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Commentary

The Role of Vertebrectomy for Degenerative Disease of the Cervical Spine

Paul R. Cooper

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John K. Ratliff and Paul R. Cooper

Object. The technique of cervical laminoplasty was developed to decompress the spinal canal in patients with multilevel anterior compression caused by ossification of the posterior longitudinal ligament or cervical spondylosis. There is a paucity of data confirming its superiority to laminectomy with regard to neurological outcome, preserving spinal stability, preventing postlaminectomy kyphosis, and the development of the “postlaminectomy membrane.”

Methods. The authors conducted a metaanalysis of the English-language laminoplasty literature, assessing neurological outcome, change in range of motion (ROM), development of spinal deformity, and complications. Seventy-one series were reviewed, comprising more than 2000 patients.

All studies were retrospective, uncontrolled, nonrandomized case series. Forty-one series provided postoperative recovery rate data in which the Japanese Orthopaedic Association Scale was used for assessing myelopathy. The mean recovery rate was 55% (range 20–80%). The authors of 23 papers provided data on the percentage of patients improving (mean ∼80%). There was no difference in neurological outcome based on the different laminoplasty techniques or when laminoplasty was compared with laminectomy. There was postlaminoplasty worsening of cervical alignment in approximately 35% and with development of postoperative kyphosis in approximately 10% of patients who underwent long-term follow-up review. Cervical ROM decreased substantially after laminoplasty (mean decrease 50%, range 17–80%). The authors of studies with long-term follow up found that there was progressive loss of cervical ROM, and final ROM similar to that seen in patients who had undergone laminectomy and fusion. In their review of the laminectomy literature the authors could not confirm the occurrence of postlaminectomy membrane causing clinically significant deterioration of neurological function. Postoperative complications differed substantially among series. In only seven articles did the writers quantify the rates of postoperative axial neck pain, noting an incidence between 6 and 60%. In approximately 8% of patients, C-5 nerve root dysfunction developed based on the 12 articles in which this complication was reported.

Conclusions. The literature has yet to support the purported benefits of laminoplasty. Neurological outcome and change in spinal alignment are similar after laminectomy and laminoplasty. Patients treated with laminoplasty develop progressive limitation of cervical ROM similar to that seen after laminectomy and fusion.

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Seth S. Joseffer and Paul R. Cooper

✓ Spinal tuberculosis (Pott disease) is uncommon in developed countries. On imaging studies diagnosis of this lesion may not be considered or it might be mistaken for pyogenic osteomyelitis. Features most strongly indicative of a diagnosis of spinal tuberculosis are relative sparing of the disc space, large paraspinous abscesses, a thick rim of enhancement around the paraspinous and intraosseous abscesses, calcifications within the paraspinous collections, and a fragmentary pattern of osseous destruction. As the disease progresses, there is worsening of the osseous destruction, leading to collapse of the vertebral body and eventual progression to kyphotic deformity. Based on recent experience, the authors review the major imaging characteristics associated with spinal tuberculosis and describe the typical course of the disease as documented on plain radiographs, computerized tomography scans, and magnetic resonance images.

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Paul R. Cooper and Joseph Ransohoff

✓ A case of craniopharyngioma originating in the sphenoid bone is presented. The tumor probably originated in the midline from epithelial cell rests along the path of the involuted craniopharyngeal duct. There was bone invasion and destruction of the floor of the middle fossa with intradural extension of tumor into the left temporal lobe. Survival from onset of symptoms was 37 years. Irradiation probably played a significant part in this patient's long survival. Modern techniques now in use might achieve cures with surgically unresectable intrasphenoidal craniopharyngiomas.

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Paul R. Cooper and Fred Epstein

✓ The management of patients with intramedullary spinal cord tumors is controversial. In the past, these tumors have often been treated with biopsy or subtotal removal followed by irradiation — a therapy that is usually associated with early tumor recurrence and progressive neurological impairment. In an attempt to improve on the outcome of patients with intramedullary tumors, the authors performed radical resection in most of the 29 adult patients who had surgery for these tumors within the past 30 months. The mean duration of symptoms was 9½ years, and all patients presented because of progressive neurological deficit.

Patients were evaluated with metrizamide myelography-computerized tomography scanning and intraoperative ultrasound imaging to define the site of the tumor and cystic components. There were 14 ependymomas, 11 astrocytomas, two lipomas, and one case each of intramedullary fibrosis and astrogliosis. Solid tumor spanned a mean of five spinal cord segments and 16 tumors were associated with cysts. Twenty tumors were in the cervical and/or cervicothoracic regions. Total removal was achieved in 14 patients and “99% removal” in seven others. In 21 of 29 patients (72%), the neurological condition was stabilized or improved as a result of the operation. Postoperative deterioration occurred for the most part in patients who could not walk or who had minimal motor function at the time of operation, and these patients are no longer considered as operative candidates. Radical resection of intramedullary tumors can be achieved, with stabilization or improvement of neurological deficit in the majority of patients.

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Paul R. Cooper and Wendy Cohen

✓ In the past, patients with injuries of the cervical spine and spinal cord have been diagnosed by means of myelography and polytomography. In an attempt to improve the radiographic evaluation of patients with cervical spinal cord injuries the authors performed computerized tomography (CT) scanning of the cervical spine following injection of metrizamide into the spinal subarachnoid space. In 23 patients with cervical spinal cord injuries, metrizamide myelography was performed via a C1–2 puncture. Myelography was used only for localization of the lesion and to determine the site of CT scanning. After myelography, CT scanning of the cervical spine in the transaxial plane was effective in determining the exact nature of compressive lesions and distinguishing the etiology among hematoma, disc, bone fragments, osteophytes, or ossification of the posterior longitudinal ligament. In several patients, metrizamide could be seen entering the spinal cord and was indicative of anatomical spinal cord disruption. In patients with fractures, CT scanning identified the site and nature of the injury without the need for turning the patient to the lateral position. In several patients with an apparently stable cervical spine, the CT scan showed apophyseal joint widening indicative of instability. The authors conclude that CT scanning of the cervical spine after the introduction of metrizamide into the subarachnoid space provides a definitive evaluation of the cervical spinal cord, the bone structures of the cervical spine, and their relationship to each other.

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Paul R. Cooper and Anthony Frempong-Boadu

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John K. Houten, Scott P. Sanderson and Paul R. Cooper

✓ Synovial cysts emanating from the lumbar facet joints may compromise the spinal canal and produce symptoms of radiculopathy or stenosis. Good results have been reported after excision of the symptomatic lesions. There are limited data, however, on the natural history involving nonoperative management and little information to suggest that these lesions ever regress spontaneously. The authors report on three patients in whom symptomatic lumbar synovial cysts spontaneously resolved and review the relevant literature.