Cervical Spondylosis with Myeloradiculopathy Multilevel Laminectomy, Foraminotomy, Fusion, and Lateral Mass Plating - Introduction
INTRODUCTION
Cervical spondylotic radiculopathy (CSR) is a progressive degenerative disease process which presents sensory motor deficiencies and wide–range discomfort. Cervical spondylotic myelopathy (CSM) is a similar degenerative condition, but presents with myelopathy due to spinal cord compression. As is often the case, cervical spondylotic patients may present radiculopathic symptoms, myelopathic manifestations, or both. Cervical spondylotic myeloradiculopathy (CSMR) usually manifests in the later decades of life (18,49) commonly involving the C6 and C7 nerve roots. (19,32) Although CSR individuals have protracted symptoms, a high probability exists of managing their symptoms conservatively.(4,21) However, CSR individuals who experience little or no pain relief after conservative treatment for at least three months or have significant neurologic deficits are likely to benefit from surgical intervention. Furthermore, patients with myelopathy and radiculopathy are usually good candidates for surgery.
Patients with multilevel degenerative changes resulting in spinal cord and nerve root compression producing myeloradiculopathy benefit from posterior laminectomy (32,68) or laminoplasty. (34,35) To provide adequate nerve root decompression, a foraminotomy is done as well. (32) One of the most important prerequisites for posterior laminectomy or laminoplasty is the presence of cervical lordosis. If the spine is kyphotic, the posterior procedures alone are contraindicated. The spine must be approached anteriorly in this case. Patients who undergo multilevel laminectomy are prone to instability and at risk to develop kyphosis. (61) Appropriate internal instrumentation and fusion may be implemented to facilitate healing and prevent post–laminectomy instability and kyphosis. Futhermore, some patients exhibit significant neck pain following laminoplasty. (37) Therefore, posterior laminectomy and fusion may decrease the incidence of postoperative neck pain.
Various techniques have surfaced to adequately stabilize, offer nerve root decompression, and provide sagittal balance of a spondylotic cervical spine with radicular symptoms. Although many avenues for spinal correction have been reported, appropriate cervical approaches are continuously evolving and questioned. To understand the present milieu available in providing adequate relief of CSMR symptoms, it is necessary to grasp the evolution of the condition and appropriate operative approaches.
Cervical spine fusion and internal instrumentation to treat instability owes its genesis to B.E. Hadra's 1891 technique of spinous process wiring to stabilize the deformity of Pott's disease.(26) In 1928, Stookey described the effects of multiple cervical intervertebral discs compressing the spinal cord contributing to canal stenosis.(67) Peet and Echols in 1934 (53) and Mixter and Ayer in 1935 (47) further elaborated on Stookey's claims noting their experience with lumbar radicular symptoms resulting from soft disc herniations. Cervical root compromise resulting in neck and radiating arm pain is credited to Semmes and Murphey in 1943. (60) Shortly after, others endeavored to correlate neck and arm pain as a result of cervical nerve root compression of the intervertebral foramen. (65,66) In 1952, Brain et al first recognized CSM as a result of vascular and neurologic spinal cord compromise. (7) However, in 1942, Rogers described posterior cervical fusion through his experience in cervical fracture reduction through spinous process wiring and bone graft. (55) Soon after, various techniques to decompress the spinal cord and nerve roots were sought through the advent of anterior approaches. (3,5,10,11,54,62,64) In the ensuing years, additional avenues for posterior decompression were elaborated. (29,32,34,35,68)
Although the anterior approach is beneficial for decompression of the spinal cord and nerve roots, multilevel involvement is favorably treated postoperatively. Interspinous wiring is considered the "gold standard" of posterior cervical stabilization. If spinous processes are absent, alternative methods for stabilization are sought. Recent studies have ushered in a new advent of posterior cervical stabilization that offers equal or greater biomechanical prowess–lateral mass plating. (12,20,30,51,69) Lateral mass plating was championed by Roy–Camille (56–58) and Saillant, (57,58) Louis,(44) Magerl et al, (38,45,46) Grob and Magerl, (24) and Nazarian and Louis. (51)
Lateral mass plating is usually implemented to treat instability due to trauma, degenerative changes, iatrogenic effects, inflammatory conditions, and neoplasia. Moreover, lateral mass plating can maintain cervical alignment, prevent kyphotic deformity, and alleviate pain. Furthermore, lateral mass plating reduces the need for postoperative halo vest immobilization and has the potential for relordosation manipulation. (2,13–15,39,59,71) The following case study is an account of an individual with CSMR who underwent posterior decompression via a multilevel laminectomy, foraminotomy, fusion, and lateral mass plating.