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Abstract Degenerative cervical myelopathy (DCM) is the most prevalent cause of spinal cord dysfunction in the aging population. Significant neurological deficits may result from a delayed diagnosis as well as inadequate neurological recovery following surgical decompression. Here, we review the pathophysiology of DCM with an emphasis on how blood-spinal cord barrier (BSCB) disruption is a critical yet neglected pathological feature affecting prognosis. In patients suffering from DCM, compromise of the BSCB is evidenced by elevated cerebrospinal fluid (CSF) to serum protein ratios and abnormal contrast-enhancement upon magnetic resonance imaging (MRI). In animal model correlates, there is histological evidence of increased extravasation of tissue dyes and serum contents, and pathological changes to the neurovascular unit. BSCB dysfunction is the likely culprit for ischemia–reperfusion injury following surgical decompression, which can result in devastating neurological sequelae. As there are currently no therapeutic approaches specifically targeting BSCB reconstitution, we conclude the review by discussing potential interventions harnessed for this purpose.

Degenerative cervical myelopathy (DCM) is the most prevalent cause of spinal cord dysfunction in the aging population. Significant neurological deficits may result from a delayed diagnosis as well as inadequate neurological recovery following surgical decompression. Here, we review the pathophysiology of DCM with an emphasis on how blood-spinal cord barrier (BSCB) disruption is a critical yet neglected pathological feature affecting prognosis. In patients suffering from DCM, compromise of the BSCB is evidenced by elevated cerebrospinal fluid (CSF) to serum protein ratios and abnormal contrast-enhancement upon magnetic resonance imaging (MRI). In animal model correlates, there is histological evidence of increased extravasation of tissue dyes and serum contents, and pathological changes to the neurovascular unit. BSCB dysfunction is the likely culprit for ischemia–reperfusion injury following surgical decompression, which can result in devastating neurological sequelae. As there are currently no therapeutic approaches specifically targeting BSCB reconstitution, we conclude the review by discussing potential interventions harnessed for this purpose. [ABSTRACT FROM AUTHOR]

Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is a chronic relapsing disease of unknown aetiology. The diagnosis of this disease is still very complicated. The treatment is medical but, in some cases, a surgical decompression might be required. In rare cases it develops a radicular hypertrophy that can cause a cervical myelopathy; this pathology should be put in differential diagnosis with neurofibromatosis 1 and Charcot-Marie-Tooth (CMT) syndromes. The cases of CIDP cervical myelopathy reported in the literature are rare and even more rarely a surgical decompression was described. Here we report a first and unique case of CIDP cervical myelopathy treated with an open-door laminoplasty technique with 10-year postoperative follow-up (FU). The surgical decompression revealed to be effective in stopping the progression of myelopathy without destabilizing the spine. The patient that before surgery presented a severe tetraparesis could return to walk and gain back his self-care autonomy. At 10-year FU he did not complain of neck pain and did not develop a cervical kyphosis. In case of cervical myelopathy caused by radicular hypertrophy, CIDP should be kept in mind in the differential diagnosis and an open-door laminoplasty is indicated to stop myelopathy progression.

Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is a chronic relapsing disease of unknown aetiology. The diagnosis of this disease is still very complicated. The treatment is medical but, in some cases, a surgical decompression might be required. In rare cases it develops a radicular hypertrophy that can cause a cervical myelopathy; this pathology should be put in differential diagnosis with neurofibromatosis 1 and Charcot-Marie-Tooth (CMT) syndromes. The cases of CIDP cervical myelopathy reported in the literature are rare and even more rarely a surgical decompression was described. Here we report a first and unique case of CIDP cervical myelopathy treated with an open-door laminoplasty technique with 10-year postoperative follow-up (FU). The surgical decompression revealed to be effective in stopping the progression of myelopathy without destabilizing the spine. The patient that before surgery presented a severe tetraparesis could return to walk and gain back his self-care autonomy. At 10-year FU he did not complain of neck pain and did not develop a cervical kyphosis. In case of cervical myelopathy caused by radicular hypertrophy, CIDP should be kept in mind in the differential diagnosis and an open-door laminoplasty is indicated to stop myelopathy progression. [ABSTRACT FROM AUTHOR]

Previous studies have retrospectively analyzed the likely causes of cerebrospinal fluid leakage (CSFL) during cervical spine surgery and the management of CSFL after its occurrence. In the present study, we aimed to develop and validate a nomogram for the risk of CSFL in Chinese patients who had undergone cervical decompression and internal fixation (CDIF) surgery. We performed a retrospective analysis of patients who had undergone CDIF surgery. Of the 1286 included patients, 54 were in the CSFL group and 1232 were in the normal group. The patients were randomly divided into training and validation tests. The risk assessment for CSFL included 21 characteristics. The feature selection for the CSFL model was optimized using the least absolute shrinkage and selection operator regression model in the training test. Multivariate logistic regression analysis was performed to construct the model according to the selected characteristics. The clinical usefulness of the predictive model was assessed using the C-index, calibration curve, and decision curve analysis with identification and calibration. The risk prediction nomogram included the diagnosis, revision surgery, ossification of the posterior longitudinal ligament, cervical instability, and a history of malignancy in the training test. The model demonstrated high predictive power, with a C-index of 0.914 (95% confidence interval, 0.876–0.951) and an area under the curve of 0.914. The results of the decision curve analysis demonstrated the clinical usefulness of the CSFL risk nomogram when the probability threshold for CSFL was 1%–62%. Our proposed nomogram for CSFL risk includes the diagnosis, revision surgery, ossification of the posterior longitudinal ligament, cervical instability, and a history of malignancy. The nomogram can be used to evaluate the risk of CSFL for patients undergoing CDIF surgery. [ABSTRACT FROM AUTHOR]

Purpose: The main anatomic variations should be taught along with the classical anatomy curriculum, since they can mislead both diagnosis and treatment. We report here a clinical and radiological case of left C6 cervicobrachial neuralgia recurrence due to a vertebral artery loop, we then describe 13 published cases of such neurovascular conflicts. Case: A 51-year-old woman suffered from recurrence of C6 cervicobrachial neuralgia after an initial C5–C6 decompression–fusion. Additional cervical angio-MR and CT scans found a tortuous aspect of the left vertebral artery that came into conflict with the left C6 spinal root, just after its emergence of the C5–C6 intervertebral foramen. A large posterior decompression was performed including a C5 and C6 left lateral mass resection to enlarge the foraminal space. The vertebral artery was kept in place. The patient reported a slow but consistent decrease in pain that disappeared after 3 months. Thirteen cases of a compressive vertebral loop are thereafter detailed. Conclusions and discussion: Vascular precursors disarrangements can lead to a vertebral artery loop in contact with emerging cervical roots and potential clinical impact. This differential diagnosis should be considered for cervico-brachial neuralgia management. Moreover, the present case highlights the key role of a careful preoperative imaging assessment, as well as the need for robust knowledge of anatomy. [ABSTRACT FROM AUTHOR]

Calcium pyrophosphate dihydrate deposition (CPPD), commonly known as pseudogout, is an inflammatory arthropathy primarily affecting the knee, wrist, hip, and shoulder joints. However, it can occasionally deposit in various structures surrounding the spinal column, including the facet joints, ligamentum flavum, bursae, and intervertebral discs. Such occurrences are typically asymptomatic or associated with mild neck pain. Nonetheless, severe cases may lead to myeloradiculopathy, characterized by severe neck pain and upper extremity weakness. Conservative management with nonsteroidal anti-inflammatory drugs is often sufficient for mild cases, while surgical decompression remains the gold standard for severe cases with significant spinal cord compression. Herein, we present a rare case of pseudogout, manifesting as cervical spine myelopathy due to calcium pyrophosphate dihydrate deposition in the ligamentum flavum and facet joints at C1-2. This was found incidentally during cervical spine decompression and fusion and subsequentially confirmed through pathological examination. Following the removal of the compressive pathology, the patient reported significant improvements in neck pain and neurological symptoms. This case underscores the importance of considering pseudogout in the differential diagnosis of acute neck pain presenting with myelopathy or radiculopathy., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Avetisian et al.)

• There is significant heterogeneity in the treatment strategies used for C5 palsy. • Patients with abnormal EMGs are more likely to be referred for nerve transfers. • Oral corticosteroids were not associated with improved recovery from C5 palsy. • Early EMGs may expedite referral of select patients to peripheral nerve specialists. The objective of this study was to examine the association between electrophysiology data post-C5-palsy and referral to peripheral nerve surgeons (PNS) using a 15-year cohort of patients who underwent posterior cervical decompression. Endpoints included the associations of postoperative treatments employed with functional recovery and abnormal electrophysiology data. Of 77 included patients (median 64 yr; 68% male), 48% completely recovered. The most common treatments were physical therapy (90%), occupational therapy (34%), oral corticosteroids (18%), and PNS referral (17%). Baseline weakness did not associate with PNS referral or postoperative treatment strategy. None of the treatments predicted recovery, though patients with no [versus complete] recovery were more likely to be recommended for nerve transfers (22.2 vs 0%; p = 0.03). Abnormal electromyography data associated with PNS referral (p < 0.01), nerve transfer recommendation (p < 0.01), occupational therapy referral, and oral corticosteroid therapy. Abnormal findings on EMG obtained between 6-weeks and 6-months post-injury were the most strongly associated with peripheral nerve surgeon referral (p = 0.02) and nerve transfer recommendation (p < 0.01). These data suggest strategies for postoperative C5 palsy management are highly heterogeneous. None of the treatments employed significantly predicted the extent of functional recovery. However, patients with abnormal electrophysiology results were most likely to receive multimodal treatment, suggesting these results may significantly alter medical management of patients with postoperative C5 palsy. Early (6-week to 6-month) electrophysiology data may help to ensure that patients likely to benefit from nerve transfer procedures are referred to a PNS within the 9–12-month time frame associated with the best recovery of function. [ABSTRACT FROM AUTHOR]

Study Design Case report and review of the literature. Objective A retro-odontoid mass is a rare cause of cervical compression and myelopathy. The differential diagnosis includes the following: metastatic disease, primary tumor, collagen disorder, or inflammatory disease. Calcium pyrophosphate dihydrate (CPPD) deposition has been referred to as "crowned dens syndrome" when there are periodontoideal calcifications. There are only a few reported cases where CPPD presents as a cystic retro-odontoid mass in the atlanto-dens interval. In previous descriptions of surgical intervention, transoral resection of the mass is associated with significant morbidity and usually requires stabilization. The objective of this article is to report a case of an unusual presentation of CPPD disease of C1/C2, where we used a novel, minimally invasive surgical technique for decompression without fusion. Patients and Methods An 83-year-old female patient presented with progressive cervical myelopathy over a 3-month period. Computed tomography and magnetic resonance imaging demonstrated a cystic odontoid mass with a separate retro-odontoid compressive mass. A novel, minimally invasive transoral aspiration was performed. Histologic confirmation of CPPD was obtained. Results Postop imaging showed satisfactory decompression, which was maintained at the 6-month follow-up. This correlated with clinical improvement postop and 6-month follow-up. Conclusion CPPD in the atlanto-dens interval may present as a cystic retro-odontoideal mass and should be included in the differential. We used a transoral minimally invasive approach to aspirate the cyst. This novel technique avoided the need for a stabilization procedure or morbid transoral resection and provided excellent results immediately and at 6 months.

Cervical radiculopathy is a common cervical spine condition. However, a paucity of data is available on the effect of partial pediculotomy and partial vertebrotomy (PPPV) for posterior endoscopic cervical foraminotomy (PECF) to treat cervical radiculopathy. We investigated the radiological and clinical outcomes of this approach. We performed a retrospective evaluation of 30 patients with cervical radiculopathy who had undergone PPPV PECF. Pre- and postoperative radiographs were performed to evaluate for stability, and computed tomography (CT) was used to evaluate the foraminal dimensions and area in the sagittal view. Three-dimensional reconstruction of the area of decompression was also performed. The clinical outcomes were evaluated using the visual analog scale, Oswestry disability index, and the MacNab criteria. No complications or recurrence developed in our PPPV PECF cohort during the study period. At the preoperative, 1-week postoperative, 3-month postoperative, and final follow-up examinations, the mean visual analog scale scores and mean Oswestry disability index showed significant improvement (score, 7.6, 3.0, 2.1, and 1.7, respectively; P < 0.05; and score, 73.9, 28.1, 23.3, and 21.5, respectively; P < 0.05). All the patients scored good to excellent using the MacNab criteria. The radiological findings showed that PPPV PECF resulted in a significant increase in decompression in the foramen area for all CT-measured parameters compared with the mean preoperative values: 1) the sagittal area increased 60.1 ± 23.1 mm2; 2) the craniocaudal length increased 4.0 ± 1.54 mm; and 3) the ventrodorsal length increased 4.0 ± 1.97 mm; Also, the 3-dimensional CT scan reconstruction decompression area had increased 996 ± 266 mm2 (P < 0.05). PPPV PECF is a safe route for decompression of the cervical spine with good clinical and radiological outcomes. [ABSTRACT FROM AUTHOR]

Background Nerve root tethering upon dorsal spinal cord (SC) migration has been proposed as a potential mechanism for postoperative C5 palsy (C5P). To our knowledge, this is the first study to investigate this relationship by anatomically comparing C5–C6 nerve root translation before and after root untethering by cutting the cervical foraminal ligaments (FL). Objective The aim of this study is to determine if C5 root untethering through FL cutting results in increased root translation. Methods Six cadaveric dissections were performed. Nerve roots were exposed via C4–C6 corpectomies and supraclavicular brachial plexus exposure. Pins were inserted into the C5–C6 roots and adjacent foraminal tubercle. Translation was measured as the distance between pins after the SC was dorsally displaced 5 mm before and after FL cutting. Clinical feasibility of FL release was examined by comparing root translation between standard and extended (complete foraminal decompression) foraminotomies. Translation of root levels before and after FL cutting was compared by two-way repeated measures analysis of variance. Statistical significance was set at 0.05. Results Significantly more nerve root translation was observed if the FL was cut versus not-cut, p = 0.001; no difference was seen between levels, p = 0.33. Performing an extended cervical foraminotomy was technically feasible allowing complete FL release and root untethering, whereas a standard foraminotomy did not. Conclusion FL tether upper cervical nerve roots in their foramina; cutting these ligaments untethers the root and increases translation suggesting they could be harmful in the context of C5P. Further investigation is required examining the value of root untethering in the context of C5P.

Study Design: Prospective cohort study.Objective: Investigate the effect of surgical decompression and fusion on gait ground reaction forces (GRFs) parameters in patients with cervical spondylotic myelopathy (CSM) and to compare these values to those of healthy controls.Summary Of Background Data: Surgical intervention to alleviate spinal cord compression is typically recommended in cases of CSM. While the primary aim of surgery is to halt disease progression, the literature suggests that some symptomatic improvement is often observed postoperatively. Gait analysis via measurement of GRFs is a particularly sensitive means of quantifying changes in ambulatory function, but no comprehensive analysis has been published in the setting of CSM.Methods: Forty patients with symptomatic CSM underwent gait analysis with measurement of horizontal and vertical GRFs before and 3 months after surgery. Thirty healthy controls (H) underwent the same battery of tests. Comparisons were made between the pre- and postoperative profiles of patients with CSM as well as to that of the control group.Results: Before surgery, patients with CSM exhibited disturbances in GRF magnitudes: significantly greater maximum weight acceptance (Pre: 113.7 vs. H: 101.1% body weight [BW], P = 0.040) and push off forces (Pre: 112.2 vs. H: 101.4% BW, P = 0.044), and timing: maximum weight acceptance occurred earlier while mid-stance (Pre: 15.8 vs. H: 17.8% gait cycle [GC], P = 0.018), toe-off (Pre: 65.0 vs. H: 62.9% GC, P = 0.001), braking (Pre: 55.6 vs. H: 54.2% GC, P = 0.003), and propulsion occurred (Pre: 11.9 vs. H: 10.6% GC, P = 0.011) later compared with healthy controls. Surgery improved all GRF parameters (P < 0.039), but postoperative gait profiles did not completely normalize to levels observed in the control group.Conclusion: These observations combined with published data on gait muscle activation and gait patterns in CSM patients support the idea that patients with CSM have an altered gait profile consistent with a series of poorly controlled near falls. Surgical intervention was observed to produce improvements in but not complete resolution of these gait disturbances. These data provide a more comprehensive understanding of gait in the setting of CSM.Level Of Evidence: 3. [ABSTRACT FROM AUTHOR]

Cervical radiculopathy is a common cervical spine condition. There is a paucity of literature discussing the effect of partial pediculotomy and partial vertebrotomy for posterior endoscopic cervical foraminotomy (PPPV PECF) on cervical radiculopathy. We investigated the radiologic and clinical outcomes of this approach. This was a retrospective evaluation of 30 cases with cervical radiculopathy who underwent PPPV PECF. Preoperative, postoperative roentgenogram for evaluation of stability, computed tomography (CT) evaluation of foraminal dimensions, and area in sagittal view was performed. Three-dimensional reconstruction area of decompression evaluation was performed. Clinical outcomes of the visual analog scale, Oswestry Disability Index, and Macnab score were evaluated. There was no complication and recurrence in our PPPV PECF cohort during the study period. At preoperative, 1 week postoperative, and 3 months postoperative and final follow-up, the mean visual analog scale score had significant improvement, with scores of 7.6, 3.0, 2.1, and 1.7, respectively, P < 0.05, and also the mean Oswestry Disability Index, with scores of 73.9, 28.1, 23.3, and 21.5 respectively, P < 0.05. Macnab criteria showed all patients scoring good and excellent. Radiologic results showed PPPV PECF had a significant increase in decompression in the foramen area in all CT-measured parameters, as compared with the mean preoperative values; 1) sagittal area increased 60.1 ± 23.1 mm2, 2) CT craniocaudal length increased 4.0 ± 1.54 mm, 3) CT ventrodorsal length increased 4.0 ± 1.97 mm, and 4) 3-dimensional CT scan reconstruction decompression area increased 996 ± 266 mm2, P < 0.05. PPPV PECF is a safe route of decompression of cervical spine with good clinical and radiologic outcome. [ABSTRACT FROM AUTHOR]

The aim of this study was to document the initial experience and challenges of cervical decompression in a resource-poor region. Forty-three patients with cervical myelopathy who had surgery were included in the study. Details including evaluations pre- and postoperative (at 6 weeks and 6 months) using the Nurick score were recorded prospectively. Details of surgery were also documented. The mean age at surgery was 58.0 years. There were 37 men and 6 women. Surgeries performed were anterior cervical decompression and fusion (51.2%), cervical laminectomy (32.6%), corpectomy and occipitocervical fixation (2.3% each), and decompression with lateral mass fixation (11.6%). Four patients presented within 3 months of onset of symptoms (early), whereas 39 after 3 months (late). The Nurick grade significantly improved in 41 patients (97.6%) following surgery (P < 0.001). The average Nurick preoperative score was 3.2, and postoperative it was 2.12 and 1.14 at 6 weeks and 6 months, respectively. In the early presentation group, scores improved from an average preoperative of 2.5–0.5 at 6 months, whereas in the late presentation group, score improved from an average of 3.3 preoperative to 1.2 at 6 months postoperative. Despite the challenges of poverty, late presentation, and lack of basic standard instruments and equipment, patients with cervical myelopathy in the resource-poor setting had outcomes similar to other well-established centers after surgical decompression. We infer that challenges in setting up a spine unit in a resource-poor region can be circumvented safely. [ABSTRACT FROM AUTHOR]

Study Design: Cadaveric study on fresh unprocessed, non- preserved, undyed specimens which has not previously been reported OBJECTIVES.: Our aim was to explore the possible topographic correlation of the C5 nerve root with regards to its course and regional relation to C6 Chassaignac Tubercle.Summary Of Background Data: C5 Palsy is reported amongst the most frequent postoperative complications of cervical spinal procedures. We hypothesized that etiologic mechanisms proposed thus far in the current literature although with some plausible explanation, still cannot explain why the C5 nerve root and not any other level suffer a post-operative palsy.Methods: Six Fresh cadavers had extensive layer by layer dissection performed by 2 surgeons (one of whom has experience as an anatomy demonstrator and dissector). Roots of brachial plexus were exposed in relation to cervical transverse processes. Photographs were taken at each stage of the exposure.Results: We observed a close relation of the path of the C5 nerve root with the C6 tubercle bilaterally. Moreover, we noted a steeper descent of C5 in comparison with the other adjacent roots.Conclusion: Steeper angle of the C5 nerve root and close proximity to C6 Chassaignac's Tubercle, may play a role in predisposing it to neuropraxia. Detail anatomical photographs on fresh unprocessed cadaveric specimens are novel. Peculiar anatomical features as well as recent experimental evidence discussed do highlight a postganglionic extraforaminal etiology corresponding well to the demographic metanalysis data on clinical features of post-operative C5 palsy. Exploring an alternative unified "neurophysiologic stress and critical tipping point" etiological model that encompasses current theories and correlates known metanalyses observations, we believe further studies would be prudent to ascertain/refute these findings.Level Of Evidence: 3. [ABSTRACT FROM AUTHOR]

Ankylosing spondylitis (AS) is an inflammatory disease that involves above all the spine and the pelvis. In the spine, the inflammatory processes cause the formation of syndesmophytes between the vertebral bodies and the ossification of ligaments, with bony overgrowth. In this setting, dysphagia is a rare but severe complication and only a few cases have been reported in the literature. We describe the case of a 50-year-old man suffering from AS, with a 6-month history of severe dysphagia caused by bone compression of the esophagus at the C3-5 level. Because the patient underwent a 10-kg weight loss 2 months after clinical onset, a gastrostomy tube placement was needed. Complete surgical excision of the bone overgrowth via an anterior cervical approach was performed, but despite continuous intensive swallowing rehabilitation therapy, the patient failed to improve in the first following months. Surprisingly, the patient started to improve 18 months after the operation, with a complete recovery from dysphagia 24 months after. Among the 5 reports (including the present case) available in the current literature with a clear dysphagia recovery follow-up, the present case (the second one harboring gastrostomy) is associated with the slowest complete recovery published so far. This unusually late recovery suggests a possible role not only of the mechanical decompression of the esophagus but also of the degeneration/regeneration ratio of the myenteric plexus, along with local neurotransmitters sensitivity changes, to better understand the dysphagia recovery time course of this unique patient. [ABSTRACT FROM AUTHOR]

Study Design: Retrospective radiological analysis OBJECTIVE.: The aim of this study was to identify the effects of posterior cervical muscle swelling on C5 palsy (C5P) by evaluating early postoperative magnetic resonance (MR) images.Summary Of Background Data: Cervical laminoplasty is an established technique, but the risk of C5P after surgery has not been fully resolved. Studies have reported that lateral stretching and postoperative swelling of the multifidus muscle may cause stretching of the medial branches and cervical nerves.Methods: A total of 214 C5 nerves of 107 consecutive patients who underwent laminoplasty were examined. We reviewed their demographic and surgical data and radiographic and MR images as parameters, including the axial cross-sectional area (CSA) of the posterior muscles. The patients and C5 nerves were divided into C5P and non-C5P groups. The parameters and changes were compared between the two groups to examine correlations with C5P.Results: In demographic data, age, sex, history of smoking, diabetes mellitus, and preoperative Japanese Orthopedic Association scores were not significantly different between the groups. Only body mass index (BMI) was significantly higher in the C5P group. Regarding the surgical and imaging data, the number of laminoplasty, operative time, decompression trough width, cervical sagittal alignment, preoperative spinal cord rotation, and posterior shift of the spinal cord were not significantly different, but the multifidus CSA change ratio was significantly higher in the C5P group. Multiple logistic regression analyses revealed that the multifidus CSA change ratio and BMI were significant independent factors.Conclusion: Multifidus swelling is associated with C5P, possibly through traction of the C5 nerve via the medial branches of the cervical dorsal rami. The medial branch is the shortest of the dorsal rami and may have the largest effect by traction force. Therefore, a gentle maneuver of the deep posterior muscles during surgery is a potential countermeasure to prevent C5P.Level Of Evidence: 3. [ABSTRACT FROM AUTHOR]

Of the myriad of variants of amyloidoses where abnormally folded proteins damage native tissue, primary cervical spine amyloidoma represents one of the rarest forms. Since clinical presentations and imaging findings appear similar to other pathologies, including abscesses, metastatic lesions, and inflammatory lesions, a definitive diagnosis requires a biopsy with specific immunohistochemical stains. We present the first known case of primary cervical amyloid light‐chain (AL)‐κ subtype amyloidoma and compare the clinical presentations, imaging findings, treatment options, and immunohistochemical subtypes of primary, hemodialysis, and multiple myeloma cervical amyloidomas. Our case is of a 58‐year‐old man who developed neck pain radiating to the left arm with bilateral upper extremity weakness over several months. Magnetic resonance imaging revealed a circumferential C1–C2 mass extending into the neural foramina inducing severe mass effect. The patient underwent C2 laminectomy and resection of the lesion which was discovered during surgery to be completely epidural. Postoperatively, his pain and weakness improved. A complete work‐up was negative for systemic amyloidosis or inflammatory conditions. In the setting of a long clinical history of hemodialysis, this patient required specific staining and laboratory testing to correctly diagnose his primary cervical AL‐κ subtype amyloidoma. Cervical amyloidomas comprise a very small minority of amyloid pathology with an exceptional prognosis following successful surgical resection and stabilization. It is recommended these patients undergo surgical resection with appropriate characterization and a complete work‐up to rule out systemic disease. [ABSTRACT FROM AUTHOR]

To compare the outcome of anterior cervical decompression and fusion (ACDF) and posterior laminoplasty (LAMP) for treating 4-level cervical spondylotic myelopathy (CSM). Data of 80 patients with 4-level CSM treated using ACDF and another 56 cases treated using LAMP were retrospectively analyzed. Radiologic outcomes evaluated by C2-7 Cobb angle and cervical range of motion (ROM) and functional outcomes evaluated by Japanese Orthopaedic Association (JOA) scale score and visual analog scale score for axial pain were compared between the 2 groups. JOA scale score in both groups improved significantly after operation (P < 0.05). There was no significant difference in the JOA scale score improvement rate between the 2 groups (P > 0.05). The C2-7 Cobb angle increased significantly in the ACDF group (P < 0.05) and decreased in the LAMP group (P > 0.05). There was a significant difference in C2-7 Cobb angle improvement between the 2 groups (P < 0.05). Cervical ROM decreased in both groups after operation (P < 0.05), but there was no significant difference in ROM loss ratio between the 2 groups (P > 0.05). Blood loss in the LAMP group was significantly more than in the ACDF group (P < 0.05); however, there was no significant difference in operation time between the 2 groups (P > 0.05). There was no significant difference in the complication rate between the 2 groups (P > 0.05). Both ACDF and LAMP were effective in the treatment of multilevel CSM. Compared with LAMP, ACDF is less invasive and may be more suitable for elderly patients with poor tolerance of surgery. [ABSTRACT FROM AUTHOR]

Study Design: A retrospective analysis of prospectively collected multicenter observational data.Objective: The aim of this study was to compare the health-related quality of life (HR-QOL) of double-door laminoplasty (DDL) and selective laminoplasty (SL) in patients with degenerative cervical myelopathy (DCM) in two institutions, with a minimum follow-up of 5 years.Summary Of Background Data: No study has compared DDL and SL regarding postoperative HR-QOL with a follow-up of more than 5 years.Methods: One-hundred ninety patients who underwent DDL (n = 77) or SL (n = 113) participated in this study. Short-form 36 (SF-36), Japanese Orthopedic Association Cervical Myelopathy Evaluation Questionnaire (JOACMEQ), Neck Disability Index (NDI), and visual analog scale (VAS) values were compared between the groups.Results: Thirty-seven DDL and 52 SL patients were evaluated. The mean follow-up period was 8 years and the follow-up rate was 46.8%. No significant differences were found regarding age and JOA score at baseline. At the follow-up, there were no significant differences in SF-36, JOACMEQ, and VAS score, while the NDI score for headache and sleeping were higher in the SL group. After dividing the SL group into short and long SL subgroups, the long SL subgroup showed a significantly lower score in bodily pain in SF-36, lower and bladder function in JOACMEQ, and pain intensity, personal care, headaches, and sleeping in NDI compared with the other groups.Conclusion: No significant differences were found in SF-36, JOA score, and NDI, except for the NDI subscale of headache and sleeping. The subgroup analysis showed that the long SL group showed a decreased QOL compared with the short SL and DDL groups.Level Of Evidence: 3. [ABSTRACT FROM AUTHOR]

Background Among the proposed hypotheses for C5 palsy, the most acceptable etiologies have been the tethering effect of the spinal nerve or reperfusion injury of the spinal cord. We performed a meta-analysis to determine a potential etiology of C5 palsy. Methods The PubMed, Embase, Web of Science, and Cochrane Library databases were searched up to 2017 for relevant studies of the incidence of C5 palsy after cervical decompression surgery. Relevant incident estimates of C5 palsy stratified by the surgical approach and underlying diagnosis were calculated using an appropriate meta-analysis. Results A total of 107 studies were included for our meta-analysis. The pooled incidence of C5 palsy was 0.00 (95% confidence interval [CI], 0.00–0.01) for anterior decompression in patients with radiculopathy, 0.04 (95% CI, 0.03–0.05) for anterior decompression and 0.07 (95% CI, 0.06–0.08) for posterior decompression in patients with myelopathy. A two-tailed t test with unequal variance accepted the null hypothesis of no differences in the incidence between anterior and posterior decompression in patients with myelopathy (P = 0.999) and rejected the hypothesis of no differences in the incidence between the patients with radiculopathy and myelopathy in anterior decompression (P < 0.001). Conclusions With no significant difference found in the incidence of C5 palsy between anterior and posterior cervical decompression in patients with myelopathy, the tethering effect of the spinal nerve might not be a plausible etiology for C5 palsy. In contrast, we found a significantly greater incidence of C5 palsy in patients with myelopathy compared with those with radiculopathy undergoing anterior decompression, which might support the reperfusion injury of the spinal cord as the etiology of C5 palsy. [ABSTRACT FROM AUTHOR]

Background Context: Postoperative C5 palsy is a well-known complication of cervical decompression procedures. Studies have shown that posterior laminectomy and fusions confer the greatest risk of C5 palsy. Despite this, pharmacologic preventive measures remain unknown. We hypothesize that prophylactic perioperative dexamethasone (DEX) will decrease the rate of postoperative C5 palsy in patients undergoing a multilevel posterior cervical laminectomy and fusion.Purpose: The purpose of this study was to assess the safety and efficacy of prophylactic perioperative DEX in decreasing the rate of postoperative C5 palsy.Design: This is a retrospective, single-institution clinical study.Patient Sample: The patient population included all patients undergoing multilevel posterior cervical laminectomy and instrumented fusion procedures for myeloradiculopathy or myelopathy, who also received a course of perioperative dexamethasone. Surgeries occurred between 2012 and 2017 at a single tertiary care center by a single surgeon with at least 1 year of follow-up. Patients who underwent decompression procedures other than multilevel posterior cervical laminectomy and instrumented fusions; had trauma, fracture; underwent decompression not including C5-level, insulin-dependent diabetes mellitus; and had documented adverse reactions to steroids were excluded.Outcome Measures: Preoperative demographics and postoperative complications, including development of postoperative C5 palsy, were considered as outcome measures.Materials and Methods: A total of 189 consecutive patients who underwent multilevel posterior cervical laminectomy and instrumented fusion and received prophylactic perioperative DEX were reviewed. The rate of C5 palsy was investigated and compared with our historical control rate of C5 palsy before the institutional implementation of perioperative DEX. Demographics were reviewed, and risk factor stratification was analyzed. The safety of using DEX was investigated by examining postoperative complications. The clinical course of patients who developed C5 palsy was then reported.Results: Postoperative C5 palsy occurred in 5 of the 138 patients (3.6%) meeting the inclusion criteria. Patients receiving perioperative DEX had a significantly decreased rate of postoperative C5 palsy compared with those who did not (3.6% vs. 9.5%, p=.01). Age was the only risk factor that was significantly correlated with development of C5 palsy (72.71±7.76 vs. 61.07±10.59, p=.02). Infection, seroma, and wound complication rates were 2.8%, 2.17%, and 1.44%, respectively, in patients receiving prophylactic DEX. All five patients receiving DEX who developed C5 palsy recovered with no residual deficits at an average of 16.8 weeks postoperatively.Conclusions: Perioperative prophylactic DEX therapy is a safe and effective way to decrease the incidence of C5 palsies in patients who undergo multilevel posterior laminectomy and fusion for myeloradiculopathy or myelopathy. [ABSTRACT FROM AUTHOR]

Abstract Introduction C5 palsy following cervical decompression is a known complication. The exact incidence is unclear, due to varying definitions in literature. C5 palsy is associated with significant morbidity due to weakness of deltoid/biceps. Aim To report incidence of postoperative C5 palsy in cervical decompression surgeries for myelopathy and its correlation with demographic factors, etiology, radiological factors, and to assess recovery of palsy. Materials and Methods All patients who underwent cervical decompression surgeries from 2006 to 2015 in a single institute were reviewed. A postoperative decrease by ≥ 1 manual muscle testing grade in only C5 myotome (deltoid/biceps/both) is taken as positive. Demographic, radiological, surgical factors resulting in C5 palsy and time of onset, duration of symptoms, and degree of recovery were noted. Results A total of 390 patients were included in the study. Out of which, 232 patients underwent anterior while 158 had posterior surgeries. In all, 72 patients had ossification of the posterior longitudinal ligament (OPLL) and rest had spondylotic myelopathy. Incidence of palsy was 6.3% and mean onset of palsy was 2.8 days. Mean duration for recovery was 6.3 months with near complete recovery seen in majority of the patients (9/10). No significant relation was noted with age, preoperative Japanese Orthopedic Association score, change in cervical lordosis, and C45 intervertebral angle. Posterior surgeries, laminectomy, C45 foraminal stenosis, and OPLL were seen as risk factors for C5 palsy. Conclusion Cervical decompression surgeries are relatively safe, with a small risk of C5 palsy. Though majority of patients recover with conservative treatment, preoperative counseling of this complication has to be explained.

Background Context: In patients with mucopolysaccharidosis (MPS), glycosaminoglycan deposits in the dura mater and supporting ligaments cause spinal cord compression and consecutive myelopathy, predominantly at the craniocervical junction. Disease characteristics of craniocervical stenosis (CCS) in patients with MPS differ profoundly from other hereditary and degenerative forms. Because of high periprocedural morbidity and mortality, patients with MPS pose a substantial challenge to the inexperienced medical care provider. As literature remains scarce, we present our experience with a large cohort of patients with MPS treated for CCS without atlanto-occipital instrumentation.Purpose: The present study aimed to describe a safe and least traumatic approach for treating CCS in children with MPS, avoiding primary instrumentation.Study Design: This is a prospective follow-up (cohort) study.Patient Samples: We report 15 consecutive patients with CCS related to MPS, who were treated with stand-alone cervical decompression.Outcome Measures: Myelopathy was assessed using magnetic resonance imaging (MRI), somatosensory evoked potentials, and clinical evaluation. Cervical instability was evaluated using plain x-ray and MRI. The disability status is quantified using either the Karnofsky or Lansky Performance Score.Methods: We describe 15 consecutive patients treated with craniocervical decompression. Data were collected prospectively. The mean follow-up is 6 years (5 standard deviation). The technique and treatment principles are described.Results: The overall clinical outcome in this patient cohort is good (mean Karnofsky Performance Score of 80). No patient developed signs of C0-C1-C2 instability or progressive myelopathy. Restenosis occurred in seven patients, requiring a total of eight reoperations.Conclusions: Surgery in patients with MPS is associated with high morbidity and mortality of up to 4.2%. Because of the unique nature of the disease, recurring stenosis is inevitable. To shorten the procedure time and simplify the anticipated reoperation, we provide data that craniocervical decompression is feasible without the necessity of primary osteosynthesis. In the absence of craniocervical instability, decompression surgery without occipitocervical stabilization yields good postoperative results and challenges the long-standing paradigm of prophylactic craniocervical fixation. [ABSTRACT FROM AUTHOR]

Background “White cord syndrome” is a very rare condition thought to be due to acute reperfusion of chronically ischemic areas of the spinal cord. Its hallmark is the presence of intramedullary hyperintense signal on T2-weighted magnetic resonance imaging sequences in a patient with unexplained neurologic deficits following spinal cord decompression surgery. The syndrome is rare and has been reported previously in 2 patients following anterior cervical decompression and fusion. We report an additional case of this complication. Case Description A 68-year-old man developed acute left-sided hemiparesis after posterior cervical decompression and fusion for cervical spondylotic myelopathy. The patient improved with high-dose steroid therapy. Conclusions The rare white cord syndrome following either anterior cervical decompression and fusion or posterior cervical decompression and fusion may be due to ischemic-reperfusion injury sustained by chronically compressed parts of the spinal cord. In previous reports, patients have improved following steroid therapy and acute rehabilitation. [ABSTRACT FROM AUTHOR]

Objective To investigate the prognostic value of preoperative Nurick grade and time with symptoms for gait improvement and recovery in patients with ataxia secondary to cervical myelopathy. Methods A retrospective chart review of all adult patients who underwent surgical decompression for cervical myelopathy between 1996 and 2013 was performed. Only adults with a Nurick grade of at least 2 or worse were included. Outcome measures included gait improvement and recovery. Results A total of 170 patients were identified. Gait improvement and gait recovery occurred in 57.7% and 45.9% of patients, respectively. Time to improvement occurred as early as 1 month up to 24 months postoperatively. A greater preoperative Nurick grade was associated with lower odds of gait improvement (odds ratio 0.74; 95% confidence interval 0.53–0.99, P = 0.048) and gait recovery (odds ratio 0.27; 95% confidence interval 0.17–0.43, P < 0.001). The proportion of patients with symptoms for 12 months or less that experienced gait improvement was 71.2%, compared with 36.4% for patients with symptoms for over 12 months ( P < 0.001). Patients with symptoms for 12 months or less had a 59.6% gait recovery rate, compared to 24.2% in patients with symptoms for over 12 months ( P < 0.001). Having symptoms for over 12 months was independently associated with lower odds of improvement and recovery. Conclusions Patients with a greater preoperative Nurick grade and symptoms for more than 12 months may have significantly lower odds of experiencing gait improvement or gait recovery after surgery for cervical myelopathy. This study's conclusion favors early intervention in patients with cervical myelopathy. [ABSTRACT FROM AUTHOR]

Study Design: Cervical decompression (CD) and cervical fusion (CF) patients in 5% Medicare Part B claims data.Objective: Evaluate the complication rate and associated risk factors after cervical spine surgery using a national sample of elderly patients.Summary Of Background Data: The number of cervical spine procedures in the United States has risen along with associated hospital costs. Postoperative complications lead to longer hospitalizations and greater costs.Methods: Demographic information and postoperative complications (90 days) were evaluated. Multivariate Cox regression was used to evaluate the risk factors for the complications, while adjusting for age, socioeconomic status, Charlson comorbidity index, race, census region, sex, and year of surgery.Results: Between 2010 and 2012, 1519 CD and 1273 CF Medicare patients were identified in the dataset. Respiratory complications (CD: 12.1% and CF: 14.6%), urinary retention (CD: 8.2% and CF: 9.1%), acute delirium (CD: 5.3% and CF: 6.0%), and nausea/vomiting (CD: 2.8% and CF: 3.1%) were the most commonly diagnosed complications. All other complications had an incidence of less than 1.5%. Older patients had higher risks of respiratory complications for both procedures, and CD patients with Charlson scores of 1 to 2 and 5+ were also at higher risk of respiratory complications. Males (P <0.001) were at higher risk of urinary retention. Patients with dementia (P <0.001) had a higher risk of acute delirium after both CD and CF. For CD patients, those aged 85 years and over had higher risk of acute delirium, along with patients with transient ischemic attack/stroke. Age was also a significant risk factor (P = 0.019) for acute delirium for CF patients. Females were at a significantly higher risk of nausea/vomiting after CD and CF.Conclusion: These data help to provide baseline information regarding the complication rates in the elderly CD and CF patient population in the United States, and will serve to help minimize these complications.Level Of Evidence: 3. [ABSTRACT FROM AUTHOR]

We report on a patient who had neurological deterioration attributed to C5 palsy post C3-C6 posterior decompression and instrumented fusion. A 60-year old man was admitted after a fall from an electric scooter. MRI of the cervical spine confirmed severe cervical spondylosis causing cord compression at C4/5 with associated cord oedema. He underwent posterior cervical decompressive surgery, and he remained neurologically stable post operatively. However, he subsequently developed acute left upper limb weakness limited to the C5 myotome 1 week after surgery whilst undergoing inpatient rehabilitation. A repeat MRI of the cervical spine did not reveal any new changes that may explain his symptoms. He was started on intravenous dexamethasone. C5 palsy after cervical decompressive surgery is not uncommon. There is no specific evidence-based treatment and it carries a generally good prognosis. The aim of this case report is to highlight this complication and raise awareness amongst physicians.

Introduction C5 palsy following cervical decompression is a known complication. The exact incidence is unclear, due to varying definitions in literature. C5 palsy is associated with significant morbidity due to weakness of deltoid/biceps. Aim To report incidence of postoperative C5 palsy in cervical decompression surgeries for myelopathy and its correlation with demographic factors, etiology, radiological factors, and to assess recovery of palsy. Materials and Methods All patients who underwent cervical decompression surgeries from 2006 to 2015 in a single institute were reviewed. A postoperative decrease by 1 manual muscle testing grade in only C5 myotome (deltoid/biceps/ both) is taken as positive. Demographic, radiological, surgical factors resulting in C5 palsy and time of onset, duration of symptoms, and degree of recovery were noted. Results A total of 390 patients were included in the study. Out of which, 232 patients underwent anterior while 158 had posterior surgeries. In all, 72 patients had ossification of the posterior longitudinal ligament (OPLL) and rest had spondylotic myelopathy. Incidence of palsy was 6.3% and mean onset of palsy was 2.8 days. Mean duration for recovery was 6.3 months with near complete recovery seen in majority of the patients (9/10). No significant relation was noted with age, preoperative Japanese Orthopedic Association score, change in cervical lordosis, and C45 intervertebral angle. Posterior surgeries, laminectomy, C45 foraminal stenosis, and OPLL were seen as risk factors for C5 palsy. Conclusion Cervical decompression surgeries are relatively safe, with a small risk of C5 palsy. Though majority of patients recover with conservative treatment, preoperative counseling of this complication has to be explained. [ABSTRACT FROM AUTHOR]

Background Context: A common complication of cervical laminectomy and fusion with instrumentation (CLFI) is development of postoperative C5 nerve palsy. A proposed etiology is excess nerve tension from posterior drift of the spinal cord after decompression. We hypothesize that laminectomy width will be significantly increased in patients with C5 palsy and will correlate with palsy severity.Purpose: The purposes of this study were to evaluate laminectomy width as a risk factor for C5 palsy and to assess correlation with palsy severity.Study Design/setting: This is a retrospective, single-institution clinical study.Patient Sample: Patient population included all patients with cervical spondylotic myelopathy who underwent CLFI between 2007 and 2014 by a single surgeon. Patients who underwent CLFI for trauma, infection, or tumor or had previous or circumferential cervical surgery were excluded. All patients with a new C5 palsy received a postoperative magnetic resonance imaging. An additional computed tomography (CT) scan was ordered to assess hardware. All control patients received a CT scan at 6 months postoperatively to evaluate fusion.Outcome Measures: The association between width of laminectomy and development of postopeative C5 palsy was measured.Methods: Patient comorbidities including obesity, smoking history, and diabetes were recorded in addition to preopertaive and postoperative deltoid and biceps motor strength. Sagittal alignment was measured with C2-C7 Cobb angle preopertaive and postoperative radiographs. The width of laminectomy was measured in a blinded fashion on the postoperative CT scan by two observers.Results: Seventeen patients with C5 nerve palsy and 12 controls were identified. There were no baseline differences in age, sex, diabetes, smoking history, number of surgical levels, or sagittal alignment. Body mass index was significantly higher in the control cohort. There was no significant increase in the C3-C7 laminectomy width in patients with postoperative C5 palsy. The width of laminectomy measurments were highly similar between the two observers. There was no correlation between laminectomy width and palsy severity.Conclusions: This is the largest series of C5 palsies after laminectomy documented with CT imaging. Laminectomy width was not associated with an increased risk of postoperative C5 palsy at any level. Reduction in laminectomy width may not reduce rate of postoperative nerve palsy. [ABSTRACT FROM AUTHOR]