|
As discussed above, cervical stenosis means, literally, tightening or narrowing
of the canal around the spinal cord. Of the degenerative disorders discussed
in this chapter, it is potentially the most serious. If the cervical stenosis
is profound enough, it can cause dysfunction of the spinal cord known as myelopathy
(my-il-lop-ah-thee). The typical person who has cervical stenosis and myelopathy
may be in his or her fifties or early sixties. The patient often has complained
of neck pain for many years. In some cases, the pain can actually be mild. Therapy
may have been prescribed, in addition to medications, for the pain. The other
features of this disorder will be demonstrated in an illustrative case.
Presentation
Mrs. S is a sixty-one year old woman with a long-term complaint of neck pain.
In the past, her pain has been amply controlled with ibuprofen (Motrin™) and
some home exercises. Occasionally, she wears a soft cervical collar to calm
her neck spasms. She is an avid knitter and has made several sweaters and scarves
for her grandchildren recently. In the past two months, however, she finds that
her fingers are becoming clumsy, and she has to take frequent breaks. In addition,
Mrs. S is finding that she is not as agile buttoning her shirts in the morning.
She is not complaining of any pain in the arms or legs. Interestingly, her legs
are a bit wobbly, but she attributes that to some arthritis that has set in
over the years. Mrs. S has had no problems urinating on her own, and no change
in her bowel habits or control.
Examination
At the doctors' office she is given a full examination. She has a somewhat decreased
range of motion of the neck, with some pain at the extremes of the movements.
She walks with an abnormal gait, which can be described as "wide-based." In
looking at her feet during ambulation, her feet are more spread apart than normal
and she stumbles a bit with some steps.
Her reflexes in her arms and legs are very jumpy. This is termed hyperreflexia
(hi-per-re-flex-e-ah). She does not have any noticeable weakness in the arms
or legs. Because of these findings, the doctor gets some x-rays in the office.
Diagnostic Tests
The plain x-rays show a degenerative spine. As discussed above, this can be
better termed as spondylosis. She has osteophytes in the front and back of the
spine, which might be protruding into the spinal canal. From the x-ray, there
does not appear to be any masses or lesions that would suggest a tumor or infection.
Mrs. S's doctor knows that these bony changes are very common at her age. Also,
he understands that the plain x-ray is not a very good way of assessing the
spinal cord or the space around it.
Mrs. S is sent for an MRI scan of her neck. This test entails her lying down
for about forty-five minutes in a long-tube. The long-tube has a very large
magnet in it. This is what is responsible for the magnetic part of the magnetic
resonance imaging (MRI). Because different tissues in the body respond to magnetic
fields in different ways, they have characteristic appearances on MR images.
Mrs. S's MRI showed severe narrowing of her spinal canal. Most of this narrowing
is coming from degenerated discs that are protruding into the spinal canal.
These discs appear hard and have bony osteophytes above and below them, making
the compression even less forgiving.
Specialist Consultation
After getting the MRI report, Mrs. S's doctor sends her to a spine surgeon.
She explains to the patient that her condition is called cervical stenosis.
Because her stenosis, or tightening, is severe, the nerves in the spinal cord
cannot function normally. The compression of the spinal cord is causing her
to fumble with her knitting needles and shirt buttons, as well as giving her
"wobbly" legs. This surprised Mrs. S the most, as she was sure that she had
knee arthritis that was causing her leg symptoms. The spine surgeon explained
that the nerves that go to both the arms and legs pass through the neck within
the spinal cord. Thus, compression at the neck can cause symptoms in the arms
and legs.
Asking what can be done about her condition, the spine surgeon explains that
it is likely that her finger and leg fumbling can get worse. In fact, the tightening
around the spinal cord can get to a point that she may lose control of her bladder
and bowels. In the best case scenario her symptoms will stay the same for the
rest of her life, which can be expected in a low percentage of patients.
The treatment options given to Mrs. S are that she can be treated non-operatively
or by surgery. The surgeon explains what comprises non-operative treatment.
It includes nonsteroidal medications (like Motrin™, Naprosyn™, Celebrex™, or
Vioxx™), physical therapy for the neck muscles, cervical collar use, and traction.
Of the options, Mrs. S was most concerned about traction, as she would have
to be lying down for a portion of the day while the weights were attached to
her chin and head.
Mrs. S was also informed of the surgical options. Because of the extent of
her disease, the surgeon explained that the best method of relieving the pressure
on the spinal cord was to remove the bone from the front of the neck and off
the spinal cord. This is known as a corpectomy (core-peck-toe-me). This would
entail an incision in the front the neck through which the surgeon can remove
the parts of the vertebral bodies that are compressing her spinal cord. In place
of the vertebral bodies, a large piece of bone from her own pelvis, or a cadaver
donor, would be inserted. This bone would be expected to heal in place. This
is known as a fusion. The likelihood of catching any disease from the cadaver
bone is extremely low and is in fact much lower than contracting any disease
from a blood transfusion. The more significant risks were from the surgery itself,
she was told. The possible complications include damage to the large arteries
that supply blood to the brain and to the spinal cord. Spinal cord damage may
cause Mrs. S to be completely paralyzed from the neck down. These are the most
serious complications; she was informed.
Other possibilities, like infection are also possible, but are more easily
treated. Damage to the nerves that supply the vocal cord is also a potential
complication. Mrs. S was made aware of this possibility, and that she could
have hoarseness permanently after the operation. After hearing the options,
Mrs. S asks the spine surgeon a few key questions. First, if she has damage
to her spinal cord already, what are the chances of her symptoms getting better
with surgery?
Because she is still highly functional, she has a good chance of resolving
some, though perhaps not all, of her neurologic symptoms. Her neck pain, though
not the focus of the surgery, may or may not get better. If the surgery is a
complete success, she will be able to return to her previous activities with
a greatly decreased chance of her spinal cord being compressed further. In essence,
the surgery is mostly to keep her from progressively getting worse and/or prevent
a catastrophic event like a spinal cord injury, which could result with a very
minor injury such as a fall or slip.
What will happen to her if she doesn't choose surgery? From the studies available,
it is probable that Mrs. S's cervical stenosis will worsen with time. Although
it is possible that she could live the rest of her life without any advancement
of her problems, it is unlikely. Furthermore, it is even more unlikely for her
neurologic symptoms to significantly improve.
"What happens if the piece of bone doesn't heal in place?" This is a rather
common complication, occurring in about 15 to 20 percent of patients undergoing
this procedure. In the event that the bone doesn't fuse in the front, a second
surgery to fuse the back of the vertebra is performed. This is done by an incision
along the back of the neck.
Outcome
Weighing the options and contemplating the possible complications of both operative
and non-operative treatment, Mrs. S decides to proceed with surgery. Thankfully,
the surgery was without complication. After surgery, she remained in the hospital
for three days. Her neck was very sore, but strong pain medication helped manage
the pain.
She was instructed to keep a hard cervical collar on at all times for six weeks.
She was able to get out of bed the day after surgery and started eating a full
diet, as she was able to tolerate. After she was discharged, she followed up
with her surgeon in the office. The wound healed well. After six weeks she did
not use the cervical collar anymore. The bone graft showed good signs of healing
to her own bone on the x-rays. After three months, she felt that her fingers
were working better and she no longer felt wobbly in the legs. She returned
to knitting, producing a blue baby bonnet for her newborn grandson.
This article is an excerpt from Dr. Stewart G. Eidelson's book, Advanced
Technologies to Treat Neck and Back Pain, A Patient's Guide (March 2005).
Continue this article...
|
