Research Article
Surgical Treatment for Hemodialysis Associated Cervical Spondyloarthropathy
Kuroki H1*, Hamanaka H2, Inomata N2, Higa K2, Nagai T2 and Chosa E2
1Department of Orthopaedic Surgery, National Hospital Organization Miyazaki Higashi Hospital, Japan
2Department of Orthopaedic Surgery, University of Miyazaki, Japan
*Corresponding author: Hiroshi Kuroki, Department of Orthopaedic Surgery, National Hospital Organization Miyazaki Higashi Hospital, 4374-1 TayoshiOoaza Miyazaki, 880- 0911, Japan
Published: 06 Sep, 2016
Cite this article as: Kuroki H, Hamanaka H, Inomata N, Higa K, Nagai T, Chosa E. Surgical Treatment for Hemodialysis Associated Cervical Spondyloarthropathy. Clin Surg. 2016; 1: 1102.
Abstract
Background: Hemodialysis associated cervical spondyloarthropathy (HA-CSA) is a serious pathology to affect not only quality of life but also life expectancy. The purpose of this study was to elucidate the long-term clinical results of surgical treatment for HA-CSA.
Methods: Ten of the 15 patients (9 male and 1 female, mean age of 61 years) of HA-CSA who were
surgically treated and underwent periodic follow-up review for more than 5 years after surgery were enrolled in this study. We retrospectively investigated preoperative complications, surgical procedures, treatment outcomes, and perioperative complications.
Results: Various preoperative complications were observed in all cases except 1. Posterior
decompression and fusion was performed in 4 cases, posterior fusion in 1, and laminoplasty in 5. Japanese Orthopaedic Association (JOA) score excluding bladder function (on a 14-point scale) improved 4.6 points postoperatively (mean recovery rate: 46.9%). Perioperative complications
occurred in 5 cases. In 8 cases, a lumbar destructive lesion with spinal canal stenosis was developed and 3 of them were subsequently performed lumbar decompressive surgery.
Conclusion: Pathological conditions of HA-CSA are divided into proliferation of the soft tissue
and destruction of the bony tissue. Even in hemodialysis patients, decompressive procedure must warrant long-term acceptable clinical results if the basal cause of symptom is spinal canal stenosis due to proliferation of the soft tissue. When selecting fusion surgery for the patient with the
destructive change, shorter posterior fusion should be adopted to reduce invasiveness of surgery. Although the risk of surgery must be extremely high in the patient on hemodialysis due to problems of general conditions, favorable clinical results are anticipated if no perioperative complications have been encountered. However, progression of lumbar lesion deteriorated the physical function again even though improvement of symptoms by cervical lesion relatively maintained for a long time after surgery.
Keywords: Cervical spine; Destructive spondyloarthropathy; Hemodialysis; Surgical treatment and β2-microgloblin
Introduction
Hemodialysis associated cervical spondyloarthropathy (HA-CSA) was first introduced as
destructive spondyloarthropathy (DSA) that is a serious complication of chronic hemodialysis
by Kuntz et al. [1] in 1984. It was radiographically characterized by severe narrowing of the
intervertebral disc space, erosions and geodes of adjacent vertebral plates, and the absence of
significant osteophytosis. The prevalence of HA-CSA is difficult to estimate, but it has been reported
around 20% in the past [2-4].
β2-microgloblin (β2-M) amyloidosis is a main cause of HA-CSA although the etiology assumes
to be probably multifactorial. β2-M serum level in patients undergoing chronic renal dialysis have
been found to be elevated 50 to 60 times the normal level [5]. Loss of renal function and lack of
satisfactory elimination through dialysis membranes are the main factors responsible for β2-M
accumulation [6].
HA-CSA is a serious pathology to affect not only quality of life but also life expectancy. It may be
treated conservatively in cases their neurological symptoms are mild, but some require an operation
because of deterioration of their symptoms. Whereas, the standard surgical management of HACSA
is still unclear, and there are no published guidelines or recommendations [7].
The purpose of this study was to retrospectively investigate the long-term clinical results of surgical treatment for HA-CSA and to explore the optimal strategies for such a challenging disorder based on pathological conditions.
Table 1
Materials and methods
Oral cancers are widely studied for their invasive morbidity,
yet little has been reported on expression profiles of transcriptional
regulators. RKIP, an important modulator of the Ras/Raf/MEK/ERK
kinase cascade, has been characterized in multiple cancer types, except
for oral. To begin our investigation, we probed for phosphorylated
and total RKIP expression in immortalized oral cancer cells lines
oral squamous cell carcinoma line 4 (SCC4) and human squamous
cell carcinoma line 3 (HSC3). Cell lysates were generated of these
cells under naïve, low serum conditions, to more closely represent
physiological significance. Furthermore, we compared the protein
expression profiles of these cancer cell lines to that of a primary
cell model, Trigeminal Ganglia (TG) neurons. The inclusion of other
immortalized cell lines for control purposes would have confounded
result interpretation given that most cell lines are derived from
cancer tissues, and that any immortalized cell line would represent an
abnormal transcriptional environment. In 1, polycystic kidney disease in 1, and unknown in 4. The length of
postoperative follow-up was from 5 years to 15 years and 4 months,
with a mean length of 8 years and 2 months.
We clinically investigated preoperative complications, surgical
procedures, clinical outcomes, and perioperative complications.
Clinical outcomes were assessed by Japanese Orthopaedic Association
(JOA) score excluding bladder function on a 14-point scale (Table 1).
Also, mobile ability was independently evaluated. Recovery rate (%)
of JOA score was calculated by a formula of “{(postoperative score –
preoperative score)/(14 – preoperative score)} x 100”.
Statistical analysis was performed using a two-tailed paired t-test. P< 0.05 level was considered statistically significant.
Written informed consent for participation in the study and
publication of this report was obtained from all patients after the
contents of the study had been fully explained. And all procedures were in accordance with the Helsinki declaration.
Table 2
Figure 1
Figure 1
Case 3 A 55-year-old man who underwent laminoplasty
a: preoperative MRI Severe spinal cord compression with high intensity change of the spinal cord from C2/3 through C5/6 levels by epidural calcification was confirmed on T2WI. b: preoperative CT Epidural space was occupied by deposit with calcification.
c: postoperative CT at 1 month after surgery Epidural space was enlarged after laminoplasty.
d: postoperative x-ray at 11 years after surgery Destructive change was less progressed and alignment of the cervical spine was maintained.
Results
Various preoperative complications were observed in all cases except 1. The most common systemic complication was hyperparathyroidism observed in 4 cases. Others were heart disease in 2 cases, hypertension in 1, diabetes mellitus in 1, and hypothyroidism in 1. Carpal tunnel syndrome and trigger finger were recognized in 5 cases and 4, respectively.
With regard to surgical procedures, posterior decompression
was employed in 9 of 10 cases who had spinal canal stenosis. In 6 of
10 cases, DSA change was accompanied. Of those, posterior fusion
underwent in 5 cases.
JOA score improved from 4.2 points preoperatively to 8.8 points
postoperatively (mean recovery rate of 46.9%). Mobile ability was
recovered in 3 cases, maintained in 4 cases, and worsened in 3 cases.
Perioperative complications requiring serious management
occurred in 5 cases; surgical site infection in 2 cases, pneumonia in 1,
gastric ulcer in 1, and cervical axial pain in 1.
At a couple of years after cervical surgery, 8 cases suffered from
a lumbar destructive lesion with spinal canal stenosis. Three cases
of them developed walking disability with neurological deficits and
obliged to subsequently receive additional lumbar decompressive
surgery (Table 2).
Illustrative Cases
Case 3
A 55-year-old man had received hemodialysis for 21 years and 2
months to treat chronic renal failure. He complained gait disturbance
due to gradually progressive quadriplegia. Preoperative images
indicated severe cord compression by epidural calcified deposits
without any destructive change of the cervical spine. At 11 years after
laminoplasty, his neurological function including walking ability was
completely recovered (Figure 1).
Case 4
A 57-year-old woman had received hemodialysis for 16 years and
6 months to treat chronic renal failure due to glomerulonephritis. She
suffered from incomplete quadriplegia by a fall. Preoperative images
revealed severe cord compression by vertebral slippage at C3/4
level. At 10 years after posterior fusion, her paralysis was extremely
recovered (Figure 2).
Figure 2
Figure 2
Case 4 A 57-year-old woman who underwent posterior fusion
a: preoperative x-ray Destructive change with spondylolisthesis of the C3 vertebra was observed.
b: preoperative MRI Severe spinal cord compression with high intensity change of the spinal cord at C3/4 level by spondylolisthesis of the C3 vertebra was revealed on T2WI.
c: postoperative x-ray at 10 years after surgery Reposition of spondylolisthesis of the C3 vertebra was maintained even though destructive change had been slightly progressed.
Discussion
In Japan, the patients who are newly instituted hemodialysis have been increasing year by year. At the end of 2014, the number of patients receiving hemodialysis reached 320,000, and further, the patients with a history of more than 25 years of hemodialysis treatment are no longer rare with the number of about 13,000 [8]. In our series, the most frequent cause of renal failure was glomerulonephritis. However, in 2010, diabetic nephropathy replaced glomerulonephritis as the most common cause of renal failure across the country [8]. Associated risk factors for the development and the progression of HA-CSA were found to be the patient’s age at onset of hemodialysis [9] and the duration of hemodialysis [3 and 9]. Therefore, the cervical and lumbar spines are affected by long-term hemodialysis, which can cause DSA. Yamamoto et al. [4] reported that the patients who received hemodialysis more than 15 years tend to develop DSA.
Successful surgical results have been reported even in the patients
with HA-CSA, so far. Driessche et al. [10] reported favorite functional
and neurologic improvement of anterior spinal fusion for cervical
DSA in hemodialysis patients despite a higher rate of complications
and mortality. Abumi et al. [11] also stated that successful surgical
outcomes can be obtained in the hemodialysis patients with cervical
DSA if anesthesiologist, nephrologist, and spine surgeons cooperate
together to prevent postoperative fetal complications. Therefore,
aggressive intervention should be considered for the HA-CSA
patients with the neurologic impairment if they are strongly willing
to receive surgical treatment.
Meanwhile, surgical intervention for HA-CSA is still regarded as a non-curative treatment and remains challenging due to multiple
medical problems. Kumar et al. [12] reported high mortality rate of surgery for the treatment of HA-CSA. In their group of 11 patients, 3 died in the immediate postoperative period, and 2 died at 6 months and 7 months after surgery, respectively. When attempting the surgical management for the HA-CSA patients, not only countermeasures for surgical site problems, such as susceptibility of bacterial infection and severe fragility of bone, but also attention for general conditions, such as anemia, water volume, electrolyte, and blood pressure are imperative in preventing occurrence of critical complications. Since increment of hemodialysis patients with systemic arteriosclerosis due to diabetes mellitus will be expected, more cautious attention in general management must be demanded.
For safety assurance, we usually attend to make more minimally
invasive method a priority as a general rule. Sudo et al. [13] advocated
that patients undergoing hemodialysis must be properly treated
according to the pathological conditions at the time they present
with their symptoms, because their general condition is usually not
ideal for invasive surgery. Cuffe et al. [5] also stated that the specific
treatment plan for a given patient must be individually determined
based upon the correct diagnosis, the presence of neural compression
and/or spinal instability, and the patient’s general condition and
projected life expectancy.
The pathological conditions of HA-CSA were broadly divided
into destruction of the bony tissue and proliferation of the soft
tissue, and differ from usual cervical spondylotic myelopathy. In
our series, regardless of HA-CSA, decompressive procedure alone
achieved good clinical results if the basal pathological condition of
the patient was spinal canal stenosis due to proliferation of the soft
tissue without spinal instability. Also, when doing fusion surgery for
the HA-CSA patients with destruction of the bony tissue, selective
fusion instead of long fusion should be adopted to reduce surgical
invasiveness as much as possible. Further, posterior approach must
be done because anterior approach to the cervical spine has a high
risk for postoperative complications [14].
Unfortunately, the number of cases enrolled in current study was
small and a 5 year follow-up period remained relatively short. Abumi
et al. [11] stated that progressive instability at the levels adjacent to a
previous circumferential spinal fusion is one of the main problems
to be solved. Therefore, further long-term investigation involved
much more patients must be necessary to confirm the validity of
our strategies. But we believe that our study will contribute to some
improvement of the management of HA-CSA because accumulation
of these minor data based on clinical experiences from a great number
of institutions may be essential to the future solution of issues around
such kind of uncommon challenging spinal disorders.
In our series, surgical outcomes of more than 5 years for the
patients with HA-CSA were acceptable. However, the rate of
perioperative complications was relatively high. After securing the
patient agreement on the hazardous treatment, the specific and
appropriate surgical method for a given patient must be individually
determined based on the correct judgment of pathological conditions
in a reasonable timing. Moreover, a prolonged periodic follow-up
should be delivered for the HA-CSA patients to lead to early detection
of not only recurrence of cervical lesion but also advent of lumbar
DSA because of their hemodialysis for the entire lifetime.
Conclusion
Although the risk of surgery must be extremely high in the patient on hemodialysis due to problems of general conditions, surgical treatment for cervical lesion is effective if no perioperative complications have been encountered. However, when planning surgical strategy to treat HA-CSA, it is important to understand accurately the pathological conditions and select suitable less invasive surgical method that is sustainable their poor general condition. Progression of lumbar lesion deteriorated the physical function again even though improvement of symptoms resulting from cervical lesion relatively maintained for a long time after surgery.
References
- Kuntz D, Naveau B, Bardin T, Drueke T, Treves R, Dryll A. Destructive spondyloarthropathy in hemodialyzed patients: a new syndrome. Arthritis Rheum. 1984; 27: 369-375.
- Fiocchi O, Bedani PL, Orzincolo C, Storari A, Cavazzini PL, Malacarne F, et al. Radiological features of dialysis amyloid spondyloarthropathy. Int J Artif Organs. 1989; 12: 216-222.
- Leone A, Sundaram M, Cerase A, Magnavita N, Tazza L, Marano P. Destructive spondyloarthropathy of the cervical spine in long-term hemodialyzed patients: a five-year clinical radiological prospective study. Skeletal Radiol. 2001; 30: 431-441.
- Yamamoto T, Matsuyama Y, Tsuji T, Nakamura H, Yanase M, Ishiguro N. Destructive spondyloarthropathy in hemodialysis patients; comparison between patients with and those without destructive spondyloarthropathy. J Spinal Disord Tech. 2005; 18: 283-285.
- Cuffe MJ, Hadley MN, Herrera GA, Morawetz RB. Dialysis-related spondyloarthropathy: report of 10 cases. J Neurosurg. 1994; 80: 694-700.
- Kröner G Stäbler A, Seiderer M, Moran JE, Gurland HJ. β2-microgloblinrelated amyloidosis causing atlantoaxial spondylarthropathy with spinalcord compression in haemodialysis patients; detection by MRI. Nephrol Dial Transplant. 1991; Supp 2: 91-95.
- Spinos P, Matzaroglou C, Parheni M, Deli A, Karanikolas M, Konstantinou D. Surgical management of cervical spondyloarthropathy in hemodialysis patients. The Open Orthopaedics Journal. 2010; 4: 39-43.
- The Japanese Society for Dialysis Therapy Database.
- Maruyama H, Gejyo F, Arakawa M. Clinical studies of destructive spondyloarthropathy in long-term hemodialysis patients. Nephron. 1992; 61: 37-44.
- Van Driessche S, Goutallier D, Odent T, Piat C, Legendre C, Buisson C, et al. Surgical treatment of destructive cervical spondyloarthropathy with neurologic impairment in hemodialysis patients. Spine. 2006; 31: 705-711.
- Abumi K, Ito M, Kaneda K. Surgical treatment of cervical destructive spondyloarthropathy (DSA). Spine. 2000; 25: 2899-2905.
- Kumar A, Leventhal MR, Freedman EL, Coburn J, Delamarter R. Destructive spondyloarthropathy of the cervical spine in patients with chronic renal failure. Spine. 1997; 22: 573-578.
- Sudo H, Ito M, Abumi K, Kotani Y, Takeuchi T, Yasui K, et al. Longterm follow up of surgical outcomes in patients with cervical disorders undergoing hemodialysis. J Neurosurg Spine. 2006; 5: 313-319.
- Shiota E, Naito M, Tsuchiya K. Surgical therapy for dialysis-related spondyloarthropathy: review of 30 cases. J Spinal Disord. 2001; 14: 165- 171.