J. Neurosurg. / Volume 32 / April, 1970

Myelopathy in Cervical Spondylosis with Vertebral Subluxation and Hyperlordosis

JOSEPH A. EPSTEIN, M.D., F.A.C.S., ROBERT CARRAS, M.D., BERNARD S. EPSTEIN, M.D., AND LEROY S. LEVINE, M.D., F.A.C.S. Division of Neurosurgery, Division of Orthopedic Surgery, and Department of Radiology, Long Island Jewish Medical Center, New Hyde Park, and the Neurosurgical Service, North Shore Hospital, Manhasset, and the Albert Einstein College o] Medicine, Yeshiva University, Bronx, New York

XCESSIVE cervical lordosis with overlap- lying soft tissues without vertebral displace- ping of the lamina may contribute to ment. Excessive cervico-dorsalkyphosis pre- E the production of myelopathy in pa- disposes these patients to compensatory tients with spondylosis. 3,4 Congenital or de- upper cervical hyperlordosis. velopmental narrowing of the spinal canal predisposes such individuals to spinal cord Clinical Findings and Course compression and to the additional problems A summary of the clinical findings and created by vertebral subluxation. 1,% s The lat- courses in the eight patients is presented in ter results from degenerative phenomena in Table 1. both the intervertebral disc and in the poste- Long Tract Signs. In all patients, long rior articulations, 5 and often occurs above an tract signs with a spastic ataxic gait ap- area of spontaneous fusion of vertebrae peared, preceded by weakness and loss of caused by advanced spondylosis. 9,1~ The in- dexterity in the arms in four. Sphincter func- folded ligamentum flavum and dura contrib- tion was intact in six patients. Hyperreflexia ute to dorsal compression of the spinal cord was present from the biceps level downward. in hyperextension. Telescoping of the lamina Bilateral Babinski signs were noted in five. often referred to as "shingling" increases this Five patients manifested decreased vibratory effect2 In the presence of subluxation, the appreciation and position sense in the toes. cord is pinched in extension or in flexion be- Gross atrophy of the small muscles of the tween the edge of the step-like defect in the hands occurred in five patients. In two, floor of the spinal canal and the leading mar- weakness was compounded by stereo- gin of the displaced infra- or suprajacent anesthesia, so that the hands were essentially lamina/, s useless. Atrophy of the shoulder girdle and proximal musculature was found in five, and Clinical Material fasciculations in four. The anatomical level The group of eight male patients with hy- appeared somewhat higher than that usually perlordosis and myelopathy that we are re- encountered in patients with cervical spon- porting had minimal to moderate spondy- dylomyelopathy. losis. All had critical narrowing of the ven- Hyperlordosis. None of these patients had trodorsal diameter of the spinal canal. Re- a clinical pattern that could be related solely trolisthesis was present in two patients at the to hyperlordosis, with or without pseudos- C4-5 interspace. Anterolisthesis was noted pondylolisthesis, although hyperlordosis of in three patients, at C3-C4 in one and at the upper cervical spine in the neutral posi- C4-C5 in the other two. One patient had re- tion was seen in all patients. The excessive trolisthesis at C3-C4, anterolisthesis at C4- cervical curve was most pronounced in a pa- C5, and fusion of the C5-C6 vertebrae. The tient with increased cervicodorsal kyphosis remaining two patients had stenosis of the (see Case 2 reported below). spinal canal further compromised by dorsal Cervical Spine Films. X-ray films in flex- intrusions of telescoped lamina and under- ion and extension in patients with hyperlor- Received for publication June 9, 1969. dosis and retrolisthesis revealed that the nar- Revision received November 17, 1969. rowing of the canal was greatest in extension 421 422 Epstein, Carras, Epstein and Levine TABLE 1 Summary of eight male patients with hyperlordosis, shingling, and stenosls of the spinal canal

Duration Pain, Spinal Onset, Age of Spondylosis Level Cervico- Preop Deficit Result Symptoms Anomaly Brachial Extremities

52 3 yrs retrolisthesis slight C4-5 q- arm spastic gait, hyper- good reflexia

57 1 yr retrotisthesis slight C4-5 0 leg atrophy hands, spastic good, gait iin- gait, hyperreflexia proved (fusion)

60 6 yrs anterolisthesisl moderate C3-4 0 leg atrophy hands, spastic good, slight gait, hyperreflexia residual spas- ticity

52 2 yrs anterolisthesis ! slight C4-5 0 leg hyperreflexia, Brown- good Sdquard

70 9 mos anterolisthesis, ~ moderate C4--5 + arm atrophy hands, spastic fair (fusion) fusion C5-6 gait, quadriparesis

62 3 yrs retrolisthesis, moderate C3-4 0 arm atrophy hands, stereo- good, em- anterolisthesis C4-5 anesthesia, mild spas- ployable, re- fusion C5-6 ticity, hyperreflexia turn of hand function

38 4 yrs upper cervical moderate C2-5 -k arm old double athetosis, temporary, hyperlordosis, C6-7-T1 torticollis, atrophy deterioration cervicodorsal hands, stereoanesthesia, 2 months kyphosis hyperreflexia later r__

45 3 days (?) hyperlordosis slight C3 -6 arlTl spastic gait, tetraparesis, minimal im- and hyperreftexia, recent provement leg CVA while forward flexion widened the canal seen in lateral exposures presented a corre- (Fig. 1). The step deformity in the floor of sponding step-ladder pattern in the antero- the spinal canal decreased or disappeared in posterior view. The dorsal intrusions of the flexion. The reverse occurred in patients lamina and ligamentous infolding contrib- with anterolisthesis. Vertebral dislocation of uted more to this effect than the osteophytes 3 to 5 mm was noted in the patients with in the floor of the canal. The extent of the pseudospondylolisthesis, well above normal laminar decompression required could be es- physiological limits. ~ In no patient was there timated as one or more lamina above and a defect in the pars interarticularis. Osteoar- below the total longitudinal deformity seen thritis of the posterior facets was found in in the myelogram in both anteroposterior patients with retrolisthesis who also mani- and lateral projections. fested degenerative disc disease. Fusion of Type of Operation. Liberal laminectomy the infrajacent two vertebral bodies was evi- and foramenotomy permitted the cord to rise dent in two patients. dorsally into an expanded and shorter canal, Spinal Fluid Protein. The CSF protein away from ventral step deformities and content was normal in five patients, and ele- ridges. 1,4,1~ In only one patient was it consid- vated from 60 to 104 rag% in the other ered advisable to excise the osteophytes in three. the floor of the canal because of the size of Myelography. Partial or almost complete the intrusions. Significant nerve root adhe- block in six patients was disclosed by myelo- sions and foraminal osteophytes were not graphy with the head and neck in the ex- found. Posterior spinal fusion was per- tended position. Ventroflexion relieved the formed in two patients, one with anterolis- block, allowing the oil to accumulate above thesis and one with retrolisthesis. Anterior and below the involved level. Measurements fusion was subsequently performed in the of the ventrodorsal depth of the spinal canal patient with anterolisthesis because of in- were 0.7 to 0.9 cm, significantly below ac- creasing deformity, with eventual stabiliza- cepted normal values. 11 The dorsal defect tion in a kyphotic position. Spinal fusion was