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It is important to remember that ESCC is a complication of systemic malignancy and usually denotes disseminated disease with poor survival rates. Early diagnosis is crucial. The initial symptom is almost always back pain, which is local, radicular, or both. Following neurologic examination and radiography, MRI scanning or myelography/CT is immediately indicated if radiculopathy or myelopathy is present or if the radiographs of the spine are abnormal. In cancer patients with local back pain and normal findings on neurologic examination and radiography of the spine, there is still a probability of 0.1 of significant ESCC. Therefore, urgent CT/MRI scanning is justified. At present, the best treatment for ESCC remains unknown. In the majority of patients, radiotherapy is the most readily available and appropriate option because it is equal in effect to posterior decompressive laminectomy in both radiosensitive and radioresistant tumors. In patients with posterior epidural disease without tissue diagnosis, laminectomy with or without stabilization should be performed. Posterior decompressive laminectomy alone is contraindicated in patients with vertebral collapse. In selected instances of anterior epidural compression without tissue diagnosis or after failure of radiotherapy, an anterior surgical approach or synchronous vertebral decompression with posterior stabilization may be indicated. In the future, after appropriate clinical trials, vertebral body resection may be the optimal approach in de novo selected patients with ESCC with radioresistant tumors and limited systemic spread of the disease.
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PMID:Metastatic epidural spinal cord compression. 175 28

A retrospective review of the surgical experience in treating 18 patients with osteomyelitis of the cervical spine is reported. The patients ranged in age from 20 to 60 years and all complained of neck pain upon admission. Ten patients had a prior history of intravenous drug abuse, three had previously suffered penetrating injuries of the neck, and one had an extraspinal site of osteomyelitis. Bacteria were isolated in 13 cases and tuberculosis in three. Neurological abnormalities were present in over one-half of the patients, consisting of myelopathy (nine cases) or radiculopathy (four cases). Plain cervical spine films and polytomography demonstrated vertebral and end-plate destruction, spinal instability, and increased paravertebral soft-tissue shadow in all cases. Computerized tomography and, more recently, magnetic resonance imaging have proven helpful in detecting bone involvement and the presence of epidural extension associated with cervical osteomyelitis. The risk of vertebral body collapse, kyphosis, and myelopathy in the osteomyelitic cervical spine has standardized the management of this problem in this institution to consist of skeletal traction, needle aspiration or blood culture for organism identification, anterior cervical debridement, autogenous iliac graft fusion, and intravenous administration of antibiotics. Spinal stability and neurological improvement were achieved in all 18 patients.
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PMID:Anterior cervical debridement and strut-grafting for osteomyelitis of the cervical spine. 271 15

Anterior cervical fractional interspace decompression (ACFID) is an anterior cervical partial discectomy that provides adequate neuroforaminal decompression but avoids segmental collapse and spontaneous fusion. Of 63 patients, 55 were followed from six to 49 months postoperatively (mean, 23 months). Good or excellent results were obtained in 64% of the patients and in 70% of the non-Workers' Compensation patients. Eighty-five percent of the patients and 91% of the non-Workers' Compensation patients were satisfied with the results of surgery. Eighty-seven percent of the patients returned to their original work status. An average of only 1 mm of disc space height was lost. Only two (4%) disc spaces spontaneously fused. ACFID is indicated for radiculopathy due to both soft and hard discs and can be particularly valuable in treating patients with disc herniation adjacent to a previous fusion or radiculopathy with multiple-level myelographic filling defects.
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PMID:Anterior cervical fractional interspace decompression for treatment of cervical radiculopathy. A review of the first 66 cases. 276 28

Degenerative spondylolisthesis is the result of chronic disc degeneration with secondary segmental spinal instability. Localized collapse and translational and rotational vertebral subluxation result in low back pain and radiculopathy. Twenty patients with L4-5 degenerative spondylolisthesis having back pain and radiculopathy were treated with a combination of decompressive laminectomy and distraction arthrodesis with short parallel Harrington rods. Patients were ambulated immediately after operation. Minimum follow-up was 2 years (average, 31.6 months). Satisfactory results were obtained in 17 patients (85%). No intraoperative complications occurred. The spondylolisthesis progressed significantly in one patient and the Harrington rods loosened in another. The procedure appears to assist in reducing pathologic motion contributing to low back pain and to relieve traction or compression forces on neural structures by restoring spinal canal anatomy.
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PMID:Decompression and distraction-derotation arthrodesis for degenerative spondylolisthesis. 371 26

Three cases are presented of thoracic radiculopathy related to collapsed thoracic vertebral bodies. In all cases proximal weakness of the legs was present, leading to the diagnosis of myopathy in two cases. Sensory symptoms were present in two cases. In one, anterior thigh paresthesias lead to a diagnosis of meralgia paresthetica. This diagnostic entity must be remembered if appropriate corroborative tests are to be performed. In cases of trauma this diagnosis should be considered if thoracic vertebral collapse is present. Conversely, an evaluation of proximal weakness should include a review of thoracic radiographs for vertebral collapse, especially in the presence of sensory findings in the lower abdominal or proximal thigh region.
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PMID:Thoracic radiculopathy related to collapsed thoracic vertebral bodies. 672 67

Fifty patients with 63 symptomatic vertebral metastases (18 sites: pain only, 28 sites: radiculopathy with pain, 17 sites: myelopathy) were treated by radiotherapy. Primary lesions were located in the lung (9 cases), breast (9 cases) colorectal area (9 cases), prostate (7 cases) and so on. We correlated the radiologic findings, symptoms and clinical effects with metastatic features which were classified into 4 types by MR imaging: non-deformity, expanding, vertebral collapse, and destructive mass. Each type of metastasis was accompanied with or without epidural tumor. Osteolytic metastases were apt to create features of deformity (expanding type: 18 vertebrae, vertebral collapse type: 17 vertebrae, destructive mass type: 9 vertebrae). The features of osteoblastic metastases were no deformity (18 vertebrae) and expanding type (2 vertebrae). The symptom of pain only occurred most frequently in the lumbosacral spine. The vertebral body deformity of symptomatic sites was relatively slight (non-deformity type: 6 sites, expanding type: 6 sites, vertebral collapse type: 6 sites), and epidural tumors were seen at only 2 sites. The effect of radiotherapy was excellent (complete pain relief: 64.7%, partial pain relief: 29.4%). Radiculopathy occurred most frequently in the lumbar spine. Vertebral body deformity was noted in most symptomatic sites (expanding type: 9 sites, vertebral collapse type: 10 sites, destructive mass type: 2 sites). Complete relief was obtained in 6 sites (22. 2%), partial relief in 18 (63.0%). Myelopathy occurred most often in the thoracic spine, followed by the lumbar spine. The vertebral body deformity was severe (expanding type: 3 cases, vertebral collapse type: 3 cases, destructive mass type: 6 cases). Epidural tumors were also present in all but one case. Six of 13 patients treated with radiation alone improved. These 6 patients had non-deformity or expanding types with epidural tumor. No improvement was seen in the vertebral collapse type with epidural tumor or destructive mass type.
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PMID:[Radiotherapy for vertebral metastases: analysis of symptoms and clinical effects by MR imaging]. 759 66

Eighty-eight consecutive patients underwent anterior cervical discectomy (ACD) with banked fibula fusion and internal fixation using the locking cervical plate. Pathology included cervical spondylotic radiculopathy in 48, cervical spondylotic radiculomyelopathy in 30, cervical facet dislocations with associated disc herniations in six, and autologous iliac crest graft collapse pseudoarthrosis with recurrent symptoms in four patients. Operations were single-level banked fibula fusion with plating in 37, multilevel banked fibula fusion with plating in 45, and combined single-level ACD banked fibula fusion with plating and posterior fusion in six patients. The only perioperative complication was transient hoarseness. There were no transfusions, infections, neurological injuries, or deaths. The mean time in the hospital for the nontraumatic cases was 1.8 days. The mean follow up was 22 months (range 12-30 months). There has been no motion at the fused level on flexion/extension films, no kyphosis, no screw plate backout, and no banked fibula has suffered graft collapse. Following a high-speed motor vehicle accident 6 months after a multilevel fusion, one alcoholic man suffered a fractured plate with transient worsening of neck pain, and the plate has remained in place for an additional 11 months of follow-up care. Compared to 100 consecutive autologous iliac crest fusions performed by the same surgeon, there were significantly fewer graft-related complications (p < 0.001). There was a significantly greater chance of autologous iliac crest collapsing with the passage of time as compared to banked fibula. Time until return to work was shorter by 5 weeks for the plate/banked fibula group (p < 0.05). When fusion is considered following ACD, the combination of banked fibula and locking cervical plates is significantly superior to autologous iliac crest grafts.
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PMID:Banked fibula and the locking anterior cervical plate in anterior cervical fusions following cervical discectomy. 881 89

Thirty-five patients were managed operatively after failure of an anterior cervical discectomy and arthrodesis. Failure was classified as the absence of fusion without deformity but with neck pain or radiculopathy, or both; the absence of fusion after anterior or posterior dislodgment of the graft; or kyphosis due to collapse of the graft or to an unrecognized posterior soft-tissue injury. Twenty-three patients had failure of the arthrodesis without deformity (with neck pain only, neck and arm pain, radiculopathy, or myelopathy). Four patients had dislodgment of the graft; in two of them the graft migrated anteriorly after a multilevel Robinson arthrodesis, and in two it migrated posteriorly after a Cloward arthrodesis. Eight patients had a failure because of a kyphotic deformity. Five of them had had a Cloward arthrodesis; one, a discectomy; and two, a Robinson arthrodesis. Six had received allograft bone. Operative treatment of the pseudarthrosis consisted of repeat resection of the disc space in the area of the failed arthrodesis followed by repeat anterior Robinson arthrodesis with decompression of the nerve root if the patient had radiculopathy. It consisted of anterior corpectomy or vertebral-body resection and strut-grafting with reduction of the deformity if the patient had migration of the graft and kyphosis. The reoperations were performed four months to fourteen years (average, thirty-two months) after the initial operation. The duration of follow-up after the second operation averaged forty-four months (range, twenty-four to 216 months). The result was excellent for twenty-nine patients, good for one, fair for four, and poor for one. We concluded that, in patients who have persistent symptoms after an anterior cervical arthrodesis, an excellent result can be achieved with repeat anterior decompression and autogenous bone-grafting.
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PMID:Failed anterior cervical discectomy and arthrodesis. Analysis and treatment of thirty-five patients. 911 96

The Cloward ventral interbody fusion is often employed for treatment of cervical degenerative disease. The present study was aimed at evaluating results and complications in this classical type of autologous bone graft procedure in a cohort of patients with radiculopathy (RP) or myeloradiculopathy (MRP). Indications for and limitations of the technique were investigated by retrospective data analysis in a series of 106 patients (30 females and 76 males). These underwent single or multiple level Cloward fusion in a total of 145 levels. Neuroradiological investigations included lateral and antero-posterior cervical spine X-rays, axial CT scans, and MRI. The presence of postoperative ossification and stable bony fusion in the fused segments was confirmed by X-rays and, when necessary, by CT. The median postoperative follow-up period was 6.5 years (range 4-10.5 years). Short term outcome in RP patients was good in 26 cases (92.9%) and fair in 2 cases (7.1%). A good short term outcome was seen in 55 MRP patients (70.5%), a fair outcome in 20 patients (25.6%), and a poor outcome in 3 patients (3.8%). Patients having myelopathy signs for less than 1 year had a significantly better outcome than those with clinical signs for more than 1 year (p < 0.05). MRP patients below the age of 40 years had a significantly better outcome than those above the age of 40 (p < 0.05). In the long term, radiculopathy was cured or significantly improved in 92.8% of cases, and myeloradiculopathy in 64%. One year after surgery, there were 139 stably fused segments (96%) and 6 segments showing osseous non-union (4%). Plain lateral radiographs demonstrated, besides the bony fusion in the respective segment, relatively frequent graft collapse with slight to severe correction losses and kyphotic deformity of the cervical spine. However, these findings did not necessarily correlate with the clinical outcome. Autologous bone graft harvesting caused a rather high short-term morbidity with donor site pain and/or wound haematoma in 33% of the cases. These surgery-related complications, however, were of a temporary nature, as long-term complications (cutaneous hypaesthesiae) were found in 2 patients (1.8%) only. In conclusion, Cloward anterior cervical fusion for degenerative spinal disease is a relatively simple and safe surgical procedure with favourable short and long term results. In our hands, graft donor site complications dominate the side effects of surgery, and the percentage of non-unions is rather low. Because of the relatively frequent bone graft collapse and the late loss of postural correction of the spine, we cannot recommend the Cloward type fusion for multisegmental procedures. In such cases, an instrumented plate fusion should be carried out in order to prevent graft collapse and non-union, and to allow for a shorter convalescence period.
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PMID:Outcome in Cloward anterior fusion for degenerative cervical spinal disease. 1081 59

We performed a metaanalysis of one- and two-level anterior cervical interbody fusion (ACDF) on data derived from published, peer-reviewed journal articles to determine whether there is a difference in fusion rate, graft complications, or clinical outcome in patients undergoing ACDF according to whether autograft or allograft was used. ACDF is a common procedure for cervical spondylotic radiculopathy. Most published studies comparing autograft and allograft have not demonstrated any difference between grafts. The medical literature dating from 1955 was reviewed. Of 395 titles, only four studies comparing autograft with allograft in ACDF were appropriate for this analysis. The data from these studies--310 patients and 379 intervertebral levels were pooled and statistical methods were applied. For both one- and two-level ACDF, autograft demonstrated a higher rate of radiographic union and a lower incidence of graft collapse. It was not possible to ascertain whether autograft is clinically superior to allograft. Although autograft has a higher fusion rate than allograft, clinical results do not depend solely on radiographic results. The risk of graft site morbidity and patient preference should be considered when choosing the type of graft for this operation.
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PMID:A meta-analysis of autograft versus allograft in anterior cervical fusion. 1105 33


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