Objectives: To describe some clinical and imaging diagnosis features of patients with multilevels cervical stenosis. Subjects and methods: Prospective study, clinical and imaging diagnosis description of 31 cases that had multi-levels cervical stenosis at 108 Central Military Hospital from February, 2011 to October, 2015.
Journal of military pharmaco-medicine n08-2017 SOME CLINICAL FEATURES AND IMAGE DIAGNOSIS FEATURES IN PATIENTS WITH MULTI-LEVEL CERVICAL STENOSIS Nguyen Khac Hieu*; Pham Hoa Binh*; Vu Van Hoe** SUMMARY Objectives: To describe some clinical and imaging diagnosis features of patients with multilevels cervical stenosis Subjects and methods: Prospective study, clinical and imaging diagnosis description of 31 cases that had multi-levels cervical stenosis at 108 Central Military Hospital from February, 2011 to October, 2015 Results and conclusion: The average age of patients was 56.8 years The male/female ratio was 2.1/1 The average illness duration was 16.19 months The patient's clinical condition was evaluated by JOA scale before surgery with an average JOA score of 7.65 ± 4.28 The median lordosis angle was 22.35 and average ROM angle was 45.26 Torg- avlov’s ratio of C5 was 0.64 The average diameter of anteroposterior (AP) of the cervical spinal canal on CT-Scanner at C3 was 10.52 mm, C4: 9.78 mm; C5: 9.57 mm; C6: 9.95 mm; C7: 11.63 mm Spinal cord hyperintensity on T2-weighted magnetic resonance imaging (MRI) was 96.8% * Keywords: Cervical stenosis; Clinical features; Imaging diagnosis INTRODUCTION Cervical stenosis resulting from degeneration is a common spine disease in middle-aged people It has various clinical symptoms at varying degrees such as neck pain, shoulder pain, radiculopathy or myelopathy Treatment of cervical stenosis restores neurological functions, relieves pain, helps patients recuperate and bring them back to normal life There are many treatment procedures that depend on the stage of the disease such as conservative treatment to operation The diagnosis of cervical stenosis resulting from degeneration is based on clinical examination and imaging diagnostic tests The right diagnosis of this disease helps to make appropriate treatment Based on these reasons, the aim of this study is: To describe some clinical and image diagnosis features of patients with multilevel cervical stenosis SUBJECTS AND METHODS Subjects 31 patients, who were diagnosed as multi-levels cervical stenosis, were operated by laminoplasty at 108 Military Central Hospital from February, 2011 to October, 2015 - Selective standards: Patients were diagnosed as cervical stenosis with over levels, determined by cervical myelopathy and MRI, and operated by laminoplasty using titanium mini plate * 108 Military Central Hospital ** 103 Military Hospital Corresponding author: Nguyen Khac Hieu (drkhachieu@gmail.com) Date received: 23/03/2017 Date accepted: 26/09/2017 232 Journal of military pharmaco-medicine n08-2017 - Exclusive criteria: Patients were diagnosed as cervical stenosis under levels and cervical stenosis after traumatic cervical injury Methods - Prospective and descriptive study - Clinical stage was evaluated by JOA score (min is and max is 17 points) - On the standard plain X-ray film, we measured lordosis angle and range of motion (ROM) angle based on flexion and extension angle and Cobb method Figure 1: Lordosis angle (A) and ROM = (Ɵ ± Ɵ1) + (Ɵ2 – Ɵ) Ɵ: Lordosis angle - Measuring the AP diameter of cervical canal on the computerized tomography at the pedicle position - Taking MRI to determine the level of stenosis the patients got We found the reasons including bulging disc, disc herniation, yellow ligament hypertrophy, hyperintensity on T2-weighted or hyporintensity on T1-weighted of spinal cord - Data storage, analysis and processing by SPSS 16.0 software RESULTS AND DISCUSSION Sex and age In 31 patients, there were 21 males (67.7%) and 10 females (32.3%) The male per female ratio was 2.1/1 According to the researches of cervical stenosis disease, the number of male patients was higher than female ones In our study, the male/female ratio was 2.1/1 Compared with Nguyen Van Thach's study [2], the proportion was similar The average of patients was 56.84 ± 8.23 years old (from 38 to 73) Most patients were in groups of age, from 51 to 60 and from 61 to 70 years old The number of 51 to 70 years old patients accounted for 77.4% The average age in our study matched with Phan Quang Son’s one [1] Studies indicated that age related cervical degeneration was more common in middle age and less common in age groups under 40 [3] The average age of 56.8 in the study was consistent with local and national studies 233 Journal of military pharmaco-medicine n08-2017 Illness duration The duration (unit:month) was from symptoms onset to admission The shortest time was month and the longest time was 96 months The average illness duration was 16.19 months In our study, most of patients admitted to the hospital within 12 months of illness, accounted for 71% The duration of illness in our study was similar to Phan Quang Son’s one [1] (p > 0.05) but was shorter than that of Nguyen Van Thach [2] (p < 0.05) Long duration of illness affected the results of surgery Clinical conditions of hospitalized patients based on JOA score The patient's clinical condition was evaluated on JOA before surgery with an average JOA score of 7.65 ± 4.28 The lowest score was and the highest one was 13 Most of the patients in the study had JOA score ≤ 12 (96.8%) The preoperative JOA score was 7.65 A JOA score ≤ indicated severe myelopathy while to 12 points showed medium myelopathy and 13 was mild myelopathy A mild myelopathy was usually treated by conservative procedure In the case, when the JOA score was less than or equal to 12 [6], surgical treatment was indicated In Cheng's study, the JOA score before surgery was 7.9 ± 2.8 Duetzmann et al, who conducted a series of studies on cervical laminoplasty (n = 4.949) had an average JOA score of 9.91 ± 1.65 JOA score in our study was not significantly different from Cheng (p > 0.05), but different from Duetzmann (p < 0.01) 234 Imaging diagnosis * Standard X-ray: In this study, we used Cobb method to measure and classify lordosis angle as well as evaluate range of motion (ROM) of the cervical spine With 31 patients, the average lordosis angle was 22.35 ± 9.03 (1 - 35) and median ROM: 45.26 ± 10.250 (24 - 63) * Computerized tomography scanner: 23 cases had been taken with computerized tomography scanner before surgery CT-scanner images clearly showed vertebral body, ossification of posterior longitudinal ligaments (OPLL), bone spur, etc We measured the diameter of AP of the cervical spinal canal by computerized tomography Table 1: The average diameter of AP of the cervical spinal canal Vertebrae Diameter (mm) C3 10.52 ± 1.13 C4 9.78 ± 1.40 C5 9.57 ± 2.05 C6 9.95 ± 1.56 C7 11.63 ± 1.48 n 23 The proportion of patients with AP cervical spinal canal diameter less than or equal to 12 mm at C3: 95.7%, C4: 100%, C5: 95.7%, C6: 100%, C7: 73.9% Preoperative CT-scanner not only accurately measured the AP cervical canal diameter but also accurately diagnosed cases of OPLL According to Kokubun [4], the AP cervical spinal canal diameter ≤ 12 mm was called spinal stenosis In our study, most of patients had diameter of AP of the cervical spinal canal ≤ 12 mm Journal of military pharmaco-medicine n08-2017 * Magnetic resonance imaging: 31 patients who took MRI without gadolinium enhanced on T1-weighted and T2-weighted on axial and sagittal, had the characteristics of cervical stenosis such as yellow ligament hypertrophy, bulging disc, disc herniation and signal change in the spinal cord Table 2: Number level of stenosis Number level of stenosis Number of patients Ratio (%) Three levels 29 Four levels 10 32.3 Five levels 12 38.7 Sum stenosis level 127 100% Compared with Phan Quang Son [2], we found that studies had the same results in the percentage of lesions between four and five levels When the lesion was levels, some surgeons could choose anterior approach such as vertebra ecorpectomy, discectomy fixation and bone grafts However, when spinal stenosis had or more levels, most surgeons chose posterior approach * Morphology lesions on MRI: Researching on 31 patients who took MRI (in which patients took dynamic MRI), we found that: Table 3: Morphology lesions on MRI Morphology lesions Number of Ratio patients (%) Bulging disc 31 100 Disc herniation 11 35.5 Yellow ligament hypertrophy 29 93.5 Hypertensive signal on T2W 30 96.8 Hyportensive signal on T1W 12.9 According to results of studies, hyperintensity signal on T2-weighted image was a recovery prognostic factor Groups with hyperintensity on T2-weighted image showed higher recovery rates than non - hyperintensity one In the Secer’s study (2017), the recovery rate of the T2-weighted hyperintensity group was 73.5 ± 25.2% This figure was significantly higher than that of the control group without T2-weighted hyperintensity (37.1 ± 1.68) [7] For those patients who had marked clinical symptoms of cervical myelopathy but the basis of MRI did not clearly show the cause as well as the location of compression, the dynamic MRI was a good choice for clarification diagnosis There had been a lot of studies in the world [5] that showed the diagnostic efficiency of the method However, this issue was rarely mentioned in Vietnam CONCLUSION Studying 31 patients with multi-levels cervical myelopathy who underwent cervical laminoplasty by using titanium mini plate at 108 Central Military Hospital from February, 2011 to October, 2015, we draw some conclusions about clinical features and imaging diagnosis as follows: - Clinical features: The average age was 56.8 and the most common age group was from 51 to 70, accounted for 77.4% The number of male patients was higher than females and the ratio of male/female was 2.1/1 The duration of illness from onset to admission was 16.1 months The average JOA score before operation was 7.65 ± 2.48 235 Journal of military pharmaco-medicine n08-2017 - Diagnosis imaging: The average lordosis angle was 22.35 ± 9.030 and the median ROM angle was 45.26 ± 10.250 The average diameter of AP of the cervical spinal canal on CT-Scanner at C3: 10.52 mm; C4: 9.78 mm; C5: 9.57 mm; C6: 9.95 mm; C7: 11.63 mm There were total 127 cervical levels with stenosis in which 12 patients had levels stenosis, 10 patients had levels stenosis and patients had levels stenosis The rate of spinal cord hyperintensity on T2-weighted MRI was 96.8% REFERENCES han uang Sơn Nghiên cứu điều trị bệnh lý hẹp ống sống cổ phương pháp tạo hình sống kết hợp ghép san hô Luận án Tiến sỹ Y học Trường ại học Y Dược TP H Chí Minh 2015 Nguyễn Văn Th ch ánh giá kết điều trị bệnh lý hẹp ống sống cổ đa tầng 236 phương pháp tạo hình cung sau đường gi a Tạp chí Y học Th c hành 2011, 779 + 780, tr.577-581 Kelly J.C et al The natural history and clinical syndromes of degenerative cervical spondylosis Advances in Orthopedics 2011, 2012 Kokubun S, Sato T Cervical myelopathy and its management Current Orthopaedics 1981, 12, pp.7-12 Muhle C et al Dynamic changes of the spinal canal in patients with cervical spondylosis at flexion and extension using MRI Investigative Radiology 1998, 33 (8), pp.444-449 Mark S.G Cervical spinal stenosis Handbook of Neurosurgery Thiem New York 2010 Secer H.I et al Open-door laminoplasty with preservation of muscle attachments of C2 and C7 for cervical spondylotic myelopathy: Retrospective study Turk Neurosurg 2015, p.1 ... were total 127 cervical levels with stenosis in which 12 patients had levels stenosis, 10 patients had levels stenosis and patients had levels stenosis The rate of spinal cord hyperintensity on... changes of the spinal canal in patients with cervical spondylosis at flexion and extension using MRI Investigative Radiology 1998, 33 (8), pp.444-449 Mark S.G Cervical spinal stenosis Handbook of Neurosurgery... underwent cervical laminoplasty by using titanium mini plate at 108 Central Military Hospital from February, 2011 to October, 2015, we draw some conclusions about clinical features and imaging diagnosis