Akinsulire A.

Introduction Natural History Treatment options

Non operative Operative
Anterior Posterior Combined

Complications Prognosis

Cervical Spondylotic Myelopathy (CSM) is a disease of variable progression Management based on understanding of pathogenesis,clinical features and correct neuroimaging investigation.

Many patients have evidence of significant compression on MRI but relatively asymptomatic Spinal cord has high degree of tolerance to chronic deformation

75%

Stepwise deterioration

20%

Steady progressive deterioration

5%

Improvement

Clarke E, Robinson PK: Cervical myelopathy: A complication of cervical spondylosis. Brain

Typically slowing progressive Step ladder progression Once moderate symptoms occur, prognosis poor

Non operative

Operative

Indications
Neuroradiological evidence of compression but no symptom/sign of myelopathy Mild neuropathy
Slight gait disturbance No functional deficit/ weakness

Plateau phase

Intermittent cervical collar Anti-inflammatory Active discouragement of high risk activities Physiotherapy Regular monitoring/ follow up Epidural steroid injection

Severity of disease Nurick 3- 5 Pain Rate of progression Compression with severe neuroradiologic findings
Kyphosis Myelomalcia Small cord area Cord atrophy

Posterior approach
Laminoplasty Laminectomy +/- fusion procedures

Anterior approach
Multiple anterior diskectomies with fusion Corpectomy with fusion +/- anterior instrumentation

Combined

Indirect technique Increases transverse diameter and size of canal Requires posterior shift of cord to diminish effect of anterior compression

Canal expansion by opening the posterior elements in a trapdoor fashion effective diameter of the spinal canal from C3 to C7 by shifting the laminae dorsally Osseous posterior arch not completely removed Post op instability reduced muscular and osseous support preserved

Decompression of spinal canal by removal of part of posterior elements useful alternative for multiple-level decompression in patients with preserved cervical lordosis Lateral margins are the junctions of the lateral masses and laminae

May require posterior instrumentation to prevent kyphosis or instability Visible expansion of the dural sac intraoperatively and pulsation of the dura suggest good canal expansion

Allows anterior decompression of dura Choice of type depending on location of compression Confined to disc@ 1-3 levels anterior cervical diskectomy + grafting Disc,PLL,end plates corpectomy with strut graft

Direct decompression the removal of disc material and posterior osteophytes impinging on the spinal cord at the level of the disc space cartilaginous end plate is completely removed, the thin osseous end plate preserved Bone graft inserted into interspace

Advantage
Dissection along fascial planes Relative preservation of stability of spinal column Low prevalence of graft extrusion

Disadvantage
Decreased visalization- incomplete decompression or injury to cord Not recommended for primary tx of severe congenital spinal stenosis

Removal of the cervical body and intervening disc 15 to 19-mm central trough is removed from the anterior aspect of the vertebral body provides a safety margin of 5 mm to the medial border of the foramen transversarium PLL also resected Defected filled with graft +/- Instrumentation

Post laminectomy kyphosis Patients with severe osteoporosis Multilevel corpectomy in 3 or more levels

No single preferred approach both have been used successfully Neither is optimal for every patient although either may be appropriate Both approaches give similar results with appropriate patient selection Various determinants of choice of approach

No of levels Cervical kyphosis Instability Spinal canal size/presence of stenosis Revision Surgeons expertise

Anterior Advantages Direct decompression

posterior Less loss of motion

Stabilization with arthrodesis Not as technically demanding Correction of deformity Good axial pain relief Disavantages Technically demanding Graft complications Post op bracing Loss of motion Adjacent segment degeneration Indirect decompression Late instability Inconsistent axial pain results Pre op kyphosis/instability limitation Less bracing needed Avoids graft complications

Approach related Decompression related Graft related Long term

Approach related
RL nerve hoarseness Dysphagia Upper airway compromise- edema,hematoma

Decompression related
Spinal cord /nv root injury C5 nerve injury Vertebral ay injury Spinal fluid leaks

Graft related
Dislodgement Fracture Severe settling into cancellous bone Displacement with esophageal injury

Anterior approach
Pseudoarthrosis Adjacent segment degeneration

Laminectomy
Post laminectomy kyphosis, Instability with neurological deteroriation

Laminoplasty
Inadvertent closure with recurrent stenosis Incomplete decompression

Age Shorter duration of symptoms Single level Severity of myelopathy before intervention Larger transverse area of cord Preoperative bladder dysfunction