Surgical Management Of Cervical Spondylotic Myelopathy Research Articles

Cervical spondylotic myelopathy and driving abilities: defining the prevalence and long-term postoperative outcomes using the Quality Outcomes Database.

Cervical spondylotic myelopathy (CSM) can cause significant difficulty with driving and a subsequent reduction in an individual's quality of life due to neurological deterioration. The positive impact of surgery on postoperative patient-reported driving capabilities has been seldom explored. The CSM module of the Quality Outcomes Database was utilized. Patient-reported driving ability was assessed via the driving section of the Neck Disability Index (NDI) questionnaire. This is an ordinal scale in which 0 represents the absence of symptoms while driving and 5 represents a complete inability to drive due to symptoms. Patients were considered to have an impairment in their driving ability if they reported an NDI driving score of 3 or higher (signifying impairment in driving duration due to symptoms). Multivariable logistic regression models were fitted to evaluate mediators of baseline impairment and improvement at 24 months after surgery, which was defined as an NDI driving score < 3. A total of 1128 patients who underwent surgical intervention for CSM were included, of whom 354 (31.4%) had baseline driving impairment due to CSM. Moderate (OR 2.3) and severe (OR 6.3) neck pain, severe arm pain (OR 1.6), mild-moderate (OR 2.1) and severe (OR 2.5) impairment in hand/arm dexterity, severe impairment in leg use/walking (OR 1.9), and severe impairment of urinary function (OR 1.8) were associated with impaired driving ability at baseline. Of the 291 patients with baseline impairment and available 24-month follow-up data, 209 (71.8%) reported postoperative improvement in their driving ability. This improvement seemed to be mediated particularly through the achievement of the minimal clinically important difference (MCID) in neck pain and improvement in leg function/walking. Patients with improved driving at 24 months noted higher postoperative satisfaction (88.5% vs 62.2%, p < 0.01) and were more likely to achieve a clinically significant improvement in their quality of life (50.7% vs 37.8%, p < 0.01). Nearly one-third of patients with CSM report impaired driving ability at presentation. Seventy-two percent of these patients reported improvements in their driving ability within 24 months of surgery. Surgical management of CSM can significantly improve patients' driving abilities at 24 months and hence patients' quality of life.

The Efficacy of Posterior Cervical Laminectomy for Multilevel Degenerative Cervical Spondylotic Myelopathy in Long Term Period.

Study Design:This was a retrospective analysis.Background:Surgical decompression is the gold standard for preventing the progression of neurological deficit in degenerative multilevel cervical spondylotic myelopathy (CSM). The efficacy of posterior laminectomy in the surgical management of CSM has been described in the past, but long-term follow-up data are scanty.Objective:The aim of this study is to assess the long-term clinical-radiological outcomes following posterior cervical decompressive laminectomy in multilevel degenerative CSM.Materials and Methods:A retrospective analysis of 110 patients with degenerative multilevel CSM who underwent posterior cervical laminectomy alone in a single hospital by a single surgeon from 2009 to 2013 with minimum 5-year follow-up. Pre- and post-operative clinical parameters (visual analog scale [VAS], Nurick and modified Japanese orthopedic association [mJOA]), radiological parameter (Sagittal cervical Cobb's Angle), perioperative complications (time, blood loss, and hospital stay), postoperative complications (infection, C5 palsy, and neurological worsening) were evaluated.Results:Totally 110 patients (males – 68 and females – 42) with age varying from 46 to 80 (mean-57) years, and the mean duration of illness was 3 months were evaluated. Mean clinical parameters are VAS (preoperative = 5 ± 1.31, postoperative = 1.49 ± 0.687), Nurick grading (preoperative = 3.23 ± 71, postoperative = 1.924 ± 0.75), and mJOA (preoperative = 6.32 ± 0.87, postoperative = 9.89 ± 1.37). The mean blood loss was 93.95 ± 19.18 ml, and the mean time taken for surgery was 83.65 ± 10.18 min. About 13% (n = 15) patients developed cervical kyphosis and 29% (n = 32) developed changes in cervical spine alignment and 10% (n = 11) developed worsening of neurology at final follow-up. Two patients developed a superficial infection which was managed with antibiotics. Three patients developed C5 palsy which recovered with due time.Conclusions:With the proper selection of patients, posterior cervical laminectomy is effective in offering a clinical improvement to patients with degenerative multilevel CSM with a low incidence of clinically significant radiological deterioration.

Fragility Fracture Risk in Elderly Patients With Cervical Myelopathy.

Retrospective review. To identify and compare the incidences of fragility fractures amongst three elderly populations: the general population, patients with surgically treated cervical spondylotic myelopathy (CSM), and patients with CSM not surgically treated. CSM is a common disease in the elderly. Progression of myelopathic symptoms, including gait imbalance, can be a source of morbidity as it can lead to increased falls. Records of elderly patients with Medicare insurance from 2005 to 2014 were retrospectively reviewed. Three mutually exclusive populations of patients were identified for analysis, including a cohort of patients with a diagnosis of CSM who were not treated with surgery; a cohort of patients with CSM who were treated with surgery; and a group of control patients who had never been treated with cervical spine surgery nor were diagnosed with CSM. Incidence of fractures of the distal radius, proximal humerus, proximal femur, and lumbar spine were assessed and compared between cohorts, adjusted by age, sex, osteoporosis, dementia, cerebrovascular disease, and Charlson Comorbidity Index. A total of 891,864 patients were identified, of which 60,332 had a diagnosis of CSM and 24,439 underwent cervical spine surgery. Compared to general population controls, the 12-month adjusted odds of experiencing at least one fragility fracture were 1.59 times higher in patients with CSM who were not treated with surgery (P < 0.001). The analogous odds ratio was 1.34 (P < 0.001) at 3 years. Compared to nonsurgically treated patients with CSM, the odds of experiencing at least one fragility fracture were reduced to 0.89 in surgically treated patients (P = 0.008). Fragility fractures are a significant source of morbidity and mortality in elderly patients. CSM is associated with increased rates of fragility fractures, although surgical management of CSM may be protective against risk of fragility fracture. 3.

Predictors of morbidity and mortality among patients with cervical spondylotic myelopathy treated surgically.

The aim of this study is to report and quantify the associated factors for morbidity and mortality following surgical management of cervical spondylotic myelopathy (CSM). The Nationwide Inpatient Sample (NIS) database was use to retrospectively review all patients over 25 years of age with a diagnosis of CSM who underwent anterior and/or posterior cervical fusion or laminoplasty between 2001 and 2010. The main outcome measures were total procedure-related complications and mortality. Multivariate regression analysis was used to identify demographic, comorbidity, and surgical parameters associated with increased morbidity and mortality risk [reported as: OR (95% CI)]. A total of 54,348 patients underwent surgical intervention for CSM with an overall morbidity rate of 9.83% and mortality rate of 0.43%. Comorbidities found to be associated with an increased complication rate included: pulmonary circulation disorders [6.92 (5.91-8.12)], pathologic weight loss [3.42 (3.00-3.90)], and electrolyte imbalance [2.82 (2.65-3.01)]. Comorbidities found to be associated with an increased mortality rate included: congestive heart failure [4.59 (3.62-5.82)], pulmonary circulation disorders [11.29 (8.24-15.47)], and pathologic weight loss [5.43 (4.07-7.26)]. Alternatively, hypertension [0.56 (0.46-0.67)] and obesity [0.36 (0.22-0.61)] were found to confer a decreased risk of mortality. Increased morbidity and mortality rates were also identified for fusions of 4-8 levels [morbidity: 1.55 (1.48-1.62), mortality: 1.80 (1.48-2.18)] and for age >65 years [morbidity: 1.65 (1.57-1.72), mortality: 2.74 (2.25-3.34)]. An increased morbidity rate was found for posterior-only [1.55 (1.47-1.63)] and combined anterior and posterior fusions [3.20 (2.98-3.43)], and an increased mortality rate was identified for posterior-only fusions [1.87 (1.40-2.49)]. Although revision fusions were associated with an increased morbidity rate [1.81 (1.64-2.00)], they were associated with a decreased rate of mortality [0.24 (0.10-0.59)]. The NIS database was used to provide national estimates of morbidity and mortality following surgical management of CSM in the United States. Several comorbidities, as well as demographic and surgical parameters, were identified as associated factors.

Regional Differences in Outcomes of Surgical Treatment for Cervical Spondylotic Myelopathy Outcomes of the AOSpine Multicenter Prospective CSM-I Study

Introduction Cervical spondylotic myelopathy (CSM) is a condition that is commonly seen in those over the age of 50 to 60 years. A progressive increase in the number of patients who present with CSM is expected in the coming decades as the proportion of those over 60 years is anticipated to double by 2050 according to the World Health Organization (WHO). Regional variations in the pattern of presentations, etiology, and surgical management of CSM are likely to be important determinants of outcome of treatment. Here, we report the current presentation and management of CSM in a large prospective international multicenter study (AOSpine CSM-International). Materials and Methods Between 2007 and 2011, all adult patients with imaging-confirmed CSM were enrolled at 16 international high-volume centers. Detailed data on presentation, treatment, and functional outcomes were collected prospectively. The decision on surgical approach, levels decompressed, and use of instrumentation was left to the attending surgeons. Patients with inflammatory, infective, or neoplastic myelopathic etiologies were excluded. Patients were followed-up for up to 24 months. Results Participating centers were based in Asia (AP, n = 150), Europe (E, n = 126), Latin (LA, n = 80), and North America (NA, n = 123). The mean age of the cohort was 56.4 years (range, 22–87 years) and majority of them were males. Patients from AP and LA were significantly younger (53.9 and 54.2 years, respectively) than those from NA and E ( p &lt; 0.0003). The presenting underlying CSM pathology varied between regions ( p &lt; 0.001). Posterior ligamentum flavum hypertrophy was most frequently seen in LA, and OPLL was prevalent in patients in AP (35%) and E (32%). Despite etiological variations, there were no differences in baseline mJOA, Nurick, and NDI scores ( p &lt; 0.1). However, patients in AP scored the highest and those in LA scored the lowest on SF36 PCS, and LA patients had highest SF36 MCS scores ( p &lt; 0.008). Anterior surgical decompression was performed in a majority in Europe (71.43%), AP (61.07%), and NA (56%) but not in LA (33%). Circumferential decompression surgery was rarely performed in NA (4.88%) and E (3.17%). At 24 months, there was significant improvement in overall outcome measures ( p &lt; 0.001) in all regions. Patients in Asia demonstrated the greatest improvement in NDI and SF-36 PCS/MCS and patients in Europe the least. Patients from Europe had lower SF-36 QOL scores and showed less functional improvement in mJOA. NDI score was highest in the AP region. Conclusion There were significant regional variations in etiology of CSM but not at presenting functional status. Anterior cervical approach for CSM was the most common surgical approach worldwide. Surgical decompression achieved statistically significant improvements in mJOA, NDI, Nurick score, and SF36v2 across centers. However, there were variations in the degree of functional improvements gained across the regions.

Surgical management of cervical spondylotic myelopathy

Cervical spondylotic myelopathy (CSM) is emerging as the most common cause of spinal cord dysfunction in the elderly worldwide. In the past decade, our understanding of the biomechanics of the spine has improved along with advances in spinal instrumentation and this has led to significant changes in the surgical management of CSM. This review will discuss the indications, advantages and limitations of different operative approaches as well as the complications and prognosis of surgery for cervical spondylotic myelopathy. Choice of surgical approach for CSM should be based on the clinical and radiological characteristics of the individual patient and not on the preferences of the surgeon.

Surgical approach to cervical spondylotic myelopathy on the basis of radiological patterns of compression: prospective analysis of 129 cases

This is a prospective analysis of 129 patients operated for cervical spondylotic myelopathy (CSM). Paucity of prospective data on surgical management of CSM, especially multilevel CSM (MCM), makes surgical decision making difficult. The objectives of the study were (1) to identify radiological patterns of cord compression (POC), and (2) to propose a surgical protocol based on POC and determine its efficacy. Average follow-up period was 2.8 years. Following POCs were identified: POC I: one or two levels of anterior cord compression. POC II: one or two levels of anterior and posterior compression. POC III: three levels of anterior compression. POC III variant: similar to POC III, associated with significant medical morbidity. POC IV: three or more levels of anterior compression in a developmentally narrow canal or with multiple posterior compressions. POC IV variant: similar to POC IV with one or two levels, being more significant than the others. POC V: three or more levels of compression in a kyphotic spine. Anterior decompression and reconstruction was chosen for POC I, II and III. Posterior decompression was chosen in POC III variant because they had more incidences of preoperative morbidity, in spite of being radiologically similar to POC III. Posterior surgery was also performed for POC IV and IV variant. For POC IV variant a targeted anterior decompression was considered after posterior decompression. The difference in the mJOA score before and after surgery for patients in each POC group was statistically significant. Anterior surgery in MCM had better result (mJOA = 15.9) versus posterior surgery (mJOA = 14.96), the difference being statistically significant. No major graft-related complications occurred in multilevel groups. The better surgical outcome of anterior surgery in MCM may make a significant difference in surgical outcome in younger and fitter patients like those of POC III whose expectations out of surgery are more. Judicious choice of anterior or posterior approach should be made after individualizing each case.