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Disclosures Pulmonary Function and Jeremy D. Shaw research - - PowerPoint PPT Presentation

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5/11/2013 Disclosures Pulmonary Function and Jeremy D. Shaw research support from DePuy Complications in Patients with Juli Martha nothing to disclose Cervical Myelopathy and Ling Li nothing to disclose David J.

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SLIDE 1

5/11/2013 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

Disclosures

  • Jeremy D. Shaw – research

support from DePuy

  • Juli Martha – nothing to

disclose

  • Ling Li – nothing to disclose
  • David J. Hunter – nothing to

disclose

  • Brian Kwon – nothing to

disclose

  • Tal Rencus – nothing to

disclose

  • David H. Kim – nothing to

disclose

Introduction

  • 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.

Purpose

  • To prospectively evaluate

pulmonary function in patients with cervical myelopathy and myelomalacia

Murray and Nadel's Textbook of Respiratory Medicine, 5th ed

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SLIDE 2

5/11/2013 2

Methods

  • 22 consecutive patients
  • Preoperative MRI showed

cord signal changes

  • Prospectively evaluated for

pulmonary function (PFT) Demographics

  • Age

– 54.7 ± 13.5, 34 – 84

  • Gender

– 63.6% Male / 36.4% female

  • Approach

– 50% anterior / 50% posterior

  • 27.3% smokers

Methods

  • 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):789-94

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):550-6.

Results

  • Reductions: FVC ~13% (p<0.0001), FEV1 ~6% (p=0.0197), peak

flow ~14% (p=0.0191)

1 2 3 4 5 6 7 8 9 10 FVC FEV1 Peak Flow Liters Actual Predicted

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SLIDE 3

5/11/2013 3

Results

  • 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 FEV1 2.86 (0.81) 3.05 (0.69) 0.0197 FEV1/ FVC 78.64 (6.96) 77.50 (2.65) 0.3330 FEF 25-75 2.83 (1.32) 3.17 (0.64) 0.1057 Peak Flow 6.79 (2.49) 7.94 (1.48) 0.0191 FIVC 3.35 (0.78)

Results

  • 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

Results

  • 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

  • 0.068 (0.76)
  • 0.061 (0.79)

FEV1

  • 0.093(0.68)

0.102 (0.65) FEV1/FVC 0.003 (0.99)

  • 0.054 (0.81)

Peak Flow 0.196 (0.38)

  • 0.088 (0.70)

FIVC

  • 0.042 (0.85)
  • 0.101 (0.66)

Results

  • 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 FEV1 94.0 (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) 0.39

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SLIDE 4

5/11/2013 4

Results

  • 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

  • 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):217-22.

  • 2. Wada E, Ohmura M, Yonenobu K. Intramedullary changes of the spinal cord in cervical spondylotic myelopathy. Spine (Phila Pa

1976). 1995;20(20):2226-32.

  • 3. 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):524-8.

  • 4. 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):1238-45.

  • 5. 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):33-45.

  • 6. 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):59-65.

  • 7. 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):660-6.

  • 8. 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):405-11.

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2003;123(3):725-30.

  • 10. 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):398-405.

  • 11. 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):129-35.

References

  • 13. Krassioukov A. Autonomic function following cervical spinal cord injury. Respir Physiol Neurobiol. 2009;169(2):157-

64.

  • 14. De Troyer A, Estenne M, Heilporn A. Mechanism of active expiration in tetraplegic subjects. The New England

journal of medicine. 1986;314(12):740-4.

  • 15. McMichan JC, Michel L, Westbrook PR. Pulmonary dysfunction following traumatic quadriplegia. Recognition,

prevention, and treatment. JAMA. 1980;243(6):528-31.

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associated with reduced baseline airway caliber. Chest. 2000;118(5):1397-404.

  • 17. 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):49-55.

  • 18. 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):279-83.

  • 19. 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):286-95.

  • 20. Nurick S. The pathogenesis of the spinal cord disorder associated with cervical spondylosis. Brain. 1972;95(1):87-

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studies: development and validation. J Chronic Dis. 1987;40(5):373-83.

  • 22. Takahashi M, Sakamoto Y, Miyawaki M, Bussaka H. Increased MR signal intensity secondary to chronic cervical cord
  • compression. Neuroradiology. 1987;29(6):550-6.
  • 23. 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):789-94.

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5/11/2013 5

Results

PFT: All subjects

  • Formal PFT revealed a mild

but significant impairment

  • f 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)

Actual Predicted p-value FVC 3.60(0.89) 4.14(0.87) <.0001 FEV1 2.86(0.81) 3.05(0.69) 0.0197 FEV1/ FVC 78.64(6.96) 77.50(2.65) 0.3330 Peak Flow 6.79(2.49) 7.94(1.48) 0.0191

10 20 30 40 50 60 70 80 90 FVC FEV1 Peak Flow FEV1/ FVC Actual Predicted

Non-smokers

Liters (SD) Actual Predicted p-value FVC 3.48(0.88) 4.01(0.87) 0.0002 FEV1 2.75(0.77) 2.93(0.69) 0.073 FEV1/ FVC 78.56(7.09) 77.31(2.73) 0.3375 FEF 25-75 2.65(1.19) 3.05(0.65) 0.0757 Peak Flow 6.74(2.41) 7.73(1.52) 0.0654 FIVC 3.30(0.79)

Smokers

Liters (SD) Actual Predicted p-value FVC 3.91 (0.90) 4.51 (0.80) 0.031 FEV1 3.14 (0.91) 3.38 (0.63) 0.156 FEV1/ FVC 78.83 (7.25) 78.00 (2.61) 1.000 FEF 25-75 3.31 (1.63) 3.49 (0.56) 1.000 Peak Flow 6.90 (2.93) 8.51 (1.33) 0.219 FIVC 3.47 (0.81) Adverse Event No Event p-value Age 46.0 (12) 53.0 (14.2) 0.41 Gender Male 4 10 1.00 Female 3 5 Approach Anterior 4 7 1.00 Posterior 3 8 Smoking Status Yes 6 0.12 No 7 9

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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 2 7 13 1.00 3 2 Pulmonary Condition Yes 2 1 0.23 No 5 14