management of the inconspicuous penis in children

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50

SURGICAL MANAGEMENT OF RECURRENT COMPRESSIVE

MYELOPATHY AFTER ANTERIOR CERVICAL DISCECTOMY AND

FUSION

Mohammad Abd Elmonem Negm

Department of Orthopedic Surgery, Faculty of Medicine, Al-Azhar University,

Cairo, Egypt.

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ABSTRACT

Recurrent myelopathy after anterior cervical discectomy and fusion is a

rare condition, the literature in this entity were limited. This recurrence may

occur at the same level or in adjacent level/s, usually the proximal level and

the compressing element either anteriorly by a newly prolapsed disc or

posteriorly by enfolding of the ligamentum flavum. From 2008 to 2012, 9 cases

of recurrent cervical myelopathy were treated surgically at Bab El-Sheria

university hospital, all of them had an anterior cervical discectomy before with

a good improvement after surgery. All patients were evaluated clinically by

both JAO score and Nurick’s grades and radiologically by plain x ray and

MRI, In MRI the pattern of compression were evaluated in T2 waited image

and the cord was evaluated according Yasutsugu classification. 6 out of the 9

cases were operated through anterior approach and 3 via posterior approach.

The mean follow up period was 30.7 months. Excellent results were obtained

through this procedure, improvement in clinical outcome and cord condition

was evident.

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51

INRODUCTION

Cervical myelopathy is a spinal cord level dysfunction that may result

in the clinical symptoms of loss of dexterity, poor coordination, motor

weakness, and/or sensory loss. A detailed and thorough neurologic

examination is the current standard to diagnose the presence of cervical

myelopathy (1).

Cervical myelopathy describes a constellation of symptoms and signs

arising from compression of the cervical spinal cord (Table 1). Because the

presentation of the myelopathic patient can be quite subtle in its early

manifestations, the diagnosis may easily be missed or delayed. However,

because the natural history is typically one of stepwise progression, early

recognition and treatment is essential for optimal outcomes before the onset of

irreversible spinal cord damage.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2852088/table/T1/


52

Table 1: Potential clinical findings in cervical myelopathy

Symptoms Signs

Hand clumsiness, difficulty with fine

motor skills (e.g., buttoning,

jewelry, handwriting)

Diffuse, non-dermatomal upper

Extremity Numbness (usually the

hands)

Gait instability, bumping into walls,

feeling drunken or wobbly

May or may not have neck or arm

pain

Lhermitte,s symptoms, electric jolts

down the spine with particular

neck movements

Bowl/ bladder incontinence.

motor weakness (mostcommonly in

the hands)

Upper motor neuron signs: hyper

reflexia , clonus babniski,

scapulohumeral reflex

Objective gait disturbance: timed

walking tests

Provocative signs: Hoffmann’s,

inverted brachioradialis reflex

Lhermitt’s sign

Muscle wasting (most commonly the

hands)

Myelopathy hands: finger escape sign,

inability to rabidly grip and

release.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2852088/table/T1/


53

Cervical spondylotic myelopathy (CSM) is a common cause of

neurologic morbidity, and can substantially decrease quality of life.(2,3) Many

authors have advocated surgical decompression for CSM, but the optimal

surgical strategy remains controversial and a number of anterior and posterior

approaches have been advocated (2). The choice between anterior, posterior,

and combined approaches for decompression is based primarily on; (1) sagittal

alignment of the spinal column, (2) the extent of disease, (3) the location of

compressive abnormality, (4) the presence of preoperative neck pain, and (5)

previous operations.(4)

The operative treatment of degenerative cervical disorders has evolved

over the past seventy-five years. Mixter and Barr initially described a posterior

approach in 1934, when they performed cervical laminectomy (5). In the 1970s,

various techniques of laminoplasty were introduced as a less destabilizing

alternative to laminectomy (6,7). Concurrently, the 1950s saw increasing

popularity of anterior procedures, with Robinson and Smith (8), Cloward (9) and

Simmons and Bhalla (10) describing anterior decompression and fusion

techniques involving the use of iliac crest bone graft. Increasing familiarity

with the anterior approach led to the development of multiple-level anterior

reconstruction and instrumentation.

The goals of operative treatment with all of these techniques have been

to prevent deterioration and, in some cases, to reverse the myelopathy by (1)

decompressing the spinal cord, (2) stabilizing the spine in cases in which

segmental motion may be a contributory factor, and (3) secondarily improving

cord perfusion by decompressing obstructed spinal vessels (11), (4) restore

normal lordosis both posterior and anterior approaches have a unique

advantages and disadvantages (12,13).


54

Anterior cervical discectomy and fusion has been accepted as one of the

prime surgical procedures for cervical myelopathy (14,15), treating a variety of

cervical conditions including degenerative or herniated discs, radicular

symptoms with or without collapse, cervical stenosis with or without

myelopathy, fractures and neoplasms. The literature varies considerably with

regards to fusion rates in part because of the variety of methods used for the

primary surgery and the number of segments fused (15).

A dorsal (posterior) approach may be selected in cases of an effective

lordosis. Laminectomy, with or without fusion laminoplasty for the treatment

of cervical myelopathy has been accepted as a standard procedure for years

(16,17). It is most commonly indicated in patients who have a compressive

myelopathy with an associated effective cervical lordosis (15,18), or for cases

with effective posterior compression (13).

Although good results are expected from this procedure, several factors

are reported to affect surgical outcomes (19-21). It is suggested that mechanical

stress on the adjacent disc levels after anterior cervical fusion aggravates the

degenerative change in these disc levels (19,22-26). Through this degenerative

course, some of these disc levels tend to show instabilities, such as translation

to various extents.26 Radiologic instability at disc levels adjacent to levels in

which anterior cervical fusion is performed have been postulated to be a factor

that reaggravates myelopathy that has recovered after the surgery(19,21,24,26,27). In

addition to the instability, the existence of spinal canal stenosis is also one of

the radiologic factors affecting the surgical results of anterior cervical

fusion(26,27). However, other opinions rejecting the correlation between

radiologic findings and clinical surgical results have also been reported (19,22,23).


55

Cervical canal size, geometry, biomechanics and previous surgeries

play an important role in the development of CSM, The normal cervical canal

diameter is 15-17mm; Patients with developmental cervical spinal canal

stenosis and an anteroposterior diameter of the spinal canal of 12 mm or less

are highly likely to develop cervical myelopathy(28-31).

Assessment of CSM in symptomatic patients is the clue for surgical

decision, depending on clinical status and imaging finding. Various clinical and

radiological parameters were set for patient’s evaluation. A Japanese

Orthopedic Association score for assessment of myelopathy (JOA)(32,33) (Table

2), and Nurick disability index (DI)(32,34) (Table 3) are reliable methods for

quantifying the severity of myelopathy.


56

(Table 2): Japanese Orthopedic Association Score (JOA score total 17

point) (32,33)

Japanese Orthopedic Association score (JOA) Scores (total 17 points) Parameter Points

I. Upper extremity function Impossible to eat with either chopsticks or Spoon 0 Possible to eat with spoon, but not with chopsticks 1 Possible to eat with chopsticks, but inadequately 2 Possible to eat with chopsticks, but awkwardly 3 Normal 4 points II. Lower extremity function Impossible to walk 0 Needs cane or aid on flat ground 1 Needs cane or aid only on stairs 2 Possible to walk without cane or aid, but Slowly 3 Normal 4 point III. Sensory function A. Upper extremity Apparent sensory loss 0 Minimal sensory loss 1 Normal 2 points B. Lower extremity Apparent sensory loss 0 Minimal sensory loss 1 Normal 2 points C. Trunk Apparent sensory loss 0 Minimal sensory loss 1 Normal 2 points IV. Bladder function Complete retention 0 Severe disturbance 1 Inadequate evacuation of the bladder, straining, dribbling of urine Mild disturbance 2 Urinary frequency, urinary hesitancy Normal 3 points


57

(Table 3); Nurick disability index (32,34)

Nurick’s disability index (DI)

Grade 0: signs or symptoms of root involvement but without evidence

of spinal cord disease

Grade 1: signs of spinal cord disease but no difficulty in walking.

Grade 2: slight difficulty in walking which does not prevent full-time

employment

Grade 3: difficulty in walking which prevented full time employment or

the ability to do all housework, but which was

not so severe as to require someone else's help to walk

Grade 4: able to walk only with someone else's help or with the aid of a

frame.

Grade 5: chair bound or bedridden.

Imaging of patients with recurrent cervical myelopathy after anterior

discectomy is the key stone for complete assessment and for selection of

appropriate surgical approach. Plain radiographs can provide useful

information about the alignment, deformity, the level of discectomy of cervical

vertebrae, fusion status, hardwear used in previous operation, but are not

sufficient to diagnose cord status or the degree of compression. Routine

evaluation may include upright antero-posterior and lateral views, as well as (if

needed) flexion-extension views. The lateral radiograph can be particularly


58

useful and can be used to determine the degree of cervical canal stenosis. A

Pavlov ratio (AP diameter of canal/ AP diameter of vertebral body) of less than

0.8 is suggestive of cervical canal stenosis (32).

MRI has proven to be a valuable tool in defining the anatomy of the

cervical spine based on its ability to differentiate neural, osseous, and soft

tissue structures with high-resolution. This modality enables visualization of

spinal cord parenchymal abnormalities, such as neoplasms, demyelinating

lesions, fluid collections, and/or edema.1 Signal changes within the cord may

be demonstrated on MRI and are suggestive of severe compression.(35)

Yasutsugu, et al, 2007 classify the degree of myelopathy in MRI into

three grads (mild, moderate and severe) (figure 1) based on increased signal

intensity (ISI) of the spinal cord on T2-weighted MRI which reflect the

severity of cord compression, Grade 0, none; Grade 1, light (obscure); and

Grade 2, intense (bright) signal changes.(36)

Figure 1: Classification of increased signal intensity (ISI) of the spinal cord in

T2-weighted MRI.


59

Radiological patterns of compression (POC) (32) is the most valuable

method in detection of the pattern of cervical cord compression, defining

significant anterior and/or posterior compressing cause in a T2 MRI. It was

grated as POC (I) to POC (V) figure (2), POC I; disc herniation causing

anterior cord compression, POC II; anterior and posterior cord compression,

POC III; and POC III-v; significant anterior and/or posterior cord compression,

POC IV; multiple levels of anterior and posterior cord compression, POC IV-v

multiple levels of cord compression with C3-4 being more significant and

severe compared to others, POC V multi-level cord compression in a

kyphotically aligned canal.

Fig. 2 Radiological patterns of compression (POC): diagrammatic and

radiological (Sagittal T2 MRI) examples of various POC (32).

If a patient cannot obtain an MRI for medical reasons (e.g., cardiac

pacemakers aneurysm clips, or severe claustrophobia), or if metal or scar from

prior cervical surgery precludes adequate visualization on MRI due to artifact,


60

then a CT-myelogram may be considered. Although invasive and therefore not

the best screening tests, CT-myelograms provide outstanding resolution of both

bony and neural anatomy for surgical planning. Alternatively, if a high quality

MRI is present but questions remain regarding bony anatomy for the purposes

of surgical planning, a non-contrast CT can provide complementary

information. CT may, for instance, diagnose the presence of OPLL that may be

difficult to see on plain radiographs or conclusively indentify on MRI but

which can have a profound effect on surgical treatment (35).

Although anterior cervical discectomy with or without fusion gives

usually good results with a high degree of improvement, there are some

patients develop symptoms and signs of myelopathy after a significant period

of improvement. While the available literatures demonstrate a low rate of

neurological complications, with the vast majority of complications being

treatable and without a long-term impact, there is a limitation in defining the

recurrence of myelopathy after anterior cervical discectomy (37). Michael et al,

2012 demonstrated that the rate of recurrent symptoms after surgery is 2.7

%.(37)

The aim of this work is to evaluate the results of surgical

decompression of the spinal cord in cases of cervical myelopathy after anterior

cervical discectomy and fusion, either at the same level or adjacent to segment

fused.


61

PATIENTS AND METHOD

From 2008 to 2012, nine cases complaining of recurrent cervical

myelopathy after anterior cervical discectomy and fusion, were treated

surgically at Bab El-Sheria university hospital, there were 6 males and 3

females, with mean age was 45.8 years (35-56), all of them had an anterior

cervical discectomy before with a period of improvement after this surgery.

The average improvement time after first surgery was 31.7 months (18-48). All

patient, at presentation, were evaluated clinically and radiologically to assess

the degree of myelopathy, the cord status and the nature of the compressing

agent. 6 out of the 9 cases (66.7%) was operated through anterior approach and

3 (33.3%) via posterior approach. The patients were followed postoperatively;

the mean follow up period was 30.7 months (10-46).

Clinical evaluation: all patients are evaluated after taking an inclusive

data and history, by clinical examination and both JAO score and Nurick’s

grades, with special consideration to the circumstances of the first surgery.

Clinical examination revealed that all patients had some degree of motor

weakness in upper and lower extremities and disturbance in sensation and bowl

habits. According to JAO score; the mean score was 10.3 ranged from 8 to 13.

According to Nurick’s grades, 5 patients were grade 3, 2 were grade 4 and 2

were grade 5 with mean grade is 3.7.

Radiological evaluation; all patients were evaluated by plain x ray and

MRI, in plain radiography, the cervical vertebrae of all patients were aligned,

only 2 patients (22%) had mild kyphotic deformity. 6 patients (66.7%) had a

single level discectomy and 3 (33.3%) had duple level. Of the total 12 level

discectomy, C5-C6 was the most operated level, 9 times (75%), C4-C5 in 2

(16.7%) and C6-C7 in one case (8.3%). Cage was used for fusion in 9 out of 12


62

levels (75%), 3 were fused by anterior cervical plate (25%). The fusion rate

was good in all fused levels.

In MRI, the cord and compressing element was evaluated. According to

Yasutsugu classification, 2 cases out of 9 (22.2%) classified as (grade 0), 4

(44.4) as (grade 1), and 3 (33.3) as (grade 2) (severe type). The pattern of

compression (POC) was evaluated in T2 waited image, 2 cases (22.2%) were

POC I, 5 cases (55.6%) were POC II, and 2 cases (22.2) were POC III.

Final assessment revealed the following, 2 cases out of 9 (22.2%) had a

significant posterior compression at the same level of previous discectomy both

were C5-C6 so they operated by simple laminectomy of C5 via posterior

approach, 7 cases (77.8%) had a significant anterior cord compression, 5

(55.6%) at adjacent proximal level of the previously operated one, 4 of them at

C4-C5,and remaining case at C3-C4, 2 cases (22.2%) at other proximal level,

both were at C3-C4 level. These 7 cases operated by anterior cervical

discectomy with cord decompression and fusion using appropriate cage filled

with hydroxy appetite bone substitute to enhance fusion. The anterior

approaches in this study were done through the opposite side of previous

operation to avoid adhesions which may lead to a serious vascular injury.

Closer of the wounds were done in layer with the skin closed subcuticular for

cosmetic purpose. The patients putted in a rigid neck collar for 6 weeks to

maintain position until satisfactory healing.


63

RESULTS

All cases in this study were improved clinically and radiologically, the

average time of surgery were 65 minutes (45-80), the average blood loss 140cc

(100-170cc), non of patient develop any major complication, only 4 cases

suffering mild dysphagia which improved spontaneously, one develop

dysphonia which also improved with time, no deep or superfacial wound

infection, no patients need ICU addmition. All patients were evaluated

clinically, postoperatively, at the second day of surgery, close follow up were

don in the first 2 week, then after one week, then every 2 weeks for next

month, then every 1-3 months. All patients were followed until this time, the

follow up period ranged from 10 to 46 months with mean of 30.7 months.

Radiological evaluation were done by x-ray at early postoperative period, in

which the operated level, the vertebral alignment , the canal congruity were

evaluated. MRI was done for 3 cases, after 3 months, whom classified as

Yasutsugu grade 2 (severe myelopathy) for assessment of cord status. (Table

4), illustrates our results as regard patient’s identification (ID), age, sex, the

time between first and second surgery, the level of operated level in the 1st and

2nd surgeries and the type fixation, the approaches used for decompression of

myelopathy. (Table 5), illustrates the postoperative improvement as regard

JAO score, Nurick disability index, Yasutsugu classification, overall results

and finally patient’s satisfaction.


64

Table 4; the results of the patients as regard patient’s identification

No

ID Age

sex

Time bet. 2 surg. & Duration of Symptoms. (Months)

Level of myelopathy

1st surg. & type of hard wear

2nd surg. & type of hard wear 1st op. 2nd op.

1 R Q

50 F 24 (3) C5-C6 C5-C6 Anterior /plate

Post./ Laminectomy

2 O A

45 M 48 (6) C5-C6 C4-C5 Anterior /cage

Anterior /cage

3 M A

38 M 30 (3) C5-C6, C6-C7

C3-C4 Anterior /plate

Anterior /cage

4 R A

48 F 18 (5) C5-C6 C4-C5 Anterior /cage

Anterior /cage

5 A K

56 F 20 (7) C5-C6 C5-C6 Anterior /plate

Post./ Laminectomy

6 M O


Anterior /cage

7 O M


Anterior /cage

8 M E

35 M 24 (3) C5-C6, C6-C7

C4-C5 Anterior /cage

Anterior /cage

9 A M

41 M 44 (2) C4-C5, C5-C6

C3-C4 Anterior /cage

Anterior /cage

(ID), age, sex, the time between 1st and 2nd surgery, the operated level in the

1st and 2nd surgeries, the type fixation and the approach used.

Improvement of JAO score was evaluated by the Recovery rate (RR),

according to Hirabayashi’s method (32) [RR = (postoperative – preoperative

JOA score) / (17 - preoperative JOA score) x 100]. The improvement in JAO

score was present in all cases, it was 5.3. The mean postoperative JAO was

15.5 (14-17) it was 10.3 preoperatively. RR was 80.4% (66,7 - 100). The mean

postoperative Nurick disability index (DI) became .67 (0-2) it was 3.7 (3-5)

preoperatively, improvement in DI was 3.03, (3.7 – .67), according to DI, 4


65

cases (44.4%) classified as grade 0, 4 (44.4) as grade 1and only one case as

grade 2 (11.1%).

All patients were satisfied as they regain all or most of their previous

activity and work. 7 out of 9 cases (77.8) classified as excellent result

according to improvement of JAO, RR ˃ 70 %, and ID 0-1. Other 2 cases

classified as good result in whom RR ≤ 70 % and ID 1-2. In the 3 case whom

classified as Yasutsugu grade 2 (severe myelopathy) in T2 MRI the post

operative MRI shows some improvement denoting that the cord may improved

by surgical decompression.


66

Table 5; Postoperative improvement as regard JAO score, Nurick disability

index, Yasutsugu classification, overall results and finally patient’s

satisfaction.

No Preoperative evaluation Postoperative evaluation last.

Level

clinical radiological Clinical radiological

JAO score

Nurick’s grade

X ray MRI JAO score

Nurick’s grade

X ray

MRI R R result Patient’s satisfaction

Y POC Y POC

1 8 5 C5-C6

2 III 13 2 G 1 29.4%

Excellent

Satisfied

2 11 3 C5-C6

1 II 16 1 G - 29.4%

Excellent

Satisfied

3 12 3 C5-C6, C6-C7

0 II 15 0 G - 17.6%

Good Satisfied

4 9 4 C5-C6

1 III 14 2 G - 29.4%

Excellent

Satisfied

5 7 5 C5-C6

2 II 12 3 G 1 29.4%

Excellent

Satisfied

6 10 4 C6-C7

2 I 16 1 G 1 35.3%

Excellent

Satisfied

7 12 3 C5-C6

1 II 15 0 G - 17.6%

Good Satisfied

8 13 3 C5-C6, C6-C7

0 II 17 0 G - 23.5%

Excellent

Satisfied

9 11 3 C4-C5, C5-C6

1 II 16 1 G - 29.4%

Excellent

Satisfied


67

Case presentation:

Case 1; RQ female patient 50 years, presented by recurrent myelopathy

for 3 months after a period of improvement for 2 years after 1st surgery. The

level of 1st surgery was C5-C6, operated by anterior cervical discectomy with

plate fixation. The recurrence was at the same level with significant posterior

compression treated by simple posterior laminectomy as the spine was properly

fixed anteriorly. Preoperatively she was JAO 8, DI 5, Y 2 and POC III.

Postoperatively she became JAO 14, DI 1, Y 1, and POC 0. RR was 66.7%,

She had a good result with high satisfaction.


68

A B

C D

E F G

Figure 3; A) AP & Lat x-ray before 1st surgery, B) MRI before 1st

surgery, C) AP & Lat x-ray at presentation with recurrent myelopathy, D) MRI

before 2nd surgery shows severe myelopathy Y (2), E) AP & Lat x-ray after

posterior decompression laminectomy, F) follow up x-ray, D) follow up MRI

shows cord improvement Y(1).


69

Case 2; OM male patient 45 years, presented by recurrent myelopathy

for 6 months after a period of improvement for 4 years after 1st surgery. The

level of 1st surgery was C5 - C6, treated by anterior cervical discectomy and

fusion by cage. The recurrence was at the adjacent proximal level C4 – C5,

with significant anterior compression treated by anterior cervical discectomy

and cage for fusion. Preoperatively he was JAO 11, DI 3, Y 1, and POC II.

Postoperatively he became JAO 16, DI 0, and POC 0. RR 83.3%, he had an

excellent result with high satisfaction.

A B C D E F

Figure 4; A&B) preoperative AP and Lat. view showing the operated

level C5-C6, C&D) preoperative MRI showing a significant anterior disc

compressing the cord at the proximal adjacent level (C4-C5), E&F)

postoperative x-ray AP & Lat. views

Case 3; MA male patient 35 years, presented by recurrent myelopathy

for 3 months after a period of improvement for 30 months after 1st surgery. The

level of 1st surgery was C5-C6 and C6-C7, treated by anterior cervical

discectomy and fusion by 2 cages. The recurrence was at the proximal level

C3-C4, with significant anterior compression treated by anterior cervical

discectomy and cage for fusion. Preoperatively he was JAO 13, DI 3, Y 0, and


70

POC II. Postoperatively he became JAO 17, DI 0, and POC 0. RR 100 %, he

had an excellent result with high satisfaction.

A B C D E F

Figure 5; A&B) preoperative x-ray AP & Lat. views shows the operated

levels C5-C6 & C6-C7, C&D) preoperative MRI shows a significant anterior

compression at the proximal level C3-C4, E&F) postoperative x-ray shows the

operated level C3-C4

DISCUSSION

Anterior cervical decompression and fusion was reported to be an

accepted procedure for patients with cervical myelopathy and cervical disc

disease19,20-24,26,27,38 regression and improvement in myelopathy after this

procedure have also been reported (21,24,26,27,38,39). Fessler et al,1998,(40) reported

92% of patients experience symptom improvement after anterior

decompression and fusion for CSM, and thus surgery is commonly advocated

for its management (4).

Although this approach is universally accepted and widely used, the

recurrence of myelopathy may be present during the postoperative period after


71

a time of improvement. Recurrent myelopathy after anterior cervical

discectomy is a rare entity (2.7 %) (37), so there are little worldwide studies

reviewing its management, and most of them concerning about

pseudoarthrosis, deformity or radiculopathy as a complication of anterior

cervical surgery. In this study we reported a nine cases or recurrent myelopathy

after anterior cervical discectomy and fusion, all of our cases were improved

for a time the shortest of them is 18 months, and the longest was 48 months

with average of 31.7 months, the degree of recurrence of myelopathy was

varied, the worst case was JAO 7 and the best were 13, all cases experienced a

progressive deterioration in myelopathy, so all cases were planned for surgical

decompression to stop progression and to decompress the cord allowing it to

repair.

Many factors may play a role in the recurrence of myelopathy. This

recurrence may attributed in some reports to radiologic changes (24,26,27),

because immobile segments after anterior cervical fusion may result in high

stress on the adjacent intervertebral segments (24), so instability and

degenerative changes at adjacent segments may occur, and the surgical

outcome may deteriorate (24,26,27). However, completely opposite opinions,

which suggest no correlation between radiologic findings and clinical results,

have also been reported (22,23).

Hinck and Sachdev (41) proposed the concept of developmental stenosis

of the cervical spinal canal, it has been suggested to be the major factor causing

cervical myelopathy, because widening of the spinal canal by anterior cervical

fusion is limited to the operated segments (19,21,26,27), preoperative canal stenosis

in adjacent levels may predispose postoperative recurrence of myelopathy

specially with development of instability and/or bony spurs (19,26,27).


72

Etsuo et al (19), supports the hypothesis that anterior cervical fusion

alone is not sufficient for management of cervical myelopathy with

developmental stenosis(19,26) due to a so-called pincer mechanism includes not

only bony impingement but also the enfolding of yellow ligament posteriorly

with anterior element compression (42).

Selection of the approach must be carefully planned according the site

and the nature of the compressing element. In this study when the compression

were manly anterior, 6 cases out of 9 (66.7), we used anterior approach in

revision surgery, and when the compression was posteriorly, posterior

approach was selected for decompression, simple laminectomy was used as the

spine in the remaining 3 cases was stable and there was no fear from

progressive kyphosis.

In this study we noticed that a proper height of the graft or cage must be

chosen when used for fusion as if the graft is higher than required it may leads

to posterior enfolding of the ligamentum flavum, this height could be assessed

by noticing the gaps between spinous processes under image during surgery,

figure (3). Another important factor we noticed in this work is the presence of

developmental cervical canal narrowing in all cases so we belief that; presence

of congenitally or developmentally narrow canal is the clue for the appearance

of myelopathy as in many patient with wide cervical canal myelopathy is not

manifested even with the presence of a significant disc, this result was agree

with Kataoka and Kurihara (43) whom reported that cervical canal of 12 mm or

less in diameter in disc adjacent to the fusion level was found to be a risk factor

for recurrence of myelopathy after surgery (19).

Improvement in the clinical and radiologic conditions encourage rabid

interference when patient start to complain of myelopathy either primary or


73

recurrent after anterior cervical decompression, consequently surgical

interference (anterior and/or posterior) must be carried out to overcome the

deterioration in cervical myelopathy which certainly occurs. In our case all

patient were improved the average improvement in JAO score were 5.3 and in

DI were 3.03 with recovery rate 80.4 % which gives the overall excellent

result. Surgical decompression is beneficial even with cases of sever

myelopathy as improvement may occurs.

Many authors have investigated the association between increased

signal intensity (ISI) and surgical outcomes. Some authors report that patients

with ISI have poor prognosis after surgery (44-48), but others could not find any

association 49-51). However we find some improvement in signal intensity in the

cord after decompression even after relatively a long period, this result match

Yasutsugu et al results(36), they found improvement in myelopathy cases,

although ISI grade 2 indicated a poorer prognosis, than light ISI grade 0 which

indicated better surgical outcomes.

SUMMARY

Recurrent myelopathy after anterior cervical discectomy and fusion is a

rare condition, the literature in this entity were limited. This recurrence may

occur at the same level or in adjacent level/s, usually the proximal level, and

the compressing element either anteriorly by a newly prolapsed disc or

posteriorly by enfolding of the ligamentum flavum.

However if any patient started to complaint of symptoms of myelopathy

after a period of improvement a thorough assessment must be done through a

clinical and radiological evaluations, clinical evaluation obtained by detailed

history and careful examination, the presence signs of myelopathy could be

assessed by different parameters, JAO score and Nurick disability index were a

good and reliable methods for clinical assessment. Radiological evaluation


74

obtained via assessment of plain radiography and MRI, in which the condition

of the vertebrae, cervical canal size, cord and the degree of myelopathy could

be identified.

When myelopathy after anterior cervical discectomy is established,

surgical decompression becomes mandatory, to decompress the cord and to

stop progression of myelopathy which is certainly occurs. Surgical

decompression was done through anterior or posterior approach, according to

the site and the nature of compressing element. Clinical and radiological

improvement were evident in all cases in this work with overall excellent result

as all of them regain most of their previous daily activities.

CONCLUSION

Recurrent myelopathy after anterior cervical discectomy although it

rare but may be occurred, when occurred a thorough assessment is required to

evaluate its degree.

Evaluations of the cases depend on clinical and radiological assessment

through investigation of plain radiography and MRI. Assessment of adjacent

level and posterior structure is important to get a good result and to avoid

recurrence of myelopathy.

When myelopathy was established, then surgical decompression (either

anterior or posterior) is indicated to stop progression of myelopathy and to

restore cord function.

Excellent results could be obtained through this procedure,

improvement in clinical outcome and cord condition was evident.


75

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الملخص العربى

المرتجع بعد عمليات اإلستئصال الجراحى لإلعتالل النخاعى اإلنضغاطىالعالج

األمامى للغضرف العنقى

محمد عبد المنعم السيد نجم

قسم جراحة العظام كلية الطب جامعة األزھر بالقاھرة

اإلعتالل النخاعى اإلنضغاطى العنقى المرتجع ھو مرض ينشأ نتيجة الضغط على النخاع :المقدمة

ولھذا ، فى المنطقة العنقية وھو نادرا ما يحدث بعد إجراء استئصال الغضروف العنقى الشوكى

وعند حدوث ھذا اإلعتالل غالبا ما يكون العالج . السبب األبحاث المتوفرة فى ھذا الموضوع قليلة

حيث يبدأ ، ھور المستمرالجراحى ھو الحل األمثل حيث أن ھذا اإلعتالل إذا حدث يبدا غالبا فى التد

المريض فى المعاناة من ضعف حركى فى األطراف و قلة فى اإلحساس مع تدھور فى وظائف

وقد يحدث ھذا اإلنضغاط المرتجع عند مستوى نفس الغضروف المستأصل أو عند . اإلخراج

جراحى والھدف من ھذا البحث ھو تقييم نتائج العالج ال. مستوى آخر غالبا ما يكون مستوى أعلى

.لھذا اإلنضغاط عن طريق إزالة اإلنضغاط وتوسيع القناة العصبية سواء من األمام أو من الخلف

مرضى يعانون ٩تم إختيار عدد ٢٠١٢إلى أغسطس ٢٠٠٨فى الفترة من يوليو :منھجية البحث

منھم من اإلعتالل النخاعى اإلنضغاطى المرتجع بعد عمليات اإلستئصال األمامى للغضرف العنقى

. تم التقييم اإل كلينيكى واإلشعاعى لھم لتحديد مدى وشدة ومستوى ھذا اإلنضغاط، إناث ٣ذكور و ٦

التقييم اإلكلينيكى إعتمد على الفحص السريرى وتقييم األعراض بواسطة مقياس جمعية جراحة

فحص والتقييم اإلشعاعى تم عن طريق). DI(ومقياس ناريك لإلعاقة ) JAO(العظام اليابانية

وبعد التقييم الدقيق تم . األشعات السينية والرنين المغناطيسى لقياس وتقييم مكان اإلنضغاط ومنشأه

مرضى ٦وقد تم إجراء الجراحة من األمام لعدد . إجراء الجراحة للمرضى إلزالة ھذا اإلنضغاط

بواسطة ٣ومن الخلف لعدد ، عن طريق إستئصال الغضروف الضاغط وتركيب قفص كربونى

. إستئصال الصفائح العظمية

المرتجع بعد أظھرت النتائج فعالية العالج الجراحى لإلعتالل النخاعى اإلنضغاطى: النتائج

مرضى وجيدة فى ٧عمليات اإلستئصال األمامى للغضرف العنقى حيث كانت النتيجة ممتازة لعدد

.مرضى مع رضا جميع المرضى عن النتائج ٢عدد

management of the inconspicuous penis in children

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