Myelopathy and Spinal Deformity: The Relevance of Spinal Alignment in Planning Surgical Intervention for Degenerative Cervical Myelopathy.

Toronto Western Hospital - Division of Neurosurgery, 399 Bathurst Street, West Wing, 4th Floor, Room WW4-446, Toronto, Ontario, Canada M5T 2S8 UCSF Medical Center - Neurosurgery Clinic, 400 Parnassus Avenue, Eighth Floor, San Francisco, CA 94143 University of Virginia - Department of Neurological Surgery, PO Box 800212, Charlottesville, VA 22908 Emory Spine Center, Department of Orthopaedic Surgery, 59 Executive Park South #3000, Atlanta, GA 30329 UW Bone and Joint Center, 4245 Roosevelt Way NE, Seattle, WA 98195 Toronto Western Hospital - Division of Neurosurgery, 399 Bathurst Street, West Wing, 4th Floor, Room WW4-449, Toronto, Ontario, Canada M5T 2S8.
Spine (Impact Factor: 2.3). 08/2013; 38(22). DOI: 10.1097/BRS.0b013e3182a7f521
Source: PubMed


: Surgical management of degenerative cervical myelopathy requires careful pathoanatomic consideration to select between various surgical options from both anterior and posterior approach. Hitherto unexplored is the relevance of cervical deformity to the pathophysiology of such neurological disability, and whether correction of that deformity should be a surgical objective when planning for reconstruction after spinal cord decompression. Such correction could address both the static cord compression and the dynamic repetitive cord injury, while also restoring more normal biomechanics to the cervical spine. The articles in this special issue's section on cervical spinal deformity reveal that cervical sagittal alignment is geometrically related to thoracolumbar spinal pelvic alignment and to T1 slope and that it is further clinically correlated to regional disability and general health scores and to myelopathy severity. These conclusions are based on narrative reviews and a selection of primary research data, reflecting the nascency of this field. They further recommend for preoperative assessment of spinal alignment when significant deformity is suspected, and that correction of cervical kyphosis should be an objective when surgery is planned.

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    ABSTRACT: In this narrative review, we aim to outline what is currently known about the pathophysiology of cervical spondylotic myelopathy (CSM), the most common cause of spinal cord dysfunction. In particular, we note the unique factors that distinguish it from acute spinal cord injury. Despite its common occurrence, the reasons why some patients develop severe symptomatology while others have few or no symptoms despite radiographic evidence confirming similar degrees of compression is poorly understood. Neither is there a clear understanding of why certain patients have a stable clinical myelopathy and others present with only mild myelopathy. Moreover, the precise molecular mechanisms which contribute to the pathogenesis of the disease are incompletely understood. The current treatment method is decompression of the spinal cord but a lack of clinically relevant models of CSM have hindered the understanding of the full pathophysiology which would aid the development of new therapeutic avenues of investigation. Further elucidation of the role of ischemia, currently a source of debate, as well as the complex cascade of biomolecular events as a result of the unique pathophysiology in this disease will pave the way for further neuroprotective strategies to be developed to attenuate the physiological consequences of surgical decompression and augment its benefits.
    Preview · Article · Mar 2014 · European Spine Journal
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    ABSTRACT: Large cohort study of volunteers aged over 50. To investigate influence of age and gender on cervical sagittal alignment among volunteers aged over 50. Few large-scale studies have described normative values in cervical spine alignment regarding age and gender among volunteers aged over 50. The study cohort included 656 volunteers aged 50-89 years. Pelvic tilt (PT), sacral slope (SS), pelvic incidence (PI), lumbar lordosis (LL), PI-LL, thoracic kyphosis (TK), T1 slope (T1S), cervical lordosis (CL), C7 sagittal vertical axis (C7 SVA), C2-7 SVA, and T1S-CL were measured using whole spine and pelvic radiographs taken in the standing position. Health-related quality of life (HRQOL) was assessed using the EuroQOL (EQ-5D) standardized instrument for measurement of health outcome and Oswestry Disability Index (ODI). There were 36 subjects aged 50-59 years, 174 aged 60-69 years, 311 aged 70-79 years, and 135 aged 80-89 years. Average T1S for each decade was 32, 31, 33, and 36 degrees for males, and 28, 29, 32, and 37 degrees for females, respectively. Average C2-7 SVA was 25, 28, 34, and 35 mm for males, and 20, 21, 22, and 28 mm for females, respectively.C2-7 SVA ≥ 40 mm, T1S ≥ 40 degrees, and T1S-CL ≥ 20 degrees pertaining to EQ-5D were significantly worse in the other cases. C2-7 SVA was significantly greater in males among all age groups, particularly among those with C2-7 SVA of ≥40 mm [males, 69% (82/118) vs. females, 33% (36/118)]. Sagittal parameters of cervical spine were significantly worse in males than females. C2-7 SVA, T1S, and T1S-CL negatively influenced EQ-5D. These results help to explain the greater prevalence of cervical spondylotic myelopathy among elderly males.
    No preview · Article · Jul 2015 · Spine
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    ABSTRACT: Unlabelled: : Cervical spinal cord dysfunction can result from either traumatic or nontraumatic causes, including tumors, infections, and degenerative changes. In this article, we review the range of degenerative spinal disorders resulting in progressive cervical spinal cord compression and propose the adoption of a new term, degenerative cervical myelopathy (DCM). DCM comprises both osteoarthritic changes to the spine, including spondylosis, disk herniation, and facet arthropathy (collectively referred to as cervical spondylotic myelopathy), and ligamentous aberrations such as ossification of the posterior longitudinal ligament and hypertrophy of the ligamentum flavum. This review summarizes current knowledge of the pathophysiology of DCM and describes the cascade of events that occur after compression of the spinal cord, including ischemia, destruction of the blood-spinal cord barrier, demyelination, and neuronal apoptosis. Important features of the diagnosis of DCM are discussed in detail, and relevant clinical and imaging findings are highlighted. Furthermore, this review outlines valuable assessment tools for evaluating functional status and quality of life in these patients and summarizes the advantages and disadvantages of each. Other topics of this review include epidemiology, the prevalence of degenerative changes in the asymptomatic population, the natural history and rates of progression, risk factors of diagnosis (clinical, imaging and genetic), and management strategies. Abbreviations: CSM, cervical spondylotic myelopathyDCM, degenerative cervical myelopathyJOA, Japanese Orthopaedic AssociationmJOA, modified Japanese Orthopaedic AssociationOPLL, ossification of the posterior longitudinal ligamentSCI, spinal cord injury.
    Full-text · Article · Sep 2015 · Neurosurgery
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