C1 cervical vertebra transverse process

C1 cervical vertebra transverse process

The transverse processes are large; they project laterally and downward from the lateral masses and serve for the attachment of muscles which assist in rotating the head. They are long, and their anterior and posterior tubercles are fused into one mass; the foramen transversarium is directed from below, upward and backward.

Fritch et al. presented a case of a 13-yr-old male with multifactorial intracranial hypertension including compression of the internal jugular vein by the transverse process of C1. Computerized tomography angiographic imaging revealed bilateral stenosis of the IJ veins due to compression from the transverse processes of C1. Medical management and shunt were attempted without resolution of symptoms. Hemodynamically significant stenosis at the right IJ was confirmed with manometry and so the C1 transverse process was resected and a stent placed endovascularly with a resolution of pressure gradient and clinical symptoms.

Contribution of C1 compression to this patient’s intracranial hypertension suggests that evaluation for IJ compression below the skull base may be needed to identify the underlying cause of intracranial hypertension in certain patients. Furthermore, surgical decompression of the IJ vein may be required as part of the treatment strategy. If venous stenting is being considered, this decompressive step must be taken before stenting is performed. Fritch et al. offer this case as evidence that decompression of the IJ vein by C1 lateral mass resection can be an effective and novel technique in the repertoire of neurosurgical management of intracranial hypertension 1) 2) 3).

References

1)

Fritch C, Voronovich Z, Carlson AP. C1 Transverse Process Resection for Management of Jugular Stenosis [published online ahead of print, 2020 Mar 17]. Oper Neurosurg (Hagerstown). 2020;opaa032. doi:10.1093/ons/opaa032
2)

Scerrati A, Zamboni P, De Bonis P. Letter: C1 Transverse Process Resection for Management of Jugular Stenosis [published online ahead of print, 2020 Jul 6]. Oper Neurosurg (Hagerstown). 2020;opaa200. doi:10.1093/ons/opaa200
3)

Brunozzi D, Alaraj A. Commentary: C1 Transverse Process Resection for Management of Jugular Stenosis [published online ahead of print, 2020 Apr 13]. Oper Neurosurg (Hagerstown). 2020;opaa071. doi:10.1093/ons/opaa071

Anterior percutaneous endoscopic cervical discectomy

Anterior percutaneous endoscopic cervical discectomy

Since the early 2000s, increasingly practical PECD techniques have been introduced because of advancements in working channel endoscope and surgical instrument technology 1) 2) 3) 4).

Anterior percutaneous endoscopic cervical discectomy (PECD) is an effective minimally invasive surgery for soft cervical disc herniation in properly selected cases 5) 6).

The PECD prototype is fluoroscopically guided percutaneous cervical disc decompression without endoscopic visualization, such as automated nucleotomy 7) 8).

Randomized controlled trials

Ahn et al. compared the surgical results of PECD and ACDF. Data from patients treated with single-level PECD (n = 51) or ACDF (n = 64) were analyzed. Patients were prospectively entered into the clinical database and their records were retrospectively reviewed. Perioperative data and clinical outcomes were evaluated using the visual analogue scale (VAS), Neck Disability Index (NDI), and modified Macnab criteriaVAS and NDI results significantly improved in both groups. The rates of excellent or good results were 88.24% and 90.63% in the PECD and ACDF group, respectively. The revision rates were 3.92% and 1.56% in the PECD and ACDF group, respectively. Operative time, hospital stay, and time to return to work were reduced in the PECD group compared to the ACDF group (p < 0.001). The five-year outcomes of PECD were comparable to those of conventional ACDF. PECD provided the typical benefits of minimally invasive surgery and may be an effective alternative for treating soft cervical disc herniation 9).


A total of 103 patients with ACDF or FACD were followed up for two years. In addition to general parameters specific measuring instruments were used. Postoperatively 85.9% of the patients no longer had arm pain, and 10.1% had occasional pain. There were no significant clinical differences between the decompression with or without fusion. The full-endoscopic technique afforded advantages in operation technique, rehabilitation and soft tissue injury. The recorded results show that FACD is a sufficient and safe alternative to conventional procedures when the indication criteria are fulfilled. At the same time, it offers the advantages of a minimally invasive intervention 10).

References

1)

Chiu, J.C.; Clifford, T.J.; Greenspan, M.; Richley, R.C.; Lohman, G.; Sison, R.B. Percutaneous microdecompressive endoscopic cervical discectomy with laser thermodiskoplasty. Mt. Sinai. J. Med. 2000, 67, 278–282.
2)

Ahn, Y.; Lee, S.H.; Lee, S.C.; Shin, S.W.; Chung, S.E. Factors predicting excellent outcome of percutaneous cervical discectomy: analysis of 111 consecutive cases. Neuroradiology 2004, 46, 378–384.
3)

Ahn, Y.; Lee, S.H.; Shin, S.W. Percutaneous endoscopic cervical discectomy: clinical outcome and radiographic changes. Photomed. Laser Surg. 2005, 23, 362–368.
4)

Ahn, Y.; Lee, S.H.; Chung, S.E.; Park, H.S.; Shin, S.W. Percutaneous endoscopic cervical discectomy for discogenic cervical headache due to soft disc herniation. Neuroradiology 2005, 47, 924–930
5)

Lee, J.H.; Lee, S.H. Clinical and radiographic changes after percutaneous endoscopic cervical discectomy: a long‐term follow‐up. Photomed. Laser. Surg. 2014, 32, 663–668.
6)

Ahn, Y. Percutaneous endoscopic cervical discectomy using working channel endoscopes. Expert. Rev. Med. Devices 2016, 13, 601–610.
7)

Courtheoux, F.; Theron, J. Automated percutaneous nucleotomy in the treatment of cervicobrachial neuralgia due to disc herniation. J. Neuroradiol. 1992, 19, 211–216.
8)

Bonaldi, G.; Minonzio, G.; Belloni, G.; Dorizzi, A.; Fachinetti, P.; Marra, A.; Goddi, A. Percutaneous cervical diskectomy: preliminary experience. Neuroradiology 1994, 36, 483–486.
9)

Ahn Y, Keum HJ, Shin SH. Percutaneous Endoscopic Cervical Discectomy Versus Anterior Cervical Discectomy and Fusion: A Comparative Cohort Study with a Five-Year Follow-Up. J Clin Med. 2020 Jan 29;9(2). pii: E371. doi: 10.3390/jcm9020371. PubMed PMID: 32013206.
10)

Ruetten S, Komp M, Merk H, Godolias G. Full-endoscopic anterior decompression versus conventional anterior decompression and fusion in cervical disc herniations. Int Orthop. 2009 Dec;33(6):1677-82. doi: 10.1007/s00264-008-0684-y. Epub 2008 Nov 18. PubMed PMID: 19015851; PubMed Central PMCID: PMC2899164.

Degenerative cervical myelopathy

Degenerative cervical myelopathy

The assessment, diagnosis, operative and nonoperative management of degenerative cervical myelopathy (DCM) have evolved rapidly over the last 20 years. A clearer understanding of the pathobiology of DCM has led to attempts to develop objective measurements of the severity of myelopathy, including technology such as multiparametric magnetic resonance imaging, biomarkers, and ancillary clinical testing. New pharmacological treatments have the potential to alter the course of surgical outcomes, and greater innovation in surgical techniques have made surgery safer, more effective and less invasive. Future developments for the treatment of DCM will seek to improve the diagnostic accuracy of imaging, improve the objectivity of clinical assessment, and increase the use of surgical techniques to ensure the best outcome is achieved for each individual patient 1).

Goel was troubled by the fact that his several PubMed and MEDLINE indexed articles on the subject published in leading journals dedicated to the study of the spine have not found any place in the huge reference list of 137 articles 2)

Definition

Epidemiology

Etiology

Pathophysiology

A review of Tetreault et al. 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 3).

Clinical features

Patients may initially experience minimal symptoms 4) 5) but subsequently often develop pain, sensory deficits especially affecting their hands and feet, spasticity, imbalance, bladder symptoms, and experience frequent falls 6).

Diagnosing DCSM has traditionally relied on presence of clinical symptoms, including clumsy hands, paralysis of the lower extremities, gait disturbances, urinary/bowel incontinence and severe neurological dysfunction disturbances, urinary/bowel incontinence, and severe neurological dysfunction 7) 8).

Many people with cervical spondylosis or CSM are asymptomatic. However, patients with CSM are at higher risk of spinal cord injury (SCI) following minor injury.

Only a small percentage of people with spondylosis go on to develop symptoms consistent with cervical spondylotic myelopathy (CSM), which can cause significant and disabling neurological deficits, leading to loss of function, morbidity, and mortality.

In addition, diabetes mellitus (DM) is a frequent comorbidity for people of this age and may impact the severity of CCM.

Scales

European myelopathy score.

As a widespread used scale, the Modified Japanese Orthopaedic Association scale (mJOA) should be translated and culturally adapted 9).

see Cervical spine stenosis scales

Diagnosis

Treatment

Outcome

Randomized, controlled trials

A National Institutes of Health-funded (1R13AR065834-01) investigator meeting was held before the initiation of the trial to bring multiple stakeholders together to finalize the study protocol. Study investigators, coordinators, and major stakeholders were able to attend and discuss strengths of, limitations of, and concerns about the study. The final protocol was approved for funding by the Patient-Centered Outcomes Research Institute (CE-1304-6173). The trial began enrollment on April 1, 2014 10).

Case series

References

1)

Wilson JRF, Badhiwala JH, Moghaddamjou A, Martin AR, Fehlings MG. Degenerative Cervical Myelopathy; A Review of the Latest Advances and Future Directions in Management. Neurospine. 2019 Sep;16(3):494-505. doi: 10.14245/ns.1938314.157. Epub 2019 Aug 26. PubMed PMID: 31476852; PubMed Central PMCID: PMC6790745.
2)

Goel A. Degenerative Cervical Myelopathy. Neurospine. 2019 Dec;16(4):793-795. doi: 10.14245/ns.1938384.192. Epub 2019 Dec 31. PubMed PMID: 31905465.
3)

Tetreault L, Goldstein CL, Arnold P, Harrop J, Hilibrand A, Nouri A, Fehlings MG. Degenerative Cervical Myelopathy: A Spectrum of Related Disorders Affecting the Aging Spine. Neurosurgery. 2015 Oct;77 Suppl 4:S51-67. doi: 10.1227/NEU.0000000000000951. PubMed PMID: 26378358.
4)

Kovalova I, Kerkovsky M, Kadanka Z, Kadanka Z Jr, Nemec M, Jurova B, Dusek L, Jarkovsky J, Bednarik J. Prevalence and Imaging Characteristics of Nonmyelopathic and Myelopathic Spondylotic Cervical Cord Compression. Spine (Phila Pa 1976). 2016 Dec 15;41(24):1908-1916. PubMed PMID: 27509189.
5)

Martin AR, De Leener B, Cohen-Adad J, Cadotte DW, Nouri A, Wilson JR, Tetreault L, Crawley AP, Mikulis DJ, Ginsberg H, Fehlings MG. Can microstructural MRI detect subclinical tissue injury in subjects with asymptomatic cervical spinal cord compression? A prospective cohort study. BMJ Open. 2018 Apr 13;8(4):e019809. doi: 10.1136/bmjopen-2017-019809. PubMed PMID: 29654015; PubMed Central PMCID: PMC5905727.
6)

Davies BM, Mowforth OD, Smith EK, Kotter MR. Degenerative cervical myelopathy. BMJ. 2018 Feb 22;360:k186. doi: 10.1136/bmj.k186. Review. PubMed PMID: 29472200; PubMed Central PMCID: PMC6074604.
7)

Guan L, Chen X, Hai Y, et al. High-resolution diffusion tensor imaging in cervical spondylotic myelopathy: A preliminary follow-up study. NMR Biomed. 2017
8)

Sampath P, Bendebba M, Davis JD, et al. Outcome of patients treated for cervical myelopathy. A prospective, multicenter study with independent clinical review. Spine (Phila Pa 1976) 2000;25(6):670–76.
9)

Augusto MT, Diniz JM, Rolemberg Dantas FL, Fernandes de Oliveira M, Rotta JM, Botelho RV. Development of the Portuguese version of the modified Japanese Orthopaedic Association Score: cross-cultural adaptation, reliability, validity and responsiveness. World Neurosurg. 2018 Jun 1. pii: S1878-8750(18)31127-6. doi: 10.1016/j.wneu.2018.05.173. [Epub ahead of print] PubMed PMID: 29864576.
10)

Ghogawala Z, Benzel EC, Heary RF, Riew KD, Albert TJ, Butler WE, Barker FG 2nd, Heller JG, McCormick PC, Whitmore RG, Freund KM, Schwartz JS. Cervical Spondylotic Myelopathy Surgical Trial: Randomized, Controlled Trial Design and Rationale. Neurosurgery. 2014 Oct;75(4):334-346. PubMed PMID: 24991714.
WhatsApp WhatsApp us
%d bloggers like this: