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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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