cervical spondylodic myelopathy: surgical management€¦ · no part of this document may be...
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Cervical spondylodic myelopathy: Surgical
managementEric M. Massicotte, MD, MSc, MBA, FRCSC
Associate ProfessorUniversity of Toronto
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Objectives
✴Definition of Cervical spondylotic myelopathy
✴Research history on CSM
✴Present the results of CSM: North America
✴Understand the indications for surgery
✴Surgical Techniques
I. Radiculopathy‣ Nerve root compression
II. Myelopathy‣ Spinal cord compression
III. Combination
IV. Axial neck pain
Presentation
1. Anatomical sources of pain‣Disc‣Facet joints (includes capsule)‣Muscle‣Tendon‣Ligament‣Vessels‣Bone‣Referred pain‣Organs
2. Pathological Causes‣ Trauma
‣ Genetic influences‣ Infection
‣ Degenerative change‣ Inflammation
‣ Disease‣ Psychosomatic**
3. Biomechanical reasons‣ Hyperlaxity
‣ Joint ‘dysfunction’
‣ Excessive aberrant **Probably strength/flexibility-related
components**‣ Postural decompensation
What are the sources of neck pain?
Nerve root - myotome‣ C5 Deltoid
‣ C5 C6 Bicep‣ C6 C7 Ext. carpi radialis‣ C7 C8 Tricep‣ C8 T1 Flexor digitorum P.‣ C8 T1 Intrinsic
Dermatomalpattern
Nerve root reflex‣ C5-6 Bicep‣ C6-7 Supinator‣ C7-8 Tricep
Clinico-anatomical Correlation
Background of Myelopathy
Cervical spondylotic myelopathy (CSM) is the commonest cause of spinal cord impairment.
There is a lack of evidence regarding the long term outcomes of surgical treatment for CSM.
Often associated with delay in diagnosis and subsequent treatment.
Symptoms‣Pain, numbness, weakness
Signs‣Sensory deficits‣Motor deficits‣Reflexes
-hyper-reflexia -Pathological reflexes (Hoffman plantar reflex)
‣Spasticity‣Sphincter dysfunction (bowel/bladder
incontinence, sexual dysfunction)
PresentationMyelopathy
Variable clinical courses
Mild protracted state
Stepwise deterioration
Relentless progression
1995
2001
Cervical Spondylotic Myelopathy (CSM)
Evidence
AUTHORS' CONCLUSIONS: The available small randomised trials do not provide reliable evidence on the effects of surgery for cervical spondylotic radiculopathy or myelopathy. It is not clear whether the short-term risks of surgery are offset by any long-term benefits.
Surgery for cervical radiculomyelopathyIP Fouyas, PAG Sandercock, PF Statham, C LynchCochrane Database of Systematic Reviews 2008 Issue 1 Status: WithdrawnCopyright © 2008 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.DOI: 10.1002/14651858.CD001466.pub2 This version first published online: 19 April 2006 in Issue 2, 2006Date of Most Recent Substantive Amendment: 30 April 2001
This record should be cited as: Fouyas IP, Sandercock PAG, Statham PF, Lynch C. Surgery for cervical radiculomyelopathy. Cochrane Database of Systematic Reviews 2006, Issue 2. Art. No.: CD001466. DOI: 10.1002/14651858.CD001466.pub2.
All Data prior to 1998
Demographics
Anterior (N=169) Posterior (N=97) Circumferential (N=14) P-value
Age 52.60 62.98 58.14 < .0001
Gender 42% 38 % 36 % n. s.
mJOA 13.48 11.88 11.48 <.0001
Nurick 3.96 4.41 4.43 <.0001
NDI 40.97 43.23 42.57 n.s.
SF36 PCS 36.64 35.41 35.57 n.s.
SF36 MCS 40.23 39.77 38.76 n.s.
# levels 3.07 5.1 4.1 <.0001
Surgical treatment for CSM results in sustained improvement in generic and disease HRQOL
Effective for mild, moderate or severe CSM;
Duration of symptoms impacts on outcome Best results with < 6 mo duration
Discussion
Case presentation
65 year-old manProgressive history of gait ataxia and decreased fine
motor skillsPhysical exam demonstrate a myelopathic patient with
sensory disturbances and proximal weakness in the upper limbs (4+/5)
Case Presentation
Base-line
6 Months
12 Months
Nurick (0-5) 5MJOA (0-18) 7
BBS (0-56) 6
30 MWT Cadence/Seconds
0/0
Dynamometry Kg/F
10
Treatment options
Surgical Approach:Anterior PosteriorHow many and which level?Decompression alone versus
with fusion?
Case Presentation
Base-line
6 Months
12 Months
Nurick (0-5) 5 4 4
MJOA (0-18) 7 11 11
BBS (0-56) 6 26 28
30 MWT Cadence/Seconds
0/0 60/51 sec 60/46 sec
Dynamometry Kg/F
10 22 24
Case Presentation
Base-line
6 Months
12 Months
Nurick (0-5) 3MJOA (0-18) 13
BBS (0-56) 20
30 MWT Cadence/Seconds
65/60
Dynamometry Kg/F
20
Case Presentation
Base-line
6 Months
12 Months
Nurick (0-5) 3 2 1MJOA (0-18) 13 17 17BBS (0-56) 20 44 4330 MWT Cadence/Seconds
65/60 45/40 30/30
Dynamometry Kg/F
20 24 23