Objective To investigate the operational method of cervical vertebral flavectomy and its cl inical appl ication in the management of cervical canal stenosis. Methods From June 1997 to June 2007, 25 patients suffering from cervical spinal canal stenosis caused by obvious flaval l igament hypertrophy were given flavectomy. There were 22 males and 3 females, with an age range of 32 to 68 years (average 54 years). The course of disease was from 3 weeks to 7 years, with an average of 3 years and 7 months. All patients had degenerative cervical canal stenosis; of them, 5 cases had a history of cervical injury 2 to 3 weeks before operation (3 cases of fall ing injury and 2 cases of traffic accident injury). The X-ray film, CT, and MRI examinations showed that the compression locations were C4-7 in 12 cases, C3-7 in 9 cases, C5-7 in 3 cases, and C6,7 in 1 case. Spinous process and vertebral lamella were exposed by central posterior approach. The insertions of flaval l igaments were cut off at the superior vertebral lamella border, then the starting points of which were cut down from the anterior side of the upper vertebral lamella at their inferior border after l ifting up the flaval l igaments. The residual flaval l igaments in front of the vertebral lamella were scraped off by slope rongeur, the dura mater then could be seen to inflate from the intervertebral lamella space, showing the compression having been rel ieved. Twenty-five cases were all given posterior flavectomy. At 1 week to 3 months after operation, 12 patients received anterior cervical discectomy or vertebral gaining decompression with fusion by bone graft. Results The time for flavectomy was from 60 to 180 minutes, with an average of 95 minutes. The blood loss during operation was from 90 to 360 mL, with an average of 210 mL. The dura maters were lacerated by knife tips during operation with the cervical vertebrae in hyperflexion in 2 cases. Immediate suture and repair were performed and there were no postoperative cerebrospinal fluid leakage. All the incisions healed by first intension after operation. All of the 25 cases were followed up from 2 to 10 years, with an average of 3 years and 9 months. All patients had no compl ication of axial symptoms, and no restenosis at their operation site of cervical canal stenosis. The section area ratios of functional spinal canal to spinal cord were 1.12 ± 0.07 before operation and 2.11 ± 0.19 at 24 months after operation, showing significant difference (P lt; 0.05). The range of motion of cervical vertebrae was (39.4 ± 3.2)º befeore operation and (42.1 ± 2.9)° at 24 months after operation in 13 cases without anterior cervical discectomy fusion, showing no significant difference (P gt; 0.05); was (34.3 ± 3.4)° before operation and (29.2 ± 3.6)° at 24 months after operation in 12 cases with anterior cervical discectomy fusion, showing significant difference (P lt; 0.05). The bone graft achieved bony union 3-5 months after operation (average 3.8 months). The Japanese Orthopaedic Association (JOA) scores were 7.9 ± 2.2 before operation and 15.6 ± 1.4 at 24 months after operation, showing significant difference (P lt; 0.05), with an average improvement rate of 86.3%. Conclusion Cervical flavectomy could rel ieve compression to spinal cord and nerves caused by the flaval l igament hypertrophy without damaging the normal integral ity of bony canal, thus avoiding the compl ication of axial symptoms and so on which are encountered in open-door expansile cervical laminoplasty.
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.
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 evaluate the effectiveness of microplate fixation in open-door cervical expansive laminoplasty (ELP) by comparing with anchor fixation. Methods Between January 2005 and October 2008, 35 patients with multi-segment cervical spondylotic myelopathy were treated. Of them, 15 patients underwent ELP by microplate fixation (microplate group) and 20 patients underwent ELP by anchor fixation (anchor group). In microplate group, there were 10 malesand 5 females with the age of (51.2 ± 11.5) years; the disease duration ranged from 6 to 60 months (mean, 14 months); and the preoperative Japanese Orthopoaedic Association (JOA) score was 7.7 ± 2.5. In anchor group, there were 13 males and 7 females with the age of (50.7 ± 10.8) years; the disease duration ranged from 3 to 58 months (mean, 17 months); and the preoperative JOA score was 7.8 ± 2.9. There was no significant difference in the general data, such as gender, age, and JOA score between 2 groups (P gt; 0.05). Results All incisions healed by first intention. Thirty-five cases were followed up 24-68 months (mean, 32 months). The operation time was (113 ± 24) minutes in anchor group and (111 ± 27) minutes in microplate group, showing no significant difference (t=0.231 3, P=0.818 5). The rate of spinal canal expansion in microplate group (60% ± 24%) was significantly higher than that in anchor group (40% ± 18%) (t=2.820, P=0.008). The JOA scores of 2 groups at 3 months and 24 months after operation were significantly higher than the preoperative scores (P lt; 0.01). There was no significant difference in JOA score between 2 groups at 3 months after operation (t=1.620 5, P=0.114 6), but the JOA score of microplate group was significantly higher than that of anchor group at 24 months after operation (t=3.454 3, P=0.001 5). X-ray film, MRI, and CT scan at 3-6 months after operation displayed that door spindle reached bony fusion. There was no occurrence of ‘‘re-close of door’’ in 2 groups. The rate of compl ication in microplate group (13.3%, 2/15) was significantly lower than that in anchor group (25.0%, 5/20) (χ2=7.160 0, P=0.008 6). Conclusion ELP by microplate fixation can achieve the stabil ity quickly after operation, which can help patients to do functional exercises early, and has satisfactory effectiveness and less complications.
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.
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 treatment methods and the cl inical therapeutic effects of symptomatic cervical vertebral hemangioma associated with cervical spondylotic myelopathy. Methods A retrospective analysis was performed in 18 patients (10 males and 8 females, aged 30-62 years with an average age of 45.3 years) with cervical vertebral hemangioma associated with cervical spondylotic myelopathy between January 2006 and September 2008. The disease duration was 10-26 months (mean, 15.6 months). All patients had single vertebral hemangioma, including 2 cases at C3, 3 cases at C4, 5 cases at C5, 5 cases at C6, and 3 cases at C7. The X-ray films showed a typical “pal isade” change. According to the cl inical and imaging features, there were 13 cases of type II and 5 cases of type IV of cervical hemangioma. The standard anterior cervical decompression and fusion with internal fixation were performed and then percutaneous vertebroplasty (PVP) was used. The cervical X-ray films were taken to observe bone cement distribution and the internal fixation after operation. The recovery of neurological function and the neck pain rel ief were measured by Japanese Orthopaedic Association (JOA) score and visual analogue scale (VAS) score. Results All operations were successful with no spinal cord and nerves injury, and the incisions healed well. Anterior bone cement leakage occurred in 2 cases without any symptoms. All cases were followed up 24-28 months (mean, 26 months) and the symptoms were improved at different degrees without fracture and collapse of vertebra or recurrence of hemangioma. During the follow-up, there was no implant loosening, breakage and displacement, and the mean fusion time was 4 months (range, 3-4.5 months). The JOA score and VAS score had a significant recovery at 3 months and at last follow-up when compared with preoperative values (P lt; 0.05). Based on JOA score at last follow-up, the results were excellent in 9 cases, good in 6 cases, fair in 2 cases, and poor in 1 case. Conclusion The anterior cervical decompression and fusion with internalfixation combined with PVP treatment is one of the ideal ways to treat symptomatic cervical vertebral hemangioma associated with cervical spondylotic myelopathy, which could completely decompress the spinal cord and effectively alleviate the cl inical symptoms caused by vertebral hemangioma.
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 compare the clinical and radiographic outcomes between laminoplasty and laminectomy compression and fusion with internal fixation to treat cervical spondylotic myelopathy. MethodsBetween September 2006 and September 2009, 143 cases of multilevel cervical myelopathy (the affected segments were more than 3) were treated by laminoplasty in 87 cases (group A) and by laminectomy decompression and fusion with lateral mass screw fixation in 56 cases (group B). There was no significant difference in gender, age, disease duration, pathological type, and affected segments between 2 groups (P gt; 0.05). The operation time, intraoperative blood loss, improvement of neurological function [Japanese Orthopaedic Association (JOA) 17 score], and the incidences of complications were observed; the cervical curvature index (CCI), range of motion (ROM), and symptoms of neck and shoulder pain [visual analogue scale (VAS) and neck disability index (NDI) scores] were recorded and compared. ResultsThere was no significant difference in operation time and intraoperative blood loss between 2 groups (P gt; 0.05). All patients were followed up 18-30 months (mean, 24 months). C5 nerve root palsy occurred in 4 cases (4.60%) of group A and in 5 cases (8.93%) of group B, showing no significant difference (χ2=0.475, P=0.482). No complication of deep infection, pseudarthrosis, or screw loosening occurred. No closure of opened laminae was observed in group A; and no screw extrusion, breakage, or nerve injury was observed in group B. At last follow-up, neck axial symptoms appeared in 35 cases (40.23%) of group A and in 11 cases (19.64%) of group B, showing significant difference (χ2=6.612, P=0.009). No significant difference was found in JOA score, CCI, ROM, or VAS scores between 2 groups at preoperation (P gt; 0.05); the JOA score, ROM, and VAS scores of groups A and B and CCI of group A at last follow-up were significantly improved when compared with preoperative ones (P lt; 0.05). No significant difference was found in the JOA score, improvement rate, and VAS score between 2 groups (P gt; 0.05); however, significant differences were found in ROM and CCI between 2 groups (P lt; 0.05). There were significant differences (P lt; 0.05) in pain intensity, lifting, work, reaction, driving, and total score between 2 groups at last follow-up. ConclusionLaminectomy decompression and fusion with internal fixation can effectively relieve pain, but it will greatly reduce the ROM; laminoplasty has less complications and satisfactory outcome. The two methods have similar effectiveness in the improvement of neurological function.