Article

The evaluation of cervical spine motion below C2: A comparison of cineroentgenographic and conventional roentgenographic methods

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Abstract

A comparison study of randomly selected patients who had roentgenographic investigation of the cervical spine by both cineroentgenography and conventional lateral roentgenograms in flexion, neutral position, and extension was made for the analysis of motion. The results of this investigation reveal that if lateral roentgenograms made in flexion, neutral position, and extension are carefully evaluated and compared, most of the information regarding abnormal motion can be detected. There were, however, a significant number of instances in which cineroentgenography demonstrated abnormal motion not detected on conventional roentgenograms. Cineroentgenography is, therefore, a valuable adjunctive technique and its continued utilization in the analysis of cervical spine motion is justified. Surprisingly, the converse situation of abnormal motion being observed by the lateral roentgenograms but not on cineroentgenography occurred in a few instances. Also observed was a high incidence of abnormal motion at one or both joints adjacent to a fusion. Whether this high incidence of abnormal motion is part of the disease process or is secondary to the imposed additional stress on the remaining active joints following surgery, remains an interesting speculation.

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... Long-term clinical studies [31][32][33][34] have demonstrated an increased incidence of pathologies in the motion segments that are adjacent to the fused segment. Many scholars have emphasized the altered biomechanics at the adjacent segment after fusion that lead to increased mobility, [31][32][33] loading, intradiscalpressure, 35,36 and accelerated disc degeneration. ...
... Long-term clinical studies [31][32][33][34] have demonstrated an increased incidence of pathologies in the motion segments that are adjacent to the fused segment. Many scholars have emphasized the altered biomechanics at the adjacent segment after fusion that lead to increased mobility, [31][32][33] loading, intradiscalpressure, 35,36 and accelerated disc degeneration. 37,38 In contrast to these findings, other studies have suggested that natural progression at adjacent levels after fusion plays a key role in adjacent spinal diseases. ...
... 37,38 In contrast to these findings, other studies have suggested that natural progression at adjacent levels after fusion plays a key role in adjacent spinal diseases. [31][32][33][34][35][36][37][38][39][40] Kellgren and Lawrence 41 reported that physiologic aging of the cervical spine was observed by plain radiographs in healthy volunteers who were .50 years of age. ...
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Study design This is an experimental animal study. Objective The objective of this study was to compare an anterior cervical discectomy and interbody fusion of a novel polylactide/nano-sized β-tricalcium phosphate (PLA/nβ-TCP) bioabsorbable self-retaining cervical fusion cage (BCFC) with an autologous bone graft and polyetheretherketone (PEEK) cages. Background Although PLA cervical cages have potential advantages compared with traditional materials, they are not currently routinely used in spine surgery because of undesirable effects such as the lack of osteoconductivity and osteolysis around the implant. This study involved the manufacturing of a bioabsorbable cage from PLA/nβ-TCP that was then used as a device for anterior cervical discectomy and fusion (ACDF) on a goat cervical spine fusion model. Materials and methods Eighteen goats underwent C3/C4 discectomy and were randomly divided into three groups based on the following methods: Group A (n=6), an autologous bone graft; Group B (n=6), PEEK cage filled with an autologous graft; and Group C (n=6), BCFC filled with an autologous iliac bone. Radiography was performed preoperatively and postoperatively and at 1, 4, 8, and 12 weeks after the operation. Disc space height (DSH) was measured at the same time. After 12 weeks, the fused segments were harvested and evaluated with functional radiographic views, biomechanical testing, and histological analyses. Results Over a 12-week period, the BCFC and PEEK cage groups exhibited significantly higher DSH values than the bone graft group. Additionally, the BCFC group yielded a significantly lower range of motion in axial rotation than both the autologous bone graft and PEEK cage groups. A histologic evaluation revealed an increased intervertebral bone volume/total volume ratio and better interbody fusion in the BCFC group than in the other groups. Conclusion The BCFC device exhibited better results than the autologous bone graft and PEEK cages in single-level ACDF models in vivo. This device may be a potential alternative to the current PEEK cages.
... However, controversy remains as to whether these conditions are related to altered biomechanics [5,[7][8][9][10][11] or represent the natural history of cervical spondylosis at the adjacent segment [12][13][14]. Clearly, patients who have undergone cervical fusions are at an increased risk of developing ASP. ...
... Many studies have focused on the altered biomechanics at the adjacent levels after fusion that result in increased mobility [5,7,9,10], increased loading [8] or increased intradiscal pressure [11] that ultimately accelerate disc degeneration [25,[31][32][33]. Increased mechanical demands adversely affect the disc by interfering with its normal nutritional supply. ...
Article
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Anterior cervical fusion has become a standard of care for numerous pathologic conditions of the cervical spine. However, subsequent development of clinically significant disc disease at levels adjacent to fused discs is a serious long-term complication of this procedure. As more patients live longer after surgery, it is foreseeable that adjacent segment pathology (ASP) will develop in increasing numbers of patients. Also, ASP has been studied more intensively with the recent popularity of motion preservation technologies like total disc arthroplasty. The true nature and scope of ASP remains poorly understood. The etiology of ASP is most likely multifactorial. Various factors including altered biomechanical stresses, surgical disruption of soft tissue and the natural history of cervical disc disease contribute to the development of ASP. General factors associated with disc degeneration including gender, age, smoking and sports may play a role in the development of ASP. Postoperative sagittal alignment and type of surgery are also considered potential causes of ASP. Therefore, a spine surgeon must be particularly careful to avoid unnecessary disruption of the musculoligamentous structures, reduced risk of direct injury to the disc during dissection and maintain a safe margin between the plate edge and adjacent vertebrae during anterior cervical fusion.
... There is mounting evidence that arthrodesis increases stress and, therefore, the rate of disc degeneration in the cervical spine. 2,4,5,13,21,26,38,41,55 The results of a cervical disc prosthesis, which was originally developed in Bristol, England, have been reported. 10 The second-generation Cummins disc is a ball-andtrough-type device constructed of stainless steel. ...
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Symptomatic degenerative spinal disease is a serious medical condition that affects many individuals. Modern neuroimaging modalities, the development of new medications, and advances in operative and nonoperative treatments have all contributed to improved outcomes. Unfortunately, there remain a significant number of patients in whom primary therapy either fails or new or recurrent symptoms develop over time. The last decade has witnessed the invention of devices designed to reconstruct the spinal motion segment. These devices can be divided into those that primarily function to replace a nucleus pulposus and those that completely replace the disc complex. In this article the author reviews the background leading to the development of the current group of disc replacements. The design and preliminary clinical results obtained using major lumbar and cervical devices are also reviewed.
... Both factors may contribute simultaneously. 14 Whereas some authors advocate the hypothesis of natural progression, [11][12][13] others focus on the altered biomechanics at adjacent levels after fusion, resulting from increased mobility, 1,7,18,21,22 increased longitudinal or shear strain, 16 or increased intradiscal pressure. 23 On the other hand, Fuller et al 39 denied the existence of adjacent level hypermobility; however, their study was performed on spine specimens harvested from cadavers that averaged 74 years of age and therefore might have been too stiff to be applicable to the situation in a younger living human being. ...
Article
The aim of this work was to add to the body of data on the frequency and severity of degenerative radiographic findings at adjacent levels after anterior cervical interbody fusion and on their clinical impact and to contribute to the insights about their pathogenesis. One hundred eighty patients who were treated by anterior cervical interbody fusion and who had a follow-up of >60 months were clinically and radiologically examined by independent investigators. For all patients, the long-term Odom score was compared with the score as obtained 6 weeks after surgery. For myelopathic cases, both the late Nurick and the Odom score were compared with the initial postoperative situation. For the adjacent disc levels, a radiologic "degeneration score" was defined and assessed both initially and at long-term follow-up. At late follow-up after anterior cervical interbody fusion, additional radiologic degeneration at the adjacent disc levels was found in 92% of the cases, often reflecting a clinical deterioration. The severity of this additional degeneration correlated with the time interval since surgery. The similarity of progression to degeneration between younger trauma patients and older nontrauma patients suggests that both the biomechanical impact of the interbody fusion and the natural progression of pre-existing degenerative disease act as triggering factors for adjacent level degeneration.
... Dans quelques études, seules les incertitudes de repérage des points anatomiques sont fournies sans préciser leur impact sur les résultats finaux d'amplitudes segmentaires [87]. La cinéradiographie permet l'obtention des amplitudes de mobilité à chaque pas de temps et donc de caractériser les patterns de mouvement des différents étages vertébraux qui constituent un des paramètres clés permettant de mettre en relief des pathologies cervicales [112], qui ne sont pas nécessairement détectables à partir de clichés radiographiques classiques [113,114]. ...
Article
The cervical spine is composed of hard and flexible components connecting the chest and the skull. Cervical mechanical disorders and their consequences are a current problem. Biomechanics provides relevant tools to quantify the kinematic of the cervical spine in order to obtain objective data supporting the clinical diagnosis or the evaluation 'of the therapeutic treatment effectiveness. The aim of this Ph.D. thesis is to improve the analysis of the impact of cervical degenerative or traumatic diseases on the 3D kinematics of the cervical spine in vivo. A global approach characterizing the 3D nobilities of the cervical spine was developed using a non-invasive specific protocol that has been evaluated in regards of the accuracy and the reproducibility. The cervical kinematic characterization, according to age and gender, were obtained on a large database of asymptomatic subjects. This database was used as a reference to demonstrate the feasibility of the quantification of pathological impact on the cervical kinematic in regards of different pathologies. A segmental approach has been proposed to quantify the contribution of each cervical unit in spinal movement. A 3D reconstruction method of the cervical spine from biplane X-rays was implemented in order to quantify the 3D segmental cervical spine magnitude in the 3 space planes during pseudo-dynamic X-rays.Thi s study proposes an original and relevant approach combining global and segmental point of view in order to characterize cervical performances. This study led to relevant perspectives about the combination of cervical global and segmental approach in order to better understand and quantify cervical disorders.
... Despite the excellent outcomes from ACA, studies indicate a change in the kinematics of the levels adjacent to the arthrodesis, which causes earlier onset of disc generation. [1][2][3][4][5][6][7][8][9][10][11][12] Hilibrand et al 5 reported adjacent degeneration rates of 2.9% per year and 25.6% over ten years following anterior arthrodesis, with 2/3 of these patients having undergone additional surgery. ...
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Objetivo: Investigar os resultados clínicos e funcionais a curto e médio prazo da artroplastia cervical total com a prótese Prestige LP® para tratamento da mielopatia compressiva, radiculopatia e dor axial com radiculopatia. Métodos: Estudo retrospectivo realizado no período de 2009 a 2012, incluindo 18 pacientes. Somente 16 foram localizados e participaram da segunda etapa da pesquisa, realizada em 2011 e 2012. Foram feitas avaliações pré e pós-operatórias utilizando-se o questionário CSOQ (Cervical Spine Outcomes Questionnaire). Os critérios de Odom foram utilizados somente na avaliação pós-operatória. Ambos foram traduzidos e adaptados para a cultura local. Resultados: Não houve radiculopatia pós-operatória ou qualquer outra complicação que exigisse hospitalização prolongada. Na maioria dos pacientes, observou-se grande melhora da dor axial e da radiculopatia, constatando-se somente um caso de indicação de conversão para artrodese. Conclusão: Em casos bem selecionados de discopatia cervical degenerativa, hérnia de disco cervical e mieolopatia compressiva, a artroplastia cervical mostrou-se um tratamento eficaz e seguro a curto e médio prazo.
... The results indicate that BMI, preoperative ADD on MRI, and disc bulge in preoperative CT examination were best predictors of SASDS for patients after posterior lumbar fusion (highest ORs) rather than age, gender, diagnosis, preoperative adjacent disc angle, postoperative distance from L1 to S1 sagittal plumb line, postoperative adjacent disc angle, and other clinical or radiographic characteristics. Many studies have focused on the altered biomechanics at the adjacent levels after fusion that result in increased mobility [9][10][11], increased loading [12], or increased intradiscal pressure [13], and, ultimately, accelerated disc degeneration [14][15][16]. This biomechanical change at the adjacent segments is affected by the range of fused segments and the sagittal angle. ...
Article
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Although measures to reduce and treat degenerative changes after fusion are discussed, these are still controversial. A retrospective study was conducted on a consecutive series of 3,799 patients who underwent posterior lumbar fusion for degenerative lumbar disease between January 1999 and January 2009. A total of 28 patients with symptomatic adjacent segment degeneration surgery were identified. Another group of 56 matched patients with degenerative lumbar disease without symptomatic adjacent segment degeneration after spinal fusion were marked as the control group. These two groups were compared for demographic distribution and clinical and radiographic data to investigate the predictive factors of symptomatic adjacent segment degeneration surgery by logistic regression. The overall incidence rate of symptomatic adjacent segment degeneration surgery was 0.74%. Strong risk factors for the development of a symptomatic adjacent segment degeneration requiring surgery were preoperative distance from L1 to S1 sagittal plumb line (p = 0.031), preoperative lumbar lordosis (p = 0.005), and preoperative adjacent disc height (p = 0.003). Mean postoperative lumbar lordosis was smaller (p = 0.000) in symptomatic adjacent segment degeneration surgery (SASDS) group compared with in the control group (33.3° vs. 39.8°). Postoperative adjacent disc height was also significantly lower in the former group compared with the latter group (p = 0.002). Logistic regression analysis showed that body mass index (BMI) (OR: 1.75; p = 0.006), preoperative adjacent disc degeneration (ADD) on MRI (OR: 13.52; p = 0.027), and disc bulge in preoperative CT examination (OR: 390.4; p = 0.000) maintained their significance in predicting likelihood of symptomatic adjacent segment degeneration surgery. The occurrence of a symptomatic adjacent segment degeneration surgery is most likely multifactorial and is related to BMI, preoperative ADD on MRI, and disc bulge in preoperative CT examination.
... Cineradiography and videofluoroscopy have allowed the visualisation of complete inter-vertebral motion sequences and have been available for many years [16,17], but analysis of the motion has been largely qualitative. However, during the last decade considerable progress has been made with detailed measurement of inter-vertebral motion using quantitative fluoroscopy (QF) [18]. ...
Article
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Background: Spinal manipulation for nonspecific neck pain is thought to work in part by improving inter-vertebral range of motion (IV-RoM), but it is difficult to measure this or determine whether it is related to clinical outcomes. Objectives: This study undertook to determine whether cervical spine flexion and extension IV-RoM increases after a course of spinal manipulation, to explore relationships between any IV-RoM increases and clinical outcomes and to compare palpation with objective measurement in the detection of hypo-mobile segments. Method: Thirty patients with nonspecific neck pain and 30 healthy controls matched for age and gender received quantitative fluoroscopy (QF) screenings to measure flexion and extension IV-RoM (C1-C6) at baseline and 4-week follow-up between September 2012-13. Patients received up to 12 neck manipulations and completed NRS, NDI and Euroqol 5D-5L at baseline, plus PGIC and satisfaction questionnaires at follow-up. IV-RoM accuracy, repeatability and hypo-mobility cut-offs were determined. Minimal detectable changes (MDC) over 4 weeks were calculated from controls. Patients and control IV-RoMs were compared at baseline as well as changes in patients over 4 weeks. Correlations between outcomes and the number of manipulations received and the agreement (Kappa) between palpated and QF-detected of hypo-mobile segments were calculated. Results: QF had high accuracy (worst RMS error 0.5o) and repeatability (highest SEM 1.1o, lowest ICC 0.90) for IV-RoM measurement. Hypo-mobility cut offs ranged from 0.8o to 3.5o. No outcome was significantly correlated with increased IV-RoM above MDC and there was no significant difference between the number of hypo-mobile segments in patients and controls at baseline or significant increases in IV-RoMs in patients. However, there was a modest and significant correlation between the number of manipulations received and the number of levels and directions whose IV-RoM increased beyond MDC (Rho=0.39, p=0.043). There was also no agreement between palpation and QF in identifying hypo-mobile segments (Kappa 0.04-0.06). Conclusions: This study found no differences in cervical sagittal IV-RoM between patients with non-specific neck pain and matched controls. There was a modest dose-response relationship between the number of manipulations given and number of levels increasing IV-RoM - providing evidence that neck manipulation has a mechanical effect at segmental levels. However, patient-reported outcomes were not related to this. Keywords: Neck pain, Manipulation, Spine kinematics, Fluoroscopy, Patient-reported outcomes
Article
The purpose of this article is to present an assessment method, in conjunction with age-related normal values, for lumbar spinal range of motion. Lumbar flexion, lumbar extension, and right and left lateral flexion were measured on 172 subjects by a combination of goniometry and spinal distraction techniques. Normal values are given for six age groups; each group had a range of 10 years. The results demonstrate that a significant decrease in lumbar spinal range of motion is expected with increasing age. The interobserver reliability based on 17 subjects was substantial for the four measurements taken; coefficients ranged from +.76 to +1.0. The information may prove useful to the clinician as an improved method for assessing the lumbar spine.
Article
Prospective, concurrently enrolled, multicenter trials of the Bryan Cervical Disc Prosthesis (Medtronic Sofamor Danek, Memphis, TN) were conducted for the treatment of patients with single-level and two-level (bi-level) degenerative disc disease of the cervical spine. The studies were designed to determine whether new functional intervertebral cervical disc prosthesis can provide relief from objective neurologic symptoms and signs, improve the patient's ability to perform activities of daily living, decrease pain, and maintain stability and segmental motion. The concept of accelerated degeneration of adjacent disc levels as a consequence of increased stress caused by interbody fusion of the cervical spine has been widely postulated. Therefore, reconstruction of a failed intervertebral disc with functional disc prosthesis should offer the same benefits as fusion while simultaneously providing motion and thereby protecting the adjacent level discs from the abnormal stresses associated with fusion. Patients with symptomatic cervical radiculopathy and/or myelopathy underwent implantation with the Bryan prosthesis after a standard anterior cervical discectomy. At scheduled follow-up periods, the effectiveness of the device was characterized by evaluating each patient's pain, neurologic function, and radiographically measured range of motion at the implanted level. Clinical success for both studies exceeded the study acceptance criteria of 85%. At 1-year follow-up, the flexion-extension range of motion per level: Discectomy and implantation of the device alleviates neurologic symptoms and signs similar to anterior cervical discectomy and fusion. Radiographic evidence supports maintenance of motion. The procedure is safe and the patients recover quickly. At least 5 years of follow-up will be needed to assess the long-term functionality of the prosthesis and protective influence on adjacent levels.
Article
The concept of accelerated degeneration of adjacent disc levels as a consequence of increased stress caused by interbody fusion of the cervical spine has been widely postulated. Therefore, reconstruction of a failed intervertebral disc with a functional disc prosthesis should offer the same benefits as fusion while simultaneously providing motion and thereby protecting the adjacent level discs from the abnormal stresses associated with fusion. This study was designed to determine whether a new, functional intervertebral cervical disc prosthesis can provide relief from objective neurological symptoms and signs, improve the patient's ability to perform activities of daily living, decrease pain, and provide stability and normal range of motion. We conducted a prospective, concurrently enrolled, multicenter trial of the Bryan Cervical Disc Prosthesis (Spinal Dynamics Corp., Mercer Island, WA) for the treatment of patients with single-level degenerative disc disease of the cervical spine. Patients with symptomatic cervical radiculopathy and/or myelopathy underwent implantation with the Bryan prosthesis after a standard anterior cervical discectomy. At scheduled follow-up periods, the effectiveness of the device was characterized by evaluating each patient's pain, neurological function, and range of motion at the implanted level. Analysis included data regarding 60 patients at 6 months with 30 of those patients at 1 year. Clinical success at 6 months and 1 year after implantation was 86 and 90%, respectively, exceeding the study's acceptance criteria of 85%. These results compare favorably with the short-term clinical outcomes associated with anterior cervical discectomy and fusion reported in the literature. At 1 year, there was no measurable subsidence of the devices (based on a measurement detection threshold of 2 mm). Evidence of anterior and/or posterior device migration was detected in one patient and suspected in a second patient. There was no evidence of spondylotic bridging at the implanted disc space. The measured range of motion in flexion-extension, as determined by an independent radiologist, ranged from 1 to 21 degrees (mean range of motion, 9 +/- 5 degrees). No devices have been explanted or surgically revised. Discectomy and implantation of the device alleviates neurological symptoms and signs similar to anterior cervical discectomy and fusion. Radiographic evidence supports normal range of motion. The procedure is safe and the patients recover quickly. Restrictive postoperative management is not necessary. However, only after long-term follow-up of at least 5 years will it become clear whether the device remains functional, thus confirming these early favorable results. In addition, the influence on adjacent motion segments can be assessed after at least 5 years of follow-up.
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Cervical motion patterns were analyzed in a normal population and in patients with cervical instability by using cineradiography. To determine normal and pathologic motion patterns in the cervical spine through an in vivo continuous motion analysis. Cineradiographic techniques have been used in a limited number of studies to quantify spinal motion. There is a paucity of information regarding dynamic motion patterns in normal and pathologic cervical spines. Ten healthy subjects and 12 patients with unstable cervical spines (C1-C2 subluxation caused by rheumatoid arthritis, n = 10; instability below C2, n = 2) were studied. Cervical motion during flexion from the maximum extension position was recorded using cineradiography. Cervical segmental motions (C1-C2 to C5-C6) were continuously measured through quantifying cineradiographic images projected on a digitizer. Normal cervical spines showed a well-regulated stepwise motion pattern that initiated at C1-C2 and transmitted to the lower segments with time lags. Pathologic spines showed a different order of onset of segmental motion. In patients with rheumatoid arthritis who had atlantoaxial subluxation, C1-C2 motion initiated significantly earlier than C2-C3 motion. In patients with segmental instability below C2, motion in the unstable segments preceded that in the upper intact segments. Different motion patterns were observed between normal and pathologic cervical spines. Cineradiographic motion analysis is a valuable adjunctive technique, especially in diagnosis or evaluation of conditions that cannot be identified through conventional radiographic examination.
Article
The purpose of this article is to report normal variation in the screw (helical) axis of rotation of the head during various types of natural tracking movements. Nine normal subjects and eighteen subjects with neck injury faced a grid of targets separated by 10-degree intervals, and were instructed to use a head pointer (laser) to track whatever target was lit. Various horizontal, vertical, and oblique target sequences were employed. The normal subjects exhibited several consistent trends in finite screw axis parameter variation: vertical movements have a laterally-directed axis whose midsagittal plane crossing position is a function of the head orientation (typical range C3-T1); oblique movements have a diagonally-directed axis and an even greater orientation-specific range (C1-T1); and horizontal movements have a vertical axis that is modified near horizontal orientation extremes and is asymmetrically influenced by upward and downward bias orientations. Subjects with neck injury were seen to exhibit a variety of abnormal screw axis patterns.
Article
Anterior cervical discectomy and fusion using cervical plates has been seen as effective at relieving cervical radiculopathy and myelopathy symptoms. Although it is commonly used, subsequent disc degeneration at levels adjacent to the fusion remains an important problem. However, data on the frequency, impact, and predisposing factors for this pathology are still rare. To evaluate the incidence, predisposing factors, and impact of radiographic and clinical adjacent-segment pathology after anterior cervical discectomy and fusion using cervical plates, as well as to analyze the efficacy of this surgical method over the long term, after a minimum follow-up period of 10 years. Retrospective clinical study. Our study was a retrospective analysis of 177 patients who underwent anterior cervical discectomy and fusion using cervical plates, with follow-up periods of at least 10 years (mean, 16.2 years). (1) Radiographic adjacent-segment pathology using plain radiographs and (2) clinical adjacent-segment pathology after anterior cervical discectomy and fusion using cervical plates. We defined a new grading system of plain radiographic evidence of degenerative changes in adjacent discs after anterior cervical discectomy and fusion using cervical plates; grade 0 is considered normal, and grade V consists the presence of posterior osteophytes and a decrease in disc height to <50% of normal. The incidence, predisposing factors, and impact of radiographic and clinical adjacent-segment pathology were analyzed according to etiologies, number of fused segments, and plate-to-disc distance. Radiographic and clinical adjacent-segment pathology was found in 92.1% and 19.2%, respectively, of patients. By etiology, clinical adjacent-segment pathology was observed in 13.5% of patients who had sustained trauma, 12.7% of those with disc herniation, and 33.3% of those with spondylosis. By number of fused segments, clinical adjacent-segment pathology was found in 13.2% of patients who underwent single-level fusion and in 32.1% of those who underwent multilevel fusion surgeries. Patients with a plate-to-disc distance of <5 mm, who had spondylosis, or who underwent multilevel fusion had a higher incidence of clinical adjacent-segment pathology after anterior cervical discectomy and fusion using cervical plates than other groups did (p<.05). Of all patients, only 6.8% needed follow-up surgery. We found that over the long term, at a minimum follow-up point of 10 years, a plate-to-disc distance of <5 mm, having spondylosis, and undergoing multilevel fusion were predisposing factors for the occurrence of clinical adjacent-segment pathology. Nevertheless, the incidence of clinical findings of adjacent-segment pathology was much lower than the incidence of radiographic findings. Also, the rate of follow-up surgery was low. Therefore, anterior cervical discectomy and fusion using cervical plates can be considered a safe, effective procedure.
Article
Few clinical studies have described the changes in the range of motion (ROM) of the cervical spine and adjacent segments following central corpectomy. We aimed to quantify the changes in range of motion (ROM) of the cervical spine and the adjacent segments at ≥24 months following uninstrumented central corpectomy (CC) for cervical spondylotic myelopathy (CSM) and to determine the contribution of the adjacent segments to the compensation for loss of motion of the cervical spine following CC. Preoperative and follow-up lateral cervical spine radiographs of 36 patients who underwent CC for CSM between 2001 and 2007 were compared for the ROM of the subaxial cervical spine, superior and inferior adjacent segment. Anterior osteophytes as seen on the radiographs were classified according to Nathan's grading system. The mean duration of follow-up was 48.5 months. At follow-up, the total cervical spine ROM decreased by 18.3° ± 2.2° (p < 0.001), the superior adjacent segment ROM increased by 2.3° ± 0.9° (p = 0.01) and the inferior adjacent segment ROM, measured in 20 cases, increased by 6.2° ± 1.7° (p = 0.01). The superior adjacent segment showed a 70% increase, whereas the inferior adjacent segment showed a 110% increase in mobility. Nathan's grade at the superior or inferior adjacent segment increased in 12 cases. CC significantly reduces the motion of the cervical spine and increases the adjacent segment mobility at intermediate follow-up. The inferior adjacent segment shows greater compensation of motion as compared to the superior adjacent segment in our series. Adjacent segment degeneration as estimated by Nathan's grade was seen in one-third of the cases.
Abstract Von 60 nachuntersuchten Patienten wurden bei 56 Halswirbelsäulen 235 nicht versteifte Bewegungssegmente (C2/3 bis C7/Thl) ein bis acht Jahre nach überwiegend vorderen Spondylodesen wegen instabiler Verletzungen überprüft: Das Augenmerk galt radiologischen und funktionellen Veränderungen. Die radiologisch auffälligsten Befunde waren 15 nasen-und spangenförmige Spondylophyten, welche sich stets in Nachbarschaft der Spondylodesen zeigten. Die Funktion der entsprechenden Segmente war auf 67,8% bzw. 46,6% reduziert, die zugehörigen Diszi blieben unauffällig. Diese Befunde werden als Folge intraoperativer Segmentschädigungen durch Längsbandpräparation oder überstehende Platten gedeutet. Siebenmal kam es rasch in vorher gesunden Segmenten zu deformierenden Spondylosen als Folge zusätzlicher, nicht erkannter Segmentverletzungen. In keinem der 134 nicht angrenzenden Segmente waren derartige Veränderungen zu sehen. Bei den traumatischen Spondylodesen der Halswirbelsäule kam es weder zu verstärktem Auftreten degenerativer Veränderungen noch zu Hypermobilität als Folge der geänderten mechanischen Verhältnisse; gesunde Bandscheiben können die Nachbarschaft zu Spondylodesen offenbar gut kompensieren. Abstract Radiologic and functional assessments were performed in 60 patients who underwent cervical fusion for traumatic instability. Follow up range was one to eight years (average 3.9 years). 235 motion segments (C2/3 to C7/thl) were analyzed. Follow up radiologic examination included a. p., flexion-extension and oblique cervical spine films. Each motion segment was analyzed for range of mobility according the method of Penning. Total, range of spinal motion was recorded, radiologie disc appearance and spondylophyte formation were also classified. The most striking findings included 15 “nose-like” and eleven “bridging” spondylophytes noted anteriorly on the lateral views. Segmental function was diminished an average of 67.8 % in “noses” and 46.6 % in “bridges”. Since the disc height remained radiologically normal, and osteophytes were located exclusively anterior, adjacent to the fusions, these changes were interpreted as secondary to excessive dissection along the anterior longitudinal ligament or the improper placement of the plates. In seven cases rapid development of degenerative change was attributed to previously undetected traumatic insult to a normal motion segment. This resulted in significant loss of function in all cases. In 134 non-adjacent motion segments no spondylophyte formation or disc degeneration secondary to operation or trauma was found. Of 235 motion segments, ten adjacent and five non-adjacent segments in nine patients were found to show increased degenerative changes. In this population the average patient age was 51 years (significantly higher than the group average of 38.7 years). The function of these segments was only 45.2% of normal. With historical controls the incidence of increased degenerative changes of the non-fused segments is at no greater risk for early degenerative phenomena than the population at large. 1. Cervical fusion for traumatic instabilities carries a higher risk for the adjacent motion segments, but lower than the risk in patients with deforming spondylosis. Careful operative technique can offer a distinct decrease in postoperative spondylophyte formation. 2. Non fused motion segments in this study were affected by degenerative disease at a rate approximately equal to the general population. 3. This investigation revealed no hypermobiiity in any non-fused motion segment. 4. Even radiologicallv normal segments could reveal a diminished range of motion.
Article
To study the influence of anterior body fusion on the adjacent vertebral discs, the radiographs of 101 patients with cervical spondylotic myelopathy (CSM) were analysed, and cervical mobility and intersegmental mobility were determined. Single level fusions were carried out in 29 patients, double level fusions in 45 patients and triple level fusions in 27 patients. Cervical mobility after surgery was inversely proportional to the number of fused discs. Angles were reduced by fusion in proportion to the number of fused discs. The compensatory increase in motion at the disc adjacent to the fusion was slight, and the number of fused discs had little influence on the compensatory increase in motion. Regarding cervical motion, extension and flexion were limited to the same extent in single level fusions, flexion was more limited in double level fusions and limitation of extension was much larger in triple level fusions. Seven patients underwent a second operation after a double level fusion, and one patient underwent a second operation after a single level fusion. In all five patients whose radiographs before the second operation were available, flexion was adequately limited, but extension was not limited at all. These results suggest that the failure to limit extension is responsible for the recurrence of CSM.
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OBJECTIVE: To evaluate results of cervical disc arthroplasty with the Bryan prosthesis for treatment of cervicobrachial pain (radiculopathy) and spinal cord compression (myelopathy). METHODS: From 2002 to 2007, the CECOL surgical staff has operated 65 patients. Only 28 patients were found in 2010 to a new data collection. The pre- and post-operative evaluation was conducted using the CSOQ questionnaire (Cervical Spine Outcomes Questionnaire). Odom criteria were used only in the postoperative evaluation. Both were translated and adapted to local culture. RESULTS: There was a significant symptomatic and functional improvement in most patients. The reduction of neck pain (axial) and brachial pain (radicular) was similar. Odom criteria showed 82.1% good and excellent results, 10% satisfactory and 7% poor. There was only one complication (3%) which was reversed with anterior arthrodesis. CONCLUSIONS: The total cervical disc arthroplasty has proved to be a safe and effective method to treat selected cases of cervical disc herniation with radiculopathy and/or myelopathy in the short and medium term.
Article
It is well demonstrated that anterior cervical interbody fusion, producing the loss of motion at the treated segment, leads to an increased stress on the adjacent nonoperated discs, which can accelerate the rate of disc degeneration. Several papers in literature show that use of cervical disc prosthesis allows to achieve both benefits of the anterior cervical arthrodesis and the possibility of preserving motion at the operated level and of avoiding biomechanical stress of adjacent spinal segments. This paper analyses preliminary data of our series to evaluate the reliability of the second generation of Bryan cervical arthroplasty (Bryan Accel instrumentation, Medtronic Sofamor Danek, Memphis, TN). To this aim 10 patients, 7 males and 3 females, with average age of 41 years, underwent implantation with the Bryan "Accel" cervical disc prosthesis after a standard anterior cervical microdiscectomy during a 6 months period. In our series there are 9 mono-level and 1 bi-level patients. All patients presented conservative treatment resistant radiculopathy or progressive myelopathy. The Neck Disability Index (NDI) questionnaire and Visual Analogue Scale (VAS) were used to assess pain and functional outcomes. Follow up duration ranged from 8 to 14 months, with a mean duration of 12 months. A statistically significant improvement in the mean NDI and VAS scores was seen between pre- and late postoperative follow up evaluations. In our opinion, preliminary data of our work show second generation of Bryan cervical arthroplasty (Bryan Accel instrumentation, Medtronic Sofamor Danek) to be as reliable as the more complex first generation instrumentation in terms of clinical and radiological outcomes and accuracy in prosthesis insertion.
Article
Objective: The concept of accelerated degeneration of adjacent disc levels as a consequence of increased stress caused by interbody fusion of the cervical spine has been widely postulated. Therefore, reconstruction of a failed intervertebral disc with a functional disc prosthesis should offer the same benefits as fusion while simultaneously providing motion and thereby protecting the adjacent level discs from the abnormal stresses associated with fusion. This study was designed to determine whether a new, functional intervertebral cervical disc prosthesis can provide relief from objective neurological symptoms and signs, improve the patient's ability to perform activities of daily living, decrease pain, and provide stability and normal range of motion. Methods: We conducted a prospective, concurrently enrolled, multicenter trial of the Bryan Cervical Disc Prosthesis (Spinal Dynamics Corp., Mercer Island, WA) for the treatment of patients with single-level degenerative disc disease of the cervical spine. Patients with symptomatic cervical radiculopathy and/or myelopathy underwent implantation with the Bryan prosthesis after a standard anterior cervical discectomy. At scheduled follow-up periods, the effectiveness of the device was characterized by evaluating each patient's pain, neurological function, and range of motion at the implanted level. Results: Analysis included data regarding 60 patients at 6 months with 30 of those patients at 1 year. Clinical success at 6 months and 1 year after implantation was 86 and 90%, respectively, exceeding the study's acceptance criteria of 85%. These results compare favorably with the short-term clinical outcomes associated with anterior cervical discectomy and fusion reported in the literature. At 1 year, there was no measurable subsidence of the devices (based on a measurement detection threshold of 2 mm). Evidence of anterior and/or posterior device migration was detected in one patient and suspected in a second patient. There was no evidence of spondylotic bridging at the implanted disc space. The measured range of motion in flexion-extension, as determined by an independent radiologist, ranged from 1 to 21 degrees (mean range of motion, 9 +/- 5 degrees). No devices have been explanted or surgically revised. Conclusion: Discectomy and implantation of the device alleviates neurological symptoms and signs similar to anterior cervical discectomy and fusion. Radiographic evidence supports normal range of motion. The procedure is safe and the patients recover quickly. Restrictive postoperative management is not necessary. However, only after long-term follow-up of at least 5 years will it become clear whether the device remains functional, thus confirming these early favorable results. In addition, the influence on adjacent motion segments can be assessed after at least 5 years of follow-up.
Chapter
Seit 1975 haben wir in Zusammenarbeit mit der Erlanger Orthopädischen Universitätsklinik und der Erlanger Neurochirurgischen Universitätsklinik Patienten mit zervikaler Myelopathic untersucht. Diesem Krankheitsbild wurde an vielen Kliniken etwa ab 1970 mit wachsendem Interesse nachgegangen (Übersicht bei Grote et al. 1979). Trotz rasch zunehmender Literaturfülle muß das Krankheitsbild in seiner Pathophysiologie bis heute als unverständlich bezeichnet werden. Hierfür ist einmal die nach wie vor bestehende Vielfalt von Syndromen, die unter dem Begriff „zervikale Myelopathic“ subsumiert werden, anzuschuldigen. Zusätzlich ungünstig wirken sich insuffiziente Untersuchungstechniken aus. Die früher weitverbreitete Annahme, daß die chronische zervikale Myelopathic zumal des älteren Menschen eine vaskuläre Myelopathic sei, also analog der zerebrovaskulären Insuffizienz eine spinovaskuläre Insuffizienz darstellte, wurde zunehmend verlassen. Statt dessen wurde die Bedeutung des mechanischen Faktors erkannt. Aber auch hierbei gab es 2 Schulen: Während einerseits die pathogenetische Bedeutung eines konstitutionell engen Spinalkanals betont wurde, auf dessen Boden zusätzliche degenerative Veränderungen der Halswirbelsäule schließlich zu einer Kompression des Rückenmarkes führen sollen, wurde auf der anderen Seite herausgestellt, daß nicht die Enge als solche, sondern das pathologische Bewegungsmuster das Krankheitsbild verursachen würde. Dieses pathologische Bewegungsmuster soll dazu führen, daß statt der überwiegenden Rollbewegung der einzelnen Wirbelkörper beim Vor- und besonders beim Rückwärtsneigen des Kopfes es vielmehr zu einem Wirbelgleiten kommen soll mit einer treppenförmigen Verformung, die auf das Rückenmark Druck ausübe.
Chapter
Pathogenesis of cervical myelopathy has not been explained up to now. A relevant component in its development is the direct mechanical lesion of the spinal cord by degenerated lumbar disc tissue or by osteophytes, congenital stenosis of the cervical canal being a decisive predisposing factor. Several authors (5, 15, 16) have stressed the importance of local vascular disturbances as another predisposing factor. In early literature (1, 13, 14) the motility of the cervical region of the ver.tebral column was discussed as relevant for the pathogenesis of cervical myelopathy. According to O’CONNEL (9), maximal motion of the cervical vertebral column in the sagittal plane leads to a difference of length of up to 5 cm. At the same time retroflexion causes a severe transverse stenosis of the horizontal plane by the folding of the ligamentum flavum (7).
Article
Retrospective analysis of 36 cases of degenerative disc disease treated by interbody fusion with polyetheretherketone (PEEK) cages. To determine the safety and efficiency of PEEK cages for anterior cervical fusion (ACF). ACF with autologous bone has been reported since over 50 years ago. The recent development of cages housing materials inducing osteogenesis simplifies the technique of interbody fusion. The main purposes of bone substitutes for ACF are immediate biomechanical support, osteo-integration of the graft, and elimination of local side effects at the donor site. This report shows our results using PEEK cages. During an 18-month period, 36 consecutive patients had cervical fusions at 43 levels between C3 and C7. All operations involved one or two disc spaces for degenerative disc disease. We implanted all disc spaces with PEEK cages (Stryker Corporation, Kalamazoo, MI) containing granulated coralline hydroxylapatite (Pro-Osteon 200, Interpore Cross International, Irvine, CA) or deantigenated pig bone in a gel solution (Gen-Os, Tecnoss, Torino, Italy). About 97% of patients had a good to excellent outcome; the result in one myelopathic patient was fair. The cervical fusion rate was 16.7% at 3 months, 61.1% at 6 months, and 100% at one year. PEEK cages appear to be safe and efficient for ACF. In order to confirm our preliminary impressions studies on larger series with long term follow-up are warranted.
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J. W. Bone J. W. spine. Cineradiography. & Joint Cineroentgenography 7. Bone In:Proceed- 7. Surg., 3963, 45-A, 1543. 5. FIELDING, cervical 39-A, JARRE, Medical Glasser. of normal Surg.,&Joint 1957, 1280-1288. H. 6. A. Roentgencinematography. I. Edited Publishers, In: Physics. Year Volumeby Chicago, Otto Book Inc., 1944,pp.3259-1260. D. Cineradiographic ofhigh 3967, 94, M. D. trafficaccidents. 85, 974-98 M.D. Cineroentgenographic withcervical 7