Disclosures. Introduction. Purpose. Pulmonary Function and Complications in Patients with Cervical Myelopathy and Myelomalacia

Transcription

1 Pulmonary Function and Complications in Patients with Cervical Myelopathy and Myelomalacia Jeremy D. Shaw, MD, MS; Juli Martha, MPH; Ling Li, MSPH; David J. Hunter, MD, PhD; Brian Kwon, MD; Tal Rencus, MD; David H. Kim, MD Jeremy D. Shaw research support from DePuy Juli Martha nothing to Ling Li nothing to David J. Hunter nothing to Brian Kwon nothing to Tal Rencus nothing to David H. Kim nothing to Disclosures Introduction Purpose The association between traumatic cervical spinal cord injury (SCI) and pulmonary complications is well-established. A potential similar relationship between cervical myelopathy and cervical myelomalacia has not previously been examined. To prospectively evaluate pulmonary function in patients with cervical myelopathy and myelomalacia Murray and Nadel's Textbook of Respiratory Medicine, 5th ed 1

2 Methods Methods 22 consecutive patients Preoperative MRI showed cord signal changes Prospectively evaluated for pulmonary function (PFT) Demographics Age 54.7 ± 13.5, Gender 63.6% Male / 36.4% female Approach 50% anterior / 50% posterior 27.3% smokers Cord signal change was graded. Type 1 = >50% faint and fuzzy border Type 2 = >50% intense and well defined border T2 MRI indicated Type 1 and Type 2 signal change respectively (left to right). Chen et al. Radiology. 2001;221(3): Methods Myelopathy was graded with mjoa and Nurick scales Pulmonary complications were noted: Prolonged intubation Reintubation Respiratory failure Pneumonia Atelectasis Cord compression and T2 intensity at C5 Takahashi et al. Neuroradiology. 1987;29(6): Liters Reductions: FVC ~13% (p<0.0001), FEV 1 ~6% (p=0.0197), peak flow ~14% (p=0.0191) FVC FEV1 Peak Flow Actual Predicted 2

3 Formal PFT revealed a mild but significant impairment of pulmonary function based on FVC, FEV1 and peak flow Liters (SD) Actual Predicted p-value FVC 3.60 (0.89) 4.14 (0.87) <.0001 FEV (0.81) 3.05 (0.69) FEV1/ FVC (6.96) (2.65) FEF (1.32) 3.17 (0.64) Peak Flow 6.79 (2.49) 7.94 (1.48) FIVC 3.35 (0.78) Findings were consistent with neuromuscular weakness FEV1 and FVC are both decreased FEV1/FVC is approximately normal (80%). Murray and Nadel's Textbook of Respiratory Medicine, 5th ed No association between myelopathy and PFT performance (mjoa / Nurick grade). Type 1 vs Type 2 myelomalacia was not associated with PFT measures (p=0.07). Spearman (p-value) mjoa Score Nurick Score FVC (0.76) (0.79) FEV (0.68) (0.65) FEV1/FVC (0.99) (0.81) Peak Flow (0.38) (0.70) FIVC (0.85) (0.66) No association between pulmonary function, myelopathy, spinal stenosis, or myelomalacia and the occurrence of adverse pulmonary events. Liters (SD) Adverse Event No Event p-value FVC 88.0 (11) 86.0 (8.9) 0.73 FEV (11.2) 95.0 (14.1) 0.94 FEV1/ FVC 82.0 (5.2) 77.0 (7.5) 0.27 Peak Flow 84.0 (27.8) 88.0 (24.9) 0.86 FIVC 2.9 (0.8) 3.6 (0.8)

4 Patients with elevated BMI and high Charlson Index score had more adverse pulmonary events BMI 35.8±6.0 vs. 28.5±6.2, p=0.05 Charlson Index score 3.0±0.8 vs. 1.0±1.4, p=0.04). Discussion Cervical stenosis with myelomalacia should be considered a form of mild chronic SCI Neuromuscular weakness may lead to measurable impairment of pulmonary function The consequences appear to be mild No association with perioperative pulmonary complications Routine PFT screening is not recommended Obesity and medical comorbidity appear to be risk factors for adverse pulmonary events References References 1. Al-Mefty O, Harkey LH, Middleton TH, Smith RR, Fox JL. Myelopathic cervical spondylotic lesions demonstrated by magnetic resonance imaging. J Neurosurg. 1988;68(2): Wada E, Ohmura M, Yonenobu K. Intramedullary changes of the spinal cord in cervical spondylotic myelopathy. Spine (Phila Pa 1976). 1995;20(20): Yukawa Y, Kato F, Ito K, et al. Postoperative changes in spinal cord signal intensity in patients with cervical compression myelopathy: comparison between preoperative and postoperative magnetic resonance images. Journal of neurosurgery. 2008;8(6): Morio Y, Teshima R, Nagashima H, Nawata K, Yamasaki D, Nanjo Y. Correlation between operative outcomes of cervical compression myelopathy and mri of the spinal cord. Spine (Phila Pa 1976). 2001;26(11): Suri A, Chabbra RP, Mehta VS, Gaikwad S, Pandey RM. Effect of intramedullary signal changes on the surgical outcome of patients with cervical spondylotic myelopathy. Spine J. 2003;3(1): Yagi M, Ninomiya K, Kihara M, Horiuchi Y. Long-term surgical outcome and risk factors in patients with cervical myelopathy and a change in signal intensity of intramedullary spinal cord on Magnetic Resonance imaging. Journal of neurosurgery. 12(1): Vedantam A, Jonathan A, Rajshekhar V. Association of magnetic resonance imaging signal changes and outcome prediction after surgery for cervical spondylotic myelopathy. Journal of neurosurgery. 15(6): Baydur A, Adkins RH, Milic-Emili J. Lung mechanics in individuals with spinal cord injury: effects of injury level and posture. J Appl Physiol. 2001;90(2): Kelley A, Garshick E, Gross ER, Lieberman SL, Tun CG, Brown R. Spirometry testing standards in spinal cord injury. Chest. 2003;123(3): Urdaneta F, Layon AJ. Respiratory complications in patients with traumatic cervical spine injuries: case report and review of the literature. J Clin Anesth. 2003;15(5): Alvisi V, Marangoni E, Zannoli S, et al. Pulmonary Function and Expiratory Flow Limitation in Acute Cervical Spinal Cord Injury. Arch Phys Med Rehabil. 12. Takahashi M, Harada Y, Inoue H, Shimada K. Traumatic cervical cord injury at C3-4 without radiographic abnormalities: correlation of magnetic resonance findings with clinical features and outcome. J Orthop Surg (Hong Kong). 2002;10(2): Krassioukov A. Autonomic function following cervical spinal cord injury. Respir Physiol Neurobiol. 2009;169(2): De Troyer A, Estenne M, Heilporn A. Mechanism of active expiration in tetraplegic subjects. The New England journal of medicine. 1986;314(12): McMichan JC, Michel L, Westbrook PR. Pulmonary dysfunction following traumatic quadriplegia. Recognition, prevention, and treatment. JAMA. 1980;243(6): Grimm DR, Chandy D, Almenoff PL, Schilero G, Lesser M. Airway hyperreactivity in subjects with tetraplegia is associated with reduced baseline airway caliber. Chest. 2000;118(5): Fein ED, Grimm DR, Lesser M, Bauman WA, Almenoff PL. The effects of ipratropium bromide on histamine-induced bronchoconstriction in subjects with cervical spinal cord injury. J Asthma. 1998;35(1): Singas E, Grimm DR, Almenoff PL, Lesser M. Inhibition of airway hyperreactivity by oxybutynin chloride in subjects with cervical spinal cord injury. Spinal Cord. 1999;37(4): Benzel EC, Lancon J, Kesterson L, Hadden T. Cervical laminectomy and dentate ligament section for cervical spondylotic myelopathy. Journal of spinal disorders. 1991;4(3): Nurick S. The pathogenesis of the spinal cord disorder associated with cervical spondylosis. Brain. 1972;95(1): Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis. 1987;40(5): Takahashi M, Sakamoto Y, Miyawaki M, Bussaka H. Increased MR signal intensity secondary to chronic cervical cord compression. Neuroradiology. 1987;29(6): Chen CJ, Lyu RK, Lee ST, Wong YC, Wang LJ. Intramedullary high signal intensity on T2-weighted MR images in cervical spondylotic myelopathy: prediction of prognosis with type of intensity. Radiology. 2001;221(3): Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977;33(1):

5 Non-smokers Actual Predicted p-value PFT: All subjects Formal PFT revealed a mild but significant impairment of pulmonary function based on forced vital capacity (FVC; p=<0.001), forced expiratory volume in 1 second (FEV1; p=0.020) and peak flow (p=0.019) FVC 3.60(0.89) 4.14(0.87) <.0001 FEV1 2.86(0.81) 3.05(0.69) FEV1/ FVC 78.64(6.96) 77.50(2.65) Peak Flow 6.79(2.49) 7.94(1.48) FVC FEV1 Peak Flow FEV1/ FVC Actual Predicted Liters (SD) Actual Predicted p-value FVC 3.48(0.88) 4.01(0.87) FEV1 2.75(0.77) 2.93(0.69) FEV1/ FVC 78.56(7.09) 77.31(2.73) FEF (1.19) 3.05(0.65) Peak Flow 6.74(2.41) 7.73(1.52) FIVC 3.30(0.79) Smokers Adverse Event No Event p-value Age 46.0 (12) 53.0 (14.2) 0.41 Liters (SD) Actual Predicted p-value FVC 3.91 (0.90) 4.51 (0.80) FEV (0.91) 3.38 (0.63) FEV1/ FVC (7.25) (2.61) FEF (1.63) 3.49 (0.56) Peak Flow 6.90 (2.93) 8.51 (1.33) FIVC 3.47 (0.81) Gender Male 4 10 Female 3 5 Approach Anterior 4 7 Posterior 3 8 Smoking Status Yes 0 6 No

6 Adverse Event No Event p-value BMI 35.8 (6) 28.5 (6.2) 0.05 Charlson Score 3.0 (0.8) 1.0 (1.4) 0.04 ASA Class Pulmonary Condition Yes 2 1 No