Some clinical features and image diagnosis features in patients with multi-level cervical stenosis

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.

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 multi-levels 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 0 and average ROM angle was 45.26 0 Torg- avlov’s ratio of C 5 was 0.64 The average diameter of anteroposterior (AP) of the cervical spinal canal on CT-Scanner at C 3 was 10.52 mm, C 4 : 9.78 mm; C 5 : 9.57 mm;

C 6 : 9.95 mm; C 7 : 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 multi-level cervical stenosis.

SUBJECTS AND METHODS

1 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

2 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

- Exclusive criteria: Patients were diagnosed as cervical stenosis under 3 levels and cervical stenosis after traumatic cervical injury

2 Methods

- Prospective and descriptive study

- Clinical stage was evaluated by JOA score (min is 0 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

1 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 2 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

2 Illness duration

The duration (unit:month) was from

symptoms onset to admission The shortest

time was 1 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

3 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 3 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 ≤ 7 indicated severe myelopathy

while 8 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)

4 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 ± 9.030 (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

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

* 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 (%)

Compared with Phan Quang Son [2],

we found that 2 studies had the same

results in the percentage of lesions

between four and five levels When the

lesion was 3 levels, some surgeons

could choose anterior approach such as

vertebra ecorpectomy, discectomy fixation

and bone grafts However, when spinal

stenosis had 4 or more levels, most surgeons

chose posterior approach

* Morphology lesions on MRI:

Researching on 31 patients who took

MRI (in which 5 patients took dynamic MRI),

we found that:

Table 3: Morphology lesions on MRI

patients

Ratio (%)

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

- 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 3 levels stenosis, 10 patients had 4

levels stenosis and 9 patients had 5 levels

stenosis The rate of spinal cord hyperintensity

on T2-weighted MRI was 96.8%

REFERENCES

1 han uang Sơn Nghiên cứu điều trị

bệnh lý hẹp ống sống cổ bằng phương pháp

tạo hình bản sống kết hợp ghép san hô Luận

án Tiến sỹ Y học Trường ại học Y Dược

TP H Chí Minh 2015

2 Nguyễn Văn Th ch ánh giá kết quả

điều trị bệnh lý hẹp ống sống cổ đa tầng bằng

phương pháp tạo hình cung sau đường gi a Tạp chí Y học Th c hành 2011, 779 + 780, tr.577-581

3 Kelly J.C et al The natural history and

clinical syndromes of degenerative cervical spondylosis Advances in Orthopedics 2011,

2012

4 Kokubun S, Sato T Cervical myelopathy

and its management Current Orthopaedics

1981, 12, pp.7-12

5 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

6 Mark S.G Cervical spinal stenosis

Handbook of Neurosurgery Thiem New York

2010

7 Secer H.I et al Open-door laminoplasty

with preservation of muscle attachments of

C 2 and C 7 for cervical spondylotic myelopathy: Retrospective study Turk Neurosurg 2015, p.1