Surgery for Cervical Myelopathy
Peter Jarzem MD FRCSC
Spine Surgeon,
McGill University,
Montreal Canada
Surgery for Cervical Myelopathy
Peter Jarzem MD FRCSC
Spine Surgeon,
McGill University,
Montreal Canada
Disclosure
• Family Ownership of a physiotherapy clinic
• On the Publication committee for a surgical device manfacturer
• None of the devices or techniques will be discussed
Disclosure
• Family Ownership of a physiotherapy clinic
• On the Publication committee for a surgical device manfacturer
• None of the devices or techniques will be discussed
Outline
• Review 3 Cases
• Review the literature as it pertains to the cases
Objectives
• Learn when surgical referral is appropriate
• Gain awareness of some surgical techniques
Determining patient’s suitability for surgery
• 6 questions:
– 1)Is their documented deterioration?
– 2) Is the patient stable or improving?
– 3) Is the problem severe enough to warrant surgery?
– 4) Is the Patient Medically Fit?
– 5) Is the problem seen on advanced imaging consistent with the patients history and physical
– 6) Is there an underlying medical problem mimicking a cervical myelopathy ?
• => a highly selected population of patients
Baron E, Youn W. CERVICAL SPONDYLOTIC MYELOPATHY A Brief review of its pathophysiology, clinical course and diagnosis. Neurosurgery 60 (Suppl 1): S-35-S-41, January 2007
Baron E, Youn W. CERVICAL SPONDYLOTIC MYELOPATHY A Brief review of its pathophysiology, clinical course and diagnosis. Neurosurgery 60 (Suppl 1): S-35-S-41, January 2007
12% of CSM attributed to Spondylosis are later found to be something
else
Case 1: Mr Mild Milo Path
• 50 year old right handed male
• PHx hypertension
• Neck pain and more recently numbness in both hands stocking and glove distribution right > left
• Active in Karate
• Patient has normal function in sports and work activities
• No complaints related to function of upper, lower limbs, or of bowel.bladder
Case 1: Mr Mild Milo Path
• Physical Exam
• Normal pupils/cranial nerves
• Brisk triceps and lower extremity reflexes, hoffman and babinski on Rt. One beat ankle clonus
• Power and sensation objectively normal
• Subjective decrease in sensation to light touch in hands
• Conclusions. The 3-year follow-up study did not show, on the average, that the surgery is superior to conservative treatment for mild and moderate forms of
Conclusions. The 3-year follow-up study
did not show, on the average, that the
surgery is superior to conservative
treatment for mild and moderate forms of
spondylotic cervical myelopathy.
How would you treat Case 1?
• We told patient that he could probably be safely observed for one year and asked him to come to our clinic after one year.
• Advised against sports that risk a blow to the head or falls.
• 64 year old rt handed male
• Phx hypertension, elevated cholesterol, and low back surgery
• Fell down stairs hitting his head 3 days ago
• Discharged from another ER
• Has neck pain, arm weakness and numbness since his fall
• Patient cannot dress or feed himself. Is able to walk, but requires assistance
Case 2: Mr Central Path
• Physical exam shows 2-3/5 power in upper extremities rt worse than lt
• Numbness both limbs from elbows to fingers.
• Unsteady gait
• Normal sensation and power both legs
• Diminished reflexes UE, hyperreflexia LE
• Positive babinski bilat
Case 2: Mr Central Path
Central cord Injury
• A syndrome characterized by disproportionately more loss of motor power in the upper extremities than the lower extremities
• Patients frequently complain of acute loss of power and sensation following a minor injury
• Typically there are no fractures
• Now 4 weeks post operative
• Has improved hand power and sensation
• Too early to comment on final outcome
Case 2: Mr Central Path
• 70 year old female with progressive weakness of the arms legs last 3 mo
• Notes increasing difficulty walking and feeding himself particularly in the past 1 week
• PHx of Rheumatoid arthritis, hypertension, numerous joint replacements
• Subjective weakness and numbness in all extremities
Case 3: Mrs Tre Progessif
Physical Exam
• Multiple joint deformities, obese
• Weak in both upper and lower extremeties
• Altered sensation, decreased sensation of all four limbs
• Positive hoffmans, babinskis
• Hyperreflexia in both upper and lower extremeties
How to Treat? • Early treatment is important
• Historical high mortality rate in severely disabled patients
• Decompression from an anterior or posterior approach can lead to important functional recovery (Shen et al, Rheum Arth:Eval and surg tx, Spine J, 2004)
• Recovery is similar to patients with Cervical spondylotic myelopathy
• 81 pts with CSM
• Prospective between 2005 - 2007
• Age, sex, period of time since symptom onset, comorbidities
Furlan et al, J Neurosurg Spine 2011
• Age and and number of previous medical conditions both predict complications and recovery from surgery.
• Patient made a good recovery
• Was able to self care, and walk around the house following 6 months of care
Case 3: Mrs Tre Progessif
Summary
• A high index of suspicion is required to detect an early or acute myelopathy. There are many etiologies
• Early myelopathy can be treated by observation
• Moderate or severe myelopathy is best treated with surgical decompression