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PubMed2002

Cervical motion segment replacement.

When symptoms bring to light a cervical spine degenerative disc process that requires surgical intervention, a symptom relieving procedure such as decompression, followed by functional restoration, arthroplasty, offers the benefit of prophylaxis of accelerated spondylosis at the operated level. In addition, by altering the biomechanical stress factors at adjacent levels, theoretically it should offer prophylactic benefit at these levels as well. The design requirements for a cervical disc prosthesis, the importance of precision instrumentation, and technique are described. Mechanical testing, animal testing, the study design for the EU clinical study, and the operative technique are discussed. The clinical 1- and 2-year data to date are presented.

Adult↗
PubMed2004

Degenerative spondylolisthesis of the cervical spine--symptoms and surgical strategies depending on disease progress.

BACKGROUND: Degenerative spondylolisthesis of the cervical spine is rare. Patients show signs of progredient myelopathy, radiculopathy and pain. Treatment strategies include ventral, dorsal and combined fusion techniques with or without repositioning and decompression. METHODS: In this study, we present 16 patients with degenerative cervical spondylolisthesis. The leading symptom was severe myelopathy in 8 patients, radiculomyelopathy in 5 patients and neck pain in 3 patients. However, neck pain was the initial symptom in all the patients and decreased when neurological symptoms became more evident. Radiographic examinations included plain radiography, MRI, CT, myelography and lateral tomography. RESULTS: Spondylolisthesis was located five times at level C3/4, C4/5 and C5/6. In three cases spondylolisthesis was located at level C7/T1. There were two patients with spondylolisthesis on two levels. Instability could be demonstrated by flexion/extension radiography in five cases. Patients were divided into three groups according to a newly introduced classification system. The surgical approach corresponded to this classification. In ten patients the spondylolisthesis could be corrected by extension and positioning, so discectomy and fusion on one or two levels with cage, plate and screws was sufficient. In five cases a corpectomy was necessary due to severe spondylosis. In one case a combined approach with dorsal decompression and release followed by ventral fusion was applied due to additional dorsal spinal cord compression. The follow-up period was 6-52 months. After surgery, none of the patients showed any signs of neurological deterioration. In all cases, a stable fusion was achieved with no signs of instability on flexion/extension radiographs. Neurological improvement was seen in 6 of 8 patients with myelopathy and 4 of 5 patients with radiculomyelopathy. The others showed stable disease. Pain relief was seen in all patients who complained of pain preoperatively. CONCLUSION: The aims of treatment for cervical spondylolisthesis are spinal cord decompression (ventral, dorsal or both), correction and fusion. The used procedure should depend on the severity of the cervical deformity, degree and side of the spinal cord compression, and the possibility of correction by extension and positioning.

Aged↗
PubMed2004

Surface-based registration accuracy of CT-based image-guided spine surgery.

Registration is a critical and important process in maintaining the accuracy of CT-based image-guided surgery. The aim of this study was to evaluate the effects of the area of intraoperative data sampling and number of sampling points on the accuracy of surface-based registration in a CT-based spinal-navigation system, using an optical three-dimensional localizer. A cadaveric dry-bone phantom of the lumbar spine was used. To evaluate registration accuracy, three alumina ceramic balls were attached to the anterior and lateral aspects of the vertebral body. CT images of the phantom were obtained (1-mm slice thickness, at1-mm intervals) using a helical CT scanner. Twenty surface points were digitized from five zones defined on the basis of anatomical classification on the posterior aspects of the target vertebra. A total of 20 sets of sampling data were obtained. Evaluation of registration accuracy accounted for positional and rotational errors. Of the five zones, the area that was the largest and easiest to expose surgically and to digitize surface points was the lamina. The lamina was defined as standard zone. On this zone, the effect of the number of sampling points on the positional and rotational accuracy of registration was evaluated. And the effects of the additional area selected for intraoperative data sampling on the registration accuracy were evaluated. Using 20 surface points on the posterior side of the lamina, positional error was 0.96 mm +/- 0.24 mm root-mean-square (RMS) and rotational error was 0.91 degrees +/- 0.38 degrees RMS. The use of 20 surface points on the lamina usually allows surgeons to carry out sufficiently accurate registration to conduct computer-aided spine surgery. In the case of severe spondylosis, however, it might be difficult to digitize the surface points from the lamina, due to a hypertrophic facet joint or the deformity of the lamina and noisy sampling data. In such cases, registration accuracy can be improved by combining use of the 20 surface points on the lamina with surface points on other zones, such as on the both sides of the spinous process.

Analysis of Variance↗
PubMed2006

Technical note: the swimmer's view for cervical facet joint injections.

Image intensifier (C-arm) guided facet infiltration of a mixture of long acting local anaesthetic and corticosteroid is a safe and effective office procedure for cervical spondylosis. Visualisation of lower cervical anatomy using C-arm may not always be possible due to the shadow cast by the shoulders. We describe the successful adaptation of swimmer's view in such cases to carry out the injections.

Anesthetics, Local↗
PubMed2001

Kyphotic malalignment after anterior cervical fusion is one of the factors promoting the degenerative process in adjacent intervertebral levels.

The aim of this study was to determine whether postoperative malalignment of the cervical spine after anterior interbody fusion surgery promotes degenerative changes in the neighboring intervertebral discs. Forty-two patients who underwent anterior interbody fusion surgery for cervical spondylosis and disc herniation (34 men, 8 women) were followed for an average of 9.8 years. The average age at surgery was 50.2 years. Twenty-three patients underwent a single-level fusion, 17 underwent two-level fusion, and 2 had three levels fused. The Japanese Orthopaedic Association cervical myelopathy score, with a normal score 17 points, was 11.7 before surgery and 14.9 at follow-up. Neurological status was significantly improved postoperatively, and the improvement was preserved thereafter in most cases (paired t-test, P<0.001). Degenerative changes were evident on radiological examination in the levels adjacent to the fused segment in 21 of the 42 (50%) patients. Eight of these 21 patients demonstrated neurological deterioration caused by an adjacent disc lesion. A total of 43% of the patients with adjacent-level degeneration had malalignment of the cervical spine, such as kyphosis or sigmoid curvature. In addition, degenerative change in adjacent intervertebral levels was observed in 77% of kyphoses of the fused segment. These were statistically significant (Fisher exact method, P<0.05, P<0.04, respectively). Our findings suggest that one of the factors promoting degenerative change in adjacent intervertebral levels after anterior cervical fusion for degenerative disorders is postoperative kyphotic change in the cervical spine and the fused segment.

Cervical Vertebrae↗
PubMed2000

Cervical radiculopathy and myelopathy: when and what can surgery contribute to treatment?

Indications and timing of surgical treatment for cervical radiculopathy and myelopathy, and the long-term results for the conditions, were reviewed. Advances in spinal imaging and accumulation of clinical experience have provided some clues as to indications and timing of surgery for cervical myelopathy. Duration of myelopathy prior to surgery and the transverse area of the spinal cord at the maximum compression level were the most significant prognostic parameters for surgical outcome. Thus, when myelopathy is caused by etiological factors that are either unchangeable by nature, such as developmental canal stenosis, or progressive, such as ossification of the posterior longitudinal ligament, surgical treatment should be considered. When an etiology of myelopathy is remissible, such as soft disc herniation and listhesis, surgery may be reserved until the effects of conservative treatment are confirmed. When surgery is properly carried out, long-term surgical results are expected to be good and stable, and the natural course of myelopathy secondary to cervical spondylosis may be modified. However, little attention has been paid to the questions "When and what can surgery contribute to treatment of cervical radiculopathy?". A well-controlled clinical study including natural history should be done to provide some answers.

Cervical Vertebrae↗
PubMed1999

Ten- to 15-year outcome of surgery for lumbar disc herniation: radiographic instability and clinical findings.

The most appropriate treatment for radiculopathy associated with disc pathology is still controversial. Since 1934, surgical treatment has consisted of hemilaminectomy and removal of the herniated material. Many authors believe that these procedures may cause degenerative spondylosis and vertebral instability. Several surgical methods have been proposed, but the long-term effects are still being debated. In addition there appear to be few well-designed outcome studies on the management of this disease. In the present study, 150 patients were selected for surgery with strict criteria and all treated with the standard technique. The series was evaluated by subjective analyses (Roland questionnaire; 120 patients), objective examinations (68 patients - 56.6%) and radiographic studies including dynamic views (analyzed by the Taillard and Boxall methods) to establish the presence of vertebral instability (50 patients - 41.6%). The subjective and objective analyses showed a high rate of good results. Radiographic studies showed vertebral instability in 30 cases, but only 9 were symptomatic. Recurrences were not observed and only a few patients suffered from leg pain. The standard procedure for lumbar disc herniation showed good results at 10- and 15-year follow-up.

Adult↗
PubMed2000

Outcome scores in degenerative cervical disc surgery.

Forty-six consecutive patients with neck pain and arm radiculopathy were treated with anterior cervical discectomy and fusion. All patients had neurological symptoms corresponding to a herniated disc and/or spondylosis at one or two cervical levels, verified by magnetic resonance imaging. The patients were stabilized with an anterior graft and randomized to either fixation with a CSLP plate or no internal fixation. Preoperatively and 2 years postoperatively the patients filled in a questionnaire that included a modified Million Index, a modified Oswestry Index and the Zung Depression Scale. They were also asked to register their pain in the arm and in the neck on a vertical visual analogue scale (VAS). At the 2-year follow-up, an unbiased observer graded the patients' clinical outcome using Odom's criteria. A test-retest procedure was carried out to examine the questionnaire reproducibility. In the group that was operated at one level, there was no significant improvement in any of the scores. Nevertheless, 81% of the patients were satisfied with the outcome of the surgery. All scores improved in the group operated at two levels. The pain in the neck and arm, as measured on a VAS, decreased in both groups. The improvement in arm pain was significantly more pronounced in patients operated with a plate at two levels compared to those who were operated without a plate. At the 2-year follow-up, patients with an excellent or good result according to Odom's criteria had a lower Million Index (P < 0.0005), Oswestry Index (P < 0.0005), and Zung (P = 0.024) score, than the group classified as fair or poor. There was a significant correlation (P < 0.0001 for all scores) between the test and retest results. We conclude that the modified Million Index and Oswestry Index are clinically useful tools in the evaluation of outcome after degenerative cervical disc surgery. The clinical benefits of plate fixation were minimal. The outcome after surgery, measured with the Oswestry Index, Million Index and VAS for arm and neck pain, seems to correlate well with the classification of outcome by Odom.

Adult↗
PubMed2002

Cervical cage fusion with 5 different implants: 250 cases.

BACKGROUND: Anterior decompression with interbody fusion is the surgical procedure of choice in cervical spondylosis. Graft harvesting complications occurring from classical fusion procedures favoured ongoing development of cage technology. To evaluate efficiency of cage fusion for surgical treatment of discogenic cervical disorders, this six-year retrospective study analyses 250 consecutive cases treated by interbody cage fusion with 5 different implants. METHODS: Indications for fusion concerned degenerative discopathies, disc herniations and selected cases of failed surgery presenting with radiculopathy (228 cases) or myelopathy (22 cases). Screwed threaded titanium cages (149 cases), impacted squared or anatomically shaped Peek cages (59 cases), and impacted titanium cages (42 cases) were used together with local graft or bone substitute. Additional plating was indicated in 16 unstable cases. FINDINGS: Excellent outcome for neck pain (96%) and radiculopathy (97%) was noted, but a less favourable one for myelopathy (60%). All cases were stabilised at 1 year. Complications leading to reoperation included cage migration and subsidence, adjacent level degeneration and stenotic myelopathy. INTERPRETATION: Cage technology simplified anterior cervical interbody fusion and proved efficient. The fact there was no graft harvesting saved operating time and hospital stay. STATEMENT: It is not the intention of the author to indicate material preference in this article.

Cervical Vertebrae↗
PubMed2004

Phrenic paresis and respiratory insufficiency associated with cervical spondylotic myelopathy.

Cervical spondylotic myelopathy is a common disease caused by chronic segmental compression of the spinal cord. Despite the fact that the columns of the nuclei of the phrenic nerve are located between the 3rd and 5th cervical nerve segments, phrenic nerve paresis is not usually clinically significant. We present one case of cervical spondylotic myelopathy with bilateral phrenic paresis in whom magnetic resonance imaging and surgical findings confirmed intrinsic cord disease as being the cause of this syndrome. This case report suggests that one pathophysiology of clinical phrenic nerve paresis may be segmental damage to the anterior horns caused by cervical spondylosis.

Cervical Vertebrae↗
PubMed1999

The extent of drilling in lateral approaches to the cranio-cervical junction area from a series of 125 cases.

The trans-condylar approach to the craniocervical junction area (CCJA) requires a more or less extensive drilling of the two first cervical joints (C0-C1 and C1-C2). The extent of drilling necessary to resect a lesion at the CCJA was analyzed from a series of 125 cases including 114 tumours and 11 non-tumoural processes treated using a lateral approach (postero-lateral or antero-lateral) over a 15-year period (1980-1995). The extent of drilling was estimated on CT scanner axial views from the reduction of the joints surface and three groups were determined: A/less than one third B/between one third and one half, and C/more than one half. The extent of drilling was compared with the lesion location in relation to the bone limits of the CCJA: within these limits, outside them and into the bony structures. It was also analyzed with regard to pathology when separated into three groups non-osseous tumours, osseous tumours and chordomas, and non tumoural processes. Only 26 cases had a significant drilling, i.e., more than one third of the joint surfaces and of these, 14 were more than one half. In all these 14 cases, the bone structures were already invaded and 13 of them were, to some extent, beyond the bone limits of the CCJA. Of the 12 cases with drilling between one third and one half, 11 involved the bone structures and 1 was located inside the CCJA bone limits. Drilling of more than one third was required only in the case of bone lesions: 10 out of 23 bone tumours, all the 14 cases of chordomas, one case of rheumatoid arthritis and one case of C1-C2 joint spondylosis. In the other cases including mostly non-osseous tumours, drilling was limited to less than one third, though a high rate of complete removal was achieved (98%). Stabilization by arthrodesis with posterior grafting (N = 10) or by lateral bone grafting (N = 5) was achieved in all cases involving more than one half drilling, and in one case of tuberculosis. By adequately choosing the surgical approach, the extent of drilling can always be minimal. Extensive bone resection is only necessary when the tumour has already destroyed the joints. In that case, lateral or posterior fusion is an efficient technique.

Axis, Cervical Vertebra↗
PubMed1999

Anterior cervical discectomy (ACD) versus anterior cervical fusion (ACF), clinical and radiological outcome study.

This study was conducted on 90 patients with symptomatic cervical disc disease with one or two-level disc pathology. Clinical and radiological outcome was compared to determine which technique was advantageous for patients with disc disease. Problems related to donor site as well as those related to fusion bed and grafts have stimulated investigators to avoid fusion. Patients were allocated at random for either the ACF (n=50) or the ACD (n=40) procedures. The standard Smith-Robinson technique was performed on all patients in this study. Patients were followed-up clinically and radiologically according to the study protocol. The clinical long-term outcome was comparable in both groups, though those who had ACF were more satisfied. There was significant incidence of kyphosis in the ACD group (P=0.02). Osseous union was slow and less satisfactory with ACD (64%) than with ACF (94%). Pain at the donor site was not a significant problem in the long-term. Hospital stay and operative time was shortened in ACD patients though not significantly. Spondylotic patients were less satisfied with ACD though not significantly. Conclusions. The issue of whether to fuse or not to fuse has not come to an end yet. The technique is still in need of more refinement of disc excision and graft harvesting and shaping, as well as more adequately controlled studies. Until that, ACD has to be limited to those patients with a soft single disc without spondylosis.

Adult↗
PubMed2001

Analgesic effect of etidronate on degenerative joint disease.

In the present study, 80 patients with degenerative joint disease, spondylosis deformans, and/or osteoarthritis of the knee with back or joint pain, especially on movement and strain, were randomly divided into four groups. Group A received no etidronate, while groups B, C and D received 66, 133 and 200 mg/day etidronate, respectively, for 12 months. Every 3 months, after evaluating subjective pain on a visual rating scale (VRS), skin impedance was measured with subjects in a quiet sitting position and with the application of various strains on the spine and knee, including standing up from quiet sitting on a chair, bending forward to flex the spine, squatting to flex the knee, walking 20 paces on a flat floor, ascending 10 stair steps and descending 10 stair steps. A dose related improvement of subjective pain on the VRS with a parallel decrease in the percentage fall in skin impedance was noted. The intra-individual coefficients of variation (CV) of L1-L4 bone mineral density (BMD) on dual-energy X-ray absorptiometry were calculated as a possible index for spondylotic changes before and after treatment as an indication of spondylotic deformity, because no established method is yet available to evaluate such changes objectively. A dose-related decrease in CV of BMD was also noted, parallel to the analgesic effect.

Aged↗
PubMed2002

The effect of active absorbable algal calcium (AAA Ca) with collagen and other matrix components on back and joint pain and skin impedance.

The effect of active absorbable algal calcium (AAA Ca) with collagen and other matrix components on aging-associated skin changes and backache and joint pain was tested in a case-controlled study of 40 test subjects and 40 age-matched control subjects (mean age, 65 years) complaining of backache and knee joint pain due to osteoarthritis, spondylosis deformans, and/or osteoporosis. Supplementation with 900 mg calcium (given as AAA Ca) and 3.5 g collagen and other matrix components, including glucosamine, daily for 4 months resulted in a marked alleviation of subjective pain, assessed by the face scale. A fall of skin impedance in response to exercise loads, such as standing up, walking, squatting, and climbing up and down stairs, reported as an objective manifestion of pain, was also alleviated. The basal skin impedance, which increases with age, was significantly reduced in response to the Ca-collagen-matrix supplementation, suggesting a change of skin properties similar to rejuvenation, along with subjective smoothening and moistening of the skin. Urinary excretion of N-terminal crosslinking telopeptide of type I collagen (NTx) was decreased in the Ca-collagen-matrix supplementation group, but not in the control group. In addition to calcium suppression of parathyroid hormone, preventing bone resorption, collagen, acting on the intestinal lymphatic system, may protect collagen from degradation through the inhibition of cytokine-induced release of metalloproteinases, including collagenase.

Absorption↗
PubMed2005

Multivariate analysis of the neurological outcome of surgery for cervical compressive myelopathy.

BACKGROUND: The neurological outcome of decompressive surgery for cervical myelopathy is influenced by several factors. Although each factor may have an independent effect, it is more likely that the outcome is influenced by more than one factor. We examined the results of multivariate analysis and multiple regression analysis of the neurological outcome of patients treated by cervical cord decompression. METHODS: A total of 77 patients with cervical spondylotic myelopathy (43 men, 34 women) and 58 with ossification of the posterior longitudinal ligament (OPLL) (39 men, 19 women) were studied with an average follow-up interval of 8.3 years. The clinical data, neurological and radiological findings, and results of spinal cord evoked potentials (SCEPs) were retrieved from the medical records and included in the analysis. RESULTS: Multivariate analysis indicated that the outcome for patients with spondylosis was positively influenced, in order of importance, by increased transverse area of the cord >or=60%, presence of single-level anterior fusion, a high preoperative neurological score, normal epidural SCEPs, and clinical features of brachialgia and cord type. In patients with OPLL, multivariate analysis showed that the long-term outcome was positively influenced, in order of importance, by the presence of mixed or localized OPLL, normal epidural SCEPs, high preoperative neurological score, a single-vertebra spondylectomy with anterior fusion, laminoplasty, widening of the transverse area of the cord >or=40%, and an expansion rate of the spinal canal after laminoplasty >or=40%. CONCLUSIONS: We suggest that multivariate analysis is useful for assessing the neurosurgical outcome in patients with cervical compressive myelopathy.

Adult↗
PubMed2000

The effect of trunk muscle exercises in patients over 40 years of age with chronic low back pain.

Previous studies of trunk muscle strength in patients with chronic low back pain (CLBP) have mainly reported on patients aged younger than 40 years. However, no such investigation has yet been done in middle-aged patients. Trunk muscle strength and the effect of trunk muscle exercises were investigated in patients with CLBP aged more than 40 years. Trunk muscle strengths were measured in a LBP group (52 patients) and a control group (60 volunteers) and the results for the two groups were compared. The LBP group was divided into three subgroups. Group A had only age-related spondylosis and group B had disk herniation and spondylolisthesis with age-related spondylotic change. Both these groups were able to continue exercises. Group C was made up of patients who had abandoned the exercise program. Trunk muscle strength and symptoms were assessed in each group. Both flexion and extension strength were decreased in the LBP group compared with the control group, with the reduction in extension strength being most marked. In both groups A and B, muscle strength increased and clinical symptoms improved. In contrast, no change was seen in group C. In older patients with CLBP, reduction of muscle strength was more marked in the spinal extensors than in the spinal flexors. It was confirmed that trunk muscle strengthening exercises are useful for increasing muscle strength and improving symptoms in such patients.

Adult↗
PubMed2002

Impact of waist/hip ratio on the therapeutic efficacy of lumbosacral corsets for chronic muscular low back pain.

Aseries of 143 new outpatients who had had chronic low back pain for longer than 3 months, with neither a positive straight leg raise test nor radiographic abnormality including lumbar spondylosis, were treated for 4 weeks with a traditional lumbosacral corset or one with a front-to-back tensile band (extensile corset). Randomization was performed according to birth date. Radiographs were used to analyze the change in sacral inclination angle with and without the respective corset. Central obesity subgroups consisted of men with a waist/hip ratio (W/H) of > or =90% and women with a W/H ratio of > or = 80%. Quebec Back Pain Disability Scale scores were measured at baseline and at 4 weeks. The mean changes in sacral inclination were +3.8 degrees +/- 5.4 degrees in the extensile corset group ( n = 72) and -2.6 degrees +/- 4.6 degrees in the traditional corset group ( n = 71). Thus, the extensile corset had a mechanical effect opposite to that of the traditional corset. Participants without central obesity who were treated with the extensile corset ( n = 30) demonstrated significant improvement compared to participants with the traditional corset ( n = 33) ( P = 0.034). Central obesity should be considered when recommending corsets for patients with chronic muscular low back pain.

Adult↗
PubMed2003

Anterior retroperitoneal lumbosacral spine exposure: operative technique and results.

We review our two-team operative technique and results of anterior retroperitoneal lumbosacral spine exposure for diskectomy, partial corpectomy, and spinal instrumentation. Seventy-two patients with lumbar spondylosis and associated symptomatic radiculopathy had this exposure between January 1, 2000 and January 1, 2002. A single disc space was isolated in 54 patients. Multilevel exposure was achieved in 18 patients. Main outcome measures included intra- and postoperative complications, blood transfusion requirements, duration of ileus, incidence of erectile/sexual dysfunction, and length of hospital stay. A single small bowel enterotomy and iliac vein laceration, both repaired primarily, were the only intraoperative complications. Perioperative blood transfusions were required in 13 patients (18%). Mean length of postoperative ileus was 3.5 days and average length of hospital stay was 5 days. Postoperative complications occurred in 7 patients (9.7%). These included erectile dysfunction (2), transient unilateral lower extremity paresis (1), acute acalculous cholecystitis (1), femoral vein thrombosis (1), pneumonia (1), and acute myocardial infarction (1). There were no genitourinary or other major vascular injuries. A two-team approach for lumbosacral spine instrumentation via anterior retroperitoneal exposure capitalizes on unique specialty-specific surgical skills. This paradigm facilitates safe lumbosacral spine surgery and major perioperative complications are rare.

Adult↗