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1.  The Natural History and Clinical Presentation of Cervical Spondylotic Myelopathy 
Advances in Orthopedics  2011;2012:480643.
Cervical spondylotic myelopathy (CSM) refers to impaired function of the spinal cord caused by degenerative changes of the cervical spine resulting in spinal cord compression. It is the most common disorder in the United States causing dysfunction of the spinal cord. A literature review of the natural history of mild cervical myelopathy is undertaken. Clinical presentation and current concepts of pathophysiology are also discussed. While many patients with mild signs of CSM will stabilize or improve over time with conservative treatment, the clinical course of a specific individual patient cannot be predicted. Asymptomatic patients with cervical stenosis and abnormalities on electrophysiologic studies may be at higher risk for developing myelopathy.
doi:10.1155/2012/480643
PMCID: PMC3253434  PMID: 22235378
2.  A Locus on Chromosome 5 Is Associated with Dilated Cardiomyopathy in Doberman Pinschers 
PLoS ONE  2011;6(5):e20042.
Dilated cardiomyopathy (DCM) is a heterogeneous group of heart diseases with a strong genetic background. Currently, many human DCM cases exist where no causative mutation can be identified. DCM also occurs with high prevalence in several large dog breeds. In the Doberman Pinscher a specific DCM form characterized by arrhythmias and/or echocardiographic changes has been intensively studied by veterinary cardiologists. We performed a genome-wide association study in Doberman Pinschers. Using 71 cases and 70 controls collected in Germany we identified a genome-wide significant association to DCM on chromosome 5. We validated the association in an independent cohort collected in the United Kingdom. There is no known DCM candidate gene under the association signal. Therefore, DCM in Doberman Pinschers offers the chance of identifying a novel DCM gene that might also be relevant for human health.
doi:10.1371/journal.pone.0020042
PMCID: PMC3098859  PMID: 21625443
3.  Risk factors for development of cervical spondylotic myelopathy: results of a systematic review 
Study design: Systematic review.
Study rationale: Cervical spondylotic myelopathy (CSM) is a common cause of spinal cord dysfunction that may be asymptomatic or may present with severe symptoms. Since CSM has an insidious manifestation, identification of risk factors associated with this condition may aid clinicians in monitoring high-risk patients and implementing appropriate management strategies.
Objective: To assess sociodemographic, clinical, radiographic, and genetic risk factors associated with presence of CSM in patients 18 years or older.
Methods: A systematic review of the literature was performed using PubMed, the National Guideline Clearinghouse Databases, and bibliographies of key articles to assess risk factors associated with CSM. Articles were reviewed by two independent reviewers based on predetermined inclusion and exclusion criteria. Each article was evaluated using a predefined quality-rating scheme.
Results: From 486 citations, eight articles met all inclusion and exclusion criteria. Larger vertebral body and smaller spinal canal and Torg/Pavlov ratio were associated with CSM diagnosis, while gender was not associated with a CSM diagnosis across multiple studies. There were inconsistent reports with respect to increased age as a risk factor for CSM diagnosis.
Conclusion: The limited data available suggests that inherent anatomical features that may contribute to congenital cervical stenosis may be associated with CSM. This systematic review is limited by the small number of high-quality studies evaluating prognostic factors for CSM. The overall strength of evidence for all risk factors evaluated is low.
doi:10.1055/s-0032-1327808
PMCID: PMC3592758  PMID: 23526904
4.  Validation of Genome-Wide Intervertebral Disk Calcification Associations in Dachshund and Further Investigation of the Chromosome 12 Susceptibility Locus 
Frontiers in Genetics  2012;3:225.
Herniation of the intervertebral disk is a common cause of neurological dysfunction in the dog, particularly in the Dachshund. Using the Illumina CanineHD BeadChip, we have previously identified a major locus on canine chromosome 12 nucleotide positions 36,750,205–38,524,449 that strongly associates with intervertebral disk calcification in Danish wire-haired Dachshunds. In this study, targeted resequencing identified two synonymous variants in MB21D1 and one in the 5′-untranslated region of KCNQ5 that associates with intervertebral disk calcification in an independent sample of wire-haired Dachshunds. Haploview identified seven linkage disequilibrium blocks across the disease-associated region. The effect of haplotype windows on disk calcification shows that all haplotype windows are significantly associated with disk calcification. However, our predictions imply that the causal variant(s) are most likely to be found between nucleotide 36,750,205–37,494,845 as this region explains the highest proportion of variance in the dataset. Finally, we develop a risk prediction model for wire-haired Dachshunds. We validated the association of the chromosome 12 locus with disk calcification in an independent sample of wire-haired Dachshunds and identify potential risk variants. Additionally, we estimated haplotype effects and set up a model for prediction of disk calcifications in wire-haired Dachshunds based on genotype data. This genetic prediction model may prove useful in selection of breeding animals in future breeding programs.
doi:10.3389/fgene.2012.00225
PMCID: PMC3485664  PMID: 23125846
canine; intervertebral disk calcification; LD pattern; haplotype effects; resequencing
5.  Cervical Spondylotic Myelopathy: Pathophysiology, Clinical Presentation, and Treatment 
HSS Journal  2011;7(2):170-178.
Age-related changes in the spinal column result in a degenerative cascade known as spondylosis. Genetic, environmental, and occupational influences may play a role. These spondylotic changes may result in direct compressive and ischemic dysfunction of the spinal cord known as cervical spondylotic myelopathy (CSM). Both static and dynamic factors contribute to the pathogenesis. CSM may present as subclinical stenosis or may follow a more pernicious and progressive course. Most reports of the natural history of CSM involve periods of quiescent disease with intermittent episodes of neurologic decline. If conservative treatment is chosen for mild CSM, close clinical and radiographic follow-up should be undertaken in addition to precautions for trauma-related neurologic sequelae. Operative treatment remains the standard of care for moderate to severe CSM and is most effective in preventing the progression of disease. Anterior surgery is often beneficial in patients with stenotic disease limited to a few segments or in cases in which correction of a kyphotic deformity is desired. Posterior procedures allow decompression of multiple segments simultaneously provided that adequate posterior drift of the cord is attainable from areas of anterior compression. Distinct risks exist with both anterior and posterior surgery and should be considered in clinical decision-making.
doi:10.1007/s11420-011-9208-1
PMCID: PMC3145857  PMID: 22754419
cervical spine; spondylosis; myelopathy; natural history; operative treatment
6.  Functional outcome of corpectomy in cervical spondylotic myelopathy 
Indian Journal of Orthopaedics  2009;43(2):205-209.
Background:
Cervical spondylotic myelopathy (CSM) is serious consequence of cervical intervertebral disk degeneration. Morbidity ranges from chronic neck pain, radicular pain, headache, myelopathy leading to weakness, and impaired fine motor coordination to quadriparesis and/or sphincter dysfunction. Surgical treatment remains the mainstay of treatment once myelopathy develops. Compared to more conventional surgical techniques for spinal cord decompression, such as anterior cervical discectomy and fusion, laminectomy, and laminoplasty, patients treated with corpectomy have better neurological recovery, less axial neck pain, and lower incidences of postoperative loss of sagittal plane alignment. The objective of this study was to analyze the outcome of corpectomy in cervical spondylotic myelopathy, to assess their improvement of symptoms, and to highlight complications of the procedure.
Materials and Methods:
Twenty-four patients underwent cervical corpectomy for cervical spondylotic myelopathy during June 1999 to July 2005.The anterior approach was used. Each patient was graded according to the Nuricks Grade (1972) and the modified Japanese Orthopaedic Association (mJOA) Scale (1991), and the recovery rate was calculated.
Results:
Preoperative patients had a mean Nurick's grade of 3.83, which was 1.67 postoperatively. Preoperative patients had a mean mJOA score of 9.67, whereas postoperatively it was 14.50. The mean recovery rate of patients postoperatively was 62.35% at a mean follow-up of 1 year (range, 8 months to 5 years).The complications included one case (4.17%) of radiculopathy, two cases (8.33%) of graft displacement, and two cases (8.33%) of screw back out/failure.
Conclusions:
Cervical corpectomy is a reliable and rewarding procedure for CSM, with functional improvement in most patients.
doi:10.4103/0019-5413.50855
PMCID: PMC2762259  PMID: 19838372
Cervical corpectomy; cervical spondylotic myelopathy (CSM); cervical decompression; anterior approach
7.  Quantification of the Trömner signs: a sensitive marker for cervical spondylotic myelopathy 
European Spine Journal  2011;20(6):923-927.
The Trömner sign is commonly used as a clinical neurological examination for upper motor neuron lesions above the fifth or sixth cervical segments of the spinal cord. This study aims to assess and quantify the Trömner signs utilizing electrophysiological test, and correlate to the severity of cord compression in cervical spondylotic myelopathy (CSM). We enlisted 46 CSM patients, and 30 healthy persons as controls. Manual Trömner and Hoffmann signs were tested in all subjects. By using a self-designed instrument, we performed electrophysiological assessments for the Trömner signs in patients and controls. Parameters of conduction latencies and amplitude of muscle action potentials were measured and compared with the cord compression ratios in CSM patients. The results showed a greater diagnostic sensitivity for the quantified Trömner signs in comparison to those of manual Trömner signs and Hoffmann signs. We found a positive correlation between the amplitude of muscle action potentials obtained in the Trömner signs and the cord compression ratios in the patients with CSM. In conclusion, the Trömner signs can be measured by electrophysiological assessments. We demonstrate a new quantification method for an established neurological sign. Not only is Trömner sign a highly sensitive test in clinical neurological examination, the electrophysiological assessment of this sign can also serve as an objective marker for evaluation of the severity of cervical cord compression.
doi:10.1007/s00586-010-1681-6
PMCID: PMC3099157  PMID: 21221662
Trömner sign; Neurological reflex; Neurophysiology; Cervical spondylotic myelopathy
8.  How Long and Low Can You Go? Effect of Conformation on the Risk of Thoracolumbar Intervertebral Disc Extrusion in Domestic Dogs 
PLoS ONE  2013;8(7):e69650.
Intervertebral disc extrusion (IVDE) is a common neurological disorder in certain dog breeds, resulting in spinal cord compression and injury that can cause pain and neurological deficits. Most disc extrusions are reported in chondrodystrophic breeds (e.g. Dachshunds, Basset Hounds, Pekingese), where selection for ‘long and low’ morphologies is linked with intervertebral discs abnormalities that predispose dogs to IVDE. The aim of this study was to quantify the relationship between relative thoracolumbar vertebral column length and IVDE risk in diverse breeds. A 14 month cross-sectional study of dogs entering a UK small animal referral hospital for diverse disorders including IVDE was carried out. Dogs were measured on breed-defining morphometrics, including back length (BL) and height at the withers (HW). Of 700 dogs recruited from this referral population, measured and clinically examined, 79 were diagnosed with thoracolumbar IVDE following diagnostic imaging ± surgery. The BL:HW ratio was positively associated with IVDE risk, indicating that relatively longer dogs were at increased risk, e.g. the probability of IVDE was 0.30 for Miniature Dachshunds when BL:HW ratio equalled 1.1, compared to 0.68 when BL:HW ratio equalled 1.5. Additionally, both being overweight and skeletally smaller significantly increased IVDE risk. Therefore, selection for longer backs and miniaturisation should be discouraged in high-risk breeds to reduce IVDE risk. In higher risk individuals, maintaining a lean body shape is particularly important to reduce the risk of IVDE. Results are reported as probabilities to aid decision-making regarding breed standards and screening programmes reflecting the degree of risk acceptable to stakeholders.
doi:10.1371/journal.pone.0069650
PMCID: PMC3722130  PMID: 23894518
9.  Polymorphisms within the canine MLPH gene are associated with dilute coat color in dogs 
BMC Genetics  2005;6:34.
Background
Pinschers and other dogs with coat color dilution show a characteristic pigmentation phenotype. The fur colors are a lighter shade, e.g. silvery grey (blue) instead of black and a sandy color (Isabella fawn) instead of red or brown. In some dogs the coat color dilution is sometimes accompanied by hair loss and recurrent skin inflammation, the so called color dilution alopecia (CDA) or black hair follicular dysplasia (BHFD). In humans and mice a comparable pigmentation phenotype without any documented hair loss is caused by mutations within the melanophilin gene (MLPH).
Results
We sequenced the canine MLPH gene and performed a mutation analysis of the MLPH exons in 6 Doberman Pinschers and 5 German Pinschers. A total of 48 sequence variations was identified within and between the breeds. Three families of dogs showed co-segregation for at least one polymorphism in an MLPH exon and the dilute phenotype. No single polymorphism was identified in the coding sequences or at splice sites that is likely to be causative for the dilute phenotype of all dogs examined. In 18 German Pinschers a mutation in exon 7 (R199H) was consistently associated with the dilute phenotype. However, as this mutation was present in homozygous state in four dogs of other breeds with wildtype pigmentation, it seems unlikely that this mutation is truly causative for coat color dilution. In Doberman Pinschers as well as in Large Munsterlanders with BHFD, a set of single nucleotide polymorphisms (SNPs) around exon 2 was identified that show a highly significant association to the dilute phenotype.
Conclusion
This study provides evidence that coat color dilution is caused by one or more mutations within or near the MLPH gene in several dog breeds. The data on polymorphisms that are strongly associated with the dilute phenotype will allow the genetic testing of Pinschers to facilitate the breeding of dogs with defined coat colors and to select against Large Munsterlanders carrying BHFD.
doi:10.1186/1471-2156-6-34
PMCID: PMC1183202  PMID: 15960853
10.  Nontraumatic Acute Paraplegia Associated With Cervical Disk Herniation 
Background:
Acute paraplegia is a true emergency. It is often the result of trauma but is rarely reported in association with cervical disk herniation in patients without antecedent injury.
Methods:
Case report.
Findings:
This 75-year-old man presented with acute paraplegia due to severe compression of the spinal cord by herniation of the C4-C5 cervical disk. He underwent emergency diskectomy and anterior fusion. Postoperatively, his neurologic functions improved gradually.
Conclusions:
Cervical disk herniation should be considered in the differential diagnosis of nontraumatic acute paraplegia. Pre-existing narrowed canal is an important predisposing factor and excessive neck movements are believed to be triggering factors. Immediate early decompressive surgery is recommended to avoid irreversible progression of neurologic deficit.
PMCID: PMC2964031  PMID: 21061902
Paraplegia, acute, nontraumatic; Cervical vertebrae; Intervertebral disk displacement; Spinal cord compression; Rehabilitation, physical
11.  Cervical spondylotic myelopathy: Part I: anatomical and pathomechanical considerations * 
This two part series reviews the recent literature concerning the etiology and clinical presentation of cervical spondylotic myelopathy (CSM). CSM is the most common neurological spinal cord disorder after middle age. It is caused by the compromise of the cervical spinal cord from narrowing of the spinal canal.
In Part I, a review of the anatomy and the pathomechanics of the cervical spine pertinent to CSM is discussed. Emphasis is placed upon the intricate relationship between the osseous, neurological and vascular structures. The consequences of degenerative changes upon this relationship is evidenced by the resulting neurovascular compression. In turn, compression may lead to spinal cord ischemia with characteristic clinical results.
Images
PMCID: PMC2484655
cervical spondylotic myelopathy; cervical spine; spondylosis; myelopathy; chiropractic; manipulation
12.  Midcervical central cord syndrome: numb and clumsy hands due to midline cervical disc protrusion at the C3-4 intervertebral level. 
Eight patients with midline cervical disc protrusion at the C3-4 intervertebral level showed unusual clinical signs: numbness in the finger tips and palms, clumsiness of the hands, and a tightening sensation at the midthoracic level. The proprioceptive and cutaneous sensory afferents essential for motor control of the upper limbs were preferentially involved, tactile discrimination of passively given stimuli being spared. Somatosensory evoked potentials subsequent to median nerve stimulation showed conduction failure through the fasciculus cuneatus, as evidenced by absent or delayed and attenuated medullary and scalp potentials. The potential originating in the lower cervical cord (N13a) had a low amplitude, indicative of the caudal extension of the lesion. On the basis of the functional anatomy of the intraspinal pathways, especially of the dorsal columns, it is concluded that involvement of the central cord at the C3-4 intervertebral level and its caudal extension is responsible for the syndrome.
Images
PMCID: PMC1073494  PMID: 7745411
13.  Cervical Intervertebral Disc Protrusion in Two Horses 
The Canadian Veterinary Journal  1983;24(6):188-191.
Two horses with ataxia of all four limbs were found to have cervical intervertebral disc protrusion. Severe pelvic limb ataxia, proprioceptive deficits and spasticity were present in both horses with similar but less severe signs in the thoracic limbs. Cerebrospinal fluid analysis was within normal limits. Metrizamide myelography allowed definitive diagnosis in one case when a compression of the spinal cord was demonstrated at the level of the second intervertebral space. In the second case, an intervertebral disc protrusion between cervical vertebrae 6 and 7 was found at necropsy. Fiber degeneration with poor myelin staining characterized the spinal cords histologically.
Images
PMCID: PMC1790361  PMID: 17422269
14.  Pediatric intervertebral disc calcification: A no touch lesion 
Intervertebral disc calcification (IVDC), though rare, remains an important differential of pediatric spinal pain. A 7-year-old boy presented with sudden-onset severe neck pain and restricted movements. There was no definite history of trauma or infection. Imaging of the cervical spine showed calcification of the intervertebral disc at C2–3 level, with significant posterior protrusion into the spinal canal causing compression of the cervical spinal cord. The child was kept on conservative management. The calcification and posterior protrusion showed near-complete resolution on 3-month follow-up. This case report emphasizes that childhood IVDC is a benign condition which commonly resolves spontaneously, without any surgical intervention and neurological sequelae.
doi:10.4103/0974-8237.110123
PMCID: PMC3669470  PMID: 23741126
Calcification; cervical; intervertebral disc; spinal pain
15.  Use of a multimodal conservative management protocol for the treatment of a patient with cervical radiculopathy 
Objective
The purpose of this study is to describe and discuss the treatment of a cervical disk herniation using a sequential multimodal conservative management approach.
Clinical Features
A 40-year-old man had complaints of headache and severe sharp neck pain radiating to his left shoulder down to his arm, forearm, and hand. Results of electromyography/nerve conduction studies were abnormal. Magnetic resonance imaging revealed a large disk protrusion at C5-C6 with indentation of the thecal sac and a spur at the posterior margin. Moderate left neural foraminal narrowing was present at C5-C6 with narrowed intervertebral disk space at C5-C6 and C6-C7.
Intervention and Outcome
High-velocity, low-amplitude chiropractic manipulation; electrotherapy; ice; and exercise were used for treatment. The Neck Disability Index was used as a primary and electromyography/nerve conduction studies as a secondary outcome measurement. Based on the Neck Disability Index, there was an overall 89.65% symptoms improvement from the baseline.
Conclusions
This case study demonstrated possible beneficial effects of the multimodal treatment approach in a patient with cervical radiculopathy.
doi:10.1016/j.jcm.2010.05.004
PMCID: PMC3110408  PMID: 22027207
Chiropractic; Cervical vertebrae; Cryotherapy; Intervertebral disk displacement; Manipulation, spinal; Radiculopathy; Rehabilitation
16.  Cervical Pedicle Screw Fixation Combined with Laminoplasty for Cervical Spondylotic Myelopathy with Instability 
Asian Spine Journal  2012;6(4):241-248.
Study Design
A retrospective study.
Purpose
To evaluate the surgical results of cervical pedicle screw (CPS) fixation combined with laminoplasty for treating cervical spondylotic myelopathy (CSM) with instability.
Overview of Literature
Cervical fixation and spinal cord decompression are required for CSM patients with instability. However, only a few studies have reported on CPS fixation combined with posterior decompression for unstable CSM patients.
Methods
Thirteen patients that underwent CPS fixation combined with laminoplasty for CSM with instability were evaluated in this study. We assessed the clinical and radiological results of the surgical procedures. The Japanese Orthopedic Association (JOA) scoring system was used to evaluate the clinical results. The percentages of sli p, difference in sli p angle between maximum flexion and maximum extension of unstable intervertebrae, and perforation rate of CPS were evaluated.
Results
The mean JOA scores before surgery, immediately after surgery, and at final follow-up were 9.1, 13.3, and 12.6, respectively. The mean percentages of sli p before surgery, immediately after surgery, and at final follow-up were 9.1%, 3.2%, and 3.5%, respectively; there were significant improvements immediately after surgery and at final follow-up. The difference in sli p angle between the maximum flexion and maximum extension of the unstable intervertebrae changed from 9.0° before surgery to 1.6° at the final follow-up. The perforation rate of CPS was 10.9%.
Conclusions
The results suggest that CPS fixation combined with laminoplasty is an effective surgical procedure for treating CSM with instability.
doi:10.4184/asj.2012.6.4.241
PMCID: PMC3530698  PMID: 23275807
Cervical spondylosis; Myelopathy; Instability; Cervical fixation
17.  Nasca classification of hemivertebra in five dogs 
Irish Veterinary Journal  2005;58(12):688-690.
Five dogs, four small mixed breed and a Doberman Pinscher, presented in our clinic with hemivertebra. Complete physical, radiological and neurological examinations were done and the spinal deformities were characterized in accord with the Nasca classification used in human medicine. Two dogs had multiple hemivertebrae (round, oval or wedge-shaped: Type 3) in the thoracic region; one dog had an individual surplus half vertebral body (Type 1) plus a wedge-shaped hemivertebra (Type 2b) in the lumbar region; one dog had multiple hemivertebrae which were fused on one side (Type 4a) in the thoracic region; and one dog had a wedge-shaped hemivertebra (Type 2a) in the cervical region.
doi:10.1186/2046-0481-58-12-688
PMCID: PMC3113915  PMID: 21851666
Dog; Vertebral anomaly; Hemivertebra; Nasca classification
18.  Cervical spondylotic myelopathy: Part II: clinical and imaging considerations * 
In this, the second of a two part series, we continue to review the recent literature pertaining to cervical spondylotic myelopathy (CSM). Caused by the compromise of the spinal canal resulting from the superimposition of spondylotic changes upon a congenitally narrowed canal, CSM has a predictable radiographic and clinical presentation. The clinical presentation frequently includes both upper and lower motor neuron signs and symptoms. Careful analysis of the plain film images usually reveals a spinal canal measuring 12 mm or less. Additional imaging modalities confirm the diagnosis.
This paper presents the clinical and imaging characteristics underlying CSM and stresses the importance of including CSM in the differential diagnosis of patients complaining of neck and leg dysfunctions.
Images
PMCID: PMC2484647
cervical spondylotic myelopathy; cervical spine; spondylosis; radiology; chiropractic; manipulation
19.  Naturally Occurring Disk Herniation in Dogs: An Opportunity for Pre-Clinical Spinal Cord Injury Research 
Journal of Neurotrauma  2011;28(4):675-688.
Abstract
Traumatic spinal cord injuries represent a significant source of morbidity in humans. Despite decades of research using experimental models of spinal cord injury to identify candidate therapeutics, there has been only limited progress toward translating beneficial findings to human spinal cord injury. Thoracolumbar intervertebral disk herniation is a naturally occurring disease that affects dogs and results in compressive/contusive spinal cord injury. Here we discuss aspects of this disease that are analogous to human spinal cord injury, including injury mechanisms, pathology, and metrics for determining outcomes. We address both the strengths and weaknesses of conducting pre-clinical research in these dogs, and include a review of studies that have utilized these animals to assess efficacy of candidate therapeutics. Finally, we consider a two-species approach to pre-clinical data acquisition, beginning with a reproducible model of spinal cord injury in the rodent as a tool for discovery with validation in pet dogs with intervertebral disk herniation.
doi:10.1089/neu.2010.1645
PMCID: PMC3070145  PMID: 21438715
animal model; canine; trauma
20.  Accuracy and reliability of MRI quantitative measurements to assess spinal cord compression in cervical spondylotic myelopathy: a prospective study 
Study type: Reliability study
Introduction: Cervical spondylotic myelopathy (CSM) is the most common spinal cord disorder in persons more than 55 years old. Despite multiple neuroimaging approaches proposed to quantify the spinal cord compromise in CSM patients, magnetic resonance imaging (MRI) remains the procedure of choice by providing helpful information for clinical decision making, determining optimal subpopulations for treatment, and selecting the optimal treatment strategies. However, the validity, reliability, and accuracy of the MRI quantitative measurements have not yet been addressed.
Objective: To assess the intra- and inter-observer reliability of MRI quantitative measurements of the spinal cord compromise in CSM patients.
Methods: Seventeen CSM patients (13 male) of mean age 54.5 years old were selected from the AOSpine North America database. The patients had different combinations of stenotic levels (1–4 levels) and the clinical severity (range mJOA baseline: 8–18). Asymptomatic or previous surgically treated CSM, active infection, neoplastic disease, rheumatoid arthritis, ankylosing spondylitis, trauma, or concomitant lumbar stenosis were excluded. The patients underwent preoperative MRI using 1.5T (15 patients) and 3T (two patients) scanner, including mid-sagittal T1-weighted, axial and mid-sagittal T2-weighted series. MRI data were analyzed (Mango 2.0 software; Multi-Image Analysis GUI) by four blind raters in three different sessions. Four measurements were analysed: transverse area (TA) (Figure 1), compression ratio (CR) (Figure 2), maximal canal compromise (MCC), and maximal spinal cord compression (MSCC) (Figure 3). The differences for each measurement were evaluated using mixed-effect ANOVA models (ratter, session, ratter x session). The intra- and inter-rater reliability was evaluated with intraclass correlation coefficients (ICC) (Figure 4).
Transverse area (TA)
Compression ratio (CR = AP/W)
Maximal canal compromise (MCC), and maximal spinal cord compression (MSCC). MCC(%) = 1−[Dx/(Da+Db)/2] × 100%; MSCC(%) = 1−[dx/(da+db)/2] × 100%
Intraclass correlation coefficients (ICC)
Results: The principal findings were: (i) for TA (71.48 ± 12.99mm2), the intra-rater agreement was 0.97 (95% CI, range 0.94–0.99) and the inter-rater agreement was 0.76 (95% CI, range 0.49–0.90); (ii) for CR (0.35 ± 0.04%), 0.94 (95% CI, range 0.88–0.98), and 0.79 (95% CI, range 0.57–0.91) respectively; (iii) for MCC (83.21 ± 2.08%), 0.95 (95% CI, range 0.89–0.98), and 0.64 (95% CI, range 0.28–0.85) respectively; and (iv) for MSCC (82.87 ± 1.52%), 0.93 (95% CI, range 0.86–0.97), and 0.84 (95% CI, range 0.65–0.93) respectively.
Conclusions: Our data suggest that three out of four measurements (TA, CR and MSCC) have acceptable intra- and interreliability coefficients (ICC > 0.75). However, for the maximal canal compromise measure, although the intrareliability was acceptable, the inter-rater reliability was not acceptable (0.64). Based on this study, we recommend that three MRI measures: transverse area, compression ratio and maximal spinal cord compression should be used in the imaging assessment of the spinal cord in CSM patients.
doi:10.1055/s-0028-1100916
PMCID: PMC3623104  PMID: 23637669
21.  A Retrospective Study of Heart Disease in Doberman Pinscher Dogs 
The Canadian Veterinary Journal  1983;24(7):205-210.
The prevalence of gross and/or histological cardiac lesions was found to be much greater in Doberman pinscher dogs (16/26 or 62%) than in non-Doberman dogs (124/417 or 30%). At least some of the affected Dobermans were unrelated. Middle aged (mean age 4.7 yr) Dobermans of both sexes (11 M:5F) were affected. Four of the Dobermans with heart lesions had congestive cardiomyopathy; three of these four had congestive heart failure and the other one died suddenly. Prominent gross lesions were ventricular dilation and atrioventricular valvular endocardiosis. Histological lesions noted were prominent myocardial fibrosis, myofiber degeneration with fatty replacement, myofiber vacuolation and arterial intimal cushion formation. A spectrum of myocardial disease exists in Dobermans and clinically overt congestive cardiomyopathy represents one end of this spectrum.
Images
PMCID: PMC1790348  PMID: 17422276
22.  Prevalence of radiographic detectable intervertebral disc calcifications in Dachshunds surgically treated for disc extrusion 
Background
An association between the occurrence of calcified discs, visible on radiographic examination (CDVR), and disc extrusions has been suggested in published literature over the past 10-20 years, mainly from Nordic countries. It has also been postulated that dogs without CDVR would not develop disc extrusions. Furthermore, inheritance of CDVR has been calculated and it has been postulated that, by selecting dogs for breeding with few, or no CDVR, the prevalence of disc extrusions in the Dachshund population may be reduced.
Methods
The prevalence of radiographic detectable intervertebral disc calcifications was calculated from one hundred surgeries for disc extrusion, performed in 95 Dachshunds, in order to determine if the disc causing clinically significant IVDD, had radiographic signs of calcification at the time of confirmed disc extrusion. Inclusion criteria, for each dog, included a complete physical, orthopedic and neurologic examination, radiographs of the entire vertebral column, a myelogram or magnetic resonance imaging examination indicating extradural spinal cord compression, and finally a surgical procedure confirming the diagnosis of a disc extrusion. In addition to descriptive statistics, age correlation with number of calcifications visible at radiographic examination and with CDVR at the surgery site was examined.
Results
We found that disc extrusions occur as frequently in discs that are found to have radiographic evidence of calcification as those discs that do not have signs of radiographic calcification, and that IVDD (intervertebral disc disease) requiring surgery does occur in the absence of any calcified discs on radiographic examination. We found that calcified discs were more frequent in our Dachshund population compared to previous studies suggesting that disc calcification might be a serious risk factor for developing disc extrusion. Further studies are needed to show, conclusively, if selection of breeding dogs based on CDVR in the Dachshund will reduce the incidence of IVDD. The presence of the calcifications of intervertebral disc should be evaluated with caution, as only part of the calcifications will be detected and the real extent of the disc degeneration may be underestimated.
doi:10.1186/1751-0147-52-24
PMCID: PMC2873269  PMID: 20398282
23.  Safety of cervical spine manipulation: are adverse events preventable and are manipulations being performed appropriately? A review of 134 case reports 
Background
Cervical spine manipulation (CSM) is a commonly utilized intervention, but its use remains controversial.
Purpose
To retrospectively analyze all available documented case reports in the literature describing patients who had experienced severe adverse events (AEs) after receiving CSM to determine if the CSM was used appropriately, and if these types of AEs could have been prevented using sound clinical reasoning on the part of the clinician.
Data sources
PubMed and the Cumulative Index to Nursing and Allied Health were systematically searched for case reports between 1950 and 2010 of AEs following CSM.
Study selection
Case reports were included if they were peer-reviewed; published between 1950 and 2010; case reports or case series; and had CSM as an intervention. Articles were excluded if the AE occurred without CSM (e.g. spontaneous); they were systematic or literature reviews. Data extracted from each case report included: gender; age; who performed the CSM and why; presence of contraindications; the number of manipulation interventions performed; initial symptoms experienced after the CSM; and type of resultant AE.
Data synthesis
Based on the information gathered, CSMs were categorized as appropriate or inappropriate, and AEs were categorized as preventable, unpreventable, or unknown. Chi-square analysis with an alpha level of 0.05 was used to determine if there was a difference in proportion between six categories: appropriate/preventable, appropriate/unpreventable, appropriate/unknown, inappropriate/preventable, inappropriate/unpreventable, and inappropriate/unknown.
Results
One hundred thirty four cases, reported in 93 case reports, were reviewed. There was no significant difference in proportions between appropriateness and preventability, P = .46. Of the 134 cases, 60 (44.8%) were categorized as preventable, 14 (10.4%) were unpreventable and 60 (44.8%) were categorized as ‘unknown’. CSM was performed appropriately in 80.6% of cases. Death resulted in 5.2% (n = 7) of the cases, mostly caused by arterial dissection.
Limitations
There may have been discrepancies between what was reported in the cases and what actually occurred, since physicians dealing with the effects of the AE, rather than the clinician performing the CSM, published many of the cases.
Conclusions
This review showed that, if all contraindications and red flags were ruled out, there was potential for a clinician to prevent 44.8% of AEs associated with CSM. Additionally, 10.4% of the events were unpreventable, suggesting some inherent risk associated with CSM even after a thorough exam and proper clinical reasoning.
doi:10.1179/2042618611Y.0000000022
PMCID: PMC3360486  PMID: 23633885
Adverse events; Case reports; Cervical spine; Manipulation; Risk of harm; Safety
24.  Cervical spondylotic myelopathy with vitamin B12 deficiency: Two case reports 
Although it has been observed that a vitamin B12 (VB12) deficiency may lead to defects in the nervous system, there is a lack of studies elucidating whether VB12 has a role in the pathogenesis of cervical spondylotic myelopathy (CSM). The present study describes two cases of CSM observed in the clinic, where the patients presented with common characteristics of the typical clinical symptoms; however, T2-weighted magnetic resonance imaging examinations revealed that although the degree of spinal cord compression was not serious, the spinal cord exhibited significant high signal changes. At the same time, the serum VB12 levels of the two patients were lower compared with those of normal controls. The symptoms of the patients improved following anterior cervical decompression surgery and VB12 replacement therapy. The incidence of CSM in the two patients may have been correlated with a lack of VB12. Therefore, it is recommended that the serum VB12 levels are checked in cases of CSM where the standard imaging and clinical manifestations do not fully match.
doi:10.3892/etm.2013.1240
PMCID: PMC3797313  PMID: 24137294
vitamin B12; cervical spondylotic myelopathy
25.  Surgical approach to cervical spondylotic myelopathy on the basis of radiological patterns of compression: prospective analysis of 129 cases 
European Spine Journal  2008;17(12):1651-1663.
This is a prospective analysis of 129 patients operated for cervical spondylotic myelopathy (CSM). Paucity of prospective data on surgical management of CSM, especially multilevel CSM (MCM), makes surgical decision making difficult. The objectives of the study were (1) to identify radiological patterns of cord compression (POC), and (2) to propose a surgical protocol based on POC and determine its efficacy. Average follow-up period was 2.8 years. Following POCs were identified: POC I: one or two levels of anterior cord compression. POC II: one or two levels of anterior and posterior compression. POC III: three levels of anterior compression. POC III variant: similar to POC III, associated with significant medical morbidity. POC IV: three or more levels of anterior compression in a developmentally narrow canal or with multiple posterior compressions. POC IV variant: similar to POC IV with one or two levels, being more significant than the others. POC V: three or more levels of compression in a kyphotic spine. Anterior decompression and reconstruction was chosen for POC I, II and III. Posterior decompression was chosen in POC III variant because they had more incidences of preoperative morbidity, in spite of being radiologically similar to POC III. Posterior surgery was also performed for POC IV and IV variant. For POC IV variant a targeted anterior decompression was considered after posterior decompression. The difference in the mJOA score before and after surgery for patients in each POC group was statistically significant. Anterior surgery in MCM had better result (mJOA = 15.9) versus posterior surgery (mJOA = 14.96), the difference being statistically significant. No major graft-related complications occurred in multilevel groups. The better surgical outcome of anterior surgery in MCM may make a significant difference in surgical outcome in younger and fitter patients like those of POC III whose expectations out of surgery are more. Judicious choice of anterior or posterior approach should be made after individualizing each case.
doi:10.1007/s00586-008-0792-9
PMCID: PMC2587678  PMID: 18946692
Cervical spondylotic myelopathy; Anterior surgical approach; Laminectomy

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