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| SYMPOSIUM - CERVICAL SPONDYLOMYELOPATHY |
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| Year : 2019 | Volume
: 2
| Issue : 1 | Page : 68-80 |
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The spine clinics – Cervical spondylotic myelopathy – Clinical scenarios
Ankur Nanda1, KR Renjith2, Abhinandan Mallepally1, C S Vishnu Prasath3, Ajoy P Shetty2
1 Department of Spine Services, Indian Spinal Injuries Center, New Delhi, India
2 Department of Spine Surgery, Ganga Medical Centre and Hospital Pvt Ltd, Coimbatore, India
3 SKS Hospitals, Salem, Tamil Nadu, India
| Date of Web Publication | 11-Jan-2019 |
Correspondence Address:
Dr. Ankur Nanda
Department of Spine Services, Indian Spinal Injuries Centre, Sector - C, Vasant Kunj, New Delhi - 110 070
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/isj.isj_67_18
This section of the symposium deals with different case scenarios related to cervical spondylotic myelopathy (CSM) which in our daily clinical practice not only act as diagnostic challenges but also test our decision-making abilities. These cases have been handled by different experts and hence help the readers in providing a wider perspective to the problem of cervical myelopathy and its management. This section ends with comments by the authors on key takeaway points from each case scenario, and some literature supported recommendations for the management of CSM.
Keywords: Cervical spondylotic myelopathy, diffusion tensor imaging, dynamic magnetic resonance imaging, ossified posterior longitudinal ligament, tandem stenosis
How to cite this article:
Nanda A, Renjith K R, Mallepally A, Prasath C S, Shetty AP. The spine clinics – Cervical spondylotic myelopathy – Clinical scenarios. Indian Spine J 2019;2:68-80 |
How to cite this URL:
Nanda A, Renjith K R, Mallepally A, Prasath C S, Shetty AP. The spine clinics – Cervical spondylotic myelopathy – Clinical scenarios. Indian Spine J [serial online] 2019 [cited 2023 Apr 1];2:68-80. Available from: https://www.isjonline.com/text.asp?2019/2/1/68/249904 |
| Introduction | |  |
Cervical spondylotic myelopathy (CSM) has been described as a progressive process, with intermittent exacerbations of symptoms often followed by periods of static, or only slightly worsening function.[1] Patients may complain of gait abnormalities, numbness or weakness in the upper extremities, diminished fine motor control, and changes in bowel or bladder function with the most severe end-stage being wheelchair-bound tetraplegia. Myelopathic symptoms are largely irreversible, and the limited degree of recovery depends on the severity of the myelopathy at the time of intervention in addition to other factors such as the duration of symptoms and patient age.[2] The literature suggests that surgical decompression may alter the natural history of this disease most typically by halting progression.[3],[4]
Decision-making for the treatment of degenerative cervical myelopathy can be challenging for treating spinal surgeons. There are a number of controversies with regard to the management of CSM. A number of studies with contradictory results are seen in the literature and guidelines are yet to be developed.[5]
Evidence for the efficacy of conservative treatment is scarce, and in moderate-to-severe myelopathy, surgery is generally the only treatment option, given its progressive nature.[6],[7] Risk stratification of symptom progression is important to understand the progression and which patients are more likely to benefit from early surgical intervention. Clear thresholds of symptoms and durations should be determined so that surgeons can make evidence-based decisions. The fundamental strategy entails decompression with or without fusion; secondly surgery aims to restore sagittal alignment and stabilize the cervical spine.
There are various surgical approaches that can accomplish these goals. A decision regarding the optimal surgical approach should take the following factors into consideration: (1) sagittal curvature, (2) locations of the compressive pathology, (3) number of levels involved, and (4) patient age. However, consensus regarding the surgical approach, whether should be made from the anterior or posterior direction is not yet met with. The concept of decompression performed from the side of major compressive factors seems to be straightforward and well accepted. Still, no agreement exists regarding the best approach for decompression.[8]
This edition of spine clinics brings you a few typical and atypical clinical situations with diagnostic dilemma in patients having CSM, where the surgeon chose a particular path of management in the best interest of the patient. It brings out the differences in the management with evidence from literature lacking clarity on the best line of management. Readers can go through any of the cases in detail, presented as clinical case situations by the authors. The key points of all the case scenarios have been summarized in [Table 1]. These clinical scenarios are an effort to help the reader in defining individualized surgical strategies to optimize patient outcomes. | Table 1: Clinical case scenarios in cervical spondylotic myelopathy An overview
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| Hirayama Disease | | |
Clinical scenario 1
A 17-year-old male college student presented to us with progressive weakness of both his hands, more pronounced on the right side, over 1-year duration without any associated pain, sensory deficit, or gait instability. Initially being treated by a neurologist as spinal muscular atrophy, the patient experienced no symptomatic improvement and consulted the author for further evaluation. The symptoms were only unilateral in the beginning, noticed on the right side as reduced grip strength which progressively worsened with the involvement of the left hand in the previous 6 months. His past medical history and family history were noncontributory.
On clinical examination, there was profound weakness and atrophy of his bilateral intrinsic hand muscles with well-maintained bulk of arms and shoulders [Figure 1]. The deep tendon reflexes of upper limbs were absent but preserved in lower limbs. Sensory disturbance, autonomic involvement, and upper motor neuron signs such as Hoffman's sign, Babinski's sign, and exaggerated reflexes were absent. Examination of the lower limbs, cranial nerves, and cerebellar functions was unremarkable. Routine blood investigations, including muscle enzymes, were normal. | Figure 1: Bilateral hands showing intrinsic muscle wasting and finger flexion deformity
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Electrodiagnostic study
Electromyography showed the evidence of chronic denervation without any fasciculations, positive sharp waves, or fibrillation potentials. Sensory studies demonstrated normal parameters whereas motor conduction study showed a bilateral reduction of the distal motor amplitudes of the C7–C8–T1 territories (greater predominance on the right), with normal distal latency and conduction velocity suggestive of pure motor neuropathy.
Imaging
Plain radiographs of the cervical spine revealed no abnormality. Routine magnetic resonance imaging (MRI) of the cervical spine and brachial plexus was unremarkable except for mild thinning of cord at C5–C6 level. No altered intramedullary signals were noted.
Diagnostic dilemma
The differential diagnoses are summarized in [Table 2].
Considering the patient's age, clinical, nerve conduction study, and imaging findings, the possibility of Hirayama disease was suspected, and we performed a forward flexion MRI of the cervical spine. It showed anterior displacement of posterior theca (maximum at C5–C6), cord flattening with obliteration of anterior subarachnoid space, posterior epidural flow voids from C4 to T1 levels, and compression of spinal cord against the vertebral body which are characteristically seen in Hirayama disease [Figure 2]. | Figure 2: (a and b) Magnetic resonance imaging cervical spine T2-weighted midsagittal image in neutral showing cord thinning at C5–C6 level and in flexion showing anterior displacement of posterior theca, cord flattening, and posterior epidural flow voids (Red arrow)
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Treatment options
Hirayama's disease (also known as juvenile muscular atrophy of the distal upper extremity) is a rare, clinical variant of amyotrophic lateral sclerosis responsible for pure motor impairment of the distal upper extremity from C7 to T1 myotomes. Typically affecting young males in their second or third decades, the pattern of involvement is unilateral in most patients and tends to be asymmetrical if involved bilaterally. It is a self-limiting pathology with biphasic development; a progressive phase over 3–4 years followed by a stationary stage. The pathophysiology is thought to be due to dynamic compressive myelopathy of the distal cervical spine caused by the forward displacement of the posterior wall of the lower cervical dural canal with neck flexion. In MRI, the detection of focal spinal cord atrophy in such a patient should prompt one to perform dynamic evaluation of the cervical spine with flexion and extension.
The management options include the following:
- Conservative – cervical collar
- Surgical – anterior/posterior cervical decompression ± fusion
Conservative management using cervical collar or cervical decompression with or without fusion (anterior or posterior) has been the proposed treatment options; however, no general consensus exists. Whatever be the mode of treatment, the basic principle is to prevent repetitive neck flexion movements, thereby avoiding further injury to the cervical cord. In patients who do not improve with cervical collar, surgical management has been shown to have better outcomes by providing a permanent, stable fixation with a shorter immobilization period.[9],[10]
Management
In the presented case, since the condition was progressing rapidly resulting in significant functional disability, the patient was counseled regarding the need for surgical management. Using standardized technique, 3-level anterior cervical discectomy and fusion (ACDF) were performed at C4–C5, C5–C6, and C6–C7 levels along with anterior plating [Figure 3]. Intraoperative and postoperative periods were uneventful. | Figure 3: Postoperative X-rays after C4–C5, C5–C6, C6–C7 anterior cervical discectomy, and fusion with anterior plating
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Follow-up
At 1-year follow-up, the patient had improved grip strength with no further progression of symptoms.
| Tandem Stenosis | | |
Clinical scenario 2
A 53-year-old homemaker female presented to us with complaints of severe bilateral lower limb radiation on walking with inability to walk beyond 100 m for a period of 2 years. She also reported the inability of being able to abduct her shoulders and some amount of numbness in both upper limbs for 2 months with worsening in the symptoms for 2 weeks. She also reported of hesitancy while passing urine. On examination, she was found to have Grade 2 power in bilateral deltoid muscles with power in multiple myotomes in upper and lower limbs between Grades 3 and 4 with exaggerated knee reflex with absent ankle reflex, bilateral Hoffman's positive sign, and mute plantars. There was sensory blunting below C5 level.
Imaging
Plain cervical radiographs showed degenerative changes with multiple osteophytes with cervical kyphosis [Figure 4]a. Plain lumbar dynamic radiographs showed mild degenerative scoliosis in the anteroposterior projection and a Grade I degenerative spondylolisthesis at L4–L5 level with mild translational instability [Figure 4]b. MRI of the cervical spine revealed a large soft disc herniation at C3–C4 level with cord edema with multiple disc bulges at C4–C5, C5–C6, and C6–C7 levels with kyphosis [Figure 5]a. The noncontrast computed tomography (NCCT) cervical spine did not show any ossification at the C3–C4 level [Figure 5]b. MRI of the lumbosacral spine showed severe L4,5 lateral recess stenosis with moderate central stenosis with facet hypertrophy [Figure 5]c. | Figure 4: (a) Preoperative cervical radiograph showing multilevel spondylotic changes with osteophytes with kyphosis and (b) lumbar radiographs showing mild degenerative scoliosis with Grade I, L4–L5 degenerative listhesis with mild instability
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 | Figure 5: (a) Preoperative magnetic resonance imaging showing a large soft disc herniation at C3–C4 level with cord edema with multiple disc bulges at C4–C5, C5–C6, and C6–C7 level with kyphosis, (b) computed tomography scan did not show any ossification at the C3–C4 level, (c) magnetic resonance imaging lumbosacral spine showed severe L4, 5 lateral recess stenosis with moderate central stenosis with facet hypertrophy
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Treatment options
A diagnosis of tandem stenosis due to large soft disc herniation at C3–C4 with cord edema with cervical kyphosis with L4–L5 Grade I listhesis with neurogenic claudication was made. The key decision-making points were whether both regions should be addressed or not, and if both were to be addressed then can they be operated at the same stage or different stages. In addition to be considered whether a cervical kyphosis correction was a priority in the present scenario and if yes what would be the best approach. The options could be broadly outlined as follows:
- C3–C4 ACDF with or without L4–L5 transforaminal lumbar interbody fusion (TLIF) in the same sitting or as a staged procedure
- C3–C5 anterior cervical corpectomy and fusion (ACCF) with or without L4–L5 TLIF in the same sitting or as a staged procedure
- Multilevel ACDF with or without L4–L5 TLIF in the same sitting or as a staged procedure
- Multilevel ACDF with posterior instrumentation and kyphosis correction with or without L4–L5 TLIF in the same sitting or as a staged procedure.
Management
We took a decision to address the cervical pathology in the first stage. The authors felt that patients' primary complaints were more related to neurological deficits due to the large soft herniation and the majority of the cervical kyphosis was between C3 and C5 with C5 inferior endplate being almost horizontal. Hence, a decision was taken to perform a C3–C5 ACCF with partial kyphosis correction in the first stage [Figure 6]a. | Figure 6: (a) Postoperative cervical X-ray after C3–C5 anterior cervical corpectomy and fusion with partial kyphosis correction and (b) Postoperative lumbar spine X-ray after performing L4–L5 transforaminal lumbar interbody fusion 2 months after index surgery
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Follow-up
The patient improved rapidly after the cervical surgery in terms of motor power in both upper and lower limbs and reported improvement in balance. However, she continued to have significant neurological claudication at her 6-week follow-up. Hence, she was again taken up for surgery for lumbar listhesis and a L4–L5 TLIF was performed around 2 months after the primary surgery [Figure 6]b. The patient went on to have a good clinical recovery in the follow-up, though some amount of walking imbalance continues to bother her when walking on a rugged surface.
| Role of Diffusion Tensor Imaging in Cervical Myelopathy | | |
Clinical scenario 3a
A 35-year-old male, mechanic by occupation, had clumsiness of hands with difficulty in doing fine mechanical work in the past 5 months. Symptoms worsened with the onset of gait unsteadiness and numbness of both lower limbs. He also had diffuse axial back pain and neck pain. The patient presented to the hospital when he could not continue with his regular mechanic profession.
On examination, he was found to have unsteady gait; however, he was able to walk without support. Cervical spine and lumbosacral spine range of movements were normal. No spinal tenderness was elicited. Upper and lower limbs motor power was normal. Sensory blunting was present in both lower limbs in L4, L5, and S1 dermatome. Deep tendon reflexes were exaggerated in both upper and lower limbs. Supinator reflex was inverted and hand myelopathic signs were positive. Plantar reflex showed extensor response. Tandem walk was not possible, and Romberg's sign was positive.
Imaging
Cervical spine X-ray showed degenerative changes with maintained lordosis [Figure 7]. There was no instability. MRI cervical spine showed C5–C6 disc osteophyte complex with cord compression and myelomalacic changes [Figure 8]. Cord indentation without much compression was seen at the proximal two levels. Rest of the spinal cord was normal. | Figure 7: Preoperative cervical spine X-ray anteroposterior and lateral view
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 | Figure 8: Preoperative magnetic resonance imaging showing C5–C6 compression in sagittal and axial view
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Diffusion tensor imaging (DTI) was done along with tractography [Figure 9]. DTI indices showed worsening of fractional anisotropy (FA) and apparent diffusion coefficient (ADC) values at C5–C6 level compared to the normal baseline datametrics of DTI. Tractography showed clear-cut cessation of tracts at C5–C6 level.
Management options
The diagnosis of CSM with maximum compression at C5–C6 level with Nurick Grade-3 was made. The treatment options were:
- C4–C5 and C5–C6 anterior cervical discectomy and bone grafting
- C4–C5 and C5–C6 anterior cervical discectomy with bone grafting and plating
- C3–C6 posterior cervical laminectomy ± instrumentation.
Since the compression was predominantly anterior and confined to two segments, it was planned for ACDF with bone grafting.
Management
C4–C5 and C5–C6 anterior cervical discectomy and removal of disc osteophyte complex were performed to decompress the cord [Figure 10]. Appropriate size tricortical iliac crest grafting was done. The patient was mobilized on the next day with cervical collar and discharged on the third postoperative day.
Follow-up
At 2-week follow-up, the patient had improvement in the clumsiness of his hands. At the third-month follow-up, the patient's gait was normalized and he started going to work. Follow-up DTI at 6 months showed improvement in DTI indices in the form of increased FA value and decreased ADC value [Table 3]. Tractography also showed the continuity of tracts [Figure 11]. | Table 3: Fractional anisotropy, apparent diffusion coefficient, and E1, E2 value improved after the surgery
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 | Figure 11: Postoperative magnetic resonance imaging and postoperative diffusion tensor imaging tractography
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Clinical scenario-3b
A 50-year-old male, farmer by occupation, presented with weakness of both upper and lower limbs with gait instability in the past 5 months. Symptoms started with numbness in the lower limbs and gradually progressed to unsteady gait and frequent falls in the field. No history of pain was present. Bladder and bowel functions were normal.
On examination, the patient had walking difficulty in the form of unsteadiness; however, he was able to walk unaided. There was no spinal tenderness and range of movements was normal. Neurological examination revealed the weakness of handgrip with bilateral C8 and T1 segments having 3/5 power. Rest of the muscle groups had normal power. Sensory blunting was noted in hand and foot involving C7, C8, T1, L5, and S1 dermatome. Hand myelopathic signs were positive. Extensor plantar response was noted.
Imaging
X-ray cervical spine [Figure 12] showed mild degenerative changes and ossified posterior longitudinal ligament (OPLL) extending from C2 vertebral body to C5–C6 disc space. Cervical lordosis was maintained and there was no instability. MRI [Figure 13] confirmed the finding of OPLL from C2 to C6 with maximum compression at C4–C5 level. There were no myelomalacic changes seen in the cord. | Figure 12: Preoperative X-ray showing ossified posterior longitudinal ligament from C2 to C5 along with degenerative changes
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 | Figure 13: Preoperative magnetic resonance imaging with axial cuts at maximum compressed level – C4–C5
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DTI was done along with tractography [Figure 14]. DTI indices [Table 4] showed worsening of FA and ADC values at C4–C5 level compared to the normal baseline datametrics of DTI. Tractography showed a clear-cut cessation of tracts at C5 level. | Table 4: Diffusion tensor imaging indices showing worsening of values despite surgical decompression
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Management options
The diagnosis of cervical myelopathy secondary to OPLL with maximum compression at C4–C5 level with Nurick Grade-3 was made. The treatment options were:
- C4 and C5 cervical corpectomy and fusion
- C3–C6 posterior cervical laminectomy ± instrumentation with C2 undercutting
- C3–C6 cervical laminoplasty with C2 undercutting.
Since there were multiple-level compressions and cervical lordosis was well maintained, it was planned for cervical laminoplasty from C3 to C6.
Management
C3–C6 cervical laminoplasty along with C2 undercutting was done decompressing the cervical spinal cord [Figure 15]. The patient was mobilized the next day with cervical collar and discharged on the 3rd postoperative day. | Figure 15: Postoperative magnetic resonance imaging and diffusion tensor imaging tractography
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Follow up
During the follow-up, the patient showed no neurological improvement. He had persistent unsteady gait and weakness of hand grip even at 6 months' follow-up. Follow-up MRI scan at 6 months showed cervical spinal cord completely decompressed [Figure 15]. DTI at 6 months showed further worsening in DTI indices in the form of decreased FA value and increased ADC value compared to the preoperative DTI indices [Table 4]. Tractography also showed discontinuity of tracts at C3–C4 level. The change in the DTI indices seems to be correlating to the clinical recovery; however, at the present level of evidence, preoperative DTI cannot prognosticate postoperative recovery in cervical myelopathic patients.
| Circumferential Cervical Decompression and Fusion | | |
Clinical scenario 4
A 56-year-old male school teacher presented to us with progressive numbness and clumsiness of bilateral hands for 9 months. He denied any preceding trauma or neck pain but reported a definite loss of coordination and feeling of unsteadiness while walking which worsened over the last 3 months. Initially, he took treatment from a nearby hospital and subsequently underwent cervical spine surgery 2 months ago (C6 corpectomy with C5–C7 fusion and anterior plating); however, he had progressive worsening of symptoms postoperatively and was referred to us for further management. There was no bowel or bladder dysfunction, and his medical history was significant only for hypertension.
On examination, his cranial nerve examination was unremarkable. The jaw jerk was not exaggerated and motor examination was normal except for mild weakness of bilateral intrinsic hand muscles (Grade 4/5). The tone was markedly increased in lower limbs with difficulty in tandem walking, and there was generalized hyperreflexia of all four limbs, bilateral positive Hoffman's sign, and equivocal plantar reflexes. His sensory examination revealed decreased dorsal column sensations with a positive Romberg's sign. The modified Japanese Orthopaedic Association (mJOA) score totaled 10/18.
Imaging
The plain cervical radiograph showed C6 corpectomy and reconstruction using bone graft and C5–C7 anterior plating [Figure 16]. There was no evidence of graft migration or implant loosening. Preoperative MRI scan revealed severe central canal stenosis with circumferential compression at C5–C6 level due to posterior disc osteophyte complex, C4–C6 OPLL, and ligamentum flavum hypertrophy [Figure 17]. A small area of myelomalacia was also present within the cord at the same level. The patient was subjected to a fresh MRI scan which showed persistent posterior compression due to the thickened and buckled ligamentum flavum [Figure 18]. Anterior decompression was found adequate. | Figure 16: Plain radiographs showing C6 corpectomy with C5–C7 fusion and anterior plating
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 | Figure 17: T2-weighted sagittal magnetic resonance imaging reveals marked narrowing of the spinal canal at C5/C6 with myelomalacia
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 | Figure 18: Postoperative magnetic resonance imaging scan showing persistent posterior compression due to thickened and buckled ligamentum flavum
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Treatment options
Numerous effective methods for cervical decompression have been described; however, the direction and site of maximum compression (front or back) dictates whether an anterior or posterior procedure should be utilized. The surgical approach is determined by multiple factors such as age, comorbidities, number of levels involved, bone quality, functional status, sagittal alignment, and the presence of instability. Although most cervical spine disorders requiring surgical intervention can be treated with a single operative approach, there remains a subpopulation with a more complex pathology who may benefit from combined approach (single-stage or two-stage). This includes patients requiring decompression involving two or more vertebral levels due to degenerative disease, OPLL or congenital stenosis, or kyphotic deformity, as well as for those with predisposing risk factors for pseudoarthrosis.[11] Furthermore, if outcomes are unsatisfactory after the first-stage operation, a second-stage operation can always be performed.
Management
After counseling the patient and relatives regarding the need for posterior decompression, C3–C7 instrumented laminectomy and fusion was performed using C3–C6 lateral mass screws and C7 pedicle screws. Patient withstood the procedure well, and there were no perioperative ill-events.
Follow-up
At the follow-up visit after 3 months, the patient had almost complete resolution of his sensory symptoms, and his X-ray and MRI scan showed good healing with adequate circumferential decompression [Figure 19] and [Figure 20]. On the final follow-up visit at 2 years, he had significant improvement of his gait instability and the final mJOA score improved to 12/18. | Figure 19: Follow-up X-ray at 3 months showing good healing after C 3-7 instrumented laminectomy
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 | Figure 20: Follow-up magnetic resonance imaging scan at 3 months showing adequate circumferential decompression
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| Ossified Posterior Longitudinal Ligament and Role of Laminoplasty | | |
Clinical scenario 5
A 29-year-old farmer presented to us with complaints of paresthesia of both upper and lower limbs for 2 years. He also reported of unsteadiness of gait and required support for walking for the last 6 months. He had difficulty in buttoning and unbuttoning of shirt and was not going to the fields for the last 1 year. He also reported of difficulty in controlling of urine and increase in frequency for the last 2 months. However, by the time he presented to us, he was already on indwelling catheter for the last 2 days.
On examination, he was found to have Grade 3 power in C8 and T1 myotomes while rest of the myotomes in both upper and lower limbs had normal grade of power. He had normal sensory examination with preserved perianal sensations as well. His reflexes were exaggerated in both upper and lower limbs with bilateral Hoffman's positive sign and extensor plantars. Jaw jerk was found to be negative. His mJOA score was calculated to be 7/18.
Imaging
Plain cervical radiographs showed a mildly lordotic cervical spine with ossification seen behind C2, C3, and C4. The interspinous area between C5–C6 and C6–C7 spinous processes also showed some ossification [Figure 21]a. Dynamic radiographs established moderately preserved mobility and ruled out any instability. MRI of the cervical spine revealed a long sheet of OPLL extending from the upper part of C2 up to C6 with severe cord compression with myelomalacic changes from C2 to C5 [Figure 21]b. The NCCT cervical spine showed a mixed type of OPLL with a combination of the continuous and segmental types from C2 to C6. It also showed some amount of ossified ligamentum flavum at C6–C7 level with interspinous ossification at C5–C6 and C6–C7 levels [Figure 21]c. | Figure 21: (a) Preoperative cervical radiograph showing ossification behind C2, C3, C4 and the interspinous area between C5–C6 and C6–C7 spinous processes, (b) magnetic resonance imaging shows severe cord compression with myelomalacic changes from C2 to C5, and (c) computed tomography scan showed a mixed type of ossified posterior longitudinal ligament from C2 to C6. It also showed some amount of ossified ligamentum flavum at C6–C7 level with interspinous ossification at C5–C6, C6–C7 levels
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Treatment options
In view of the fact that mJOA was 7/18 and the patient had a recent-onset urinary retention, the surgery becomes imperative. The dilemma in such cases is whether one should approach the pathology anteriorly for a direct decompression or take a posterior approach and aim for an indirect decompression. Type of surgical procedure to be undertaken is yet another decision which depends on multiple factors such as age, sagittal alignment of cervical spine, levels of involvement, type of OPLL, dural ossification, K-line, amount of canal compromise, and presence of instability. The options for this case could be broadly outlined as follows:
- Cervical laminectomy C3–C7 with C2 undercutting
- Cervical laminectomy C3–C7 with C2 undercutting with instrumentation from C2 to C7/T1
- Cervical laminoplasty C3–C7 with C2 undercutting with or without mini-plate fixation
- Multilevel ACDF and plating with excision of OPLL
- Multilevel combined ACCF and ACDF with plating with excision of OPLL.
Management
This young patient had a preserved cervical lordosis and cervical mobility, with multilevel OPLL of a combined variety falling to the front of the K-line as assessed on plain radiographs. Hence, we decided to do a cervical laminoplasty C3–C7 with C2 undercutting with mini-plate fixation [Figure 22]a. This allowed the patient to have a good decompression [Figure 22]b with preservation of cervical movement and also minimized the chances of developing any postoperative cervical kyphosis. | Figure 22: (a) Postoperative X-ray showing cervical laminoplasty C3–C7 with C2 undercutting with mini-plate fixation and (b) postoperative magnetic resonance imaging showing a good cord fall back with adequate decompression
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Follow-up
The patient had good symptomatic improvement in the immediate postoperative period with the paresthesia reducing significantly. The patient went on to regain bladder control and began self-voiding around 4 months later. He improved in terms of his balance and was able to walk without support in plain areas. The grip strength, however, did not improve to normal grade and neither was he able to return to full-time farming.
| Comments and Recommendations | | |
The case scenarios discussed above include both typical cases which we see in our clinical practice and atypical cases which pose a diagnostic challenge to us. The first case of Hirayama disease clearly brings out the role of dynamic imaging, especially the flexion-extension MRI which can prove to be a very useful investigational tool in situ ations where the clinician feels that there is poor clinic-radiological correlation. On the other hand, the second case of tandem stenosis brings out the value of thorough clinical evaluation in this modern world where a plethora of investigational tools is available to us. The authors chose to operate the lumbar spine in a staged manner; however, there are plenty of reports wherein surgeons have gone ahead and done both the surgeries in the same sitting. There is no consensus on this, as factors, such as age, comorbidities, prominence of relevant symptoms and surgeon experience also play a role in decision-making.
The third case introduces a new evaluative approach toward spondylotic cervical myelopathy in the form of DTI. This technique helps both in the early diagnosis of myelopathy even before the myelomalacic changes in the cord have become apparent and also may help in prognosticating the recovery pattern with the help of postoperative DTI. However, it must be understood that this technique and our understanding of its implications is in very early stages. It requires to be further studied in larger studies before we can accept it as the standard of care. The fourth case of circumferential decompression and fusion stresses on the importance of good preoperative planning and readers must realize that there are some complex cases wherein a single approach alone may not solve the clinical problem. We must anticipate these issues and also make our patients aware regarding the same. One must not shy away from postoperative imaging in cases of doubt to check the adequacy of our surgical procedures.
The last case wherein a laminoplasty was done for OPLL in a young farmer brings out the importance of considering multiple factors in your surgical decision-making. The authors went ahead and did a laminoplasty for the patient as the patient was young, had a maintained lordosis and preserved mobility with an extensive continuous OPLL at multiple levels with deteriorating neurology.
CSM is a major cause of disability, particularly in elderly patients. Awareness and understanding of CSM are imperative to facilitate early diagnosis and management. Surgical decompression is known to be the only effective treatment option for advanced CSM. The optimal surgical approach is still under debate and can vary depending on the location of the spinal cord compression, number of levels involved, sagittal alignment, instability, associated axial neck pain, risk factors for pseudarthrosis, and patient comorbidities. It may seem intuitive to approach the spinal canal from the direction which dominates cord compression. Excluding some specific situations where one approach has a clear advantage over the other, the most recent meta-analyses indicate that both approaches show similar neurological recovery and quality of life improvement.
Currently, there are no widely accepted guidelines that outline how to best manage patients with mild (mJOA score of 15–17), moderate (mJOA score of 12–14), or severe (mJOA score of <11) disease, or nonmyelopathic patients with evidence of cord compression.[12] It is essential that the surgeon identifies patients at high risk of neurological deterioration, defines the role of nonoperative and operative management in each patient, and determines which patients are most likely to benefit from surgical intervention.
Based on available literature and experience, the authors recommend surgical intervention for patients with severe CSM, surgical intervention for patients with moderate CSM, and in patients with mild CSM offer surgical intervention or a supervised trial of structured rehabilitation. If initial conservative management is pursued, operative intervention is to be considered in the presence of neurological deterioration or if the patient fails to improve. Nonmyelopathic patients with evidence of cord compression without signs and symptoms of radiculopathy should be counseled as to potential risks of progression, educated about relevant signs and symptoms of myelopathy, and be followed clinically and in nonmyelopathic patients with image evidence of cord compression and clinical and/or electrophysiological evidence of radiculopathy offer either surgical intervention or nonoperative treatment consisting of close serial follow-up or a supervised trial of structured rehabilitation.[13]
The ultimate goal is to improve outcomes and reduce morbidity in patients with CSM by making evidence-informed decisions. Patients' expectations and characteristics should be carefully considered preoperatively. Surgeons may also have to consider their own experiences and familiarity with each technique.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
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| 3. | Fehlings MG, Skaf G. A review of the pathophysiology of cervical spondylotic myelopathy with insights for potential novel mechanisms drawn from traumatic spinal cord injury. Spine (Phila Pa 1976) 1998;23:2730-7. |
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| 9. | Hassan KM, Sahni H. Nosology of juvenile muscular atrophy of distal upper extremity: From monomelic amyotrophy to Hirayama disease – Indian perspective. Biomed Res Int 2013;2013:478516. |
| 10. | Imamura H, Matsumoto S, Hayase M, Oda Y, Kikuchi H, Takano M, et al. Acase of Hirayama's disease successfully treated by anterior cervical decompression and fusion. No To Shinkei 2001;53:1033-8. |
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| 13. | Fehlings MG, Tetreault LA, Riew KD, Middleton JW, Aarabi B, Arnold PM, et al. Aclinical practice guideline for the management of patients with degenerative cervical myelopathy: Recommendations for patients with mild, moderate, and severe disease and nonmyelopathic patients with evidence of cord compression. Global Spine J 2017;7:70S-83S. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17], [Figure 18], [Figure 19], [Figure 20], [Figure 21], [Figure 22]
[Table 1], [Table 2], [Table 3], [Table 4]
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