Anterior cervical corpectomy for cervical spondylotic myelopathy

OBJECTIVE: To evaluate the efficacy of anterior surgery for the treatment of cervical spondylotic myelopathy, we have reviewed our experience with anterior cervical corpectomy (ACC) at the University of Florida, specifically analyzing neurological outcomes and complications. These results have been compared with historical control subjects receiving laminectomy or "no treatment." METHODS: Between 1982 and 1992, 93 ACC operations were performed for the primary diagnosis of cervical spondylotic myelopathy. This consecutive series of patients was reviewed retrospectively. Age, gender, pre- and postoperative myelopathy severity, number of levels decompressed, and neurological complications were assessed. Myelopathy severity was graded using the Nurick myelopathy grading system. The average follow-up period was 39 months (range, 2-137 mo). RESULTS: Symptomatic improvement was achieved for 92% of patients (F = 28.9, df = 2172, P < 0.001). Nurick scores reflected improvement for 86% of patients, with the conditions of 13% remaining unchanged and only one patient showing worsening. Preoperative myelopathy severity was weakly correlated with age (P < 0.05) but was not correlated with gender or number of levels decompressed. Similarly, postoperative myelopathy severity was not significantly correlated with age, gender, preoperative myelopathy severity, or number of levels decompressed. ACC-treated patients showed an average improvement of 1.24 points on the Nurick scale, compared with an improvement of 0.07 points for patients treated with laminectomy (P < 0.001) and a deterioration of 0.23 points for patients undergoing conservative treatment (P < 0.001). Complications were slightly more likely to occur in older patients (P < 0.05). The number of levels decompressed was not significantly correlated with complications. Only one permanent neurological complication was seen in this series of patients. CONCLUSION: We conclude that ACC is a safe and effective treatment for cervical spondylotic myelopathy. In an average of 39 months, ACC showed improved results in terms of myelopathy scores, compared with historical control subjects receiving either no treatment or laminectomy. Age, gender, preoperative myelopathy severity, and extent of disease were not negative predictors of clinical outcomes.     

Recruitment patterns in the cervical paraspinal muscles during cervical forward flexion: evidence of cervical flexion-relaxation

The phenomenon of lumbar paraspinal flexion-relaxation has been well established and its clinical significance to low back pain has been demonstrated. Conversely, cervical paraspinal flexion-relaxation has not been consistently observed. This may be attributable to the inappropriate use of trunk flexion motion used to observe the phenomenon in previous studies. This investigation reports on the observance of cervical flexion-relaxation when flexion is limited to the cervical spine. Results demonstrate the observance of cervical flexion-relaxation in ten of ten asymptomatic subjects when flexion is limited to the cervical region in the seated orthograde position.     

Diagnostic evaluation of the cervical nystagmus in cervical torsion test

The long-term effects of streptozotocin (30-70 mg/kg) were studied on plasma glucose and insulin levels, islet morphology, and glucose-stimulated insulin secretion in rats. In addition, the protective effect of short-term (7 days) insulin treatment on streptozotocin-induced diabetes was examined. Streptozotocin administration at dose levels exceeding 40 mg/kg resulted in a long-term, stable hyperglycemia with no insulin response to glucose at 3 months and with a marked derangement of islet morphology (few insulin cells, accumulation of glucagon cells). In contrast, at 30 and 40 mg/kg, streptozotocin induced a transient diabetes. Thus, the blood glucose levels, being elevated at days 1-7, returned to normal levels within 10 days after streptozotocin administration and the glucose-induced insulin secretion, being absent at day 1, was normal at 3 months. Furthermore, the islet morphology was also normal in these groups at 3 months. Short-term (7 days) insulin treatment normalized the long-term diabetes in rats given 50 mg/kg streptozotocin, but not in rats given 60 or 70 mg/kg streptozotocin. Thus, after insulin treatment, all rats receiving 50 mg/kg streptozotocin returned to normoglycemia within the following 2 weeks, and the glucose-induced insulin secretion was normal after 3 months, as was islet morphology.(ABSTRACT TRUNCATED AT 250 WORDS)     

Clinical study of cervical radiculopathy after laminoplasty for cervical myelopathy

We have retrospectively determined the preoperative risk factors in cervical radiculopathy after laminoplasty for cervical myelopathy using preoperative neuroradiographical findings and electrophysiological studies. Of the 67 patients who underwent laminoplasty, 10 patients (14.9%) postoperatively showed cervical radioculopathy. The preoperative radiographical findings had included cervical lordosis, intraspinal cord centering, and anterior protrusion of the apex of the superior articular process. Needle electromyography, somatosensory evoked potentials (SEPs), sensory nerve action potentials (SNAP) were preoperatively examined in 42 cases. There was no relationship between the postoperative radiculopathy and the preoperative radiographical findings. Six (100%) of 6 cases preoperatively diagnosed as C5 radiculopathy (postganglionic type) with Erb-P 14 interpeak latency of dermatomal SEPs and SNAP, developed postoperative C5 radiculopathy. One (25%) of 4 cases preoperatively diagnosed as C6 radiculopathy developed postoperative C6 radiculopathy. No case preoperatively diagnosed as C7 or C8 radiculopathy developed postoperative radiculopathy. This study suggested that an important risk factor for postoperative radiculopathy was subclinical C5 radiculopathy (postganglionic type) that could be preoperatively evaluated using electrophysiological studies.     

Midline cervical cleft

The effect of m-chlorophenylbiguanide, a selective 5-HT3 receptor agonist, on gastric antral motility was investigated in conscious dogs with a force transducer implanted chronically. m-Chlorophenylbiguanide (0.1-1 mg/kg i.v.) dose dependently enhanced antral motility in the fasted state, and the amplitude of m-chlorophenylbiguanide (1 mg/kg i.v.)-induced antral contractions reached the level of natural phase III contractions. In contrast, m-chlorophenylbiguanide reduced the amplitude of antral contractions in the fed state. A selective 5-HT3 receptor antagonist, ramosetron (0.0003-0.03 mg/kg i.v.), inhibited both effects of m-chlorophenylbiguanide. m-Chlorophenylbiguanide (1 mg/kg i.v.)-induced contractions were inhibited by atropine (0.03 or 0.1 mg/kg i.v.). These results indicate that pharmacological activation of 5-HT3 receptors has opposite effects on canine gastric antral motility in the fasted and in the fed state, being stimulatory and inhibitory, respectively. The stimulatory effect seems to be mediated mainly via the release of acetylcholine.     

Posttraumatic cervical dystonia

Posttraumatic cervical dystonia has been described as a distinct syndrome with some similarities to idiopathic nontraumatic cervical dystonia (torticollis). We describe five patients in whom cervical dystonia developed immediately after relatively mild trauma to the neck. Four of the five patients had persistent contractions of all cervical muscles including the trapezius muscles, which almost completely prevented motion of the neck and resulted in muscle hypertrophy. The condition persisted unabated in all patients for the entire period of follow-up (duration, 1 1/2 to 3 years). Pharmaceutical interventions, which had been used previously for idiopathic nontraumatic cervical dystonia, failed to benefit these patients. Two patients who received injections of botulinum toxin had no more than mild benefit. Selective denervation was inapplicable because of the widespread involvement of all cervical muscles in all but one patient. Physical therapy was essentially ineffective. Because of the unusual features and possible medicolegal setting, clinicians may tend to diagnose this condition as a psychogenic disorder or litigation-oriented behavior. The clinical picture, however, is consistent with an organic dystonia that may render the patient functionally and occupationally disabled.     

Four-level cervical corpectomy

STUDY DESIGN: Retrospective analysis of 31 cases of cervical spondylotic myelopathy treated by four-level subaxial cervical corpectomy. OBJECTIVE: To determine whether extremes of anterior decompression and fusion have inordinate or unique levels of morbidity. SUMMARY OF BACKGROUND DATA: There is a paucity of data on experience with four-level corpectomy. However, counsel against such surgery can be found. MATERIALS AND METHODS: The records and studies of 31 consecutive cases of cervical spondylotic myelopathy, treated by four-level corpectomy, were retrospectively analyzed. Patients in 26 cases were observed longer than 2 years. No hardware was used in the procedures. External orthosis, worn for 6 months, was a Philadelphia-type collar in 25 patients and a halo vest in 6. RESULTS: Three patients died within 3 weeks of surgery (9.7%). Delayed radiculopathy occurred in four patients after surgery, three had acute graft complications, and one had pseudomeningocele, for a morbidity rate of 25.8%. There was no infection or worsened myelopathy. CONCLUSIONS: No unique morbidity is associated with extremes of subaxial decompression when compared with surgery of lesser extent.     

Extended cervical mediastinoscopy

Organic solvent inhalation is a serious problem among youths in Japan. It induces physical and mental disorders, and is related closely to crime and delinquency. The relationship between solvent inhalation and antisocial behavior was investigated in 75 youths. The subjects were divided into three groups according to the level of violent behavior and the time of appearance: a non-violent group, a late-onset group (violence occurred after the start of inhalation) and an early-onset group (violence had occurred before the start of inhalation). Various parameters were compared among the groups. The late-onset group showed the following characteristics; (i) the frequency of inhalation was high, and many subjects experienced hallucinations and mood changes caused by inhalation; (ii) the family environment was characterized by conflict; and (iii) the subjects had strong psychological conflicts and showed dissociative coping with frustration. The violence, psychological conflict and dissociation in this group were found to be related to the inhalation, with familial conflict as a background. The violence in the early-onset group was considered to be the manifestation of a violent personality as the frequency of inhalation and the incidence of mental symptoms were both low. The subjects in this group showed weak psychological conflict and tended to be demanding of others when attempting to cope with frustration. Two types of violent behaviors in the teenagers who inhaled solvents were identified. The violence of solvent inhalers should be managed according to the type.     

Multilevel anterior cervical corpectomy and fibular allograft fusion for cervical myelopathy

This study was conducted to determine the safety and efficacy of multilevel anterior cervical corpectomy and stabilization using fibular allograft in patients with cervical myelopathy. Thirty-six patients underwent this procedure for cervical myelopathy caused by spondylosis (20 patients), ossified posterior longitudinal ligament (four patients), trauma (one patient), or a combination of lesions (11 patients). The mean age (+/- standard deviation) of the patients was 58 +/- 10 years and 30 of the patients were men. The mean duration of symptoms before surgery was 30 +/- 6 months and 11 patients had undergone previous surgery. Prior to surgery, the mean Nurick grade of the myelopathy was 3.1 +/- 1.4. Seventeen patients also had cervicobrachial pain. Four vertebrae were removed in six patients, three in 19, and two in 11 patients. Instrumentation was used in 15 cases. The operative mortality rate was 3% (one patient) and two patients died 2 months postoperatively. Postoperative complications included early graft displacement requiring reoperation (three patients), transient dysphagia (two patients), cerebrospinal fluid leak treated by lumbar drainage (three patients), myocardial infarction (two patients), and late graft fracture (one patient). One patient developed transient worsening of myelopathy and three developed new, temporary radiculopathies. All patients achieved stable bone union and the mean Nurick grade at an average of 31 +/- 20 months (range 0-79 months) postoperatively was 2.4 +/- 1.6 (p < 0.05, t-test). Cervicobrachial pain improved in 10 (59%) of the 17 patients who had preoperative pain and myelopathy improved at least one grade in 17 patients (47%; p < 0.05). Twenty-six surviving patients (72%) were followed for more than 24 months and stable, osseous union occurred in 97%. These results show that extensive, multilevel anterior decompression and stabilization using fibular allograft can be achieved with a perioperative mortality and major morbidity rate of 22% and with significant improvement in pain and myelopathy.     

Symptoms of the cervical spine in temporomandibular and cervical spine disorders

This study was performed to assess the prevalence of signs and symptoms related to cervical spine disorders (CSD) in subgroups of patients with temporomandibular disorders (TMD) and to compare TMD patients and CSD patients with regard to the results of orthopaedic cervical spine tests. One hundred and eleven consecutive patients with TMD and 103 consecutive patients with signs and symptoms of CSD were examined. The results indicated that there is a considerable overlap in the signs and symptoms of patients with TMD and patients with CSD. Signs and symptoms on neck extension occurred more often in CSD patients than in subgroups of TMD patients. No significant differences in upper cervical extension, neck flexion, and shoulder girdle function were found between CSD patients and subgroups of patients with TMD. Patients with CSD reported neck pain during active and passive movements of the neck more often than the subgroups of patients with TMD. TMD patients and CSD patients did not differ with regard to pain on shoulder girdle function and palpation of the shoulder girdle. Logistic regression analyses showed that orthopaedic tests of the cervical spine are of minor importance in discriminating between patients with TMD and patients with CSD. It is concluded that TMD with a myogenous involvement in contrast to TMD with only an arthrogenous involvement should no longer be viewed as a local disorder of the stomatognathic system. The upper quarter, including the stomatognathic system, cervical spine, and shoulder girdle, should be evaluated in patients with more complex or persistent symptoms in the head and neck region.     

Reconstruction of cervical stability following old facet dislocation of cervical spine]

One hundred fifty adolescent inpatients with major depression were systematically assessed for demographic and clinical differences between psychotic and nonpsychotic depression. Delusions and/or hallucinations were present in 10% of the subjects. The psychotic group had significantly more frequent and severe suicidal ideation. Posttraumatic stress disorder was also more frequent in the psychotic group.     

Screening for cervical cancer

As part of a continuing series on how the work of pathology laboratories contributes to patient care, this article looks at the Papanicolaou (Pap) or cervical smear test, which involves the microscopical examination of cells recovered by scraping the surface of the cervix. The incidence, causes and aetiology are described and the organisation of cervical screening is shown. Finally, the range of findings from a positive smear test is explained.     

Nontuberculous mycobacterial cervical adenitis

Granulomatous inflammation is a common finding in pathologic evaluation of surgically excised chronic lymphadenopathy in children. Confusion exists regarding diagnosis and management of these lesions. Over a 10-year period at The Children's Hospital of Philadelphia, a total of 81 children were identified with biopsy-confirmed granulomatous lesions of the head and neck, with nontuberculous mycobacteria (NTM) accounting for 67 of the cases. The typical presentation was that of a nontender mass in the cervicofacial area present for weeks to months, unresponsive to antimicrobials. All underwent surgical excision, which was curative in 54 patients; 13 children required additional procedures. This paper reviews NTM, its typical clinical presentation, difficulty in diagnosis, and the methods of treatment.     

Differential expression of telomerase activity in human cervical cancer and cervical intraepithelial neoplasia lesions

PURPOSE: Telomeres are tandem arrays of repeated DNA sequences located at the ends of eukaryotic chromosomes, and are synthesized by the enzyme telomerase. Loss of telomeric DNA may play an important role in the development of human cancers. However, very little is known about the status of telomerase during human cervical cancer development. PATIENTS AND METHODS: Telomerase activity was measured by telomere repeat amplification protocol (TRAP) assay in 24 cervical cancers, one carcinoma in situ (CIS), and 20 cervical intraepithelial neoplasia (CIN) lesions. Adjacent nontumor cervical tissue from the same 24 cervical cancer patients and normal cervical tissues from 11 control individuals also were examined for the presence of telomerase activity. RESULTS: Twenty two of the 24 (91.7%) cervical cancer specimens and the single CIS tissue were strongly positive for telomerase activity. Relatively weak but distinctive telomerase activity also was detectable in one of four CIN-I (25%), two of eight CIN-II (25%), and two of eight CIN-III (25%), respectively. However, telomerase activity was not found in the 24 corresponding nontumor cervical tissues from the same cervical cancer patients and the 11 normal cervical tissues from control individuals. CONCLUSION: The majority of cervical cancers contain strong telomerase activity. Significant proportions of noncancerous CIN tissues also contain telomerase activity, although weaker than that in cervical cancer. It seems that there is a progressive increase of telomerase activity in association with an increased degree of cervical malignancy. These results seem to suggest that the expression of telomerase may play a crucial role in cervical cancer carcinogenesis.