Cervical Spondylotic Myelopathy: Pathophysiology, Clinical Presentation, and Treatment

Spine and Scoliosis Surgery, The Hospital For Special Surgery, 535 East 70th Street, New York, NY 10021, USA; The Spine Surgery Service, Spine Care Insititute, The Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA; Weill Cornell Medical College, New York, NY 10065, USA
HSS Journal 01/2011; 7(2):170-178. DOI: 10.1007/s11420-011-9208-1

ABSTRACT 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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    ABSTRACT: Cervical spondylotic myelopathy (CSM) may be caused by static and dynamic spinal cord compression, particularly during neck extension. Dynamic compression may be better evaluated with dynamic magnetic resonance (MR) images. We performed a retrospective study to determine the clinical indication for dynamic MR imaging, and conducted a survey regarding image interpretation by clinicians. A total of 32 patients (M:F = 20:12, 60.1 ± 10.7 years) who had undergone neutral/extension cervical MR imaging were included. The study population consisted of 22 patients with signs of cervical myelopathy (M group) and 10 patients without signs of myelopathy (NM group). The number of compression levels (complete obliteration of the anterior and posterior subarachnoid space) was assessed at each level in mid-sagittal, T2-weighted, neutral and extension MR images. Reproduced images from 22 patients in the M group were randomly arranged, and four experienced spine surgeons at four different institutes interpreted them to reach a clinicians' agreement. The agreements were then assessed with inter-rater correlation coefficients (ICC). Analysis with extension MR images found an increased number of compression levels in 23/32 (72 %) of patients; 20/22 in the M group and 3/10 in the NM group (p < 0.01, chi-squared test), as compared to findings of the neutral MR images. Clinical factors for increased compression levels in extension MR images were age (p < 0.01, 63.3 ± 10.0 years vs. 51.9 ± 8.1) and signs of myelopathy (p < 0.01, odds ratio, 23.33). Clinician agreement was improved with extension MR images; ICC was 0.67 with neutral and 0.81 with extension MR images. The evaluation of CSM may be improved with dynamic MR images. Dynamic MR scanning may be considered for elderly patients with signs of myelopathy, but an interpretation for asymptomatic spinal compression based exclusively on extension MR image should be made with caution.
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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.
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