A. Chirianc, Giorgiana Ion, Z. Faiyad, I. Poeata DOI: 10.33962/roneuro -2020-036 Outcome analysis of upper and lower limb motor functions after anterior cervical discectomy and fusion for degenerative cervical disc disease Ninad N. Srikhande, V.A. Kiran Kumar, N.A. Sai Kiran, Amrita Ghosh, Ranabir Pal, Luis Rafael Moscote-Salazar, V. Anil Kumar, Vishnu Vardhan Reddy, Amit Agrawal Romanian Neurosurgery (2020) XXXIV (1): pp. 238-244 DOI: 10.33962/roneuro-2020-036 www.journals.lapub.co.uk/index.php/roneurosurgery Outcome analysis of upper and lower limb motor functions after anterior cervical discectomy and fusion for degenerative cervical disc disease Ninad N. Srikhande1, V.A. Kiran Kumar1, N.A. Sai Kiran1, Amrita Ghosh2, Ranabir Pal3, Luis Rafael Moscote-Salazar4, V. Anil Kumar5, Vishnu Vardhan Reddy1, Amit Agrawal1 1 Department of Neurosurgery, Narayana Medical College Hospital, Chinthareddypalem, Nellore, Andhra Pradesh, INDIA 2 Department of Biochemistry, Calcutta Medical College, 88, College street, Kolkata-700073, INDIA 3 Department of Community Medicine, MGM Medical College and LSK Hospital, Kishanganj -855107, Bihar, INDIA 4 Neurosurgery-Critical Care, Red Latino, Organización Latinoamericana de Trauma y cuidado, Neurointensivo, Bogota, COLOMBIA 5 Department of Anaesthesia, Narayana Medical College Hospital, Chinthareddypalem, Nellore, Andhra Pradesh, INDIA ABSTRACT Background: Anterior cervical discectomy and fusion (ACDF) is the most commonly performed surgical procedure for symptomatic cervical disc disease. In this study, we analysed the upper and lower limb motor functions after ACDF for disc prolapse in patients with degenerative cervical disc disease. Methods: One hundred consecutive adult patients who underwent ACDF for single or two-level cervical disc prolapse during the study period (October 2015 to October 2017) were included in the study. Results: Preoperative motor deficits in limbs were noted in 73% (73/100) of the patients. Enhance recovery of motor deficits was noted in 72.6% (53/73) of these patients and persisting motor deficits in the remaining patients (20/73- 27.4%). Five patients (5/27- 18.5%) without any preoperative motor deficits developed motor deficits after ACDF. Detailed pre and postoperative (at the time of discharge) motor power (graded by MRC grade) in all 4 limbs (Shoulder abduction / adduction / flexion / extension, elbow flexion / extension, wrist flexion / extension, hip abduction / adduction / flexion / extension, knee flexion/extension, ankle flexion/extension) was recorded. Statistically significant improvement in motor power (as recorded at the time of discharge) was noted in all the tested muscle groups after ACDF. Conclusion: Early improvement in preoperative motor deficits can be expected in the majority of the patients with cervical PIVD following ACDF. Keywords anterior cervical discectomy and fusion, outcome, cervical disc degeneration Corresponding author: V. A. Kiran Kumar Assistant Professor of Neurosurgery, Narayana Medical CollegeHospital Chinthareddypalem, Nellore, Andhra Pradesh, India drananth21@gmail.com Copyright and usage. This is an Open Access article, distributed under the terms of the Creative Commons Attribution Non–Commercial No Derivatives License (https://creativecommons .org/licenses/by-nc-nd/4.0/) which permits non- commercial re-use, distribution, and reproduction in any medium, provided the original work is unaltered and is properly cited. The written permission of the Romanian Society of Neurosurgery must be obtained for commercial re-use or in order to create a derivative work. ISSN online 2344-4959 © Romanian Society of Neurosurgery First published June 2020 by London Academic Publishing www.lapub.co.uk http://www.lapub.co.uk/ 239 Outcome analysis of upper and lower limb motor functions after anterior cervical discectomy and fusion INTRODUCTION ACDF is most commonly done to treat a symptomatic cervical PIVD. (1, 16, 20, 22, 23, 25) ACDF is a safe procedure and is rarely associated with post- operative complications. (2, 7, 9, 12, 17) Significant proportion of patients shows remarkable recovery in motor deficits following ACDF. (11, 16) Authors in this publication analysed in detail the early recovery of motor deficits following ACDF for single or two level degenerative cervical PIVD. MATERIAL AND METHODS One hundred consecutive adult patients who underwent ACDF for degenerative cervical PIVD during the study period (October 2015 to October 2017) were included in the study. Patients with traumatic PIVD were excluded. Approval from the institutional ethical committee was taken for this study. Detailed pre and postoperative (At the time of discharge) motor power (graded by MRC grade except hand grip which was subjectively graded from 0-100%) in all 4 limbs (Shoulder abduction / adduction / flexion / extension, elbow flexion / extension, wrist flexion / extension, hip abduction / adduction / flexion / extension, knee flexion / extension, ankle flexion / extension) were analysed. Statistical analysis Data analysis was done by using statistical software SPSS Statistics Version 24.0. Descriptive statistics including mean and standard deviation for continuous variables, and frequency and percentage for categorical variables were used for data expression. Appropriate tests like Chi-square test, Wilcoxon signed rank test etc. were used for checking statistically significant correlation. A probability (P) value of <0.05 was considered significant. RESULTS Preoperative motor deficits in limbs were noted in 73% (73/100) of the patients. At the time of discharge, enhance recovery of motor deficits was noted in 72.6% (53/73) of these patients and persisting motor deficits in the remaining patients (20/73- 27.4%). Five patients (5/27- 18.5%) without any preoperative motor deficits developed motor deficits after ACDF. Pre and postoperative (At the time of discharge) motor power in all 4 limbs is compared in Tables 1-4. Statistically significant improvement in motor power at the time of discharge was recorded in all the tested muscle groups after ACDF. Right upper limb Preoperative (n=100) Postoperative (n=100) P-value Mean# Median# Range# IQR Mean# Median# Range# IQR Shoulder Should er abducti on 3.80±1.4 4 0-5 2 4.15±1.29 5 0-5 1 0.001 (S)* Should er adducti on 3.80±1.4 4 0-5 2 4.16±1.29 5 0-5 1 0.001 (S)* Should er flexion 3.81±1.4 4 0-5 2 4.18±1.29 5 0-5 1 0.001 (S)* Should er extensi on 3.80±1.4 4 0-5 2 4.17±1.32 5 0-5 1 0.001 (S)* 240 Ninad N. Srikhande, V.A. Kiran Kumar, N.A. Sai Kiran et al. Table 1. Comparison of preoperative and postoperative motor power in right upper limb. #Power graded according to MRC grade. *Obtained Using Wilcoxon signed rank test; † Obtained using Chi square test; S: Significant. Left upper limb Preoperative (n=100) Postoperative (n=100) P- value* Mean# Median# Range# IQR Mean# Median# Range # IQR Shoulder Shoulder abduction 3.75±1.4 1 4 0-5 2 4.12±1.36 5 0-5 1 0.001 (S)* Shoulder adduction 3.74±1.4 1 4 0-5 2 4.14±1.34 5 0-5 1 0.001 (S)* Shoulder flexion 3.72±1.4 2 4 0-5 2 4.13±1.34 5 0-5 1 0.001 (S)* Shoulder extension 3.72±1.4 5 4 0-5 2 4.13±1.32 5 0-5 1 0.001 (S)* Elbow Elbow Elbow flexion 3.73±1.5 4 0-5 1 4.17±1.32 5 0-5 1 0.001 (S)* Elbow extensi on 3.71±1.5 4 0-5 2 4.16±1.33 5 0-5 1 0.001 (S)* Wrist Wrist flexion 3.71±1.6 4 0-5 1 4.14±1.27 5 0-5 1 0.001 (S)* Wrist extensi on 3.72±1.6 4 0-5 2 4.14±1.29 5 0-5 1 0.001 (S)* Right hand grip Preoperative (Number of patients) Postoperative (Number of patients) P-value 0-25% 11 4 0.001 (S)† 25-50 % 11 13 50-75 % 29 22 75- 100% 49 61 241 Outcome analysis of upper and lower limb motor functions after anterior cervical discectomy and fusion Elbow flexion 3.70±1.4 8 4 0-5 2 4.13±1.30 5 0-5 1 0.001 (S)* Elbow extension 3.70±1.4 8 4 0-5 2 4.13±1.29 5 0-5 1 0.001 (S)* Wrist Wrist flexion 3.64±1.5 1 4 0-5 1 4.2±1.26 5 0-5 1 0.001 (S)* Wrist extension 3.64±1.5 3 4 0-5 2 4.14±1.3 5 0-5 1 0.001 (S)* Left hand grip Preoperative (Number of patients) Postoperative (Number of patients) P-value 0-25% 12 3 0.001 (S)† 25-50 % 11 13 50-75 % 34 16 75-100% 43 68 Table 2. Comparison of preoperative and postoperative motor power in left upper limb. #Power graded according to MRC grade *Obtained Using Wilcoxon signed rank test; † Obtained using Chi square test; S: Significant Right lower limb Preoperative (n=100) Postoperative (n=100) P-value* Mean# Median# Range# IQR Mean# Median# Range# IQR Hip Hip abduction 3.42±1.85 4 0-5 2 3.90±1.59 5 0-5 2 0.001(S) Hip adduction 3.43±1.88 4 0-5 2 3.91±1.59 5 0-5 1 0.001(S) Hip flexion 3.43±1.88 4 0-5 2 3.91±1.59 5 0-5 1 0.001(S) Hip extension 3.42±1.88 4 0-5 2 3.88±1.59 5 0-5 2 0.001(S) Knee 242 Ninad N. Srikhande, V.A. Kiran Kumar, N.A. Sai Kiran et al. Knee flexion 3.40±1.86 4 0-5 2 3.90±1.60 5 0-5 2 0.001(S) Knee extension 3.38±1.86 4 0-5 2 3.90±1.59 5 0-5 2 0.001(S) Ankle Ankle flexion 3.33±1.85 4 0-5 2 3.84±1.58 4.5 0-5 2 0.001(S) Ankle extension 3.35±1.86 4 0-5 2 3.85±1.58 5 0-5 2 0.001(S) Table 3. Comparison of preoperative and postoperative motor power in right lower limb. #Power graded according to MRC grade *Obtained Using Wilcoxon signed rank test; S: Significant Left lower limb Preoperative (n=100) Postoperative (n=100) P-value* Mean Median Range IQR Mean Median Range IQR Hip Hip abduction 3.32±1.86 4 0-5 2 3.98±1.53 5 0-5 1 0.001 (S) Hip adduction 3.33±1.87 4 0-5 2 3.99±1.52 5 0-5 1 0.001 (S) Hip flexion 3.32±1.86 4 0-5 2 4.00±1.49 5 0-5 1 0.001 (S) Hip extension 3.29±1.84 4 0-5 2 3.98±1.49 5 0-5 1 0.001 (S) Knee Knee flexion 3.27±1.83 4 0-5 2 3.95±1.52 5 0-5 1 0.001 (S) Knee extension 3.27±1.84 4 0-5 2 3.94±1.51 5 0-5 1 0.001 (S) Ankle Ankle flexion 3.22±1.89 4 0-5 3 3.88±1.55 5 0-5 2 0.001 (S) Ankle extension 3.20±1.89 4 0-5 3 3.89±1.56 5 0-5 2 0.001 (S) Table 4. Comparison of preoperative and postoperative motor power in right lower limb. #Power graded according to MRC grade *Obtained Using Wilcoxon signed rank test; S: Significant DISCUSSION Cervical PIVD is a common degenerative disc disease affecting millions of people. (24) Cervical disc herniation can occur as a result of ageing, wear and tear, or sudden stress from an accident.(5) Majority of these patients present with neck pain radiating to upper limbs. (24) Other presenting symptoms include motor deficits, stiffness in limbs, sensory deficits, paresthesias in limbs etc. (16, 24) Majority of the patients presenting with only neck pain or radicular pain can be managed with medicationas and conservative measures like physiotherapy, cervical collar etc. Patients with significant pain not responding to conservative measures and patients with neurological deficits like sensory/motor deficits and bladder symptoms respond well to surgery. (10, 16, 21) ACDF is a common surgical procedure performed for symptomatic degenerative cervical disc disease. (6, 16) It helps to relieve the pressure on nerve roots and/or on the spinal cord, (14) thus resulting in improvement in various clinical symptoms including 243 Outcome analysis of upper and lower limb motor functions after anterior cervical discectomy and fusion neck pain, radicular pain, motor weakness, sensory symptoms, tightness in limbs and bladder disturbances. (10, 13, 16) Various complications reported with ACDF include dysphagia, hoarseness of voice, wound hematoma, graft migration, pseudoarthrosis, wound infection etc. (13) Patients can rarely have sensory or motor deficits after ACDF due to small risk of damage to the spinal cord, nerve roots or both. (10, 13, 16) Improvement in neurological deficits ranging from 36-93% has been reported in various series after ACDF.(3, 13, 15, 16, 18) Lehman et al (16) reported preoperative motor deficits in 55% of the patients and reported recovery of these deficits in 95% of them at 1 year. Chiles et al(4) reported strength improvement rates ranging form 79.1% to 90.9% in various individual muscle groups of upper and lower limbs following ACDF. In the present study very high proportion of patients (73%) presented with motor deficits and early complete recovery of these deficits were noted in 72.6% (53/73) of these patients. Majority of the studies on ACDF have graded neurological deficits using various scores like Nurick’s grade, JOA, modified JOA scores etc. which combine both sensory and motor deficits. (4, 8, 16, 19) Detailed assessment of motor deficits with grading of motor power for various muscle groups has not been done in most of the studies on ACDF. 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