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PubMed2003

Contraindications to the Dix-Hallpike manoeuvre: a multidisciplinary review.

The Dix-Hallpike manoeuvre is widely used in the diagnosis of positional vertigo and is regarded as safe. The manoeuvre involves a degree of neck rotation and extension, and consequently one might expect there to be some patients, particularly those with neck problems, in whom the manoeuvre is contraindicated. The term 'neck problem', however, encompasses a whole range of conditions, including soft tissue disorders, cervical spondylosis, prolapsed intervertebral disk, and severe rheumatoid arthritis with cervical instability. These in turn will give rise to a variety of symptoms, which will vary from minimal pain or stiffness to severe pain or complete immobility, and, in some cases, neurological deficit. Clarification is therefore needed to establish the point at which any neck pain or stiffness ceases to be a minor problem and becomes a contraindication to performing the Dix-Hallpike manoeuvre. This paper clarifies this issue by discussing the issue of absolute contraindications and proposing a simple functional assessment of neck mobility which can be performed prior to performing the Dix-Hallpike manoeuvre. Relative contraindications such as back pathology, vertebrobasilar ischaemia (posterior circulation ischaemic disease), nerve root compression and medical fitness are also discussed.

Humans↗
PubMed1988

Anterolateral uncoforaminotomy for cervical spondylotic myeloradiculopathy.

Thirty-five patients with cervical spondylotic radiculopathy and myeloradiculopathy had anterolateral uncoforaminotomy. Spondylotic spurs associated with radiculopathy were continuous from the uncovertebral joint to the posterior ridge of the vertebral body in 33 patients and to the posteriorly bulging disc with posterolateral bony spurs in 2 patients. Anterolateral uncoforaminotomy was found safe to remove the continuous type of spur, resulting in decompression of the cord-root complex, which shifted anteriorly after surgery. The outcome was satisfactory in 19 of 20 radiculopathy patients, and in all 15 myeloradiculopathy patients. Decompression of the cord-root complex is the most important factor in relieving neurologic manifestations of cervical spondylosis.

Adult↗
PubMed1995

[Central cervical cord syndrome: a case report on rehabilitation, with special references to accidental falls in the elderly].

An 81-year-old man with Parkinson's disease was admitted to our hospital with impaired function of all extremities. Four weeks before his symptoms developed, he had tripped on the steps, fallen and bruised his jaw. Following this episode he experienced a few more falls inside his house. On examination his greatest weakness was in the hands and wrists. He was hyper-reflexic in all extremities and had bilateral Babinski's sign. He could not walk and needed physical assistance in most of his daily living activities. X-ray films of the cervical spine showed significant degenerative changes. The magnetic resonance images suggested central cervical cord damage at the level of the C6 vertebral body. After three months' rehabilitation treatment, he became able to walk with a cane and became independent in all the basic activities of daily living except for bathing. He never regained skillful function of his hands despite later levodopa treatment of Parkinson's disease. His clinical features were consistent with the central cervical cord syndrome, described by Schnneider and co-workers in 1954. This syndrome may occur as a result of hyperextension neck injury, occasionally associated with an accidental fall in the elderly with cervical spondylosis. Thirteen patients with cervical spinal cord injury above 65 of age were admitted to our department from 1983 to 1993. Six of them presented with the central cervical cord syndrome, and all patients had a history of accidental injuries related to falling.

Accidental Falls↗
PubMed1997

Posterior lumbar interbody fusion in the treatment of symptomatic spinal stenosis.

Lumbar spinal stenosis is often the result of advanced degeneration of motion segments of the lumbar spine. Loss of disc height, facet displacement and hypertrophy, spondylosis, and spondylolisthesis, as well as buckling of the ligamentum flavum and annulus fibrosus, all contribute to impingement on the spinal canal and intervertebral foramen in lumbar stenosis. There is a subgroup of patients with spinal stenosis in whom the spine is unstable preoperatively or becomes destabilized following decompression who would benefit from an initial fusion procedure. Posterior lumbar interbody fusion (PLIF) addresses several aspects of the multifactorial pathophysiology responsible for spinal stenosis and may arrest the degenerative changes at the fused level. Fusion, in particular PLIF, should be considered in complex cases of lumbar spinal stenosis, most notably in patients with postlaminectomy stenosis or stenosis associated with spondylolisthesis.

Journal Article↗
PubMed1999

Efficacy of variable-angle screws in transpedicular fixation.

The purpose of this study was to evaluate the usefulness and efficacy of variable-angle screws in transpedicular fixation. Sixteen patients (10 men and six women, age range 44-73 years) underwent a posterior transpedicular fixation procedure in which variable-angle screws were placed at two or more levels. Four patients experienced spinal instability secondary to trauma, 10 patients suffered from degenerative spondylosis requiring fusion, and two patients were treated for spinal metastatic disease. All patients underwent posterior transverse process fusion in which autologous bone was used. In total, 37 vertebral levels were fixed with variable-angle screws placed at 22 levels. Postoperatively all patients were fitted with an external orthosis that was worn for 12 weeks. Serial postoperative plain x-ray films were obtained in all cases. Follow-up periods ranged from 11 to 24 months. Based on clinical and radiographic data, solid fusion was achieved in 14 of 16 patients. There were two early disconnections of the rod/screw connectors, which were related to errors in technique. With the exception of these disconnections, there were no cases of construct failure. There were no wound infections, and no patient experienced a decline in neurological function as compared with preoperative levels. Both instrumentation systems were easy to use, and the flexibility in trajectory allowed for quicker screw placement and decreased operating room time. Variable-angle pedicle screws are a safe, useful adjunct to transpedicular fixation, particularly in multisegment fixation and in spines with abnormal alignment.

Journal Article↗
PubMed2002

Two-level anterior cervical discectomy and cage-assisted fusion without plates.

OBJECT: Anterior cervical discectomy (ACD) is an effective and safe treatment for nerve root or spinal cord compression caused by disc herniation or spondylosis. Cervical interbody fusion allows preservation of the physiological lordosis and stability of the cervical spine. Based on data reported in the literature, fusion rates decrease significantly when more than one level undergoes surgery, and some authors recommend the addition of a plate system to improve results. At the authors' institution cervical carbon fiber cages (CFCs) are routinely used after ACD. They describe their experience in the treatment of 24 patients with two-level disease treated with CFCs alone. METHODS: Twenty-one patients with cervical radiculopathy and three with radiculomyelopathy underwent ACD. Surgery was performed at C5-6 and C6-7 in 18, at C4-5 and C5-6 in four, and at C3-4 and C5-6 in two patients. All the patients underwent magnetic resonance imaging and 15 also underwent computerized tomography (CT) to assess the results of surgery. Radiculopathy improved after surgery in all the cases, whereas myelopathy resolved in only one patient. At 1 year fusion was achieved in 96% of the surgically treated discs; this was verified on cervical spine x-ray films in all patients and on CT scans in three patients. Cervical lordosis was restored in eight of the nine patients in whom it was lost preoperatively. No complications related to cage extrusion and no cases of symptomatic pseudarthrosis were observed. CONCLUSIONS: Interbody fusion cages have a load-sharing function and stabilize the spine to increase segmental stiffness, thus achieving fusion rates similar to those associated with bone grafts, even in multilevel disease.

Adult↗
PubMed2002

Posterior cervical fixation using a new polyaxial screw and rod system: technique and surgical results.

OBJECT: Standard lateral mass plate and screw systems are of limited use in patients with abnormal cervical anatomy and do not easily allow for extension to either the occipit or the thoracic spine. The objective of this study was to demonstrate the safety, surgical efficacy, and advantages of a new cervical polyaxial screw and rod system for posterior occipitocervicothoracic arthrodesis. METHODS: The authors reviewed a multicenter series of patients who underwent surgery in which they used a new posterior cervical polyaxial screw and rod system. The system was implanted in 32 (20 women and 12 men) adult patients (mean age 56.9 years, range 23-84 years). Twenty-three of the patients were treated for spondylostenosis; four for cervical fracture/dislocations; four for kyphosis; and one patient was treated for pseudarthrosis that developed after prior surgery. The system was successfully implanted in all patients despite the presence of anatomical lateral mass anomalies in the majority of cases. The mean number of levels fused was 3.9 (range one-eight levels). This dynamic system allowed for screw placement into the occiput, C-1 lateral masses, C-2 pars, C3-7 lateral masses, and low cervical as well as upper thoracic pedicles. Selective application of compressive or distractive forces was possible in adjacent segments. Surgery-related complications included one dural tear and one malpositioned screw. There were two cases of wound infection. CONCLUSIONS: Unlike standard lateral mass plate and screw systems, the new cervical polyaxial screw and rod system easily accommodates severe degenerative cervical spondylosis and curvatures. This instrumentation system allows for polyaxial screw placement with subsequent multiplanar rod contouring and offset attachment. The authors have used this system successfully, and without significant complications, to achieve posterior cervical arthrodesis.

Adult↗
PubMed2002

Ossification of the cervical posterior longitudinal ligament: a review.

Ossification of the cervical posterior longitudinal ligament (OPLL) represents a continuum beginning with hypertrophy of the posterior longitudinal ligament (PLL) followed by progressive coalescence of centers of chondrification and ossification. Early OPLL mimicking disc disease appears opposite multiple disc spaces associated with significant retrovertebral extension, helping to differentiate it from spondylosis. On computerized tomography examinations, the single- and double-layer signs indicate possible dural penetration with the increased potential for an intraoperative cerebrospinal fluid fistula during dissection. Direct ventral resection of OPLL in patients younger than 65 years of age is optimal and includes single- or multilevel anterior corpectomy with fusion, the latter accompanied by posterior fusion. For patients older than the age of 65 years, with a well-preserved cervical lordosis, laminectomy with or without fusion and/or laminoplasty may suffice in providing indirect dorsal decompression. Patients undergoing circumferential procedures with halo devices are managed with a specific anesthetic protocol, including awake intubation and positioning with intraoperative monitoring of somatosensory evoked potentials, electromyography, and the option of undergoing motor evoked potential monitoring. Intubation is maintained during the 1st postoperative night. When circumferential procedures are performed intubation is always maintained during the 1st postoperative night, and fiberoptic postoperative extubation is electively performed by specifically trained anesthesiologists when deemed appropriate. Patients exhibiting three or more major risk factors are considered candidates for delayed extubation and rarely, tracheostomy. Repeated anterior surgery, operations lasting more than 10 hours, involving four or more levels (including C-2), obesity, asthma, and blood transfusions of more than 4 U (1000-1200 ml) are all considered major risk factors.

Cervical Vertebrae↗
PubMed2002

Complications of cervical spine manipulation therapy: 5-year retrospective study in a single-group practice.

OBJECT: The authors report a series of 22 patients in whom major complications developed after cervical spinal manipulation therapy (CSMT). A second objective was to estimate the regional incidence of these complications and to compare it with the very low incidences reported in the literature. METHODS: During a 5-year period, practioners at a single group neurosurgical practice in Tulsa, Oklahoma, treated 22 patients, who were markedly worse during, or immediately after, CSMT. The details of these cases are reported. The 1995 US Government National Census was used to define the regional referral population for Tulsa. The published data regarding the incidence of serious CSMT-related complications and the rate of CSMTs undertaken nationally were used to estimate the expected number of CSMT-related complications in the authors' region. The number (22 cases) reported in this series was used to estimate the actual regional incidence. Complications in the series included radiculopathy (21 cases), myelopathy (11 cases), Brown-Séquard syndrome (two cases), and vertebral artery (VA) occlusion (one case). Twenty-one patients underwent surgery. Poor outcomes were observed in three, outcome was unchanged in one, and 17 improved. The number of patients in this series exceeded the expected number for the region. CONCLUSIONS: Cervical spinal manipulation therapy may worsen preexisting cervical disc herniation or cause disc herniation resulting in radiculopathy, myelopathy, or VA compression. In cases of cervical spondylosis, CSMT may also worsen preexisting myelopathy or radiculopathy. Manipulation of the cervical spine may also be associated with higher complication rates than previously reported.

Adult↗
PubMed2003

Complications of revision spinal surgery.

Surgical treatment for symptomatic cervical and lumbar spondylosis has become prevalent in recent years. With this increased intervention, increasing numbers of patients experience persistent symptoms and require revision spinal surgery. Although many aspects of the workup and operation are similar for both primary and revision surgery, there are special considerations that must be examined when determining if a patient is a candidate for revision surgery. Preoperative workup should include evaluation for spinal instability. Intraoperatively, scar tissue may complicate the procedure, and care must be taken to avoid incidental durotomy. The prognosis for a revision surgery can be predicted best by the patient's outcome after the primary surgery. As with any surgical procedure, patient selection is imperative for successful outcome.

Antibiotic Prophylaxis↗
PubMed1975

Experimental cervical myelopathy. Effects of ischemia and compression of the canine cervical spinal cord.

The authors report experiments designed to test the effect of regional ischemia induced by selective vascular ligations and anterior compression of the cervical cord at two adjacent segments (C-4, C-5) in the same dog. They conclude that local ischemia of the cervical cord, caused by local deformation, when superimposed on a regional reduction in spinal cord blood flow, accounts for the myelopathy of cervical spondylosis whether produced experimentally in animals or occurring naturally in man.

Animals↗
PubMed1978

Cervical myeloradiculopathy caused by arthrotic hypertrophy of the posterior facets and laminae.

Five patients with typical cervical myeloradiculopathy caused by focal cervical spinal stenosis are presented. Dorsal intrusions into the spinal canal by hypertrophied apophyseal joints and thickened laminae resulted in cord and nerve root compression. Minor spondylotic changes were present in the floor of the spinal canal. Laminar decompression with formainotomy and facetectomy relieved the patients of their symptoms. An anterior approach should not be considered in the management of this disorder. Our findings of severe apophyseal arthrosis with lesser degrees of associated spondylosis are similar to those described in anatomical studies by other authors. While uncommon, myelopathy caused by dorsal compression of the spinal cord and nerve roots deserves specific mention so that therapy can be directed to the proper quadrants of the spinal canal wherein the significant pathology is located.

Aged↗
PubMed1978

Foramen magnum tumors. Analysis of 57 cases of benign extramedullary tumors.

This study involved 57 patients with benign extramedullary tumors of the foramen magnum (19 neurinomas, 37 meningiomas, and one teratoma), who were operated on between 1957 and 1976. The 37 meningiomas represented 3.2% of 1139 meningiomas of the neuraxis. The initial neurological examinations of about half of these patients were unremarkable. The clinical presentation of tumors of the foramen magnum frequently mimics multiple sclerosis, cervical spondylosis, intramedullary tumor, syrinx, carpal tunnel syndrome, and even normal-pressure hydrocephalus. All operations were performed through a posterior approach, and two surgical deaths (3.5%) were recorded. No surgery for recurring of tumor was recorded. The follow-up review of 56 patients (98.2%) showed good functional results if the tumor was detected before severe neurological deficits occurred. The possible mechanism of the sensory symptoms and muscle atrophy of the hands is discussed, and the electromyographic findings are reviewed.

Adolescent↗
PubMed1979

Cervical myelopathy caused by developmental stenosis of the spinal canal.

The authors present six patients with myelopathy caused by developmental stenosis of the cervical spine. Hyperextension injuries precipitated the onset of symptoms in two patients, aged 19 and 20 years. In four, 41 to 69 years of age, symptoms were gradual in onset, progressing to severe disability. X-ray films revealed narrowing of the dorsoventral diameter of the spinal canal to as little as 1.0 cm. The myelograms showed widening of the cord in the transverse plane strongly suggestive of an intramedullary tumor. A unique finding was maldevelopment with flattening of the neural arch often hidden by the posterior portions of the articular facets when seen in the lateral views. These patients showed no significant evidence of spondylosis, arthrosis, or any of the structural stigmata usually observed in cervical spondylotic myelopathy. When indicated, decompressive laminectomy is the treatment of choice.

Adult↗
PubMed1984

Calcium pyrophosphate dihydrate deposits in the cervical ligamenta flava causing myeloradiculopathy.

Three cases of cervical myeloradiculopathy associated with multiple calcified nodules containing identified calcium pyrophosphate dihydrate (CPPD) crystals in the ligamenta flava are described, with a comprehensive review of the 12 cases of this entity reported to date. The disease is characterized by: 1) oval or triangular areas of radiodensity in the posterior aspect of the cervical canal as seen in the lateral x-ray films and laminograms; 2) hemispherical areas of high density located almost symmetrically in the paramedial portion of the posterior spinal canal on computerized tomography scans; and 3) CPPD crystals in the nodules. It occurs independently or in association with cervical spondylosis or ossification of the posterior longitudinal ligament.

Aged↗
PubMed1993

Progressive myelopathy secondary to odontoid fractures: clinical, radiological, and surgical features.

Late-onset progressive myelopathy, years after odontoid fracture, is considered a rarity. Sixteen patients with diagnosis of their odontoid fractures delayed from four months to 45 years have been studied and treated. Three had forgotten about the injury and, in the rest, the significance had been minimized by their clinicians. Fifteen patients had characteristic C-2 nerve root pain and 10 had noted weak hands and walking difficulties. Fifteen patients had Type II fractures, which were mobile in 11; hypertrophic pseudoarthrosis was marked in two. In seven patients it was confirmed at surgery that all or part of the transverse ligament was interposed in the fracture. Transoral surgery, combined with a variety of posterior fusion techniques, has allowed cord decompression, an understanding of the pathomechanics, and sound posterior bone fusion with arrest of the myelopathic condition. Measurements of craniovertebral angles and cord cross-sectional area in this series revealed a rough correlation, but the most striking relationship was between length of delay in diagnosis and diminished cord area in both non-union and malunion, suggesting a progressive injury mechanism. It is proposed that late myelopathy following odontoid fracture may be more common than hitherto believed and should be considered in the evaluation of patients with cervical spondylosis. The condition may be progressive. Finally, non-union may be due to interposition of the transverse ligament.

Adolescent↗
PubMed1993

Experimental chronic compressive cervical myelopathy.

A canine model simulating both cervical spondylosis and its results in delayed progressive myelopathy is presented. This model allowed control of compression, an ongoing assessment of neurological deficits, and evaluation using diagnostic images, frequent electrophysiological tests, local blood flow measurements, and postmortem histological examinations. Subclinical cervical cord compression was achieved in 14 dogs by placing a Teflon washer posteriorly and a Teflon screw anteriorly, producing an average of 29% stenosis of the spinal canal. Four dogs undergoing sham operations were designated as controls. Twelve of the animals undergoing compression developed delayed and progressive clinical signs of myelopathy, with a mean latent period to onset of myelopathy of 7 months. Spinal cord blood flow studies using the hydrogen clearance method showed a significant transient increase in blood flow immediately after compression and a decrease before sacrifice. Somatosensory evoked potential studies indicated progressive deterioration during the period of compression. Magnetic resonance images revealed intramedullary changes. Histological studies showed abnormalities overwhelmingly within the gray matter, including changes in vascular morphology, loss of large motor neurons, necrosis, and cavitation. Axonal degeneration and obvious demyelination were rarely seen. The most profound morphological changes occurred at the site of greatest compression. It is proposed that a momentary arrest of microcirculation occurs during extension of the neck because of loss of the reserve space in the compromised spinal canal. This microcirculatory disturbance is predominant in the watershed area of the cord and mainly affects the highly vulnerable anterior horn cells, leading to neuronal death, necrosis, and eventual cavitation at the junction of the dorsal and anterior horns. Additional supportive evidence of this hypothesis was derived from the literature.

Angiography↗