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Cervical spondylotic myelopathy
This document discusses the diagnosis and treatment of cervical spondylotic myelopathy. It begins with a brief history of the condition and its early treatments. It then covers the epidemiology, pathophysiology, clinical presentation, diagnostic imaging, and grading scales used to evaluate the severity of myelopathy. Key points include the natural degenerative processes that cause spinal canal narrowing, common symptoms like neck stiffness and leg weakness, and the use of MRI to identify cord/canal compression and signal changes indicative of edema or cystic necrosis. Surgical intervention aims to decompress the spinal cord through procedures like laminectomy or laminoplasty to relieve pressure on the spinal cord.
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Introduction to the topic and presenters of the session on Diagnosis and Treatment of Cervical Spondylotic Myelopathy.
Historical references to cervical disorders and surgeries, mentioning key figures and early surgical interventions leading up to modern understandings.
Statistics highlighting the prevalence of cervical spondylosis in males and females, emphasizing its common occurrence and impact.
Details on the degenerative processes of cervical spondylosis, including disc degeneration, reduced spinal canal size, and disc herniation.
Description of ossification of the posterior longitudinal ligament (OPLL), its prevalence, and its connection to various health factors.
Normal measurements of cervical spinal canal diameter and implications for cervical spondylosis.
Clinical symptoms associated with cervical spondylotic myelopathy including neurologic deficits, symptoms of weakness, and abnormal reflexes.
Japanese Orthopaedic Association criteria for evaluating upper and lower extremity functions and sensory responses in cervical myelopathy patients.
Various imaging modalities, such as X-rays and MRIs, detailing their roles in diagnosing cervical spondylotic myelopathy.
An overview of non-operative and operative treatments for cervical myelopathy, including indications for surgical treatment.
Description of surgical procedures for cervical spondylosis, including complications and issues associated with acute care.
Details on complications post-surgery, comparative studies on outcomes of various surgical approaches, and specific surgical considerations.
Outcomes and evidence from studies comparing laminoplasty with laminectomy in patients with cervical myelopathy.
Summary of the necessity of surgical intervention for patients with CSM and emphasizing the importance of patient-specific evaluations.
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Cervical spondylotic myelopathy
- 1. DIAGNOSIS AND TREATMENTOFDIAGNOSIS AND TREATMENT OFDIAGNOSIS AND TREATMENT OFDIAGNOSIS AND TREATMENT OF CERVICAL SPONDYLOTICCERVICAL SPONDYLOTIC MYELOPATHYMYELOPATHY MODERATORMODERATOR-- DR SDR S SS KALEKALE PRESENTERPRESENTER-- DR ANAND V KDR ANAND V K DEPARTMENT OF NEUROSURGERYDEPARTMENT OF NEUROSURGERY AIIMS, NEW DELHIAIIMS, NEW DELHI
- 2. History of CervicalSpondylosisHistory of Cervical Spondylosis Earliest references to cervical disorders causingEarliest references to cervical disorders causing neurological deteriorationneurological deteriorationeu o og ca de e o a oeu o og ca de e o a o –– StrumpellStrumpell 18881888 –– Marie 1898Marie 1898Marie 1898Marie 1898 •• (Marie(Marie--StrumpellStrumpell Disease=Disease=AnkylosingAnkylosing spondylitisspondylitis)) –– VonVon BecktrenBecktren 18991899–– VonVon BecktrenBecktren 18991899 HorselyHorsely in 1892 performed firstin 1892 performed first surgical intervention for myelopathysurgical intervention for myelopathysurgical intervention for myelopathysurgical intervention for myelopathy –– C6 laminectomyC6 laminectomy Patient had full recovery within one yearPatient had full recovery within one year–– Patient had full recovery within one yearPatient had full recovery within one year
- 3. SpurlingSpurling andand ScovilleScoville(1940) described(1940) described foraminalforaminalSpurlingSpurling andand ScovilleScoville (1940) described(1940) described foraminalforaminal decompression.decompression. Brain et al (1952) define the etiologyBrain et al (1952) define the etiologyBrain et al (1952) define the etiologyBrain et al (1952) define the etiology pathophysiologypathophysiology of CSM.of CSM. Robinson and Smith (1955)Robinson and Smith (1955) ClowardCloward (1958)(1958)Robinson and Smith (1955),Robinson and Smith (1955), ClowardCloward (1958)(1958) described anterior cervical discectomy and fusion.described anterior cervical discectomy and fusion. Bailey andBailey and BadgleyBadgley (1960) published(1960) published onlayonlay strutstrutBailey andBailey and BadgleyBadgley (1960) published(1960) published onlayonlay strutstrut grafting.grafting. HirabayashiHirabayashi et alet al-- Open door laminoplasty.Open door laminoplasty.abayasabayas et aet a Ope doo a op astyOpe doo a op asty
- 4. Epidemiology of CervicalEpidemiologyof Cervicalp gyp gy SpondylosisSpondylosis Prevalence in malesPrevalence in males Age 30, 13%Age 30, 13% Age 70, 100%Age 70, 100% Prevalence in femalesPrevalence in females %%Age 40, 5%Age 40, 5% Age 70, 96%Age 70, 96% Cervical spondylotic myelopathy is the mostCervical spondylotic myelopathy is the mostCervical spondylotic myelopathy is the mostCervical spondylotic myelopathy is the most common cause of spastic paraparesis orcommon cause of spastic paraparesis or d i id i iquadriparesis.quadriparesis.
- 5. Pathophysiology of CervicalPathophysiologyof Cervical SpondylosisSpondylosisSpondylosisSpondylosis Reduction in spinal canal diameter is the primaryReduction in spinal canal diameter is the primaryp p yp p y degenerative process.degenerative process. Disc Degeneration.Disc Degeneration. 3rd decade begins a progressive decline in water3rd decade begins a progressive decline in water content of disc due to loss of glycosaminoglycanscontent of disc due to loss of glycosaminoglycans 90% water at age 20, 70% at age 8090% water at age 20, 70% at age 80g , gg , g Loss of water, protein, mucopolysaccharides with age allow theLoss of water, protein, mucopolysaccharides with age allow the nucleus pulposus to become smaller and more fibrous.nucleus pulposus to become smaller and more fibrous. The annulus fibrosis takes on more weight bearingThe annulus fibrosis takes on more weight bearingThe annulus fibrosis takes on more weight bearingThe annulus fibrosis takes on more weight bearing responsibility.responsibility. Loss of disc height occurs.Loss of disc height occurs.oss o d sc e g t occu soss o d sc e g t occu s Annulus begins to bulgeAnnulus begins to bulge Disc becomes an indistinct mass of fibrocartilage.Disc becomes an indistinct mass of fibrocartilage.
- 6. Pathophysiology of CervicalPathophysiologyof Cervical SpondylosisSpondylosis Osteophytic bars form likely to stabilizeOsteophytic bars form likely to stabilize adjacent vertebrae by increasing theadjacent vertebrae by increasing theadjacent vertebrae by increasing theadjacent vertebrae by increasing the weight bearing of the endplates.weight bearing of the endplates. Uncinate process hypertrophy occurs,Uncinate process hypertrophy occurs, encroaching on the intervertebralencroaching on the intervertebralencroaching on the intervertebralencroaching on the intervertebral foramina.foramina.
- 7. Pathophysiology of CervicalPathophysiologyof Cervical S d l iS d l iSpondylosisSpondylosis Disc herniationDisc herniationDisc herniationDisc herniation –– Layers of annulus fibrosis are thinner dorsally, leadingLayers of annulus fibrosis are thinner dorsally, leading t t d di t i l h i ti t i l i tt t d di t i l h i ti t i l i tto tears and disc material herniating posteriorly intoto tears and disc material herniating posteriorly into the canal.the canal. Spondylotic SpursSpondylotic SpursSpondylotic SpursSpondylotic Spurs –– Annulus dissects away from the PLL and endplates,Annulus dissects away from the PLL and endplates, leaving exposed boneleaving exposed boneleaving exposed bone.leaving exposed bone. –– Bare edges of dorsal vertebral bodies form reactiveBare edges of dorsal vertebral bodies form reactive bone ( subperiosteal reaction).bone ( subperiosteal reaction).bone ( subperiosteal reaction).bone ( subperiosteal reaction). -- Extend along the ventral aspect, encroach on nervousExtend along the ventral aspect, encroach on nervous tissue.tissue.
- 8. OPLLOPLLOPLLOPLL -- It isa misnomerIt is a misnomer -- Ossification is an entity by itself of ossificOssification is an entity by itself of ossific process.process. -- Commonly involves cervical spine in middle &Commonly involves cervical spine in middle & elderly age.elderly age. -- Cytokine related abnormal bone growth,Cytokine related abnormal bone growth, HLAHLA related genotype aberration, diabetes,related genotype aberration, diabetes, VitVit--DD deficiency, genetic recessive transmission.deficiency, genetic recessive transmission.
- 10. OPLLOPLL -- Most commonin JapanMost common in Japanpp (burning candle variety)(burning candle variety) -- Not rare in IndiaNot rare in India Overall incidence is 5%Overall incidence is 5%-- Overall incidence is 5%.Overall incidence is 5%.
- 12. Physiological Measurements ofPhysiologicalMeasurements of th C i l S ith C i l S ithe Cervical Spinethe Cervical Spine Pavlov's Ratio:Pavlov's Ratio: ≥1 is normal.≥1 is normal. ≤ 0.85 abnormal.≤ 0.85 abnormal. • A canal diameter of 17 mm or greater at the mid• A canal diameter of 17 mm or greater at the mid vertebral body level is considered normal.vertebral body level is considered normal. < 10< 10--13 mm are at risk for symptomatic13 mm are at risk for symptomatic spondylosisspondylosis..y py p p yp y
- 13. THE DIAMETER OFTHEDIAMETER OF CERVICAL SPINAL CANALCERVICAL SPINAL CANAL C1 22.1C1 22.1 C2 18.8C2 18.8 C3 16 2C3 16 2C3 16.2C3 16.2 C4 15.8C4 15.8 C5 15 7C5 15 7C5 15.7C5 15.7 C6 15.6C6 15.6 C7 15.9C7 15.9
- 14. Pincer mechanism inextensionPincer mechanism in extensionPincer mechanism in extensionPincer mechanism in extension Pinching forcesPinching forces compromisecompromisecompromisecompromise micro circulationmicro circulation -->> I h i i t h dI h i i t h dIschemia in watershed areaIschemia in watershed area Edema andEdema and cavitationcavitation..
- 15. Progression of cervicalkyphosis,Progression of cervical kyphosis, loss of lordosisloss of lordosisloss of lordosisloss of lordosis AA, the, the nonpathologicalnonpathological state, in which the dorsal vertebral bodystate, in which the dorsal vertebral body height is less than the ventral vertebralheight is less than the ventral vertebral body height, results in normal cervical lordosis.body height, results in normal cervical lordosis. B, loss of the ventral discB, loss of the ventral disc interspaceinterspace height, which occurs with the natural degenerative process, results inheight, which occurs with the natural degenerative process, results in loss of lordosis. This causes elongation of the moment arm applied to the spine (D), leading to ventralloss of lordosis. This causes elongation of the moment arm applied to the spine (D), leading to ventral vertebral body compression.vertebral body compression. C, a further exaggeration of pathologicalC, a further exaggeration of pathological kyphotickyphotic posture may then ensue,posture may then ensue,
- 16. CLINICAL PRESENTATIONCLINICAL PRESENTATION SymptomsSymptoms ––Neck stiffness (early complaint)Neck stiffness (early complaint)Neck stiffness (early complaint)Neck stiffness (early complaint) –– Leg weakness, stiffnessLeg weakness, stiffness –– Gait abnormalitiesGait abnormalities –– Difficulty with fine motor movements and tasksDifficulty with fine motor movements and tasks with hands. “Clumsywith hands. “Clumsy myelopathicmyelopathic Hands”Hands” –– Loss of bladder or bowel sphincter controlLoss of bladder or bowel sphincter control SignsSignsgg –– Abnormal reflexesAbnormal reflexes –– Hyperactive DTR, clonus, spasticity, Babinski, Hoffman,Hyperactive DTR, clonus, spasticity, Babinski, Hoffman, inverted radialinverted radial reflex,Lhermitte’sreflex,Lhermitte’s sign.sign.
- 17. contdcontd CLINICAL SYNDROMES:CLINICAL SYNDROMES: --Transverse lesion syndrome : End stageTransverse lesion syndrome : End stage CSTCST andand STT, dorsal columnSTT, dorsal column -- Motor system syndromeMotor system syndrome -- Central cord syndromeCentral cord syndrome -- BrownBrown--SequardSequard syndromesyndrome -- BrachialgiaBrachialgia and cord syndromeand cord syndromegg yy Crandall PCrandall P BatzdorfBatzdorf U et al: CervicalU et al: Cervical spondyliticspondylitic myelopathy Jmyelopathy J NeurosurgNeurosurgCrandall P,Crandall P, BatzdorfBatzdorf U et al: CervicalU et al: Cervical spondyliticspondylitic myelopathy. Jmyelopathy. J NeurosurgNeurosurg 25:5725:57--66,196666,1966..
- 18. Japanese Orthopaedic AssociationCriteria for the Evaluation of Operative Results in Patients with Cervical Myelopathy* I. Upper extremity function I ibl i h i h h i k (0 i )Impossible to eat with either chopsticks or spoon (0 points) Possible to eat with spoon, but not with chopsticks (1 point) Possible to eat with chopsticks but inadequate (2 points) Possible to eat with chopsticks but awkward (3 points) Normal (4 points) II. Lower extremity function Impossible to walk (0 points)Impossible to walk (0 points) Need cane or aid on flat ground (1 point) Need cane or aid only on stairs (2 points) Possible to walk without cane or aid, but slow (3 points) Normal (4 points) III. Sensory Upper extremity Apparent sensory loss (0 points) Minimal sensory loss (1 point) Normal (2 points) Lower extremity Apparent sensory loss (0 points) Minimal sensory loss (1 point) Normal (2 points)Normal (2 points) Trunk Apparent sensory loss (0 points) Minimal sensory loss (1 point) Normal (2 points) IV. Bladder function Complete retention (0 points)p ( p ) Severe disturbance (1 point) Inadequate evacuation of bladder Straining Dribbling of urine Mild disturbance (2 points) Urinary frequency U i h itUrinary hesitancy Normal (3 points) *Total normal score = 17 points.
- 19. Nurick Grades forthe Severity of Myelopathyy p y Grade Findings 0 Signs or symptoms of root involvement but without evidence of spinal cord diseasep 1 Signs of spinal cord disease but no difficulty in walking 2 Slight difficulty in walking that does not prevent fulltime employment 3 Difficulty in walking that prevents full-time employment or the ability to do all houseworkor the ability to do all housework 4 Able to walk only with someone else’s help or with the aid of a frame 5 Chair bound or bedridden
- 20. DIAGNOSTIC RADIOLOGYDIAGNOSTIC RADIOLOGY XX--RAYSRAYS DiDiDiscspaceDisc space narrowing /narrowing / osteophytes, loss ofosteophytes, loss of lordosis,lordosis, uncovertebraluncovertebral hypertrophy canalhypertrophy canalhypertrophy, canalhypertrophy, canal diameter, Neuraldiameter, Neural foraminaforamina Dynamic X ray :Dynamic X ray : instabilityinstability
- 21. DIAGNOSTIC RADIOLOGYDIAGNOSTIC RADIOLOGY MRI:standardMRI: standardMRI: standardMRI: standard diagnostic testdiagnostic test Cord / SAS /Cord / SAS /Cord / SAS /Cord / SAS / Disc / IntrinsicDisc / Intrinsic tumors / Signaltumors / Signalgg changeschanges /Nerve roots//Nerve roots/ Li t /S ftLi t /S ftLigament /SoftLigament /Soft tissue .tissue .
- 22. MRI SIGNAL CHANGESMRISIGNAL CHANGES 280 Pts (1996280 Pts (1996 -- 2005)2005)280 Pts (1996280 Pts (1996 2005)2005) Follow up of 108 Pts , 71 Pts MRI data availableFollow up of 108 Pts , 71 Pts MRI data available T2 WI → EdemaT2 WI → Edema MyelomalaciaMyelomalacia Gliosis InflammationGliosis InflammationT2 WI → Edema,T2 WI → Edema, MyelomalaciaMyelomalacia, Gliosis, Inflammation, Gliosis, Inflammation T1 WI → cystic necrosisT1 WI → cystic necrosis 3 level grading system3 level grading system3 level grading system3 level grading system Grade I HSI on T2 (1 disc level) no change on T1Grade I HSI on T2 (1 disc level) no change on T1 Grade II HSI on T2 (>1 disc level) no change on T1Grade II HSI on T2 (>1 disc level) no change on T1Grade II HSI on T2 (>1 disc level) no change on T1Grade II HSI on T2 (>1 disc level) no change on T1 Grade III Hypo intensity on T1Grade III Hypo intensity on T1 MitsuruMitsuru YagiYagi et al: Longet al: Long--Term surgical outcome and risk factors in patients with cervical myelopathy and aTerm surgical outcome and risk factors in patients with cervical myelopathy and a change in signal intensity ofchange in signal intensity of intramedullaryintramedullary spinal cord on magnetic resonance imaging; Jspinal cord on magnetic resonance imaging; J NeursurgNeursurg SpineSpine 12/5912/59--65/201065/2010
- 23. Summary ofSummary ofintramedullaryintramedullary signal intensity change on MRsignal intensity change on MR images in 50 patientsimages in 50 patients JOA Score (mean ± SD) Grade No. of pts Preop 1 yr Postop At Final FU I 10 9.2 ± 1.6 14.1 ± 1.9 13.9 ± 1.4 II 19 10 4 ± 1 1 14 4 ± 1 9 12 8 ± 1 4II 19 10.4 ± 1.1 14.4 ± 1.9 12.8 ± 1.4 III 21 8.1 ± 1.3 11.9 ± 1.1 11.0 ± 1.3 Mitsuru Yagi et al: Long-Term surgical outcome and risk factors in patients with cervical myelopathy and a change in signal intensity of intramedullary spinal cord on magnetic resonance imaging; J Neursurg Spine 12/59-65/2010
- 24. ContdContd…… NCCT : Sizeand shapeNCCT : Size and shapepp of canal / osteophyticof canal / osteophytic ridges / Kyphosis /OPLLridges / Kyphosis /OPLL CT myelography:CT myelography: Invasive / Used for whoInvasive / Used for who t d MRIt d MRIcan not undergo MRIcan not undergo MRI -- Useful to define bonyUseful to define bony t d lt d lanatomy and neuralanatomy and neural foramina / Excellentforamina / Excellent definition of herniateddefinition of herniated Eli M. Baron, M.D et al; CSM: A Brief review of its definition of herniateddefinition of herniated disc and Spondyloticdisc and Spondylotic ridges.ridges. , ; pathophysiology, clinical course , and diagnosis . Neurosurg /Vol 60/1/jan 2007 suppl
- 25.
- 26. TREATMENTTREATMENT NONNON OPERATIVEOPERATIVENONNON ––OPERATIVEOPERATIVE OPERATIVEOPERATIVEOPERATIVEOPERATIVE
- 27. NonoperativeNonoperative Treatment ofCSMTreatment of CSM Intermittent cervical immobilization in a softIntermittent cervical immobilization in a soft collarcollarcollar.collar. AntiAnti--inflammatory medications.inflammatory medications. B d tB d tBed rest.Bed rest. Active discouragement of highActive discouragement of high--risk activities.risk activities. A id f h i l l diA id f h i l l diAvoidance of physical overloading.Avoidance of physical overloading. Exposure to cold.Exposure to cold. Movement on slippery surfaces.Movement on slippery surfaces. Manipulation therapies.Manipulation therapies. Vigorous or prolonged flexion of the head.Vigorous or prolonged flexion of the head.
- 28. Medical Therapy ofCervicalMedical Therapy of Cervical S d l iS d l iSpondylosisSpondylosis SteroidsSteroids doubtful valuedoubtful valueSteroidsSteroids -- doubtful valuedoubtful value Physical TherapyPhysical Therapy Supervised isometric exercises do produce clinicallySupervised isometric exercises do produce clinically–– Supervised isometric exercises do produce clinicallySupervised isometric exercises do produce clinically significant improvement in pain.significant improvement in pain. –– Cervical Traction therapy widely used but studies areCervical Traction therapy widely used but studies areCervical Traction therapy widely used, but studies areCervical Traction therapy widely used, but studies are poor quality and flawed.poor quality and flawed. • Intermittent traction, 10• Intermittent traction, 10--20 lbs, 15 minutes, 3 times per day20 lbs, 15 minutes, 3 times per dayp yp y –– SwezeySwezey, et al 1999: Retrospective study found that, et al 1999: Retrospective study found that cervical traction provided symptomatic relief in 81% ofcervical traction provided symptomatic relief in 81% of patientspatientspatients.patients.
- 29. Choosing the OperativeProcedureChoosing the Operative ProcedureChoosing the Operative ProcedureChoosing the Operative Procedure Sagittal alignmentSagittal alignment Extent of diseaseExtent of disease Location of abnormalityLocation of abnormality Previous operationsPrevious operationspp
- 30. Indications for OperativeIndicationsfor Operative Treatment of Cervical MyelopathyTreatment of Cervical Myelopathy Progressive clinicalProgressive clinical myelopathymyelopathy with evidence ofwith evidence of spinal stenosis.spinal stenosis.pp Progression of a neurological deficit.Progression of a neurological deficit.g gg g The failure of neurological findings to improveThe failure of neurological findings to improveThe failure of neurological findings to improveThe failure of neurological findings to improve with nonwith non--operative treatment (> 12 wks).operative treatment (> 12 wks).
- 31. CLINICORADIOLOGICAL FACTORSCLINICORADIOLOGICAL FACTORS CG OC G OINDICATING OPERATIVE TREATMENTINDICATING OPERATIVE TREATMENT Myelopathic hands/ Unsteady gait /Myelopathic hands/ Unsteady gait / Weakness / Spasticity / Bowel, bladderWeakness / Spasticity / Bowel, bladderWeakness / Spasticity / Bowel, bladderWeakness / Spasticity / Bowel, bladder involvement.involvement. Midsagittal diameter < 13mmMidsagittal diameter < 13mmgg VertebralVertebral olisthesisolisthesis > 3.5 mm> 3.5 mm Pincer diameter (dynamic stenosis) < 12 mmPincer diameter (dynamic stenosis) < 12 mmPincer diameter (dynamic stenosis) 12 mmPincer diameter (dynamic stenosis) 12 mm MRIMRI –– signal changes (T2WI high signalsignal changes (T2WI high signal intensity).intensity).y)y)
- 32. Illustration depicting theradiographic criteriaIllustration depicting the radiographic criteria used in the assessment of cervical stenosis andused in the assessment of cervical stenosis and myelopathymyelopathymyelopathy.myelopathy. a, Thea, The midsagittalmidsagittal diameter of thediameter of the spinal canal is measured as the distance from thespinal canal is measured as the distance from the middle of the dorsal surface of the vertebralmiddle of the dorsal surface of the vertebral body to the nearest point on the spinolaminarbody to the nearest point on the spinolaminarbody to the nearest point on the spinolaminarbody to the nearest point on the spinolaminar line. Patients in whom the osseous canalline. Patients in whom the osseous canal measures <13 mm are considered to bemeasures <13 mm are considered to be developmentally stenotic.developmentally stenotic. b, A distance of <12 mm fromb, A distance of <12 mm from thethe posteroinferior corner of a vertebral body to theposteroinferior corner of a vertebral body to the anterosuperior edge of the lamina of theanterosuperior edge of the lamina of the immediately caudal vertebra with the neck inimmediately caudal vertebra with the neck in extension is suggestive of dynamic stenosis.extension is suggestive of dynamic stenosis. c Olisthesis of >3 5 mmc Olisthesis of >3 5 mm is a measure ofis a measure ofc, Olisthesis of >3.5 mmc, Olisthesis of >3.5 mm is a measure ofis a measure of excessive translation between the vertebralexcessive translation between the vertebral bodies.bodies.
- 33. THE GOALS OFOPERATIVETHE GOALS OF OPERATIVE TREATMENTTREATMENTTREATMENTTREATMENT PRIMARY GOALPRIMARY GOALPRIMARY GOALPRIMARY GOAL:: -- To prevent deteriorationTo prevent deterioration -- Reverse the myelopathyReverse the myelopathy Decompressing the spinal cordDecompressing the spinal cord Stabilizing the spineStabilizing the spine Secondarily improving cord perfusionSecondarily improving cord perfusion SECONDARY GOALSECONDARY GOAL:: -- Achieve successful fusionAchieve successful fusion -- Prevent late deformityPrevent late deformity
- 34. Surgical Treatment ofCervicalSurgical Treatment of Cervicalgg SpondylosisSpondylosis Overview :Overview : ACDFACDF ACCFACCF Posterior cervicalPosterior cervical foraminotomyforaminotomy Cervical laminectomy and fusionCervical laminectomy and fusion Cervical laminoplastyCervical laminoplasty N t h i M lti l bliN t h i M lti l bli ttNewer techniques : Multiple obliqueNewer techniques : Multiple oblique corpectomycorpectomy Endoscopic techniquesEndoscopic techniques
- 35. Operative Options forand Issues Related toOperative Options for and Issues Related to A t i S i l A h t CSMA t i S i l A h t CSMAnterior Surgical Approaches to CSMAnterior Surgical Approaches to CSM ACDFACDFACDFACDF -- Removal of disc/ posterior osteophytesRemoval of disc/ posterior osteophytes -- End plates are completely removedEnd plates are completely removed -- Distraction of disc space results in indirectDistraction of disc space results in indirect decompression of foramendecompression of foramen -- Insertion of appropriate sized bone graft (2mm)Insertion of appropriate sized bone graft (2mm) AdvantagesAdvantages -- Relative preservation of stabilityRelative preservation of stability -- Low prevalence of graft extrusionLow prevalence of graft extrusion
- 36. ContdContd…… DisadvantagesDisadvantagesDisadvantagesDisadvantages -- Less exposureLessexposure Ri k f i l t d iRi k f i l t d i-- Risk of incomplete decompressionRisk of incomplete decompression -- Accelerated disease at adjacent levelAccelerated disease at adjacent level N d d f i l C l iN d d f i l C l i-- Not recommended for congenital Canal stenosisNot recommended for congenital Canal stenosis
- 37. COMPLICATIONS OF ACDFCOMPLICATIONSOF ACDFCOMPLICATIONS OF ACDFCOMPLICATIONS OF ACDF Donor site morbidityDonor site morbidityDonor site morbidityDonor site morbidity Graft extrusionGraft extrusion C llC llCollapseCollapse Non unionNon union PseudarthrosisPseudarthrosis If plating is usedIf plating is used Screw breakageScrew breakage Screw migrationScrew migration SoftSoft-- tissue injurytissue injury
- 38. CERVICAL CORPECTOMYCERVICAL CORPECTOMYCERVICALCORPECTOMYCERVICAL CORPECTOMY Complete removal of vertebral body, adjacentComplete removal of vertebral body, adjacent dididiscdisc Removal of large osteophytesRemoval of large osteophytes Removal of PLLRemoval of PLL Central decompression of 15mm at C3, 19mmCentral decompression of 15mm at C3, 19mm t C6 id f t i f 5 t tht C6 id f t i f 5 t that C6 provides safety margin of 5mm to theat C6 provides safety margin of 5mm to the medial border of foramen transversarium.medial border of foramen transversarium. I tI t i di t f d t d ii di t f d t d iIntraopIntraop indicators of adequate decompressionindicators of adequate decompression -- 1515--19 mm wide trough19 mm wide trough Vi l fi ti f i l dVi l fi ti f i l d-- Visual confirmation of spinal cordVisual confirmation of spinal cord decompressiondecompression
- 39. Fusion TechniquesFusion TechniquesFusionTechniquesFusion Techniques ClowardCloward techniquetechnique -- Uses cylindrical boneUses cylindrical boneClowardCloward techniquetechnique Uses cylindrical boneUses cylindrical bone dowel from iliac crestdowel from iliac crest -- Circular hole of 10 x14mm hole drilledCircular hole of 10 x14mm hole drilled -- Bone graft sits on softBone graft sits on soft cancellouscancellous bonebone above and belowabove and belowabove and belowabove and below Disadvantages:Disadvantages: -- Fusion is less stableFusion is less stableFusion is less stableFusion is less stable -- No distractionNo distraction Risk of collapseRisk of collapse-- Risk of collapse.Risk of collapse. Melvin D. Law et al: Evaluation and Management of CSM; J Bone JointMelvin D. Law et al: Evaluation and Management of CSM; J Bone Joint SurgSurg / 76:1420/ 76:1420--1433/19941433/1994
- 40. contdcontd Smith Robinson Technique:most commonly usedSmith Robinson Technique: most commonly used -- Uses horseshoeUses horseshoe –– shaped graft (height 6shaped graft (height 6--10mm)10mm) -- Ends plate preparedEnds plate prepared -- 2mm posterior shelf created in the superior aspect2mm posterior shelf created in the superior aspect of inferior VB to prevent migrationof inferior VB to prevent migration Ad tAd tAdvantages:Advantages: -- Provides distraction → Opens the foraminaProvides distraction → Opens the foramina -- Provides most stable constructProvides most stable construct -- Reduces invagination ofReduces invagination of ligamentumligamentum flavumflavum Disadvantages:Disadvantages:Disadvantages:Disadvantages: -- Difficult to decompress root directlyDifficult to decompress root directly Li it d i ibilitLi it d i ibilit-- Limited visibilityLimited visibility -- Difficult to remove osteophytesDifficult to remove osteophytes MelvinMelvin D.LawD.Law et al : Evaluation and Management of CSM; J Bone Jointet al : Evaluation and Management of CSM; J Bone Joint SurgSurg / 76:1420/ 76:1420--1433/19941433/1994
- 41. RROLE OF ANTERIORPLATINGOLE OF ANTERIOR PLATING Appropriate plate length is selectedAppropriate plate length is selected Distance of 5mm between the ends of plate andDistance of 5mm between the ends of plate andDistance of 5mm between the ends of plate andDistance of 5mm between the ends of plate and adjacent disc to be maintainedadjacent disc to be maintained S h ld b l d i d b tiS h ld b l d i d b tiScrew should be placed in a dense bone tissueScrew should be placed in a dense bone tissue Use locking mechanism to resist screw pulloutUse locking mechanism to resist screw pullout Ad tAd tAdvantages:Advantages: Improves the rate of fusionImproves the rate of fusion Reduces length of postop immobilizationReduces length of postop immobilizationReduces length of postop immobilizationReduces length of postop immobilization Does not add substantially to duration of surgeryDoes not add substantially to duration of surgery Less postop kyphosisLess postop kyphosisp p ypp p yp Decreases the prevalence of graft related complicationsDecreases the prevalence of graft related complications
- 42. contdcontd……contdcontd…… Disadvantages:Disadvantages: Screw breakageScrew breakage MigrationMigration Softtissue injurySoft tissue injury D h iD h iDysphagiaDysphagia Plate fatiguePlate fatigue Raj D.Raj D. RaoRao et al : Operative treatment of CSM : J Bone Jointet al : Operative treatment of CSM : J Bone Joint SurgSurg /88/88 //16191619--16401640 //20062006
- 43. Illustration depicting commonIllustrationdepicting commonp gp g anterior procedures used inanterior procedures used in cervical myelopathy.cervical myelopathy. A, Anterior cervicalA, Anterior cervical discectomy and insertion of adiscectomy and insertion of a bone spacer for fusionbone spacer for fusionbone spacer for fusion.bone spacer for fusion. B, Anterior cervicalB, Anterior cervical corpectomy and insertioncorpectomy and insertion of aof a bone strut graft.bone strut graft. C, Anterior cervicalC, Anterior cervical discectomy followed bydiscectomy followed by insertion of a bone spacer forinsertion of a bone spacer for fusionfusion and anterior plating.and anterior plating. D,D, Anterior cervical corpectomy,Anterior cervical corpectomy, strut graft insertion andstrut graft insertion andstrut graft insertion, andstrut graft insertion, and anterior platinganterior plating..
- 44. Fi 3Fi 3F d 3F d 3 G R di h d ft th ti t d ith t f th C5G R di h d ft th ti t d ith t f th C5Figs. 3Figs. 3--F and 3F and 3--G Radiographs made after the patient was managed with corpectomy of the C5G Radiographs made after the patient was managed with corpectomy of the C5 and C6 vertebral bodies, strutand C6 vertebral bodies, strut--grafting with use of a titanium mesh cage packed with localgrafting with use of a titanium mesh cage packed with local autogenous bone, and the application of an anterior cervical plate from C4 to C7.autogenous bone, and the application of an anterior cervical plate from C4 to C7.
- 45. MULTIPLE OBLIQUE CORPECTOMYMULTIPLEOBLIQUE CORPECTOMY Prospective study 268 pts.Prospective study 268 pts. 527 levels527 levels -- decompresseddecompressed C2C2--C3C3 –– 15, C315, C3––C4C4 -- 69, C469, C4--C5C5 –– 138, C6138, C6--C7C7 –– 99, C799, C7--T1T1--44 MOC doneMOC done 1 level1 level –– 108, 2 level108, 2 level-- 87, 3 level87, 3 level--57, 4 level57, 4 level-- 18, 5 level18, 5 level --44 OT tiOT ti 129 i (92129 i (92 183 i )183 i )OT timeOT time --129 min (92129 min (92--183 min).183 min). Blood lossBlood loss –– 68ml68ml Group (m JOA range) Preop No. of Patients (%) Postop No. of Patients (%) I (0–4) 0 9 (3.4) II (5–9) 178 (66.4) 20 (7.5) III (10–13) 90 (33.6) 98 (36.6) IV (14–17) 0 141 (52.6)IV (14 17) 0 141 (52.6) Salvatore Chibbaro et al : Multilevel oblique corpectomy without fusion in managing CSM : Long-term outcome and stability evaluation in 268 pts. J. Neursurg: Spine/vol10 may2009
- 46. ContdContd…… Indication: Acquired multilevel CSM (anterior)Indication: Acquired multi level CSM (anterior) C t i di ti k h i t iC t i di ti k h i t iContraindication: kyphosis, posteriorContraindication: kyphosis, posterior compressioncompression Ad antages M lti le el s rger completeAd antages M lti le el s rger completeAdvantages: Multi level surgery ,completeAdvantages: Multi level surgery ,complete decompression anteriorly , no need fordecompression anteriorly , no need for instrumentation / fusion avoiding the scar ofinstrumentation / fusion avoiding the scar ofinstrumentation / fusion, avoiding the scar ofinstrumentation / fusion, avoiding the scar of previous anterior surgeryprevious anterior surgery Disadvantages: Bilateral foramenDisadvantages: Bilateral foramenDisadvantages: Bilateral foramenDisadvantages: Bilateral foramen decompression can not be achieved.decompression can not be achieved. Complications:Complications: HornersHorners, XI N injury, VA injury, XI N injury, VA injurypp , j y, j y, j y, j y Salvatore Chibbaro et al : Multilevel oblique corpectomy without fusion in managing CSM : Long- term outcome and stability evaluation in 268 pts. J. Neursurg: Spine/vol10 may2009
- 47. Evidentiary summary ofstudies examiningEvidentiary summary of studies examining laminoplasty or laminectomy withlaminoplasty or laminectomy with arthrodesisarthrodesis asas compared to anterior surgery for CSM*compared to anterior surgery for CSM* Authors & year Description of study Commentsy p y Lee et al 2007 348 patients who underwent ACDF (n = 121) or ACCF (n = 173) over 4-yr period. FU over 2 yrs in 310 patients Patients were Overall prevalence for dysphagia at 1, 2, 6, 12, & 24 months was 54.0, 33.6, 18.6, 15.2, & 13.6%, respectively The prevalence of dysphagia was found to2007 over 2 yrs in 310 patients. Patients were prospectively interviewed at 1, 2, 6, 12, & 24 mos regarding the presence & subjective severity of dysphagia using the dysphagia grading system defined by Bazaz et al.† Proportion analysis (chi-square or Fisher t t t) l ti & 95% CI respectively. The prevalence of dysphagia was found to be significantly higher in women, after revision surgery, & with > 2-level surgery. N o statistical difference in dysphagia rates was seen between ACDF & ACCF. This study was graded Class III due to unbalanced allocation of study groups since the ACCF group had a greater ti f i 3 l l ( 0 01) & th fexact test), prevalence ratios, & 95% CIs were used to compare the prevalence of dysphagia w/ age, sex, type of surgery (e.g., discectomy vs corpectomy, primary vs revision), use of instrumentation, number & location of surgical levels. proportion of surgeries >3 levels (p < 0.01) & the use of fixation was surgeon dependent. Nirala et al 2004 201 patients who underwent multilevel anterior cervical decompression & fusion w/o fixation using autograft. ACDF (n = 69) or ACCF (n = 132) over a 10-yr period. ACDF had 69.6% fusion rate vs ACCF 93.9% (p = 0.0001). Within subgroups, 2-level ACDF had 86.7% fusion vs 1-level ACCF (96.3%). 3-level ACDF had 57.6% vs 2-level ACCF (92.4%). 4-level ACDF had Radiological outcomes in followed using dynamic radiographs. Patients wore a hard cervical collar for 3 mos. Outcomes using Odom’s criteria. 50% fusion vs 3-level ACCF (91.7%). O dom’s criteria (good/excellent) similar in both groups. More graft dislodgements in ACCF (3.8%) vs ACDF (1.4%). Class III due to biased allocation (more Pott’s disease in ACCF) & unblinded radiographic assessment
- 48. Authors & yearDescription of study Comments Swank et al Allograft tricortical iliac crest reconstruction Non-union: ACDF 42% vs ACCF 31% 2-level ACDF Swank et al 1997 Allograft tricortical iliac crest reconstruction & anterior cervical plating were studied in 64 patients (38 ACDF & 26 ACCF). The average FU was 39 mos. Hard cervical collar for 4–6 wks. Outcome assessed w/ plain radiographs. Clinical outcomes were subjective Non union: ACDF 42% vs ACCF 31%. 2 level ACDF 36% vs 1-level ACCF 10%. 3 level ACDF 54% vs 2 level ACCF 44%. C lass III due to biased allocation of groups (constrained plates had a higher fusion rate than dynamic; more of dynamic plates in ACDF group; retrospective nature also leads to bias; no blinding of radiographic assessors) Clinical outcomes subjectivesubjective. radiographic assessors). Clinical outcomes subjective. Wang et al 2001 Anterior decompression/fusion over 2 levels w/ iliac crest & plate fixation in 52 patients (20 ACCF & 32 ACDF). Average FU was 3.6 yrs. Hard cervical collar for 6–8 wks. Outcome w/ dynamic radiographs & Odom’s criteria. Fusion rates were not statistically significant (p = 0.385). The clinical results of the surgeries were similar between the groups based on Odom's criteria. The addition of cervical plates to either 2-level ACDF or single-level ACCF yielded similar fusion & complication rates. 1 nonunion in ACCF group. No difference in graft collapsecriteria. nonunion in ACCF group. No difference in graft collapse (1 mm in both groups) or kyphosis (1° in both groups) Odom’s outcomes similar. Class III due to biased allocation & unblinded outcome assessors
- 49. Posterior Surgery inCSMPosterior Surgery in CSMg yg y LaminectomyLaminectomy -- Useful alternative for multiple level D/CUseful alternative for multiple level D/C Elderly ptsElderly pts-- Elderly ptsElderly pts -- All levels of stenosis should be includedAll levels of stenosis should be included -- Inclusion of C2 and T1Inclusion of C2 and T1 ------ ↑ instability↑ instability -- Adequacy of D/C to be confirmedAdequacy of D/C to be confirmed
- 50. INDICATIONS FOR LAMINECTOMYINDICATIONSFOR LAMINECTOMYINDICATIONS FOR LAMINECTOMYINDICATIONS FOR LAMINECTOMY Single or multilevel diseaseSingle or multilevel disease Congenital stenosisCongenital stenosis To access intradural pathologyTo access intradural pathology Operative factorsOperative factors –– decreasing riskdecreasing risk Combined supplementary procedure in anteriorCombined supplementary procedure in anterior and posterior approachand posterior approachp ppp pp Need to perform posterior instrumentation.Need to perform posterior instrumentation.
- 51. CONTRAINDICATIONS FORCONTRAINDICATIONS FOR LAMINECTOMYLAMINECTOMYLAMINECTOMYLAMINECTOMY Nt lN t l k h tik h ti iiNeutral orNeutral or kyphotickyphotic spinespine Children and young adultsChildren and young adults Loss of anterior column support from tumor,Loss of anterior column support from tumor, trauma, infectiontrauma, infection Complications:Complications: -- Neurological worseningNeurological worsening -- KyphoticKyphotic deformitydeformity -- InjuriesInjuries -- Blood lossBlood loss YoumansYoumans neurologicalneurological surgsurg 55thth editionedition
- 52. LAMINECTOMYLAMINECTOMYLAMINECTOMYLAMINECTOMY For multilevel →identify C2 spinous processFor multilevel → identify C2 spinous process Use the drill inner cortical bone thinned outUse the drill inner cortical bone thinned out Use 1mmUse 1mm KerrisonKerrison Transect lamina /Transect lamina / liglig flavumflavumgg Remove one level above and one belowRemove one level above and one below Width should be to the lateral aspect of DuraWidth should be to the lateral aspect of DuraWidth should be to the lateral aspect of DuraWidth should be to the lateral aspect of Dura Facet to be preservedFacet to be preserved Confirm the adequacyConfirm the adequacyConfirm the adequacyConfirm the adequacy
- 53. INSTRUMENTATION FOLLOWINGINSTRUMENTATION FOLLOWING LAMINECTOMYLAMINECTOMYLAMINECTOMYLAMINECTOMY Providesimmediate stabilityProvides immediate stability Obviates dynamic factors contributing toObviates dynamic factors contributing toObviates dynamic factors contributing toObviates dynamic factors contributing to cord compressioncord compression O iO iOptions:Options: InterfacetInterfacet wiringwiringInterfacetInterfacet wiringwiring Facet wiringFacet wiring Lateral mass platesLateral mass platesLateral mass platesLateral mass plates
- 54. CERVICAL LAMINECTOMYCERVICAL LAMINECTOMY-- OUTCOMEOUTCOMEOUTCOMEOUTCOME 50patients over a 4 year period50 patients over a 4 year period50 patients over a 4 year period50 patients over a 4 year period All presented with symptomatic cervical myelopathyAll presented with symptomatic cervical myelopathy –– 33 male 17 female33 male 17 female33 male, 17 female33 male, 17 female –– Clinical assessmentClinical assessment NurickNurick gradinggrading All patients underwentAll patients underwent multisegmentmultisegment cervicalcervicalAll patients underwentAll patients underwent multisegmentmultisegment cervicalcervical laminectomy with lateral mass fixationlaminectomy with lateral mass fixation Patients followed up at 6 weeks 3 months 6Patients followed up at 6 weeks 3 months 6Patients followed up at 6 weeks, 3 months, 6Patients followed up at 6 weeks, 3 months, 6 months, and one yearmonths, and one year LaliLali H.S.SekhonH.S.Sekhon et al : Posterior cervical decompression and fusion for circumferentialet al : Posterior cervical decompression and fusion for circumferential spondyloticspondylotic cervical stenosiscervical stenosis : Review of 50 consecutive cases; J Clinical: Review of 50 consecutive cases; J Clinical NeursurgNeursurg/ 23/ 23--36 /36 / 20062006
- 55. Table 1Table 1 Patientdemographics n=50,(meanPatient demographics n=50,(mean ±± s.ds.d)) Male 33 Female 17 Average age (years) 63±12 4Average age (years) 63±12.4 Diabetes 12% Smoker 14% Clinical myelopathy 95% Cord signal change on sagittal T2W MRI scan 75% Preoperative Nurick grade 1.93±2.5 Preoperative Oswestry Neck Disability Score 25.7±3.6 Preoperative circumferential cord compression 100% Preoperative C2/C7 angle 13.4· ± 14.3·p / g Lali H.S.Sekhon et al: Posterior cervical decompression and fusion for circumferential spodylotic cervical stenosis : Review of 50 consecutive cases; J Clinical Neursurg/ 23-36 / 2006
- 56. Table 2:Table 2: Resultssummary (Results summary (meanmean±±s.ds.d))y (y ( )) Total levels instrumented 138 A l l i t t d 2 88±1 00Average levels instrumented 2.88±1.00 Total number of screws placed 376 Postoperative Nurick grade 1.21± 1.2 Postoperative circumferential cord compression 0% Postoperative Oswestry Neck Disability Score 1.66 ± 7.1 Worsening of preoperative deformity with screw 4%Worsening of preoperative deformity with screw pullout 4% Reoperation? 2% Adjacent segments requiring surgery 2%Adjacent segments requiring surgery 2% Range of follow-up (months) 12-50 Average follow-up (months) 30.1 ± 9.03 Postoperative C2/C7 angle 13.4º ± 14.3º Lali H.S.Sekhon : Posterior cervical decompression and fusion for circumferential spodylotic cervical stenosis : Review of 50 consecutive cases; J Clinical Neursurg/ 23-36 / 2006
- 57. O SO SLAMINOPLASTYLAMINOPLASTY HirabayashiHirabayashi(1983 )(1983 ) Several modificationsSeveral modificationsSeveral modificationsSeveral modifications Increases the effective diameter (C3Increases the effective diameter (C3--C7)C7) Retains the covering of posterior laminar boneRetains the covering of posterior laminar boneRetains the covering of posterior laminar boneRetains the covering of posterior laminar bone Minimizes instabilityMinimizes instability Li it D l t i ti b id lLi it D l t i ti b id lLimits Dural constriction by epidural scarLimits Dural constriction by epidural scar Obviates the need for fusionObviates the need for fusion
- 58. TYPES OF LAMINOPLASTYTYPESOF LAMINOPLASTY Single door laminoplastySingle door laminoplasty Single door laminoplasty with use of boneSingle door laminoplasty with use of bone graftgraft Single door laminoplasty with use ofSingle door laminoplasty with use of miniplates and screwsminiplates and screws Double door laminoplastyDouble door laminoplastyp yp y R j DR j D RR t l O ti t t t f CSM J B J i tt l O ti t t t f CSM J B J i t SS /88/88 //16191619 16401640 //20062006Raj D.Raj D. RaoRao et al : Operative treatment of CSM : J Bone Jointet al : Operative treatment of CSM : J Bone Joint SurgSurg /88/88 //16191619--16401640 //20062006
- 59. INDICATIONS FOR LAMINOPLASTYINDICATIONSFOR LAMINOPLASTYINDICATIONS FOR LAMINOPLASTYINDICATIONS FOR LAMINOPLASTY OPLL lti l l lOPLL lti l l lOPLL over multiple levelsOPLL over multiple levels Congenital canal stenosisCongenital canal stenosis Multilevel cervicalMultilevel cervical spondylosisspondylosis Posterior compression fromPosterior compression from ligamentousligamentous hypertrophyhypertrophy As part of a staged anterior and posterior canalAs part of a staged anterior and posterior canal expanding procedureexpanding procedure D. Agarwal et al: Efficacy and results of expansive laminoplasty in patients with severe cervicalD. Agarwal et al: Efficacy and results of expansive laminoplasty in patients with severe cervical myelopathy due to cervical canal stenosis ; Neurologymyelopathy due to cervical canal stenosis ; Neurology indiaindia/ march 2004/vol52/ march 2004/vol52
- 60. CONTRAINDICATIONS FORCONTRAINDICATIONS FORCONTRAINDICATIONSFORCONTRAINDICATIONS FOR LAMINOPLASTYLAMINOPLASTY Isolated radiculopathyIsolated radiculopathy Loss of anterior column support resulting fromLoss of anterior column support resulting from tumor, trauma, or infectiontumor, trauma, or infection Focal anterior compressionFocal anterior compression Absolute kyphosisAbsolute kyphosisypyp
- 61. Illustrations depicting commonIllustrationsdepicting commonp gp g techniques used for cervicaltechniques used for cervical laminoplasty.laminoplasty. A, SingleA, Single--door laminoplasty.door laminoplasty. Sutures areSutures are placed through the spinous process toplaced through the spinous process to thethe articulararticular capsule on the hinge side tocapsule on the hinge side to hold the lamina elevated.hold the lamina elevated.hold the lamina elevated.hold the lamina elevated. B, DoubleB, Double--door laminoplasty. Thedoor laminoplasty. The spinous process isspinous process is osteotomizedosteotomized in thein the midline, and the two halves are priedmidline, and the two halves are pried open on laterally based hinges.open on laterally based hinges. Structural bone graft or a spacer fills theStructural bone graft or a spacer fills the defect between the split spinousdefect between the split spinousdefect between the split spinousdefect between the split spinous processes and prevents closure of theprocesses and prevents closure of the laminoplasty doors.laminoplasty doors. C, SingleC, Single--door laminoplasty with use ofdoor laminoplasty with use of bone graft or spacer tobone graft or spacer to prop the doorprop the door open.open. D SingleD Single door laminoplasty with use ofdoor laminoplasty with use ofD, SingleD, Single--door laminoplasty with use ofdoor laminoplasty with use of a laminoplasty plate.a laminoplasty plate. E, UnilateralE, Unilateral musclemuscle--stripping approachstripping approach to maintain the integrity of soft tissuesto maintain the integrity of soft tissues on theon the contralateralcontralateral side. Theside. The laminaelaminae on one side are exposed withon one side are exposed with ti f thti f th h lh lpreservation of thepreservation of the nuchalnuchal,, supraspinoussupraspinous andand interspinousinterspinous ligaments. The spinous processes areligaments. The spinous processes are osteotomizedosteotomized at their bases and areat their bases and are reflected to the intact side, allowingreflected to the intact side, allowing exposure of the posterior laminar bone.exposure of the posterior laminar bone. The arrows indicate the plane of theThe arrows indicate the plane of the osteotomyosteotomy and exposure.and exposure.
- 62. Radiograph made afterRadiographmade afterRadiograph made afterRadiograph made after the patient underwent athe patient underwent a laminoplasty with uselaminoplasty with use of miniof mini--plates.plates.
- 63. LAMINOPLASTY OUTCOMELAMINOPLASTY OUTCOME (AIIMS)(AIIMS) 24Pts over 4 yrs24 Pts over 4 yrs Stiffness gait, disturbance 100%Stiffness gait, disturbance 100%Stiffness gait, disturbance 100%Stiffness gait, disturbance 100% Neck pain 45%Neck pain 45% Bladder disturbance 45%Bladder disturbance 45%Bladder disturbance 45%Bladder disturbance 45% Operating time 187min (90Operating time 187min (90 -- 360 min)360 min) Blood loss 716 ml (100Blood loss 716 ml (100--1400 ml)1400 ml)Blood loss 716 ml (100Blood loss 716 ml (100--1400 ml)1400 ml) Complications : CSF leak (1), redo surgery (1)Complications : CSF leak (1), redo surgery (1) D. Agarwal et al: Efficacy and results of expansive laminoplasty in patients with severe cervicalD. Agarwal et al: Efficacy and results of expansive laminoplasty in patients with severe cervical myelopathy due to cervical canal stenosis ; Neurologymyelopathy due to cervical canal stenosis ; Neurology indiaindia/ march 2004/vol52/ march 2004/vol52
- 64. IMPROVEMENT IN NURICK’SGRADEIMPROVEMENT IN NURICK’S GRADE Nurick’s grade Preoperative (no. of pts) Postoperative (no. of pts)( p ) ( p ) GRADE 1 0 1 GRADE 2 0 2GRADE 2 0 2 GRADE 3 4 14 GRADE 4 15 6 GRADE 5 5 1 D. Agarwal et al: Efficacy and results of expansive laminoplasty in patients with severe cervical myelopathy due to cervical canal stenosis ; Neurology india/ march 2004/vol52
- 65. ADVANTAGES OF CERVICALADVANTAGESOF CERVICAL LAMINOPLASTY COMPARED WITHLAMINOPLASTY COMPARED WITHLAMINOPLASTY COMPARED WITHLAMINOPLASTY COMPARED WITH LAMINECTOMYLAMINECTOMY Reconstruction and preservation of dorsalReconstruction and preservation of dorsal t bili i t tt bili i t tstabilizing structuresstabilizing structures Reduces the risk ofReduces the risk of postlaminectomypostlaminectomy kyphosiskyphosis Limits range of motion of cervical spineLimits range of motion of cervical spine Reduces formation ofReduces formation of postlaminectomypostlaminectomy membranemembrane Low risk of adjacentLow risk of adjacent-- level disease.level disease.
- 66. Evidentiary summary ofstudies examining laminoplasty orEvidentiary summary of studies examining laminoplasty or laminectomy withlaminectomy with arthrodesisarthrodesis as compared to anterioras compared to anterior surgery for CSM*surgery for CSM*surgery for CSM*surgery for CSM* Authors & yr Desription Results Conclusions Wada et al 2001 Subtotal corpectomy compared to ODL in different yrs for CSM. JOA scores similar in Group A (7.9 to 13.4) & Group B Both approaches clinically effective; however, increased 2001 Corpectomy (Group A, n = 23, 2.5 levels, 15-yr FU, average age 53 yrs). Laminoplasty (n = 24, 12-yr FU, average age 56 yrs). JOA used to follow along w/ evaluation of ROM & axial pain (7.4 to 12.2). Incidence of moderate /severe axial pain greater in laminoplasty (40 vs 15%, p < 0.05). ROM only 29% in Group B vs Group A (49%) Higher rates of C 5 pain & decreased ROM w/ laminoplasty along w/ an increase in C-5 palsy; corpectomy carries risk of pseudoarthrosis. of ROM & axial pain. (49%). Higher rates of C-5 palsy & kyphosis w/ laminoplasty. Yonenobu et al 1992 100 patients w/ CSM of which 83 had 2-yr FU; 41 patients d t ACF (1976 83) hil 42 JOA improved in both groups (44% in laminoplasty & 55% i ACF t i ifi t) I Groups compared over different time periods (Class III) R lt h i il1992 underwent ACF (1976-83) while 42 underwent laminoplasty (“French window”). in ACF, not significant). In subset w/ canal < 12 mm, outcomes were 55% in laminoplasty & 59% in ACF. Complication rate was graft related & 29% in ACF III). Results show similar clinical improvement but higher complication rates in ACF. related & 29% in ACF. Laminoplasty had 7% C-5 radiculopathy.
- 67. 38 patients CSMstudied retrospective w/ matched Nurick improved 1.9 to 1.0 in Group A & 2.3 to 0.8 in Group B Unclear matching technique & different Edwards et al 2002 retrospective w/ matched cohorts Group A (13 corpectomy, <1996) & Group B (25 laminoplasty of which 13 chosen, >1996). ODL in 3 patients & T-saw in 10. FU Group A & 2.3 to 0.8 in Group B (not significant). Pain improved to 0.5 in Group A & 1.0 in Group B (not significant); ROM reduced from 37 to 16° in Group A & 39° to 24° in Group B (not technique & different periods. Both corpectomy & laminoplasty reliable. Laminoplasty appears to have fewer complications. >40 mos. significant) w/ pseudoarthrosis; Group A had higher complication (9/1). Sakaura et al 2005 43 pts w/ cervical disc displacement & myelopathy. Recovery rate of JOA was 71% in Group A & 70% in Group B. ROM Anterior approach associated w/ higher reoperation rate 2005 y y Group A (ACF, n = 15/21, age 44 yrs, 1984-7). Group B (Laminoplasty, n = 18/22, age 51, 1987-94). Average FU was 15 yrs in Group A/10 yrs Group B maintained 65% in Group A & 64% in Group B. Similar late deterioration. g due to pseudarthrosis but outcomes similar. B. Hasegawa et 90 patients w/ CSM. Age > 70 yrs (n = 40, 27 mos FU) & < 60 (n = 50 36-mo FU) Anterior No significant differences in final JOA score between groups. No significant difference in preop JOA Multiple subgroups in series. However, age does not appear to be negative riskHasegawa et al 2002 (n 50, 36 mo FU). Anterior fusion (n = 35), laminoplasty (n = 29), & laminectomy (n = 26). Comparison between technique & age group (6 groups). significant difference in preop JOA scores between groups. Complication rate greater in older patients (15%) vs 8% in younger patients. appear to be negative risk factor except for complication. Also, technique does not appear to change control of myelopathy.
- 68. Consequences and ComplicationsConsequencesand Complications Following Operative TreatmentFollowing Operative Treatment Post operative neck pain and C5 radiculopathyPost operative neck pain and C5 radiculopathy -- IIncidence 25ncidence 25 –– 60% (60% (HosonoHosono et al)et al) -- Laminoplasty (60% of 203 ) Vs Laminectomy (27% of 115)Laminoplasty (60% of 203 ) Vs Laminectomy (27% of 115) Vs anterior decompression (19% of 209)Vs anterior decompression (19% of 209) YonenobuYonenobu et al. (1992)et al. (1992) -- Soft tissue injurySoft tissue injury -- FacetFacet arthrosisarthrosis -- PreopPreop stiffnessstiffness -- Old ageOld age P l d t i bili tiP l d t i bili ti-- Prolonged postop immobilizationProlonged postop immobilization Wada E et al . SubtotalWada E et al . Subtotal corpectomycorpectomy versus laminectomy for multilevel CSM : a long term followversus laminectomy for multilevel CSM : a long term follow ––up study over 10 yrs. Spine./ 26/1443up study over 10 yrs. Spine./ 26/1443--8/20018/2001
- 69. Consequences and ComplicationsConsequencesand Complications Following Operative TreatmentFollowing Operative TreatmentFollowing Operative TreatmentFollowing Operative Treatment Postop stiffness :Postop stiffness :pp -- InterlaminarInterlaminar or facet fusion on hinge sideor facet fusion on hinge side Postop stability:Postop stability: -- Incidence of instability 21% for laminectomyIncidence of instability 21% for laminectomyIncidence of instability 21% for laminectomyIncidence of instability 21% for laminectomy -- Relatively rare for laminoplastyRelatively rare for laminoplasty Adjacent segment degenerationAdjacent segment degeneration C5C5 C6 and C6C6 and C6 C7 most vulnerableC7 most vulnerable-- C5C5 –– C6 and C6C6 and C6 –– C7 most vulnerableC7 most vulnerable -- 3% each yr (3% each yr (HilibrandHilibrand et al)et al)
- 70. NEUROLOGICAL COMPLICATIONSNEUROLOGICAL COMPLICATIONSNEUROLOGICALCOMPLICATIONSNEUROLOGICAL COMPLICATIONS RadiculopathyRadiculopathyRadiculopathyRadiculopathy Permanent myelopathyPermanent myelopathy Recurrent laryngeal nerve palsyRecurrent laryngeal nerve palsy HornersHorners syndromesyndromeyy DysphagiaDysphagia Esophageal injuriesEsophageal injuriesEsophageal injuriesEsophageal injuries Vertebral artery injuriesVertebral artery injuries Injuries to tracheaInjuries to trachea
- 71. OverviewOverviewOverviewOverview Surgery indicated formost pts with clinicallySurgery indicated for most pts with clinicallySurgery indicated for most pts with clinicallySurgery indicated for most pts with clinically evident CSMevident CSM Risk benefit ratio to be assessed in pts withRisk benefit ratio to be assessed in pts withpp early diseaseearly disease Main objective ofMain objective of SxSx is to decompressis to decompressjj pp adequately and to maintain stabilityadequately and to maintain stability Type ofType of SxSx depends upon location ,extent ofdepends upon location ,extent of pathology and also the alignment ,pathology and also the alignment , dimensions of spinal cord.dimensions of spinal cord. Improvement being higher in young pts,Improvement being higher in young pts, early disease.early disease.