Nurick Grade Research Articles

Successful Motor Evoked Potential Monitoring in Cervical Myelopathy : Related Factors and the Effect of Increased Stimulation Intensity.

ObjectiveIntraoperative neurophysiological monitoring (IONM) has been widely used during spine surgery to reduce or prevent neurologic deficits, however, its application to the surgical management for cervical myelopathy remains controversial. This study aimed to assess the success rate of IONM in patients with cervical myelopathy and to investigate the factors associated with successful baseline monitoring and the effect of increasing the stimulation intensity by focusing on motor evoked potentials (MEPs). MethodsThe data of 88 patients who underwent surgery for cervical myelopathy with IONM between January 2016 and June 2018 were retrospectively reviewed. The success rate of baseline MEP monitoring at the initial stimulation of 400 V was investigated. In unmonitorable cases, the stimulation intensity was increased to 999 V, and the success rate final MEP monitoring was reinvestigated. In addition, factors related to the success rate of baseline MEP monitoring were investigated using independent t-test, Wilcoxon rank-sum test, chi-squared test, and Fisher’s exact probability test for statistical analysis. The factors included age, sex, body mass index, diabetes mellitus, smoking history, symptom duration, Torg-Pavlov ratio, space available for the cord (SAC), cord compression ratio (CCR), intramedullary increased signal intensity (SI) on magnetic resonance imaging, SI length, SI ratio, the Medical Research Council (MRC) grade, the preoperative modified Nurick grade and Japanese Orthopedic Association (JOA) score. ResultsThe overall success rate for reliable MEP response was 52.3% after increasing the stimulation intensity. No complications were observed to be associated with increased intensity. The factors related to the success rate of final MEP monitoring were found to be SAC (p<0.001), CCR (p<0.001), MRC grade (p<0.001), preoperative modified Nurick grade (p<0.001), and JOA score (p<0.001). The cut-off score for successful MEP monitoring was 5.67 mm for SAC, 47.33% for the CCR, 3 points for MRC grade, 2 points for the modified Nurick grade, and 12 points for the JOA score. ConclusionIncreasing the stimulation intensity could significantly improve the success rate of baseline MEP monitoring for unmonitorable cases at the initial stimulation in cervical myelopathy. In particular, the SAC, CCR, MRC grade, preoperative Nurick grade and JOA score may be considered as the more important related factors associated with the success rate of MEP monitoring. Therefore, the degree of preoperative neurological functional deficits and the presence of spinal cord compression on imaging could be used as new detailed criteria for the application of IONM in patients with cervical myelopathy.

Reliability and Validity of the Thai Version of the Modified Japanese Orthopaedic Association Score (mJOA score)

Objective: To evaluate the reliability and validity of the Thai version of the modified Japanese Orthopaedic Association scale.Methods: The modified Japanese Orthopaedic Association scale was translated into Thai language to create the Thai version of the Modified Japanese Orthopaedic Association (Thai-mJOA) scale. Translation was performed according to international standards using a forward-backward translation protocol. Translation was performed by 2 expert translators and 1 physician, and the final version was approved by an expert committee. Thai patients with cervical spondylosis with myelopathy were enrolled and evaluated using the Thai-mJOA scale, Nurick Grading, the Thai version of the Neck Disability Index (Thai-NDI), and the Thai version of the Short Form-36 (Thai-SF-36). Reliability and validity of the Thai-mJOA were assessed via comparison with the Nurick Grading and the Thai-NDI.Results: Ninety-two patients were included. The most common compression level was C5-C6 vertebral disc. Cronbach’s alpha of the total Thai-mJOA showed excellent internal consistency (0.991). The intraclass correlation coefficient (ICC) for test-retest reliability was 0.981 (95% confidence interval [CI]: 0.972-0.988). Regarding concurrent validity, the motor dysfunction score of the lower extremities and the total score of the Thai-mJOA were strongly correlated with Nurick Grading (r=0.825, r=0.712, respectively). The total score of the Thai-mJOA was moderately correlated with the Thai-NDI (r=0.670).Conclusion: The Thai-mJOA was found to be a valid and reliable tool for evaluating symptom severity in Thai patients with cervical spondylosis with myelopathy.

Role of Combined Vertebroplasty and Spinal Decompression in the Management of Aggressive Vertebral Hemangiomas.

Background:There are different surgical modalities designed to manage aggressive vertebral hemangioma (VH) that causes neurological symptoms. The selection of the best approach is still controversial. It is crucial to safely achieve neurological recovery with the elimination of the risk of recurrence. The combined use of surgical decompression and vertebroplasty is one of the surgical modalities that are used to manage these cases.Patients and Methods:From January 2012 to January 2019, nine patients with aggressive VH were retrospectively included in the study. All of them were operated upon using combined surgical decompression and vertebroplasty. We evaluated all the patients preoperatively, immediate postoperative, 1 month, and 12 months later. Clinical and radiological outcomes were assessed.Results:Affected spinal levels were dorsal in six cases and lumbar in three cases. There was no postoperative worsening of the preoperative neurological status. For the cases presented with sciatica, the mean VAS score has dropped from 8.33 preoperatively to 2.67 postoperatively. One month later, all of them are free from the radicular pain. For the cases presented with myelopathy, they regain their motor power in both lower limbs over a period of 4 weeks with a mean Nurick grade of 1.17. The postoperative radiological studies revealed near total occlusion of the VH with the maintenance of the vertebral body height. No clinical or radiological signs of spinal instability or recurrence are observed over the period of follow-up.Conclusions:The combined use of surgical decompression and vertebroplasty is considered a safe and effective modality in the management of aggressive VHs.

A Prospective, Single-Blinded, Bicentric Study, and Literature Review to Assess the Need of C2-Ganglion Preservation - SAVIOUR's Criteria.

ObjectiveJoint manipulation for craniovertebral junction instability is often hindered by the C2-ganglion (C2G). Our study aims to compare the surgical outcome among patients with or without C2G preservation and discuss the technical nuances. MethodsWe did a prospective, bicentric study and included all the operated patients with craniovertebral junction anomaly. The outcome was assessed by the Pain Numeric Rating Scale, Patient Satisfactions Score, and Stony Brook Scar Evaluation Scale. The fusion was assessed using Lenke fusion grade. ResultsOne hundred seventy-one patients (88 in group A and 83 in group B) were included. The most common symptom was spastic quadriparesis (n = 165, 96.5%) with median Nurick grade 3.3. Thirteen patients had suboccipital numbness and 12 patients had paraesthesia. Mean blood loss in group A was 490 ± 96.2 mL and group B was 525 ± 45.7 mL; median operative time was 217.9 and 162.2 minutes in the groups A and B, respectively (p < 0.05). At the follow-up (median, 46.8 months), Lenke fusion grade A was achieved in 92.4% and grade B in 7.6%. A trend suggesting better functional outcomes (numbness, parestheisa, scar outcome, and postoperative ulcer formation) in group A was seen with all 6 patients, who underwent O-C2 fixation, developed pressure sore. ConclusionOur results support ganglion preservation, especially in the subset of patients where occipital plating is required. Although the study fails to show any statistical significance, we suggest that one should always start with an ‘intent’ of preservation as the functional outcome is better.

Functional Outcomes and Temporal Profile of Recovery in Patients with Intradural Extramedullary Spinal Cord Tumors with Poor Nurick Grade

Patients with spinal intradural extramedullary (IDEM) tumors usually have a good functional outcome after tumor excision. However, the literature is sparse on the functional outcome in patients with poor Nurick grade (NG 4 and 5). A retrospective review of 81 patients with IDEM tumors presenting with a poor NG was performed to determine postoperative functional outcome and the temporal pattern of recovery. The following risk factors were analyzed: preoperative NG, duration of symptoms, tumor location, peritumoral edema, presence of syrinx, and tumor type. Neurologic function started recovering soon after surgery, with >80% of the patients improving by ≥1 grade at the end of 1 week after surgery. Of the 66 patients available for follow-up of >6 months after surgery, 63 (95.5%) improved to NG 0-2 and 51 (77.2%) became asymptomatic (NG 0 or 1). Three patients had a poor functional outcome on follow-up of >31 months; 2 had improved from NG 5 to NG 4, whereas 1 patient continued to be in NG 4. Factors associated with a poor outcome were an upper thoracic location (P= 0.025) and presence of a syrinx (P= 0.004). None of the patients had bladder dysfunction at follow-up of >6 months. After excision of spinal IDEM tumors, in patients who present with a poor neurologic function (NG 4 and 5), good functional outcome (NG 0-2) can be expected in >95% of patients. No recovery can be anticipated beyond 1 year after surgery.

Crossing the Cervicothoracic Junction During Posterior Cervical Fusion for Myelopathy Is Associated With Superior Radiographic Parameters But Similar Clinical Outcomes.

For laminectomy and posterior spinal fusion (LPSF) surgery for cervical spondylotic myelopathy (CSM), the evidence is unclear as to whether fusions should cross the cervicothoracic junction (CTJ). To compare LPSF outcomes between those with and without lower instrumented vertebrae (LIV) crossing the CTJ. A consecutive series of adults undergoing LPSF for CSM from 2012 to 2018 with a minimum of 12-mo follow-up were identified. LPSF with subaxial upper instrumented vertebrae and LIV between C6 and T2 were included. Clinical and radiographic outcomes were compared. A total of 79 patients were included: 46 crossed the CTJ (crossed-CTJ) and 33 did not. The mean follow-up was 22.2 mo (minimum: 12 mo). Crossed-CTJ had higher preoperative C2-7 sagittal vertical axis (cSVA) (33.3±16.0vs 23.8±12.4mm, P=.01) but similar preoperative cervical lordosis (CL) and CL minus T1-slope (CL minus T1-slope) (P > .05, both comparisons). The overall reoperation rate was 3.8% (crossed-CTJ: 2.2%vs not-crossed: 6.1%, P=.37). In adjusted analyses, crossed-CTJ was associated with superior cSVA (β = -9.7; P=.002), CL (β = 6.2; P=.04), and CL minus T1-slope (β = -6.6; P=.04), but longer operative times (β = 46.3; P=.001). Crossed- and not-crossed CTJ achieved similar postoperative patient-reported outcomes [Visual Analog Scale (VAS) neck pain, VAS arm pain, Nurick Grade, Modified Japanese Orthopedic Association Scale, Neck Disability Index, and EuroQol-5D] in adjusted multivariable analyses (adjusted P>.05). For the entire cohort, higher postoperative CL was associated with lower postoperative arm pain (adjusted Pearson's r -0.1, P=.02). No postoperative cervical radiographic parameters were associated with neck pain (P>.05). Subaxial LPSF for CSM that crossed the CTJ were associated with superior radiographic outcomes for cSVA, CL, and CL minus T1-slope, but longer operative times. There were no differences in neck pain or reoperation rate.

Composite Grip Strength as a Marker of Outcome in Patients Surgically Treated for Degenerative Cervical Myelopathy.

Study DesignRetrospective case series.PurposeThis study aimed to examine the efficacy of composite grip strength as a marker of surgical outcome in patients with moderate to severe degenerative cervical myelopathy.Overview of LiteratureDegenerative cervical myelopathy causes loss of dexterity, muscle strength, and sensations in the hand. The impact of surgical management on improvement in composite grip strength has received scant attention.MethodsThis retrospective study was performed on degenerative cervical myelopathy patients with a complete composite grip strength assessment between January 2013 to January 2019. The Biometrics E-link hand kit was used for the assessment. The following parameters were measured: maximum grip strength, sustained grip strength, three-jaw pinch, maximum key pinch, and sustained key pinch. The pre- and postoperative functional status was assessed using the Nurick grade and the modified Japanese Orthopaedic Association (mJOA) score.ResultsA total of 40 patients were included in the study. The mean patient age was 51.9 years. The mean preoperative Nurick grade was 3.5 and the mJOA score was 10.9. The anterior approach was used in 25 patients, and the posterior approach was used in 15 patients. Four patients developed complications. Degenerative cervical myelopathy resulted in decreased handgrip and pinch strength as compared to normative Indian data. There was a significant improvement in the postoperative composite grip strength for all five parameters. There was no differential improvement between the anterior and posterior surgical groups. The improvement in the composite grip strength correlated with the improvement in functional scores.ConclusionsComposite grip strength analysis is an objective method for assessing the impact of degenerative cervical myelopathy on grip strength and monitoring the postoperative improvement. Decompressive surgery resulted in global improvement in all the parameters of composite grip strength.

Outcome of Surgery for Congenital Craniovertebral Junction Anomalies with Atlantoaxial Dislocation/Basilar Invagination: A Retrospective Study of 94 Patients

To evaluate the results of surgery for congenital craniovertebral junction (CVJ) anomalies with atlantoaxial dislocation (AAD)/basilar invagination (BI) and compare the results of transoral odontoidectomy and posterior fusion (TOO+PF) with only posterior fusion (PF) in patients with irreducible AAD/BI. All 94 patients with congenital CVJ anomalies with AAD/BI operated on during the 3-year study period (June 2013-May 2016) were included. Of these patients, 55 had irreducible AAD/BI and the remaining 39 had reducible AAD/BI. TOO+PF was restricted to patients (34/94; 36.2%) with irreducible AAD/BI when reduction and realignment by intraoperative C1-C2 facet joint manipulation were considered technically difficult and risky. The remaining patients with irreducible AAD/BI and all the patients with reducible AAD/BI (60/94; 63.8%) were managed with only posterior fusion. Poor preoperative Nurick grade, preoperative dyspnea/lower cranial nerve deficits, and syringomyelia were associated with significantly higher incidence of postoperative pulmonary complications. Follow-up ≥3 months (final follow-up) was available for 87 patients. Good outcome (Nurick grade 0-3) at final follow-up was noted in 90% (45/50) of the patients with irreducible AAD/BI and 91.9% (34/37) of the patients with reducible AAD/BI. Preoperative poor Nurick grade (4-5) was the only factor associated with poor outcome. No significant difference in perioperative complications, outcome, and fusion was noted between patients who underwent TOO+PF or only PF for irreducible AAD/BI. Many of the patients with congenital AAD/BI showed remarkable recovery after surgery. Preoperative poor Nurick grade (4-5) is associated with poor outcome. TOO+PF is a safe alternative treatment option for irreducible AAD/BI when only PF techniques are technically difficult/risky.

Does Spondylolisthesis Affect Severity and Outcome of Degenerative Cervical Myelopathy? A Systematic Review and Meta-analysis.

Study Design:This was a systematic review and meta-analysis.Objectives:Degenerative cervical myelopathy (DCM) with spondylolisthesis remains not well defined, poorly studied, and underreported and plays a minor role in the therapeutic decision-making. Spondylolisthesis, however, is not uncommon and may result in dynamic injury to the spinal cord. We aim to describe the impact of spondylolisthesis in DCM severity and postoperative outcomes.Methods:Two independent reviewers conducted a Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA 2015)-based review between 1970 and May 2020 for articles reporting outcome of DCM in patients with degenerative cervical spondylolisthesis. Patient clinical and radiological data was recorded at baseline and during postoperative follow-up (FU). A meta-analysis comparing surgical outcome between DCM patients with and without spondylolisthesis assessed by the regular/modified Japanese Orthopaedic Association Assessment Scale (mJOA) recovery ratio was completed.Results:A total of 3 studies were included (1 ambispective and 2 retrospective cohorts); 607 patients with DCM were identified, 102 (16.8%) of whom also had spondylolisthesis. DCM patients with spondylolisthesis were significantly older (P < .05), presented with worse baseline mJOA and Nurick grades (P < .05 in 2 studies), and were more commonly operated via posterior approaches (P < .05). All groups experienced a (m)JOA and/or Neck Disability Index score improvement during FU. In the pooled meta-analysis, spondylolisthesis patients showed a significantly lower functional recovery ratio at 2 years compared with other DCM patients (P = .05).Conclusions:Spondylolisthesis is frequent in older DCM patients and may be a predictor of a more advanced degeneration and subsequent worse baseline conditions and postoperative outcome.

Surgical Outcomes in Patients Operated for Cervical Myelopathy using Japanese Orthopaedic Association Cervical Myelopathy Evaluation Questionnaire

Study Design: This was a retrospective case series. Objective: The objective of the study was to assess the surgical outcomes of patients with cervical myelopathy, using the Japanese Orthopaedic Association Cervical Myelopathy Evaluation Questionnaire (JOACMEQ). Summary of Background Data: Degenerative cervical myelopathy (DCM) is a leading cause of morbidity. Patients present with spasticity, gait imbalance, and loss of fine motor function. Most patients present early; however, few manage with disability for years and present late. Methods: Fifty-two consecutive patients underwent surgery for cervical myelopathy from 2008 to 2013; however, detailed follow-up was available in only 42 patients. Thirty-nine patients were ambulatory, while 3 were non-ambulatory at the outset. Nineteen patients underwent anterior surgery and 23 patients underwent posterior surgery. Frankel, Nurick grades, Neck Disability Index (NDI), and JOACMEQ scores were recorded at time of admission, 6, 12, 24, and 52 weeks, and then annually. Outcomes at final follow-up were included for statistical analysis. Results: Thirty-four (81%) patients improved, 4 (9.5%) patients remained static, and 4 (9.5%) patients worsened according to Nurick scale. Nurick grades improved from 3.52 to 1.64. Mean NDI scores improved from 42.28 to 20.28. Analyzing the JOACMEQ scores, cervical spine function improved in 15 (35.7%), upper extremity (UE) function improved in 33 (78.6%) patients, while lower extremity (LE) function improved in 32 (76.2%) patients. Bladder function improved in 17 (40.47%). Quality of life improved in 37 (88.1%) patients. LE improved more than UE, in the younger (&lt;45 years) group, and in those with subaxial myelopathy. Pre-operative symptoms greater than 12 months had a negative impact on outcome. Pre-operative neurology, approach, and instrumentation did not impact outcomes. Four (9.5%) patients developed major neurological deficit, 4 (9.5%) patients had C5 deltoid palsy, while 1 patient had

Magnetic resonance imaging and dynamic X-ray\u2019s correlations with dynamic electrophysiological findings in cervical spondylotic myelopathy: a retrospective cohort study

BackgroundDynamic somatosensory evoked potentials (DSSEP) can be used to disclose abnormalities of ascending sensory pathways at dynamic positions and diagnose cervical spondylotic myelopathy (CSM). However, radiographic tests including magnetic resonance imaging (MRI) and dynamic X-ray are used much more widely in the management of CSM. Our study aims to clarify the correlations between several radiographic parameters and the DSSEP results, and further determine their reliability with clinical data.MethodsWe retrospectively enrolled 38 CSM patients with surgical intervention. DSSEP tests were performed before surgery. Amplitude ratios of DSSEP N13 and N20 waves at extension and flexion were calculated and recorded as N13_E, N20_E, N13_F, N20_F, respectively. Baseline severity was evaluated with the modified Japanese Orthopedic Association (mJOA) score and the Nurick grades. Prognosis was evaluated based on the 2-year recovery rate. Sagittal diameter and transverse areas of the cord and canal were measured and the the compressive ratios at the compressed site (Compression_Ratio), central (Central_Ratio), and 1/4-lateral points (1/4-Lateral_Compression_Ratio), and spinal cord/Canal Area Ratio were calculated. The intramedullary T2 hyperintensity patterns (Ax-CCM types) were also collected from MRI axial images. Dynamic X-rays were used to test for segmental instability of the cervical spine. The correlations between radiologic findings, DSSEP data, and clinical assessments were investigated.ResultsWe found that DSSEP N13_E and N13_F correlated with the Compression_Ratio, Central_Ratio, 1/4-Lateral_Compression_Ratio (Pearson, p < 0.05) and Ax-CCM types (ANOVA, p < 0.05) in MRI axial images and cervical segmental instability in dynamic X-ray (t-test, p < 0.05). Apart from the 1/4-Lateral_Compression_Ratio, these radiographic parameters above also correlated with the baseline clinical assessments (Spearman or ANOVA or t-test, p < 0.05) and postoperative recovery rate (Pearson or ANOVA or t-test, p < 0.05).ConclusionsWe found that the preoperative Compression_Ratio, Central_Ratio and 1/4-Lateral_Compression_Ratio in MRI and cervical segmental instability in dynamic X-ray could reflect the dynamic neural dysfunction of the spinal cord. Different Ax-CCM types corresponded to different DSSEP results at extension and flexion, suggesting divergent pathophysiology. These radiographic parameters could help evaluate disease severity and predict postoperative prognosis.

Cervical spondylotic myelopathy: Association of MRI changes and outcome predictors after surgical intervention

Introduction: Cervical spondylotic myelopathy (CSM) is the most common cause of spinal cord dysfunction in older individuals. Controversy remains in terms of the optimal timing and indications for surgical intervention. In this context, it would be of benefit to define clinical and magnetic resonance imaging (MRI) predictors of outcome after intervention for CSM. Material and Methods: This was a prospective and observational study conducted in the Department of Radio diagnosis, Subbaiah Institute of Medical Sciences, Shimoga. All patients with functional disability secondary to cervical degenerative myelopathy and radiculopathy underwent surgery for decompression of the spinal cord with or without spinal stabilization from January 2020 to September 2020 were studied. A diagnosis of CSM required radiological confirmation (MRI) and at least one or more “upper motor neuron” findings (spasticity, hyper-reflexia, clonus and positive Babinski sign). Result: Among group A patients, 7 patients (77.7%) have improved postoperatively when compared according to Nurick grading. 9 patients (60%) have improved postoperatively. Among group C patients, only 2 patient (33.3%) have improved and majority (66.6%) remained in same grade as per Nurick grading. Conclusions: MR techniques play an indispensable role in the management of CSM patients and have evolved primarily from a diagnostic modality to a method that can potentially predict patient outcome following surgical intervention. Functional MRI can help to assess the neurological functional recovery after decompression surgery for CSM

Comparison of the Accuracy of C1 Pedicle Screw Fixation Using Fluoroscopy and Free-Hand Techniques in Patients With Posterior Arch Thickness of Less Than 4 mm.

C1 pedicle screw insertion is not easy, and more fluoroscopy can be required for safe insertion. Fluoroscopy is time consuming and increases patient radiation exposure. There have been no studies comparing the accuracy of C1 pedicle screw insertion using the fluoroscopy and free-hand techniques. To describe a free-hand C1 pedicle screw insertion method in patients with the posterior arch thickness of less than 4 mm in the thinnest part of the groove, and to compare the clinical and radiological outcomes of C1 pedicle screw insertion using fluoroscopy vs using the free-hand technique. A total of 25 patients who had atlantoaxial instability with a C1 posterior arch<4 mm and were treated with C1 pedicle screw insertion were included. In 10 patients, fluoroscopy was used for C1 pedicle screw insertion, and 15 patients underwent the free-hand technique. We compared the radiologic and clinical outcomes between the 2 groups. In patients who underwent the free-hand technique, 96.5% of screws were rated as safe (grade A or B), and 80.0% of screws in the fluoroscopy group were rated as safe. Postoperative occipital neuralgia occurred in one patient in the fluoroscopy group and did not occur in the free-hand technique group. There was no significant difference in the improvement of Nurick grade between the 2 groups. C1 pedicle screw insertion using the free-hand technique is feasible and safe in patients with a C1 posterior arch<4 mm.

Magnetic resonance imaging predictors of outcome after surgical intervention for cervical spondylotic myelopathy

Background: Cervical spondylotic myelopathy (CSM) is a commonly seen spinal cord disease. There are no well-defined indications and optimal timing for surgical intervention. Therefore, defining predictors for outcome after surgical intervention will have great advantage in taking decisions for interventions.Methods: A consecutive series of all patients having signs and symptoms of cervical spondylotic myelopathy admitted to Department of Neurosurgery, Medical College, Thiruvananthapuram who underwent decompressive surgery with or without stabilization in one year were studied. Pre-operative magnetic resonance imaging (MRI) findings were correlated with post-operative surgical outcomes (Nurick grade) after 3 months of follow up. The pattern of spinal cord signal intensity was classified as: group A (MRI N/N) - no SI T1WI or T2WI, group B (MRI N/Hi) - no SI T1WI and high SI on T2WI and, group C (MRI Lo/Hi) - low SI T1WI and high SI on T2WI. CSM clinical outcomes were evaluated using Nurick grading system, which was used pre- and post-operatively (pre op and post op).Results: Post operatively improvement was seen in 75% of group A and 61.35 % of group B patients, but among group C only 25% patient improved according to Nurick grading pre op and post op.Conclusions: Patients with high intramedullary signal intensity on T2WI may experience a good surgical outcome. A less favorable surgical outcome is predicted by the presence of low intramedullary signal on T1WI.

Do Intraoperative Neurophysiological Changes During Decompressive Surgery for Cervical Myeloradiculopathy Affect Functional Outcome? A Prospective Study.

Study Design:Prospective cohort.Objective:To investigate whether intraoperative neuromonitoring (IONM) positive changes affect functional outcome after surgical intervention for myeloradiculopathy secondary to cervical compressive pathology (cervical compressive myelopathy).Methods:Twenty-eight patients who underwent cervical spine surgery with IONM for compressive myeloradiculopathy were enrolled. During surgery motor-evoked potential (MEP) and somatosensory evoked potential (SSEP) at baseline and before and after decompression were documented. A decrease in latency >10% or an increase in amplitude >50% was regarded as a “positive changes.” Patients were divided into subgroups based on IONM changes: group A (those with positive changes) and group B (those with no change or deterioration). Nurick grade and modified Japanese Orthopaedic Association (mJOA) score were evaluated before and after surgery.Results:Nine patients (32.1%) showed improvement in MEP. The mean preoperative Nurick grade and mJOA score of group A and B were (2.55 ± 0.83 and 11.11 ± 1.65) and (2.47 ± 0.7 and 11.32 ± 1.24), respectively. The mean postoperative Nurick grade of groups A and B at 6 months was 1.55 ± 0.74 and 1.63 ± 0.46, respectively, and this difference was not significant. The mean postoperative mJOA score of groups A and B at 6 months was 14.3 ± 1.03 and 12.9 ± 0.98, respectively, and this difference was statistically significant (P = .011). Spearman correlation coefficient showed significant positive correlation between the IONM change and the mJOA score at 6 months postoperatively (r = 0.47; P = .01).Conclusion:Our study shows that impact of positive changes in MEP during IONM reflect in functional improvement at 6 months postoperatively in cervical compressive myelopathy patients.

Management of CVJ tuberculosis: the changing paradigm.

The literature seems fractured for the management of craniovertebral junction (CVJ)-tuberculosis (TB). Presently, non-surgical management has been in vogue for neurologically intact patients. On the contrary, severely disabled cases of CVJ-TB continue to attract discussion, tilted towards surgical intervention. We present our experience with the non-surgical management of CVJ-TB tailored to their neurological status. Authors managed 37 cases (2004-2019; age 1-57 years, mean 36 years) of CVJ-TB, of which eighteen (18/37, 48.6%) were severely disabled (Nurick grade ≥ 3) with a mean follow-up of 84 months (48-192 months). Irrespective of the clinical status and radiological findings, all patients were managed on medical management only. Needle aspiration established pathology in 23 (62.2%) cases, while 9 (24.3%) cases required drainage of an abscess. All patients received 18 months of anti-tubercular therapy (ATT). In patients with Nurick grade ≥ 3 and documented AAD, we applied halo vest for 12 months to achieve cervical immobilization. Only hard cervical collar for 3 months was prescribed in patients with no documented AAD. All minimally disabled cases (Nurick grade ≤ 2, n = 19) responded favorably (n = 18) to ATT, except for an infant, who succumbed to irreversible hypoxic brain damage due to the obstructed aero-digestive gateway. Of the severely disabled cases (Nurick grade ≥ 3, n = 18), 16 cases had favorable outcomes with only external orthosis (12) and 18-month ATT. One patient succumbed to multiple cerebral infarcts, while one required realignment surgery at CVJ due to fusion in malaligned position. The authors conclude that the disability grading of CVJ-TB is pertinent only for assessing the functional disability of patients at presentation, with minimal relevance in deciding its management strategy. Irrespective of neurological disability, almost all patients respond favorably to external immobilization and ATT.

Management of congenital craniovertebral anomalies: a single-centre experience of 71 cases by an algorithmic approach.

Retrospective study. Congenital craniovertebral (CV) anomalies include a wide variety of conditions involving basilar invagination (BI), atlantoaxial dislocation (AAD), bony congenital anomalies and Chiari malformation. The management of these disorders is more surgeon dependent rather than based on clear guidelines. This study aims to provide a step-by-step algorithmic approach to the management of congenital CV anomalies to achieve good CV alignment, neural recovery and long lasting stability. The study retrospectively analyses 71 patients of congenital CV anomalies treated by our algorithmic approach. Clinical assessment was done with the help of Nurick's grading pre- and post-operatively. Radiological outcome was assessed by plain radiographs, and computed tomographic scan was done at 12-month follow-up. Mean age at presentation was 17.9years (6-41years). Mean Nurick score pre-operatively was 3.8 which was reduced to 1.3 at a mean follow-up of 13.6months. Sixty-one patients had type I BI, 6 had type II BI, and 4 patients had os odontoideum. Most common symptom at presentation was weakness in limbs, neck pain and difficulty in walking. Patients of isolated AAD with os odontoideum required posterior atlantoaxial fixation and fusion only. Thirty-two patients of type I BI and 4 patients of type II BI required anterior release procedures prior to occipitocervical instrumentation. Bony fusion was achieved in 96% (68) cases with the help of autologous bone grafting. Three patients of occipitocervical fusion developed pseudoarthrosis. Our retrospective analysis demonstrates that the algorithm is effective in ensuring long lasting results in all types congenital CV anomalies.

Functional and Quality of Life Outcomes of Surgery for Degenerative Cervical Myelopathy: a Quality Improvement Study

Background: This study aimed to determine the outcome of surgical treatments in patients with degenerative cervical myelopathy (DCM). During one-year follow-up period, we evaluated patient-reported functional and quality of life (QOL) measures. Methods: In a retrospective single-center study, we collected data of patients with DCM who underwent cervical fusion surgeries in Imam Khomeini Hospital, Tehran, Iran, from 2011 to 2015. Patients underwent single or multi-level anterior cervical discectomy and fusion (ACDF), anterior cervical corpectomy and fusion (ACCF), or posterior laminectomy and fusion. We utilized patient-reported assessments including Short Form 36 (SF-36), Visual Analogue Scale (VAS), Neck Disability Index (NDI), and Nurick grade. Follow-up was performed at 6 weeks, 3 months, 6 months, and 12 months post-operatively to assess the outcome of surgery. Results: Ninety patients (56 men, 34 women) with a mean age of 54.1 (27-87) years were included. Comparison of pre- and post-operative scores showed significant improvement in SF-36 parameters, VAS, NDI, and Nurick grade (P &lt; 0.001). Also, women’s VAS scores improved more than men's VAS scores during the follow-up period (P &lt; 0.050). Age and type of surgery did not significantly affect the SF-36 parameters, VAS, NDI, and Nurick grade (P &gt; 0.05). Conclusions: Cervical surgeries in patients with different severity of DCM can improve different aspects of QOL during one-year after surgery

Full endoscopic unilateral laminotomy for bilateral decompression of the cervical spine: surgical technique and early experience.

Full-endoscopic decompression surgery has been shown to be safe and efficacious in the lumbar spine, while its role remains to be determined in the cervical spine. We describe the utility of cervical endoscopic unilateral laminotomy for bilateral decompression (CE-ULBD) in a series of elderly patients with severe central stenosis, significant medical comorbidity, and existing cervical deformity. A prospectively collected spine surgery registry at the University of Washington was retrospectively queried for patients with cervical spondylotic myelopathy receiving CE-ULBD. Demographic data, operative details, imaging, and patient reported outcomes, including visual analogue scale (VAS) for neck and upper extremity pain, Nurick grade, and the modified Japanese Orthopedic Association (mJOA) score, were reviewed. Description of the surgical technique is provided. Descriptive statistics were calculated. From 2014 through 2018, 10 patients with an average age of 70.2±5.0 years underwent CE-ULBD for symptomatic upper cervical stenosis due to ligamentum flavum buckling. Half of these patients had one stenotic segment, the other half had two stenotic segments. The most commonly affected segment was C3/4 (5/10 patients). Average length of surgery was 128±18.4 minutes. Average length of stay was 1.2±0.2 days. Average clinical follow-up time was 22.0±4.7 months; clinical outcomes at most recent follow-up were improved via both the Nurick grade (1.2±0.4, P<0.01) and modified Japanese Orthopedic Association (14.6±1.0, P<0.001) compared with pre-operative values. One patient experienced a transient loss of motor evoked potentials intraoperatively, but there were no cases of permanent neurological deficit. Severe central cervical stenosis is a safe and viable target for full-endoscopic decompression via an interlaminar approach.

A Feasibility Study of a New Muscle Sparing "C3 Dome-Hybrid Open-Door Laminoplasty": A Surgical Technique, Clinical Outcome, and Learning Curve Description.

Retrospective case series to investigate the result of a new C3 dome-hybrid open-door laminoplasty technique. This study reports the design and feasibility of a new hybrid laminoplasty technique aimed to reduce the complications of the conventional laminoplasty, with the incorporation of C3 dome-osteotomy, an open-door C4-6 instrumented laminoplasty and C7 cephalad dome-osteotomy. Recent findings showed that the preservation of the dorsal muscles attached at either C2 or C7 cervical spine reduced the complications of C3-C7 open-door laminoplasty. A retrospective review of consecutive patients who underwent the C3 dome-hybrid laminoplasty technique by a single surgeon with at least 2 years follow-up was performed. The surgical technique was described in detail. Clinical and radiological outcome data were analyzed. Twenty six patients with cervical cord compression who underwent C3 dome-hybrid laminoplasty were recruited. The mean postoperative follow-up was 45.6 ± 24.7 (24-101) months. Significant improvements were observed in the preoperative to postoperative mean Japanese Orthopaedic Association (JOA) score (13→15, P < 0.001), Nurick grade (2.3→1.2, P < 0.001), neck disability index (NDI) (23→11, P = 0.011), 36-item short form survey (SF-36) physical component score (40→46, P = 0.027), and neck visual analogue scale (VAS) (3.1→0.3, P < 0.001). There was no significant loss in cervical lordosis from 12° preoperatively to 8° at final follow-up. Postoperative cervical range of motion (ROM) was preserved at 85% and 78% of the preoperative ROM at 2 years and at final follow-up, respectively. When comparing the first 10 patients with the next 16 patients, there was a reduction in mean operation time from 252 ± 75 to 208 ± 7 minutes, mean blood loss from 359 ± 326 to 211 ± 177 mL, and median hospital stay from 7 days (interquartile range [IQR]: 34) to 5 days (IQR: 6).At final follow-up, no patients had revision surgery, spinal infection, C5 palsy, symptomatic cervical kyphosis, or axial neck pain. The new C3 dome-hybrid laminoplasty technique is safe, feasible, and reproducible with good clinical outcomes. This technique may be considered as an alternative to traditional laminoplasty for patients with C3-C7 multi-level myelopathic disease. 3.