CERVICAL SPONDYLOSIS
PROGNOSTIC VALUE OF P R E O P E R A T I V E S I G N S A N D SYMPTOMS
REYNALDO A . BRANDT *
CHARLES A . FAGER **
Although the clinical picture in cervical radiculopathy and myelopathy
due to spondylosis is well known nowadays
1 2>
1 3.
1 6>
1 8.
2 2, its treatment is still
a matter of discussion. Conflicting opinions exist regarding its pathogenesis
and consequently different forms of treatment have been proposed. Bony
spurs *>
3»
31>, compression of the anterior spinal a r t e r y
1 5, vascular compres
sion in the foramina
2>
2 9, atheromasia
1 0, hypertrophic ligamenta flava
3.
1 1,
cord deformity over a spondylotic ridge with flexion of the spine
4and its
upanddown movements
2 4, have all been pointed as important factor ii.
pathogenesis, although some of them have been denied as s u c h
2 1,
3 0.
L e e s
1 4suggested that surgery does not benefit the patients more than
conservative treatment and that "a very conservative approach should be the
rule in patients with spondylotic myelopathy". N u r i c k
2 0found that results
were similar in patients with surgical and conservative treatments. Keegan
1 2stated that "operation for relief of neurological symptoms caused by cervical
spondylosis should be undertaken early before permanent nerve or cord da
mage have developed". Some authors
5»
17>
2 5presented their results and pre
ference for the anterior approach, while others prefer laminectomy
7>
8>
9»
1 1>
26, 27, 28^
wi t h or without excision of bone spurs and with or without section
of the dentate ligaments. Stoops and King
2 1,
2 8did not find prognostic value
in the age, sex, duration of symptoms per se, spinal fluid protein level,
history of trauma, congenital abnormalities, number of transverse bars re
quiring decompression and myelographic findings; profound quadripareses and
severe atrophy in the upper limbs showed poor prognosis after surgery.
Peserico et al.
2 3found that the duration of symptoms prior to surgery was
of importance, with their degree. Combalbert and P e l l e t
6described better
results in the younger patients. It is possible that different results are seen
with the several forms of treatment; however, it is also probable that preope
rative factors are important in the outcome of these patients. Thus, we
decided to study our patients with cervical spondylosis, looking for a possible
prognostic value in preoperative signs and symptoms. One hundred and
fortyone patients with cervical spondylosis, surgically treated at the Lahey
Clinic in Boston from 1967 to 1972 were studied.
R E S U L T S
Radiculopathy — P u r e r a d i c u l a r s i g n s and s y m p t o m s w e r e present in 99 p a t i e n t s ; in o t h e r 2 3 t h e s e w e r e a s s o c i a t e d to c e r v i c a l m y e l o p a t h y . C6 n e r v e root s i g n s w e r e found in 5 4 . 5 % and C7 n e r v e root in 5 1 . 4 % . U n i l a t e r a l s i g n s w e r e present in 7 7 . 4 % and b i l a t e r a l in 2 2 . 6 % . T h e f o l l o w i n g s u r g i c a l t e c h n i q u e w e r e used in t h o s e w i t h pure r a d i c u l o p a t h y : a) h e m i l a m i n e c t o m y , f o r a m e n o t o m y and e x c i s i o n of bone spur, f r e q u e n t i l y w i t h e x c i s i o n of disc f r a g m e n t s (82 p a t i e n t t s ) ; b) same, b i l a t e r a l l y (11 p a t i e n t s ) ; c) a n t e r i o r fusion in one l e v e l (4 p a t i e n t s ) ; d) anterior fusion in t w o l e v e l s (2 p a t i e n t s ) .
P a t i e n t s w i t h m y e l o r a d i c u l o p a t h y w e r e t r e a t e d by l a m i n e c t o m y and f o r a m e n o t o m y . T h e best s u r g i c a l r e s u l t s could be seen after t h e first m o n t h , m a i n l y b e t w e e n one and t h r e e m o n t h s after s u r g e r y . 2 2 . 8 % of t h o s e t r e a t e d by h e m i l a m i n e c t o m y h a d c o m p l e t e r e c o v e r y and 5 9 . 6 % m a r k e d i m p r o v e m e n t ( 8 2 . 5 % of e x c e l l e n t and good r e s u l t s ) ; 1 2 . 3 % h a d mild i m p r o v e m e n t . T w o of t h o s e t r e a t e d by anterior fusion in one l e v e l h a d m a r k e d i m p r o v e m e n t , one recovered c o m p l e t e l y and one had h i s s y m p t o m s a r r e s t e d . One of t h o s e t r e a t e d by a n t e r i o r fusion in t w o l e v e l s h a d c o m p l e t e r e c o v e r y in t h e first m o n t h after s u r g e r y and t h e o t h e r h a d his s y m p t o m s arrested in t h e first t h r e e m o n t h s of f o l l o w u p .
P o s t o p e r a t i v e r e s u l t s compared to d u r a t i o n of t h e clinical picture ( T a b l e 1) — 9 . 7 % of t h e p a t i e n t s w i t h r a d i c u l o p a t h y c a m e in t h e first m o n t h of s y m p t o m s ; 55% c a m e b e t w e e n t h e first and 1 2t h
m o n t h s after t h e o n s e t and t h e r e m a i n d i n g c a m e b e t w e e n o n e and f i v e y e a r s . Surgical r e s u l t s did not differ s i g n i f i c a n t l y in p a t i e n t s w i t h c l i n i c a l picture l a s t i n g from one m o n t h to five y e a r s u n t i l l t r e a t m e n t w a s e s t a b l i s h e d .
w a s 4 . 5 X more frequent in t h e p a t i e n t s w i t h o u t m u s c l e a t r o p h y in t h e upper limb compared to t h o s e w i t h a t r o p h y ; e x c e l l e n t and good r e s u l t s w e r e s e e n in 8 4 . 9 % of t h e former and in 6 2 . 2 % of t h e latter (p < C . 0 5 ) . Complete recovery w a s less frequent in p a t i e n t s w i t h h y p o a c t i v e or a b s e n t r e f l e x e s in t h e upper l i m b . P a t i e n t s w i t h no sensory loss h a d c o m p l e t e recovery 4 . 5 X more f r e q u e n t l y t h a n t h o s e w i t h h y p o e s t h e s i a . Complete r e c o v e r y w a s 4 X m o r e frequent in p a t i e n t s w i t h m y e l o g r a p h y deffects in one or t w o disc levels, c o m p a r e d to those w i t h m o r e l e v e l s i n v o l v e d . Surgical r e s u l t s did not differ in p a t i e n t s w i t h normal CSF protein l e v e l compared to those w i t h a b n o r m a l l e v e l s .
P o s t o p e r a t i v e r e s u l t s c o m p a r e d to a g e ( T a b l e 3) — 9 7 . 1 % of t h e p a t i e n t s older t h a n 60 y e a r s h a d m i l d or s e v e r e p a r e s e s of t h e upper limb, c o m p a r e d to 7 3 . 3 % of the p a t i e n t s u n d e r 60 y e a r s w i t h t h e s a m e defficit. I n t h e latter, e x c e l l e n t and good r e s u l t s w e r e 2 X m o r e f r e q u e n t t h a n in t h e older p a t i e n t s .
Myelopathy — Spinal cord s i g n s w e r e p r e s e n t in 42 p a t i e n t s ; 24 w e r e t r e a t e d by c e r v i c a l l a m i n e c o t o m y and s e c t i o n of t h e d e n t a t e l i g a m e n t s . Complete r e c o v e r y w a s s e e n in 3 0 . 8 % and m a r k e d i m p r o v e m e n t in 5 3 . 3 % ( 8 4 . 1 % of e x c e l l e n t and good r e s u l t s ) . F o u r t e e n p a t i e n t s w e r e t r e a t e d by e x t e n s i v e c e r v i c a l l a m i n e c t o m y w i t h o u t o p e n i n g of t h e dura; 9.1%> had c o m p l e t e r e c o v e r y and 63.6%) m a r k e d i m p r o v e m e n t ( 7 2 . 7 % of e x c e l l e n t and good r e s u l t s ) . T h e s e d a t a c a n n o t be c o m pared b e c a u s e there w e r e 20.8%> of p a t i e n t s w i t h s e v e r e p a r e s e s of t h e l o w e r limbs in t h e first group a n d 4 6 . 7 % of t h e s e in t h e second g r o u p . T h r e e p a t i e n t s w e r e t r e a t e d by anterior fusion a n d l a m i n e c t o m y ; after three m o n t h s , o n l y o n e h a d m i l d i m p r o v e m e n t of h i s s y m p t o m s .
P o s t o p e r a t i v e r e s u l t s c o m p a r e d to t h e d e g r e e of t h e c l i n i c a l p i c t u r e ( T a b l e 4) — N o p a t i e n t w i t h s e v e r e p a r e s e s of t h e l o w e r limbs h a d c o m p l e t e r e c o v e r y in t h e first y e a r after surgery; 2 9 . 4 % of t h o s e w i t h mild p a r e s e s h a d c o m p l e t e recovery in t h e s a m e period of t i m e . Marked i m p r o v e m e n t w a s seen in 6 6 . 7 % o f t h o s e w i t h mild p a r e s e s and in 4 7 . 1 % of t h o s e w i t h s e v e r e p a r e s e s of t h e l o w e r limbs
r e c o v e r y and 6 6 . 7 % m a r k e d i m p r o v e m e n t ; 25% of t h e p a t i e n t s w i t h p a r e s t h e s i a only but no o b j e c t i v e sensory loss had c o m p l e t e recovery and 50% m a r k e d impro v e m e n t in t h e first t h r e e m o n t h s ; t h e s e r e s u l t s did not c h a n g e untill 12 m o n t h s after s u r g e r y . P a t i e n t s w i t h m y e l o g r a p h i c d e f f e c t s in three l e v e l s had e x c e l l e n t and good r e s u l t s in h i g h e r proportion t h a n t h o s e w i t h t w o l e v e l s i n v o l v e d and t h e s e h a d b e t t e r r e s u l t s t h a n those w i t h only one level d e f f e c t . There w a s no difference in the s u r g i c a l r e s u l t s of p a t i e n t s w i t h normal and a b n o r m a l CSF protein level.
P o s t o p e r a t i v e r e s u l t s compared to a g e ( T a b l e 5) — 1 6 . 6 % of t h e p a t i e n t s w i t h m y e l o p a t h y w e r e under 49 years; 6 6 . 6 % w e r e b e t w e e n 50 and 69 y e a r s old. S e v e r e p a r e s e s w a s 2 . 5 X m o r e f r e q u e n t in the older t h a n 60 y e a r s and c o m p l e t e r e c o v e r y w a s 2 X less frequent in this a g e group (p < 0 . 0 5 ) .
DISCUSSION
SUMMARY
One hundred and fortyone patients with cervical spondylosis were studied,
looking for a possible prognostic value in preoperative signs and symptoms.
Duration of symptoms lasting from one month to five years untill surgical
treatment and spinal fluid protein level had no prognostic value in these
patients. In those with radiculopathy, the degree of upper limb pareses,
muscle atrophy, absent or diminished reflexes, sensory involvement, number
of myelographic deffects and age had prognostic value. In those with mye
lopathy, the degree of lower limbs pareses and spasticity, sensory involvement,
number of myelographic deffects and age had prognostic value. Surgery
is a definite method of treatment for patients with progressive signs and
symptoms due to cervical spondylosis; some of the preoperative signs and
symptoms are valuable in establishing their prognosis.
RESUMO
Espondilose cervical: valor prognóstico dos sinais e sintomas pré-operatórios
Cento e quarenta e um pacientes com espondilose cervical foram estu
dados com o objetivo de se determinar um possνvel valor prognσstico nos
sinais e sintomas prιoperatσrios; 99 apresentaram radiculopatia, 19 mielopa
tia e 23 mielorradiculopatia. Nos pacientes com radiculopatia, recuperaηγo
completa foi 2,5 vezes mais freq٧ente nos com paresia moderada dos mem
bros superiores em relaηγo aos com paresia intensa, 4,5 vezes mais freq٧ente
nos que nγo apresentaram atrofia muscular, 4,5 vezes mais freq٧ente nos que
nγo apresentaram dist٥rbios objetivos da sensibilidade, 4 vezes mais fre
q٧ente nos que apresentaram defeitos mielogrαficos em menos do que dois
nνveis discais; pacientes com mais de 60 anos apresentaram maior proporηγo
de comprometimento motor grave e tambιm tiveram piores resultados com
a cirurgia. Nos pacientes com mielopatia, nenhum com paresia intensa e
nenhum com espasticidade intensa dos membros inferiores teve recuperaηγo
completa no primeiro ano apσs a cirurgia; resultados melhores foram obser
vados nos que apresentaram paresia moderada nos membros inferiores. Me
lhores resultados foram vistos em pacientes com n٥mero maior de defeitos
mielogrαficos. Comprometimento motor grave dos membros inferiores foi
mais freq٧ente nos pacientes com mais de 60 anos e estes apresentaram
tambιm piores resultados apσs a cirurgia em relaηγo aos com menos de
60 anos. A cirurgia foi i>m marco na recuperaηγo destes pacientes. Con
cluise que a padronizaηγo da avaliaηγo destes sinais e sintomas prιoperatσ
rios permite um prognσstico em relaηγo ΰ radiculopatia e ΰ mielopatia con
seq٧entes ΰ espondilose cervical.
R E F E R E N C E S
1 9 5 2 .
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