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. Hunter – nothing to Myelomalacia disclose • Brian Kwon – nothing to Jeremy D. Shaw, MD, MS; Juli Martha, disclose MPH; Ling Li, MSPH; David J. Hunter, • Tal Rencus – nothing to MD, PhD; Brian Kwon, MD; Tal Rencus, disclose MD; David H. Kim, MD • David H. Kim – nothing to disclose Introduction Purpose • The association between • To prospectively evaluate traumatic cervical spinal pulmonary function in cord injury (SCI) and patients with cervical pulmonary complications is myelopathy and well-established. myelomalacia • A potential similar relationship between cervical myelopathy and cervical myelomalacia has not previously been examined. Murray and Nadel's Textbook of Respiratory Medicine, 5th ed 1
5/11/2013 Methods Methods • Cord signal change was Demographics graded. • 22 consecutive patients • Age – Type 1 = >50% faint and – 54.7 ± 13.5, 34 – 84 • Preoperative MRI showed fuzzy border • Gender cord signal changes – Type 2 = >50% intense – 63.6% Male / 36.4% female • Prospectively evaluated for and well defined border • pulmonary function (PFT) Approach – 50% anterior / 50% posterior • 27.3% smokers T2 MRI indicated Type 1 and Type 2 signal change respectively (left to right) . Chen et al. Radiology. 2001;221(3):789-94 Methods Results • Myelopathy was graded • Reductions: FVC ~13% (p<0.0001), FEV 1 ~6% (p=0.0197), peak with mJOA and Nurick flow ~14% (p=0.0191) scales 10 9 • Pulmonary complications 8 were noted: 7 – Prolonged intubation 6 – Reintubation Liters Actual 5 – Respiratory failure Predicted 4 – Pneumonia 3 – Atelectasis 2 1 Cord compression and T2 intensity at C5 0 FVC FEV1 Peak Flow Takahashi et al. Neuroradiology. 1987;29(6):550-6. 2
5/11/2013 Results Results • Formal PFT revealed a mild but significant impairment of • Findings were consistent pulmonary function based on FVC, FEV1 and peak flow with neuromuscular weakness Liters (SD) Actual Predicted p-value • FEV1 and FVC are both decreased FVC 3.60 (0.89) 4.14 (0.87) <.0001 • FEV1/FVC is approximately FEV1 2.86 (0.81) 3.05 (0.69) 0.0197 normal (80%). 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) Murray and Nadel's Textbook of Respiratory Medicine, 5th ed Results Results • No association between myelopathy and PFT performance • No association between pulmonary function, myelopathy, (mJOA / Nurick grade). spinal stenosis, or myelomalacia and the occurrence of adverse pulmonary events. • Type 1 vs Type 2 myelomalacia was not associated with PFT measures (p=0.07). Liters (SD) Adverse Event No Event p-value Spearman (p-value) mJOA Score Nurick Score FVC 88.0 (11) 86.0 (8.9) 0.73 -0.068 (0.76) -0.061 (0.79) FVC FEV1 94.0 (11.2) 95.0 (14.1) 0.94 -0.093(0.68) 0.102 (0.65) FEV1 FEV1/ FVC 82.0 (5.2) 77.0 (7.5) 0.27 0.003 (0.99) -0.054 (0.81) FEV1/FVC Peak Flow 84.0 (27.8) 88.0 (24.9) 0.86 0.196 (0.38) -0.088 (0.70) Peak Flow FIVC 2.9 (0.8) 3.6 (0.8) 0.39 -0.042 (0.85) -0.101 (0.66) FIVC 3
5/11/2013 Results Discussion • Patients with elevated BMI and high Charlson Index score had • Cervical stenosis with myelomalacia should be considered a more adverse pulmonary events form of mild chronic SCI – BMI 35.8±6.0 vs. 28.5±6.2, p=0.05 • Neuromuscular weakness may lead to measurable impairment of pulmonary function – Charlson Index score 3.0±0.8 vs. 1.0±1.4, p=0.04). • 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 13. Krassioukov A. Autonomic function following cervical spinal cord injury. Respir Physiol Neurobiol. 2009;169(2):157- 1. Al-Mefty O, Harkey LH, Middleton TH, Smith RR, Fox JL. Myelopathic cervical spondylotic lesions demonstrated by magnetic 64. resonance imaging. J Neurosurg. 1988;68(2):217-22. 14. De Troyer A, Estenne M, Heilporn A. Mechanism of active expiration in tetraplegic subjects. The New England 2. Wada E, Ohmura M, Yonenobu K. Intramedullary changes of the spinal cord in cervical spondylotic myelopathy. Spine (Phila Pa journal of medicine. 1986;314(12):740-4. 1976). 1995;20(20):2226-32. 15. McMichan JC, Michel L, Westbrook PR. Pulmonary dysfunction following traumatic quadriplegia. Recognition, 3. Yukawa Y, Kato F, Ito K, et al. Postoperative changes in spinal cord signal intensity in patients with cervical compression prevention, and treatment. JAMA. 1980;243(6):528-31. myelopathy: comparison between preoperative and postoperative magnetic resonance images. Journal of neurosurgery. 16. Grimm DR, Chandy D, Almenoff PL, Schilero G, Lesser M. Airway hyperreactivity in subjects with tetraplegia is 2008;8(6):524-8. associated with reduced baseline airway caliber. Chest. 2000;118(5):1397-404. 4. Morio Y, Teshima R, Nagashima H, Nawata K, Yamasaki D, Nanjo Y. Correlation between operative outcomes of cervical 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. compression myelopathy and mri of the spinal cord. Spine (Phila Pa 1976). 2001;26(11):1238-45. 18. Singas E, Grimm DR, Almenoff PL, Lesser M. Inhibition of airway hyperreactivity by oxybutynin chloride in subjects 5. Suri A, Chabbra RP, Mehta VS, Gaikwad S, Pandey RM. Effect of intramedullary signal changes on the surgical outcome of with cervical spinal cord injury. Spinal Cord. 1999;37(4):279-83. patients with cervical spondylotic myelopathy. Spine J. 2003;3(1):33-45. 19. Benzel EC, Lancon J, Kesterson L, Hadden T. Cervical laminectomy and dentate ligament section for cervical 6. Yagi M, Ninomiya K, Kihara M, Horiuchi Y. Long-term surgical outcome and risk factors in patients with cervical myelopathy and spondylotic myelopathy. Journal of spinal disorders. 1991;4(3):286-95. a change in signal intensity of intramedullary spinal cord on Magnetic Resonance imaging. Journal of neurosurgery. 12(1):59-65. 20. Nurick S. The pathogenesis of the spinal cord disorder associated with cervical spondylosis. Brain. 1972;95(1):87- 7. Vedantam A, Jonathan A, Rajshekhar V. Association of magnetic resonance imaging signal changes and outcome prediction 100. after surgery for cervical spondylotic myelopathy. Journal of neurosurgery. 15(6):660-6. 21. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal 8. Baydur A, Adkins RH, Milic-Emili J. Lung mechanics in individuals with spinal cord injury: effects of injury level and posture. J studies: development and validation. J Chronic Dis. 1987;40(5):373-83. Appl Physiol. 2001;90(2):405-11. 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. 9. Kelley A, Garshick E, Gross ER, Lieberman SL, Tun CG, Brown R. Spirometry testing standards in spinal cord injury. Chest. 23. Chen CJ, Lyu RK, Lee ST, Wong YC, Wang LJ. Intramedullary high signal intensity on T2-weighted MR images in 2003;123(3):725-30. cervical spondylotic myelopathy: prediction of prognosis with type of intensity. Radiology. 2001;221(3):789-94. 10. Urdaneta F, Layon AJ. Respiratory complications in patients with traumatic cervical spine injuries: case report and review of 24. Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977;33(1):159-74. 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. 4
5/11/2013 Results Non-smokers Actual Predicted p-value PFT: All subjects FVC 3.60(0.89) 4.14(0.87) <.0001 • Formal PFT revealed a mild Liters (SD) Actual Predicted p-value FEV1 2.86(0.81) 3.05(0.69) 0.0197 but significant impairment 3.48(0.88) 4.01(0.87) 0.0002 FVC FEV1/ FVC 78.64(6.96) 77.50(2.65) 0.3330 of pulmonary function based on forced vital 2.75(0.77) 2.93(0.69) 0.073 FEV1 Peak Flow 6.79(2.49) 7.94(1.48) 0.0191 capacity (FVC; p=<0.001), 90 78.56(7.09) 77.31(2.73) 0.3375 FEV1/ FVC forced expiratory volume in 80 1 second (FEV1; p=0.020) 70 2.65(1.19) 3.05(0.65) 0.0757 FEF 25-75 60 and peak flow (p=0.019) 50 6.74(2.41) 7.73(1.52) 0.0654 Actual Peak Flow 40 Predicted 30 3.30(0.79) FIVC 20 10 0 FVC FEV1 Peak Flow FEV1/ FVC Adverse Event No Event p-value Smokers Age 46.0 (12) 53.0 (14.2) 0.41 Gender Male 4 10 1.00 Liters (SD) Actual Predicted p-value Female 3 5 3.91 (0.90) 4.51 (0.80) 0.031 FVC Approach FEV1 3.14 (0.91) 3.38 (0.63) 0.156 Anterior 4 7 1.00 78.83 (7.25) 78.00 (2.61) 1.000 FEV1/ FVC Posterior 3 8 3.31 (1.63) 3.49 (0.56) 1.000 FEF 25-75 Smoking 6.90 (2.93) 8.51 (1.33) 0.219 Peak Flow Status 3.47 (0.81) FIVC Yes 0 6 0.12 No 7 9 5
Recommend
More recommend
