Preoperative cervical sagittal alignment parameters and their impacts on myelopathy in patients with cervical spondylotic myelopathy: a retrospective study.
ABSTRACT: Background:Cervical sagittal alignment plays an important role in the pathogenesis of cervical spondylotic myelopathy (CSM), but there are limited studies on the cervical sagittal parameters in CSM patients and their correlations with myelopathy. The aim of this study is to investigate the correlations among the preoperative cervical sagittal alignment parameters and their correlations with the development of myelopathy in patients with CSM. Methods:We retrospectively collected 212 patients with CSM who underwent surgical interventions. Gender, age, modified Japanese Orthopedic Association score (mJOA), cervical lordosis (CL), C2-C7 sagittal vertical axis (C2-C7 SVA), T1 slope (T1S), neck tilt (NT) and thoracic inlet angle (TIA) were collected before operation. Interobserver and intraobserver reliability were calculated for all measurements (intraclass correlation coefficient, ICC). Data were analyzed with Pearson and Spearman correlation tests and multiple linear regression analysis. Results:A total of 212 patients with CSM were included in this study (male: 136, female: 76) with an average age of 54.5 ± 10.1 years old. Intraobserver and interobserver reliability for all included radiographic parameters presented good to excellent agreement (ICC > 0.7). No significant differences in demographic and radiological parameters have been observed between males and females (P > 0.05). We found statistically significant correlations among the following parameters: age with CL (r = 0.135, P = 0.049), age with T1S (r = 0.222, P = 0.001), CL with T1S (r = 0.291, P < 0.001), CL with C2-C7 SVA (r = - 0.395, P < 0.001), mJOA with age (r = - 0.274, P < 0.001), mJOA with C2-C7 SVA (r = - 0.219, P < 0.001) and mJOA with T1S(r = - 0.171, p = 0.013). Linear regression analysis showed that C2-C7 SVA was the predictor of CL (adjusted R2 = 0.152, P < 0.001) and multiple linear regression showed that age combined with C2-C7 SVA was a sensitive predictor of mJOA (adjusted R2 = 0.106, P < 0.001). Discussion:There were significant correlations among certain preoperative cervical sagittal parameters in CSM patients. CL was the only predictor of C2-C7 SVA. Age combined with C2-C7 SVA could predict the severity of myelopathy.
Project description:PURPOSE:To compare sagittal alignment and clinical outcomes between three-level hybrid surgery (HS) and anterior cervical discectomy and fusion (ACDF) on cervical spondylotic myelopathy (CSM) over a 5-year follow-up. METHOD:The study included 32 patients with ACDF, 36 patients with 1 prosthesis and 2 cages (HS1 group), and 25 cases with 2 prostheses and 1 cage (HS2 group). Alignment parameters included C2-C7 cervical lordosis (CL), C2-C7 sagittal vertical axis (SVA), T1 slope (T1S), and T1S minus CL (T1SCL). Radiographic parameters were range of motion (ROM), upper and lower adjacent ROM (UROM and LROM), and operated-segment lordosis (OPCL), as well as adjacent segment degeneration (ASD). Clinical outcomes included the neck disability index (NDI) and Japanese Orthopedic Association (JOA) score. RESULTS:Three groups were well-matched in demographics. All groups gained comparable improvement on NDI and JOA (P?<?0.01). All groups gained CL improvement at the final visit (P?<?0.05). There were no statistical differences on SVA and T1SCL among the groups and among preoperation, 1?week later, and final follow-up (P > 0.05) while T1S improved at 1?week later and final follow-up with HS2. The final change of all alignment parameters among the three groups was of no differences. ROM decreased and OPCL increased in all groups at the final follow-up (P?<?0.05). UROM and LROM increased with ACDF but kept stable with HS1 and HS2. There was no inter-group difference on the incidence of ASD (P > 0.05). CONCLUSION:Cervical alignment was comparably improved. HS and ACDF provided identified mid-term efficacy, and it was not necessary to have to use prosthesis on three-level CSM.
Project description:The cervical sagittal parameters of the normal population and the impact of disc degeneration on cervical sagittal alignment have not been clearly defined yet. This study is applied to investigate the characteristics and relationships of cervical sagittal parameters in normal adults and patients with cervical disc degeneration.We reviewed 50 normal control subjects (normal group, NG) and 50 patients with cervical disc degeneration (degeneration group, DG), who had both cervical MRI and radiographs obtained together, between January 2010 and September 2015. Data including C2-7 lordosis (CL), T1 slope (T1S), thoracic inlet angle (TIA), neck tilt (NT), C2-7 sagittal vertical axis (C2-7 SVA), cervical tilting, and cranial tilting on cervical radiographs were collected and analyzed.T1S in the NG was significantly greater than in the DG (P?<?0.05), while NT and C2-7 SVA in the NG were significantly lower than in the DG (P?<?0.01 and P?<?0.05, respectively). T1S positively correlated with CL in both groups (Pearson correlation coefficients of 0.588 in the NG and 0.504 in the DG). No significant difference was seen in TIA between the NG and DG.T1S was involved in the occurrence and development of cervical disc degeneration, and TIA could be considered as a constant morphological parameter in both the normal population and cervical disc degeneration patients.
Project description:Prospective observational cohort study.To determine if postoperative cervical sagittal balance is an independent predictor of health-related quality of life outcome after surgery for cervical spondylotic myelopathy.Both ventral and dorsal fusion procedures for CSM are effective at reducing the symptoms of myelopathy. The importance of cervical sagittal balance in predicting overall health-related quality of life outcome after ventral versus dorsal surgery for CSM has not been previously explored.A prospective, nonrandomized cohort of 49 patients undergoing dorsal and ventral fusion surgery for CSM was examined. Preoperative and postoperative C2-C7 sagittal vertical axis was measured on standing lateral cervical spine radiographs. Outcome was assessed with 2 disease-specific measures-the modified Japanese Orthopedic Association scale and the Oswestry Neck Disability Index and 2 generalized outcome measures-the Short-Form 36 physical component summary (SF-36 PCS) and Euro-QOL-5D. Assessments were performed preoperatively, and at 3 months, 6 months, and 1 year postoperatively. Statistical analyses were performed using SAS version 9.3 (SAS Institute).Most patients experienced improvement in all outcome measures regardless of approach. Both preoperative and postoperative C2-C7 sagittal vertical axis measurements were independent predictors of clinically significant improvement in SF-36 PCS scores (P = 0.03 and P = 0.02). The majority of patients with C2-C7 sagittal vertical axis values greater than 40 mm did not improve from an overall health-related quality of life perspective (SF-36 PCS) despite improvement in myelopathy. The postoperative sagittal balance value was inversely correlated with a clinically significant improvement of SF-36 PCS scores in patients undergoing dorsal surgery but not ventral surgery (P = 0.03 vs. P = 0.93).Preoperative and postoperative sagittal balance measurements independently predict clinical outcomes after surgery for CSM.2.
Project description:<h4>Background</h4>Cervical disc replacement (CDR) has been widely used to treat one- and two-level cervical degenerative disc disease. Studies have shown the effectiveness of CDR in preserving range of motion (ROM) and delaying adjacent segment degeneration (ASD). Cervical sagittal alignment is an important factor affecting favorable clinical outcomes in cervical spine surgery. This study aimed to explore whether cervical sagittal alignment can be maintained after CDR and to identify the impact of cervical sagittal alignment on outcomes after CDR.<h4>Methods</h4>This was a single-center, retrospective study. 132 patients who underwent one-level CDR were included. Cervical sagittal alignments, including cervical lordosis (CL), segmental alignment (SA), sagittal vertical axis (SVA), T1 slope (T1s), and T1s minus CL (T1s-CL), were measured. The effects of cervical sagittal alignment on the CDR outcomes were analyzed. Patients were divided into the heterotopic ossification (HO) group and ASD group to determine the potential impacts of cervical sagittal parameters.<h4>Results</h4>The cervical sagittal alignment parameters, except for the SVA, were significantly improved after CDR and showed decreasing trends at the last follow-up. Significantly higher CL and T1s were found in patients with better ROM after CDR. SVA???20?mm increased the risk of anterior HO (odds ratio?=?2.945, P?=?0.007). Significantly kyphotic SA and lower T1s values were found in the ASD patients than in the non-ASD patients (P?<?0.05). Patients with ASD at the inferior level showed significantly worse CL (P?<?0.05).<h4>Conclusion</h4>CDR had limited function of improving cervical sagittal alignment. Poor cervical sagittal alignment after CDR was associated with HO, ASD, and less ROM.
Project description:BACKGROUND:For patients with spinal canal stenosis in the upper cervical spine who undergo C3-7 laminoplasty alone, it remains impossible to achieve full decompression due to its limited range. This study explores the extension of expansive open-door laminoplasty (EODL) to C1 and C2 for the treatment of cervical spinal stenosis of the upper cervical spine and its effects on cervical sagittal parameters. METHODS:A retrospective analysis of 33 patients presenting with symptoms of cervical spondylosis myelopathy (CSM) and ossification in the posterior longitudinal ligament (OPLL) of the upper cervical spine from February 2013 to December 2015 was performed. Furthermore, the changes in the C0-2 Cobb angle, C1-2 Cobb angle, C2-7 Cobb angle, C2-7 SVA, and T1-Slope in lateral X-rays of the cervical spine were measured before, immediately after, and 1 year after the operation. JOA and NDI scores were used to evaluate spinal cord function. RESULTS:The C0-2 and C1-2 Cobb angles did not significantly increase (P?=?0.190 and P?=?0.081), but the C2-7 Cobb angle (P?=?0.001), C2-7 SVA (P?<?0.001), and T1-Slope (P?<?0.001) significantly increased from preoperative to 1?year postoperative. In addition, C2-7 SVA was significantly correlated with the T1-Slope (Pearson?=?0.376, P?<?0.001) and C0-2 Cobb angle (Pearson?=?0.287, P?=?0.004), and the C2-7 SVA was negatively correlated with the C2-7 Cobb angle (Pearson?=?-?0.295, P?<?0.001). The average preoperative and postoperative JOA scores were 8.3?±?1.6 and 14.6?±?1.4 points, respectively, indicating in a postoperative neurological improvement rate of approximately 91.6%. The average preoperative and final follow-up NDI scores were 12.62?±?2.34 and 7.61?±?1.23. CONCLUSIONS:The sagittal parameters of patients who underwent EODL extended to C1 and C2 included loss of cervical curvature, increased cervical anteversion and compensatory posterior extension of the upper cervical spine to maintain visual balance in the field of vision. However, the changes in cervical spine parameters were far less substantial than the alarm thresholds reported in previous studies. We believe that EODL extended to C1 and C2 for the treatment of patients with spinal canal stenosis in the upper cervical spine is a feasible and safe procedure with excellent outcomes.
Project description:Study Design Prospective cohort study. Objective To clarify long-term surgical outcomes of C3-6 laminoplasty preserving muscles attached to the C2 and C7 spinous processes in patients with cervical spondylotic myelopathy (CSM). Methods Twenty patients who underwent C3-6 open-door laminoplasty for CSM and who were followed for 8 to 10 years were included in this study. Myelopathic symptoms were assessed using Japanese Orthopaedic Association (JOA) score. Axial neck pain was graded as severe, moderate, or mild. C2-7 angle was measured using lateral radiographs of the cervical spine before surgery and at final follow-up. Results Mean JOA score before surgery (11.7) was significantly improved to 15.2 at the time of maximum recovery (1 year after surgery), declining slightly to 14.9 by the latest follow-up. Late deterioration of JOA score developed in eight patients, but was unrelated to the cervical spine lesions in each case. No patient suffered from prolonged postoperative axial neck pain at final follow-up. The mean C2-7 angle before surgery (13.8 degrees) significantly increased to 19.2 degrees at final follow-up. Conclusions C3-6 laminoplasty preserving muscles attached to the C2 and C7 spinous processes in patients with CSM maintained satisfactory long-term neurologic improvement with significantly reduced frequencies of prolonged postoperative axial neck pain and loss of C2-7 angle after surgery.
Project description:Study Design?Systematic review. Objective?In patients aged 18 years or older, with cervical spondylotic myelopathy or ossification of the posterior longitudinal ligament (OPLL), does sparing the C2 muscle attachments and/or C7-preserving cervical laminoplasty lead to reduced postoperative axial pain compared with conventional C3 to C7 laminoplasty? Do these results vary based on early active postoperative cervical motion? Methods?A systematic review of the English-language literature was undertaken for articles published between 1970 and August 17, 2012. Electronic databases and reference lists of key articles were searched to identify studies evaluating C2/C3- or C7-preserving cervical laminoplasty for the treatment of cervical spondylotic myelopathy (CSM) or OPLL in adults. Studies involving traumatic onset, cervical fracture, infection, deformity, or neoplasms were excluded, as were noncomparative studies. Two independent reviewers assessed the level of evidence quality using the grading of recommendations assessment, development and evaluation (GRADE) system, and disagreements were resolved by consensus. Results?We identified 11 articles meeting our inclusion criteria. Only the randomized controlled trial (RCT) showed no significant difference in late axial pain (at 12 months) when C7 spinous muscle preservation was compared with no preservation. However, seven other retrospective cohort studies showed significant pain relief in the preserved group compared with the nonpreserved group. The preservation group included those with preservation of the C7 spinous process and/or attached muscles, the deep extensor muscles, or C2 muscle attachment and/or C3 laminectomy (as opposed to laminoplasty). One study that included preservation of either the C2 or C7 posterior paraspinal muscles found that only preservation of the muscles attached to C2 resulted in reduced postoperative pain. Another study that included preservation of either the C7 spinous process or the deep extensor muscles found that only preservation of C7 resulted in reduced postoperative pain. Conclusion?Although there is conflicting data regarding the importance of preserving C7 and/or the semispinalis cervicis muscle attachments to C2, there is enough evidence to suggest that surgeons should make every attempt to preserve these structures whenever possible since there appears to be little downside to doing so, unless it compromises the neurologic decompression.
Project description:OBJECTIVE: To report the outcomes of a posterior hybrid decompression protocol for the treatment of cervical spondylotic myelopathy (CSM) associated with hypertrophic ligamentum flavum (HLF). BACKGROUND: Laminoplasty is widely used in patients with CSM; however, for CSM patients with HLF, traditional laminoplasty does not include resection of a pathological ligamentum flavum. METHODS: This study retrospectively reviewed 116 CSM patients with HLF who underwent hybrid decompression with a minimum of 12 months of follow-up. The procedure consisted of reconstruction of the C4 and C6 laminae using CENTERPIECE plates with spinous process autografts, and resection of the C3, C5, and C7 laminae. Surgical outcomes were assessed using Japanese Orthopedic Association (JOA) score, recovery rate, cervical lordotic angle, cervical range of motion, spinal canal sagittal diameter, bone healing rates on both the hinge and open sides, dural sac expansion at the level of maximum compression, drift-back distance of the spinal cord, and postoperative neck pain assessed by visual analog scale. RESULTS: No hardware failure or restenosis was noted. Postoperative JOA score improved significantly, with a mean recovery rate of 65.3 ± 15.5%. Mean cervical lordotic angle had decreased 4.9 degrees by 1 year after surgery (P<0.05). Preservation of cervical range of motion was satisfactory postoperatively. Bone healing rates 6 months after surgery were 100% on the hinge side and 92.2% on the open side. Satisfactory decompression was demonstrated by a significantly increased sagittal canal diameter and cross-sectional area of the dural sac together with a significant drift-back distance of the spinal cord. The dural sac was also adequately expanded at the time of the final follow-up visit. CONCLUSION: Hybrid laminectomy and autograft laminoplasty decompression using Centerpiece plates may facilitate bone healing and produce a comparatively satisfactory prognosis for CSM patients with HLF.
Project description:Study Design Retrospective study. Objective We previously reported that the long-term neurologic outcomes of C3-C6 laminoplasty for cervical spondylotic myelopathy (CSM) are satisfactory, with reduced frequencies of postoperative axial neck pain and kyphotic deformity. However, only 20 patients were included, which is a limitation in that study. The present study investigated the incidence of late neurologic deterioration (LND) of myelopathic symptoms after C3-C6 laminoplasty for CSM and attempted to identify significant risk factors for LND in a larger patient population. Methods Subjects comprised 137 consecutive patients with CSM who underwent C3-C6 laminoplasty (bilateral open-door laminoplasty, n = 85; unilateral open-door laminoplasty, n = 52) and were followed for >24 months (mean follow-up, 70 months; range, 25 to 124 months). The patients' medical records were examined for evidence of LND due to cervical myelopathy. The age at time of surgery, sex, surgical procedures, anteroposterior spinal canal diameter at the C7 level, type of C6 spinous process, pre- and postoperative C2-C7 angle, C3-C6 range of motion (ROM), and disk height at the C6-C7 level were analyzed to identify risk factors for LND. Results Three patients (2.2%) developed LND of myelopathic symptoms due to caudal segment pathology adjacent to the C3-C6 laminoplasty (LND group). In these three patients, mean Japanese Orthopaedic Association (JOA) score improved from 10.2 before surgery to 12.2 at the time of maximum recovery, and declined to 9.7 just before additional surgery. On the other hand, in 134 patients without LND (non-LND group), the mean JOA score significantly improved from 10.2 before surgery to 13.4 at the time of maximum recovery and was maintained by the final follow-up (13.2). Compared with the non-LND group, the LND group showed significantly smaller anteroposterior spinal canal diameter at C7, more restricted postoperative C3-C6 ROM, and greater postoperative decrease in disk height at C6-C7, although a logistic regression analysis showed no significant differences. Conclusions In patients with CSM with more severe developmental spinal canal stenosis at C7, accelerated degeneration at the caudal segment resulting from restricted C3-C6 ROM after C3-C6 laminoplasty might lead to LND.
Project description:BACKGROUND:Cervical spondylotic myelopathy (CSM) is a degenerative cervical disease in which the spinal cord is compressed. Patients with CSM experience balance disturbance because of impaired proprioception. The weighting of the sensory inputs for postural control in patients with CSM is unclear. Therefore, this study investigated the weighting of sensory systems in patients with CSM. METHOD:Twenty-four individuals with CSM (CSM group) and 24 age-matched healthy adults (healthy control group) were analyzed in this observational study. The functional outcomes (modified Japanese Orthopaedic Association Scale [mJOA], Japanese Orthopaedic Association Cervical Myelopathy Questionnaire [JOACMEQ], Nurick scale) and static balance (eyes-open and eyes-closed conditions) were assessed for individuals with CSM before surgery, 3 and 6?months after surgery. Time-domain and time-frequency-domain variables of the center of pressure (COP) were analyzed to examine the weighting of the sensory systems. RESULTS:In the CSM group, lower extremity function of mJOA and Nurick scale significantly improved 3 and 6?months after surgery. Before surgery, the COP mean velocity and total energy were significantly higher in the CSM group than in the control group for both vision conditions. Compared with the control group, the CSM group exhibited lower energy content in the moderate-frequency band (i.e., proprioception) and higher energy content in the low-frequency band (i.e., cerebellar, vestibular, and visual systems) under the eyes-open condition. The COP mean velocity of the CSM group significantly decreased 3?months after surgery. The energy content in the low-frequency band (i.e., visual and vestibular systems) of the CSM group was closed to that of the control group 6?months after surgery under the eyes-open condition. CONCLUSION:Before surgery, the patients with CSM may have had compensatory sensory weighting for postural control, with decreased weighting on proprioception and increased weighting on the other three sensory inputs. After surgery, the postural control of the patients with CSM improved, with decreased compensation for the proprioceptive system from the visual and vestibular inputs. However, the improvement remained insufficient because the patients with CSM still had lower weighting on proprioception than the healthy adults did. Therefore, patients with CSM may require balance training and posture education after surgery. TRIAL REGISTRATION:Trial Registration number: NCT03396055 Name of the registry: ClinicalTrials.gov Date of registration: January 10, 2018 - Retrospectively registered Date of enrolment of the first participant to the trial: October 19, 2015.