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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_6032_Библиотеки_им_академика_М_И_Перельмана
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This 7-year multicenter randomized controlled trial compared TDA with ACDF.
Equivalency was found in neck pain, arm pain, functional status, and adverse events.
Patients who underwent TDA were less likely to undergo secondary surgery compared
with patients who underwent ACDF. Level of evidence: I.
Comparison of anterior surgical options for the treatment of multilevel cervical
spondylotic myelopathy: A systematic review. Spine (Phila Pa 1976)
2013;38(22suppl 1):S195-S209.
This systematic review of 10 studies compared diskectomy, corpectomy, and hybrid
options for the treatment of multilevel CSM. Multiple diskectomies result in superior
clinical outcomes and correction of sagittal alignment, and are preferred when possible.
cervical artificial disc versus anterior discectomy and fusion: A prospective,
randomized, controlled multicenter clinical trial with 4-year follow-up results. J
Neurosurg Spine 2015;22(1):15-25.
This 4-year follow-up of a prospective randomized study compared two-level TDA with
ACDF. Significantly greater improvements were noted in NDI, SF-12 physical
component summary, and patient satisfaction scores for the TDA group. Revision
surgery was performed less commonly after TDA. Level of evidence: I.
degenerative disc diseases: A systematic review of biomechanical and clinical evidence.
Eur Spine J 2014;23(8):1619-1632.
This systematic review of biomechanical and clinical studies investigated hybrid
surgery in the treatment of degenerative cervical pathology. Biomechanical data support
preservation of segment motion with reduced effect on adjacent levels. Clinical studies
support significant improvements in functional outcome scores.
cervical laminoplasty. Spine (Phila Pa 1976) 2016;41(20):1570-1579.
This retrospective review reported on long-term clinical outcomes in patients treated
with laminoplasty for cervical degenerative disease. JOA scores and neurologic
recovery rates improved postoperatively and were maintained at 10-year follow-up, but
subsequently deteriorated as spinal degeneration progressed. Level of evidence: IV.
minimum 2-year follow-up study compared with open-door laminoplasty. Spine (Phila
Pa 1976) 2003;28(24):2667-2672.
Alternative procedures for the treatment of cervical spondylotic myelopathy:
Arthroplasty, oblique corpectomy, skip laminectomy: evaluation of comparative
effectiveness and safety. Spine (Phila Pa 1976) 2013;38(22suppl 1):S210-S231.
In this systematic review of alternative treatment options for CSM, insufficient
evidence exists to preferentially recommend TDA over ACDF or skip laminectomy
over open-door laminoplasty. Oblique corpectomy is not recommended as a first-line
treatment, given its high morbidity.
laminoplasty compared with laminectomy and fusion in patients with cervical
myelopathy: A systematic review. Spine (Phila Pa 1976) 2013;38(22suppl 1):S183S194.
This systematic review of four retrospective cohort studies compared laminectomy and
fusion with laminoplasty in the treatment of CSM. Both procedures were equally
efficacious regarding neurologic outcomes, pain, and complication rates. Level of
evidence: III.
laminoplasty for the treatment of degenerative cervical myelopathy: Results from the
AOSpine North America and International prospective multicenter studies. Spine J
2017;17(1):102-108
This international multicenter prospective cohort study compared results of
laminoplasty with laminectomy and fusion in the treatment of CSM. Both procedures
significantly improved modified JOA, NDI, and SF-36 scores with no difference in
degree of improvement. Complication rates were equivalent. Level of evidence: II.
Anterior versus posterior approach for treatment of cervical spondylotic myelopathy: A
systematic review. Spine (Phila Pa 1976) 2013;38(22suppl 1):S173-S182.
This systematic review compared anterior and posterior surgical intervention in
multilevel CSM. Improvements in JOA scores were equivalent and postoperative C5
palsy rates were similar. Anterior surgery resulted in fewer infections and posterior
surgery resulted in a lower rate of dysphagia. Level of evidence: III.
treat cervical spondylotic myelopathy: Outcomes of the prospective multicenter
AOSpine North America CSM study in 264 patients. Spine (Phila Pa 1976)
2013;38(26):2247-2252.
This prospective observational cohort study compared anterior and posterior approaches
for CSM. Improvement in modified JOA scores was lower in the anterior group,
although baseline impairment was less. Improvements in Nurick Scale, NDI, and SF-36
scores showed no difference between groups. Level of evidence: III.
longitudinal ligament in the cervical spine. J Am Acad Orthop Surg 2014;22(7):420-
429.
This comprehensive review reported on the epidemiology, pathoanatomy, natural
history, and treatment options for ossification of the PLL.
treatment for ossification of the posterior longitudinal ligament versus other forms of
degenerative cervical myelopathy: Results from the prospective, multicenter AOSpine
CSM-international study of 479 patients. J Bone Joint Surg Am 2016;98(5):370-378.
This prospective cohort study compared treatment outcomes in CSM patients with and
without ossification of the PLL. No differences were found in improvements of
modified JOA, Nurick scale, NDI, and SF-36 scores. A higher complication rate was
reported in the group with ossification of the PLL. Level of evidence: II.
regarding the surgical approach for cervical ossification of the posterior longitudinal
ligament: The K-line. Spine (Phila Pa 1976) 2008;33(26):E990-E993.
treatment for cervical myelopathy caused by ossification of the posterior longitudinal
ligament: A prospective comparative study of anterior decompression and fusion with
floating method versus laminoplasty. Spine (Phila Pa 1976) 2012;37(5):367-376.
This prospective cohort study compared ACDF with laminoplasty when treating CSM
caused by ossification of the PLL. At 5-year follow-up, anterior surgery had superior
results when the ossification of the PLL mass occupied more than 50% of the canal or
the patient had preoperative kyphotic alignment. Level of evidence: II.
ossification of the posterior longitudinal ligament with an occupying ratio of 60% or
more. Spine (Phila Pa 1976) 2014;39(1):58-67.
This retrospective review compared ACDF with laminoplasty for CSM resulting from
ossification of the PLL. ACDF had significantly higher recovery rates when the
ossification of the PLL lesion occupied more than 60% of the spinal canal. In the
posterior group, there was a significant association between increasing cervical lordosis
and good or excellent outcomes. Level of evidence: III.
Myelopathy is associated with increased all-cause morbidity and mortality following
anterior cervical discectomy and fusion: A study of 5256 patients in American College
of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). Spine
(Phila Pa 1976) 2015;40(7):443-449.
This retrospective cohort study investigated morbidity and mortality differences in
ACDF for patients with and without CSM. For patients with myelopathy, a significant
increase was noted in all-cause morbidity and a ninefold increase was noted in the
likelihood of mortality. Level of evidence: III.
decompression in patients with cervical spondylotic myelopathy: Results of the
AOSpine North America prospective multi-center study. J Bone Joint Surg Am
2013;95(18):1651-1658.
This prospective cohort study evaluated the safety and efficacy of surgical
decompression for CSM. At 1-year follow-up, modified JOA, Nurick grade, NDI, and
SF-36 scores all improved significantly. The overall complication rate was 18.7%, with
a 2.2% rate of revision surgery. Level of evidence: II.
treated cervical spondylopathic myelopathy: A prospective validated observational
study. Spine (Phila Pa 1976) 2015;40(5):292-298.
This prospective observational study evaluated surgical complications in the treatment
of CSM. The adverse event rate was 42.3%. The number of preoperative comorbidities,
anterior approach, and number of levels fused were all significantly associated with an
increased rate of adverse events. Level of evidence: III.
cervical spine disease according to different surgical procedures: National populationbased cohort study. Spine (Phila Pa 1976) 2016;41(19):1484-1492.
This retrospective cohort study evaluated revision surgery rates following surgery for
cervical degenerative disease. The overall revision surgery rate was 3.31%; the rate was
higher for posteriorly based procedures. Male sex, diabetes, and the number of
comorbidities all significantly increased the rate. Level of evidence: III.
and surgical predictors of complications following surgery for degenerative cervical
myelopathy. J Neurosurg Spine 2016;24(1):77-99.
This systematic review investigated the predictors of surgical complications in CSM
treatment. Increased patient age, longer surgical time, and two-stage surgery were
associated with an increased complication rate. Body mass index, smoking status, and
baseline symptom severity did not increase complications. Level of evidence: III.
myelopathy at segments adjacent to the site of a previous anterior cervical arthrodesis. J
Bone Joint Surg Am 1999;81(4):519-528.
the cervical spine. J Spinal Disord Tech 2004;17(2):79-85.
occurrence of adjacent segment disease after anterior cervical discectomy and fusion: A
study of 672 consecutive patients. Spine (Phila Pa 1976) 2014;39(26):2143-2147.
This retrospective cohort study evaluated the occurrence of adjacent-segment disease in
patients undergoing ACDF. The overall revision surgery rate was 15% at 31-month
follow-up, with 7% for adjacent-segment disease. The annual incidence of adjacentsegment disease was 4%. Level of evidence: III.
discectomy and fusion: Clinical outcomes after first repeat surgery versus second repeat
surgery. Spine (Phila Pa 1976) 2014;39(2):120-126.
This retrospective observational study evaluated adjacent-segment disease following
ACDF over a 20-year period; 12.2% of patients required revision surgery for
symptomatic adjacent-segment disease after the index procedure. This rate increased to
25% after a second cervical fusion. Level of evidence: III.
disc arthroplasty versus single-level fusion: Meta-analysis of prospective studies. Spine
(Phila Pa 1976) 2013;38(26):2253-2257.
This meta-analysis of six randomized controlled trials compared rates of adjacentsegment disease in patients who underwent ACDF (6.9%) and TDA (5.1%). The
difference was not significant. Level of evidence: I.
rate in single-level anterior cervical discectomy and fusion with allograft and rigid plate
fixation? Clinical article. J Neurosurg Spine 2013;19(5):527-531.
This retrospective cohort study investigated the effect of smoking on fusion rates
following single-level ACDF. Fusion rates were equivalent for nonsmokers (91.6%)
and smokers (91.0%). Level of evidence: III.
the outcome of anterior cervical arthrodesis with interbody or strut-grafting. J Bone
Joint Surg Am 2001;83(5):668-673.
Comprehensive assessment techniques and potential importance in cervical myelopathy.
Spine (Phila Pa 1976) 2013;38(22suppl 1):S149-S160.
This comprehensive review reported on cervical alignment parameters, normative
values, and methods for quantifying cervical alignment. Cervical alignment was
discussed relative to global cervical-pelvic parameters, and weight-bearing 3-foot
lateral radiographs should be considered as part of preoperative planning.
clinical study evaluating the correlation of clinical outcomes and cervical sagittal
alignment. Neurosurgery 2011;68(5):1309-1316, discussion 1316.
This prospective randomized trial evaluated differences in sagittal alignment when
using lordotic versus parallel grafts in ACDF. Graft choice made no difference, but
maintenance or improvement in cervical sagittal alignment resulted in greater
improvements in SF-36 physical component summary and NDI scores. Level of
evidence: I.
laminectomy alone versus laminectomy and fusion for cervical ossification of the
posterior longitudinal ligament: Is there a difference in the clinical outcome and sagittal
alignment? Clin Spine Surg 2016;29(1):E9-E15.
This retrospective review reported on posterior surgery for CSM resulting from
ossification of the PLL. All groups lost cervical lordosis and C2-C7 sagittal vertical axis
was maintained only in the fusion group. Fusion was recommended for patients with a
sagittal vertical axis greater than 40 mm. Level of evidence: III.
laminoplasty: Radiographical data from more than 500 cases with cervical spondylotic
myelopathy and a review of the literature. Spine (Phila Pa 1976) 2012;37(20):E1243E1250.
This prospective radiographic study reported on cervical alignment and range of motion
following double-door laminoplasty for treatment of CSM. At 33.3-month follow-up,
patients had a mean 1.8° increase in cervical lordosis and preservation of 87.9% of
preoperative range of motion. Level of evidence: IV.
deformity after laminoplasty in cervical spondylotic myelopathy patients without
preoperative kyphotic alignment. Spine (Phila Pa 1976) 2016;41(4):299-305.
This retrospective cohort study investigated the influence of preoperative cervical
alignment on postoperative kyphosis following laminoplasty. The overall rate of
deformity was 5.2%. Age older than 75 years and a cervical sagittal vertical axis greater
than 42 mm were significant risk factors. Level of evidence: IV.
surgery for cervical myelopathy: Review of the literature. Spine (Phila Pa 1976)
2003;28(21):2447-2451.
anterior cervical decompression and fusion for cervical degenerative disease. J Spinal
Disord Tech 2014;27(8):436-441.
This retrospective cohort study evaluated radiographic parameters associated with C5
palsy after ACDF. A substantial increase in lordosis seen in the palsy group suggests
that aggressive restoration of cervical lordosis can cause traction injury and contribute
to C5 dysfunction. Level of evidence: III.
cervical open-door laminoplasty: Relationship between C5 palsy and foraminal
stenosis. J Spinal Disord Tech 2013;26(4):177-182.
This retrospective cohort study evaluated the influence of foraminal stenosis on the
development of C5 nerve palsy following laminoplasty for CSM treatment. Patients
with palsy had significantly smaller foramen than those without (1.99 versus 2.76 mm).
Level of evidence: III.
cord drift are risk factors for postoperative C5 palsy. J Spinal Disord Tech
2014;27(2):86-92.
This retrospective case-control study evaluated the effect of laminectomy width and
spinal cord drift on C5 palsy rates after laminectomy and fusion for CSM. Patients in
the palsy group had both increased spinal cord drift and increased laminectomy width
compared with control subjects. Level of evidence: III.
after cervical laminectomy and fusion: Does width of laminectomy matter? Spine J
2016;16(4):462-467.
This retrospective case-control study evaluated the influence of laminectomy width on
C5 nerve palsy. Postoperative CT scans showed no significant difference in
laminectomy width between the groups with and without palsy. Level of evidence: III.
decompression causes postoperative C5 palsy: An analysis of 32 patients with
postoperative C5 palsy after anterior cervical decompression and fusion. Spine (Phila
Pa 1976) 2013;38(25):2184-2189.
This retrospective case-control study evaluated the effect of decompression width and
asymmetry on C5 nerve palsy in ACDF for CSM. Decompression on the palsy side was
significantly larger and overall decompression width was increased in the palsy group.
Level of evidence: IV.
C4/C5 foraminotomy prevent postoperative C5 palsy after open-door laminoplasty?: A
prospective study. Spine (Phila Pa 1976) 2012;37(9):748-754.
A prospective cohort study evaluated the effect of prophylactic C4/C5 foraminotomy on
C5 nerve palsy rates in patients undergoing laminoplasty for CSM. Patients in the
foraminotomy group had a palsy rate of 1.4% compared with 6.4% in those not
undergoing foraminotomy. Level of evidence: III.
infection after posterior cervical fusion with routine local application of vancomycin
powder. Spine (Phila Pa 1976) 2013;38(12):991-994.
This retrospective cohort study evaluated the effect of vancomycin powder on infection
rates in posterior cervical laminectomy and fusion. Routine vancomycin powder
application reduced the infection rate from 10.9% to 2.5%. Level of evidence: II.
following posterior cervical spine surgery. J Bone Joint Surg Am 2013;95(6):549-554.
This retrospective review evaluated the effect of alcohol foam prep, suprafascial drains,
and vancomycin powder on infection rates in posterior cervical surgery and reported
that infection rates reduced from 1.86% to zero. Level of evidence: III.
Chapter 16
Degenerative Disease of the
Thoracic Spine
Christopher G. Furey, MD
Abstract
Clinically relevant degenerative disease of the thoracic spine is relatively
uncommon because of the inherent stability provided by the rib cage.
However, disk herniation or spinal stenosis can cause spinal cord
compression with resulting severe neurologic consequences. When
indicated, surgery can be effective in relieving pain and preserving or
restoring function. Various surgical strategies can be used in the thoracic
spine and are based on the type and location of the compressive pathology,
the clinical history of the patient, and the experience of the treating surgeon.
Keywords: disk; disk herniation; myelopathy; spine surgery;
stenosis; thoracic spine
Dr. Furey or an immediate family member serves as a board member, owner,
officer, or committee member of the American Academy of Orthopaedic Surgeons
Board of Councilors, the North American Spine Society, and the Ohio Orthopedic
Society.
Introduction
Although the thoracic spine is susceptible to the same degenerative cascade
that occurs throughout the spinal column, clinically relevant disk herniations
and spinal stenosis are much less common than in the cervical and lumbar
spines. The relative protection of the thoracic spine arises mainly from the
inherent stability afforded by the rib cage. However, compression of the
thoracic spinal cord can result in severe symptoms and progressive
neurologic dysfunction. Given the relatively infrequent occurrence of
thoracic pathology, a high index of suspicion is required for prompt,
appropriate diagnosis. When indicated, thoracic spine surgery is technically
challenging because of the vulnerability of the thoracic spinal cord and the
array of surgical approaches and techniques available (Figure 1).
Nonetheless, with the appropriate indications and technique, surgery can
result in a predictably high degree of symptomatic relief and neurologic
improvement.
Anatomy
The unique features of the thoracic spine provide greater proportionate
stability than elsewhere in the spinal column. The anterior articulation of the
ribs with the sternum provides substantial rigidity in flexion and extension.
However, the caudal third of the thoracic spine is less rigid. Ribs 8 through
10, the “false ribs,” articulate by using elongated costal cartilage attached to
the inferior sternum. The free-floating 11th and 12th ribs have no sternal
articulation. In addition, the facets become more coronally oriented in the
lower thoracic spine, similar to the lumbar facets. Together, these anatomic
differences allow proportionately greater motion in the lower thoracic spine.
Degenerative changes and clinically relevant thoracic disk herniations and
spinal stenosis are proportionately more common.
Several anatomic features make the spinal cord more susceptible to injury
in the thoracic region. The spinal cord occupies a greater proportion of the
thoracic spinal canal than within the cervical spine, which makes it more
susceptible to extrinsic compression from pathologic processes. The thoracic
canal is especially narrow cranially to T6 and gradually increases in diameter
toward the thoracolumbar junction.1 Congenital thoracic stenosis has a
prevalence of 1% and is less common than in the cervical or lumbar spine,
but similarly predisposes individuals to extrinsic compression.
The kyphotic alignment of the thoracic spine predisposes the spinal cord
to drape over ventrally located disk pathology. The blood supply of the
thoracic spinal cord is relatively tenuous compared with that of the cervical
spine, especially in the watershed region of T4 through T9, resulting in a
proportionately greater susceptibility to mechanical and vascular insult.
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