Assessing hand dysfunction in cervical spondylotic myelopathy.

METHODS: Twenty patients with CSM and 17 controls were recruited. Clinical scores of modified Japanese Orthopedic Association (mJOA) and Nurick were collected. MRI based compression grades such as cord distortion were assessed. Hand dysfunction was tested using a custom motorized apparatus. Subject's forearm was placed in a cast and positioned such that their metacarpophalangeal (MCP) joint was vertically aligned with the motor shaft. Surface electromyographic sensors were placed on flexor digitorum superficialis (FDS) and extensor digitorum communis muscles. Hyperreflexia was measured as the FDS muscle activation during reflex when the MCP joint was moved from flexion to extension at 300°/sec. Proprioception was quantified as the angle of detection in absence of visual or auditory cues (subjects were blindfolded and given noise-cancelling headphones). Strength was measured as the maximum isometric force at the MCP joint. 2-sample t-test (p<0.05) were performed to assess significant differences in reflexes, proprioception and strength among patients and controls (SPSS software version 24). RESULTS: Patients reported higher Nurick (1.90±1.0 vs 0±0, p<0.001) and lower mJOA scores (14.3±1.9 vs 18.0±0, p<0.001) as compared to controls. Similarly, patients with CSM had increased reflexes (peak FDS EMG) (0.073±0.096 vs. 0.014±0.010, p = 0.019). Patient proprioception was significantly worse; mean angle of detection was greater than twice as high in patients (9.6± 9.43°) compared to controls (4.0± 2.3°), p = 0.022. MRI based compression ratio (CR) was a significant predictor of hyperreflexia, CR<0.44 resulted in steep increase in reflex activity. Fifteen of the 20 patients who completed follow up testing at 6 months after surgery show substantial clinical improvement in reflexes and proprioceptive angle, while repeated testing in controls were unchanged. CONCLUSION: In conclusion, hyperreflexia and decline in proprioception are the main drivers of hand disability in patients with CSM. Of multiple scales, only a select few MRI scales (such as compression ratio) were predictive of increased reflexes. The study describes a pre-clinical testing apparatus to quantitatively and objectively assess primary presenting symptoms in CSM. This pilot apparatus has the potential to evaluate treatment efficacy through repeated testing. Objective testing of hand dysfunction can help inform the design of clinically feasible devices, guide MRI biomarker analysis, and improve our understanding of the progression of neurological injury in this patient population.

Cervical osteophytosis and spine posture: contribution to swallow disorders and symptoms.

PURPOSE OF REVIEW: The article reviews the effects of cervical osteophytosis and spine posture on swallowing, and how they can cause dysphagia. RECENT FINDINGS: Cerivical osteophytosis which is a bony overgrowth of the cervical spines, it affects the swallowing through different mechanisms, including direct mechanical compression of the pharynx and esophagus, disturbances of normal epiglottic tilt over the inlet of the larynx by the osteophytes at C3-C4 level, inflammatory reactions in the tissues around the esophagus and cricopharyngeal spasm. Also, cervical spine posture in normal individuals could affect the swallowing mechanism by disturbance of the sphincteric action of the larynx and upper esophageal sphincter. SUMMARY: Cervical osteophytosis and abnormal cervical curvature may be overlooked by the Otolaryngologists as causes of swallowing disorders. The diagnosis is usually confirmed by radiologic study for the cervical spine. Cervical abnormality should be kept in mind while we are investigating patients with swallowing problem, and postural modification may help in treatment of such cases.

Degenerative Pathways of Lumbar Motion Segments--A Comparison in Two Samples of Patients with Persistent Low Back Pain.

BACKGROUND: Magnetic resonance imaging (MRI) is used to identify spinal pathoanatomy in people with persistent low back pain. However, the clinical relevance of spinal degenerative MRI findings remains uncertain. Although multiple MRI findings are almost always present at the same time, research into the association with clinical outcomes (such as pain) has predominantly focused on individual MRI findings. This study aimed to: (i) investigate how multiple MRI lumbar spine findings cluster together within two different samples of patients with low back pain, (ii) classify these clusters into hypothetical pathways of degeneration based on scientific knowledge of disco-vertebral degeneration, and (iii) compare these clusters and degenerative pathways between samples. METHODS: We performed a secondary cross-sectional analysis on two dissimilar MRI samples collected in a hospital department: (1) data from the spinal MRI reports of 4,162 low back pain patients and (2) data from an MRI research protocol of 631 low back pain patients. Latent Class Analysis was used in both samples to cluster MRI findings from lumbar motion segments. Using content analysis, each cluster was then categorised into hypothetical pathways of degeneration. RESULTS: Six clusters of MRI findings were identified in each of the two samples. The content of the clusters in the two samples displayed some differences but had the same overall pattern of MRI findings. Although the hypothetical degenerative pathways identified in the two samples were not identical, the overall pattern of increasing degeneration within the pathways was the same. CONCLUSIONS: It was expected that different clusters could emerge from different samples, however, when organised into hypothetical pathways of degeneration, the overall pattern of increasing degeneration was similar and biologically plausible. This evidence of reproducibility suggests that Latent Class Analysis may provide a new approach to investigating the relationship between MRI findings and clinically important characteristics such as pain and activity limitation.

[Effects of spinal cord decompression in patients with cervical spondylotic myelopathy oncortical brain activations]. / Efekt dekomprese krcní míchy pri spondylogenní myelopatii na korové funkce mozku.

INTRODUCTION: The aim of this project was to compare and evaluate cortical sensorimotor adaptations as measured by brain fMRI (functional magnetic resonance imaging) in patients before and after surgery for cervical spondylotic myelopathy (CSM), i.e., after spinal cord decompression. MATERIAL AND METHODS: Study inclusion required evidence of CSM on MRI of the cervical spine, anterior compression of the spinal cord by osteophytes, or disc herniation. We measured the antero-posterior diameter of the spinal canal stenosis before and 3 months after surgery. Surgery was performed at one or two levels from the anterior approach with implantation of radiolucent spacers, without plate fixation. Each participant underwent two fMRI brain examinations, the first one preoperatively and the second one 6 months following surgery. Subjects performed acoustically paced repetitive wrist flexion and extension of each upper extremity according to block design. MRI data were acquired using 1.5 Tesla scanners. Statistical analysis was carried out using the general linear model implemented in FEAT 6.00 (FMRI Expert Analysis Tool), part of the FSL 5.0 package (FMRIB Software Library). The group differences were evaluated using paired t-test and the resulting statistical maps evaluated as Z-score (standardised value of the t-test) were thresholded at a corrected significance level of p <0.05. The study group consisted of 7 patients including 5 female and 2 male patients, with the average age of 55.7 years. Patients with cervical spondylogenous radiculopathy were evaluated as a control group. RESULTS: The analysis of mean group effects in brain fMRI during flexion and extension of both wrists revealed significant activation in dorsal primary motor cortex contralaterally to the active extremity and in adjacent secondary motor and sensory areas, bilaterally in supplementary motor areas, the anterior cingulum, primary auditory cortex, in the region of the basal ganglia, thalamus and cerebellum. After surgery, the cortical activations and maximum Z-scores decreased in most areas. Analysis of differences between sessions before and after surgery showed a statistically significant activation decrease during movement of both extremities in the right parietal operculum and the posterior temporal lobe. During left wrist movement, there was additional activation decrease in the right superior parietal lobe, the supramarginal gyrus, insular cortex, and the central operculum. In contrast, an activation decrease was detected in the left middle temporal gyrus during right wrist movement. CONCLUSION: An average difference of anteroposterior cervical spinal canal distance before and after surgery of CSM was 2.67 millimetres, representing a 40% increase; the cross-sectional area of the spinal canal increased by 37% and that of the spinal cord by 36%. Functional MRI of the brain revealed significant activation especially in primary and secondary motor cortex and sensory areas in patients with CSM. After surgical decompression of the spinal cord, cortical activations and maximum Z-score decreased in the majority of areas. We proved decreased cortical activation on functional MRI of the brain after surgery in patients with CSM (evaluated according to MRI of cervical spine), even at an initial stage of the disease.

Dysphagia associated with cervical spine and postural disorders.

Difficulties with swallowing may be both persistent and life threatening for the majority of those who experience it irrespective of age, gender, and race. The purpose of this review is to define oropharyngeal dysphagia and describe its relationship to cervical spine disorders and postural disturbances due to either congenital or acquired disorders. The etiology and diagnosis of dysphagia are analyzed, focusing on cervical spine pathology associated with dysphagia as severe cervical spine disorders and postural disturbances largely have been held accountable for deglutition disorders. Scoliosis, kyphosis­lordosis, and osteophytes are the primary focus of this review in an attempt to elucidate the link between cervical spine disorders and dysphagia. It is important for physicians to be knowledgeable about what triggers oropharyngeal dysphagia in cases of cervical spine and postural disorders. Moreover, the optimum treatment for dysphagia, including the use of therapeutic maneuvers during deglutition, neck exercises, and surgical treatment, is discussed.

[Mathematical simulation of biomechanical background of osteophyte formation in cervical vertebra]. / Matematický model biomechanického pozadí osteodegenerativního procesu krcního obratle.

PURPOSE OF THE STUDY: The aim of this study was to simulate different types of cervical vertebra loading and to find out whether mechanical stress would concentrate in regions known in clinical practice as predilection sites for osteophyte formation. The objective was to develop a theoretical model that would elucidate clinical observations concerning the predilection site of bone remodelling in view of the physiological changes inside the cervical vertebral body. MATERIAL AND METHODS: A real 3D-geometry of the fourth cervical vertebra had been made by the commercially available system ATOS II. This is a high-resolution measuring system using principles of optical triangulation. This flexible optical measuring machine projects fringe patterns on the surface of a selected object and the pattern is observed with two cameras. 3D coordinates for each camera pixel were calculated with high precision and a polygon mesh of the object's surface was further generated. In the next step an ANSYS programme was used to calculate strains and stresses in each finite element of the virtual vertebra. The applied forces used in the experiment corresponded in both magnitude and direction to physiological stress. Mechanical loading in neutral position was characterized by a distribution of 80% mechanical stress to the vertebral body and 10% to each of the zygoapophyseal joints. Hyperlordotic loading was simulated by 60% force transfer to the vertebral body end-plate and 20% to each of the small joint while kyphotic loading involved a 90% load on the vertebral body endplate and 5% on each facet. RESULTS: Mechanical stress distribution calculated in a neutral position of the model correlated well with bone mineral distribution of a healthy vertebra, and verified the model itself. The virtual mechanical loading of a vertebra in kyphotic position concentrated deformation stress into the uncinate processes and the dorsal apophyseal rim of the vertebral body. The simulation of mechanical loading in hyperlordosis, on the other hand, shifted the region of maximum deformation into the articulation process of the Z-joint. All locations are known as areas of osteophyte formation in degenerated cervical vertebrae. DISCUSSION AND CONCLUSIONS: The theoretical model developed during this study corresponded well with human spine behaviour in terms of predilection sites for osteodegenerative changes, as observed in clinical practice. A mathematical simulation of mechanical stress distribution in pre-operative planning may lead to the optimisation of post-operative anatomical relationship between adjacent vertebrae. Such improvement in our surgical practice may further reduce the incidence of degenerative changes in adjacent motion segments of the cervical spine and possibly also lead to better subjective and clinical results after cervical spine reconstruction.

The mechanical response of the lumbar spine to different combinations of disc degenerative changes investigated using randomized poroelastic finite element models.

Degeneration of the intervertebral disc is related to progressive changes in the disc tissue composition and morphology, such as water loss, disc height loss, endplate calcification, osteophytosis. These changes may be present separately or, more frequently, in various combinations. This work is aimed to the biomechanical investigation of a wide range of clinical scenarios of disc degeneration, in which the most common degenerative changes are present in various combinations. A poroelastic non-linear finite element model of the healthy L4-L5 human spine segment was employed and randomly scaled to represent ten spine segments from different individuals. Six different degenerative characteristics (water loss in the nucleus pulposus and annulus fibrosus; calcification and thickness reduction of endplate cartilage; disc height loss; osteophyte formation; diffuse sclerosis) were modeled in 30 randomly generated models, 10 for each overall degree of degeneration (mild, moderate, severe). For each model, a daily loading cycle including 8 h of rest, 16 h in the standing position with superimposed two flexion-extension motion cycles was simulated. A tendency to an increase of stiffness with progressing overall degeneration was observed, in compression, flexion and extension. Hence, instability for mild degeneration was not predicted. Facet forces and fluid loss decreased with disc degeneration. Nucleus, annulus and endplate degeneration, disc height loss, osteophytosis and diffuse sclerosis all induced a statistically significant decrease in the total daily disc height variation, facet force and flexibility in flexion-extension. Therefore, grading systems for disc degeneration should include all the degenerative changes considered in this work, since all of them had a significant influence on the spinal biomechanics.

Mechanical function of vertebral body osteophytes, as revealed by experiments on cadaveric spines.

STUDY DESIGN: Mechanical testing of cadaveric spines. OBJECTIVE: To determine whether vertebral body osteophytes act primarily to reduce compressive stress on the intervertebral discs, or to stabilize the spine in bending. SUMMARY OF BACKGROUND DATA: The mechanical significance of vertebral osteophytes is unclear. METHODS: Thoracolumbar spines were obtained from cadavers, aged 51 to 92 years, with vertebral body osteophytes, mostly anterolateral. Twenty motion segments, from T5-T6 to L3-L4, were loaded in compression to 1.5 kN, and then in flexion, extension, and lateral bending to 10 to 25 Nm (depending on specimen size) with a compressive preload. Vertebral movements were tracked using an optical 2-dimensional MacReflex system. Tests were performed in random order, and were repeated after excision of all osteophytes. Osteophyte function was inferred from (a) changes in the force or moment resisted and (b) changes in tangent stiffness, measured at maximum displacement or rotation angle. Volumetric bone mineral density (BMD) was measured using dual photon x-ray absorptiometry and water immersion. Results were analyzed using repeated measures analysis of variance. RESULTS: Resistance to compression was reduced by an average of 17% after osteophyte removal (P < 0.05), and resistance to bending moment in flexion, extension, and left and right lateral bending was reduced by 49%, 36%, 36%, and 35%, respectively (all P < 0.01). Changes in tangent stiffness were similar. Osteophyte removal increased the neutral zone in bending (P < 0.05) and, on average, reduced motion segment BMD by 7% to 9%. Results were insensitive to applied loads and moments, but several changes were proportional to osteophyte size. CONCLUSION: Vertebral body osteophytes resist bending movements more than compression. Because they reverse the instability in bending that can stimulate their formation, these osteophytes seem to be adaptive rather than degenerative. Results suggest that osteophytes could cause clinical BMD measurements to underestimate vertebral compressive strength.

[The prevalence of spinal osteoporosis in relation to the clinical forms and advance of cervical spondylosis in male patients]. / Czestosc wystepowania osteoporozy kregoslupa w zaleznosci od rodzaju i stopnia nasilenia choroby zwyrodnieniowej kregoslupa szyjnego u mezczyzn.

The research was performed on 36 male patients between 65 and 83 years who were either hospitalised or treated in the out-patients clinic due to cervical spondylosis. The aim of the research was to evaluate the frequency of spinal osteoporosis relating to the type and severity of degenerative lesions in cervical spine. The study showed significant relation between the degree of advance of cervical spondylosis and the prevalence of osteoporosis in the study group. The authors have emphasized the need of precise evaluation and differentiation of presented forms of degenerative spine disease.

Effects of robot-driven gait orthosis treadmill training on the autonomic response in rehabilitation-responsive stroke and cervical spondylotic myelopathy patients.

Body weight supported treadmill training (BWSTT) assisted with a robotic-driven gait orthosis is utilized in rehabilitation of individuals with lost motor skills. A typical rehabilitation session included: sitting, standing, suspension, robotic-assisted walking at 1.5 and 2.5km/h, respectively with 50% body weight support and recovery. While the effects of robotic-assisted BWSTT on motor performances were deeply studied, the influences on the cardiovascular control are still unknown. The aim of the study was to evaluate in stroke (ST) and cervical spondylotic myelopathy (CSM) patients: (1) the autonomic response during a traditional robotic-assisted BWSTT session of motor rehabilitation; (2) the effects of 30 daily sessions of BWSTT on cardiovascular regulation. The autonomic response was assessed through symbolic analysis of short-term heart rate variability in 11 pathologic subjects (5 ST and 6 CSM patients) whose motor skills were improved as a result of the rehabilitation therapy. Results showed variable individual responses to the rehabilitation session in ST patients at the beginning of the therapy. At the end of the rehabilitation process, the responses of ST patients were less variable and more similar to those previously observed in healthy subjects. CSM patients exhibited an exaggerated vagal response to the fastest walking phase during the first rehabilitative session. This abnormal response was limited after the last rehabilitative session. We conclude that robotic-assisted BWSTT is helpful in restoring cardiovascular control in rehabilitation-responsive ST patients and limiting vagal responses in rehabilitation-responsive CSM patients.

[A clinical, electromyographic, and magnetic resonance imaging study of cervical spondylotic myelopathy: analysis of 96 cases].

OBJECTIVE: To investigate the clinical, electromyographic, and magnetic resonance imaging (MRI) manifestations of the patients with cervical spondylotic myelopathy (CSM) and the correlation among them. METHOD: 96 CSM patients, 56 males and 40 females, aged 53 (2/32-72), underwent electromyography (EMG) of the deltoid muscle (C5), biceps muscle of arm (C6), common extensor muscle of fingers (C7), and short abductor muscle of thumb and abductor muscle of little finger (C8-T), and MRI of the cervical vertebrae before surgical treatment. The clinical symptoms were graded according to the Japanese Orthopaedic Association (JOA) scoring system. The correlation among the JOA score, MIR classification, and EMG manifestation was analyzed. RESULTS: EMG showed that 61 of the 96 patients (64%) with root injury at C5, 6, 7, and 8. Those positive in EMG showed higher severity in MRI (Z=2.863, P=0.004). The JOA score was not correlated with the degree of spinal cord compression demonstrated by MRI and the EMG results. CONCLUSION: The root injury rate is high in the CSM patients. The patients positive in EMG have severe MRI results. No clear correlation is between the severity of clinical symptom and MRI of cervical vertebrae and root injury demonstrated by EMG. Hence, treatment should be considered by integration of EMG, MRI and JOA scores.

Direction of the formation of anterior lumbar vertebral osteophytes.

BACKGROUND: X-ray images of lumbar degenerative diseases often show not only claw osteophytes, but also pairs of osteophytes that form in a direction away from the adjacent disc. We have investigated the direction of the formation of anterior lumbar vertebral osteophytes across the lumbar vertebrae using a sufficient number of lumbar radiographs, because osteophytes images can provide essential information that will contribute to the understanding of the pathology and progress of lumbar spine degeneration. METHODS: The direction of the formation of 14,250 pairs of anterior lumbar vertebral osteophytes across the adjacent intervertebral discs in 2,850 patients who were all over 60 years old was investigated. Anterior lumbar vertebral osteophytes were distributed into six groups based on the direction of extension of each pair of osteophytes across the intervertebral disc space. RESULTS: In L1-L2 and L2-L3, the number of patients classified into groups B (the pair of osteophytes extended in the direction of the adjacent disc) and C (almost complete bone bridge formation by a pair of osteophytes across the intervertebral disc space) was larger than that classified into group D (the pair of osteophytes extended in a direction away from the adjacent disc). In L3-L4, L4-L5 and L5-S1, the number of patients in group D was greater than that of patients belonging to groups B and C. CONCLUSION: Our study showed that pairs of osteophytes frequently formed in the direction of the adjacent disc in the upper lumbar vertebrae (L1-L2 and L2-L3) and in the direction away from the adjacent disc in middle or lower lumbar vertebrae (L3-L4, L4-L5, and L5-S1).

Qualitative and quantitative assessment of degeneration of cervical intervertebral discs and facet joints.

Degeneration of intervertebral discs and facet joints is one of the most frequently encountered spinal disorders. In order to describe and quantify degeneration and evaluate a possible relationship between degeneration and biomechanical parameters, e.g., the intervertebral range of motion and intradiscal pressure, a scoring system for degeneration is mandatory. However, few scoring systems for the assessment of degeneration of the cervical spine exist. Therefore, two separate objective scoring systems to qualitatively and quantitatively assess the degree of cervical intervertebral disc and facet joint degeneration were developed and validated. The scoring system for cervical disc degeneration consists of three variables which are individually scored on neutral lateral radiographs: "height loss" (0-4 points), "anterior osteophytes" (0-3 points) and "endplate sclerosis" (0-2 points). The scoring system for facet joint degeneration consists of four variables which are individually scored on neutral computed tomography scans: "hypertrophy" (0-2 points), "osteophytes" (0-1 point), "irregularity" on the articular surface (0-1 point) and "joint space narrowing" (0-1 point). Each variable contributes with varying importance to the overall degeneration score (max 9 points for the scoring system of cervical disc degeneration and max 5 points for facet joint degeneration). Degeneration of 20 discs and facet joints of 20 patients was blindly assessed by four raters: two neurosurgeons (one senior and one junior) and two radiologists (one senior and one junior), firstly based on first subjective impression and secondly using the scoring systems. Measurement errors and inter- and intra-rater agreement were determined. The measurement error of the scoring system for cervical disc degeneration was 11.1 versus 17.9% of the subjective impression results. This scoring system showed excellent intra-rater agreement (ICC = 0.86, 0.75-0.93) and excellent inter-rater agreement (ICC = 0.78, 0.64-0.88). Surgeons as well as radiologists and seniors as well as juniors obtained excellent inter- and intra-rater agreement. The measurement error of the scoring system for cervical facet joint degeneration was 20.1 versus 24.2% of the subjective impression results. This scoring system showed good intra-rater agreement (ICC = 0.71, 0.42-0.89) and fair inter-rater agreement (ICC = 0.49, 0.26-0.74). Both scoring systems fulfilled the criteria for recommendation proposed by Kettler and Wilke. Our scoring systems can be reliable and objective tools for assessing cervical disc and facet joint degeneration. Moreover, the scoring system of cervical disc degeneration was shown to be experience- and discipline-independent.

Effect of cervical spondylosis on vertebral arterial flow and its association with vertigo.

The aim in this study was to evaluate the effect of cervical spondylosis on vertebral arterial flow. The flow changes on Doppler measurements in patients with vertigo were also assessed. Ninety-one patients with different grades of degeneration on disks and apophysis were evaluated. The severity of degeneration was determined by two observers, and the effect of cervical degeneration on vertebral arterial flow was assessed. The relation between vertigo and changes in Doppler measurements of vertebral artery in neck and cranium was analyzed. As total degeneration increases, the flow volume decreases in the right vertebral artery but increases in the left. No other correlation between degeneration scores, cervical curve measurements, and Doppler measurements was noted. According to the total degeneration scores, no differences were noted between the patients with and without vertigo. In patients with vertigo, the resistive index was higher in the neck before the vertebral foramina. In correlations of the ratios of the intra/extracranial vertebral artery with Doppler measurements, the only change was observed in the left flow volume. The severity of degeneration in disks and apophysis does not cause a considerable change in vertebral arterial flow, and also no significant finding on Doppler measurements were noted in patients with vertigo.

[The comparative study of effect of a modified open door laminoplasty using anchor method on axial symptoms and cervical curvature].

OBJECTIVE: To evaluate the effect of a modified open door laminoplasty using anchor method on reducing the occurrence of axial symptoms and loss of cervical curvature. METHODS: From October 2004 to May 2007,56 patients with cervical spondylotic myelopathy underwent this procedure and been followed up (group A). Another 50 patients who underwent conventional unilaterally open-door laminoplasty served as control (group B). The operation time, blood loss, JOA scores and the incidence of newly developed or deteriorated axial symptoms were recorded. Preoperative and postoperative curvature angle which was presented on the tangent of posterior vertebral body margins of C2 and C7 in the cervical spine were measured on cervical radiographs. RESULTS: The operative time was (116 +/- 27.9) min in group A and (120 +/- 18.9) min in group B,showing no statistically significant difference (P > 0.05). The operative blood loss was (148 +/- 68.3) ml in group A and (152 +/- 63.4) ml in group B (P > 0.05). According to JOA scores, the average recovery rates were (61.1 +/- 24.5)% in group A and(53.3 +/- 23.3)% in group B (P < 0.05). Postoperative development or deterioration of axial symptoms occurred in 41.1% of patients in group A and 76.0% of patients in group B,showing statistically significant difference (P < 0.05). There was no significant difference between preoperative (6.3 degrees +/- 5.1 degrees) and postoperative (6.6 degrees +/-4.5 degrees) cervical curvature angle in group A,whereas the mean value of postoperative angle(4.8 degrees +/- 3.5 degrees) was significantly smaller than that of preoperative one(5.9 degrees +/- 5.1 degrees) in group B (P < 0.05). CONCLUSION: The modified open door laminoplasty using anchor method was effective on reducing the occurrence of axial symptoms and loss of cervical curvature and to the benefit of early functional training.

[Lumbar spinal stenosis--claudicatio spinalis. Pathophysiology, clinical aspects and treatment]. / Lumbale Spinalkanalstenose - Claudicatio spinalis. Pathophysiologie, Klinische Aspekte und Therapie.

The lumbar spinal stenosis (LSS) is defined as a narrowing of the spinal canal together with neuronal and vascular structures via circumjacent bone and soft tissue. In patients aged over 65 years, the LSS is among the most frequent causes of lumbago, either with or without sciatica. The prevalence will continue to augment because of the increased life expectancy. The leading symptom is neurogenic claudicatio with lumbogluteal or sciatic pain, which occurs while walking and leads to a limitation of the walking distance. Its typical constellation of symptoms including subjective leg weakness is leading to the tentative diagnosis. Nowadays, the imaging technique of choice for the diagnosis is magnetic resonance imaging. A conservative treatment is initially sufficient in most cases. The indication for surgery is given, if the pain and limitation of walking distance are not tolerable any more. Additional fusion should be taken into account, when degenerative spondylolisthesis or other pathomorphological alterations result in an instability. Conservative and surgical therapeutic goals imply pain relief, amelioration of the physical functionality, mobility and general quality of life.

Value of somatosensory evoked potentials in diagnosis, surgical monitoring and prognosis of cervical spondylotic myelopathy.

BACKGROUND: The value of somatosensory evoked potentials (SEPs) in the diagnosis and prognosis of cervical spondylotic myelopathy, as well as the usefulness of monitoring intraoperative potentials in terms of safety and predictive factors were investigated. METHODS: Each of the 76 myelopathic patients underwent surgical intervention. According to the wave configurations of the SEPs, the cases were categorised into four groups: Type I, II, III and IV. The clinical myelopathy disability was classified and the severity of neurological deficits was scored. Clinical function after surgery was evaluated. Preoperative potentials and intraoperative monitoring were categorized. The correlations between .evoked potentials detection, monitoring, myelopathy disability and surgical outcome in the different groups were discussed. RESULTS: According to the configurations of the SEPs, there were 27 patients (36%) of Type I, 30 patients (39%) of Type II, 8 patients (11%) of Type III, and 11 patients (14%) of Type IV. The categorised evoked potentials were shown to be significantly associated with the clinical representation of myelopathy (P<0.01) and the recovery rate from identifiable SEPs waves (groups A, B and C) was significantly higher than unidentifiable waves (group D, P<0.01). A deterioration of SEPs was detected in 23 cases (30%), whereas there was no change in 40 cases (53%) and improvements in 13 cases (17%). A significant difference in recovery rates could be observed in various monitoring groups within the short-term follow-up period, while there were no obvious differences in the long-term follow-up groups. CONCLUSIONS: SEP technique is a valuable and practical tool for the diagnosis, monitoring and prognosis of myelopathy. Classified evoked potentials are well correlated with cervical spondylotic myelopathy disability, and unidentifiable SEPs waves in patients are indicative of a relatively poor outcome. In addition, intraoperative monitoring of SEPs plays an important role in protecting neural structures during cervical spine surgery.

Stance ataxia and delayed leg muscle responses to postural perturbations in cervical spondylotic myelopathy.

OBJECTIVE: We studied balance control in patients with cervical spondylosis, on the hypothesis that ataxia and changes in postural responses occur concurrently as a consequence of structural problems in the cervical cord. SUBJECTS AND PATIENTS: Seventeen patients and 17 healthy subjects were recruited. Based on magnetic resonance imaging, the patients were divided into 2 groups, with (n=9) and without (n=8) signs of myelopathy. METHODS: Body sway was recorded under quiet stance on a force platform. Postural perturbations evoked early and late responses in soleus and tibialis anterior. RESULTS: Most patients showed increased body sway during stance, which was larger in cervical spondylosis with myelopathy than cervical spondylosis. Early postural responses in the soleus were not affected. Late responses in soleus and tibialis anterior were delayed in cervical spondylosis with myelopathy. Across all patients, latency of tibialis anterior late response was correlated with lower limb sensory impairment and amplitude of body sway. CONCLUSION: Abnormal transmission through the cervical cord of proprioceptive input to supraspinal centres and of descending commands to caudal cord levels are accountable for ataxia in cervical spondylosis with myelopathy. Stabilometry may be an economic and easy way in a clinical and rehabilitative setting to distinguish severe from mild forms of cervical spondylosis prior to physical treatment and to help the differential diagnosis from other diseases featuring similar signs.

Cervical spondylotic myelopathy: proposal of a surveillance algorithm.

The review of the publications concerning cervical spondylotic myelopathy (CSM) suggests that it has not been achieved a clear consensus about the treatment of this pathology. In this paper an algorithm of surveillance, conceived as an assistant tool to decide the best indications of treatment is presented. The algorithm permits a clear separation of the symptomatic patients on the base of the presence or the absence of neurologic damage resulting at the evoked potentials examination. The negativity of the evoked potentials, that means neurologic integrity, excludes any type of surgical treatment. In case of proved neurologic damage, the algorithm permits a further differentiation in subgroups according to the degree of clinical disability. If evoked potentials are positive, a surgical decompression should be always performed in patients affected by a severe clinical disability. The group of patients affected by a mild degree of clinical disability but with positive evoked potentials represents the most challenging for the spinal surgeons. Actually, several studies support either surgical and non surgical treatment for these patients. Although the Authors think that a surgical decompression has to be always performed in case of proved neurologic damage, only further randomized studies based on accurate algorithms could elucidate the outcome of the CSM and could permit to choose the best treatment according to the degree of the disease.