Chronic Myelopathy with Inadequate Surgical Decompression Critical Decision Making

Transcription

1 CSRS, Instructional Course Lecture Date: 10/04/2015 Chronic Myelopathy with Inadequate Surgical Decompression Critical Decision Making Introduction This instructional course lecture will present various cases that highlight the critical decisions that must be considered when treating the patient with chronic myelopathy. This especially will factor into those who have had previous surgical intervention. Its basic algorithmic strategy is presented. A select bibliography is presented. Critical Decisions What is the condition of the patient's myelopathy? New Stable Improved Progressive Was the diagnosis of cervical spondylitic myelopathy correct? Other differential diagnosis must considered such as ALS, MS, Lyme disease, vitamin D deficiency, etc. Are there significant remedial host factors? i.e., smoking, malnutrition, vitamin deficiency, cardiopulmonary, etc. What was the previous surgical approach? Anterior Posterior Combined Was the previous surgery anterior, right, or left? Right Left Was there evidence of recurrence laryngeal nerve or superior laryngeal nerve palsy? If so, such as dysphonia or severe swallowing dysfunction, ENT evaluation

2 Patient: Instructional Course Lecture CSRS Date of Birth: Patient MRN: Page 2 If previous ACDF, is the fusion solid? CT scan (coronal extra cage bone), flexion-extension radiographs If ACDF, is instrumentation present? Type: Plates Interbody prosthesis Bone, metal, plastics, other What is the cervical alignment? Lordotic Neutral Kyphotic Is the cervical spine biomechanically stable? At level of index surgery or other levels If cervical deformity is present, is it fixed or flexible? Fixed Flexible Combined Where does imaging reveal compression? Index level Adjacent segment Ventral Dorsal Was previous surgery posterior alone? Laminectomy number of levels Laminoplasty number of levels

3 Patient: Instructional Course Lecture CSRS Date of Birth: Patient MRN: Page 3 If posterior, is instrumentation present? What type Number of levels Was the previous procedure a disc arthroplasty? If so, what implant is present Case Presentations 1. Status post anterior cervical decompression and fusion, stable fusion, remnant bone, myelopathy worsening, allograft bone and plate, mitigating factor ankylosing spondylitis. Patient had correct diagnosis, previous right-sided approach, has no deformity with no previous signs of recurrent laryngeal nerve involvement. 2. Post laminectomy kyphosis with instability. 3. Status post cervical arthroplasty with new onset myelopathy. 4. Post laminectomy with OPLL with still ventral deforming bone. 5. Status post ACDF with solid fusion, eccentric remnant bone. 6. Status post C1-C2 posterior spinal fusion with instrumentation with nonunion and instability. Timothy A. Garvey, MD TAG/10693 T: 10/05/2015

4 Bibliography Costa F, Tomei M, Sassi M, Cardia A, Ortolina A, Servello D, Fornari M. "Evaluatoin of the rate of decompression in anterior cervical corpectomy using an intra-operative computerized tomography scan (O-Arm System)." European Spine Journal, 2012 Feb: Kaptain GJ, Simmons NE, Replogle RE, Pobereskin L. "Incidence and outcome of kyphotic deformity following laminectomy for cervical spondylotic myelopathy." Journal of Neurosurgery Spine, 2000 Oct: Pang CH, Leung HB, Yen CH. "Laminoplasty after anterior spinal fusion for cervical spondylotic myelopathy." Journal of Orthopedic Surgery (Hong Kong), 2009 Dec: Park Y, Riew KD, Cho W. "The long term results of anterior surgical reconstruction in patients with postlaminectomy cervical kyphosis." Spine Journal, 2010, May: Riew, KD, Hilibrand AS, Palumbo MA, Bohlman, HH. "Anterior cervical corpectomy in patients previously managed with a laminectomy: short term complications." The Journal of Bone and Joint Surgery, 1999: Shamji MF, Mohanty C, Massicotte EM, Fehlings MG. "The Association of Cervical Spine Alignment with Neurological Recovery in a Prospective Cohort of Surgical Myelopathy Patients: Analysis of a Series of 124 Cases." World Neurosurgery, 2015 Sept. Taniyama T, Hirai T, Yamada T, Yuasa M, Enomoto M, Yoshii T, Kato T, Kawabata S, Inose H, Okawa A. "Modified K-line in magnetic resonance imaging predicts insufficient decompression of cervical laminoplasty." Spine, 2013 Mar: Tetreault LA, Dettori JR, Wilson JR, Singh A, Nouri A, Fehlings MG, Brodt ED, Jacobs WB. "Systematic review of magnetic resonance imaging characterstics that affect treatment decision making and predict clinical outcome in patients with cervical spondylotic myelopathy." Spine, 2013 Oct: Uchida K, Nakajima H, Sato R, Yayama T, Mwaka ES, Kobayashi S, Baba H. "Cervical spondylotic myelopathy associated with kyphosis or sagittal sigmoid alignment: outcome after anterior or posterior decompression." Journal of Neurosurgery Spine, 2009 Nov: Wang MY, Green BA. "Laminoplasty for the treatment of failed anterior cervical spine surgery." Neurosurgery Focus, 2003 Sept.

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