Degenerative cervical myelopathy outcome

Degenerative cervical myelopathy outcome

Preoperative duration of symptoms may significantly impact outcomes in patients treated surgically for degenerative cervical myelopathy (DCM).

Tetreault et al. analyzed whether duration of symptoms is associated with preoperative functional impairment, disability, and quality of life and (ii) determine the optimal timing for decompressive surgery.

Patients with DCM were prospectively enrolled in either the AOSpine North American or International study at 26 global sites (n = 757). Postoperative functional impairment was evaluated at 1-yr using the modified Japanese Orthopaedic Association (mJOA) score. Change scores between baseline and 1-yr were computed for the mJOA. Duration of symptoms was dichotomized into a “short” and “long” group at several cut-offs. Analysis of covariance was used to evaluate differences in change scores on the mJOA between the duration of symptoms groups in 4-mo increments.

The cohort consisted of 424 men and 255 women, with a mean duration of symptoms of 26.1 ± 36.4 mo (0.25-252 mo). Duration of symptoms was not correlated with preoperative mJOA, Nurick, Neck Disability Index, or Short-Form (SF)-36 Physical and Mental Component Scores. Patients with a duration of symptoms shorter than 4 mo had significantly better functional outcomes on the mJOA than patients with a longer duration of symptoms (>4 mo). Thirty-two months was also a significant cut-off.

Patients who are operated on within 4 mo of symptom presentation have better mJOA outcomes than those treated after 4 mo. It is recommended that patients with DCM are diagnosed in a timely fashion and managed appropriately 1).


Zileli et al. conducted a study to review the literature systematically to determine the most reliable outcome measures, important clinical and radiological variables affecting the prognosis in cervical spondylotic myelopathy patients. A literature search was performed for articles published during the last 10 years. As functional outcome measures they recommended to use modified Japanese Orthopaedic Association scaleNurick scale, and Myelopathy Disability Index. Three clinical variables that affect the outcomes are age, duration of symptoms, and severity of the myelopathy. Examination findings require more detailed study to validate their effect on the outcomes. The predictive variables affecting the outcomes are hand atrophy, leg spasticityclonus, and Babinski sign. Among the radiological variables, the curvature of the cervical spine is the most important predictor of prognosis. Patients with instability are expected to have a poor surgical outcome. Spinal cord compression ratio is a critical factor for prognosis. High signal intensity on T2-weighted magnetic resonance images is a negative predictor for prognosis. The most important predictors of outcome are preoperative severity and duration of symptoms. T2 hyperintensity and cord compression ratio can also predict outcomes. New radiological tests may give promising results in the future 2).


Left untreated degenerative cervical myelopathy can lead to spastic tetraparesis 3).

A study investigating quality of life in DCM patients indicated they suffer among the worst SF36 health scores of all chronic diseases 4).

Cervical spondylotic myelopathy surgery outcome

References

1)

Tetreault L, Wilson JR, Kotter MRN, Côté P, Nouri A, Kopjar B, Arnold PM, Fehlings MG. Is Preoperative Duration of Symptoms a Significant Predictor of Functional Outcomes in Patients Undergoing Surgery for the Treatment of Degenerative Cervical Myelopathy? Neurosurgery. 2019 Nov 1;85(5):642-647. doi: 10.1093/neuros/nyy474. PubMed PMID: 30445506.
2)

Zileli M, Maheshwari S, Kale SS, Garg K, Menon SK, Parthiban J. Outcome Measures and Variables Affecting Prognosis of Cervical Spondylotic Myelopathy: WFNS Spine Committee Recommendations. Neurospine. 2019 Sep;16(3):435-447. doi: 10.14245/ns.1938196.098. Epub 2019 Sep 30. PubMed PMID: 31607075.
3)

Chen LF, Tu TH, Chen YC, Wu JC, Chang PY, Liu L, Huang WC, Lo SS, Cheng H. Risk of spinal cord injury in patients with cervical spondylotic myelopathy and ossification of posterior longitudinal ligament: a national cohort study. Neurosurg Focus. 2016 Jun;40(6):E4. doi: 10.3171/2016.3.FOCUS1663. PubMed PMID: 27246487.
4)

Oh T, Lafage R, Lafage V, Protopsaltis T, Challier V, Shaffrey C, Kim HJ, Arnold P, Chapman J, Schwab F, Massicotte E, Yoon T, Bess S, Fehlings M, Smith J, Ames C. Comparing Quality of Life in Cervical Spondylotic Myelopathy with Other Chronic Debilitating Diseases Using the Short Form Survey 36-Health Survey. World Neurosurg. 2017 Oct;106:699-706. doi: 10.1016/j.wneu.2016.12.124. Epub 2017 Jan 5. PubMed PMID: 28065875.

Cervical spinal schwannoma

Cervical spinal schwannoma

Spinal schwannoma are most frequently seen in the cervical and lumbar regions, far more frequently than in the thoracic spine.

Classification

Asazuma Classification

1).


Eden’s classification for dumbbell tumors of the spine, long considered a “gold standard,”

no longer is sufficient to determine surgical strategy in view of recent advances in computed tomography and magnetic resonance imaging.

Treatment

Cervical dumbbell spinal schwannomas with an extraspinal extension through the intervertebral foramina pose significant challenges for complete resection while avoiding injury to the vertebral artery and preserving the integrity of the cervical spine. Posterior approaches may require an extensive soft-tissue dissection and bone removal with potential spinal instability. Moreover, they offer only a limited access to an extraspinal tumor component that entails an additional anterior approach for complete resection of a dumbbell-shaped lesion.

Goga et al., used an anterolateral transforaminal approach that preserves the bony elements of the intervertebral foramen and offers a comprehensive access to the extraspinal, foraminal and intraspinal/intradural components of a cervical dumbbell tumor 2).

Outcome

Cervical spinal schwannoma is benign, and outcomes after surgical resection are generally excellent. A surgical dilemma sometimes arises as to whether to perform total tumor removal, which carries a risk of sacrificing the nerve root, or subtotal removal, where the risk can be tumor recurrence.

Case series

Chowdhury et al. reported schwannomas arising from C1, C2 and C3 spinal nerve roots were regarded as high cervical spinal schwannoma. All patients with high cervical spinal schwannomas that were consecutively operated microneurosurgically from 2006-2010 were included in the study. Postoperatively all patients were followed up regularly both clinically and neuro-radiologically (MRI of cervical spine).

Average follow up was 31.5 months. The mean age of the series was 35.8 years (range 10-61 years). There were 8 male and 7 female patients. The mean duration of symptoms at the time of presentation was 32 months (range 06 months-5 years). Two schwannomas were completely extradural, seven were intradural and rest six were interdural or hourglass type (both extra and intradural) as identified during surgery. The standard midline posterior approach was used in all patients. A C2 hemilaminectomyor C2 laminectomy with or without cutting of posterior arch of atlas was used for most intradural and large interdural C2 schwannomas. Tumor removal was complete in all cases. Preservation of the nerve root fibers was not possible in 9 cases and was possible only in 3 cases. In two patients CSF leak developed after operation. One patient who had severe myelopathic features with bed sore failed toimprove and expired 5 months after operation. Rest of the patients showed postoperative improvement in their preoperative symptoms and returned to their normal life by the end of sixth month. There was no tumor recurrence in any patient till last follow up.

Proper 3-D anatomical orientation & physiological knowledge, deep neuro-radiological observation,pathological appreciations and micro-neurosurgical skill and expertization can make the surgical management of these tumors ( in a surgically complex site) simple with gratifying result (i.e.neurological outcome) without extensive bone removal or soft tissue manipulation through a standard midline posterior approach 3).


Thirty cases of cervical schwannomas treated by Yamane et al. were retrospectively reviewed;initial symptoms, tumor location, Eden classification, surgical method, functional outcome, and tumor recurrence were investigated. All permanent motor deficits were the result of resecting functionally relevant nerve roots (i.e., C5-8). The rate of permanent sensory deficit was 11% after C1-4 nerve root resection, and 67% after C5-8 nerve root resection. Permanent neurological deficits occurred in 14% of patients younger than 40 years and 38% of those older than 40. Dumbbell tumors were associated with the need for total or ventral nerve root transection, as well as with a high incidence of tumor recurrence. The incidence of permanent neurological deficit was significantly higher in patients undergoing C5-8 nerve root resection, and tended to be higher in those over 40 4).


Forty-two patients with cervical dumbbell tumors were analyzed retrospectively using a new three-dimensional classification.

To establish optimal surgical strategies, we considered shapes and three-dimensional locations of cervical dumbbell tumors based on diagnostic images and intraoperative findings.

Forty-two cervical dumbbell tumors were characterized according to transverse-section images (Toyama classification; nine types) and craniocaudal extent of intervertebral and transverse foraminal involvement (IF and TF staging; three stages each).

Type IIIa tumors, involving dura plus an intervertebral foramen, accounted for 50% of cases. A posterior approach was used in 35 patients; 7 others underwent a combined anterior and posterior approach. A posterior approach was used for all type IIa and IIIa tumors, and for some type IIIb (upper cervical), IV, and VI tumors; a combined posterior and anterior approach was used for type IIb and the remainder of type IV and VI. Reconstruction was performed using spinal instrumentation in 4 patients (9.5%). Resection was subtotal in 6 patients (14.3%) and total in 36 (85.7%).

Systematic, imaging-based three-dimensional characterization of shape and location of cervical dumbbell tumors is essential for planning optimal surgery. The classification used here fulfills this need 5).


Case reports

Pokharel et al. reported a case of extradural cervical schwannoma in a 14-year-old boy with swelling in the posterior triangle of his neck. The radiological features suggested solitary extradural cervical schwannoma which was confirmed later by histopathological findings. There were no postoperative neurological complications 6)


Perry et al. reported in 2019 the third case of synchronously presenting primary progressive multiple sclerosis (MS) and spinal schwannoma. A 65-year-old man presented with six months of progressive weakness and pain of the right shoulderforearm, and handMRI demonstrated a contrast-enhancing transforaminal lesion at C7, most consistent with a benign nerve sheath tumor. Additional history disclosed several years of worsening fatigue, accompanied by bilateral weakness and lancinating leg pain. MRI of the neuraxis demonstrated abnormalities consistent with chronic demyelinating disease intracranially and within the spinal cordcerebrospinal fluid (CSF) analysis revealed nine oligoclonal bands and an elevated IgG index, resulting in the diagnosis of MS. Given the symptomatic C7 lesion, the patient subsequently underwent right C6-C7 facetectomygross total resection of the tumor, and C6-T1 posterior instrumented fusion. Postoperatively, the patient rapidly recovered normal right upper extremity function, and pathology confirmed benign schwannoma. Synchronously presenting co-morbid neurologic diagnoses are exceedingly rare. Nonetheless, the high incidence and protean nature of MS make it particularly susceptible to such confounding clinical cases. Correspondingly, MS should be considered when neurologic abnormalities are not compatible with a focal radiographic lesion, and the present report emphasizes the value of a good history and exam in unraveling similarly challenging cases 7).

References

1) , 5)

Asazuma T, Toyama Y, Maruiwa H, Fujimura Y, Hirabayashi K. Surgical strategy for cervical dumbbell tumors based on a three-dimensional classification. Spine (Phila Pa 1976). 2004 Jan 1;29(1):E10-4. PubMed PMID: 14699292.
2)

Goga C, Türe U. The Anterolateral Transforaminal Approach to a Dumbbell Schwannoma of the C3 Nerve Root. A 3-Dimensional Operative Video. Neurosurgery. 2014 Sep 24. [Epub ahead of print] PubMed PMID: 25255264.
3)

Chowdhury FH, Haque MR, Sarker MH. High cervical spinal schwannoma; microneurosurgical management: an experience of 15 cases. Acta Neurol Taiwan. 2013 Jun;22(2):59-66. PubMed PMID: 24030037.
4)

Yamane K, Takigawa T, Tanaka M, Osaki S, Sugimoto Y, Ozaki T. Factors predicting clinical impairment after surgery for cervical spinal schwannoma. Acta Med Okayama. 2013;67(6):343-9. PubMed PMID: 24356718.
6)

Pokharel A, Rao TS, Basnet P, Pandey B, Mayya NJ, Jaiswal S. Extradural cervical spinal schwannoma in a child: a case report and review of the literature. J Med Case Rep. 2019 Jul 17;13(1):230. doi: 10.1186/s13256-019-2108-6. PubMed PMID: 31311599; PubMed Central PMCID: PMC6636037.
7)

Perry A, Peters P, Graffeo CS, Carlstrom LP, Krauss WE. Synchronous Presentation of a Cervical Spinal Schwannoma and Primary Progressive Multiple Sclerosis in a 65-year-old Man. Cureus. 2019 Mar 4;11(3):e4176. doi: 10.7759/cureus.4176. PubMed PMID: 31093475; PubMed Central PMCID: PMC6502288.

Cervical Spine Deformity Surgery Book

Cervical Spine Deformity Surgery Book

by Christopher Ames (Author), K. Daniel Riew (Author), Justin Smith (Author), Kuniyoshi Abumi (Author)

List Price: $149.99

Buy

The first comprehensive book dedicated solely to the evaluation and treatment of cervical spine deformity!

The number of cervical fusion procedures has increased in the U.S. and globally during the last decade, in part due to an aging population and higher incidence of complex cervical problems. Despite advances in the surgical treatment of cervical deformities, few resources detail modern clinical assessment, radiographic evaluation, and surgical approaches. Cervical Spine Deformity Surgery by world-renowned spine surgeons Christopher Ames, K. Daniel Riew, Justin Smith, and Kuniyoshi Abumi fills a void in the literature. It provides a concise, state-of-the-art resource on current cervical deformity knowledge compiled from the literature and recognized masters in the field.

The generously illustrated text begins with a background on the marked health impact of cervical deformity. Opening chapters provide primers on the clinical and radiographic assessment of patients, malalignment and disability scores, and the physical exam. Subsequent chapters detail surgical planning and approaches for a full spectrum of cervical spine conditions, such as semi-rigid and rigid deformities, sagittal deformities, distal junctional kyphosis, congenital cervical deformity, and hemivertebra.

Key Features

Insightful technical nuances and pearls on managing surgical, neurological, and medical complications associated with cervical procedures, as well as risk stratification and patient frailty

Diverse osteotomies including low grade, uncovertebral joint (anterior view), cervical pedicle subtraction, cervical opening wedge, upper thoracic, C1-2 joint, and cervical pedicle screw fixation

Focused discussion on continuing efforts to create a clinically meaningful comprehensive cervical osteotomy classification system

Neurosurgical and orthopedic residents and practicing spine surgeons who treat patients with cervical deformities will greatly benefit from consulting this comprehensive and unique resource.

This book includes complimentary access to a digital copy on https://medone.thieme.com.

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