ObjectiveTo investigate the effect of prophylactic C4, 5 foraminal dilatation in posterior cervical open-door surgery on postoperative C5 nerve root palsy syndrome.MethodsThe clinical data of patients with cervical spondylotic myelopathy (cervical spinal cord compression segments were more than 3) who met the selection criteria between March 2016 and March 2019 were retrospectively analyzed. Among them, 40 patients underwent prophylactic C4, 5 foraminal dilatation in posterior cervical open-door surgery (observation group) and 40 patients underwent simple posterior cervical open-door surgery (control group). There was no significant difference between the two groups (P>0.05) in gender, age, disease duration, Nurick grade of spinal cord symptoms, and preoperative diameter of C4, 5 intervertebral foramen, Japanese Orthopaedic Association (JOA) score, and visual analogue scale (VAS) score. The occurrence of C5 nerve root paralysis syndrome was recorded and compared between the two groups, including incidence, paralysis time, recovery time, and spinal cord drift. VAS and JOA scores were used to evaluate the improvement of pain and function before operation and at 12 months after operation.ResultsThe incisions of the two groups healed by first intention, and there was no early postoperative complications such as cerebrospinal fluid leakage. Patients of both groups were followed up 12-23 months, with an average of 17.97 months. C5 nerve root paralysis syndrome occurred in 8 cases in the observation group (3 cases on the right and 5 cases on the left) and 2 cases in the control group (both on the right). There was significant difference of the incidence (20% vs. 5%) between the two groups (χ2=4.114, P=0.043). Except for 1 case in the observation group who developed C5 nerve root palsy syndrome at 5 days after operation, the rest patients all developed at 1 day after operation; the recovery time of the observation group and the control group were (3.87±2.85) months and (2.50±0.70) months respectively, showing no significant difference between the two groups (t=–0.649, P=0.104). At 12 months after operation, the JOA score and VAS score of cervical spine in the two groups significantly improved when compared with those before operation (P<0.05); there was no significant difference in the difference of the cervical spine JOA score and VAS score between at 12 months after operation and before operation and the degree of spinal cord drift between the two groups (P>0.05).ConclusionProphylactic C4, 5 foraminal dilatation can not effectively prevent and reduce the occurrence of postoperative C5 root palsy, on the contrary, it may increase its incidence, so the clinical application of this procedure requires caution.
Objective To investigate the imaging characteristics of cervical kyphosis and spinal cord compression in cervical spondylotic myelopathy (CSM) with cervical kyphosis and the influence on effectiveness. Methods The clinical data of 36 patients with single-segment CSM with cervical kyphosis who were admitted between January 2020 and December 2022 and met the selection criteria were retrospectively analyzed. The patients were divided into 3 groups according to the positional relationship between the kyphosis focal on cervical spine X-ray film and the spinal cord compression point on MRI: the same group (group A, 20 cases, both points were in the same position), the adjacent group (group B, 10 cases, both points were located adjacent to each other), and the separated group (group C, 6 cases, both points were located >1 vertebra away from each other). There was no significant difference between groups (P>0.05) in baseline data such as gender, age, body mass index, lesion segment, disease duration, and preoperative C2-7 angle, C2-7 sagittal vertical axis (C2-7 SVA), C7 slope (C7S), kyphotic Cobb angle, fusion segment height, and Japanese Orthopedic Association (JOA) score. The patients underwent single-segment anterior cervical discectomy with fusion (ACDF). The occurrence of postoperative complications was recorded; preoperatively and at last follow-up, the patients’ neurological function was evaluated using the JOA score, and the sagittal parameters (C2-7 angle, C2-7 SVA, C7S, kyphotic Cobb angle, and height of the fused segments) were measured on cervical spine X-ray films and MRI and the correction rate of the cervical kyphosis was calculated; the correlation between changes in cervical sagittal parameters before and after operation and the JOA score improvement rate was analyzed using Pearson correlation analysis. Results In 36 patients, only 1 case of dysphagia occurred in group A, and the dysphagia symptoms disappeared at 3 days after operation, and the remaining patients had no surgery-related complications during the hospitalization. All patients were followed up 12-42 months, with a mean of 20.1 months; the difference in follow-up time between the groups was not significant (P>0.05). At last follow-up, all the imaging indicators and JOA scores of patients in the 3 groups were significantly improved when compared with preoperative ones (P<0.05). The correction rate of cervical kyphosis in group A was significantly better than that in group C, and the improvement rate of JOA score was significantly better than that in groups B and C, all showing significant differences (P<0.05), and there was no significant difference between the other groups (P>0.05). The correlation analysis showed that the improvement rate of JOA score was negatively correlated with C2-7 angle and kyphotic Cobb angle at last follow-up (r=−0.424, P=0.010; r=−0.573, P<0.001), and positively correlated with the C7S and correction rate of cervical kyphosis at last follow-up (r=0.336, P=0.045; r=0.587, P<0.001), and no correlation with the remaining indicators (P>0.05). Conclusion There are three main positional relationships between the cervical kyphosis focal and the spinal cord compression point on imaging, and they have different impacts on the effectiveness and sagittal parameters after ACDF, and those with the same position cervical kyphosis focal and spinal cord compression point have the best improvement in effectiveness and sagittal parameters.
Objective To investigate an individualized treatment program of a patient with multilevel cervical spondylotic myelopathy by the method of evidence-based medicine. Methods One patient with multilevel cervical spondylotic myelopathy was admitted into West China Hospital on October 19th, 2015. After evaluating the patient’s condition adequately, we proposed the problem according to the " patient, intervention, control, and outcome” (PICO) principles. Then, we searched and evaluated the systematic reviews, randomized controlled trials (RCTs), cohort studies from Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials, Medline, Embase, PubMed, OVID ACP Journal Club, CNKI, Wanfang and so on. The search date was from January 1991 to December 2015. And the best evidences from the databases were utilized in clinical practice. Results Twelve studies (five systematic reviews, two RCTs, four cohort studies and one latest guideline) were listed. To patients with multilevel cervical spondylotic myelopathy with ossification of the posterior longitudinal ligament (OPLL), posterior laminoplasty was less traumatic and had less complication. Expansive open-door laminoplasty was better. And the use of mini-plate fixation also reduced the related complications. Conclusions Posterior expansive open-door laminoplasty with mini-plate fixation has less traumatic and complication incidence, which can treat multilevel cervical spondylotic myelopathy effectively. For the best results and avoiding adverse outcomes, the procedure should be preferred in patients with OPLL.
Objective To assess the mid-term effectiveness of anterior decompression and fusion with nano-hydroxyapatite/polyamide 66 (n-HA/PA66) cage in treatment of cervical spondylotic myelopathy. Methods A retrospective study was made on 48 patients with cervical spondylotic myelopathy who underwent anterior decompression and fusion with n-HA/PA66 cage between August 2008 and January 2010. There were 33 males and 15 females with an average age of 54.5 years (range, 42-72 years). The disease duration was 3-12 months (mean, 6 months). The affected segments included 35 cases of single segment (C3, 4 in 7, C4, 5 in 18, and C5, 6 in 10) and 13 cases of double segments (C3-5 in 7 and C4-6 in 6). Of 48 patients, 28 was diagnosed as having intervertebral disc protrusion, 12 as having ossification of posterior longitudinal ligament, and 8 as having vertebral osteophyte; 35 patients underwent single segmental anterior corpectomy and fusion, and 13 patients underwent single segmental anterior discectomy and fusion. The pre- and post-operative radiographs (cervical anteroposterior and lateral X-ray films and three-dimensional CT scans) were taken to measure the segmental height and lordosis angle. Brantigan et al assessment standard and visual analogue scale (VAS) and Japanese Orthopaedic Association (JOA) scores were used to evaluate the graft fusion and the improvement of clinical symptoms, respectively. Results All patients were followed up for 46 months on average (range, 36-54 months). No cage breaking, displacement, or sliding was found. At last follow-up, 36 cases were rated as Brantigan grade E, 10 cases as grade D, and 2 cases as grade C; the fusion rate was 96%. Both segmental height and lordosis angle were corrected significantly at immediate and 6 months after operation and last follow-up than those before operation (P lt; 0.05), but no significant difference was found among different time points after operation (P gt; 0.05). At last follow-up, the cage subsidence was (1.3 ± 1.0) mm. The VAS and JOA scores at 6 months after operation and last follow-up were significantly improved when compared with preoperative scores (P lt; 0.05), and the scores at last follow-up were superior to ones at 6 months after operation (P lt; 0.05). Conclusion The mid-term effectiveness of anterior decompression and fusion with the n-HA/PA66 cage in patients with cervical spondylotic myelopathy is satisfactory because it can effectively restore and maintain segmental height and lordosis angle and promote osseous fusion.
ObjectiveTo analyze the clinical outcome of anterior cervical discectomy and fusion using a Zero-profile interbody fusion and fixation device (Zero-P) for cervical spondylotic myelopathy. MethodsBetween April 2011 and September 2013, 26 cases of cervical spondylotic myelopathy underwent anterior cervical discectomy and fusion with the Zero-P. Of 26 cases, 12 were male and 14 were female, aged 43-82 years (mean, 58.3 years). The disease duration was from 3 months to 10 years (mean, 5.9 years). The involved segments included C3,4 in 5 cases, C4,5 in 3 cases, C5,6 in 6 cases, and C6,7 in 12 cases. The clinical outcome was evaluated using visual analogue scale (VAS) score, Japanese Orthopaedic Association (JOA) score, and Neck Disability Index (NDI) score before operation and after operation. ResultsThe operations were successful and the operation time was 75-140 minutes (mean, 105 minutes); and blood loss was 20-150 mL (mean, 45 mL). There was no complications of infection, neural injury, esophageal fistula, prevertebral hematoma, or leakage of cerebrospinal. Dysphagia occurred in 1 case within 1 week after operation,and disappeared after 1 month. All patients were followed up for an average of 15.3 months (range, 12-18 months). The clinical symptoms were relieved after operation. During follow-up, no implant displacement or subsidence, screw breakage, and cervical instability were observed. At 3 and 12 months after operation, the VAS score and NDI reduced significantly (P<0.05); the JOA score increased significantly (P<0.05); and the intervertebral space height and the cervical Cobb angle improved significantly (P<0.05). But there was no significantly difference between at 3 and 12 months (P>0.05). According to JOA evaluation, the results were excellent in 14 cases, good in 10 cases, and fair in 2 cases, with an excellent and good rate of 92.3% at last follow-up. ConclusionThe clinical outcome of anterior cervical discectomy and fusion using a Zero-P is satisfactory and reliable in the treatment of cervical spondylotic myelopathy. It can restore the cervical physiological curve and the intervertebral space height and decrease the incidence of postoperative dysphagia.
Objective To evaluate the cl inical appl ication value and short-term results of Vertex rod-screw system in cervical expansive open-door laminoplasty. Methods Between February 2008 and January 2010, 28 patients underwent Vertex rod-screw system fixation in cervical expansive open-door laminoplasty, including 15 cases of cervical spondylotic myelopathy, 5 cases of ossification of posterior longitudinal l igament，and 8 cases of cervical spondylosis with spinal stenosis. There were 16 males and 12 females, aged 42-77 years (mean, 61.3 years). The disease duration was 2 months to 11 years. The decompression range of cervical spine was from C3 to C7. The operation time, blood loss, Japanese Orthopedic Association (JOA) scores, and incidence of axial symptom were recorded. Pre- and postoperative curvature angles were demonstrated by the cross angle between posterior vertebral body margins of C2 and C7 on cervical X-ray films. The angle of the opened laminae was measured on CT scan at last follow-up. Results The operation time was (142.5 ± 22.8) minutes, and the blood loss was (288.2 ± 55.1) mL. All incisions healed by first intention. All patients were followed up 14-25 months (mean, 22 months). CT showed that no reclosed open-laminae or loosening and breakage of rod-screw system occurred at 1 week and 1 year after operation. The axial bony fusion rate was 89.3% (25/28). The improvement rate of JOA scores at 1 week after operation (29.5% ± 15.0%) was significantly smaller than that at 1 year after operation (64.9% ± 28.1%) (t=0.810, P=0.000). No case presented with C5 nerve root palsy. The cervical curvature angle was (24.29 ± 5.04)° before operation, was (23.89 ± 3.57)° at 1 week, and was (23.41 ± 3.35)° at 1 year after operation, showing no significant difference between pre- and postoperative angles (P gt;0.05). The angle of the opened laminae was (27.90 ± 4.74)° at 1 week after operation, and was (28.07 ± 4.21)° at 1 year after operation, showing no significant difference (P gt; 0.05). Conclusion Vertex rod-screw system in cervical expansive opendoor laminoplasty is effective in preventing reclosed open-laminae, which can reduce the loss of cervical curvature angle.
Objective To compare the effectiveness of a zero-profile three-dimensiaonal (3D)-printed microporous titanium alloy Cage and a conventional titanium plate combined with a polyether-ether-ketone (PEEK)-Cage in the treatment of single-segment cervical spondylotic myelopathy (CSM) by anterior cervical discectomy and fusion (ACDF). Methods The clinical data of 83 patients with single-segment CSM treated with ACDF between January 2022 and January 2023 were retrospectively analyzed, and they were divided into 3D-ZP group (35 cases, using zero-profile 3D-printed microporous titanium alloy Cage) and CP group (48 cases, using titanium plate in combination with PEEK-Cage). There was no significant difference in gender, age, disease duration, surgical intervertebral space, and preoperative Japanese Orthopaedic Association (JOA) score, visual analogue scale (VAS) score, neck disability index (NDI), vertebral height at the fusion segment, Cobb angle, and other baseline data between the two groups (P>0.05). The operation time, intraoperative blood loss, hospital stay, complications, interbody fusion, and prosthesis subsidence were recorded and compared between the two groups. VAS score, NDI, and JOA score were used to evaluate the improvement of pain and function before operation, at 3 months after operation, and at last follow-up, and the vertebral height at the fusion segment and Cobb angle were measured by imaging. The degree of dysphagia was assessed by the Bazaz dysphagia scale at 1 week and at last follow-up. Results The operation was successfully completed in all the 83 patients. There was no significant difference in intraoperative blood loss and hospital stay between the two groups (P>0.05), but the operation time in the 3D-ZP group was significantly shorter than that in the CP group (P<0.05). Patients in both groups were followed up 24-35 months, with an average of 25.3 months, and there was no significant difference in the follow-up time between the two groups (P>0.05). The incidence and grade of dysphagia in CP group were significantly higher than those in 3D-ZP group at 1 week after operation and at last follow-up (P<0.05). There was no dysphagia in 3D-ZP group at last follow-up. There was no complication such as implant breakage or displacement in both groups. The intervertebral fusion rates of 3D-ZP group and CP group were 65.71% (23/35) and 60.42% (29/48) respectively at 3 months after operation, and there was no significant difference between the two groups [OR (95%CI)=1.256 (0.507, 3.109), P=0.622]. The JOA score, VAS score, and NDI significantly improved in the 3D-ZP group at 3 months and at last follow-up when compared with preoperative ones (P<0.05), but there was no significant difference between the two groups (P>0.05). There was no significant difference in the improvement rate of JOA between the two groups at last follow-up (P>0.05). At 3 months after operation and at last follow-up, the vertebral height at the fusion segment and Cobb angle significantly improved in both groups, and the two indexes in 3D-ZP group were significantly better than those in CP group (P<0.05). At last follow-up, the incidence of prosthesis subsidence in 3D-ZP group (8.57%) was significantly lower than that in CP group (29.16%) (P<0.05). ConclusionThe application of zero-profile 3D-printed Cage and titanium plate combined with PEEK-Cage in single-segment ACDF can both reconstruct the stability of cervical spine and achieve good effectiveness. Compared with the latter, the application of the former in ACDF can shorten the operation time, reduce the incidence of prosthesis subsidence, and reduce the incidence of dysphagia.
Objective To investigate the effect and safety of the anterior uncovertebral joint resection in treatment of cervical spondylotic myelopathy accompanied by radiculopathy. Methods From March 2002 toJuly 2004, 9 patients (5 males, 4 females; aged 38-66) with cervical spondylotic myelopathy accompanied by radiculopathy underwent the anterior uncovertebral joint resection and discectomy using the titanium cage implantation. There were 6 unilateral and 3 bilateral compressed nerve roots. Results During the follow-up for 3-16 months, CT scanning or X-ray films revealed thatall the patients improved with an enlargement of the intervertebral foramen, and MRI demonstrated that compression of the spinal cord and nerve roots vanished.Seven patients had a relief in the radicular pain although the other 2 still had a residual pain. All the patients improved to some extent in symptoms of myelopathy. No patient suffered vertebral artery injury during the operation. Conclusion The uncovertebral joint resection can directly decompressthe nerve roots. The key to avoidance of an injury to the vertebral artery is agood understanding of the regional anatomy and a good performance of the operation.
Objective To evaluate the cl inical effects of anterior segmental decompression and autograft fusion in treating multi-level cervical spondylotic myelopathy (CSM). Methods Between January 2007 and May 2009, 23 patients with multi-level CSM were treated with anterior segmental decompression, autograft fusion, and internal fixation. There were 16 males and 7 females with an average age of 58 years (range, 49-70 years). Consecutive 3 segments of C3,4, C4, 5, and C5, 6 involvedin 15 cases and C4, 5, C5, 6, and C6, 7 in 8 cases. All patients suffered sensory dysfunction in l imbs and trunk, hyperactivity of tendon reflexes of both lower extremities, walking with l imp, and weakening of hand grip. Cervical MRI showed degeneration and protrusion of intervertebral disc and compression of cervical cord. The disease duration was 6 to 28 months (12.5 months on average). Japanese Orthopaedic Association (JOA) score system was adopted for therapeutic efficacy evaluation. JOA scores were recorded preoperatively, 1 week, 3 months, and 12 months postoperatively. Results Dura tear occurred in 1 case and was treated by fill ing with gelatinsponge during operation; no cerebrospinal fluid leakage was observed after operation. All the incisions healed by first intention. All cases were followed up 12 to 24 months (15.1 months on average), and no vertebral artery injury or recurrent laryngeal nerve injury occurred. The nervous symptoms in all cases were improved significantly within 1 week after operation. Lower l imb muscle strength increased, upper l imb abnormal sensation disappeared, and l imb moved more agile. A 2-mm collapses of titanium mesh into upper terminal plate were found in 1 case and did not aggravated during followup.The other internal fixator was in appropriate situation, and the fusion rate was 100%. The JOA score increased from 9.1 ±0.3 preoperatively to 14.3 ± 0.4 at 12 months postoperatively with an improvement rate of 65.8% ± 0.2%, showing significant difference (P lt; 0.01). According to Odom evaluation scale, the results were excellent in 10 cases, good in 8 cases, fair in 4 cases, and poor in 1 case. Conclusion Anterior segmental decompression and autograft fusion is a recommendable technique for multi-level CSM, which can make full decompression, conserve the stabil ity of cervical cord, and has high fusion rate.
ObjectiveTo observe the effectiveness of posterior cervical laminoplasty, and to determine the significance of the classification of spinal cord compression of multi-level cervical spondylotic myelopathy (CSM). MethodsThe clinical data were analyzed from 1 216 cases of multi-level CSM undergoing posterior cervical laminoplasty between February 1998 and February 2013. The patients were divided into 4 groups: soft anterior spinal cord compression and light canal occupation (<50%) in 569 cases (46.8%, group A), soft anterior spinal cord compression and heavy canal occupation (≥ 50%) in 365 cases (30.0%, group B), bony anterior spinal cord compression and light canal occupation in 210 cases (17.3%, group C), and bony anterior spinal cord compression and heavy canal occupation in 72 cases (5.9%, group D). There was no significant difference in gender, age, disease duration, lesion level, and complications among 4 groups (P>0.05). Because of different levels of spinal cord compression, there were significant differences in visual analogue scale (VAS) and Japanese Orthopaedic Association (JOA) score among 4 groups (P<0.05). ResultsCerebrospinal fluid leakage occurred in 9 cases (2 cases in group A, 1 case in group B, 3 cases in group C, and 3 cases in group D), and was cured after symptomatical treatment. There was no postoperative complication of wound infection, lamina re-closing, or C5 nerve root paralysis in 4 groups. The follow-up time ranged from 24 to 74 months (mean, 35 months). In group D, 17 patients (23.6%) had deteriorated symptom at 6-12 months after operation, and good recovery was achieved in the patients of the other 3 groups. At last follow-up, the JOA score and VAS score were significantly improved when compared with the preoperative scores in 4 groups (P<0.05); the JOA score, improvement rate, and VAS score of group D were significantly lower than those of groups A, B, and C (P<0.05), but there was no significant difference among groups A, B, and C (P>0.05). ConclusionIn the multi-level CSM, the anterior compression of the spinal cord should be classified, this has a guiding significance for the prognosis of CSM and the choice of surgical method.