Cervical Spondylotic Myelopathy: Pathophysiology, Clinical Presentation, and Treatment

The Spine Surgery Service, Spine Care Insititute, The Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
HSS Journal 07/2011; 7(2):170-178. DOI: 10.1007/s11420-011-9208-1


Age-related changes in the spinal column result in a degenerative cascade known as spondylosis. Genetic, environmental, and
occupational influences may play a role. These spondylotic changes may result in direct compressive and ischemic dysfunction
of the spinal cord known as cervical spondylotic myelopathy (CSM). Both static and dynamic factors contribute to the pathogenesis.
CSM may present as subclinical stenosis or may follow a more pernicious and progressive course. Most reports of the natural
history of CSM involve periods of quiescent disease with intermittent episodes of neurologic decline. If conservative treatment
is chosen for mild CSM, close clinical and radiographic follow-up should be undertaken in addition to precautions for trauma-related
neurologic sequelae. Operative treatment remains the standard of care for moderate to severe CSM and is most effective in
preventing the progression of disease. Anterior surgery is often beneficial in patients with stenotic disease limited to a
few segments or in cases in which correction of a kyphotic deformity is desired. Posterior procedures allow decompression
of multiple segments simultaneously provided that adequate posterior drift of the cord is attainable from areas of anterior
compression. Distinct risks exist with both anterior and posterior surgery and should be considered in clinical decision-making.

Keywordscervical spine–spondylosis–myelopathy–natural history–operative treatment

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    • "Cervical spondylotic myelopathy (CSM) is characterized by spondylosis leading to compression of the spinal cord [1]. When conservative therapy fails, surgical management involving anterior cervical discectomy, with or without fusion, is the most common approach. "
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    ABSTRACT: This study introduces the use of multivariate linear regression (MLR) and support vector regression (SVR) models to predict postoperative outcomes in a cohort of patients who underwent surgery for cervical spondylotic myelopathy (CSM). Currently, predicting outcomes after surgery for CSM remains a challenge. We recruited patients who had a diagnosis of CSM and required decompressive surgery with or without fusion. Fine motor function was tested preoperatively and postoperatively with a handgrip-based tracking device that has been previously validated, yielding mean absolute accuracy (MAA) results for two tracking tasks (sinusoidal and step). All patients completed Oswestry disability index (ODI) and modified Japanese Orthopaedic Association questionnaires preoperatively and postoperatively. Preoperative data was utilized in MLR and SVR models to predict postoperative ODI. Predictions were compared to the actual ODI scores with the coefficient of determination (R(2)) and mean absolute difference (MAD). From this, 20 patients met the inclusion criteria and completed follow-up at least 3months after surgery. With the MLR model, a combination of the preoperative ODI score, preoperative MAA (step function), and symptom duration yielded the best prediction of postoperative ODI (R(2)=0.452; MAD=0.0887; p=1.17×10(-3)). With the SVR model, a combination of preoperative ODI score, preoperative MAA (sinusoidal function), and symptom duration yielded the best prediction of postoperative ODI (R(2)=0.932; MAD=0.0283; p=5.73×10(-12)). The SVR model was more accurate than the MLR model. The SVR can be used preoperatively in risk/benefit analysis and the decision to operate. Copyright © 2015 Elsevier Ltd. All rights reserved.
    Journal of Clinical Neuroscience 04/2005; DOI:10.1016/j.jocn.2015.04.002 · 1.38 Impact Factor
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    ABSTRACT: Objective: To evaluate the sensitivity of contact heat evoked potentials (CHEPs) compared with dermatomal somatosensory evoked potentials (dSSEPs) and clinical sensory testing in myelopathic spinal cord disorders (SCDs). Methods: In a prospective cohort study, light-touch (LT) and pinprick (PP) testing was complemented by dermatomal CHEPs and dSSEPs in patients with a confirmed SCD as defined by MRI. Patients with different etiologies (i.e., traumatic and nontraumatic) and varying degrees of spinal cord damage (i.e., completeness) were included. SCD was distinguished into 3 categories according to MRI pattern and neurologic examination: a) complete, b) incomplete-diffuse, and c) central or anterior cord damage. Results: Seventy-five patients were included (complete n = 7, incomplete-diffuse n = 33, central/anterior n = 35). In total, 319 dermatomes were tested with combined CHEPs and dSSEPs. CHEPs, dSSEPs, and clinical sensory testing were comparably sensitive to detect the myelopathy in complete (CHEPs 100%, dSSEPs 91%, PP and LT 82%) and incomplete-diffuse (CHEPs 92%, dSSEPs and PP 86%, LT 81%, p > 0.05 for all comparisons) cord damage. In central/anterior cord damage, CHEPs showed a significantly higher sensitivity than dSSEPs (89% compared with 24%, p < 0.001) and clinical sensory testing (PP 62%, LT 57%, p < 0.05). A subclinical sensory impairment was detected more frequently by CHEPs than dSSEPs (60% compared with 29%, p = 0.001). Conclusions: Assessment of spinothalamic pathways with CHEPs is reliable and revealed the highest sensitivity in all SCDs. Specifically in incomplete lesions that spare dorsal pathways, CHEPs are sensitive to complement the clinical diagnosis.
    Neurology 03/2013; 80(15). DOI:10.1212/WNL.0b013e31828c2ed1 · 8.29 Impact Factor
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    ABSTRACT: Objective: To provide a basis for the choice of anterior surgery procedures in the treatment of cervical spondylotic myelopathy (CSM) through long-term follow-up. Methods: A consecutive series of 89 patients with CSM having complete follow-up data were analyzed retrospectively. All patients were treated with anterior cervical discectomy and fusion (ACDF), and anterior cervical corpectomy and fusion (ACCF) from July 2000 to June 2007. The lesions were located in one segment (n = 25), two segments (n = 56), and three segments (n = 8). Preoperative and postoperative, the C2-C7 angle, cervical intervertebral height, radiographic fusion status, result of the adjacent segment degeneration, the Japanese Orthopaedic Association (JOA), and the Short Form 36-item (SF36) questionnaire scores were used to evaluate the efficacy of the surgery. Results: According to the different compression conditions of the 89 cases, different anterior operation procedures were chosen and satisfactory results were achieved, indicating that direct anterior decompressions were thorough and effective. The follow-up period was 60-108 months, and the average was 79.6 months. The 5-year average symptom improvement rate, effectiveness rate, and fineness rate were 78.36 %, 100 % (89/89), and 86.52 % (77/89), respectively. Conclusions: For CSM with compression coming from the front side, proper anterior decompression based on the specific conditions could directly eliminate the compression. Through long-term follow-up, the effect of decompression became observable.
    Archives of Orthopaedic and Trauma Surgery 03/2013; 133(6). DOI:10.1007/s00402-013-1719-4 · 1.60 Impact Factor
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