The evaluation of results following posterior decompression and fusion for the management of cervical spondylotic myelopathy

Between July 2006 and May 2008, 68 patients with cervical myelopathy underwent posterior decompression with laminectomies and pedicle screw fixation of the cervical spine. All patients were selected based on the presence of multi-level degenerative disease and the correction of cervical lordosis on the pre-operative dynamic radiographs. Patient demographics, co-morbidities and post-operative complications were recorded and analysed. Functional outcome was assessed by using the Japanese Orthopaedic Association (JOA) score.

There were 37 male and 31 female patients with an average age 67.4 years. The average follow up period was 18 months. The mean pre-operative JOA score was 8.7, whereas the mean post-operative score was 12.1 on the latest follow-up visit. 9 patients had unsatisfactory clinical results and consequently underwent anterior procedures with significant improvement. Complications included 1 epidural haematoma, 2 superficial infections and 4 cases of myofascial pain. In three cases there was mild dysfunction of the C5 nerve root which resolved spontaneously with conservative measures.

In the present series of patients posterior decompression with laminectomies is an effective method for the management of cervical spondylotic myelopathy.

The circulatory effects of multilevel balloon kyphoplasty (BK) are not adequately addressed, neither the effectiveness of egg shell cementoplasty in preventing anticipated cement leakage in difficult cases. The purpose of this study was to evaluate

the effect of multilevel BK to blood pressure and arterial blood gasses;

Materials and methods: This is a prospective study of 89 patients (215 vertebral bodies-VBs) with osteoporotic compressive fractures (OCF), and 27 with osteolytic tumors (OT) (88 VBs). The mean age was 67.6 years. 27 patients with OCF were treated at one level, 26 at two, 21 at three, 7 at four, 6 at five, and 2 at six levels at the same sitting. Three patients with OT were treated at one level, 6 at two, 9 at three, 3 at four, 4 at five, and 2 at seven. Egg shell balloon cementoplasty to prevent cement leakage was performed in 10 patients with severe endplate fracture or vertebral wall lytic destruction. Arterial blood pressure and oxygen saturation were monitored during surgery. Arterial blood gases were measured before and 3 min after cement injection. Cement leakage was assessed by the postoperative x rays and computer tomography scans.

Results: A drop in blood pressure of more than 25mmHg during cement injection was observed in 6 patients, and was not associated with the number of VB treated. Blood pressure was dropped more than 40mm in 2 patients and the procedure was aborted after completing 1 level in the first and 2 levels in the second. Drop in arterial O2 saturation was noted in 4 patients. One patient treated for 5 levels developed fever and tachepnoea for 24 hours after surgery. Arterial O2 and chest x-rays were normal. Cement leakage was found in 9.7% (21/215) of VBs treated for OCF. Its incidence per location was: epidural, 0.9% (2 VBs); intraforaminal, 0.5% (1 VB); intradiscal, 3.2% (7 VBs); and through anterior or lateral walls, 5.1% (11 VBs). In the OT group cement leakage was found in 10.2% (9/88) of the treated VBs. Its location included 8 (9%) through the anterior or lateral walls and one (1.1%) intradiscal. Cement leakage had no clinical consequences. No cement leakage was observed in cases treated with egg shell balloon cementoplasty.

Conclusions: BK is a safe procedure when applied for multiple levels in the same sitting, and its rare circulatory effects are not related to the number of levels treated. The incidence of cement leakage in this study was 10%, which is far less than that reported with vertebroplasty using routine postoperative CT scan. Egg shell balloon cementoplasty can effectively minimize cement leakage in cases with fractured endplate or lytic destruction of VB walls.

Vertebral haemangiomas are usually asymptomatic and discovered fortuitously during imaging. A small proportion may develop variable degrees of pain and neurological deficit. We prospectively studied six patients who underwent eight surgical procedures on 11 vertebral bodies. There were 11 balloon kyphoplasties, six lumbar and five thoracic. The mean follow-up was 22.3 months (12 to 36). The indications for operation were pain in four patients, severe back pain with Frankel grade C paraplegia from cord compression caused by soft-tissue extension from a thoracic vertebral haemangioma in one patient, and acute bleeding causing Frankel grade B paraplegia from an asymptomatic vascular haemangioma in one patient. In four patients the exhibited aggressive vascular features, and two showed lipomatous, non-aggressive, characteristics. One patient who underwent a unilateral balloon kyphoplasty developed a recurrence of symptoms from the non-treated side of the vertebral body which was managed by a further similar procedure.

Balloon kyphoplasty was carried out successfully and safely in all patients; four became asymptomatic and two showed considerable improvement. Neurological recovery occurred in all cases but bleeding was greater than normal. To avoid recurrence, complete obliteration of the lesion with bone cement is indicated. For acute bleeding balloon kyphoplasty should be combined with emergency decompressive laminectomy. For intraspinal extension with serious neurological deficit, a combination of balloon kyphoplasty with intralesional alcohol injection is effective.

Aim: Presentation of the technique, the mistakes and the results of a new minimal invasive surgical procedure for reduction and augmentation of pathological fractures of the vertebrae in spine.

Patients and Methods: 12 patients (2 men / 10 women) with mean age 68 years (54–73) with pathological vertebral underwent kyphoplasty. The mean pain according to VAS was 7, 3 (6–10) and the mean follow up time is 8 months (5–14). 11/12 patients (20 vertebrae) had osteoporotic vertebral and 1/12 (1 vertebra) had metastatic lesion. 8/21 vertebrae were in thoracic spine and 13/21 in lumbar spine. In 20/21 the procedure was transcervical to the vertebra and in 1/21 was out of the cervix. 11/12 patients had kyphotic deformity in the plain x-ray and 18/21 vertebrae had decreased their height. To all patients was spilled PMMA.

Results: 10/12 patients referred degrease of their pain in the first 48 hours and 2/12 in the 5th postoperative day. Correction of the kyphotic deformity was observed in 11/12 and reduction of the reduction of the fracture was occurred in 16/21 vertebrae. Leakage of PMMA was occurred in 5/21 vertebrae; in 2/5 the leakage was in the canal, in 1/5 in the intervertebral space and in 2/5 out of the vertebrae. 1/12 patient 2 moths postperatively had another vertebral fracture in a lower vertebra that was deled again with kyphoplasty. None of the patients had neurological deficit postoperatively. According to Oswestry questionnaire all the patients referred return to all their before fracture daily activities.

Conclusions: Kyphoplasty in pathological vertebral fractures has as a result the immediate decrease of the pain and the return of the patient to his/her daily activities. Also there is correction of the kyphotic deformity decreases the possibility of a new vertebral fracture and the establishment of chronic back pain.