Treatment of Cervical Spondylotic Myelopathy

8/3/2019 Treatment of Cervical Spondylotic Myelopathy

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Akinsulire A.T


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Introduction Natural History

Treatment options

Non operative Operative

Anterior

Posterior

Combined

Complications

Prognosis


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Cervical Spondylotic Myelopathy (CSM) is adisease of variable progression

Management based on understanding ofpathogenesis,clinical features and correctneuroimaging investigation.


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Many patients have evidence of significantcompression on MRI but relativelyasymptomatic

Spinal cord has high degree of tolerance tochronic deformation


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75% Stepwise

deterioration

20% Steady

progressive

deterioration

5% Improvement

Clarke E, Robinson PK: Cervical myelopathy: A complication of cervical spondylosis. Brain


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Typically slowing progressive Step ladder progression

Once moderate symptoms occur, prognosis

poor


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Non operative

Operative


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Indications Neuroradiological evidence of compression but no

symptom/sign of myelopathy

Mild neuropathy

Slight gait disturbance No functional deficit/ weakness

Plateau phase


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Intermittent cervical collar Anti-inflammatory

Active discouragement of high risk activities

Physiotherapy Regular monitoring/ follow up

Epidural steroid injection


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Severity of disease Nurick 3- 5 Pain

Rate of progression

Compression with severe neuroradiologicfindings Kyphosis

Myelomalcia

Small cord area Cord atrophy


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Posterior approach Laminoplasty

Laminectomy +/- fusion procedures

Anterior approach Multiple anterior diskectomies with fusion

Corpectomy with fusion +/- anteriorinstrumentation

Combined


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Indirect technique Increases transverse diameter and size of

canal

Requires posterior shift of cord to diminisheffect of anterior compression


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Canal expansion by opening the posteriorelements in a trapdoor fashion

effective diameter of the spinal canal from C3to C7 by shifting the laminae dorsally

Osseous posterior arch not completelyremoved

Post op instability reduced muscular and

osseous support preserved


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Decompression of spinal canal by removal ofpart of posterior elements

useful alternative for multiple-leveldecompression in patients with preservedcervical lordosis

Lateral margins are the junctions of thelateral masses and laminae


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May require posterior instrumentation toprevent kyphosis or instability

Visible expansion of the dural sacintraoperatively and pulsation of the durasuggest good canal expansion


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Allows anterior decompression of dura Choice of type depending on location of

compression

Confined to disc@ 1-3 levels anteriorcervical diskectomy + grafting

Disc,PLL,end plates corpectomy with strut

graft


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Direct decompression the removal of disc material and posterior

osteophytes impinging on the spinal cord atthe level of the disc space

cartilaginous end plate is completelyremoved, the thin osseous end platepreserved

Bone graft inserted into interspace


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Advantage Dissection along fascial planes

Relative preservation of stability of spinal column

Low prevalence of graft extrusion

Disadvantage Decreased visalization- incomplete decompression

or injury to cord

Not recommended for primary tx of severe

congenital spinal stenosis


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Removal of the cervical body and interveningdisc

15 to 19-mm central trough is removed fromthe anterior aspect of the vertebral body

provides a safety margin of 5 mm to themedial border of the foramen transversarium

PLL also resected

Defected filled with graft +/- Instrumentation


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Post laminectomy kyphosis Patients with severe osteoporosis

Multilevel corpectomy in 3 or more levels


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No single preferred approach both have been used successfully

Neither is optimal for every patient althougheither may be appropriate

Both approaches give similar results withappropriate patient selection

Various determinants of choice of approach


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No of levels Cervical kyphosis

Instability

Spinal canal size/presence of stenosis

Revision

Surgeons expertise


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Anterior posteriorAdvantages Direct decompression Less loss of motion

Stabilization with arthrodesis Not as technicallydemanding

Correction of deformity Less bracing needed

Good axial pain relief Avoids graft complications

Disavantages

Technically demanding Indirect decompression

Graft complications Late instability

Post op bracing Inconsistent axial painresults

Loss of motionAdjacent segmentdegeneration

Pre op kyphosis/instabilitylimitation


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Approach related Decompression related

Graft related

Long term


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Approach related RL nerve hoarseness

Dysphagia

Upper airway compromise- edema,hematoma


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Decompression related Spinal cord /nv root injury

C5 nerve injury

Vertebral ay injury

Spinal fluid leaks


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Graft related Dislodgement

Fracture

Severe settling into cancellous bone

Displacement with esophageal injury


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Anterior approach Pseudoarthrosis

Adjacent segment degeneration

Laminectomy Post laminectomy kyphosis, Instability with neurological deteroriation

Laminoplasty Inadvertent closure with recurrent stenosis

Incomplete decompression


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Age Shorter duration of symptoms

Single level

Severity of myelopathy before intervention

Larger transverse area of cord Preoperative bladder dysfunction


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Documents

Treatment of Cervical Spondylotic Myelopathy