Review Question - QID 3674

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Cervical Myelopathy Treatment Operative QID: 3674 (OBQ11.251)

QID 3674 (Type "3674" in App Search)

A 68-year-old female presents with progressive loss of ability to ambulate and dexterity problems with her hands. Six months ago she was able to walk with a cane, but now has difficulty with ambulating with a walker. She also reports difficulty with her hands and needs assistance with eating. Physical exam shows limited neck extension. Radiographs, tomography, and magnetic-resonance-imaging are shown in Figure A, B, and C respectively. What is the most appropriate treatment?

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NSAIDS, physical therapy, and clinical observation

67/5466

C3 to C6 cervical laminectomy

31/5466

C3 to C6 laminoplasty using an open-door technique

54/5466

C3 to C6 decompressive laminectomy with instrumented fusion

15%

829/5466

Multilevel anterior cervical decompression with strut grafting and anterior plate fixation, followed by posterior decompression and fusion

82%

4464/5466

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The patients symptoms are consistent with progressive cervical myelopathy. Her symptoms are progressive and severe, and therefore surgical decompression is indicated. She has cervical kyphosis as demonstrated on physical exam and imaging, with compression at three levels (C3/4, C4/5, C5/6). An anterior procedure is mandatory to correct her kyphosis and remove the anterior compressive lesions. Of the options listed, only answer 5 involves an anterior procedure, and therefore, it is the most appropriate treatment.

Possible treatment options in this case could: 1) multi-level ACDF with anterior plate fixation, 2) a hybrid C5 corpectomy with ACDF as C3/4 and anterior plate fixation, or 3) a C3 and C4 corpectomy, anterior plate fixation, followed by posterior decompression and fusion. It is important to remember any two level corpectomy needs to be stabilized posterior due to the high rate of graft migration.

Suda et al showed that signal intensity change on MRI and local kyphosis were the most crucial risk factors for poor surgical outcomes. They recommend when patients have local kyphosis exceeding 13 degrees, anterior decompression should be performed with an attempt to correct the deformity, followed by posterior decompression in some cases. Expansive laminoplasty alone should be avoided in patients with local kyphosis greater than 13 degrees.

Chiba et al reviewed the long-term results of open-door laminoplasty for cervical myelopathy. They found satisfactory results of open-door laminoplasty at an average follow up of 14 years. Overall cervical range of motion decreased by 36%. Segmental motor palsy developed in 8 of 80 patients.

Illustration A demonstrates why a posterior decompression is ineffective in patients with rigid kyphosis and cervical myelopathy.

Incorrect Answers:
Answer 1: Due to her severe and progressive symptoms, there is no role for nonoperative treatment in this patient.
Answer 2, 3, 4: Any posterior procedure alone, including a laminectomy, laminectomy with fusion, or laminoplasty would not correct her kyphotic deformity and address the anterior compression caused by the spinal cord "draping" over the anterior compressive elements. A posterior procedure alone should be avoided in patients with excessive kyphosis.

ILLUSTRATIONS: