Surgery For Cervical Spondylotic Myelopathy Research Articles

Bilateral C5 Palsy Following A Circumferential Surgery for Cervical Spondylotic Myelopathy: A Case Report and Review

Background and Importance: The development of C5 root palsy is a well-known potential complication of cervical spine surgeries for the correction of cervical spondylotic myelopathy. It typically occurs unilaterally, but on extremely rare occasions, bilaterally. The value of intraoperative neurophysiologic monitoring in detecting iatrogenic acute versus delayed onset C5 palsy, the rarity of bilateral C5 palsy, and its optimal management require further discussion. Case Presentation: A 49-year-old woman with quadriparesis due to cervical spondylotic myelopathy is presented. She underwent circumferential 360° cervical spine surgery. This operation was subsequently complicated by a delayed bilateral C5 palsy, despite normal transcranial motor evoked potentials (MEPs). With the utilization of conservative treatment, the complete resolution of this complication took roughly eight months. Conclusion: Bilateral C5 palsy is an infrequent consequence of multilevel cervical spine surgeries. Although intraoperative monitoring of transcranial electrical stimulation-induced MEPs has high sensitivity and specificity in foreseeing the acute-onset C5 palsy, it cannot predict delayed-onset palsy. Including the current case, only seven cases have been reported in the medical literature. Overall, conservative management in adherence to rigorous physical therapy may be an acceptable treatment.

Factors Affecting Postoperative Complications and Outcomes of Cervical Spondylotic Myelopathy with Cerebral Palsy : A Retrospective Analysis.

ObjectiveCervical surgery in patients with cervical spondylotic myelopathy (CSM) and cerebral palsy (CP) is challenging owing to the complexities of the deformity. We assessed factors affecting postoperative complications and outcomes after CSM surgery in patients with CP. MethodsThirty-five consecutive patients with CP and CSM who underwent cervical operations between January 2006 and January 2014 were matched to 35 non-cerebral palsy (NCP) control patients. Postoperative complications and radiologic outcomes were compared between the groups. In the CP group, the Japanese Orthopaedic Association score; Oswestry neck disability index; modified Barthel index; and values for the grip and pinch, Box and Block, and Jebsen-Taylor hand function tests were obtained preand postoperatively and compared between those with and without postoperative complications. ResultsSixteen patients (16/35%) in the CP group and seven (7/35%) in the NCP group (p=0.021) had postoperative complications. Adjacent segment degeneration (p=0.021), postoperative motor weakness (p=0.037), and revisions (p=0.003) were significantly more frequent in the CP group than in the NCP group; however, instrument-related complications were not significantly higher in the CP group (7/35 vs. 5/35, p=0.280). The number of preoperative fixed cervical deformities were significantly higher in CP with postoperative complications (5/16 vs. 1/19, p=0.037). In the CP group, clinical outcomes were almost similar between those with and without postoperative complications. ConclusionThe occurrence of complications during the follow-up period was high in patients with CP. However, postoperative complications did not significantly affect clinical outcomes.

227. Continued improvement in functional gait and balance parameters to one year following decompression surgery for cervical spondylotic myelopathy

<h3>BACKGROUND CONTEXT</h3> Cervical spondylotic myelopathy (CSM) tends to produce a progressive decline in function characterized by gait disturbance, worsening balance and loss of upper extremity dexterity. Traditionally, the goal of decompressive surgery for CSM was to arrest neurological deterioration and prevent further disability rather than to provide functional recovery. In recent years, studies utilizing functional outcome measurements (FOMs) have demonstrated objective improvements in gait and balance dysfunction out to three months after surgery for CSM, but 1-year follow-up has yet to be reported. <h3>PURPOSE</h3> To determine whether the trends in improvements in gait, balance, pain levels, and psychological profiles observed at three months after cervical decompression for CSM continue out to one year postoperatively. <h3>STUDY DESIGN/SETTING</h3> Prospective, concurrent control cohort study. <h3>PATIENT SAMPLE</h3> The study included 22 symptomatic CSM patients, 20 age-matched healthy control volunteers (C). <h3>OUTCOME MEASURES</h3> Gait and balance parameters, neck disability index (NDI), Visual analog scale (VAS) neck, and psychological measures – Tampa Scale for Kinesiophobia (TSK) and Fear Avoidance Beliefs Questionnaire (FABQ). <h3>METHODS</h3> Patients performed gait and balance evaluations prior to surgery (Pre) and at 3 months (Post3) and 12 months (Post12) postoperatively. Functional data were recorded and analyzed using human motion capture and dynamic surface EMG. Patients also completed outcomes questionaries at the same time points. Repeated measurements and one-way analysis of variance (ANOVA) were used to analyze data. <h3>RESULTS</h3> Continued improvement in multiple gait parameters was observed out to one year postoperatively: faster walking speed (Post3: 0.92 vs Post12: 0.99 m/s, p=0.048; C: 1.02 m/s, p>0.050), shorter step time (Post3: 0.44 vs Post12: 0.42 s, p=0.041; C: 0.42 s, p>0.050), and longer step length (Post3: 0.52 vs Post12: 0.55, p=0.048; C: 0.57, p>0.050). Additional gains in balance occurred between 3 and 12 months: head total sway (Post3: 57.70 vs Post12: 51.35 cm, p=0.045 cm; C: 46.42, p>0.050) as well as cone of economy (CoE) dimensions in the coronal plane for both the head (Post3: 3.14 vs Post12: 2.55 cm, p=0.037 cm; C: 2.19, p>0.050) and center of mass (Post3: 2.11 vs Post12: 1.85 cm, p=0.034 cm; C: 1.64, p>0.050). There were significant improvements in all PROMs after surgery: VAS neck (Pre: 5.4, Post3, 2.1, Post12 1.3, p<0.021) and NDI (Pre: 44.6, Post3: 28.5, Post12 20.1, p=0.032). Progressive improvements were observed in TSK and FABQ scores (p<0.050). <h3>CONCLUSIONS</h3> This study reports objective functional measures and psychological outcomes in addition to standard patient-reported outcome measures for CSM patients out to one year postoperatively, thereby providing a comprehensive global assessment of their recovery. Select measures of gait and balance improved at all time points postoperatively and ultimately resembled those of the healthy controls at one year. These results provide important insight regarding the continued recovery that occurs between 3 and 12 months after surgical decompression for CSM. In turn, this information enriches the discussion surgeons can have with patients before and after surgery. FOMs provide both clinicians and patients with a more detailed and sensitive assessment of overall treatment outcomes and the timeframe of functional recovery. <h3>FDA DEVICE/DRUG STATUS</h3> This abstract does not discuss or include any applicable devices or drugs.

Risk Factors for Cervical Deformity After Posterior Cervical Decompression Surgery: A Multicenter Study.

Retrospective multicenter study. Posterior decompression surgery for cervical spondylotic myelopathy (CSM) and ossification of the posterior longitudinal ligament (OPLL) is a common surgery; however, it can cause postoperative cervical deformity (CD). The purpose of this study was to investigate the risk factors for CD. The participants were 193 patients underwent laminoplasty or laminectomy for CSM or OPLL. CD was defined as a C2-7 sagittal vertical axis (SVA) ≥ 40 mm or a cervical lordosis angle (CL) ≤ -10°. The participants were divided into 2 groups: NCD (without CD before surgery), CD (with CD before surgery). NCD group was divided based on the presence of CD 1 year after surgery as follows: postoperative CD (PCD) and no PCD (NPCD). There were 153 patients (NCD), 40 (CD), 126 (NPCD), and 27 (PCD). There was significant difference in the number of decompressed lamina (NPCD: PCD = 4.1:4.5), the presence of C2 decompression (2: 11%), and C5 palsy (0: 11%). The risk factors for onset of CD, PCD, and CL ≤ -10° as assessed by multiple logistic regression analysis were preoperative C2-7 SVA ≥ 30 mm (odds ratio [OR]: 19.0), decompression of C2 or C7 lamina (OR 3.1), and preoperative CL ≤ 2° (OR 42.0), respectively. To prevent postoperative CD, it is important to avoid decompression of the C2 or C7 lamina. Moreover, in case with C2-7 SVA ≥ 30 mm or CL ≤ 2° before surgery, it is important to explain the risks and consider adding fusion surgery.

Postdecompressive spinal cord blood flow increments in a cervical chronic myelopathy model in rats.

In cervical spondylotic myelopathy (CSM), compromise of blood flow to the compressed spinal cord has been postulated to contribute to the development of myelopathy. Although decompressive surgery has been considered to improve spinal cord blood flow, evidence to support this notion is scarce. To determine whether blood flow improves after decompressive surgery for CSM, regional blood flow was measured in a model of chronic cervical compression in rats by using a fluorescent microsphere technique. Thin polyurethane sheets, measuring precisely 3 × 5 × 0.7 mm, were implanted under the C5-6 laminae in 24 rats to induce continuous compression on the cervical spinal cord. These sheets expand gradually by absorbing tissue fluid. This animal model has been demonstrated to reproduce the clinical features and histological changes of CSM, including progressive motor weakness with delayed onset and insidious tissue damage prior to symptom onset. Twenty-four rats that underwent sham operation were allocated to a control group. To confirm the development of cervical myelopathy, motor functions were measured weekly over the study period. Nine weeks after implantation of the sublaminar expanding sheets, histological studies and C5-6 decompressive surgery were conducted. Regional blood flow in the brainstem and cervical spinal cord was measured sequentially until 120 minutes after decompression. In the CSM group, bilateral forepaw grip strength deteriorated progressively from 5 weeks after implantation. In the compressed C5-6 segment of the spinal cord, significant flattening of the cord, a decreased number of motor neurons, and vacuolations of gray matter were demonstrated. In the control group, blood flow in the brainstem and cervical spinal cord was unchanged by the decompressive surgery. In the CSM group, however, diminished blood flow and continuous blood flow increments for 120 minutes after decompression were demonstrated in the compressed C5-6 spinal cord segment. Chronic mechanical compression induced regional spinal cord blood flow insufficiency concomitant with progressive neuronal loss and motor dysfunction in a chronic compression model in rats. Decompressive surgery increased spinal cord blood flow. These findings suggest that blood flow recovery may contribute to postoperative neurological improvement.

경추증성 척수증에 대한 수술에서 재관류손상의 수술중신경계감시

Neurologic deficit after cervical decompressive surgery for cervical spondylotic myelopathy is a rare but critical complication. Spinal cord reperfusion injury is one of the major causes of sudden neurologic deterioration associated with the surgery. If reperfusion injury occurs during the surgery, intraoperative neurophysiologic monitoring is essential for early diagnosis and intervention including surgical modification and maintaining proper mean blood pressure to reverse the neurologic damage. We review reperfusion injury in surgery for cervical spondylotic myelopathy.

Spinal Cord Drift Following Laminoplasty Versus Laminectomy and Fusion for Cervical Spondylotic Myelopathy.

Cervical laminoplasty and laminectomy and fusion (LF) are posterior-based surgical techniques for the surgical treatment of cervical spondylotic myelopathy (CSM). Interestingly, the comparative amount of spinal cord drift obtained from these procedures has not been extensively described. The purpose of this study is to compare spinal cord drift between cervical laminoplasty and LF in patients with CSM. The laminoplasty group consisted of 22 patients, and the LF group consisted of 44 patients. Preoperative and postoperative alignment was measured using the Cobb angle (C2-C7). Spinal cord position was measured on axial T2-magnetic resonance imaging of the cervical spine preoperatively and postoperatively. Spinal cord drift was quantified by subtracting preoperative values from postoperative values. Functional improvement was assessed using the modified Japanese Orthopaedic Association (mJOA) score. Mean spinal cord drift was higher following LF compared to laminoplasty (2.70 vs 1.71 mm, P < .01). Using logistic regression analysis, there was no correlation between sagittal alignment and spinal cord drift. Both groups showed an improvement in mJOA scores postoperatively compared to their preoperative values (laminoplasty, +2.0, P = .012; LF, +2.4, P < .01). However, there was no difference in mJOA score improvement postoperatively between both groups (P = .482). This study demonstrates that patients who had LF for CSM achieved more spinal cord drift postoperatively compared to those who had laminoplasty. However, the increased drift did not translate into superior functional outcome as measured by the mJOA score. 3. Spinal cord drift following LF may differ from laminoplasty in patients undergoing surgery for CSM. This finding should be considered when assessing CSM patients for surgical intervention.

Pattern and Rate of Functional Recovery After Surgery for Cervical Spondylotic Myelopathy: Egyptian Prospective Study

To study pattern and rate of neurological functional recovery after surgery for cervical spondylotic myelopathy (CSM). This prospective study comprised 25 patients with CSM who underwent surgical decompression at our institution. Upper limb, lower limb, and sphincter functions were assessed using the modified Japanese Orthopaedic Association score (mJOA). Assessment was done before the operation and at 1 month, 3 months, and 1 year after surgery. The mJOA score did not significantly increase at 1 month after surgery (P= 0.051); however, increase in mJOA score was statistically significant at 3 and 1 year after surgery (P < 0.001 and P < 0.001, respectively). Upper limb motor dysfunction improved in 65% of patients, lower limb motor dysfunction improved in 52% of patients, upper limb sensory dysfunction improved in 48% of patients, and sphincter dysfunction improved in 14.2% of patients. There was a significant positive correlation between preoperative and postoperative mJOA score at 1 month, 3 months, and 1 year after surgery. Minimal improvement occurred in the first month after CSM surgery to reach a peak at 3 months after surgery and steady improvement up to 1 year after surgery. Upper limbs recovered better and earlier than lower limbs and sphincter function. Preoperative severity of CSM is one of the main predictors of postoperative neurological outcome.

Baseline severity of myelopathy predicts neurological outcomes after posterior decompression surgery for cervical spondylotic myelopathy: a retrospective study.

Retrospective multicenter study. To identify the usefulness of the baseline severity of myelopathy for predicting surgical outcomes for cervical spondylotic myelopathy (CSM). Seventeen institutions in Japan. This study included 675 persons with CSM who underwent posterior decompression. According to baseline severity, the individuals were divided into the mild (Japanese Orthopaedic Association [JOA] score ≥ 14.5), moderate (JOA score = 10.5-14), and severe (JOA score ≤ 10) groups. Surgical outcomes and clinical variables were compared between the groups. Logistic regression analysis was used to develop a prediction model for unsatisfactory symptom state (postoperative JOA score ≤ 14, residual moderate or severe myelopathy). The mean (±standard deviation) age was 67 ± 12 years. The participants in the severe group were older than those in the mild group. Postoperative JOA scores were higher in the mild group than in the severe group. According to multivariate logistic regression analysis, the prediction model included preoperative JOA scores (odds ratio [OR] 0.60; 95% confidence interval [CI] 0.55-0.67) and age (OR 1.06, 95% CI 1.04-1.08). On the basis of the model, a representative combination of the thresholds to maximize the value of "sensitivity - (1 - specificity)" demonstrated a preoperative JOA score of 11.5 as a predictor of postoperative unsatisfactory symptom state in people around the mean age of the study cohort (67 years). The combination of the baseline severity of myelopathy and age can predict postoperative symptom states after posterior decompression surgery for CSM.

Return to work after surgical treatment for cervical spondylotic myelopathy

Purpose: The purpose of the study was to determine the rate and predictors of return to work (RTW) after surgery for cervical spondylotic myelopathy (CSM). Overview of Literature: RTW is arguably the most important outcome following spine surgery from a patient’s perspective. But, to the best of our knowledge, there have been no reports in the English literature describing RTW among patients undergoing surgery for moderate-to-severe CSM. Materials and Methods: We included adult patients with CSM with Nurick grade ≥ 3 who underwent surgery. They were divided into two groups: those who returned to work within 6 months (group 1) and those who did not (group 2) and their outcomes were analyzed. Results: A total of 34 patients were included in the study. Baseline characteristics were comparable between the groups. Only 18 (52.9%) patients returned to work by 6 months. The nature of work had a statistically significant association with RTW by 6 months (P = 0.005) with failure to RTW specifically seen in manual laborers. Age, body mass index, symptom duration, pre-operative absenteeism, smoking, diabetes mellitus, number of levels operated, surgical approach, and post-operative complications did not have significant association with RTW. Better functional outcomes were seen in patients who returned to work as calculated using Nurick grade (P = 0.000) and modified Japanese Orthopedic Association score (P = 0.001). All the patients who returned to work and 75% of the patients who did not RTW were satisfied with the outcome of surgery (P = 0.039). Conclusion: In spite of functional improvement, CSM was associated with poor RTW with manual laborers being the most vulnerable group. This study will help surgeons modulate patient expectations as well as provide a platform for counseling them.

Comparison of Three Different Surgical Methods in the Treatment of Cervical Spondylotic Myelopathy

The course of cervical spondylotic myelopathy is slow, the surgical treatment is difficult and the effect is general, and it is easy to cause the decline of patient’s quality of life, even death. The aim of this study was to compare the efficacy of anterior, posterior and combined approaches in the treatment of cervical spondylotic myelopathy. A total of 105 cervical spondylotic myelopathy patients were selected from orthopedics department of our hospital from January 2016 to March 2019 according to the diagnosis and exclusion criteria. All patients were divided into the former group (n=36 cases), the latter group (n=34 cases) and the combined group (n=35 cases). After 3-12 mo of follow-up, Japanese Orthopaedic Association score was observed and the expression of interleukin 6, interleukin 8 and Tumor Necrosis Factor-alpha were detected. There was no significant difference in age, gender, course of disease, number of intervertebral space involvement and level of inflammatory factors among the three groups. The effective rate of the combined group was 91.4 %, which was significantly higher than that of the anterior group (66.7 %) and of the posterior group (67.6 %). After 3-12 mo of follow-up, we found that the Japanese Orthopaedic Association scores of the three groups were improved at 3, 6 and 12 mo after operation, and the improvement degree was positively correlated with the follow-up time, but the efficacy of the combined group was significantly better than that of the former group and the latter group. In addition, we found that the expression of Tumor Necrosis Factor-alpha, interleukin 6 and interleukin 8 in the three groups were significantly reduced at 3 mo after operation, and the level of Tumor Necrosis Factor-alpha, interleukin 6 and interleukin 8 in the combined treatment group was more significantly lower than that in the former and the latter two groups. The combination of anterior and posterior cervical surgery for cervical spondylotic myelopathy could achieve better therapeutic effect, recover and maintain the physiological radian of cervical spine, and effectively reduce the level of serum inflammatory cytokines in patients with cervical spondylotic myelopathy.

An independent agreement study of modified Pfirrmann grading system for cervical inter-vertebral disc degeneration in cervical spondylotic myelopathy

Objective Neck pain, sensory disturbance and motor dysfunction in most patients suffered cervical spondylotic myelopathy (CSM). For CSM surgery, it is necessary to evaluate preoperative inter-vertebral disc degeneration (IDD) which determines whether to adopt fusion strategy, and postoperative IDD which is one of the main reasons for reoperation. Modified Pfirrmann grading system is commonly used to evaluate IDD. The objective of this study is to evaluate its reliability and reproducibility on cervical IDD in CSM patients, and to explore its clinical application value. Methods All 165 patients with CSM were enrolled. 6 physicians (3 spine surgeons and 3 radiologists) who have certain clinical experience were selected. They graded cervical inter-vertebral disc according to modified Pfirrmann grading system, we used intra-class correlation coefficient (ICC) and weighted kappa (wκ) to assess the inter- and intra-observer agreement. After 12 weeks, we repeated the analysis. Results The inter-observer reliability of modified Pfirrmann grading system was excellent with an ICC value of 0.76 and near perfect with wκ value of 0.82. The intra-observer reproducibility of modified Pfirrmann grading system was excellent with ICC values ranging from 0.80 to 0.91, and near perfect with wκ values ranging from 0.83-0.92. Conclusion Modified Pfirrmann grading system has excellent inter-observer reliability and intra-observer reproducibility on cervical IDD in CSM. In addition, it indicates a good appliance among spine surgeons and radiologists, clinical and radiological studies applying it should be deemed accurate. Thus, modified Pfirrmann grading system can be widely used as an appropriate instrument in clinical care.

Using a Combined Classification of Increased Signal Intensity on Magnetic Resonance Imaging (MRI) to Predict Surgical Outcome in Cervical Spondylotic Myelopathy.

BackgroundThe aim of this study was to verify whether the combined classification of increased signal intensity (ISI) on magnetic resonance imaging is more closely related to surgical outcomes than signal quality changes or signal longitudinal extent changes alone and to evaluate whether the combined classification ISI method could be used to predict surgical outcomes in cervical spondylotic myelopathy.Material/MethodsEighty-four patients (61 men and 23 women) who underwent surgery for cervical spondylotic myelopathy were included in this retrospective study. The patterns of ISI were classified into 3 categories based on (1) the quality of ISI into Grade 0: none, Grade 1: faint (fuzzy), and Grade 2: intense (sharp); (2) the longitudinal extent of ISI into none, focal, and multisegmental; and (3) the combined classification of the quality and longitudinal extent into Type 1 (none/none), Type 2 (focal/faint), Type 3 (focal/intense), Type 4 (multisegmental/faint), and Type 5 (multisegmental/intense). The multifactorial effects of variables were studied. A stepwise regression analysis was performed to verify whether this combined classification could predict outcome.ResultsOf the 3 categories, the combined classification type of ISI was most closely related to recovery rate. Stepwise regression analysis confirmed the significance of combined classification of ISI as a predictor for surgical outcome.ConclusionsA combined classification of ISI is more closely related to surgical outcomes than either signal quality changes or signal longitudinal extent changes alone and it could be used as a meaningful indicator for predicting surgical outcomes. We recommend further studies to confirm this finding.

Diabetes Does Not Adversely Affect Neurological Recovery and Reduction of Neck Pain After Posterior Decompression Surgery for Cervical Spondylotic Myelopathy: Results From a Retrospective Multicenter Study of 675 Patients.

Retrospective multicenter study. The aim of this study was to identify the impact of diabetes on surgical outcomes of posterior decompression for cervical spondylotic myelopathy (CSM). Although some previous studies have reported surgical outcomes of posterior decompression for CSM in diabetic patients, their results were inconsistent. We included 675 patients with CSM who underwent posterior decompression. Patients were divided into diabetic (n = 140) and nondiabetic (n = 535) groups according to the diabetic criteria for glucose intolerance. Surgical outcomes as assessed by the Japanese Orthopedic Association (JOA) scores and visual analog scale (VAS) for neck pain were compared between groups. Subsequently, the functional outcomes of diabetic patients were compared between the mild (n = 131) and moderately severe (n = 9) groups. All patients were followed up for at least 1 year after surgery. Compared with the nondiabetic group, the diabetic group showed lower pre- and postoperative JOA scores (P = 0.025 and P = 0.001, respectively) and a lower JOA score recovery rate (RR) (P = 0.009). However, the preoperative-to-postoperative changes in JOA scores in the diabetic and nondiabetic groups were not significantly different (P = 0.988). Pre- and postoperative VAS for neck pain and postoperative reduction of neck pain were comparable between groups (P = 0.976, P = 0.913 and P = 0.688, respectively). Although statistical analysis was not performed due to the small underpowered sample size, functional outcomes assessed by the JOA score RR (43.3 ± 37.1% vs. 45.3 ± 33.9%) and preoperative-to-postoperative changes in JOA scores (3.0 ± 2.2 vs. 2.7 ± 2.5) were similar between the mild and moderately severe diabetes groups. CSM patients with diabetes experienced improvements in neurological function and neck pain as a result of posterior decompression to the same extent seen in patients without diabetes.Level of Evidence: 3.

Time Course of Physical and Mental Well-being Improvements After Cervical Surgery.

Retrospective cohort study. To elucidate the postoperative time course of improvements in physical and mental well-being in patients with cervical spondylotic myelopathy (CSM). Spinal surgeons should understand the postoperative course in detail. However, data are still needed regarding the time course of improvements in well-being, a fundamental aspect of human life, after cervical surgery for CSM. One hundred consecutive patients who underwent laminoplasty for CSM, with complete clinical data preoperatively and 3 months and 2 years postoperatively, were enrolled. The Short Form-36 physical component summary (PCS) and mental component summary (MCS) scores were used as parameters of physical and mental well-being, respectively, and 4.0 was defined as the minimal clinically important difference (MCID) for both parameters. On average, PCS and MCS scores were significantly improved after surgery (P < 0.001, P=0.004, respectively). Moreover, 64 and 48 patients achieved meaningful improvement (>MCID) in PCS and MCS scores at 3 months postoperatively, with maintained improvement (to 2 yr) in 46/64 (71.9%) and 34/48 patients (70.8%), respectively (PCS vs. MCS: P = 0.912). Additionally, 15 of 36 patients (41.7%) and 8 of 52 patients (15.4%) achieved late improvement (meaningful improvement at 2 yr but not at 3 months) in PCS and MCS scores, respectively (PCS vs. MCS: P = 0.007). In multivariate regression analysis, improvement in cJOA score was significantly associated with PCS improvement, but not MCS improvement, at both 3 months and 2 years (P = 0.001, P > 0.001, respectively). The overall outcome of physical well-being improvement is decided within 3 months postoperatively, in proportion to the recovery in myelopathy, with a relatively high chance of meaningful improvement over the next 21 months. The outcome of improvement in mental well-being is decided within 3 months postoperatively, independently from the recovery in myelopathy, with a low chance of meaningful improvement over the next 21 months.Level of Evidence: 3.

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.

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

24. Cervical spine steroid injections for delay of surgery for cervical spondylotic myelopathy

BACKGROUND CONTEXT Cervical spine steroid injections are increasingly being used for diagnosis and treatment of degenerative pathology. For cervical spondylotic myelopathy traditionally treated with surgery, there has been little investigation of the possible therapeutic or preventive effects of targeted injections. As injections may be targeted to the epidural space, the transforaminal region, or the zygapophyseal joints, differing injection modalities may also have variable therapeutic effects. PURPOSE To determine the potential for cervical spine steroid injections to delay surgical treatment for cervical spondylotic myelopathy. STUDY DESIGN/SETTING Retrospective cohort study. PATIENT SAMPLE A total of 39,590 patients with a new diagnosis of cervical spondylotic myelopathy, without previous cervical spine surgery. OUTCOME MEASURES Timing of surgical treatment (cervical decompression, fusion, or arthroplasty, from anterior or posterior approaches). METHODS Administration of cervical epidural, transforaminal, or zygapophyseal steroid injections was determined based on Current Procedural Terminology (CPT) codes. Timing of surgical treatment (cervical decompression, fusion, or arthroplasty, from anterior or posterior approaches) was also determined based on CPT codes. Multivariate logistic regression was used to determine the association of steroid injection administration with surgical treatment at various time points after initial diagnosis (1, 3, 6 months, and 1, 2, 5 years). RESULTS A total of 39,590 patients with a new diagnosis of cervical spondylotic myelopathy were identified. A total of 6,405 patients (16.2%) underwent cervical epidural steroid injections, 1,426 (3.6%) underwent transforaminal steroid injections, and 647 (1.6%) underwent zygapophyseal injections. Mean time from initial diagnosis to surgery was 180.2 days (standard deviation=345.9 days). In multivariate analysis epidural injections were associated with decreased odds of surgery within 1 month of diagnosis (odds ratio [OR]=0.69, P CONCLUSIONS Epidural steroid injections do not prevent surgical treatment of cervical spondylotic myelopathy in the long run. There may be some short-term symptomatic benefits that lead to delayed surgical treatment, although the clinical benefits have yet to be demonstrated. No significant benefit is seen with transforaminal or zygapophyseal injections for treatment of cervical myelopathy. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

224. The utility of neuromonitoring in cervical myelopathy patients

BACKGROUND CONTEXT Intra-operative neuromonitoring (IONM) was developed and is now used as a method of monitoring and potentially preserving spinal cord function during critical spine procedures. Although there is in theory utility to the use of this technology, particularly for deformity surgery where corrections may be reversed in conjunction with IONM findings, the utility in degenerative cases for cervical spondylotic myelopathy (CSM) where no similar opportunity exists is lacking in practice. In fact, IONM does add cost and time to each surgery and it may just be used for medicolegal reasons by some physicians. PURPOSE To examine the utility, sensitivity and specificity of IONM for patients undergoing surgery for CSM. STUDY DESIGN/SETTING Retrospective review of a consecutive series of CSM patients undergoing surgery in a safety net county hospital system PATIENT SAMPLE A total of 540 CSM surgical patients. OUTCOME MEASURES N/A METHODS Retrospective comparison of IONM findings was made against preoperative to immediate postoperative and perioperative clinical examination findings for a consecutive series of 540 CSM surgeries performed over a 10-year period from 2009-2019 in a safety net hospital system. The senior author (K.R.) kept track of all positive and negative findings. RESULTS There were seven positive IONM findings where loss of motor evoked potentials suggested a major intraoperative neurologic despite none of these patients having any clinical neurological deterioration pre- to postoperatively, neither subjectively when asking the patient nor objectively on physical examination by the spine team. There were no false negative findings and all IONM negatives were true negatives that maintained baseline neurologic function postoperatively (n=533). Thus, the overall sensitivity of detecting a new neurologic deficit was 0% given there were no true positive cases in this series. The specificity for ruling in normal post-operative neurologic function was 98.7%. CONCLUSIONS Though IONM is proposed to offer benefits during spinal surgery, the present series revealed only false positive findings for CSM surgeries. IONM added significant set-up time and additional cost without patient benefit. These data suggest the use of IONM may not be clinically valuable in practice apart from the idea of medicolegal or intraoperative security, but at the price of significant anxiety, not security, for the 1.3% false positive rate. FDA DEVICE/DRUG STATUS This abstract does not discuss or include any applicable devices or drugs.

Canadian Spine SocietyPresentation CPSS1: Spinal insufficiency fracture in the geriatric pediatric spinePresentation CPSS2: The clinical significance of tether breakages in anterior vertebral body growth modulation: a 2-year postoperative analysisPresentation CPSS3: Anterior vertebral body growth modulation for idiopathic scoliosis: early, mid-term and late complicationsPresentation CPSS4: Ovine model of congenital chest wall and spine deformity with alterations of respiratory mechanics: follow-up from

Canadian Spine SocietyPresentation CPSS1: Spinal insufficiency fracture in the geriatric pediatric spinePresentation CPSS2: The clinical significance of tether breakages in anterior vertebral body growth modulation: a 2-year postoperative analysisPresentation CPSS3: Anterior vertebral body growth modulation for idiopathic scoliosis: early, mid-term and late complicationsPresentation CPSS4: Ovine model of congenital chest wall and spine deformity with alterations of respiratory mechanics: follow-up from