Cervical Spondylotic Myelopathy : Postoperative Results and Prognostic Factors

Kim, Hyun Jib,Chung, Chun-Kee 대한신경외과학회 1994 Journal of Korean neurosurgical society Vol.23 No.6

목 적 : Cervical Spondylotic Myelopathy(CSM)의 치료에 대하여는 많은 논란이 있다. 이의 예후에는 연령, 수술전 증세정도, 증상지속기간등이 관계한다고 알려져 있다. 본 연구는 영향력이 있다고 알려진 예후 인자들의 영향력을 조사하여 치료의 지침을 삼고자 하였다. 대상 및 방법 : 최근 10년간 본 교실에서 수술하였던 CSM증례중 검토가 가능하였던 56례를 대상으로 하였다. 남녀비는 남자가 53례, 여자가 3례였다. 연령분포는 22세에서 74세로 평균 50.8세였다. 전방경유법을 25례, 후방경유법을 33례에서 시행하였다. 2례에서는 전방 및 후방경유법을 같이 시행하였다. 척수증의 정도는 Nurick Grade를 사용하였다. 수술전 Nurick Grade의 분포는 2.75±0.16(mean±standard error)였다. 추적 관찰기간은 13.8±2.1개월이었다. 전 증례들을 대상으로 연령, 수술전 증세정도 및 증상지속기간의 예후영향력을, 87년도 이후의 증례에서는 자기공명영상상 T2WI에서 보이는 고신호강도의 예후영향력을 검토하였다. 결 과 : 마지막 추적검사상의 Nurick Grade는 2.125±0.14로 수술전과 비교하면 0.63±0.12의 호전을 관찰할 수 있었다. 전방경유법의 경우 0.52±0.14, 후방경유법의 경우 0.73±0.18의 호전이 관찰되었으나 통계적으로 의미가 없었다(P=0.82). 합병증으로는 전방경유법에서 식도루가 1례, 이식골편의 골절 또는 흡수가 2례에서 관찰되었다. 후방경유법의 경우 경추의 굴곡변화가 6례에서 관찰되었다. 예후인자의 분석에서 마지막 추적검사상의 Nurick Grade와 수술전후의 호전에 미치는 영향력은 수술전 증세정도만이 의의 가 있었다(P=0.000). 기타 연령, 증상지속기간 및 T2WI상의 고신호강도는 의미있는 영향력을 보이지 못했다. 결 론 : 적절한 적응증을 적용한다면 전방 경유법이나 후방경유법이나 예후에 차이는 없다고 판단된다. 수술전 증세정도가 마지막 추적검사상의 Nurick Grade에 영향을 미치는 유일한 수술전 예후인자였다. There a* many factors affecting surgical results of cervical spondylotic myelopathy. Age, duration of symptom, neurologic status, and direction of surgical approach are said to have prognostic implications. Also a high signal intensity on T2 weighted magnetic resonance imaging (HSI on T2WI) is insisted as a poor prognostic factor. We analyzed these factors in 56 patients treated over a 10-year period retrospectively. Statistical analysis was done using chi square, Mantel-Haenszel, Cochran-Mantel-Haenszel, Wilcoxon, and logistic procedure. We preferred anterior decompression when compressive lesions existed ventrally. H o w e r posterior decompression was performed in a 4 or more level stenosis Age ranged from 22 to 74 yeadmean : 50.8). 25 patients underwent the anterior procedure, 33 patients the posterior procedure, and 2 both procedures. Neurologic status was graded both preoperatively and at follow-up using the Nurick grading system from 1 to 5. The preoperative Nurick grade was 2.75f 0.16(meank SE.) Mean follow-up period was 13.8 months(SE 0.14). The follow-up Nurick grade was 2125f 0.14, and these was noted an improvement of 0.63f0.12. The amount of improvement was equivalent between the anterior and the posterior approaches(0.52 vs. 0.73 respectively, p=0.67). There was no mortality. Uni- and multivariant analysis demonstrated that age, duration of symtom and HSI on T2WI had no si@icant effect on either follow-up Nurick grade or amount of improvement but the preoperative Nurick grade had a significant effect(p<O.W). Comparable results can be obtained with either approaches if chosen properly. Only the preoperative Nurick grade has the prognostic value.

Stand-Alone Cervical Cages in 2-Level Anterior Interbody Fusion in Cervical Spondylotic Myelopathy: Results from a Minimum 2-Year Follow-up

Eugene Pak-Lin Ng,Andrew Siu-Leung Yip,Keith Hay-Man Wan,Michael Siu Hei Tse,Kam Kwong Wong,Tik-Koon Kwok,Wing Cheung Wong 대한척추외과학회 2019 Asian Spine Journal Vol.13 No.2

Study Design: A retrospective review of patients who underwent 2-level anterior cervical discectomy and fusion (ACDF) with stand-alone polyetheretherketone (PEEK) cages for cervical spondylotic myelopathy (CSM). Purpose: To evaluate the efficacy of stand-alone PEEK cage in 2-level cervical interbody fusion for CSM. Overview of Literature: ACDF is a standard surgical procedure to treat degenerative disc disease. However, the use of additional anterior plating for 2-level ACDF remains controversial. Methods: We reviewed outcomes of patients who underwent 2-level ACDF with stand-alone PEEK cages for CSM over a 7-year period (2007–2015) in a regional hospital. Japanese Orthopaedic Association (JOA) score, fusion rate, subsidence rate, cage migration, and cervical alignment by the C2–7 angle as well as the local segmental angle (LSA) of the cervical spine were assessed. Results: In total, 31 patients (mean age, 59 years; range, 36–87 years) underwent 2-level ACDF with a cage-only construct procedure between 2007 and 2015. The minimum follow-up was 24 months; mean follow-up was 51 months. C3–5 fusion was performed in 45%, C4–6 fusion in 32%, and C5–7 fusion in 23%. Mean JOA score improved from 10.1±2.2 to 13.9±2.1 (p<0.01) at the 24-month follow-up. Fusion was achieved in all patients. Subsidence occurred in 22.5% of the cages but was not associated with differences in JOA scores, age, sex, or levels fused. Lordosis of the C2–7 angle and LSA increased after surgery, which were maintained for up to 1 year but subsequently disappeared after 2 years, yet the difference was not statistically significant. No cage migration was noted; two patients developed adjacent segment disease requiring posterior laminoplasty 3 years after ACDF. Conclusions: The use of a stand-alone PEEK cage in a 2-level cervical interbody fusion achieves satisfactory improvements in both clinical outcomes and fusion.

Outcome Measures and Variables Affecting Prognosis of Cervical Spondylotic Myelopathy: WFNS Spine Committee Recommendations

Mehmet Zileli,Shradha Maheshwari,Shashank Sharad Kale,Kanwaljeet Garg,Sajesh K. Menon,Jutty Parthiban 대한척추신경외과학회 2019 Neurospine Vol.16 No.3

This study is conducted to review the literature systematically to determine most reliable outcome measures, important clinical and radiological variables affecting the prognosis in cervical spondylotic myelopathy patients. A literature search was performed for articles published during the last 10 years. As functional outcome measures we recommend to use modified Japanese Orthopaedic Association scale, Nurick’s grade, and Myelopathy Disability Index. Three clinical variables that affect the outcomes are age, duration of symptoms, and severity of the myelopathy. Examination findings require more detailed study to validate their effect on the outcomes. The predictive variables affecting the outcomes are hand atrophy, leg spasticity, clonus, and Babinski’s sign. Among the radiological variables, the curvature of the cervical spine is the most important predictor of prognosis. Patients with instability are expected to have a poor surgical outcome. Spinal cord compression ratio is a critical factor for prognosis. High signal intensity on T2-weighted magnetic resonance images is a negative predictor for prognosis. The most important predictors of outcome are preoperative severity and duration of symptoms. T2 hyperintensity and cord compression ratio can also predict outcomes. New radiological tests may give promising results in the future.

Cervical Spondylotic Myelopathy: Natural Course and the Value of Diagnostic Techniques –WFNS Spine Committee Recommendations

Mehmet Zileli,Sachin A. Borkar,Sumit Sinha,Rui Reinas,Óscar L. Alves,김세훈,Sumeet Pawar,Bala Murali,Jutty Parthiban 대한척추신경외과학회 2019 Neurospine Vol.16 No.3

Objective: This study presents the results of a systematic literature review conducted to determine most up-to-date information on the natural outcome of cervical spondylotic myelopathy (CSM) and the most reliable diagnostic techniques. Methods: A literature search was performed for articles published during the last 10 years. Results: The natural course of patients with cervical stenosis and signs of myelopathy is quite variable. In patients with no symptoms, but significant stenosis, the risk of developing myelopathy with cervical stenosis is approximately 3% per year. Myelopathic signs are useful for the clinical diagnosis of CSM. However, they are not highly sensitive and may be absent in approximately one-fifth of patients with myelopathy. The electrophysiological tests to be used in CSM patients are motor evoked potential (MEP), spinal cord evoked potential, somatosensory evoked potential, and electromyography (EMG). The differential diagnosis of CSM from other neurological conditions can be accomplished by those tests. MEP and EMG monitoring are useful to reduce C5 root palsy during CSM surgery. Notable spinal cord T2 hyperintensity on cervical magnetic resonance imaging (MRI) is correlated with a worse outcome, whereas lighter signal changes may predict better outcomes. T1 hypointensity should be considered a sign of more advanced disease. Conclusion: The natural course of CSM is quite variable. Signal changes on MRI and some electrophysiological tests are valuable adjuncts to diagnosis.

Outcome Measures of Functionality, Social Interaction, and Pain in Patients with Cervical Spondylotic Myelopathy: A Validation Study for the Iranian Version of the Copenhagen Neck Functional Disability Scale

Hossein Nayeb Aghaei,Parisa Azimi,Sohrab Shahzadi,Shirzad Azhari,Hassan Reza Mohammadi,Pooyan Alizadeh,Ali Montazeri 대한척추외과학회 2015 Asian Spine Journal Vol.9 No.6

Study Design: Cross-sectional. Purpose: To translate and validate the Iranian version of the Copenhagen Neck Functional Disability Scale (CNFDS). Overview of Literature: Instruments measuring patient-reported outcomes should satisfy certain psychometric properties. Methods: Ninety-three cases of cervical spondylotic myelopathy were entered into the study and completed the CNFDS pre and postoperatively at the 6 month follow-up. The modified Japanese Orthopedic Association Score was also completed. The internal consistency, test-retest, convergent validity, construct validity (item scale correlation), and responsiveness to change were assessed. Results: Mean age of the patients was 54.3 years (standard deviation, 8.9). The Cronbach α coefficient was satisfactory (α=0.84). Test-retest reliability as assessed by the intraclass correlation coefficient analysis was 0.95 (95% confidence interval, 0.92–0.98). The modified Japanese Orthopedic Association score correlated strongly with the CNFDS score, lending support to its good convergent validity (r =−0.80; p <0.001). Additionally, the correlation of each item with its hypothesized domain on the CNFDS was acceptable, suggesting that the items had a substantial relationship with their own domains. These results also indicate that the instrument was responsive to change (p <0.0001). Conclusions: The findings suggest that the Iranian version of the CNFDS is a valid measure to assess functionality, social interaction, and pain among patients with cervical spondylotic myelopathy.

Cervical Lordosis Ratio as a Novel Predictor for the Loss of Cervical Lordosis After Laminoplasty

Kosei Ono,Sohei Murata,Mutsumi Matsushita,Hiroshi Murakami 대한척추신경외과학회 2021 Neurospine Vol.18 No.2

Objective: Maintaining cervical lordosis (CL) after laminoplasty is important for indirect decompression of the spinal cord. This study aimed to identify preoperative dynamic radiographic predictors for the loss of CL after laminoplasty. Methods: We retrospectively analyzed 141 consecutive patients who underwent cervical laminoplasty for cervical myelopathy. The following radiographic parameters were measured before surgery and at 1 year of follow-up: CL, C7 slope, C2–7 sagittal vertical axis (SVA), C2–7 range of motion (ROM), CL in flexion, CL in extension, ROM of flexion (Flex ROM), and ROM of extension. The CL ratio (CLR) was defined as 100×Flex ROM/C2–7 ROM. ΔCL was defined as postoperative CL minus preoperative CL. Patients were classified into 2 groups: group K (kyphotic change group, ΔCL ≤-10) and group C (control group, ΔCL >-10). Results: The patient population comprised 94 men and 47 women (mean age, 70.9±9.4 years), with 24 patients (17.0%) classified into group K. CL, C7 slope, and CLR were significantly higher in group K than in group C. The groups did not significantly differ in age, sex, C2–7 SVA, and C2–7 ROM. On multivariable analysis, the CLR was significantly associated with postoperative kyphotic changes. On receiver-operating characteristic curve analysis (area under the curve=0.717, p<0.001), the cutoff value for CLR was 68.9%, with sensitivity and specificity of 87.5% and 57.3%, respectively. Conclusion: The CLR, reflecting the balance between flexion and extension mobility, was identified as a novel predictor for CL loss after laminoplasty, with a cutoff value of 68.9%.

Value of Surgery and Nonsurgical Approaches for Cervical Spondylotic Myelopathy: WFNS Spine Committee Recommendations

Jutty Parthiban1,Oscar L. Alves,Komal Prasad Chandrachari,Premanand Ramani,Mehmet Zileli 대한척추신경외과학회 2019 Neurospine Vol.16 No.3

Cervical spondylotic myelopathy (CSM) is a common cause of adult spinal cord dysfunction. Although the therapeutic options for moderate to severe CSM patients have been established well, the existing guidelines for therapeutic decisions in mild cases of CSM are unclear. We present a review of literature on conservative treatment and surgery for CSM and suggest general recommendations applicable in various clinical presentations and in different geographic locations across the globe, with due considerations to available resources and locally prevalent practices.

A Severe Cervical Spondylotic Myelopathy Patient Treated with Integrative Korean Medicine Including Acupuncture, Bee Venom Pharmacopuncture and Herbal Medicine: a case report

An, Da-young,Kim, Chae-eun,Han, Suzy,Kim, Mi-kyung,Yu, Jun-Sang,Sun, Seung-ho KOREAN PHARMACOPUNCTURE INSTITUTE 2022 Journal of pharmacopuncture Vol.25 No.2

Cervical spondylotic myelopathy (CSM) is common in elderly people and severe CSM patients are recommended to receive surgery. However, in some cases, surgery may fail to improve the patients' symptoms. An 80-year-old man diagnosed with CSM complained of right hemiplegia and right arm and leg pain with the presence of a Foley catheter, despite treatment with laminectomy and laminoplasty. Acupuncture, bee venom pharmacopuncture, and herbal medicine were administered for 129 days. As a result, manual muscle testing (MMT) and the Modified Barthel Index (MBI) improved, the pain in his right arm and leg decreased, and he was able to urinate by himself. This case report implies that integrative Korean medicine (IKM) can be an option for patients suffering from muscular weakness resulting from myelopathy.

퇴행성 경추질환의 MRI 및 임상소견 분석

김원기,김동원,이장철,손은익,임만빈,김인홍 대한신경외과학회 1993 Journal of Korean neurosurgical society Vol.22 No.2

계명의대 동산의료원 신경외과에 1990년 5월부터 1991년 4월가지 1년간 MRI검사 후 퇴행성 경추질환으로 입원한 30명의 MRI 소견, 임상소견 및 수술 소견을 분석하여 요약하면, 1) MRI 소견상 척수압박정도와 임상 증상의 정도와 상호 밀접한 연관성이 있었을 뿐 아니라 MRI 추적검사로써 수술전후 임상소견의 예측에 도움이 되었다. 2) T2WI에 보이는 척수내 국소 HSI은 심한 척수압박과 척수병증을 보이는 환자애서 호발되었다. 3) 그러므로 MRI는 퇴행성 경추질환의 진단과 수술의 decision-making에 우선적으로 이용될 수 있는 진단방법으로 생각되며 척수내 국소 HSI 소견은 좋은 예후 판정인자로 생각된다. We undertook a retrospective analysis of 30 patients admitted to the Department of Neurosurgery Dongsan Medical Center Keimyung University utilizing Magnetic Resonanace Imaging (MRI) to make diagnosis and surgical indication of degenerative cervical spine lesions. All patients were taken T1 Weighted Image(T1W1) T2 Weighted Image (T2WI) and gradient echo image on 2.0 Tesla unit Pre- and postoperative MRI were obtained seven of 15 cases with myelopathy. All patients could be evaluated the extent and degree of disc herniation, osteophytes and cord compression. A focal area of High-Signal-Intensity (HSI) was observed on T2WI in 15 patients with myelopathy predominantly. HSI diminished postoperatively in the patients who improved clinically and remained the same in on case whose condition remained unchanged after decompression. We think MRI with high resolution images in the initial procedure of choice in decision-making of patients with degenerative cervical spine lesion. Furthermore HSI of the spinal cord produced by compressive lesions appears to be an important indicator for predicting prognosis of patients with myelopathy.

경추증성 척수증에서 경추 후궁 성형술 후 경추 운동범위의 변화

안재성,이준규,이우용,황정모 대한척추외과학회 2012 대한척추외과학회지 Vol.19 No.3

Study Design: A retrospective study. Objectives: This study examined the cervical range of motion (ROM) of cervical spondylotic myelopathy patients, before and after open door laminoplasty. Summary of Literature Review: Majority of the cases regarding the change of cervical range of motion after cervical laminoplasty showed decreased range of motion, and the results were diverse. Materials and Methods: Of the 487 patients, who underwent open door laminoplasty at our hospital from March 1997 to March 2008,98 had been followed for at least 2 years and had cervical flexion-extension lateral x-rays. In all patients, open door laminoplasty involved at least three segments: three, four, and five segments in 11, 52, and 35 patients, respectively. In previous cases, fixation involved sutures using suture anchors. The lordosis or kyphosis between C2 and C7 was analyzed using cervical flexion-extension lateral radiographs before and 2 years after the operation. Results: The average patient age was 62.7 (range 32–82) years; 65 patients were male and 33 were female. From preoperatively to postoperatively, the average kyphosis of cervical flexion decreased from 10.7° to 7.8°, average lordosis decreased from 21.2° to 14.2°,and cervical ROM decreased from 31.9° to 22.0°, respectively (mean 9.9°, 31.0%). Conclusions: We could observe decreased cervical range of motion after cervical laminoplasty for cervical spondylotic myelopathic patients. Thus, the treatment to prevent the postoperative decrease of cervical range of motion and further study to find a new treatment are thought to be essential. 연구 계획: Suture anchor를 이용한 경추 후궁 성형술 후 경추 운동범위의 변화에 대한 후향적 연구목적: 경추 후궁 성형술을 시행한 경추증성 척수증 환자에서 수술 전과 후의 경추 운동범위의 변화에 대해 살펴보고자 한다. 선행문헌의 요약: 경추 후궁 성형술 후 경추 운동범위의 변화에 대한 많은 연구에서 운동범위의 감소가 있었고, 다양한 결과를 보고하였다. 대상 및 방법: 1997년 3월부터 2008년 3월까지 본원에서 경추 후궁 성형술을 시행한 487예 중 2년 이상 추시가 가능하였으며, 수술 전과 후에 경추부굴곡-신전 측면 단순 방사선 촬영을 시행하였던 경추증성 척수증 환자 98예를 대상으로 후향적 연구를 시행하였다. 모든 환자들은 3분절 이상의 경추후궁 성형술을 시행 받았다. 전례에서 suture anchor를 삽입하여 봉합사를 이용하여 고정하였으며, 수술 전 및 수술 후 2년 추시 시에 시행한 경추부 굴곡-신전 측면 단순 방사선 사진을 이용하여 제 2-7 경추 간의 전만 또는 후만각을 측정하였다. 결과: 평균 연령은 62.7(32~82)세였고, 총 98예(남자 65예, 여자 33예)였다. 경추부 굴곡 시 수술 전 후만각은 평균 10.7도에서 수술 후 7.8도로 유의하게 감소하였고 경추부 신전 시 수술 전 전만각은 평균 21.2도에서 수술 후 평균 14.2도로 유의하게 감소하였다. 경추부의 운동범위는 수술 전 평균 31.9도에서 수술 후 평균 22.0도로 9.9도(31.0%) 감소하였다. 분절 범위에 따라서는 3분절, 4분절, 5분절의 경추 후궁 성형술을 받은 군에서는 경추부의 운동범위가 각각 수술 전 평균 47.0도, 32.2도, 26.7도에서 수술 후 평균 33.7도, 23.8도, 15.5도로 각각 13.3도(28.3%), 8.4도(26.1%), 11.2도(41.9%) 씩유의하게 감소하였다. 결론: 경추증성 척수증 환자에서 경추 후궁 성형술 후 경추 운동범위의 감소를 확인하였다. 그러므로 수술 후 경추 운동범위 감소 예방을 위한 치료와새로운 수술법에 대한 추가 연구가 필요할 것으로 사료된다.