Cervical spinal stenosis: outcome after anterior corpectomy, allograft reconstruction, and instrumentation

2002 ◽  
Vol 96 (1) ◽  
pp. 10-16 ◽  
Author(s):  
Matthew T. Mayr ◽  
Brian R. Subach ◽  
Christopher H. Comey ◽  
Gerald E. Rodts ◽  
Regis W. Haid
Keyword(s):  
Spinal Stenosis ◽  
Content Type ◽  
Cervical Corpectomy ◽  
Allograft Reconstruction ◽  
Postoperative Hematoma ◽  
Asymptomatic Patients ◽  
Anterior Corpectomy ◽  
Cervical Spinal Stenosis ◽  
Anterior Plating ◽  
Fine Print

Object. The authors undertook a retrospective single-institution review of 261 patients who underwent anterior cervical corpectomy, reconstruction with allograft fibula, and placement of an anterior plating system for the treatment of cervical spinal stenosis to assess fusion rates and procedure-related complications. Methods. Between October 1989 and June 1995, 261 patients with cervical stenosis underwent cervical corpectomy, allograft fibular bone fusion, and placement of instrumentation for spondylosis (197 patients), postlaminectomy kyphosis (27 patients), acute fracture (25 patients), or ossification of the posterior longitudinal ligament (12 patients). All patients suffered neck pain and cervical myelopathy or radiculopathy refractory to medical management. Of the procedures, 133 involved a single vertebral level (two disc levels and one vertebral body), 96 involved two levels, 31 involved three levels, and a single patient underwent a four-level procedure. Clinical and radiographic outcomes were assessed postoperatively and at 6-month intervals. The mean follow-up period was 25.7 months (range 24–47 months). Successful fusion was documented in 226 patients (86.6%). A stable, fibrous union developed in 33 asymptomatic patients (12.6%), whereas an unstable pseudarthrosis in two patients (0.8%) required reoperation. There were no cases of infection, spinal fluid leakage, or postoperative hematoma. Complications included transient unilateral upper-extremity weakness (two patients), dysphagia (35 transient and seven permanent), and hoarseness (35 transient and two permanent). In 14 patients (5.4%) radiological studies demonstrated evidence of hardware failure. Conclusions. Cervical corpectomy with fibular allograft reconstruction and anterior plating is an effective means of achieving spinal decompression and stabilization in cases of anterior cervical disease. Symptomatic improvement was achieved in 99.2% of patients. In their series the authors found a fusion rate of 86.6% and rates of permanent hoarseness of 3.4%, dysphagia of 0.7%, and an instrumentation failure rate of 5.4%.

Modified open-door laminoplasty for treatment of neurological deficits in younger patients with congenital spinal stenosis: analysis of clinical and radiographic data

1999 ◽  
Vol 90 (2) ◽  
pp. 170-177 ◽  
Author(s):  
Christopher I. Shaffrey ◽  
Gregory C. Wiggins ◽  
Cynthia B. Piccirilli ◽  
Jacob N. Young ◽  
LaVerne R. Lovell
Keyword(s):  
Spinal Stenosis ◽  
Neurological Deficits ◽  
Open Door ◽  
Younger Patients ◽  
Content Type ◽  
Flexion Extension ◽  
Postoperative Flexion ◽  
Cervical Spinal Stenosis ◽  
Fine Print

Object. Multilevel anterior cervical decompressive surgery and fusion effectively treats cervical myeloradiculopathy that is caused by severe cervical spinal stenosis, but degenerative changes at adjacent vertebral levels frequently result in long-term morbidity. The authors performed a modified open-door laminoplasty procedure in which allograft bone and titanium miniplates were used to treat cervical myeloradiculopathy in younger patients with congenital canal stenosis while maintaining functional cervical motion segments. Pre- and postoperative magnetic resonance imaging and/or computerized tomography myelography were performed to assess changes in cervical spinal canal dimensions. Pre- and postoperative flexion—extension radiographs were compared to determine the residual motion of the targeted operative segments. Methods. Twenty younger patients (average age 37.7 years) underwent modified open-door laminoplasty for treatment of myelopathy or myeloradiculopathy related to significant cervical spinal stenosis with or without associated central or lateral disc herniation or foraminal stenosis. These surgeries were performed during a 2-year period and follow-up review remains ongoing (average follow-up period 21.6 months). Reconstructive procedures were performed on an average of 4.1 levels (range three—six). Operative time averaged 186 minutes (range 93–229 minutes). Average blood loss was 305 ml (range 100–650 ml). No cases were complicated by neurological deterioration, infection, wound breakdown, graft displacement, or hardware failure. The patients' Nurick Scale grade improved from a preoperative average of 1.8 to a postoperative average of 0.5. Pre- and postoperative sagittal spinal diameter averaged 11.2 mm (8–14 mm) and 16.6 mm (13–19 mm), respectively. The sagittal compression ratio (sagittal/lateral × 100%) increased from 48% pre- to 72% postoperatively. The spinal canal area increased an average of 55% (range 19–127%). In patients in whom pre- and postoperative flexion—extension radiographs were obtained, 72.7% residual neck motion was maintained. No patient developed increased neck or shoulder pain. Neurological symptoms improved in all patients, with total relief of myelopathy in 50% and partial improvement in 50%. Conclusions. Modified open-door laminoplasty with allograft bone and titanium miniplates effectively treats neurological deficits in younger patients with congenital and spinal stenosis. Although long-term results are unknown, short-term results are good and there is a low incidence of complications.

A fatal, chronically growing basilar artery: a new type of dissecting aneurysm

1996 ◽  
Vol 84 (6) ◽  
pp. 962-971 ◽  
Author(s):  
Tohru Mizutani
Keyword(s):  
Mr Imaging ◽  
Basilar Artery ◽  
Dissecting Aneurysm ◽  
Neurological Deficits ◽  
Vertebrobasilar Insufficiency ◽  
Content Type ◽  
Asymptomatic Patients ◽  
Basilar Arteries ◽  
Fine Print

✓ A long-term follow-up study (minimum duration 2 years) was made of 13 patients with tortuous dilated basilar arteries. Of these, five patients had symptoms related to the presence of such arteries. Symptoms present at a very early stage included vertebrobasilar insufficiency in two patients, brainstem infarction in two patients, and left hemifacial spasm in one patient. Initial magnetic resonance (MR) imaging in serial slices of basilar arteries obtained from the five symptomatic patients showed an intimal flap or a subadventitial hematoma, both of which are characteristic of a dissecting aneurysm. In contrast, the basilar arteries in the eight asymptomatic patients did not show particular findings and they remained clinically and radiologically silent during the follow-up period. All of the lesions in the five symptomatic patients gradually grew to fantastic sizes, with progressive deterioration of the related clinical symptoms. Dilation of the basilar artery was consistent with hemorrhage into the “pseudolumen” within the laminated thrombus, which was confirmed by MR imaging studies. Of the five symptomatic patients studied, two died of fatal subarachnoid hemorrhage (SAH) and two of brainstem compression; the fifth patient remains alive without neurological deficits. In the three patients who underwent autopsy, a definite macroscopic double lumen was observed in both the proximal and distal ends of the aneurysms within the layer of the thickening intima. Microscopically, multiple mural dissections, fragmentation of internal elastic lamina (IEL), and degeneration of media were diffusely observed in the remarkably extended wall of the aneurysms. The substantial mechanism of pathogenesis and enlargement in the symptomatic, highly tortuous dilated artery might initially be macroscopic dissection within a thickening intima and subsequent repetitive hemorrhaging within a laminated thrombus in the pseudolumen combined with microscopic multiple mural dissections on the basis of a weakened IEL. The authors note and caution that symptomatic, tortuous dilated basilar arteries cannot be overlooked because they include a group of malignant arteries that may grow rapidly, resulting in a fatal course.

The therapeutic window for spinal cord decompression in a rat spinal cord injury model

2005 ◽  
Vol 3 (4) ◽  
pp. 302-307 ◽  
Author(s):  
Christopher B. Shields ◽  
Y. Ping Zhang ◽  
Lisa B. E. Shields ◽  
Yingchun Han ◽  
Darlene A. Burke ◽  
...  
Keyword(s):  
Spinal Cord ◽  
Spinal Cord Injury ◽  
Spinal Stenosis ◽  
Spinal Cord Compression ◽  
Cord Compression ◽  
Therapeutic Window ◽  
Content Type ◽  
Significant Difference ◽  
Cord Injury ◽  
Fine Print

Object. There are no clinically based guidelines to direct the spine surgeon as to the proper timing to undertake decompression after spinal cord injury (SCI) in patients with concomitant stenosis-induced cord compression. The following three factors affect the prognosis: 1) severity of SCI; 2) degree of extrinsic spinal cord compression; and 3) duration of spinal cord compression. Methods. To elucidate further the relationship between varying degrees of spinal stenosis and a mild contusion-induced SCI (6.25 g-cm), a rat SCI/stenosis model was developed in which 1.13- and 1.24-mm-thick spacers were placed at T-10 to create 38 and 43% spinal stenosis, respectively. Spinal cord damage was observed after the stenosis—SCI that was directly proportional to the duration of spinal cord compression. The therapeutic window prior to decompression was 6 and 12 hours in the 43 and 38% stenosis—SCI lesions, respectively, to maintain locomotor activity. A significant difference in total lesion volume was observed between the 2-hour and the delayed time(s) to decompression (38% stenosis—SCI, 12 and 24 hours, p < 0.05; 43% stenosis—SCI, 24 hours, p < 0.05) indicating a more favorable neurological outcome when earlier decompression is undertaken. This finding was further supported by the animal's ability to support weight when decompression was performed by 6 or 12 hours compared with 24 hours after SCI. Conclusions. Analysis of the findings in this study suggests that early decompression in the rat improves locomotor function. Prolongation of the time to decompression may result in irreversible damage that prevents locomotor recovery.

Efficacy of neuroradiological imaging, neurological examination, and symptom status in follow-up assessment of patients with high-grade gliomas

2000 ◽  
Vol 93 (2) ◽  
pp. 201-207 ◽  
Author(s):  
Evanthia Galanis ◽  
Jan C. Buckner ◽  
Paul Novotny ◽  
Roscoe F. Morton ◽  
William L. McGinnis ◽  
...  
Keyword(s):  
Mr Imaging ◽  
Neurological Examination ◽  
High Grade ◽  
Performance Score ◽  
Content Type ◽  
Asymptomatic Patients ◽  
Symptom Status ◽  
High Grade Gliomas ◽  
Fine Print

Object. It is standard practice for the oncological follow-up of patients with brain tumors (especially in the setting of clinical trials) to include neurological examination and neuroradiological studies such as computerized tomography (CT) or magnetic resonance (MR) imaging in addition to evaluation of the patients' symptomatology and performance score. The validity of this practice and its impact on the welfare of patients with high-grade gliomas has not been adequately assessed. The purpose of this study is to provide such an assessment.Methods. The authors studied 231 similarly treated patients who were participating in three prospective North Central Cancer Treatment Group or Mayo Clinic trials who developed progressive disease during follow up. According to the protocol, the symptom status, performance score, results of neurological examination, and CT or MR status were recorded prospectively in each patient at each evaluation (every 6–8 weeks).At progression, 177 (77%) of 231 patients experienced worsening of their baseline symptoms or they developed new ones. In the remaining 54 asymptomatic patients (23%), neuroradiological imaging revealed the progression. Asymptomatic progression was more likely to be detected on MR imaging compared with CT studies (p < 0.01). In no asymptomatic patient was progression detected on neurological examination alone. The median survival time after tumor recurrence was 13.3 weeks in symptomatic patients compared with 41.7 weeks in the asymptomatic group (p < 0.0001). Asymptomatic patients were more aggressively treated, with surgery (p < 0.0001) and second-line chemotherapy (p < 0.0002). Multivariate analysis of survival time following first progression by using both classification and regression trees and Cox models showed that treatment at recurrence was the most important prognostic variable.Conclusions. Symptoms are the most frequent indicators of progression in patients with high-grade gliomas (77%). All asymptomatic progressions were detected on neuroradiological studies; MR imaging was more likely than CT scanning to reveal asymptomatic recurrences. Survival after disease progression was significantly longer in asymptomatic patients and could be related both to treatment following progression and to other favorable prognostic factors such as performance score.

Radiculopathy of C-5 after anterior decompression for cervical myelopathy

2005 ◽  
Vol 3 (3) ◽  
pp. 210-217 ◽  
Author(s):  
Minoru Ikenaga ◽  
Jitsuhiko Shikata ◽  
Chiaki Tanaka
Keyword(s):  
Cervical Myelopathy ◽  
Japanese Orthopaedic Association ◽  
Posterior Longitudinal Ligament ◽  
Manual Muscle Testing ◽  
Radiographic Evaluation ◽  
Anterior Decompression ◽  
Content Type ◽  
Muscle Testing ◽  
Anterior Corpectomy ◽  
Fine Print

Object. The authors conducted a study to examine the incidence and causes of postoperative C-5 radiculopathy, and they suggest preventive methods for C-5 palsy after anterior corpectomy and fusion. Methods. The authors included in the study 18 patients with postoperative C-5 radiculopathy from 563 patients who underwent anterior decompression and fusion for cervical myelopathy. There were 10 cases of ossification of the posterior longitudinal ligament (OPLL) and eight cases of cervical spondylotic myelopathy (CSM). All patients received conservative treatment. Posttreatment full recovery was present in eight patients, and Grade 3/5 strength was documented in six in whom some weakness remained. Radiographic evaluation revealed that the C3–4 and C4–5 cord compression was significantly more severe in patients with paralysis than in those without paralysis. The incidence of paralysis was higher in patients with OPLL than in those with CSM (chi-square test, p = 0.03). The incidence of paralysis increased in parallel with the number of fusion levels (correlation coefficient r = 0.94). Multivariate analysis revealed that the final manual muscle testing (MMT) value was closely related to the preoperative MMT value (computed t value 4.17; p < 0.01) and preoperative Japanese Orthopaedic Association (JOA) score for cervical myelopathty (computed t value, 2.75; p < 0.05). Conclusions. Preexisting severe stenosis at C3–4 or C4–5 in patients with OPLL is a risk factor for paralysis. Preoperative muscle weakness and a low JOA score are factors predictive of poor recovery.

Atlantoaxial stabilization in rheumatoid arthritis

1991 ◽  
Vol 74 (1) ◽  
pp. 1-7 ◽  
Author(s):  
Stephen M. Papadopoulos ◽  
Curtis A. Dickman ◽  
Volker K. H. Sonntag
Keyword(s):  
Rheumatoid Arthritis ◽  
Spinal Cord ◽  
Spinal Cord Compression ◽  
Cord Compression ◽  
Atlantoaxial Subluxation ◽  
High Rate ◽  
Content Type ◽  
Operative Stabilization ◽  
Asymptomatic Patients ◽  
Fine Print

✓ Atlantoaxial subluxation in patients with rheumatoid arthritis is common. Operative stabilization is clearly indicated when signs and symptoms of spinal cord compression occur. However, many recommend early operative fusion before evidence of appreciable neural compression occurs because 1) the myelopathy in these patients may be irreversible; 2) the overall prognosis is poor once symptoms of cord compression are present; and 3) the risk of sudden death associated with atlantoaxial subluxation is increased even in asymptomatic patients. The authors believe that rheumatoid arthritis patients in relatively good health without advanced multisystem disease and less than 65 years of age should be considered for operative stabilization if mobile atlantoaxial subluxation is greater than 6 mm. Seventeen patients with severe rheumatoid arthritis and atlantoaxial subluxation treated with a posterior arthrodesis are presented. A new method of fusion, devised by the senior author (V.K.H.S.), was utilized in all cases. Indications for operative therapy in these patients included evidence of spinal cord compression in 11 patients (65%) and mobile atlantoaxial subluxation greater than 6 mm but no signs or symptoms of cord compression in six patients (35%). Thirteen patients developed a stable osseous fusion, two patients a well-aligned fibrous union, one patient a malaligned fibrous union, and one patient died prior to evaluation of fusion stability. The details of the operative technique and management strategies are presented. Several technical advantages of this method of fusion make this approach particularly useful in patients with rheumatoid arthritis. Because of multisystem involvement of this disease, a high rate of osseous fusion is often difficult to achieve.

Tonsillar herniation: the rule rather than the exception after lumboperitoneal shunting in the pediatric population

1993 ◽  
Vol 78 (4) ◽  
pp. 568-573 ◽  
Author(s):  
Paul D. Chumas ◽  
Derek C. Armstrong ◽  
James M. Drake ◽  
Abhaya V. Kulkarni ◽  
Harold J. Hoffman ◽  
...  
Keyword(s):  
Morphological Changes ◽  
Pediatric Population ◽  
Pseudotumor Cerebri ◽  
Foramen Magnum ◽  
Tonsillar Herniation ◽  
Content Type ◽  
Asymptomatic Patients ◽  
The Mean ◽  
Sick Children ◽  
Fine Print

✓ Although the development of tonsillar herniation (acquired Chiari malformation) in association with lumboperitoneal (LP) shunting is well recognized, it has previously been considered rare. In order to ascertain the incidence of this complication after LP shunting, the authors undertook a retrospective study of all patients in whom this form of shunt had been inserted between 1974 and 1991 at The Hospital for Sick Children, Toronto. In the 143 patients, the mean age at insertion was 3.3 years and the indications for shunt placement were hydrocephalus (81%), pseudotumor cerebri (7%), cerebrospinal fluid fistula (6%), and posterior fossa pseudomeningocele (6%). The mean follow-up period was 5.7 years, during which time there was one shunt-related death due to unsuspected tonsillar herniation. Five other patients developed symptomatic tonsillar herniation treated by suboccipital decompression. Review of all computerized tomography (CT) scans not degraded by artifact showed evidence of excess soft tissue at the level of the foramen magnum in 38 (70%) of 54 patients so studied. In order to confirm that this CT finding represented hindbrain herniation, sagittal and axial magnetic resonance (MR) images were obtained for 17 asymptomatic patients and revealed tonsillar herniation (range 2 to 21 mm) in 12 (70.6%). In addition, some of these asymptomatic patients had evidence of uncal herniation and mesencephalic distortion. Similarities and distinctions are drawn between the morphological changes occurring after LP shunting and those seen in association with the Chiari I and II malformations. Although less than 5% of this study population required treatment for tonsillar herniation, the incidence of this complication was high in asymptomatic patients; MR imaging surveillance for patients with LP shunts is therefore recommended.

Odontoid upward migration in rheumatoid arthritis

1985 ◽  
Vol 63 (4) ◽  
pp. 500-509 ◽  
Author(s):  
Arnold H. Menezes ◽  
John C. VanGilder ◽  
Charles R. Clark ◽  
George El-Khoury
Keyword(s):  
Rheumatoid Arthritis ◽  
Cervical Vertebrae ◽  
Posterior Arch ◽  
Upward Migration ◽  
Lower Cranial Nerve ◽  
Content Type ◽  
Cervicomedullary Junction ◽  
Asymptomatic Patients ◽  
Cranial Nerve Palsies ◽  
Fine Print

✓ Lack of correlation between the severity of rheumatoid subluxation of the upper cervical vertebrae and supposed absence of neurological damage has led to the erroneous supposition that this finding is innocuous. Incomplete autopsy studies in rheumatoid arthritis have failed to recognize the cause of death, despite previously proven dramatic occipito-atlanto-axial dislocations. The most feared entity of rheumatoid basilar invagination, namely “cranial settling,” is poorly understood. Between 1978 and 1984, the authors treated 45 rheumatoid arthritis patients who were symptomatic with “cranial settling.” This consisted of vertical odontoid penetration through the foramen magnum (9 to 33 mm), occipito-atlanto-axial dislocation, lateral atlantal mass erosion, downward telescoping of the anterior arch of C-1 on the axis, and rostral rotation of the posterior arch of C-1 producing ventral and dorsal cervicomedullary junction compromise. Cervicomedullary junction dysfunction has mistakenly been called “entrapment neuropathy,” “progression of disease,” or “vasculitis.” Occipital pain occurred in all 45 patients, myelopathy in 36, blackout spells in 24, brain-stem signs in 17, and lower cranial nerve palsies in 10. Four patients had prior tracheostomies. Four previously asymptomatic patients with “cranial settling” presented acutely quadriplegic. The factors governing treatment were reducibility and direction of encroachment determined by skeletal traction and myelotomography. Transoral odontoidectomy was performed in seven patients with irreducible pathology. All patients underwent occipitocervical bone fusion (with C-1 decompression if needed) and acrylic fixation. Improvement occurred during traction, implying that compression might be the etiology for the neurological signs. There were no complications. Thus, “cranial settling” is a frequent complication of rheumatoid arthritis; although it is poorly recognized, it has serious implications and is treatable.

Syndrome of the incidental herniated lumbar disc

1983 ◽  
Vol 59 (1) ◽  
pp. 137-141 ◽  
Author(s):  
James E. Wilberger ◽  
Dachling Pang
Keyword(s):  
Clinical Features ◽  
Lumbar Disc Herniation ◽  
Lumbar Disc ◽  
Herniated Disc ◽  
Content Type ◽  
Asymptomatic Patients ◽  
Appropriate Treatment ◽  
Herniated Lumbar Disc ◽  
Fine Print

✓ Lumbar myelographic defects consistent with herniated disc were found in 108 asymptomatic patients undergoing myelography for other reasons. Within 3 years, 64% of these patients developed symptoms of lumbosacral radiculopathy. The clinical features of these patients comprise a syndrome significantly different from that typically associated with classical lumbar disc herniation: the syndrome described here carries a much higher incidence of silent root compression with minimal pain. Incidental lumbar myelographic defects are not necessarily benign findings, and patients in whom they are encountered deserve close clinical follow-up review and appropriate treatment if the defects become symptomatic.

Surgical treatment of lumbar spinal stenosis in patients older than 75 years of age

1999 ◽  
Vol 91 (2) ◽  
pp. 181-185 ◽  
Author(s):  
Todd W. Vitaz ◽  
George H. Raque ◽  
Christopher B. Shields ◽  
Steven D. Glassman
Keyword(s):  
Surgical Treatment ◽  
Spinal Stenosis ◽  
Lumbar Spinal Stenosis ◽  
Intraoperative Complication ◽  
Content Type ◽  
Fusion Procedure ◽  
Lumbar Decompression ◽  
Preoperative Selection ◽  
Lumbar Spinal ◽  
Fine Print

Object. The purpose of this study was to evaluate the safety and efficacy of the surgical treatment of lumbar spinal stenosis in patients older than 75 years of age. Methods. The authors reviewed the records of 65 patients with lumbar spinal stenosis who were at least 75 years of age at the time of surgery, which was performed between November 1990 and May 1996. The 65 patients (43 women, 22 men; average age 78 years) underwent a total of 71 operations (one patient underwent three, and four patients underwent two). Fifteen patients (21%) underwent isolated lumbar decompression, and 56 patients (79%) underwent decompression in conjunction with posterior spinal fusion. There was an average of 1.7 levels decompressed per isolated lumbar decompression and 2.6 levels per decompression and fusion procedure. Seven patients (10%) experienced one or more serious postoperative complication, which included wound infection, septicemia, small bowel obstruction, stroke, myocardial infarction, gastrointestinal bleeding, and pulmonary embolus. In addition there was one intraoperative complication (hypotension [1%]) that required modification of the planned surgical procedure. No deaths were documented in the perioperative period. Conclusions. With appropriate preoperative selection and evaluation, careful intraoperative monitoring, and attentive perioperative care, the surgical treatment of elderly patients with lumbar spinal stenosis can effect significant improvement with acceptable levels of morbidity and mortality.

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