Cervical MyelopathyCervical Myelopathy

Operative treatmentOperative treatment

George SapkasGeorge SapkasProfessor of OrthopaedicsProfessor of Orthopaedics

““Metropolitan” HospitalMetropolitan” HospitalN. FaliroN. Faliro

Athens GreeceAthens Greece

Myelopathy Myelopathy - Canal dimensions- Canal dimensions

17 mm (13 – 20 mm) midsagital diameter17 mm (13 – 20 mm) midsagital diameter< 13 mm – congenital stenosis< 13 mm – congenital stenosis

– Cord dimensionsCord dimensions10 mm (8.5 – 11.5), 90 – 100 mm10 mm (8.5 – 11.5), 90 – 100 mm22

< 60 mm< 60 mm22 (Penning et al, 1986) (Penning et al, 1986)Better recovery > 40 mmBetter recovery > 40 mm22, A-P ratio > 0.40, A-P ratio > 0.40

– Vascular factorsVascular factorsBrieg et al, 1952 – spondylosis leads to Brieg et al, 1952 – spondylosis leads to decreased flow in anterior brancesdecreased flow in anterior brances

– Dynamic factorsDynamic factorsHyperextensionHyperextensionPincer effectPincer effectHypermobility above stiff segmentHypermobility above stiff segmentDynamic cord and vascular changesDynamic cord and vascular changes

– Cord degenerationCord degenerationIrreversible cord changes – demyelination, Irreversible cord changes – demyelination, cavitation, gliosis, wallerian degenerationcavitation, gliosis, wallerian degeneration

Natural history Natural history

Neck pain – RadiculopathyNeck pain – Radiculopathy

43% complete resolution43% complete resolution25% mild residual pain25% mild residual pain32% moderate or severe pain32% moderate or severe painRadicular symptoms – less Radicular symptoms – less favourablefavourableTreatment did not influence Treatment did not influence outcomeoutcome

(Gore et al. Spine 1987)(Gore et al. Spine 1987)

Myelopathy Myelopathy

Did not follow radiculopathy Did not follow radiculopathy Episodic progression, static disability for yearsEpisodic progression, static disability for yearsProgressive deterioration rareProgressive deterioration rare

(Lees et al, BMJ 1963)(Lees et al, BMJ 1963)

Disability established early Disability established early Static periods for many yearsStatic periods for many years

(Nurick, Brain 1972)(Nurick, Brain 1972)

67% steady progressive deterioration67% steady progressive deterioration(Symon et al, Neurology 1967)(Symon et al, Neurology 1967)

Poor prognosis Poor prognosis Non improvement if symptoms > 2 yearsNon improvement if symptoms > 2 years

(Phillips, J. Neur. 1973)(Phillips, J. Neur. 1973)

Clinical evaluationClinical evaluation

Radiculopathy Radiculopathy

Look for specific dermatomal distribution Look for specific dermatomal distribution to painto painShoulder abduction signShoulder abduction signSpurling signSpurling signC3, C4 – diaphragm involvementC3, C4 – diaphragm involvementC5 – dermatome – epaulet, Deltoid ? C5 – dermatome – epaulet, Deltoid ? Biceps reflexBiceps reflexC6 – dermatome – radial forearm and C6 – dermatome – radial forearm and hand, muscles, biceps reflexhand, muscles, biceps reflexC7 – dermatome – long finger – medial C7 – dermatome – long finger – medial scapula, muscles, triceps reflexscapula, muscles, triceps reflexC8 – dermatome – ulnar hand and C8 – dermatome – ulnar hand and forearm, finger flex -intrinsicsforearm, finger flex -intrinsics

Cont…

Myelopathy Myelopathy

Medial Medial Lateral Lateral CombinedCombinedVascular Vascular

(Ferguson & Caplan)(Ferguson & Caplan)

Transverse lesionTransverse lesionMotor system Motor system Central cordCentral cord

(Grandall & Bartzdorf)(Grandall & Bartzdorf)

Brachial and cord syndromeBrachial and cord syndrome(Brown & Sequard)(Brown & Sequard)

Neck pain 50%Neck pain 50%Radicular pain 38%Radicular pain 38%Radiating pain 27%Radiating pain 27%Bladder – Bowel 44%Bladder – Bowel 44%

(Grandall & Bartzdorf 62 pts)(Grandall & Bartzdorf 62 pts)Cont…

Unsteady gaitUnsteady gaitAtaxicAtaxicSpastic Spastic Romberg’sRomberg’sReflexesReflexesHyperflexiaHyperflexiaClonusClonusAbsent supf reflexesAbsent supf reflexesPathologic reflexesPathologic reflexesSensory examinationSensory examinationLight touchLight touchSharp touchSharp touchVibration - proprioceptionVibration - proprioception

Cont…

MyelopathyMyelopathy’s’s hand hand

ClumsinessClumsinessIntrinsic wasting Intrinsic wasting Finger escape signFinger escape signGrip and release testGrip and release test

– Watch out for:Watch out for:Multiple sclerosisMultiple sclerosisALSALSSubacute combined degenerationSubacute combined degenerationPeripheral neuropathyPeripheral neuropathyTumors - infectionTumors - infection

Cervical anginaCervical anginaChronic breast painChronic breast painFacial painFacial painSpurs – dysphagia, Spurs – dysphagia, dysphonia, dyspneadysphonia, dyspneaVertebral artery thrombosisVertebral artery thrombosisHemiparesisHemiparesisSympathetic involvementSympathetic involvementCombined with lumbar Combined with lumbar stenosis – peripheral stenosis – peripheral neuropahyneuropahy

Atypical clinical presentations Atypical clinical presentations of cervical spondylosisof cervical spondylosis

Nurick grading of disability Nurick grading of disability based on gait abnormalitybased on gait abnormality

Grade IGrade I No difficulty in walkingNo difficulty in walking

Grade IIGrade II Mild gait involvement. Does not interfere with Mild gait involvement. Does not interfere with employmentemployment

Grade III Grade III Gait abnormality prevents employmentGait abnormality prevents employment

Grade IVGrade IV Able to ambulate only with assistanceAble to ambulate only with assistance

Grade VGrade V Chairbound or bedriddenChairbound or bedridden

Imaging studiesImaging studies

Flexion and extension views can be added to Flexion and extension views can be added to evaluate the dynamic properties of the cervical evaluate the dynamic properties of the cervical spinespinePlain radiography can demonstrate:Plain radiography can demonstrate:

Congenital stenosisCongenital stenosisSpondylotic segmentsSpondylotic segmentsForaminal narrowingForaminal narrowingDegenerative subluxationDegenerative subluxationCongenital malformation Congenital malformation Autofused spinal segmentsAutofused spinal segmentsOsteochondrosis of the nucleous puplosusOsteochondrosis of the nucleous puplosusSpondylosis of the annulus fibrosis Spondylosis of the annulus fibrosis Vacuum phenomenon and disk space height lossVacuum phenomenon and disk space height lossReactive sclerosis of the endplatesReactive sclerosis of the endplatesSchmorl´s nodes Schmorl´s nodes

M.R.IM.R.I

Progressive neurologic Progressive neurologic deficitdeficitDisabling weakness Disabling weakness Long tract signsLong tract signsCervical radiculopathy with Cervical radiculopathy with failure to improve following 6 failure to improve following 6 – 8 weeks of conservative – 8 weeks of conservative measures measures Vertebral body destruction Vertebral body destruction or instability detected on or instability detected on plain film plain film

Myelography - Computed tomographyMyelography - Computed tomographyProvides excellent details and differentiation of bone Provides excellent details and differentiation of bone versus soft tissue lesionsversus soft tissue lesionsIndicated when MRI fails to provide sufficient detail or Indicated when MRI fails to provide sufficient detail or does not match clinical findingsdoes not match clinical findingsStudy of choice in the presence of severe degenerative Study of choice in the presence of severe degenerative changes and in the presence of significant endplate changes and in the presence of significant endplate osteophytesosteophytesModic found MRI to be as sensitive as CT myelography at Modic found MRI to be as sensitive as CT myelography at detecting disease level, but less specific in terms of detecting disease level, but less specific in terms of distinguishing bony from soft tissue impingement distinguishing bony from soft tissue impingement DisadvantagesDisadvantages√ Intrathecal contrast administration and risk to spinal cord rootsIntrathecal contrast administration and risk to spinal cord roots√ Exposure to radiationExposure to radiation

CT-Myelography can be considered a complementary CT-Myelography can be considered a complementary study to a MRI scanstudy to a MRI scan

3–D3–D scan scan

Electrodiagnostic studiesElectrodiagnostic studies

Applied when clinical examination and imaging Applied when clinical examination and imaging fail to provide a clear diagnosis or perhaps fail to provide a clear diagnosis or perhaps conflicting diagnosesconflicting diagnosesMay include needle electromyelography, May include needle electromyelography, somatosensory evoked potentials or cervical root somatosensory evoked potentials or cervical root stimulationstimulationOperator dependedOperator dependedMay help differentiate primary cervical disorders May help differentiate primary cervical disorders from peripheral nerve entrapments syndromes or from peripheral nerve entrapments syndromes or pain eminating from the intrinsic shoulder pain eminating from the intrinsic shoulder pathologypathology

Treatment Treatment

ConservativeConservativeOperative Operative

Cervical Myelopathy can be painless Cervical Myelopathy can be painless and have an insidious onsetand have an insidious onset..

Myelopathy Myelopathy

Conservative care of spondylotic Conservative care of spondylotic myelopathy limitedmyelopathy limitedObservation of myelopathy Observation of myelopathy caused by soft disc herniation is caused by soft disc herniation is acceptable with close attention to acceptable with close attention to progression of signs or symptomsprogression of signs or symptoms

– Options include:Options include:Immobilization of the neck with an Immobilization of the neck with an orthosis and rest to reduce neural orthosis and rest to reduce neural irritationirritationTraction or epidural steroids not Traction or epidural steroids not recommendedrecommended

Cont…

Surgical indicationsSurgical indications

Three basic goals Three basic goals

Decompression of neural elementsDecompression of neural elementsStabilization of unstable segmentsStabilization of unstable segmentsAblation of painful articulationsAblation of painful articulations

MyelopathyMyelopathy

Surgical indicationsSurgical indicationsA diagnosis of cervical spondylotic myelopathy is A diagnosis of cervical spondylotic myelopathy is almost always an indication for surgeryalmost always an indication for surgeryParticulary important factorsParticulary important factors

Progression of signs or symptomsProgression of signs or symptomsPresence of myelopathy for six months or longerPresence of myelopathy for six months or longerCanal – vertebral body diameter ratio approaching Canal – vertebral body diameter ratio approaching 0.40.4Difficulty walking Difficulty walking Loss of balanceLoss of balanceBowel of bladder incotinenceBowel of bladder incotinenceSignal changes within the substance of the spinal Signal changes within the substance of the spinal cordcord

In patients with rheumatoid arthritis, myelopathy In patients with rheumatoid arthritis, myelopathy caused by AAI, basilar invagination or subaxial caused by AAI, basilar invagination or subaxial instability should to be addressed surgically in a instability should to be addressed surgically in a timely manner `timely manner `

Myelopathy Myelopathy

Operative treatmentOperative treatment– OptionsOptions

Anterior procedureAnterior procedure√ Discectomy(ies) and stabilizationDiscectomy(ies) and stabilization√ Corpectomy(ies) and stabilizationCorpectomy(ies) and stabilization

Posterior proceduresPosterior procedures√ LaminectomiesLaminectomies√ Laminectomies and stabilizationLaminectomies and stabilization√ Laminoplasty Laminoplasty

Anterior proceduresAnterior procedures

Indications Indications

Better for central soft disc Better for central soft disc herniation or bilateral herniation or bilateral radiculopathy on the radiculopathy on the same levelsame levelUnilateral soft disc or Unilateral soft disc or foraminal stenosisforaminal stenosis1 or 2 level spondylotic 1 or 2 level spondylotic myelopathymyelopathy

Contra-IndicationContra-Indication

Cervical stenosis due Cervical stenosis due to pathology of the to pathology of the posterior elementsposterior elements

Anterior decompression and fusion (bone graft)

Anterior decompression and stabilization with Mesh cylinder and plate

Anterior decompression and stabilization expandable cages and plate

Ε.Δ. F 60

20/7/99

1ST POP

Vertebrectomy and stabilization Mesh cylinder and plate

Anterior Cervical Corpectomy(ies) fusion and stabilization

Advantages

• allows for more complete cord decompression

• may be safer better visualizationless distraction

• higher fusion rate

• less levels to fuse

Disadvantages Disadvantages PseudarthrosisPseudarthrosisGraft dislodgement Graft dislodgement Implants failureImplants failure

Posterior proceduresPosterior procedures

Indications Indications

Unilateral disc herniation or foraminal Unilateral disc herniation or foraminal stenosisstenosisCervical spondylotic myelopathyCervical spondylotic myelopathy due to due to >> 3 level pathology3 level pathology– Congenital stenosisCongenital stenosis– Ossification of posterior longitudinal ligament Ossification of posterior longitudinal ligament

(OPLL)(OPLL)

Cervical stenosis due to degeneration – Cervical stenosis due to degeneration – hypertrophy of posterior cervical hypertrophy of posterior cervical elementselementsPrior anterior cervical procedures (Prior anterior cervical procedures (±)±)

The cervical spine must be in lordosis

Contra-Contra-indicationsindications

Pre-existed cervical Pre-existed cervical kyphosiskyphosisPathology of the anterior Pathology of the anterior vertebral elements (vertebral elements (±)±)

Laminoplasty

Laminoplasty

Laminectomy and stabilization

withplates – rods and screws

Γ.ΠΜ 66Ν(+)

Γ.ΠΜ 66Ν(+)

Γ.ΠΜ 66Ν(+)Γ.Π

Μ 66Ν(+)

Γ.ΠΜ 66Ν(+)

ComplicationsComplicationsPitfalls Pitfalls

Dysphagia Dysphagia Esophageal InjuriesEsophageal InjuriesVocal cord paralysis Vocal cord paralysis after anterior cervical after anterior cervical spine surgeryspine surgerySpinal cord injury Spinal cord injury Incidental durotomy Incidental durotomy Epidural HenatomaEpidural HenatomaPostolaminectomy kyphosisPostolaminectomy kyphosisCervical pseudartrhosisCervical pseudartrhosisProblems related to instrumentationsProblems related to instrumentations

Anterior procedure

Inadequate decompression

Implants failure(plate removal)

Laminoplastyfracture of the bony hinge

Post-laminectomy instability

Post-laminectomy instabilityswan-neck deformity

Conclusions Conclusions

TreatmentTreatment

ConservativeConservative Operative Operative Neck painNeck pain MainlyMainly Rarely Rarely

RadiculopathyRadiculopathy OftenOften OftenOften

MyelopathyMyelopathy Rarely Rarely Mainly Mainly