Pulmonary function test correlation with subclinical respiratory dysfunction in chronic cervical cord compression

Background: To assess respiratory function in cervical chronic compressive myelopathy (CCM) patients in pre-operative period, post-operative period and to compare pre-operative status with post-operative status. Aims and Objectives: 1. To assess respiratory function in cervical CCM patients in pre-operative period. 2. To assess respiratory function in cervical CCM patients in post-operative period, following relief of compression. 3. To compare, pre-operative status with post-operative status. Materials and Methods: A prospective study was done in 50 patients with cervical CCM due to either cervical disc disease or ossified posterior longitudinal ligament (OPLL) who were operated. None of the patients included in the study had any clinical signs & symptoms of respiratory dysfunction. Spirometry was performed in pre-operative and postoperative period after 3 months and results were analyzed. Forced vital capacity (FVC), forced expiratory volume in first second (FEV1), ratio of mean FEV1 to FVC (FEVI: FVC%) and peak expiratory flow rate (PEFR) were calculated. Results: Majority of the patients were in their fourth decade of life with male predominance. Thirty-six patients (72%) presented with prolapsed intervertebral disc and 14 patients (28%) had ossified posterior longitudinal ligament (OPLL). Patients were operated depending upon the pathology. The present study showed that there was significant reduction in preoperative FVC, FEV1, PEFR values as compared with predicted values and they showed significant improvement in post-operative period after surgical relief of compression. Conclusion: Significant yet occult respiratory dysfunction in form of impairment of various lung capacities exists in patients with cervical CCM. An objective evaluation of this occult respiratory dysfunction is essential to prognosticate, prevent respiratory complications and to improve post-operative respiratory rehabilitation. Institution of incentive spirometry as a routine in all cervical CCM cases will be of benefit in preventing respiratory complications.

Ossification of Posterior Longitudinal Ligament in Cervical Spine and Its Association With Ossified Lesions in the Whole Spine: A Cross-Sectional Study of 2500 CT Scans

Study Design: A retrospective study. Objective: To identify the prevalence and characteristics of ossified posterior longitudinal ligament (OPLL) in the cervical spine and its association with other spinal ligament ossifications. Method: This study is a retrospective review of whole spine CT scans of polytrauma patients from 2009 to 2018. Patients were screened for cervical OPLL (C-OPLL), thoracolumbar OPLL, thoracic ossified ligamentum flavum (OLF), cervical and thoracolumbar ossified anterior longitudinal ligament (C-OALL AND T-L OALL), ossified nuchal ligament (ONL) and, diffuse idiopathic skeletal hyperostosis (DISH) using CT scans. Their prevalence and distributions were assessed using statistical tools. Chi-square tests were used to determine statistical association between the categorical parameters. Results: Out of 2500 patients, 128 had C-OPLL with a prevalence rate of 5.12% with mean age of 55.89 year. The most commonly affected level was C5, followed by C6, and C4. The segmental OPLL was highest in number (77.7%), followed by localized type (14.8%). While the prevalence rate of thoracic OPLL was 0.56%, OLF was 9.9%. Ossifications that coexisted along with C-OPLL were thoracic OPLL (7.81%), thoracic OLF (36.71%), cervical OALL (29.68%), thoracolumbar OALL (37.5%), DISH (27.34%) and, ONL (7.03%). Conclusion: Our study indicated a prevalence rate of 5.12% for C-OPLL with a predominance of segmental OPLL (77.7%). Among these patients, approximately 36% had coexisting thoracic OLF. In patients with symptomatic OPLL induced cervical myelopathy, MRI analysis of whole spine with relevant CT correlation may help in detecting additional ossification sites of compression.

Microsurgical Anterior Controllable Antedisplacement Fusion to Treat Cervical Ossified Posterior Longitudinal Ligament: 2-Dimensional Operative Video

The anterior decompression technique, including vertebral body sliding osteotomy1 and anterior controllable antedisplacement fusion (ACAF),2 treats ossified posterior longitudinal ligament (OPLL) without actual excision of the OPLL.3 The fundamental strategy is to separate the mid-portion of the vertebral body along with the OPLL using bilateral anterior osteotomies followed by controllable antedisplacement. These techniques restore the space of the spinal canal anteriorly by anterior translation of the OPLL, avoiding excision and dural manipulation.4 We illustrate the case of a patient who had failed laminoplasty and the surgical decision making for ACAF. We discuss the other surgical options regarding patient selection, present preoperative and postoperative imaging, to demonstrate the efficacy of ACAF and show strategies of ACAF to make it a safe and effective procedure. We demonstrate our technique of ACAF using the intraoperative microscope and models in this video to illustrate the steps of ACAF. A written consent to the procedure was obtained from the patient.

Retrospective and prospective analysis of clinical, radiological and prognostic factors affecting surgical denouement in ossified posterior longitudinal ligament: an institutional experience

Background: The most common cause of radiculopathy or myelopathy is “ossification of the posterior longitudinal ligament (OPLL)”. Surgical management consists of various anterior and posterior procedures. Anterior procedures done are corpectomy and fusion. Posterior procedures include laminectomy and laminectomy with fusion that include the use of lateral mass or pedicle screws with rods. Objective was to study the clinical course and to delineate clinico-radiological prognostic factors with regard to surgical outcome.Methods: Patients operated for cervical OPLL were included. Detailed clinical history and radiological findings were retrospectively taken from the case records of the patients and prospectively recorded in the cases operated till May 2018. A minimum follow-up of 6 months was done for improvement. Preoperative clinical evaluation was done. Surgical options were individualized for each patient. Detailed clinical evaluation was done at discharge and at follow-up.Results: It has been found that those patients who were admitted with Nurick’s myelopathy grade IV and V at admission, those with higher number of levels involved like 5, 6 and 7, those with duration of symptoms of more than one year were more likely to have same or deteriorated outcome compared to their counterparts. Other parameters were not found to be significantly associated with outcome.Conclusions: Duration of symptoms >12 months, Sphincter disturbances were significant poor clinical prognostic markers. Significant poor radiological prognostic markers were segmental stenotic index <0.4, MRI T2-Weighted hyper intense signal change.

Role of Decompressive Laminectomy without Instrumentation in the Management of Nurick Grade 4 and 5 Cervical Compressive Myelopathy

ABSTRACT Introduction: Cervical laminectomy is a very well-known posterior decompressive procedure for cervical compressive myelopathy (CCM). Our objective is to evaluate the functional effect of posterior decompressive laminectomy for poor grade CCM. Methods: This study was an observational retrospective study carried out on patients with poor-grade CCM who underwent decompressive laminectomy from January 2010 to December 2015. Patients with Nurick Grades 4 and 5 (walking with support or bedbound) were included in the study. Clinical data and radiological information were collected from medical records, and objective scales were applied to compare the surgical outcome between preoperative score and postoperative score. Results: A total of 69 patients who underwent decompressive laminectomy for poor grade CCM were included. The mean age was 54.9 years, and the male-to-female ratio was 5.3:1. Ossified posterior longitudinal ligament comprised 52.6% cases. The follow-up data of at least 6 months' duration after surgery was available for 57 (82.6%) cases. On comparing with preoperative Nurick grade at follow-up, 40 of the 57 patients (70.2%) were found to have improvement following surgery by at least one grade. The remaining 17 (29.8%) had either remained the same or had deteriorated further. The mean preoperative modified Japanese Orthopedic Association score was 8.4 ± 2.8, and the mean follow-up score was 11.8±0.3 (P = 0.0001). On multivariate analysis, the number of levels of laminectomy, postoperative deterioration, and anesthesia grade were predictors of outcome. Conclusion: Decompressive laminectomy for poor grade myelopathy is effective in improving functional outcome.