Cervical Spondylotic Myelopathy in an Amateur Golfer
The patient is a 63-year-old male presenting with complaints of upper extremity paresthesia, loss of dexterity and irregular gait. He denies bowel or bladder irregularity.
His past medical history includes two coronary artery bypass graft procedures and repair of an abdominal aortic aneurysm. He has no known allergies.
He takes antihypertensives and narcotics for neck pain.
He is 5'8", weighs 184 pounds with a BMI of 28. His vital signs are stable.
- Wide-based gait
- Ulnar drift in left hand
- Brisk right triceps reflex
- Reduced left Achilles reflex
- Postive Hoffmann's sign on right
- Negative Babinski bilaterally
- No focal motor or sensory deficits
- Visual Analogue Scale-Neck (VASN): 50
- Visual Analogue Scale-Arm (VASA): 0
- Neck Oswestry Disability Index (NODI): 38
- Patient Healthcare Questionnaire-9 (PHQ-9): 11
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Multilevel MIS posterior decompression without fusion using a 16 mm tubular retractor and microscope via a right-sided approach.
In this particular case, the retractor is repositioned twice. First, over the C4 lamina allowing decompression of C3 through the top of C5. Then, over the inferior lamina of C5 allowing for completion of decompression at C5 and C6.
Two years after surgery the patient notes dramatic improvement in all preoperative symptoms: upper extremity paresthesia, dexterity and gait.
The patient has returned to playing golf and no longer requires narcotics for neck pain.
Surgeon's Case Commentary
Cervical spondylotic myelopathy is a progressive condition presenting with a myriad of symptomatic complaints. Here, the patient has significant upper and lower extremity symptoms of paresthesia and reduced dexterity accompanied by loss of gait stability and neck pain. Our goals were to maintain cervical stability and reduce spinal cord compression. As indicated by the improvement in patient's function, and illustrated by postoperative images, our goals were achieved.
The tubular retractor and microscope allowed excellent visualization of the compressing structures bilaterally via a unilateral approach. Most patients require less than 24 hours of hospitalization and minimal postoperative immobilization. Here, neck pain remains a concern, as suggested by the VASN score of 60. However, the patient is not requiring any narcotic medications for this complaint.
Also note, on the postoperative sagittal MRI, the apparent cord atrophy consistent with the chronic nature of this condition. Despite decompression, the spinal cord has not filled the available space.
The patient remains active in his community and is very pleased with the clinical results.
Dr. Knight's case presents a patient with cervical spondylotic myelopathy (CSM) secondary to multilevel compression extending—based on the sagittal MRI T2 sequence—from C3-C4 to at least the C6-C7 disc space. The patient's exam and symptoms are consistent with those that are typically seen in patients with CSM. However, use of a scale that measures myelopathy (such as the modified Japanese Orthopedic Association scale) would have been useful to assess the extent of the patient's disability and improvement postoperatively.
The patient has significant preoperative axial complaints; a VASN of 50 and NODI of 38. Review of the available images demonstrates spondylosis with reduced range of motion on dynamic x-rays. Review of the preoperative cervical axial T2 MRI demonstrates a large ventral component of the compression. Considering the patient is a golfer who likely wants to return to play, does not want to lose much of his range of motion.
Minimally invasive surgical (MIS) options have the potential to restore function with reduced blood loss, hospital stay, and recovery time. However, a successful MIS operation must accomplish the same goal as an open procedure. Dr. Knight describes a thought-provoking approach using a 16mm tubular retractor to circumferentially decompress the patient's multilevel stenosis. I regularly utilize a 16mm retractor for MIS laminoforamenotomies and microdiscectomies in the cervical spine; a procedure that I believe is underutilized. However, I am less enthusiastic—that at least in my hands, I would be able to achieve adequate decompression.
Posterior cervical decompression, whether it be a simple laminectomy, laminoplasty or laminectomy with fusion, establishes enough space for the spinal cord to drift away from ventral pathology. Given the extent of the patient's neck disability, I would favor a combined decompression and fusion procedure from C3-C7—such as a laminectomy and fusion or a 4-level anterior cervical discectomy and fusion.
The patient has relative maintenance of cervical lordosis, so a conversation regarding a simple laminectomy could be had, but postoperative kyphosis would remain a concern. Cervical laminoplasty would also be a good option if some motion preservation were desired, although some studies have suggested inferior results with respect to axial complaints when compared to a laminectomy and fusion.