Influence of Preoperative Sagittal Alignment on Functional Recovery in Operated Cases of Cervical Spondylotic Myelopathy.

Objective We examine the influence of preoperative cervical sagittal curvature (lordotic or nonlordotic) on the functional recovery of surgically managed cases of cervical spondylotic myelopathy (CSM). The impact of sagittal alignment on the functional improvement of operated CSM cases has not been thoroughly investigated. Materials and Methods We did retrospective analysis of consecutively operated cases of CSM from March 2019 to April 2021. Patients were grouped into two categories: lordotic curvature (with Cobb angle > 10 degrees) and nonlordotic curvature (including neutral [Cobb angle 0-10 degrees] and kyphotic [Cobb angle < 0 degrees]). Demographic data, and preoperative and postoperative functional outcome scores (modified Japanese Orthopaedic Association [mJOA] and Nurick grade) were analyzed for dependency on preoperative curvature, and correlations between outcomes and sagittal parameters were assessed. Results In the analysis of 124 cases, 63.1% (78 cases) were lordotic (mean Cobb angle of 23.57 ± 9.1 degrees; 11-50 degrees) and 36.9% (46 cases) were nonlordotic (mean Cobb angle of 0.89 ± 6.5 degrees; -11 to 10 degrees), 32 cases (24.6%) had neutral alignment, and 14 cases (12.3%) had kyphotic alignment. At the final follow-up, the mean change in mJOA score, Nurick grade, and functional recovery rate (mJOArr) were not significantly different between the lordotic and nonlordotic group. In the nonlordotic group, cases with anterior surgery had a significantly better mJOArr than those with posterior surgery ( p = 0.04), whereas there was similar improvement with either approach in lordotic cases. In the nonlordotic group, patients who gained lordosis (78.1%) had better recovery rates than those who had lost lordosis (21.9%). However, this difference was not statistically significant. Conclusion We report noninferiority of the functional outcome in the cases with preoperative nonlordotic alignment when compared with those with lordotic alignment. Further, nonlordotic patients who were approached anteriorly fared better than those approached posteriorly. Although increasing sagittal imbalance in nonlordotic spines portend toward higher preoperative disability, gain in lordosis in such cases may improve results. We recommend further studies with larger nonlordotic subjects to elucidate the impact of sagittal alignment on functional outcome.

Clinicoradiological Risk Factors Associated with Inability to Achieve Minimum Clinically Important Difference in Operated Cases of Cervical Spondylotic Myelopathy.

STUDY DESIGN: This is a retrospective cohort study. PURPOSE: This study aimed to identify the clinicoradiological risk factors associated with the inability to achieve minimum clinically important difference (MCID) on the modified Japanese Orthopaedic Association (mJOA) Scale in operated cases of cervical spondylotic myelopathy (CSM). OVERVIEW OF LITERATURE: Only a few studies have evaluated the outcomes of surgery performed for CSM using MCID on the mJOA scale. METHODS: We analyzed 124 operated CSM cases from March 2019 to April 2021 for preoperative clinical features, cervical sagittal radiographic parameters, and magnetic resonance imaging (MRI) signal intensities (SI). The risk factors associated with missing the MCID (poor outcome) on mJOA at the final follow-up were identified using binary logistic regression. Multivariate analysis was used to find significant risk factors, and odds ratios (OR) were computed. RESULTS: A total of 110 men (89.2%) and 14 women (10.8%) with an average age of 53.5±13.2 years were included in the analysis. During the last follow-up, 89 cases (72.1%) achieved MCID (meaningful gains following surgery) while 35 (27.9%) could not. The final model identified the following parameters as significant risk factors for poor outcome: increased duration of symptoms (OR, 6.77; p=0.001), lower preoperative mJOA scale (OR, 0.75; p=0.029), the presence of multilevel T2-weighted (T2W) MRI SI (OR, 4.79; p=0.004), and larger change in cervical sagittal vertical axis (ΔcSVA) (OR, 1.06; p=0.013). Also, an increase in cSVA postoperatively correlated with a reduced functional recovery rate (r=-0.4, p<0.001). CONCLUSIONS: Surgery for CSM leads to significant functional benefits. However, poorer outcomes are observed in cases of greater duration of symptoms, higher preoperative severity with multilevel T2W MRI SI, and a larger increase in the postoperative cSVA (sagittal imbalance).

Lumbar Canal Stenosis: A Prospective Clinicoradiologic Analysis.

BACKGROUND: Although spinal canal narrowing is thought to be the defining feature for the clinical diagnosis of lumbar canal stenosis, the degree of spinal canal stenosis necessary to elicit neurologic symptoms is not clear. Several studies have been performed to detect an association between a narrow spinal canal and clinical symptoms. Through our prospective study, we compared the radiologic criteria with the clinical criteria using the Oswestry Disability Index (ODI) and assessed how they correlate. MATERIALS AND METHODS: We used the qualitative grading (morphological classification system on magnetic resonance imaging [MRI]) system, dural sac cross-sectional area (DSCA), and sedimentation sign on MRI images and compared them with the Self-Paced Walking Ability (Self-Paced Walking Test) and ODI of the patients in the study. The systems were applied to 85 patients divided into three groups: group A: 43 patients with neurogenic claudication and able to walk < 30 minutes; group B: 11 patients with neurogenic claudication and able to walk > 30 minutes; and group C: 31 patients with simple back pain and no signs of neurologic claudication. RESULTS: The mean ODI was 21.19 in group C, 46.50 in group B, and 61.95 in group A. The difference was statistically significant. The mean DSCA was 164.42 mm2 in group C, 49.94 mm2 in group B, and 35.07 mm2 in group A. The difference was statistically significant. The sedimentation sign was negative in 96.8% patients in group C, 54.5% patients in group B, and 32.6% patients in group A. The difference was statistically significant. Group C had 9.3% patients in morphology grade A3, 51.6% in grade A2, and 38.7% patients in grade A1. Group B had 63.6% patients in grade C, 18.2% patients in grade B, 9.1% in grade A4, and 9.1% in grade A3. Group A had 18.6% patients in grade D, 39.5% in grade C, 27.9% in grade B, 11.6% in grade A4, and 2.3% in grade A3. The mean DSCA of group C was significantly different from group A and group B, but the difference of the mean DSCA between group A and group B was not statistically significant. The relationship of ODI to DSCA, ODI to sedimentation sign, and ODI to morphological grading for group C and group A was not statistically significant. The relationship of morphological grading to DSCA was statistically significant for all three groups. CONCLUSION: DSCA, morphological grading, and sedimentation sign are good to excellent radiologic indicators differentiating patients with simple back pain from those with lumbar spinal stenosis. Clinically, ODI is an excellent indicator of the severity of stenosis. But ODI statistically has no significant correlation to any of these radiologic parameters.

Odontoid fracture with missed diagnosis of Transverse Atlantal Ligament (TAL) injury resulting in late-onset instability.

BACKGROUND: Concurrent injuries to both the odontoid and transverse atlantal ligament are rare and can be easily missed. Failure to diagnose both lesions potentially leads to the late onset of sagittal plane instability and acute myelopathy. Here, we present a patient with an odontoid fracture whose transverse atlantal ligament (TAL) injury was originally missed on magnetic resonance imaging (MRI) and computed tomography (CT) scans. He later developed atlantoaxial instability requiring surgery. CASE DESCRIPTION: A 17-year-old male presented with neck pain, restricted cervical range of motion, but a normal neurological exam following a motor vehicle accident. The original X-rays showed a moderately displaced type-3 odontoid fracture. Additional MRI and CT scans excluded ligamentous injury, and he was initially treated with 13 weeks of halo vest immobilization. Radiographs 5 months later showed an enlarged atlanto-dens interval (e.g., >3 mm); the diagnosis of an odontoid fracture with an accompanying TAL injury was established, following which the patient successfully underwent a posterior C1-C2 fusion. CONCLUSION: Odontoid fractures require strict clinical and radiographic (X-ray, MRI, CT) surveillance to help rule out accompanying TAL injuries that may warrant surgical intervention.

Scalloping Sacral Arachnoid Cyst as a Cause of Perianal Pain- A Case Report.

INTRODUCTION: Scalloping sacral arachnoid cyst though a rare condition, should be suspected in cases of persistent perianal pain without any obvious urological or anorectal pathology. Such difficult cases justify ordering an M.R.I of spine as plain X-Rays and clinical examination may come out to be inconclusive. X-ray in later stages may show changes corresponding to scalloping of bone due pressure effect of cyst on surrounding tissue. Diagnosis may further be confirmed by doing contrast MRI which differentiates arachnoid cyst from other intradural and extradural pathologies. Though anatomically spinal arachnoid cysts are just an out pouching from the spinal meningeal sac or nerve root sheath they may be extradural or intradural in their location, communicating to main C.S.F column through their pedicle or an ostium leading to continuous enlargement in size. CASE REPORT: A 32 year old female was admitted under our spine unit with 1.5 year history of chronic pain, swelling and reduced sensation in perianal region. On examination she had tenderness and hypoesthesia over lower sacral region. The pain was continuous, dull aching in nature, not related to activity, localized over lower sacrum and perianal area. The neurological examination of her both lower limbs were unremarkable. Anal tone and anal reflex were normal. No sign of inflammation or tenderness was found over coccyx. Since the X-rays were inconclusive an MRI scan was done which showed a cystic lesion in the sacral area extending from S2 to S4 region with mechanical scalloping effect on the surrounding bone. The lesion had same intensity as C.S.F in both T1 &T2 weighted images. The treatment was done by way of surgical decompression with complete excision of cyst and obliteration of space by a posterior midline approach. Presently the patient is 1 year post operative and no sign of recurrence is there. CONCLUSION: Sacral arachnoid cysts should be considered as a differential diagnosis of perianal pain. Large symptomatic sacral cysts should be treated early with complete removal of the cyst including the cyst wall, to reduce the chances of recurrence. Complete decompression of the cyst cavity should be aimed at, but careful dissection of neural element is of highest importance.