Review Question - QID 4816

The clinical presentation is consistent with an acute Central Cord Syndrome (CSS) in a patient with preexisting cervical spondylotic myelopathy. Because the patient had preexisting function impairment and currently has active compression on MRI, surgery is indicated for the myelopathy alone. The patient has lordotic alignment and compression at C3/4, C4/5, and C5/6, and therefore a posterior laminoplasty is most the appropriate treatment listed.

Spondylotic cord compression is a common radiographic finding in older patients. Asymptomatic patients without functional impairment warrant nonoperative treatment, regardless of the presence of hyper-reflexia. Patients with myelopathic symptoms that cause functional impairment and spinal cord compression seen on imaging are candidates for operative intervention.

Spondylotic cord compression can predispose a patient to spinal cord injury with minor trauma, especially elderly patients who sustain hyperextension neck injury. A common manifestation of this is a Central Cord Syndrome (CCS), which is the most common form of incomplete spinal cord injury. The treatment of acute central cord syndrome in patients WITHOUT active compression is nonoperative. In patient with an acute CCS WITH active compression seen on MRI the treatment is controversial.

Emery et al. reviewed treatment of cervical spondylotic myelopathy. They advocate the anterior approach for patients with pathologic changes at 1 or 2 levels and posterior surgery for those with involvement at 3 or more levels.

Harrop et al. reviewed radiographic evaluation in cervical spondylotic myelopathy. They report that MRI findings of spinal cord compression (indentation on the spinal cord parenchyma) and increased T2 intraparenchymal cord signal abnormalities aid diagnosis of cervical spondylotic myelopathy.

Fehlings et al. performed a prospective study that compared anterior versus posterior surgical approaches to treat cervical spondylotic myelopathy. In contrary to classic teaching, they found equivalent efficacy with either approach in treatment of multi-level cervical spondylotic myelopathy. They conclude that the approach should be left up to the surgeon, as both procedures provided significant improvements with regard to neurological, functional, and quality-of-life outcomes.

Figure A is a sagittal T2-weighted MRI showing stenosis from C3/4 to C5/6 interspaces and myelomalacia (there is borderline compression at C6/7). Posterior decompression will have to span C3-C6 (maybe C7). Illustration A shows the finger escape sign. The fingers are held extended and adducted. The 2 ulnar digits will flex and abduct in patients with cervical myelopathy. Illustration B shows the grip-and-release test. Normal patients can make a fist and rapidly release it 20 times in 10 seconds.

Incorrect Answers:
Answer 1: Acute spinal cord injury with background myelopathy is best addressed with surgical decompression.
Answer 2: MRI of the lumbar spine is indicated if lumbar spinal stenosis is suspected (e.g. if distal lower extremity muscle groups are WEAKER than proximal muscle groups).
Answer 3: C4 corpectomy and instrumented fusion would fail to decompress the C5/6 level.
Answer 4: While a C4 and C5 corpectomy and anterior instrumented fusion would provide adequate decompression, a two level corpectomy must alwasy be combined with a posterior fusion to provide a stable construct.