Kinematic alteration in three-dimensional reaching movement in C3-4 level cervical myelopathy.

OBJECT: This study aimed to compare the reaching movement between two different spinal cord compression level groups in cervical myelopathy (CM) patients. METHODS: Nine CM patients with maximal cord compression at the C3-4 level (C3-4 group) and 15 CM patients with maximal cord compression at the C4-7 level (C4-7 group) participated in the study. We monitored three-dimensional (3D) reaching movement using an electronic-mechanical whack-a-mole-type task pre-and post-operatively. Movement time (MT) and 3D movement distance (MD) during the task were recorded. An analysis of variance for split-plot factorial design was performed to investigate the effects of compression level or surgery on MT and MD. Moreover, we investigated the relationship between these kinematic reaching parameters and conventional clinical tests. RESULTS: The 3D reaching trajectories of the C3-4 group was unstable with higher variability. The C3-4 group showed longer MT (p < 0.05) and MD (p < 0.01) compared with the C4-7 group both before and after surgery. Moreover, MT was negatively correlated with the Japanese Orthopedic Association score only in the C3-4 group (r = - 0.48). CONCLUSION: We found that spinal cord compression at the C3-4 level had a negative effect on 3D reaching movement and the kinematic alteration influenced the upper extremity performance. This new knowledge may increase our understanding of kinematic alteration in patients with CM.

Grip force control during object manipulation in cervical myelopathy.

STUDY DESIGN: Cross-sectional research. OBJECTIVES: To objectively evaluate grip force (GF) control while holding a freely movable object in individuals with cervical myelopathy (CM). SETTING: Harunaso Hospital, Takasaki, Japan. METHODS: We studied 52 hands from 26 individuals with CM. Participants performed a grip-and-lift task by pulp pinch using the thumb and index finger before surgery. We monitored individual finger GF (N) during the first 3 s while lifting and holding an object. Correlations between the GF and other clinical tests were evaluated. A multiple stepwise regression analysis was used to examine the contribution of the GF to the severity of clinical symptoms. RESULTS: Thumb GF was negatively correlated with the 10-s test (rs = -0.32), and index finger GF was positively correlated with its cutaneous pressure threshold (rs = 0.34). Multiple regression for the severity of upper extremity symptoms revealed that the model including the GF had a larger adjusted R2 and a lower AIC value than that of conventionally used clinical tests. CONCLUSIONS: These results suggested that the assessment of individual finger GF control could provide an indicator of the clinical severity of upper extremity in individuals with CM.

Changes in reaching skill in patients with cervical spondylosis after cervical decompression surgery.

[Purpose] The aim of this study was to evaluate the changes in reaching function during a reaching task in cervical spondylosis (CS) patients before and after surgery. [Participants and Methods] Nine patients participated in the study. Wrist acceleration peaks were monitored pre- and postoperatively using a tri-axial accelerometer, and the Japanese Orthopedic Association (JOA) score was recorded preoperatively. Additional upper extremity function tests were performed pre- and postoperatively. Multiple stepwise regression analysis was used to investigate the contribution of wrist acceleration peak to the severity of clinical symptoms. Moreover, we compared the acceleration peaks produced during the reaching task before and after surgery. [Results] Multiple regression analysis showed that wrist acceleration peak, grip strength and pinch strength were associated with the upper extremity function of the JOA score, explaining 61.0% of the variance. There was a significant improvement in x-axis acceleration peak after surgery. [Conclusion] Our results suggested that quantitative assessments of reaching function are useful to objectively evaluate the changes in reaching function in patients undergoing cervical decompression surgery.

Occipitosacral Fusion for Multiple Vertebral Fractures with Kyphotic Deformity in a Patient with Mutilating Rheumatoid Arthritis: A Case Report.

Osteoporotic vertebral fractures are well-known complications of rheumatoid arthritis. The management of multiple vertebral fractures with kyphotic deformity is controversial. We present a case of a patient with mutilating rheumatoid arthritis who had multiple vertebral fractures with kyphotic deformity after occipitothoracic fusion for rheumatoid cervical disorder. Occipitosacral fusion was effective to create stable spine with better sagittal alignment in this case, but careful clinical assessment for early detection and management of postoperative insufficient pelvic fracture were required.

Clinical and Anatomical Features as well as Pathological Conditions of Surgically Treated Adult Patients with Occipitalization of the Atlas.

BACKGROUND: This paper intends to clarify clinical and anatomical features as well as pathological conditions of surgically treated adult patients with occipitalization of the atlas. METHODS: The authors reviewed 12 consecutive adult patients with occipitalization of the atlas who underwent surgery for myleopathy in our hospital. Mainly using preoperative computed tomography and three-dimensional computed tomography angiography, we investigated their anomalies of the osseous structures and vertebral artery at the cervical spine including the craniovertebral junction (CVJ). We also developed a new classification system for occipitalization of the atlas. RESULTS: Atlantoaxial subluxation (AAS) was detected in 9 patients (75%). The condition of AAS was irreducible in 7 patients. Among these 7 patients, deformity at the lateral atlantoaxial joints was detected in 2 patients. C2-3 fusion was detected in 6 patients (67%) among 9 patients with AAS. Anomalies of the VA were detected in 11 patients (92%). Occipitalization of the atlas was classified into three types according to their pathological conditions. In type 1 (2 patients) the medial atlantoaxial joint is semi-dislocated and the lateral atlantoaxial joints are severely deformed. Type 2 (7 patients) exhibits AAS but the lateral atlantoaxial joints are not deformed. Type 3 (3 patients) is not associated with AAS and therefore does not exhibit osseous stenosis at the CVJ. In type 3 the myelopathy was caused by another coexisting condition. CONCLUSIONS: Occipitalization of the atlas is classified into three types. The main pathological condition in both types 1 and 2 is AAS. Reduction of AAS is essential in both; however, reduction of AAS in type 1 is more technically demanding than in type 2. The pathological conditions of type 3 are completely different from those of the others, so an accurate diagnosis must be made. The new classification system is a useful guide for surgeons when planning surgical strategies.

Distal Junctional Disease after Occipitothoracic Fusion for Rheumatoid Cervical Disorders: Correlation with Cervical Spine Sagittal Alignment.

Study Design Retrospective radiographic study. Objective We have performed occipitothoracic (OT) fusion for severe rheumatoid cervical disorders since 1991. In our previous study, we reported that the distal junctional disease occurred in patients with fusion of O-T4 or longer due to increased mechanical stress. The present study further evaluated the association between the distal junctional disease and the cervical spine sagittal alignment. Methods Among 60 consecutive OT fusion cases between 1991 and 2010, 24 patients who underwent O-T5 fusion were enrolled in this study. The patients were grouped based on whether they developed postoperative distal junctional disease (group F) or not (group N). We measured pre- and postoperative O-C2, C2-C7, and O-C7 angles and evaluated the association between these values and the occurrence of distal junctional disease. Results Seven (29%) of 24 patients developed adjacent-level vertebral fractures as distal junctional disease. In group F, the mean pre- and postoperative O-C2, C2-C7, and O-C7 angles were 12.1 and 16.8, 7.2 and 11.2, and 19.4 and 27.9 degrees, respectively. In group N, the mean pre- and postoperative O-C2, C2-C7, and O-C7 angles were 15.9 and 15.0, 4.9 and 5.8, and 21.0 and 20.9 degrees, respectively. There were no significant differences between the two groups. The difference in the O-C7 angle (postoperative angle - preoperative angle) in group F was significantly larger than that in group N (p = 0.04). Conclusion Excessive correction of the O-C7 angle (hyperlordotic alignment) is likely to cause postoperative distal junctional disease following the OT fusion.

A novel skull clamp positioning system and technique for posterior cervical surgery: clinical impact on cervical sagittal alignment.

A prospective radiographic study.The purpose of this study was to analyze whether a novel skull clamp positioning system and technique is useful for obtaining good, quantitative cervical sagittal alignment during posterior cervical surgery.Different surgical procedures depend on cervical spine positioning. However, maneuver of the device and cervical position depends on the skill of the operator.This study included 21 male and 10 female patients with cervical spondylotic myelopathy and ossification of the posterior longitudinal ligament of the cervical spine, undergoing posterior cervical surgery using the novel skull clamp positioning system. The average patient age was 68.6 years (range: 56-87 years). The novel system has a scale to adjust the neck position and to enable intended cervical sagittal alignment. First, the patient was placed on the operating table in the prone position with preplanned head-neck sagittal alignment (neutral position in general). The head was rotated sagittally, and the head was positioned in the military tuck position with the novel device that was used to widen the interlaminar space. After completing the decompression procedure, the head was rotated again back to the initial preplanned position. During this position change, the scale equipped with the device was useful in determining accurate positions. The C0-C1, C0-C2, C1-C2, C2-C7, and C0-C7 angles were measured on lateral radiographs taken pre-, intra-, and postoperatively.This novel system allowed us to obtain adequate, quantitative cervical sagittal alignment during posterior cervical surgery. There were no clinically significant differences observed between the pre- and postoperative angles for C1-C2 and C2-C7.Sagittal neck position was quantitatively changed during posterior cervical surgery using a novel skull clamp positioning system, enabling adequate final cervical sagittal alignment identical to the preplanned neck position.

The Association of Each Disability Based on the Three Sub-Categories of the Roland-Morris Disability Questionnaire during Hospitalization with Itself at 1 Year Postoperatively in Patients with Degenerative Lumbar Spinal Stenosis.

STUDY DESIGN: A prospective study in a hospital. PURPOSE: To investigate whether each disability based on the three sub-categories of the Roland-Morris disability questionnaire (RDQ) during hospitalization is associated with itself at 1 year postoperatively in patients with degenerative lumbar spinal stenosis (LSS). OVERVIEW OF LITERATURE: Although the total score of the RDQ represents whole pain-related disabilities or health-related quality of life, it is a shortcoming that multi-dimensional changes in disabilities are difficult to understand when only using the RDQ. METHODS: Fifty-seven patients with LSS (men, 28; women, 29; 63.0±12.1 years) were included. Disabilities, pain intensity and depressive feelings were assessed at preoperation, discharge and 1 year postoperatively. RESULTS: The range of "mental and physical activities (MPA)," "functional movements on/around a bed (FM)" and "walking function (WF)" scores were 0 to 13 (median, 8), 0 to 6 (median, 6) and 0 to 4 (median, 3) at preoperation; 0 to 12 (median, 0), 0 to 6 (median, 0), and 0 to 4 (median, 0) at discharge; and 0 to 8 (median, 0), 0 to 5 (median, 0), and 0 to 4 (median, 0) at 1 year postoperatively, respectively. The following significant multiple regression equations were obtained: MPA at 1 year postoperatively=0.56 (MPA at discharge)-0.10 (depression at discharge)+0.90 (adjusted r (2)=0.41), FM at 1 year postoperatively=0.35 (MPA at discharge)-0.06 (depression at discharge)+0.40 (adjusted r (2)=0.45) and WF at 1 year postoperatively=0.59 (WF at discharge)-0.08 (depression at discharge)+0.63 (adjusted r (2)=0.29). CONCLUSIONS: In our LSS population, each disability based on MPA and WF at discharge is associated with itself in the future. Therefore, disabilities excluding functional movements are longitudinally independent.

Adjacent-level failures after occipito-thoracic fusion for rheumatoid cervical disorders.

INTRODUCTION: The natural history of cervical spine lesions in rheumatoid arthritis (RA) is variable. We have actively performed occipito-thoracic fusion for severe destructive rheumatoid cervical disorders and reported its clinical results and complications. In our previous study, the most frequent complication was the adjacent-level failures caused by the fragile spine. The objective of this study was to determine risk factors for adjacent-level failures after occipito-thoracic fusion. MATERIALS AND METHODS: Subjects were 35 RA patients (31 females and 4 males) who underwent occipito-thoracic fusion using RRS Loop Spinal System(®) (Robert Reid Inc. Tokyo, Japan), and the incidence and characteristics of adjacent-level failures were investigated. Furthermore, the adjacent-level failures were divided into two types according to their levels, fracture at the lowest level of the fusion area and that at the level inferior to the fusion area, and the characteristics of each type were evaluated. RESULTS AND CONCLUSION: Nine (26%) of 35 patients suffered adjacent-level failures (10 vertebral fractures). Adjacent-level failures occurred when the distance of fixation was "O-T4" or longer. The long fusion might cause adjacent-level failures due to greater mechanical stress. Seven fractures occurred at the lowest level of the fusion area, and all of them were cured without symptoms by conservative treatment. Three fractures occurred at the level inferior to the fusion area, and one of them needed additional surgery due to sudden paraplegia resulting from collapse of the adjacent vertebra. After occipito-thoracic fusion, burst fractures at the level inferior to the fusion area might cause sudden paraplegia, and therefore a careful observation should be required for patients with these fractures.

Neurological improvement and prognosis after occipito-thoracic fusion in patients with mutilating-type rheumatoid arthritis.

INTRODUCTION: Mutilating-type rheumatoid arthritis, the most aggressive type of rheumatoid arthritis, is frequently associated with destructive cervical involvement, both at the high-cervical and subaxial levels, causing significant neurological deficit, and their natural course of the disease and the survival are discouraging. For such cases, we have been actively performing occipito-thoracic fusion since 1991. Although medical treatment for rheumatoid patients has represented a marked improvement, it could not treat all of these patients because of several reasons. Therefore, it is still important to evaluate the past treatment results. METHODS: We investigated the neurological improvement and prognosis in 51 mutilating-type rheumatoid arthritis patients who underwent occipito-thoracic fusion between 1991 and 2010. The neurological status was evaluated using modified Ranawat classification; class IIIB was subdivided into IIIBa (able to sit upright) and IIIBb (bedridden). RESULTS: The preoperative neurologic status was IIIBa in 19 patients and IIIBb in 17 patients. 15 of the 19 patients with class IIIBa improved to being able to walk (79 %), whereas only 3 of the 17 patients with class IIIBb improved to being able to walk (18 %) after surgery. Of the 51 patients, 28 died during follow-up; the mean age at death was 67.2 years. The postoperative 5- and 10-year survival rates were 60.3 and 26.4 %, respectively. CONCLUSION: The neurological improvement and prognosis after surgery was poorer in class IIIBb patients than in the other patient groups. Occipito-thoracic fusion can improve the neurological symptoms and prognosis. However, early surgical intervention is recommended, before a patient becomes bedridden (class IIIBb).