR imaging. The multiple regression equation was expressed as follows: recovery rate = 82.981 + 0.101 x (age) - 0.675 x (duration) - 1.452 x (number of compressed segments) - 1.451 x (preoperative Neurosurgical Cervical Spine Scale) - 13.826 x (number of high intensity segments). Based on this predicted formula, we compared the predicted and actual recovery rates for 17 patients treated recently. The two values were similar except in two patients with long duration of symptoms. We conclude that the surgical outcome can be predicted to a certain extent and this information could be provided to patients considering surgery for cervical compressive myelopathy.

８０歳以上の超高齢者における脊椎脊髄手術の効果と問題点

The object of this study was to investigate surgical results and problems associated with spinal surgery in patients older than 80 years of age. Since April, 2003, we have performed 25 operations in 20 elderly patients (7 men and 13 women with ages ranging from 80-89 years) for lumbar lesions (14 cases) and cervical lesions (6 cases). Data obtained from chart review included age, sex, duration of neurological symptoms, associated illnesses, type of anesthesia, time of operation, blood loss during operation, and complications attributable to surgery. Neurological deficits before and after surgery were assessed using the Japanese Orthopedic Association (JOA) score for lumbar lesions, and the Neurosurgical Cervical Spine Scale (NCSS) for cervical lesions. Four patients had histories of heart disease and one had a history of lung disease. Twelve patients with lumbar lesions underwent surgery under lumbar anesthesia, and 2 patients general anesthesia. Mean operation time was 98 minutes, and mean blood loss during surgery was 54 grams in patient with lumbar lesions, and 260 minutes, 138 grams with cervical lesions. Two patients with both cervical and lumbar lesions underwent cervical and lumbar operations simultaneously. In patients with lumbar lesions, the preoperative mean JOA score was 12, and postoperative 19.3, and the mean recovery rate was 43.3%. In patients with cervical lesions, the preoperative mean NCSS was 5.8 and postoperative 8.0, and the mean recovery rate was 29.3%. There were no deaths and three patients had postoperative complications including transient foot drop in one, hypotension in one, and instrumentation failure in the other. Our data suggest that spinal surgery is a reasonable alternative with satisfactory results in patients older than 80 years who are in good general health.

Long-term outcome for surgically treated cervical spondylotic radiculopathy and myelopathy.

Long-term follow-up results were examined to verify the efficacy of anterior osteophytectomy for cervical spondylotic myelopathy and radiculopathy, in particular the outcome for patients with developmentally narrow cervical canals and patients with associated ossification of the posterior longitudinal ligament (OPLL). One hundred thirty-nine patients who had undergone anterior osteophytectomy with interbody fusion between 1976 and 1990 were followed up for 1 to 22.5 years (mean 11.4 years). Overall results evaluated by the neurosurgical cervical spine scale scoring and grading showed significant improvement in both improvement score (2.7 +/- 2.3) and improvement rate (52.3 +/- 45.7%). Lower extremity motor function improved in 66.1% of patients, upper extremity motor function in 82.0%, and sensory/pain function in 70.5%. Improvement ranged from one to three grades. Severely affected patients showed good recovery. Outcome for patients with narrow cervical canals (41 patients, 29.5%) did not differ significantly from that for patients with normal canals (98, 70.5%). Patients with associated OPLL (32 patients, 23.0%) had approximately the same outcomes as those with only spondylosis (107, 77.0%). Fifteen patients (10.8%) underwent reoperation because of myelopathy due to disc degeneration adjacent to the fused level (11 patients) or OPLL (4 patients). Anterior osteophytectomy with interbody fusion can achieve good outcomes in patients with cervical spondylotic myelopathy and radiculopathy, regardless of the size of the spinal canal and association with OPLL.

Laminoplasty improves respiratory function in elderly patients with cervical spondylotic myelopathy.

Respiratory insufficiency after acute cervical trauma is well documented, but the relationship between respiratory function and chronic lesions, such as cervical spondylosis, has received scant attention. This clinical study investigated the effect of cervical spondylosis on respiratory function in 12 patients over 65 years of age who underwent expansive laminoplasty. Functional and neurological status were assessed using the Japanese Orthopaedic Association (JOA) scale and Neurosurgical Cervical Spine Scale (NCSS). To assess the effect of laminoplasty on respiratory function in patients with cervical spondylotic myelopathy, lung volumes including vital capacity, tidal volume (TV), inspiratory reserve volume, expiratory reserve volume, inspiratory capacity, and forced expiratory volume were measured by spirometer before surgery and 6 months after surgery. The arterial blood gas values were also measured before and after surgery. All patients showed functional improvement after surgery, and neurological examination 6 months after surgery revealed a significant improvement in both JOA scale and NCSS scores (p < 0.001). There were no significant differences in most lung volumes, but TV (p = 0.039) at 6 months after surgery showed a significant increase compared to before surgery. PCO2 also showed a significant reduction after surgery (p = 0.047). This limited study revealed that laminoplasty improved respiratory function in patients over 65 years of age with cervical spondylotic myelopathy. Lung volume measurement may be one method to estimate spinal cord function after a surgical procedure.

CG-clip expansive open-door laminoplasty: a technical note

The CG clip is a device designed for use in expansive open-door laminoplasty with both a spacer and means of attachment in a single unit. It provides an effective technique for open-door laminoplasty, which obviates the need for bone grafting or complex internal fixation by providing dynamic stabilization of the open laminae. A number of techniques for expansive open-door laminoplasty have been devised for the decompression of the spinal cord and nerve roots in cervical spondylotic myeloradiculopathy. Each of these techniques requires some degree of internal fixation and/or bone grafting.The CG clip is a single device which is composed of both a spacer and a spring clip for attachment. The spacer ensures a 4-5-mm sagittal expansion of the cervical spinal canal. The spacer is held in place along the lateral cut margin of the laminae by a spring-wound titanium clip, which folds over the central spinous process of the unilaterally elevated laminar block. In all respects except for grafting and internal fixation, the surgery is performed as for a standard expansive open-door laminoplasty. Sixteen of the first 24 patients to undergo this procedure improved at least one point on the Neurosurgical Cervical Spine Scale. Of the remaining eight patients, four remained the same and four deteriorated. The authors have found the CG-clip laminoplasty technique quick and easy to perform, with early results in the treatment of cervical spondylotic myeloradiculopathy consistent with those of other decompressive procedures.

頚椎後方要素を温存した棘突起縦割法の手術成績

We studied the clinical and radiological follow-up of patients with double door laminoplasty, splitting the spinous processes, but preserving the posterior supporting structures and using a hydroxyapatite spacer for cervical degenerative diseases. In our hospital standard double door laminoplasty, splitting the spinous processes and using a hydroxyapatite spacer has been performed on 44 patients from July 1994 to September 1995. This standard procedure has gradually produced favorable clinical results. However the partial removal of the spinal posterior structures, as happens in this method, might possibly spoil the stability of the cervical spine. Because of this danger, we incorporated into our standerd method the preservation of the maximum amount of the posterior supporting structures. This modified procedure has been performed on 69 patients since November 1995. Among them, 41 patients who had been followed-up for more than 1 year were selected. Thirty patients had cervical spondylotic myelopathy, 6 had ossification of the posterior longitudinal ligament and 5 had cervical myelopathy due to disc herniation. The average age at operation was 60.0 years old. The average follow-up period was 18.1 months. Preoperative and postoperative clinical assessments were evaluated by Neurosurgical Cervical Spine Scale (NCSS). Radiological courses were examined by the cervical range of motion on the lateral flexion and extension radiographs and the cervical curvature index calculated by Ishihara's method. The improvement of the postoperative clinical courses by NCSS was maintained over 1 year, including cases where the patients were over 70 years old. Radiologically, the cervical range of motion decreased after the operation, but the cervical curvature was generally maintained better after the operation, compared with results obteined by the former standard procedure. We emphasize that double door laminoplasty splitting the spinous processes but preserving the posterior supporting structures is a useful posterior approach, which is easily and safely performed and produces good clinical results for cervical degenerative diseases. However, it should be noted that follow-up periods were short.

Surgical Treatment for Ossification of the Posterior Longitudinal Ligament of the Cervical Spine

The results of surgical management of ossification of the posterior longitudinal ligament (OPLL) of the cervical spine consisting of either anterior or posterior surgical decompression of the spinal cord and/or nerve roots were evaluated in 75 patients. The OPLL was continuous (COPLL) in 37 patients, segmental (SOPLL) in 29, mixed COPLL and SOPLL (MOPLL) in five, and circumscribed disk type (DOPLL) in four. Fourteen of the patients with COPLL, 27 with SOPLL, three with MOPLL, and all four with DOPLL were treated via the anterior approach with vertebrectomy and discectomy with anterior fusion. The remaining patients were treated by posterior laminoplasty or laminectomy. The overall mean improvement in the neurosurgical cervical spine scale (NCSS) score after surgery was 78.0% in those treated with anterior decompression and 46.1% in those treated with posterior decompression. The NCSS score in the latter group decreased during the follow-up period, from 10.4 to 9.7 points, whereas that in the anterior decompression group increased, from 12.9 to 13.0.

Grading and scoring system for neurological function in degenerative cervical spine disease--Neurosurgical Cervical Spine Scale.

Grading and scoring system for neurological function in degenerative cervical spine disease--Neurosurgical Cervical Spine Scale.