Cervical spondylodic myelopathy: Surgical

managementEric M. Massicotte, MD, MSc, MBA, FRCSC

Associate ProfessorUniversity of Toronto

Copyright © 2017 by Sea Courses Inc.

All rights reserved. No part of this document may be reproduced, copied, stored, or transmitted in any form or by any means –graphic, electronic, or mechanical, including photocopying, recording, or information storage and retrieval systems without prior written permission of Sea Courses Inc. except where permitted by law.

Sea Courses is not responsible for any speaker or participant’s statements, materials, acts or omissions.

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

Clinico-anatomical Correlation

Clinico-anatomical Correlation

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.

Cervical Spondylotic Myelopathy: Pathophysiology

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

Research History

CSM North America

CSM International

CSM Protect

Literature Support

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

mJOA

Nurick grading

Nurick

Neck Disability Index (NDI)

SF36v2 - PCS

The improvement in Nurick score was significantly associated with duration of symptoms.

Nurick

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

Presenter

Presentation Notes

What other images are very useful to review? Axial MRI, but also X-ray to look at overall alignment and dynamic x-rays.

C2-3

C3-4

C6-7

Treatment options

Surgical Approach:Anterior PosteriorHow many and which level?Decompression alone versus

with fusion?

a-operative images

Pre-op Post-op

Post-operative CT scan

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

Right versus Left

Right Recurrent Laryngeal

NerveLeftRecurrentLaryngeal

nerve

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

Thank you.

Questions?