Introduction
Methods
Perioperative data
Radiological findings of instability
Indications for surgery
Exclusion criteria for surgery
The surgical procedure
Outcome measures
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Severity and frequency of head and/or neck pain (both pre-op and post-op pain scores (1–5) as well as questionnaire on post-op improvement in pain severity/frequency. The pain scores were evaluated by comparing those patients with CSF flow obstruction from CMI, LLCT, or FM stenosis against those patients who did not have CMI or LLCT with CSF flow obstruction.
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Use of pain medication
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Changes in neurological, autonomic, and connective tissue disorder symptoms
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Functional status (Karnofsky Performance Scale) [44]
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Global Clinical Impression of Change score (changes in activity, symptoms, and quality of life since the surgery or last visit) [45]
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Patient satisfaction survey
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Orthostatic Grading Scale, in which patients reported the frequency and severity of orthostatic symptoms with daily activities before surgery and at final follow-up [46].
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Wood Mental Fatigue Inventory. Before surgery and at the final follow-up, a subset of patients completed this 9-item questionnaire which asks how much in the preceding month the respondent was bothered by difficulty with memory, decision-making ability, concentration, processing, and symptoms of foggy head. Responses include 0 = not bothered at all, 1 = bothered a little, 2 = bothered somewhat, 3 = bothered quite a lot, and 4 = bothered very much; Possible scores ranged from 0 to 36 (maximal mental fatigue) [47, 48].
Data analysis
Results
N | % | |
---|---|---|
Sex | ||
Female | 50 | 94.3 |
Male | 3 | 5.7 |
Age (years) | ||
Median | 32 | |
Range | 18–65 | |
Race | ||
Asian | 2 | 3.8 |
Black or African American | 2 | 3.8 |
White | 46 | 86.8 |
More than one race | 3 | 5.6 |
Ethnicity | ||
Hispanic or Latino | 1 | 1.9 |
Not Hispanic or Latino | 52 | 98.1 |
Total | 53 |
Precipitating event prior to neurosurgery clinic visit
Preoperative neurological deficits
Health care utilization and complications
Primary outcomes: headache and/or neck pain and use of pain medication
1 = None, 2 = Mild, 3 = Moderate, 4 = Severe, 5 = Incapacitating | Pre-op headache pain | Post-op headache pain | p value | Pre-op neck pain | Post-op neck pain | p value |
---|---|---|---|---|---|---|
All Subjects* (n = 46 headache, n = 45 neck pain) | 4.3 | 3.3 | < 0.00001 | 4.3 | 3.3 | < 0.00001 |
CM/LLCT with CSF flow obstruction (n = 28) | 4.4 | 3.2 | 0.0002 | 4.3 | 3.2 | 0.00002 |
No CSF flow obstruction (n = 18 headache, n = 17 neck pain) | 4.3 | 3.5 | 0.0003 | 4.3 | 3.5 | 0.02 |
Secondary outcomes: improvement of Karnofsky Performance Status and symptoms
Symptoms: mean severity rating 1 = None, 2 = Mild, 3 = Moderate, 4 = Severe, 5 = Incapacitating | Pre-surgery (n = 48) | Post-surgery (n = 48) | p value |
---|---|---|---|
Neurological | |||
Hyperacusis/sensitivity to noise | 3.2 | 2.8 | 0.018 |
Vertigo | 2.5 | 2.0 | 0.005 |
Dizziness/lightheadedness | 3.6 | 2.9 | < 0.001 |
Headache | 4.4 | 3.3 | < 0.001 |
Neck pain | 4.3 | 3.3 | < 0.001 |
Loss of consciousness/syncope | 1.9 | 1.4 | < 0.001 |
Presyncope | 3.5 | 2.7 | < 0.001 |
Concentration difficulties | 3.8 | 3.0 | < 0.001 |
Memory loss | 2.9 | 2.4 | 0.003 |
Double vision | 2.1 | 1.5 | 0.002 |
Photosensitivity | 3.2 | 2.7 | 0.011 |
Facial numbness | 2.2 | 1.7 | 0.006 |
Leg weakness | 2.8 | 2.5 | 0.043 |
Arm weakness | 2.8 | 2.2 | 0.002 |
Nausea/vomiting | 3.1 | 2.5 | < 0.001 |
Poor coordination | 3.1 | 2.5 | < 0.001 |
Speech difficulty | 2.3 | 1.8 | 0.002 |
Constitutional | |||
Fatigue | 4.3 | 3.7 | 0.001 |
Joint pain | 3.9 | 3.3 | < 0.001 |
Musculoskeletal | |||
Neck pain on bumpy roads | 3.8 | 3.0 | < 0.001 |
Muscle pain at rest | 3.5 | 2.9 | < 0.001 |
Cramps/stiff muscles | 3.4 | 3.0 | 0.043 |
Pain in legs while walking | 3.1 | 2.6 | 0.013 |
Cardiovascular/autonomic nervous system | |||
Feeling heart beats/palpitations | 3.1 | 2.6 | 0.002 |
Chest tightness/pain at rest | 2.3 | 1.8 | 0.005 |
Chest pain on exertion | 2.5 | 1.9 | 0.003 |
Shortness of breath at night | 2.3 | 1.8 | 0.008 |
Shortness of breath at rest | 2.2 | 1.7 | 0.013 |
Shortness of breath on exertion | 3.2 | 2.6 | 0.012 |
Fingers change color with temperature | 2.7 | 2.4 | 0.035 |
Heat intolerance | 3.5 | 2.9 | 0.018 |
Elevated temperature of > 101.5° | 1.3 | 1.1 | 0.044 |
Gastrointestinal | |||
Abdominal pain | 3.0 | 2.6 | 0.004 |
Bloating | 2.9 | 2.6 | 0.013 |
Constipation | 3.0 | 2.6 | 0.011 |
Heartburn / GERD | 2.3 | 2.0 | 0.027 |
Diarrhea | 2.2 | 2.0 | 0.022 |
Black stool / blood in stool | 1.3 | 1.1 | 0.027 |
Genitourinary | |||
Increased frequency urination | 2.66 | 2.3 | 0.041 |
Psychiatric | |||
Anxiety panic | 2.6 | 2.2 | 0.030 |
Patients reported improvement of orthostatic symptoms and mental fatigue
WMFI measure (n = 32) | Median before surgery | Median after surgery | ||||
---|---|---|---|---|---|---|
Confusion | 2 | (0–4) | 1 | (0–3) | NS | |
Thoughts mixed up | 3 | (1–4) | 2 | (0–4) | p < 0.01 | |
Poor concentration | 3 | (1–4) | 2 | (0–4) | p < 0.001 | |
Difficulty making decisions | 2 | (0–4) | 2 | (0–4) | p < 0.05 | |
Poor memory recent events | 2 | (0–4) | 2 | (0–4) | NS | |
Can’t take things in when Speaking | 2 | (0–4) | 2 | (0–3) | p < 0.001 | |
Thoughts slow | 3 | (0–4) | 2 | (0–4) | p < 0.001 | |
Foggy head | 3 | (1–4) | 2 | (0–4) | p < 0.001 | |
Can’t find right words | 3 | (1–4) | 2 | (0–4) | p < 0.005 | |
Total | 23 | (0–33) | 18 | (10–36) 0.005 | p < |
Radiological findings
Surgical Case | Harris* (Basion-axis interval) (flex) abnl ≥ 12 mm | Harris Translation (flex-ext) abnl ≥ 4 mm | Grabb-Oakes (mm) abnl ≥ 9 mm | CAA* abnl < 135 | Right/Left C1-2 Angular displacement abnl ≥ 41° | CSF flow obstruction | Other radiological findings |
---|---|---|---|---|---|---|---|
1 | 12 | 4 | 1 | 122* | 41/40 | ||
2 | 11 | 11 | 140 | 46/42 | CM1 (5.5 mm) | Poor CSF space maintenance posterior and anterior of the brainstem | |
3 | 9 | 7 | 7 | 152 | 41/42 | Did not have adequate flex/ext on MRI; lateral translation/AAI on DMX | |
4 | 12 | 2 | 9.5 | 132 | 37/35 | ||
5 | 7 | 7 | 8 | 135 | Was only able to do 65 total rotations in each direction, insufficient to show any subluxation; lateral translation/AAI on DMX | ||
6 | 10* | 4 | 7 | 144* | 40/40 | AAI, displacement of 41 on another CT, listed on op report | |
7 | 12 | 118 | 41/40 | ||||
8 | 12 | 9 | 139 | 43/44 | On flexion, the length of the brainstem is 3.5 cm. On extension, the length of the brainstem is 2.7 cm | ||
9 | 12.5 | 10 | 128 | CM1 (> 5 mm) | |||
10 | 10 | 2 | 140 | 40/35 | 30% facet overlap. On DMX BAI 12 on flexion; significant overhang of the lateral mass of C1 bilaterally; significant change in the para-odontoid space | ||
11 | 12 | 6 | 11 | 43/44 | LLCT | ||
12 | 12 | 1 | 9 | 135 | 41/43 | CM1 (6 mm) | Left Kimerle Anomaly |
13 | 12 | 7.5 | 9 | 124 | Did not turn far enough for CT; DMX showed increased ADI, significant overhang of the lateral mass of C1 bilaterally; significant change in the para-odontoid space | ||
14 | 10 | 6 | 10 | 125 | LLCT | DMX shows increased ADI, significant overhang of the lateral mass of C1 bilaterally; significant change in the para-odontoid space | |
15 | 11.4 | 2.4 | 9.5 | 119 | 42/42 | CM1 (9 mm) | CCI with translation > 4 mm translation |
16 | 10 | 8 | 9 | 127 | 39/39 | CM1 (> 5 mm) | 80% loss facet overlap |
17 | 11 | 8 | 8 | 118 | 40/41 | FM stenosis | |
18 | 10 | 4 | 11 | 42/42 | LLCT, FM stenosis | 80% loss facet overlap | |
19 | 10 | 4 | 142 | 39/39 | LLCT | 80% loss facet overlap | |
20 | 15 | 5 | 11 | 120 | 41/41 | congenital non-union of the posterior arch of C1, 90% loss fact overlap. On DMX, significant overhang of the lateral mass of C1 bilaterally; significant change in the para-odontoid space | |
21 | 16 | 6 | 11 | 120 | 43/44 | ||
22 | 6 | 0 | 5.5 | 136 | 45/43 | CM1 (> 5 mm) | Foramen magnum crowding with CSF obstruction/AAI; 90% loss facet overlap |
23 | 12 | 4 | 10 | 135 | 35/35 | On DMX, significant overhang of the lateral mass of C1 to the left | |
24 | 10 | 4 | 10 | 118 | 40/46 | ||
25 | 11 | 5 | 9 | 130 | 43/41 | 90% loss facet overlap, On DMX significant overhang of the lateral mass of C1 bilaterally; change in the para-odontoid space | |
26 | 11 | 8.5 | 9 | 140* | 42/- | ||
27 | 13 | 9 | 128 | 41/43 | LLCT, FM stenosis | On DMX overhang of the lateral mass of C1 bilaterally | |
28 | 11.6 | 2.63 | 9.5 | 126 | 40/42 | CM1 (8 mm) | Previous CM decompression |
29 | 11 | 3 | 9 | 118 | 43/43 | LLCT | |
30 | 14 | 10 | LLCT | On DMX increased ADI; overhang of the lateral mass of C1 bilaterally; significant change in the para-odontoid space | |||
31 | 7 | 7 | 7 | 44/48 | Inadequate flexion | ||
32 | 13 | 7 | 10 | 119 | Insufficient rotation, Klippel-Feil C5-C6 | ||
33 | 12 | 8 | 10 | 131 | 42/42 | ||
34 | 10 | 7 | 10 | 130 | 38/40 | LLCT, FM narrowing | |
35 | 8 | 8 | 8 | 140* | 43/43 | CM1 (> 5 mm) | 90% loss facet overlap, previous CM decompression |
36 | 9.5 | 5.5 | 8 | 147 | 45/41 | ||
37 | 16 | 5 | 10 | 121 | 43/45 | CM1 (14 mm) | Small syrinx |
38 | 11 | 5 | 10 | 133 | 38/38 | LLCT | |
39 | 13 | 5.5 | 111 | 43/42 | LLCT | ||
40 | 9 | 5 | 10 | 134 | 44/42 | LLCT | |
41 | 12 | 3.5 | 134 | 42/42 | Ventral brainstem compression | ||
42 | 10.5 | 8.5 | 9 | 131 | 44/45 | CM1 (5 mm), FM narrowing | Previously fused C5-C7 |
43 | 13 | 5 | 11 | 128 | 40/49 | CM1 (5 mm) | Incompetent alar ligaments with over 4 mm of translation of C1upon C2 on left and right tilt |
44 | 12.5 | 7.5 | 10 | 126 | 43/44 | CM1 (> 5 mm) | |
45 | 12.4 | 3.4 | 8.8 | 128 | 46/45 | CM1 (> 5 mm) | |
46 | 12 | 2 | 9 | 137 | CM1 (> 5 mm) | ||
47 | 8 | 3 | 128 | LLCT, FM stenosis | CCI and AAI on DMX (translation > 4mm), significant overhang of the lateral mass of C1 bilaterally | ||
48 | 13 | 5 | 104 | 43/38 | CM1 (> 5 mm) | ||
49 | 10 | 6 | 11 | 105 | CM1 (20 mm) | Insufficient rotation, previous CM decompression | |
50 | 13 | 5 | 9.4 | 127 | 42/- | LLCT | |
51 | 13* | 10.2 | 3 | 131* | 40/38 | LLCT | 4 mm lateral translation on DMX |
52 | 9 | 6 | 10 | 121 | CM1 (> 5 mm) | Previous CM decompression | |
53 | 7 | 4 | 9.5 | 138 | CM1 (8 mm) |
Patient’s satisfaction with surgery and global impression of change
Conditions | % Subjects | Conditions (Cont’d) | % Subjects |
---|---|---|---|
Neurospinal/neurovascular | 83% (44) | Gastrointestinal | 53% (28) |
Tethered cord syndrome | 49% (26) | Gastroparesis | 17% (9) |
Chiari malformation | 34% (18) | IBS | 13% (7) |
Intracranial HTN/pseudotumor cerebri | 34% (18) | GERD | 13% (7) |
LLT | 26% (14) | Gastritis/colitis/esophagitis | 9% (5) |
Other (Tarlov cyst, CSF Leak, Lumbar Fusion, Hx TIA/stroke, scoliosis, transverse sinus stent, arachnoid cyst, torticollis, meningocele, Klippel Feil, SI joint dysfunction, Scheuermann’s disease, basilar artery aneurysm, cavernous hemangioma, jugular vein obstruction, spondylolisthesis, subaxial instability) | 49% (26) | Other (Gallstones/hx cholecystectomy, SIBO, esophageal dysmotility, diverticulitis, celiacs, chronic constipation, chronic abdominal pain) | 28% (15) |
Musculoskeletal | 43% (23) | ||
Severe TMJD | 26% (14) | ||
Inflammatory and immune disorders | 74% (39) | Hx joint surgery or bone fracture | 17% (9) |
Osteoarthritis | 9% (5) | ||
Mast cell disorder/MCAS | 45% (24) | Hx trauma | 11% (6) |
GI (IBS, celiacs, gastritis, colitis, esophagitis) | 25% (13) | Other (arthralgia, Ernest Syndrome, muscle spasm or tear) | 13% (7) |
PANDAS/history of severe infection (e.g. Lyme’s, meningitis) | 19% (10) | ||
Cardiac/hematologic | 25% (13) | ||
Asthma | 15% (8) | Bleeding disorders (platelet aggregation disorder, prothrombin II def, low fibrinogen) | 6% (3) |
Allergic rhinitis | 13% (7) | ||
Other (RA, Hlab27 Positive Arthropathy, CIDP, SLE, MG, Hashimoto’s, Sjogren’s, PI, APS, vitiligo, rosacea) | 15% (8) | Other (clotting, APS, Tachycardia, HTN, anemia, diastolic HF, leaky heart valve, aortic root dilation, MVP, hx heart block) | 19% (10) |
Neurologic | 98% (52) | Endocrine | 21% (11) |
POTS | 58% (31) | Hypothyroidism | 11% (6) |
Migraine | 28% (15) | Other (adrenal insufficiency, Hashimoto’s, Cushing’s, hyperthyroidism, pituitary and thyroid disease, hyperadrenergic state) | 13% (7) |
Dysautonomia/dystonia | 25% (13) | ||
Occipital neuralgia | 23% (12) | ||
Severe chronic fatigue/CFS | 15% (8) | Psychiatric | 17% (9) |
Fibromyalgia | 15% (8) | Clinical anxiety | 9% (5) |
Autonomic neuropathy | 11% (6) | Clinical depression | 8% (4) |
Other neuropathy (peripheral, small fiber) | 9% (5) | Other (ADHD, OCD, hx eating disorders, | 11% (6) |
Other (DSPS, spastic hemiplegia, seizures/epilepsy, CRPS, RSD, PLMD, RLS, hx concussion) | 15% (8) | PTSD, cognitive disorder) | |
Other | 40% (21) | ||
Genitourinary | 34% (18) | Compression syndromes (TOS, MALS, May-Thurner, SMAS) | 15% (8) |
Endometriosis | 8% (4) | ||
Kidney or liver dysfunction | 8% (4) | Optical disorders | 9% (5) |
Other (pelvic floor issues, hip dysplasia/impingement, PCOS, interstitial cystitis, hx hysterectomy, uterine fibroids, varicocele) | 23% (12) | Integumentary (erythromelalgia, Hailey-Hailey Disease, rosacea, vitiligo, granuloma annulare) | 8% (4) |
Sleep apnea/UARS | 6% (3) |