Richard Chaloupka

Approaches to spondylotic cervical myelopathy: conservative versus surgical results in a 3-year follow-up study.

Study Design. A 3-year prospective randomized study was conducted. Objective. To compare conservative and operative treatments of mild and moderate, nonprogressive, and slowly progressive forms of spondylotic cervical myelopathy. Summary of Background Data. It is not known whether the results of decompressive surgery for the mild and moderate forms of spondylotic cervical myelopathy are any better than those of the conservative approach. Methods. For this study, 68 patients were randomized into two groups. Group A, treated conservatively, consisted of 35 subjects, whereas Group B, treated surgically, was composed of 33 patients. The clinical outcome was evaluated by modified JOA score, timed 10-m walk, the score for daily activities recorded by video and evaluated by two observers blinded to the type of therapy, and subjective assessment by the patients themselves at months 6, 12, 24, and 36 of the follow-up period. Results. There was, on the average, no significant deterioration in mJOA score in the two groups over the 3-year follow-up period, but there was a slightly expressed decrease in the self-evaluation score in Group B, and a slight deterioration of the score for daily activities in Group A. Comparison of the two groups showed a significant difference in the timed 10-m walk test favoring group A, but no difference in mJOA score or self-evaluation by the patients themselves, with the exception of a better score at month 6 in favor of Group B. Conclusions. The 3-year follow-up study did not show, on the average, that the surgery is superior to conservative treatment for mild and moderate forms of spondylotic cervical myelopathy.

Conservative treatment versus surgery in spondylotic cervical myelopathy: a prospective randomised study

Abstract A prospective randomised 2-year study was performed to compare the conservative and operative treatment of mild and moderate forms of spondylotic cervical myelopathy (SCM). Forty-eight patients presenting with the clinical syndrome of SCM, with a modified Japanese Orthopaedic Association (mJOA) score of 12 points or more, were randomised into two groups. Group A, treated conservatively, consisted of 27 patients, mean age 55.6 ± 8.6 years, while group B was treated surgically (21 patients, mean age 52.7 ± 8.1 years). The clinical outcome was measured by the mJOA score, recovery rate (RR), timed 10 m walk, score of daily activities (recorded by video and evaluated by two observers blinded to the therapy), and by the subjective assessment of the patients at 6, 12, and 24 months of the follow-up. There was, on average, no significant deterioration in mJOA score, recovery ratio, or timed 10 m walk within either group during the 2 years of follow-up. In the surgery group there was a slight decline in the scores for daily activities and subjective evaluation. A comparison of the two groups showed no significant differences in changes over time in mJOA score or quantified gait, but there were significant differences in the score of daily activities recorded by video at 24 months, which was a little lower in the surgical group, and also in RR and subjective evaluation, which were both worse in the surgical group at months 12 and 24. However, at month 6, this last parameter was significantly better in the surgical than in conservative group. Surgical treatment of mild and moderate forms of SCM in the present study design, comprising the patients with no or very slow, insidious progression and a relatively long duration of symptoms, did not show better results than conservative treatment over the 2-year follow-up.

Predictive factors for spondylotic cervical myelopathy treated conservatively or surgically.

A prospective 3‐year randomized study comparing conservative and surgical treatment of spondylotic cervical myelopathy to establish predictive factors for outcome after conservative treatment and surgery. The clinical, electrophysiological and imaging parameters were examined to reveal how they characterized the clinical outcome. The patients with a good outcome in the conservatively treated group were of older age before treatment, had normal central motor conduction time (CMCT), and possessed a larger transverse area of the spinal cord. The patients with a good outcome in the surgically treated group had a more serious clinical picture (expressed in mJOA score and slower walk). Patients should rather be treated conservatively if they have a spinal transverse area larger than 70 mm2, are of older age and have normal CMCT. Surgery is more suitable for patients with clinically worse status and a lesser transverse area of spinal cord.

The role of the autonomic nervous system in the etiology of idiopathic scoliosis: prospective electron microscopic and morphometric study

ObjectsThe exact etiology of scoliosis is still unknown. The main purpose of this study is to search for the possible causation of scoliosis in the development changes of autonomic nervous structures. In this prospective study, we followed-up the changes in peripheral nerve structures and its discrepancies regarding the concavity and convexity of the scoliotic curve.Materials and methodsWe evaluated 12 patients with the idiopathic scoliotic deformity and the control group of 3 patients without any scoliotic deformity. The samples from the peripheral nerves of the convexity and concavity of the scoliotic deformity were drawn during the surgical correction by using the transthoracic approach. The samples were examined by the electron microscopic method and morphometric statistical evaluation.ResultsIn samples taken from the scoliotic convexity, 23.71% of myelinized nerve fibers (MNF), 12.21% of unmyelinized nerve fibers (UNF), and 5.0% of Schwann cells (SC) were found by the morphometric measurement. There were 17.36% of MNF, 5.82% of UNF, and 5.27% of SC in samples taken from the concavity and 29.9% of MNF, 19.9% of UNF, and 16.7% of SC in the control nonscoliotic samples. Statistically significant differences between both sides of scoliotic deformity (convexity and concavity) and differences between the scoliotic samples and the nonscoliotic control samples were found. In all scoliotic samples, significant morphologic changes were found, mostly in the myelin sheaths and axon fiber abnormalities compression.ConclusionThere are significant morphologic changes in spinal autonomic nervous structures in scoliotic patients. These findings can help us in the search for the etiology of scoliosis.

Complete rotational burst fracture of the third lumbar vertebra managed by posterior surgery. A case report.

STUDY DESIGN Case report of a young man with rotational burst fracture of the third lumbar vertebra, treated by posterior surgery. OBJECTIVES To describe the management of a rotational burst fracture of the third lumbar vertebra by posterior surgery consisting of reduction, decompression, fusion, and transpedicular instrumentation. SUMMARY OF BACKGROUND DATA Surgery is the generally recommended means of managing lumbar burst fractures with neurologic deficit. Some surgeons recommend anterior decompression, fusion, and instrumentation. Posterior surgery with decompression through laminectomy, spongioplasty of the vertebral body, interbody fusion of damaged discs, posterolateral fusion, and transpedicular fixation is also a safe and successful management technique. The combined approach consists of posterior decompression, fusion, transpedicular fixation, and anterior fusion using pelvic autografts. The optimum method of management remains in question. METHOD An 18-year-old man with complete rotational burst fracture of the third lumbar vertebra was treated by posterior surgery. This surgery consisted of reduction, laminectomy, decompression, structure of dural sac tears, spongioplasty of the vertebral body, interbody fusion of both damaged discs, and the implantation of a transpedicular Socon fixator (Aesculap, Tuttlingen, Germany), including a transverse connector. The case was documented by radiographs and computed tomography scans before surgery and after fixator removal 19 months after surgery. RESULTS The patient healed solidly with no instrumentation failure. The neurologic deficit Frankel Grade B improved to Frankel Grade D. CONCLUSION Surgery to manage lumbar burst fracture must include reduction, decompression, restoration and fusion of anterior and posterior elements by using autologous pelvic spongious autografts, and anterior or posterior instrumentation. Posterior surgery including suturing of dural sac tears, fusion of damaged structures, and transpedicular fixation is successful in young patients and patients with good bone quality.