Cervical Spondylosis with Myelopathy
The patient is a 68-year-old male with a several-month history of progressive gait difficulty, neck and bilateral arm pain, and difficulty with fine motor function.
The neurological exam found:
- Slight spastic gait
- Diffuse 4+/5 weakness in all extremities
- Brisk DTR's
- Babinski response present bilaterally
Figure 1: T1-weighted sagittal MRI
T2-weighted sagittal MRI (Fig. 2) demonstrating multi-level epidural encroachment due to osteophyte formation. There is also a high signal in the spinal cord at the C3-C4 level.
Figure 3: Sagittal and axial views at C3-C4
Figure 4: Sagittal and axial views of C4-C5 demonstrating prominent anterior encroachment
Figure 5: Sagittal and axial views of C5-C6
Figure 6: Sagittal and axial views of C6-C7
Cervical spondylosis with myelopathy
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Anterior multi-level discectomy with fixation and fusion was performed on this patient. It was decided to use an anterior-only approach because most of the compression was in front of the spinal cord, particularly at the C4-C5 level. A corpectomy was not performed because most of the epidural compression was at the level of the disc space only. Leaving the vertebrae in place also allows for additional points of screw fixation.
The patient did well and reported significant improvement of his symptoms.
One year post-operative AP radiograph (Fig. 7) demonstrated anterior fixation at C3-C4, C4-C5, and C5-C6 disc spaces.
Figure 8: One year post-operative lateral radiograph
This interesting case of cervical stenotic myelopathy has several potential treatments. There is no "right or wrong" answer for this case. Surgeons may choose to decompress the cervical spine anteriorly, posteriorly, or circumferentially.
One imaging modality that was not employed in this case is a pre-operative cervical CT scan. I might have requested one in this case to see if there was any calcification of the disc spaces or ossified posterior longitudinal ligament (OPLL). With significant calcification ventrally (OPLL), I might try a multi-level posterior decompressive procedure with either a laminoplasty or a laminectomy and fusion as a first step. If going dorsally, I would favor decompression of C3-C7 with a laminoplasty. A laminoplasty would allow for some maintenance of neck motion and allows the construct to stop at C7. The drawback with an open-door laminoplasty is that it is relatively straightforward to do ipsilateral foraminal decompression with foraminotomies on the open side of the laminoplasty, but the contralateral foraminal decompression may be difficult.
A laminectomy and fusion, on the other hand, would allow excellent access to do multi-level bilateral foraminotomies. The issue with a laminectomy and fusion is the caudal ending point. Should the surgeon stop at C6 when there is early foraminal compromise at C6-C7? Or should the construct extend inferiorly to C7 or cross the cervicothoracic junction and extend to T1 or T2? Stopping at C6 may predispose the patient to have to return for surgery at C6-C7 at a later date. Extending the fusion across the cervicothoracic junction would be more morbid to the cervicothoracic musculature.
If the CT scan demonstrated cervical spondylosis with uncalcified, herniated discs or mildly calcified herniated discs, then a ventral approach is ideal. The ventral approach allows for direct decompression of the anterior cord. Multi-level discectomies and fusion may be performed from C3-C6 or C3-C7. If there is a calcified component of the herniated discs, then a partial corpectomy or a full corpectomy of C4 may be considered.
I would not employ a combined ventral and dorsal approach for this case. I would try either a ventral or a dorsal approach first. Then I would observe the patient. If the patient's neurological recovery is not satisfactory, then a second stage operation could be performed for further decompression.
The surgeon's choice of performing a multi-level discectomy from C3-C6 worked well in this case. It allowed for ventral decompression and fixation of the most severely compressed levels. The patient needs to be followed to ensure that the C6-C7 level does not need to be treated later.
Doctor Mummaneni correctly points out that there are several acceptable surgical options for the management of this patient. The predominance of ventral epidural compression and the location of this compression, primarily at the level of the disc spaces were the factors that led to my selection of the anterior multi-level discectomy approach. However, with other acceptable surgical options available in a case like this, each surgeon should select the approach that he or she feels works best in their hands.
This patient presented with cervical myelopathy and was found to have multi-level cervical stenosis on magnetic resonance imaging. A 3-level anterior cervical discectomy and fusion resulted in stabilization of the myelopathy with solid fusion that was evident on radiographs at 1-year follow-up.
In addition to decompression of the spinal canal, advantages of an anterior approach in this case include the ability to restore cervical lordosis and decompress the neuroforamen. The patient did have bilateral arm pain, which could have been a component of the myelopathy, but also could have represented a myeloradiculopathy, given the multi-level neuroforaminal stenosis that is present. Accordingly, neuroforaminal decompression was necessary to address this. A posterior approach may have resulted in adequate central canal decompression by allowing the spinal cord to “fall back” off the anterior osteophytes. However, multi-level neuroforaminal decompression from a posterior approach does require resection of a portion of the lateral mass and makes it more difficult to place instrumentation. Although no significant central canal compression was present at C6-C7, there is the presence of bilateral neuroforaminal compression. This level could have been included if a C7 radiculopathy was suspected of contributing to his bilateral arm pain.