Nurick Grade Research Articles

Clinical study of single-level cervical disc herniation treated by full-endoscopic decompression via anterior transcorporeal approach

To investigate the clinical feasibility of full-endoscopic decompression for the treatment of single-level cervical disc herniation via anterior transcorporeal approach. According to the inclusion and exclusion criteria, 21 patients with cervical disc herniation who received full-endoscopic decompression via anterior transcorporeal approach between September 2014 and March 2016 were retrospectively analyzed. There were 12 males and 9 females with an age ranged from 32 to 65 years, with an average of 48.5 years. The duration of symptoms ranged from 6 to 18 weeks, with an average of 10.5 weeks. According to the Nurick grading of spinal cord symptoms, there were 2 cases with grade 1, 7 cases with grade 2, and 12 cases with grade 3. Operative segment was C 3, 4 in 2 cases, C 4, 5 in 8 cases, C 5, 6 in 9 cases, and C 6, 7 in 2 cases. The operation time and related complications were recorded. The central vertical height of the vertebral body and the diseased segment space were measured on the cervical X-ray film. The neck and shoulder pain were evaluated by visual analogue scale (VAS) score; Japanese Orthopaedic Association (JOA) score was used to evaluate the improvement of neurological function in patients. The MRI of cervical spine was reexamined at 3 months after operation, and the CT of cervical spine was reexamined at 12 months after operation. The decompression of spinal cord and the healing of bone canal in the vertebral body were further evaluated. Full-endoscopic decompression via anterior transcorporeal approach were achieved at all 21 patients. The operation time was 85-135 minutes, with an average of 96.5 minutes. All patients were followed up 24-27 months, with an average of 24.5 months. There was no complication such as residual nucleus pulposus, spinal cord injury, large esophageal vessels injury, pleural effusion, endplate collapse, intraspinal hematoma, cervical spine instability, protrusion of disc in the same segment, or kyphosis. Both VAS scores of neck and shoulder pain and JOA scores were significantly improved at 12 months after operation ( P<0.05). At 3 months after operation, it was confirmed by the cervical MRI that neural decompression was sufficient and the abnormal signal was also degraded in the patients with intramedullary high signal at T2-weighted image. The cervical CT showed that bone healing were achieved in the surgical vertebral bodies of all patients at 12 months after operation. At 24 months after operation, the central vertical height of the diseased segment space significantly decreased compared with preoperative one ( t=2.043, P=0.035); but there was no significant difference in the central vertical height of the vertebral body between pre- and post-operation ( t=0.881, P=0.421). Full-endoscopic decompression via anterior transcorporeal approach, integrating the advantages of the endoscopic surgery and the transcorporeal approach, provide an ideal and thorough decompression of the ventral spinal cord with satisfactory clinical and radiographic results.

Cervical Decompression for Myelopathy in a Resource-Poor Region: Initial Experience

The aim of this study was to document the initial experience and challenges of cervical decompression in a resource-poor region. Forty-three patients with cervical myelopathy who had surgery were included in the study. Details including evaluations pre- and postoperative (at 6 weeks and 6 months) using the Nurick score were recorded prospectively. Details of surgery were also documented. The mean age at surgery was 58.0 years. There were 37 men and 6 women. Surgeries performed were anterior cervical decompression and fusion (51.2%), cervical laminectomy (32.6%), corpectomy and occipitocervical fixation (2.3% each), and decompression with lateral mass fixation (11.6%). Four patients presented within 3 months of onset of symptoms (early), whereas 39 after 3 months (late). The Nurick grade significantly improved in 41 patients (97.6%) following surgery (P < 0.001). The average Nurick preoperative score was 3.2, and postoperative it was 2.12 and 1.14 at 6 weeks and 6 months, respectively. In the early presentation group, scores improved from an average preoperative of 2.5-0.5 at 6 months, whereas in the late presentation group, score improved from an average of 3.3 preoperative to 1.2 at 6 months postoperative. Despite the challenges of poverty, late presentation, and lack of basic standard instruments and equipment, patients with cervical myelopathy in the resource-poor setting had outcomes similar to other well-established centers after surgical decompression. We infer that challenges in setting up a spine unit in a resource-poor region can be circumvented safely.

Clinical and Radiologic Features of Degenerative Cervical Myelopathy Depending on the Presence of Cord Signal Change

Cord signal change (CSC) on magnetic resonance (MR) imaging is an important radiologic feature of degenerative cervical myelopathy (DCM). Occasionally, DCMs correlate with clinical symptoms with no CSC. The aim of this study was to evaluate clinical and radiologic features, depending on the presence of CSC in DCM. This retrospective study included 73 patients who underwent cervical laminoplasty for DCM. They were divided into 2 groups based on the presence of CSC on static MR imaging (positive CSC in group A and negative CSC in group B). Preoperative radiologic parameters on lateral radiographs and the severity of canal stenosis on MR imaging were analyzed. The functional outcomes were evaluated using the modified Japanese Orthopedic Association score and Nurick grade. Group A showed more deteriorated canal stenosis (P < 0.001) and kyphotic change than did group B. C2-7 sagittal vertical axis (P= 0.003) of group A and C2-7 range of motion (C27ROM; P < 0.001) of group B were greater than in the opposite groups, respectively. In a multivariate analysis, greater width of the cervical canal (P= 0.002) and increased C27ROM (P= 0.002) were statistically significant radiologic parameters related to negative CSC. Group B showed better functional outcomes until 6 months postoperatively, with statistical significance. DCM with negative CSC can be caused by a well-preserved cervical ROM, even with less deteriorated canal stenosis and kyphosis. C27ROM may be a helpful radiologic parameter in diagnosing DCM before CSC appears.

Laminectomy versus open-door laminoplasty for cervical spondylotic myelopathy: A clinical outcome analysis.

Background: Cervical spondylotic myelopathy (CSM) is one of the most common diseases in the geriatric population. Decompressive laminectomy or laminoplasty is the predominant surgical procedure of choice, but there remains debate as to which procedure is optimal for managing CSM.Methods: Here, we retrospectively analyzed 64 patients with CSM undergoing laminectomy (39 patients) versus laminoplasty (25 patients). The data were collected included respective Japanese orthopedic association (JOA) scores, Nurick grades, and Visual analog scale (VAS) values preoperatively versus 12 months postoperatively.Results: The JOA score after 1 month improved in both groups utilizing laminectomy or laminoplasty. However, at 12 postoperative months, the JOA scores and Nurick grades showed greater improvement following laminoplasty, despite no differences in postoperative pain and complication rates.Conclusion: Patients with cervical spondylotic myelopathy undergoing laminoplasty (25 patients) showed better 12-month postoperative outcomes (JOA scores and Nurick grades) versus those having laminectomies (39 patients).

MRI findings in Pott's spine and correlating clinical progress with radiological findings.

To document magnetic resonance imaging (MRI) changes in Pott's spine and to correlate these with clinical findings and outcome. Patients with Pott's spine having more than one set of MRI were included in the study. Patients were grouped according to timing of their second MRI. The MRI findings included changes in bone, disc, spinal cord, and soft tissue. The MRI changes were categorized into improvement, no change, or worsening. "Paradoxical worsening" was defined as radiological worsening in setting of clinical improvement, as described by improvement of Nurick's grade. Outcome was defined by mRS scale at three, six, and 12months. The MRI findings and outcome were correlated. The results are based on 36 patients. The MRI changes included vertebral changes in form of spondylodiscitis in 33 (92%), epidural abscess in 29 (81%), spinal cord changes including edema and granuloma in 17 (47%), paravertebral abscess in 29 (81%), and vertebral body collapse in 12 (33.3%) patients. At threemonths, clinical improvement occurred in eight out of 12 patients, deterioration in two, and no change in two. Spinal MRI revealed improvement in one patient only; whereas eight had deterioration and three had no change. At sixmonths, all nine patients improved clinically, but MRI showed improvement in only four, while another four showed deterioration and one had no change. In the nineand 12months group, while all patients clinically improved, MRI showed minimal worsening. In Pott's spine, the clinical improvement precedes the radiological improvement.

Occipitocervical fusion complicated with cerebellar abscess: a case report

BackgroundOccipitocervical (OC) fusion is indicated for OC instability and other conditions. Surgical complications include infection, malunion, and instrument failure.Case presentationWe described a patient who underwent OC fusion and subsequently developed complication of cerebellar abscess and obstructive hydrocephalus. A 63-year-old male patient had been suffering from long-term neck pain and limb numbness and weakness. Cervical spine examination revealed tight stenosis at C1 level and instability in the C1-C2 joints. A C1 laminectomy with OC fusion was performed, and the patient was discharged. Unfortunately, a few days later, he went to the emergency department and complained of persistent dizziness, vomiting, and unsteady gait. Computed tomography (CT) and magnetic resonance imaging (MRI) images revealed a suspicious cerebellar abscess formation and hydrocephalus. Furthermore, CT images indicated that the left screw was loose, and the diameter of the right screw hole was much larger than the size of the screw. Besides, inappropriate length of the screw penetrated the occipital bone and may cause the disruption of dura mater. The patient underwent external ventricular drainage first, followed by abscess drainage and C1-C2 fixation a few days later. He was discharged without any further neurological deficits or infectious problems. The patient recovered with intact consciousness, full muscle strength, and improved numbness throughout the extremities, with a Nurick grade of 1. A follow-up magnetic resonance imaging at 3 months after surgery revealed near total resolution of the abscess. Inform consent was obtained from this patient.ConclusionsCarefully conducting the procedure using the most tailored approach is essential to successful surgery, but this rare complication should always be kept in mind.

The Relationship Between Gastrointestinal Comorbidities, Clinical Presentation and Surgical Outcome in Patients with DCM: Analysis of a Global Cohort.

Degenerative cervical myelopathy (DCM) is the most common cause of spinal cord impairment in adults, presenting most frequently in patients 50 years or older. Gastrointestinal comorbidities (GICs) commonly occur in this group; however, their relationship with DCM has not been thoroughly investigated. It is the objective of the present study to investigate the difference between patients with or without GICs who are surgically treated for DCM. A cohort of 757 patients with clinical data and 458 with magnetic resonance imaging (MRI) data from the AOSpine North America and AOSpine International studies on DCM was evaluated. GICs were obtained at presentation and included gastric, intestinal, hepatic, and pancreatic conditions. Patients were dichotomized into 2 groups: those with GICs and those without GICs. Both clinical and MRI presentation, as well as baseline neurological and functional status, were compared. Neurological and functional outcomes at 2-year follow-up were also compared. GICs were present in 121 patients (16%). These patients were less commonly male (48.76% vs. 65.4%, p = 0.001) and were slightly less neurologically impaired based on the Nurick grade (3.05 ± 1.10 vs. 3.28 ± 1.16, p = 0.044) but not based on mJOA (12.74 ± 2.62 vs. 12.48 ± 2.76, p = 0.33). They also had a worse physical health score (32.80 ± 8.79 vs. 34.65 ± 9.38 p = 0.049), worse neck disability (46.31 ± 20.04 vs. 38.23 ± 20.44, p < 0.001), a lower prevalence of upper motor neuron signs (hyperreflexia, 70.2% vs. 78.9%, p = 0.037; Babinski’s sign 24.8% vs. 37.3%, p = 0.008), and a higher rate of psychiatric comorbidities (31.4% vs. 10.4%, p < 0.0001). On MRI, GIC patients less commonly exhibited signal intensity changes (T2 hyperintensity, 49.2% vs. 75.6%, p < 0.001; T1 hypointensity, 9.7% vs. 21.1%, p = 0.036), and had a lower number of T2 hyperintensity levels (0.82 ± 0.98 vs. 1.3 ± 1.11, p = 0.001). There was no difference in surgical outcome between the groups. DCM patients with GICs are more likely to be female and have significantly more general health impairment and neck disability. However, these patients have less clinical and MRI features typical of more severe neurological impairment. This constellation of symptoms is considerably different than those typically observed in DCM, and it is therefore plausible that nutritional factors may contribute to this unique observation.

Prevalence of anemia and its relationship with neurological status in patients undergoing surgery for degenerative cervical myelopathy and radiculopathy: A retrospective study of 2 spine centers

Both degenerative cervical myelopathy (DCM) and anemia are common among older patients, however insufficient data exists evaluating their co-occurrence and the influence of anemia on baseline neurological status. To address this, we examined a retrospective multicenter series of patients treated for DCM or radiculopathy. Myelopathy was graded using the Nurick scale. Established criteria for diagnosing abnormalities were used to identify blood abnormalities, including macrocytic and microcytic anemia. Multivariable regression was used to determine the impact of hematological anomalies on Nurick grades. In our analysis, we included 725 patients (age of 57.1 ± 11.7), of whom 398 presented with myelopathy and 327 presented with radiculopathy alone. Twenty six percent of all patients were anemic at baseline and the mean preoperative Nurick grade across all patients was 2.09 ± 1.29; mean Nurick grade amongst those with DCM was 2.98 ± 1.12. Compared to those with myelopathy, patients with radiculopathy were significantly younger (53.8 ± 11.0 vs 59.8 ± 11.6, p < 0.001) and less likely to be anemic (16.8% vs 33.7%, p < 0.0001). Nurick grading was significantly higher in myelopathy patients with anemia (3.13 ± 1.19 vs 2.91 ± 1.07, p = 0.05) and macrocytic anemia (4.00 ± 1.41 vs 2.97 ± 1.11, p = 0.04). Multivariate regression demonstrated that anemia (p < 0.001), age (p < 0.0001), and posterior surgical approach (p < 0.0001) were related to worse preoperative Nurick grade. In sum, these data suggest that anemia and degenerative cervical spine pathologies commonly co-occur. Anemia, and macrocytic anemia specifically, is associated with poorer neurological status in myelopathic patients. These data suggest anemia may influence baseline neurological status and impact surgical recovery in patients treated for DCM or radiculopathy.

Does kyphosis in healed subaxial cervical spine tuberculosis equate to a poor functional outcome?

Introduction:Tuberculosis (TB) of the subaxial cervical spine has a high percentage of morbidity. It accounts for about 10% of cases with the major concerns being quadriparesis and localized kyphosis.Aim:The study aims to provide an insight in the management of subaxial cervical spine TB treated by multiple modalities.Materials and Methods:A retrospective analysis of 91 patients with subaxial cervical (C3–C7) TB was performed. Neurology was assessed by Nurick's grading and pain using the visual analog scale (VAS) (in mm). Radiological evaluation was done with standard anteroposterior and lateral view of the cervical spine at presentation and 3 monthly intervals after intervention. Magnetic resonance imaging was done in all patients. Angle of kyphosis (K angle) was calculated from plain radiographs.Results:Mean age of the patients was 31.5 years. Neurological status was Nurick's Grade 5 in 8, Grade 4 in 15, Grade 3 in 28, Grade 2 in 22, Grade 1 in 7, and further 11 had Nurick's Grade 0. Operative intervention was either anterior, or posterior, or a combination of both depending on extent of vertebral destruction. All patients with Nurick's 5 and 4 improved to 3 or less at final follow-up. The kyphosis angle at presentation ranged from 2° to 58° of with an average kyphosis of 16.05°. The postoperative kyphosis was graded as mild (loss of lordosis to 10° kyphosis), moderate (10°–30°), and severe (>30°). Ten patients had mild kyphosis and 6 patients had moderate kyphosis. Mean VAS score at presentation was 45.5 mm which improved to 14.48 mm at follow-up. Patients with mild and moderate kyphosis remained asymptomatic till the last follow-up.Conclusion:Healing of subaxial cervical TB in kyphosis does not necessitate a poor clinical outcome as most patients remain asymptomatic.

Vertebral Body Anterior Translation, a Novel Technique for Delayed Myelopathy Due to Osteoporotic Spine Fractures.

BackgroudOsteoporotic vertebral compression fractures (OVCFs) are often associated with delayed myelopathy. Surgical treatment of delayed myelopathy following an OVCF comprises spinal canal decompression and stable fixation of the vertebral column with an acceptable sagittal alignment. However, such surgical methods are not usually feasible because of medical comorbidities and osteoporosis. We devised a novel, simple technique to decompress the spinal canal and reconstruct the middle column by translating the fractured vertebral body anteriorly through a posterior approach and verified the validity of the new technique.MethodsWe conducted a single-center, retrospective study. Patients who underwent vertebral body anterior translation (VBaT) between 2014 and 2017 due to delayed myelopathy after OVCFs were included. Through a posterior approach, discs between the fractured vertebra and the adjacent vertebrae were released. The fractured vertebra was translated anteriorly with pedicle screws and rods to realign the middle column. Radiological and functional improvement was analyzed.ResultsThere were 12 consecutive patients. The mean age was 70.3 ± 9.4 years. There were 8 female and 4 male patients. Follow-up period was 35.9 ± 13.1 months. Nine patients had pedicle screw augmentation with polymethyl methacrylate. The mean number of fusion segments was 3.4 (range, 2–4). There were 3 types of spinal canal invasion. Five patients had vertebral body vacuum clefts with posterior wall fractures. Five patients had vertebral body angulation with endplate protrusion. Two patients had 3 column fractures. In radiological analysis, the regional kyphotic angle was 35.1° ± 9.1° preoperatively and improved to 8.8° ± 6.8° postoperatively and 9.8° ± 6.1° at the final follow-up (p < 0.001). The anterior vertebral body height ratio was 27.6% ± 7.0% preoperatively and improved to 80.5% ± 13.7% postoperatively and 83.7% ± 12.5% at the final follow-up (p < 0.001). The spinal canal invasion ratio was 52.6% ± 9.1% preoperatively and improved to 25.2% ± 10.4% postoperatively (p < 0.001). Neurological deficit was improved in all patients by 1–3 grades according to Nurick's grading system.ConclusionsIn delayed myelopathy following an OVCF, although the posterior cortex invades the spinal canal, it is usually already in the union state. Therefore, it can bear compression force as a middle column if realigned to be in line with the adjoining vertebrae. VBaT demonstrated satisfactory reduction of kyphosis and maintenance of stability until the last follow-up.

Craniovertebral junction instability in Larsen syndrome: An institutional series and review of literature.

Objective:Larsen syndrome (LS) is characterized by osteo-chondrodysplasia, multiple joint dislocations, and craniofacial abnormalities. Symptomatic myelopathy is attributed to C1–C2 instability and sub-axial cervical kyphosis. In this article, we have analyzed the surgical outcome after posterior fixation in LS with craniovertebral junction instability.Methods:Ten symptomatic pediatric patients, operated between 2011 and 2019, were included, and the clinical outcome was assessed by Nurick grade, neurological improvement, and complications. The requirement of anti-spasticity drugs, the degree of bony fusion, and restriction of neck movement were also noted. At last follow-up, patient satisfaction score (PSS) and back to school status were studied. We also reviewed the literature and categorized two types of presentation of reported LS patients and discussed the pattern of disease progression among both.Results:Ten patients, age range 1.5–16 years, underwent 12 surgeries (6 C1–C2 fixation, 4 long-segment posterior cervical fixation, and 2 trans-oral decompressions as the second stage); the mean follow-up was 23 (range, 6–86 months). All the ten patients in our study had the characteristic “dish-” like face and nine patients had acral anomalies. The median Nurick grade improved from preoperative (median = 4) to follow-up (median = 3). The requirement of anti-spasticity drugs decreased in seven patients and the neck-pain improved in nine patients. The median satisfaction at follow-up was good (median PSS = 2); five patients were going back to school.Conclusion:Craniovertebral junction instability in LS is rare and surgically challenging. Early posterior fixation showed a promising outcome with a halt in the disease progression.

Evaluation of the effectiveness of expandable cages for reconstruction of the anterior column of the spine.

For anterior spine column reconstruction after corpectomy, expandable cages offer solid anterior support and allow correction of deformity, providing excellent primary stability. To provide a larger body of clinical observations concerning the effectiveness of the approach, this retrospective study examines patients treated by corpectomy and reconstruction with an expandable cage for different pathologies. Across 5 years, 39 patients underwent vertebral reconstruction with expandable cages after single (n = 34), double (n = 4), or triple (n = 1) corpectomy. Pathologies were tumors (n = 21), fractures, or deformities in traumatic injuries (n = 14), degenerative pathology (n = 2), and infection (n = 2). Levels were cervical (n = 10), thoracic (n = 14), and lumbar (n = 15). All patients were evaluated clinically and radiographically. There were no cases of neurologic deterioration. Nurick grade showed significant improvement at 3 months postoperative versus preoperative (p < 0.01). Visual analog scale significantly improved preoperatively versus 3 and 12 months postoperatively (both p = 0). Regional angulation was significantly corrected, from preoperative to 3 and 12 months postoperative, at cervical, thoracic, and lumbar levels. We achieved reconstruction of the normal local anatomy with full recovery of the height of the vertebral body. Six patients (15.4%) had complications and two (5.1%) underwent revision surgery. In our experience, expandable cages confer stable anterior support, providing significant improvement of the segmental kyphosis angle and restoration of the original somatic height. Our clinical results are favorable, and the low rate of complications and revision accentuates the expandable cage as a valuable tool to replace the vertebral body in diverse pathologies and different spine levels.

Endoscopic Anterior Cervical Discectomy (Disc Preserving).

Endoscopic anterior cervical approach has several advantages compared to conventional anterior cervical discectomy and fusion (ACDF). This video demonstrates a step-by-step procedure for endoscopic anterior cervical discectomy. The patient is placed supine with the neck extended. A standard anterior cervical approach using about 3 cm skin incision is made and under "Easy Go" (Karl Storz, Tuttlingen, Germany) endoscopic vision, the uncinate process and uncus are drilled. Only a small portion of the normal disc, posterior longitudinal ligament (PLL), and compressing disc is removed. The closure is done in a standard manner. In 240 patients, the average postoperative reduction in disc height, operating time, and blood loss were 1.1 ± 0.2 mm, 110 ± 17 min, and 30 ± 11 mL, respectively. The average postoperative VAS score and Nurick grading improved significantly. There were no permanent complications or any mortality. Endoscopic technique is an effective and safe alternative to ACDF after attaining the learning curve.

Evaluation of Results of Anterior Cervical Discectomy Fusion (ACDF) by Cervical Cage with Bone Graft for the Treatment of Single Level Cervical Spondylotic Myelopathy

Background: Cervical spondylotic myelopathy (CSM) is a common spinal cord disorder that develops in elderly people. Anterior cervical decompression and fusion (ACDF) is an effective and reliable procedure for the treatment of CSM.&#x0D; Objective: To find out the results of ACDF by cervical cage with bone graft for the treatment of single level cervical spondylotic myelopathy.&#x0D; Methods: This prospective observational study was conducted in the Department of Orthopedics, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, over a period of two years from March 2015 to August 2017. Forty patients with cervical spondylotic myelopathy were diagnosed on the basis of presenting complains, clinical examination and investigations and were enrolled in this study. The history of the patients was collected, clinical examination was done and relevant investigations were done for each patient. In this study, Nurick grading and VAS scale were used for evaluation of the result.&#x0D; Result: Male gender was predominant in this study; male-female ratio was 2.63:1. Mean age of the patients was 45.9 ± 9.1 years within the range of 30-65 years. Both sides were affected in 14 (35.0%) cases, only right side was affected in 15 (37.5%) cases and only left side was affected in 11 (27.5%) cases. Involved disc spaces were C3/4 (10.0%), C4/5 (22.5%), C5/6 (42.5%) and C6/7 (25.0%). Transientdysphagia was observed in 2 (5.0%), transient para paresis in 1 (2.5.0%), wound infection in 1(2.5.0%) case and damage to the dura was observed in 1 (2.5.0%) case. Signs of fusion were observed in 10 (25.0%) cases after 3 months, 30 (75.0%) cases after 6 months and in all patients after 12months. The result was found to be excellent in 35 (87.5%) and good in 5 (12.5%) cases.&#x0D; Conclusion: Anterior cervical discectomy and fusion by cervical cage with bone graft is an effective procedure for management of CSM.

The effect of renin-angiotensin system blockers on spinal cord dysfunction and imaging features of spinal cord compression in patients with symptomatic cervical spondylosis

BACKGROUND CONTEXTCervical spondylosis may lead to spinal cord compression, poor vascular perfusion, and ultimately, cervical myelopathy. Studies suggest a neuroprotective effect of renin-angiotensin system (RAS) inhibitors in the brain, but limited data exist regarding their impact on the spinal cord. PURPOSETo investigate whether RAS blockers and other antihypertensive drugs are correlated with preoperative functional status and imaging markers of cord compression in patients with symptomatic cervical spondylosis. STUDY DESIGNRetrospective observational study. PATIENT SAMPLEIndividuals with symptomatic degenerative cervical stenosis who underwent surgery. OUTCOME MEASURESImaging features of spinal cord compression and functional status (modified Japanese Orthopedic Association [mJOA] and Nurick grading scales). METHODSTwo hundred sixty-six operative patients with symptomatic degenerative cervical stenosis were included. Demographic data, comorbidities, antihypertensive medications, and functional status (including mJOA and Nurick grading scales) were collected. We evaluated canal compromise, cord compromise, surface area of T2 signal cord change, and pixel intensity of signal cord change compared with normal cord on T2-weighted magnetic resonance imaging sequences. RESULTSOf 266 patients, 41.7% were women, 58.3% were men; median age was 57.2 years; 20.6% smoked tobacco; 24.7% had diabetes mellitus. One hundred forty-nine patients (55.8%) had hypertension, 142 (95.3%) of these were taking antihypertensive medications (37 angiotensin-II receptor blockers [ARBs], 44 angiotensin-converting enzyme inhibitors, and 61 other medications). Patients treated with ARBs displayed a higher signal intensity ratio (ie, less signal intensity change in the compressed cord area) compared with untreated patients without hypertension (p=.004). Patients with hypertension had worse preoperative mJOA and Nurick scores than those without (p<.001). In the multivariate analysis, ARBs remained an independent beneficial factor for lower signal intensity change (p=.04), whereas hypertension remained a risk factor for worse preoperative neurological status (p<.01). CONCLUSIONSIn our study, patients with hypertension who were treated with RAS inhibitors had decreased T2-weighted signal intensity change than untreated patients without hypertension. Patients with hypertension also had worse preoperative functional status. Prospective case-control studies may deepen understanding of RAS modulators in the imaging and functional status of chronic spinal cord compression.

Endoscopic Endonasal Odontoidectomy.

Odontoidectomy is a standard procedure employed in the treatment of irreducible, compressive ventral pathologies of the craniovertebral junction (CVJ). The traditionally used transoral route is often challenging due to the increased depth of the surgical corridor and risk of injuries to the soft tissues in the oral cavity. The emergence of endoscopic endonasal (EE) surgery has provided an attractive alternative route to the traditional treatment algorithm, and it has the advantages of avoiding complications related to tongue swelling, tracheal swelling, prolonged intubation, velopharyngeal insufficiency, dysphagia, and dysphonia.We present a case of a 66-year-old man with no pertinent past medical history, who presented with progressive quadriparesis and gait ataxia over last 6 months (Nurick's grade 2). Neurological exam revealed pattern suggestive of high-cervical myelopathy with no evidence of cranial nerve paresis. Magnetic resonance imaging (MRI) of his CVJ revealed a large pannus behind the dens with severe spinal cord compression, mild contrast enhancement was noted posterior to the pannus, likely from the ligamentous structures; pannus was hypointense on both T1- and T2-weighted images. Further, a computerized tomography (CT) scan did not reveal any obvious malalignment. He underwent an EE odontoidectomy, followed by posterior cervical fusion. He had an unremarkable postoperative period and recovered fully from his myelopathy over the next 6 months. The histopathological examination of the pannus revealed a degenerated disk. In this video, we have a step by step description of the EE approach to the odontoid and discuss the surgical nuances. The link to the video can be found at: https://youtu.be/pjg68_vK0C4 .

Retrospective Study of Craniovertebral Junction (CVJ) Anomalies: A Clinical Profile and Outcome Analysis of Surgically Treated Patients

Craniovertebral junction (CVJ) is a complex anatomic region providing stability and mobility to the most important part of the craniospinal axis. The purpose of this study is to analyse clinical characteristics and outcome after surgical management of patients with CVJ anomalies presented to Neurosurgery department, Bir hospital Kathmandu Nepal. A retrospective analysis of 21 patients, managed surgically for craniovertebral instability between 2013 and 2017, was performed. Imaging studies were reviewed for bony and soft tissue details. Patients managed with posterior approach alone (either occipitocervical fusion or C1-2 fusion with or without bony decompression) were included in the study. Outcome was assessed by comparing pre and post operative Nurick grade. Most common causes of CVJ instability were non union of old odontoid fracture (38.1%)and OsOdontoidium (38.1%). 76.2% had intramedullary high signal intensities in T2 weighted MRI while 90% had cervicomedullary compression. Pre operatively, 52.38% had Nurick grading scale of 4 to 5 while 47.62%had 0-3 Nurick grade scale. Post operatively, 71.42% improved clinically, 23.80% remained unchanged while one patient deteriorated. Mean duration of follow up was 20.87 months (6-60 months). Pre operative Nurick grade was significantly associated with post operative outcome (p=0.042). Early surgical intervention is associated with better clinical outcome. Larger prospective study with clinical and radiological follow up is recommended.

Clinical and Radiographic Outcome of Patients With Cervical Spondylotic Myelopathy Undergoing Total Disc Replacement.

A nonrandomized, prospective, and single-center clinical trial. The aim of this study was to investigate the clinical and radiographic efficacy of ProDisc Vivo cervical total disc replacement (cTDR) in patients with clinical and radiographic documented cervical spondylotic myelopathy (CSM), due to degenerative changes at the index level. Decompression and fusion is still the gold standard in patients with cervical myelopathy. Very limited data are available regarding the application of cTDR in patients with clinical and radiological documented CSM in context of clinical and radiographic outcomes. Clinical outcome scores included the Neck Disability Index (NDI), Visual Analogue Scale (VAS), arm and neck pain self-assessment questionnaires as well as the Nurick grade and the Japanese Orthopaedic Association (JOA) score. The radiological outcome included the range of motion (ROM), the segmental and global (C2-C7) lordosis, and the occurrence of heterotopic ossifications. Eighteen consecutive patients (10 males, 8 females) with documented clinical and radiological signs of myelopathy were included in this investigation. The study population had a mean age of 52.4 years and a follow-up period of 20.3 months in average (range 3-48 months). The mean range ROM of the index level stayed consistent with 6.8° preoperatively and 7.2° (P = 0.578) at the last follow-up; the global lordosis in neutral position changed from 3.5° to 14.2° significantly (P = 0.005) in mean. The JOA score improved from 11.3 to 16.6 (P < 0.001) as well as the NDI 36.7 to 10.3 (P < 0.001) and the VAS score from 5.7/6.1 (arm/neck) to 1.3/2.0 (P < 0.001/P < 0.001). The mean Nurick grade was 1.33 preoperatively and dropped down in all cases to Nurick grade of 0 (P < 0.001). cTDR (with ProDisc Vivio) in patients with CSM yielded good clinical and radiographic outcomes and found as a reliable, safe, and motion-preserving surgical treatment option, although its indication is very limited due to numerous exclusion criteria. 4.

Thoracic spine ossified ligamentum flavum: single-surgeon experience of fifteen cases and a new MRI finding for preoperative diagnosis of dural ossification

Purpose: Ossification of ligamentum flavum (OLF) is an infrequent cause of thoracic spinal stenosis, mostly found in Japan and other East Asian countries, and uncommon in other populations. The incidence of dural ossification (DO) ranges from 11–62%. None of the previously described imaging findings can accurately diagnose DO preoperatively. Author reports outcomes of 15 cases of thoracic OLF from an Indian tertiary center, propose a new MRI finding to preoperatively diagnose DO and compare the various differences between subjects with and without DO.Methods: Three and half year retrospective analysis. Demographic, clinico-radiological and operative details, and outcome were analyzed. Correlation between new MRI finding and intraoperative DO was also noted.Results: Fifteen patients (10 males, 5 females) with mean age of 51.3 years were analyzed. Ten (66.6%) cases had DO and the new MRI finding (T2 ring sign) had high correlation with intraoperative DO (sensitivity of 90%, specificity of 100%). The T2 hypointense rim corresponds to the calcified/ossified dura present around the thecal sac. Important clinico-radiological differences were observed in patients with and without DO. Canal diameter was uniformly <5 mm in Nurick grade V cases and <9 mm in those with DO. Mean follow-up duration was 19.5 months (range 4–45 months). All, except one, had significant symptomatic improvement, however, only two patients with DO attained Nurick grade I, perhaps because of the poor preoperative Nurick grade in those patients.Conclusions: Decompressive laminectomy (till the normal interlaminar space caudally and cranially) with complete removal of flavum including ossified dura, if possible, is the ideal treatment. Even after significant improvement, patients with DO may have mild residual myelopathy. Presence of DO, CSF leak and myelomalacia are neither related to wound problems nor clinical improvement. Higher preoperative Nurick grade was consistently associated with good clinical recovery. T2 ring sign is of benefit to surgeons in preoperative diagnosis of DO.

Functional outcome of surgically managed cervical degenerative disease patients with anterior cervical discectomy &amp; fusion using standalone PEEK cages

Conservative management of cervical spondylosis comprises of analgesics, physiotherapy, traction, postural training and activity modification. Surgery is indicated when symptoms are not relieved or neurological deficits occur. Anterior cervical discectomy and fusion (ACDF) using a locking plate is the standard treatment for cervical spondylosis with prolapsed disc causing radicular or myelopathy symptoms. This study was undertaken to study outcomes of ACDF using standalone Polyethyl ether ketone (PEEK) cages without plate fixation. 9 operated patients were followed up for a minimum period of 6 months. 6 patients had radiculopathy and 3 had myelopathy. At 6 months all radiographs showed fusion. VAS reduced from an average 8.22 pre-op to 2.33 postoperatively. All myelopathy patients showed improvements in Nurick grade and mJOA scores. As per Odom’s criteria 5 patients showed excellent outcome, 2 patients had good outcome, 1 patient had fair outcome and 1 patient showed worsening.