The surgical management of dysphagia secondary to diffuse idiopathic skeletal hyperostosis

OBJECTIVE: This study reviews the management pathway and surgical outcomes of patients referred to and operated on at a tertiary neurosurgical centre, for dysphagia associated with anterolateral cervical hyperostosis (ACH) in diffuse idiopathic skeletal hyperostosis (DISH). PATIENTS & METHODS: Electronic patient records for 6 patients who had undergone anterior cervical osteophytectomy for dysphagia secondary to ACH were reviewed. ACH diagnosis was made by an Ear, Nose and Throat (ENT) specialist and patients were referred to a neurosurgical-led multidisciplinary team (MDT) for review. A senior radiologist performed imaging measurements and vertebral level localization was confirmed via barium-swallow video-fluoroscopy. Speech and language therapists (SLTs) determined the suitability of pre-operative conservative management. Patients were followed-up post-operatively with clinical and radiological assessments. RESULTS: 6 patients (Male to female ratio, 6:0; mean age, 59 years) were referred to a tertiary neurosurgical centre with DISH related dysphagia, an average of 25 months after ENT review (range, 14-36 months) between 2005 and 2016. The vertebral levels implicated in dysphagia ranged from C2 to T1 with a median of 4 vertebral levels involved. The most frequently affected vertebral levels were C4-6 (all 6 patients). The average antero-posterior height (as measured on axial images) of the most prominent osteophyte was 15.9 mm (range 12.0-20.0 mm). Patients underwent elective cervical osteophytectomy on average 10.8 months after neurosurgical review (range, 3-36 months). One patient had a post-operative haematoma needing evacuation and prolonged hospital stay. The average duration of follow-up was 42.3 months. All our patients maintained good symptomatic resolution without osteophyte recurrence. CONCLUSIONS: All our patients experienced significant and sustained clinical improvement. Anterior cervical osteophytectomy consistently leads to improvement in symptomatic ACH patients without recurrence. Early referral to a neurosurgical multi-disciplinary team (MDT) is indicated in ACH related dysphagia, once conservative management has failed

Computer-assisted screw insertion for cervical disorders in rheumatoid arthritis

To reconstruct highly destructed unstable rheumatoid arthritis (RA) cervical lesions, the authors have been using C1/2 transarticular and cervical pedicle screw fixations. Pedicle screw fixation and C1/2 transarticular screw fixation are biomechanically superior to other fixation techniques for RA patients. However, due to severe spinal deformity and small anatomical size of the vertebra, including the lateral mass and pedicle, in the most RA cervical lesions, these screw fixation procedures are technically demanding and pose the potential risk of neurovascular injuries. The purpose of this study was to evaluate the accuracy and safety of cervical pedicle screw insertion to the deformed, fragile, and small RA spine lesions using computer-assisted image-guidance systems. A frameless, stereotactic image-guidance system that is CT-based, and optoelectronic was used for correct screw placement. A total of 21 patients (16 females, 5 males) with cervical disorders due to RA were surgically treated using the image-guidance system. Postoperative computerized tomography and plane X-ray was used to determine the accuracy of the screw placement. Neural and vascular complications associated with screw insertion and postoperative neural recovery were evaluated. Postoperative radiological evaluations revealed that only 1 (2.1%; C4) of 48 screws inserted into the cervical pedicle had perforated the vertebral artery canal more than 25% (critical breach). However, no neurovascular complications were observed. According to Ranawat’s classification, 9 patients remained the same, and 12 patients showed improvement. Instrumentation failure, loss of reduction, or nonunion was not observed at the final follow-up (average 49.5 months; range 24–96 months). In this study, the authors demonstrated that image-guidance systems could be applied safely to the cervical lesions caused by RA. Image-guidance systems are useful tools in preoperative planning and in transarticular or transpedicular screw placement in the cervical spine of RA patients