Gregory S. McLoughlin

Surgical treatment of cervical spondylotic myelopathy with anterior compression: a review of 67 cases

OBJECT In patients with cervical spondylotic myelopathy (CSM), ventral disease and loss of cervical lordosis are considered to be relative indications for anterior surgery. However, anterior decompression and fusion operations may be associated with an increased risk of swallowing difficulty and an increased risk of nonunion when extensive decompression is performed. The authors reviewed cases involving patients with CSM treated via an anterior approach, paying special attention to neurological outcome, fusion rates, and complications. METHODS Retrospectively, 67 cases involving consecutive patients with CSM requiring an anterior decompression were reviewed: 46 patients underwent anterior surgery only (1-to3-level anterior cervical discectomy and fusion [ACDF] or 1-level corpectomy), and 21 patients who required > 3-level ACDF or > or = 2-level corpectomy underwent anterior surgery supplemented by a posterior instrumented fusion procedure. RESULTS Postoperative improvement in Nurick grade was seen in 43 (93%) of 46 patients undergoing anterior decompression and fusion alone (p < 0.001) and in 17 (81%) of 21 patients undergoing anterior decompression and fusion with supplemental posterior fusion (p = 0.0015). The overall complication rate for this series was 25.4%. Interestingly, the overall complication rate was similar for both the lone anterior surgery and combined anterior-posterior groups, but the incidence of adjacent-segment disease was greater in the lone anterior surgery group. CONCLUSIONS Significant improvement in Nurick grade can be achieved in patients who undergo anterior surgery for cervical myelopathy for primarily ventral disease or loss of cervical lordosis. In selected high-risk patients who undergo multilevel ventral decompression, supplemental posterior fixation and arthrodesis allows for low rates of construct failure with acceptable added morbidity.

Surgical management of cervical spondylotic myelopathy with laminectomy and instrumented fusion.

Abstract Objective: The indications for treating cervical spondylotic myelopathy (CSM) with laminectomy and instrumented fusion remain ill-defined. Cervical laminectomy without instrumented fusion has been associated with suboptimal outcomes, particularly in the setting of cervical kyphosis. This works purpose is to retrospectively review our experience in patients who underwent laminectomy with instrumented fusion for CSM and to assess the neurological and radiological outcomes of patients treated with this technique. Methods: Fifty-four consecutive patients underwent multilevel laminectomy and instrumented fusion for CSM. The indications were patients with (1) cervical stenosis ≥ 3 spinal segments and (2) absence of a cervical kyphosis or (3) patients older than 65 years with significant medical comorbidities. Nurick myelopathy grades and cervical radiographs were obtained preoperatively and at 3, 6, 12 and 24 months post-operatively. Perioperative complications, radiographic and clinical outcomes were assessed and reported in this paper. Results: Forty-four (81%) of patients showed improvement in Nurick grade after surgery by a mean of 17 months. Ten patients (19%) demonstrated stable but unimproved myelopathy. Increasing pre-operative Nurick grade was associated with an improved post-operative outcome (p<0.02). Increasing duration of pre-operative myelopathy was associated with a decreased likelihood of myelopathy improvement (p<0.001). Discussion: Multilevel cervical laminectomy with instrumented fusion for patients with CSM resulted in an improvement in myelopathy in the majority of cases. Efficacy was similar for patients who may not have tolerated an anterior decompression, such as elderly patients with significant medical comorbidities. Hardware-related complication rates were relatively low.

Revision surgery for cervical spondylotic myelopathy: surgical results and outcome.

OBJECTIVEThe role of additional or revision surgery in patients with cervical spondylotic myelopathy (CSM) is challenging. Postoperative pseudoarthrosis, instability, hardware failure, and recurrent cervical stenosis are conditions that require detailed clinical and radiographic assessment to define the pathology and assess the need for surgical decompression and fusion. The purpose of this study is to assess the neurological outcome, radiological outcome, and complications of patients undergoing additional or revision surgery for CSM. METHODSBetween 2002 and 2006, 30 patients with CSM and postoperative pseudoarthrosis, instability, hardware failure, or recurrent stenosis underwent surgical decompression and stabilization. The specific procedure was selected according to each patients medical condition, cervical sagittal alignment, and extent of stenosis. All patients underwent an anterior, posterior, or combined anterior and posterior decompression and instrumented fusion. The charts of these patients were reviewed to assess neurological and radiographic outcomes. RESULTSTwenty-five patients (83%) improved postoperatively as measured by the Nurick Myelopathy Scale over a mean follow-up period of 19 months (range, 2–64 mo). The overall complication rate was 27%, consisting of transient monoradiculopathy (7%), dysphagia (10%), and infection (7%). The incidence of nonunion during the follow-up period was 3%. CONCLUSIONAlthough patients with CSM and postoperative pseudoarthrosis, instability, hardware failure, or junctional stenosis who require revision surgery may risk a substantial likelihood of surgical complications (25% in this series), a significant proportion of patients may experience improved neurological outcomes. In our experience, the cervical sagittal alignment and the extent of stenosis are critical factors to consider when selecting the eventual procedure.

Are computed tomography scans adequate in assessing cervical spine pain following blunt trauma

Good quality three-view radiographs (anteroposterior, lateral, and open-mouth/odontoid) of the cervical spine exclude most unstable injuries, with sensitivity as high as 92% in adults and 94% in children. The diagnostic performance of helical computed tomography (CT) scanners may be even greater, with reported sensitivity as high as 99% and specificity 93%. Missed injuries are usually ligamentous, and may only be detected with magnetic resonance imaging (MRI) or dynamic plain radiographs. With improvements in the accessibility of advanced imaging (helical CT and MRI) and with improvements in the resolution of such imaging, dynamic screening is now used less commonly to screen for unstable injuries. This case involves a patient with an unstable cervical spine injury whose cervical subluxation was only detected following use of dynamic radiographs, despite a prior investigation with helical CT. In this way, the use of dynamic radiographs following blunt cervical trauma should be considered an effective tool for managing acute cervical spine injury in the awake, alert, and neurologically intact patient with neck pain.

Mediastinal lymphangioma presenting as an acute epidural hematoma: Case report

Lymphangiomas are benign collections of blind-ended lymphatic and vascular channels. Lesions typically occur in the soft tissues of the head and neck, although any region of the body can be affected. Involvement of the spine is very rare. A complete resection is generally curative. On rare occasions, these tumors are complicated by infection or hemorrhage. The authors present an unusual case of a hemorrhagic lymphangioma in a 1-year-old male child. The lesion originated in the mediastinum and extended into the cervicothoracic epidural space via a neural foramen. This resulted in an acute epidural hematoma and quadriparesis. Emergency decompression resulted in full neurological recovery. This may be the first report of a lymphangioma resulting in an acute epidural hematoma and quadriparesis.