Progressive Cervical Myelopathy Research Articles

Cervical Disc Arthroplasty Device Failure Causing Progressive Cervical Myelopathy and Requiring Revision Cervical Corpectomy.

Cervical disc arthroplasty is a well-established alternative to anterior cervical fusion but requires precise placement for optimal outcomes. We present the case of a 2-level cervical disc arthroplasty with suboptimal implantation of the interbody devices, requiring revision corpectomy. Supplemental video, Supplemental Digital Content 1 (http://links.lww.com/CLINSPINE/A358) content of the revision surgery is also provided. This report highlights the importance of proper implant sizing and position and reviews the nuances of surgical revision. A retrospective review of the clinical and radiographic data was performed from prior to the index operation through the 3-month postoperative period after the surgical revision. The patient presented approximately 2 years post-cervical arthroplasty with increasing neck pain and early cervical myelopathy. An imaging workup revealed severe cervical stenosis at the caudal level with cord compression and concern for device failure. Intraoperatively, the core of the caudal device was found to have ejected into the spinal canal. A cervical corpectomy of the intervening vertebra with the removal of both devices was performed. The patient had a complete neurologic recovery. Although failure of a cervical disc arthroplasty device is rare, the likelihood can be significantly increased with poor sizing (over or under sizing), asymmetric placement, endplate violation, or poor patient selection. In the case presented herein, early device failure was unrecognized, and the patient went on to develop progressive cervical myelopathy requiring revision corpectomy.

Circumferential Pannus at C1-C2 Causing Spinal Cord Compression

Periodontoid pannus formation is a pathologic condition caused by a multitude of different etiologies, however, it is most commonly due to rheumatoid arthritis. In these cases, the pannus is typically located in the retro-odontoid space ventral to the spinal cord, leading to progressive neural compression. We describe in this report, a patient who presented with progressive high cervical myelopathy, who on imaging revealed both a retro-odontoid pannus and a posterior C1-C2 mass causing severe circumferential compression of the spinal cord. The patient was successfully treated with a C1-C2 laminectomy and occipitocervical fusion. Periodontoid pannus is a common entity; however, the presence of a C1-C2 posterior pannus is a unique finding. To our knowledge, circumferential pannus at C1-C2 causing neural compression is a clinical entity that has not been previously reported.

Anterior vs Posterior Surgery for Patients With Degenerative Cervical Myelopathy: An Observational Study From the Canadian Spine Outcomes and Research Network.

The advantages and disadvantages of anterior vs posterior surgical approaches for patients with progressive degenerative cervical myelopathy (DCM) remain uncertain. Our primary objective was to evaluate patient-reported disability at 1 year after surgery. Our secondary objectives were to evaluate differences in patient profiles selected for each approach in routine clinical practice and to compare neurological function, neck and arm pain, health-related quality of life, adverse events, and rates of reoperations. We analyzed data from patients with DCM who were enrolled in an ongoing multicenter prospective observational cohort study. We controlled for differences in baseline characteristics and numbers of spinal levels treated using multivariable logistic regression. Adverse events were collected according to the Spinal Adverse Events Severity protocol. Among 559 patients, 261 (47%) underwent anterior surgery while 298 (53%) underwent posterior surgery. Patients treated posteriorly had significantly worse DCM severity and a greater number of vertebral levels involved. After adjusting for confounders, there was no significant difference between approaches for odds of achieving the minimum clinically important difference for the Neck Disability Index (odds ratio 1.23, 95% CI 0.82 to 1.86, P = .31). There was also no significant difference for change in modified Japanese Orthopedic Association scores, and differences in neck and arm pain and health-related quality of life did not exceed minimum clinically important differences. Patients treated anteriorly experienced greater rates of dysphagia, whereas patients treated posteriorly experienced greater rates of wound complications, neurological complications, and reoperations. Patients selected for posterior surgery had worse DCM and a greater number of vertebral levels involved. Despite this, anterior and posterior surgeries were associated with similar improvements in disability, neurological function, pain, and quality of life. Anterior surgery had a more favorable profile of adverse events, which suggests it might be a preferred option when feasible.

Facet Articular Irregularity Is the Most Relevant Risk Factor for Rapidly Progressive Degenerative Cervical Myelopathy.

Facet articular irregularity is associated with rapidly progressive degenerative cervical myelopathy (DCM). However, its significance compared with other known risk factors remains unknown. Therefore, this retrospective study aimed to clarify the potential impact of facet articular irregularity as a risk factor for rapid DCM progression. This study included 141 consecutive patients with DCM who underwent surgical treatment at our institution. Clinical variables and radiological findings related to DCM progression were collected. Imaging findings were analyzed at the segmental level of myelopathy in each case. The patients were divided into 2 groups based on the presence or absence of rapid DCM progression, and independent risk factors were determined using logistic regression analyses. Overall, 131 patients with a mean age of 63.9 ± 12.6 years were analyzed; 27 patients (20.6%) were classified into the rapid DCM progression group. The mean age was significantly higher in the rapid progression group than in the slow progression group (72.4 ± 9.6 vs. 61.7 ± 12.4, p < 0.001). According to univariate analysis, facet articular irregularity, dynamic segmental translation (≥ 1.6 mm), upper cervical spine involvement above C4-5, history of cerebrovascular events, preceding minor trauma, local lordotic angle (≥ 4.5°), diabetes, hypertension, ligamentum flavum hypertrophy, and age were independent risk factors. Additionally, multivariate analysis showed that facet articular irregularity was the highest risk factor for rapid DCM progression (p = 0.001). Facet articular irregularity is the most clinically significant finding among the known risk factors in patients with rapid DCM progression.

Surgical Management of Cervical Myelopathy: Current Algorithm

Cervical myelopathy (CM) is a progressive disorder associated with a varied spectrum of etiological factors. Cervical spondylotic myelopathy (CSM) encompasses two-thirds of the cases of CM, while ossified posterior longitudinal ligament (OPLL) and ossified ligamentum flavum (OLF) are significant regional etiological factors. Microvascular disruption, resulting from repetitive dynamic compression or static pressure to the spinal cord, is attributed as a primary pathophysiological mechanism for CM. Magnetic resonance imaging (MRI) is the investigation of choice to assess the spinal cord. Lateral cervical radiographs are crucial for lordosis assessment, and tomographic scans (CT) can delineate the extent of OPLL and OLF. Non-surgical treatment is usually not successful once the patient develops progressive myelopathy. Anterior cervical procedures are ideal for one or two level disc-osteophytes complexes or in patients with kyphotic cervical alignment. Laminoplasty is an effective motion-preserving option in patients with adequate cervical lordosis. Laminectomy or laminoplasty and fusion are optimal for patients with significant preoperative neck pain. Posterior surgery is preferred over anterior surgery for CM involving three or more levels. Older age at presentation, longer duration of symptoms, and severity of pre-operative symptoms are adverse prognostic factors. Progressive cervical myelopathy is a surgical disease, and early intervention is rewarded with better outcomes. Keywords: Cervical myelopathy, Cervical spondylotic myelopathy, OPLL, OLF, Laminoplasty, Laminectomy, ACDF, Cervical corpectomy.

Recovery from Progressive Cervical Myelopathy Following High-Voltage Electrical Injury

High-voltage electrical injuries are often life-threatening and can cause immediate and delayed neurologic complications. Here, we report a case of a 50-year-old male with progressive quadriplegia as a sequela of cervical myelopathy following high-voltage electrical injury and his recovery following multidisciplinary rehabilitation. The existing literature on the management of such neurological conditions is limited. While most of the available literature suggests no or minimal recovery, our patient had significant improvement following IV steroids and an early rehabilitation programme. He was reintegrated into the community successfully.

Composite hemangioendothelioma in the cervical spine with kaposiform hemangioendothelioma features in an elderly patient: a case report.

Composite hemangioendothelioma (CHE) is an intermediate group of tumors with features between hemangioma and angiosarcoma both histologically and biologically. CHE is predominant in young and middle-aged adults, but very infrequently affects the spine. We describe the case of primary CHE in the cervical spine exhibiting kaposiform hemangioendothelioma (KHE)-like components that was associated with cervical myelopathy with vertebral body destruction in an elderly woman. We retrospectively reviewed the case of a primary cervical spinal tumor, diagnosed as CHE with KHE-like components in pathological findings, associated with cervical myelopathy and cervical vertebral body destruction. An 80-year-old woman presented with progressive cervical myelopathy caused by a cervical spine tumor. Preoperative cervical MRI revealed a neoplastic lesion invading the cervical spine that strongly compressed the spinal cord, causing right upper-limb paralysis. We performed partial tumor resection along with posterior decompression and fixation. Postoperatively, pathological findings showed that the tumor was CHE with KHE-like features. Following radiotherapy, no recurrences have been observed in 21 months. This is the first report of CHE with features of KHE in the spine of an elderly patient. Posterior decompression and fusion of the cervical spine and subsequent radiotherapy resulted in a good outcome.

Massive Obstruction of the Spinal Canal and Progressive Cervical Myelopathy due to Osseous Hypertrophy of a Facet Joint: A Case Report

Introduction: Cervical spondylotic myelopathy is one of the most common causes of cervical spinal cord dysfunction. Case Report: A 65-year-old patient was admitted with slowly-progressing myelopathic symptoms. Imaging studies indicated a massive lesion, which was thought to be a primary bone tumor. Resection at Segment C4 was performed, and histopathology showed hypertrophic facet joint. Discussion: Age-related degenerative changes and adaptation mechanisms result in hypertrophy of the joint and synovial cyst formation. In our case, it was enormous, and could be easily mistaken for a tumorous process. Conclusion: Such extensive hypertrophic changes are rarely addressed in the literature and should be considered as differential diagnosis.

Progressive Cervical Myelopathy With Medullary Involvement as a Presentation of Dural Arteriovenous Fistula.

HomeStrokeVol. 53, No. 12Progressive Cervical Myelopathy With Medullary Involvement as a Presentation of Dural Arteriovenous Fistula No AccessCase ReportRequest AccessFull TextAboutView Full TextView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toNo AccessCase ReportRequest AccessFull TextProgressive Cervical Myelopathy With Medullary Involvement as a Presentation of Dural Arteriovenous Fistula Francisco Millet Barros, MD, Rita Machado, MD, Diogo Carneiro, MD, Helena Gens, MD and Gustavo Cordeiro Santo, MD Francisco Millet BarrosFrancisco Millet Barros Correspondence to: Francisco Millet Barros, MD, Serviço de Neurologia, Centro Hospitalar e Universitário de Coimbra, Praceta Professor Mota Pinto, 3004-561, Coimbra, Portugal. Email E-mail Address: [email protected] https://orcid.org/0000-0003-3962-3080 Department of Neurology, Centro Hospitalar e Universitário de Coimbra, Portugal. Search for more papers by this author , Rita MachadoRita Machado https://orcid.org/0000-0003-3605-277X Department of Neurology, Centro Hospitalar e Universitário de Coimbra, Portugal. Search for more papers by this author , Diogo CarneiroDiogo Carneiro https://orcid.org/0000-0001-8912-4736 Department of Neurology, Centro Hospitalar e Universitário de Coimbra, Portugal. Search for more papers by this author , Helena GensHelena Gens Department of Neurology, Centro Hospitalar e Universitário de Coimbra, Portugal. Search for more papers by this author and Gustavo Cordeiro SantoGustavo Cordeiro Santo https://orcid.org/0000-0002-8353-6913 Department of Neurology, Centro Hospitalar e Universitário de Coimbra, Portugal. Search for more papers by this author Originally published27 Sep 2022https://doi.org/10.1161/STROKEAHA.122.040163Stroke. 2022;53:e515–e516"Progressive Cervical Myelopathy With Medullary Involvement as a Presentation of Dural Arteriovenous Fistula." Stroke, 53(12), pp. e515–e516FootnotesFor Disclosures, see page e516.Presented in part at the 8th Congress of the European Academy of Neurology, Vienna, Austria, June 25–28, 2022.Correspondence to: Francisco Millet Barros, MD, Serviço de Neurologia, Centro Hospitalar e Universitário de Coimbra, Praceta Professor Mota Pinto, 3004-561, Coimbra, Portugal. Email [email protected]com

Operative Technique for Resection of a Ventral Transdural Retro-Odontoid Pannus: A 2-Dimensional Operative Video

Retro-odontoid pseudotumors are rare inflammatory complications of atlantoaxial instability often associated with cervical degenerative disease and rheumatoid arthritis. While propagation of these lesions has been shown to cause spinal cord compression and cervical myelopathy, intradural extension has rarely been reported. In this manuscript and 2-dimensional illustrative intraoperative video, we demonstrate cervical decompression, removal of the intradural component, and stabilization with C1-2 instrumentation using a posterior approach. A 71-year-old patient presented with progressive cervical myelopathy. Preoperative imaging demonstrated a large retro-odontoid pannus causing severe spinal cord compression and an associated contrast-enhancing intradural lesion, in the absence of obvious C1-2 instability or fractures on computed tomography scan. C1-2 posterior decompression and fusion were performed with maximally safe intradural pannus resection and ventral dural reconstruction. Postoperatively, the patient experienced significant improvement in myelopathic symptoms. Imaging demonstrated good spinal cord decompression with complete intradural pannus resection and debulking of the extradural component. Our outcome in this rare complication suggests a posterior approach may be effective in treating similar patients.

P14. Outcome and predictive factors in rapid progressive cervical spondylotic myelopathy: A retrospective case control study

<h3>BACKGROUND CONTEXT</h3> Cervical spondylotic myelopathy (CSM) is a major cause of cervical spinal cord dysfunction in people over 55 years of age. Most patients with CSM usually present with chronic and phased compression, however, some patients with CSM develop rapid severe neurological dysfunction without any trauma. To our knowledge, markers that can be used for early identi cation of patients with potential to develop rapid neurological deterioration have not been totally identified. <h3>PURPOSE</h3> Here, we evaluate epidemiological, clinical and radiographic features associated with the development and prognosis of rapid progressive cervical spondylotic myelopathy (rp-CSM). <h3>STUDY DESIGN/SETTING</h3> Retrospective study <h3>PATIENT SAMPLE</h3> A total of 175 patients. <h3>OUTCOME MEASURES</h3> Modified Japanese Orthopaedic Association (mJOA) score, Torg-Pavlov Ratio (TPR), intervertebral disc level compression ratio and increased signal intensity (ISI) on T2W1. <h3>METHODS</h3> A retrospective study was carried out for 175 patients diagnosed with CSM between March 2011 and January 2017 at West China Hospital. Patients were divided into rp-CSM group and chronic CSM (c-CSM) group based on the time taken for neurological deterioration to occur and the severity of preoperative neurological dysfunction. The clinical outcomes were assessed using the Modified Japanese Orthopaedic Association (mJOA) score, and imaging parameters such as Torg-Pavlov Ratio (TPR), intervertebral disc level compression ratio and increased signal intensity (ISI) on T2W1. Multivariate analysis was used to compare the outcomes between the two groups and identify potential predictors for rapid neurological dysfunction in CSM patients. <h3>RESULTS</h3> Out of the 175 patients enrolled in the study, 25 developed rp-CSM (18 males; median age 59.04 ± 12.81 years) and the remaining 75 (54 males; median age 56.88 ± 12.31 years) were used as controls for the study (c- CSM group). The average time taken to develop severe neurological deterioration was 0.8 month in rp-CSM group and 24-month in c-CSM group (p = 0.001), while the preoperative mJOA scores were 6 in rp-CSM patients and 12 in c-CSM patients (p = 0.014). In addition, rp-CSM patients demonstrated worse outcomes than the controls in one year after surgery (mJOA improvement rate 54.5% and 80%, respectively, p = 0.021). There were no differences in the clinical parameters evaluated between the two groups except for the history of diabetes and smoking. Analysis of radiographic parameters indicated that TPR MRI, intervertebral disc level compression ratio and increased signal intensity (ISI) on T2W1 were poor in rp-CSM patients compared to c-CSM patients. Regression analysis also showed that the history of diabetes, TPR MRI < 0.4, compression ratio ≥50%, and the sagittal diameter of ISI ≥ 50% of spinal canal diameter on T2W1 were strongly associated with the rapid progressive neurological dysfunction in patients with CSM. <h3>CONCLUSIONS</h3> The prognosis of rapid progressive CSM is worse than that of common chronic CSM. The rapid neurological deterioration can be identified by TPR MRI (<0.4), compression ratio (≥50%), sagittal diameter of ISI (≥50% of spinal canal diameter). Besides, a history of diabetes is a risk factor for the development of rp-CSM. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Posterior Surgical Approach for Ventral Cervical Spinal Cord Herniation: 2-Dimensional Operative Video.

Spinal cord herniation (SCH) is a rare condition that is typically of idiopathic origin. Although SCH is mostly found in the thoracic region because of a dural defect, there are some reports of cervical SCH following surgery or trauma.1-3 Spinal cord tethering can be a result of SCH or as a standalone issue.4,5 These conditions can lead to progressive neurological deficits, including numbness, gait disturbances, and decreased muscle strength, requiring surgical correction. There are limited reports of surgical procedures for ventral SCHs. Several reports exist using a ventral approach for intradural tumors, but it is not commonly employed because of the inability to obtain adequate dural closure.6 Much of the literature on SCH comes from idiopathic and congenital cases in the thoracic spine.7,8 Posterior and posterolateral approaches for a ventral thoracic SCH have been described, as well as an anterior approach for a ventral cervical SCH.9-12 In this video, we describe a posterior approach for a ventral cervical SCH. A 38-yr-old male presented with progressive cervical myelopathy 9 yr after a C2-C3 schwannoma resection requiring an anterior approach and corpectomy of C3 with partial corpectomies of C2 and C4. A preoperative magnetic resonance imaging showed a ventrally herniated spinal cord at the top of the C3 vertebral body and below the C4 vertebral body. Informed consent was obtained. The posterior surgical approach involved a C1-C5 laminectomy, sectioning the dentate ligament, ventral cord untethering, removal of residual tumor, and placement of a ventral sling. A significant improvement in sensory and motor function was observed postoperatively.

Risk factors for rapid progressive neurological deterioration in patients with cervical spondylotic myelopathy

BackgroundThe rapid progressive cervical spondylotic myelopathy (rp-CSM) which had a course of CSM less than 1 month and suffered rapidly progressive neurological deterioration had few reports. Therefore, it is important for us to recognize the pathophysiology of CSM especially the rp-CSM. The study aimed to investigate the risk factors for rapidly progressive (rp) neurological deterioration in patients with cervical spondylotic myelopathy (CSM).MethodsA total of 159 patients were reviewed and divided into an rp-CSM group and a chronic-CSM (c-CSM) group. Various clinical indexes, including age, sex, Japanese Orthopaedic Association (JOA) score, intramedullary MR T2-hyperintensity, congenital/degenerative spinal stenosis, and local type of ossification of the posterior longitudinal ligament (OPLL), were analyzed, and independent risk factors were investigated.ResultsThirty-four of 159 patients (21.4%) were diagnosed with rp-CSM. All patients were followed up for a mean of 68.56 ± 14.00 months in the rp-CSM group and 62.66 ± 19.95 months in the c-CSM group. No significant difference was found in sex, mean age, smoking and drinking status, diabetes mellitus (DM), hypertension, surgery time, blood loss, JOA score, degenerative spinal stenosis, or OPLL (local). Univariate analyses demonstrated that rp-CSM patients tended to have MR T2-hyperintensity, longer hospital stay, shorter waiting time for surgery, more congenital spinal stenosis, and worse neurological function and to prefer more posterior surgeries than c-CSM patients. A multiple logistic regression analysis showed that congenital spinal stenosis and MR T2-hyperintensity were independently related to the presence of rp-CSM.ConclusionsMR T2-hyperintensity and congenital spinal stenosis were risk factors for rp-CSM. Although neurological function deteriorates rapidly, early surgical decompression is recommended and can achieve good neurological recovery after surgery, indicating that rp-CSM could be a reversible condition.

Far Lateral Transcondylar Transtubercular Approach for Microsurgical Resection of Foramen Magnum Meningioma: Operative Video and Technical Nuances.

Surgical access to the ventral foramen magnum remains a technical challenge. With large lesions in this region compressing the brainstem and distorting the regional neurovascular relationships, formulating a surgical plan and its appropriate execution have crucial importance in achieving favorable outcomes. While the endoscopic endonasal approaches have gained increasing attention to access the clivus and the ventral brainstem, foramen magnum meningiomas are still preferred to be removed via an approach that obviates a trajectory through the nasopharyngeal mucosa. Therefore, the far lateral approach remains one of the most practical approaches for these challenging lesions. This operative video demonstrates the use of the far lateral transcondylar transtubercular approach to remove a large meningioma in the ventral foramen magnum in a 63-year-old male with progressive cervical myelopathy, presenting as spastic quadriparesis without any cranial nerve abnormality. Using a right-sided far lateral transcondylar transtubercular approach, the meningioma was exposed within the cerebellomedullary gutter engulfing the vertebral artery and distorting the course of the adjacent cranial nerves. Using the different corridors identified between the vertebral artery, spinal accessory, vagus, and hypoglossal nerves, multiple angles of attacks to the tumor were established and utilized to resect the lesion. A gross total resection was achieved and the patient was neurologically intact without any neurological deficits. This video demonstrates the importance of understanding the intricacies of neurovascular anatomy of the cervicomedullary region (i.e., the various triangles formed between these structures), and the effective use of these corridors to safely and efficiently remove a challenging ventral foramen magnum meningioma with neurovascular involvement, while preserving cranial nerve function. The surgical technique and nuances are described in a step-by-step fashion in this illustrative operative video. The link to the video can be found at: https://youtu.be/s1dFhuaRSt8 .

Degenerative Cervical Myelopathy: Pathophysiology and Current Treatment Strategies.

Chronic compression or ischemia of the spinal cord in the cervical spine causes a clinical syndrome known as cervical myelopathy. Recently, a new term “degenerative cervical myelopathy (DCM)” was introduced. DCM encompasses spondylosis, intervertebral disk herniation, facet arthrosis, ligamentous hypertrophy, calcification, and ossification. The pathophysiology of DCM includes structural and functional abnormalities of the spinal cord caused by static and dynamic factors. In nonoperative patients, cervical myelopathy has a poor prognosis. Surgical treatments, such as anterior or posterior decompression accompanying arthrodesis, arthroplasty, or laminoplasty, should be considered for patients with chronic progressive cervical myelopathy. Surgical decompression can prevent the progression of myelopathy and improve the neurologic status, functional outcomes, and quality of life, irrespective of differences in medical systems and sociocultural determinants of health. The anterior surgical approach to the cervical spine has the advantage of removing or floating the intervertebral disk, osteophytes, and ossification of the posterior longitudinal ligament that compress the spinal cord directly. The posterior surgical approach to the cervical spine is mainly used for multisegment spinal cord compression in patients with cervical lordosis. In this review article, we addressed the pathophysiology, clinical manifestations, differential diagnosis, and treatment options for DCM.

Cervical myelopathy caused by ventrally located atlanto-axial synovial cysts: An open quest for the safest and most effective surgical management. Case series and systematic review of the literature

Summary of background dataDespite a good understanding of the natural history of spinal synovial cysts (SCs), a widespread agreement regarding their optimal management is still lacking. This is particularly true for SCs occurring at the C1-C2 level, which are rare, but oftentimes lead to a rapidly evolving cervical myelopathy. MethodsWe report a series of 4 patients (M:F ratio=1:1; mean age 63.5 years) presenting with progressive cervical myelopathy secondary to ventrally located C1-C2 SCs. All patients underwent a postero-lateral facet-sparing intradural approach with total excision of the SCs. Functional status was assessed pre- and postoperatively with Nurick scale and the modified Japanese Orthopaedic association grading. Furthermore we conducted a systematic review, following PRISMA guidelines of pertinent literature to contextualize the options for surgical management of such lesions. ResultsComplete excision of the SCs was confirmed radiologically and on histological analysis. All measures of functional status improved post-operatively, and no cyst recurrence or need for instrumented fusion were noted during follow up (range from 22 to 88 months). ConclusionOur experience suggests that the facet-sparing intradural approach provides excellent clinical outcomes without causing any C1–C2 instability. This is in keeping with the take home message emerging from our literature review, which confirms that treatment should aim at radical resection of SCs while minimizing the risk of postoperative instability.

Outcome and predictive factors in rapid progressive cervical spondylotic myelopathy: A retrospective case-control study

BackgroundCervical spondylotic myelopathy (CSM) is a major cause of cervical spinal cord dysfunction in people over 55 years of age. Most patients with CSM usually present with chronic and phased compression, however, some patients with CSM develop rapid severe neurological dysfunction without any trauma. To our knowledge, markers that can be used for early identification of patients with potential to develop rapid neurological deterioration have not been totally identified. Here, we evaluate epidemiological, clinical and radiographic features associated with the development and prognosis of rapid progressive cervical spondylotic myelopathy (rp-CSM). MethodsA retrospective study was carried out for 175 patients diagnosed with CSM between March 2011 and January 2017 at West China Hospital. Patients were divided into rp-CSM group and chronic CSM (c-CSM) group based on the time taken for neurological deterioration to occur and the severity of preoperative neurological dysfunction. The clinical outcomes were assessed using the Modified Japanese Orthopaedic Association (mJOA) score, and imaging parameters such as Torg-Pavlov Ratio (TPR), intervertebral disc level compression ratio and increased signal intensity (ISI) on T2W1. Multivariate analysis was used to compare the outcomes between the two groups and identify potential predictors for rapid neurological dysfunction in CSM patients. ResultsOut of the 175 patients enrolled in the study, 25 developed rp-CSM (18 males; median age 59.04 ± 12.81 years) and the remaining 75 (54 males; median age 56.88 ± 12.31 years) were used as controls for the study (c-CSM group). The average time taken to develop severe neurological deterioration was 0.8 month in rp-CSM group and 24 month in c-CSM group (p = 0.001), while the preoperative mJOA scores were 6 in rp-CSM patients and 12 in c-CSM patients (p = 0.014). In addition, rp-CSM patients demonstrated worse outcomes than the controls in one year after surgery (mJOA improvement rate 54.5 % and 80 %, respectively, p = 0.021). There were no differences in the clinical parameters evaluated between the two groups except for the history of diabetes and smoking. Analysis of radiographic parameters indicated that TPR MRI, intervertebral disc level compression ratio and increased signal intensity (ISI) on T2W1 were poor in rp-CSM patients compared to c-CSM patients. Regression analysis also showed that the history of diabetes, TPR MRI < 0.4, compression ratio ≥50 %, and the sagittal diameter of ISI ≥ 50 % of spinal canal diameter on T2W1 were strongly associated with the rapid progressive neurological dysfunction in patients with CSM. ConclusionThe prognosis of rapid progressive CSM is worse than that of common chronic CSM. The rapid neurological deterioration can be identified by TPR MRI (<0.4), compression ratio (≥50 %), sagittal diameter of ISI (≥50 % of spinal canal diameter). Besides, a history of diabetes is a risk factor for the development of rp-CSM.

Calcium pyrophosphate deposition disease of the cervical and thoracolumbar spine: A report of two cases

BackgroundSpinal calcium pyrophosphate deposition disease (CPPD) is uncommon, and often resembles more common spine pathologies causing pain and neural compression. Here, we present two unusual cases of CPPD of the cervical and thoracolumbar spines. Case descriptionCase 1: A 71-year old female smoker presented with a large epidural mass causing rapidly progressive cervical myelopathy with weakness in the upper and lower extremities.Case 2: A 66-year-old morbidly obese male presented with chronic back pain for several years associated with progressively worsening radicular pain in his left lower extremity. OutcomeThe first case is an example of tumoral CPPD involving the facet joint and expanding into the epidural space. The second case was an example of CPPD involving a thoracolumbar facet cyst, resulting in unilateral radiculopathy. Both patients were treated surgically and had significant improvement in symptoms post-operatively. ConclusionsCPPD in the spine is an uncommon diagnosis but should be considered in the differential diagnosis of patients presenting with back pain and associated neurological symptoms. Accurate diagnosis of spinal CPPD is important in that it will guide postoperative management with anti-inflammatory medications and reduce risk of recurrence.

Is C2-3 fusion an evidence of atlantoaxial instability? An analysis based on surgical treatment of seven patients.

Objective:The authors analyze the rationale of atlantoaxial fixation in patients presenting with symptoms related to cervical myelopathy and wherein the radiological images depicted C2–3 fusion and presence of single or multiple level neural compression of the subaxial cervical spinal cord attributed to “degenerative” spine.Materials and Methods:Seven adult males were analyzed who presented with long-standing symptoms of progressive cervical myelopathy and where imaging showed presence of C2–3 fusion, no cord compression related to odontoid process, and evidence of single or multiple level lower cervical cord compression conventionally attributed to spinal degeneration. There was no other bone or soft tissue abnormality at the craniovertebral junction. There was no evidence of atlantoaxial instability when assessed by conventional radiological diagnostic parameters. Atlantoaxial instability was diagnosed on the basis of clinical understanding, atlantoaxial facetal malalignment, and manual assessment of instability by bone handling during surgery. All the seven patients underwent atlantoaxial fixation and no surgical manipulation at lower cervical spinal levels.Results:At an average follow-up of 34 months, all patients have recovered satisfactorily in their neurological function.Conclusion:The presence of C2–3 fusion is an indication of atlantoaxial instability and suggests the need for atlantoaxial stabilization. Effects on the subaxial spine and spinal cord are secondary events and may not be surgically addressed.

The effect of length of follow-up on substantial clinical benefit thresholds in patients undergoing surgery for cervical degenerative myelopathy

Patient-reported outcome measures are increasingly used to access pain, disability, physical function, and mental status to quantify effectiveness of surgical intervention in cervical myelopathy, yet each score has little meaning without established thresholds linked to clinical benefit. We set out to develop thresholds for substantial clinical benefit (SCB) in patients undergoing surgery for cervical myelopathy and to evaluate the effect of length of follow-up on SCB thresholds.Thirty-five patients undergoing spinal surgery for progressive cervical myelopathy were tracked from 2005 to 2015. Observations were categorized into three groups: short-term, intermediate, and long-term, corresponding to average follow-up intervals of 3.8, 9.2, and 29.0 months. SCB thresholds were calculated for neck visual analog score (VAS), Neck Disability Index (NDI), Short Form-12 physical (PCS), SF-12 mental component scores (MCS), and modified Japanese Orthopedic Association score (mJOA) using receiver operating curve analysis with a 5-level patient satisfaction index as the anchor.SCB thresholds for each outcome measure were obtained with a range of areas under the curve indicating varying degrees of discriminatory ability, reported with increasing length of follow-up. NDI and PCS were most discriminatory of SCB at any time period. Stratification of thresholds by length of time revealed a significant effect of follow-up time with NDI but not PCS.NDI and PCS thresholds have significantly strong discriminatory value in identifying patients receiving substantial clinical benefit with regard to cervical myelopathy. When NDI is used to predict outcome, choosing thresholds calibrated for follow-up time is recommended to maximize predictive power.