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304 North Cardinal St.
Dorchester Center, MA 02124
Cervical stenosis with preservation of lordosis
Introduction
Although first described in 1952 by Brian et al., cervical spondylotic myelopathy (CSM) continues to be a frequently misdiagnosed pathology. The insidious onset is often mistaken as part of the normal aging process, while patients often have progressive and debilitating neurological deficits. In fact, CSM is the leading cause of spinal cord–related disability in older adults. This results from degenerative changes of the cervical spine, which leads to narrowing of the spinal canal and chronic compression of the cervical spinal cord. The chronic compression leads to ischemia of the spinal cord, demyelination, axonal loss, and, in severe cases, neuronal loss. This leads to the cavitation often seen on magnetic resonance imaging. There is believed to be components of both static and dynamic compression, which contributes to ongoing damage to the spinal cord. This leads to symptoms such as gait instability, weakness, paresthesia, loss of dexterity, and urinary dysfunction. The degree of compression at which a patient presents with symptoms is highly variable, as is the rate of symptomatic progression. There are many factors that may contribute to spondylosis leading to canal stenosis such as genetics, smoking, trauma, heavy labor, and congenital spinal anomalies. Likewise, there are a number of factors that affect the progression of symptoms, and there has been increasing interest in how genetics play into this process.
Example case
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Chief complaint: gait imbalance
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History of present illness: A 77-year-old male with a history of increasing difficulty with balance. He recently suffered a fall, fracturing his hip. The patient has also had increasing difficulty with his dexterity including difficulty buttoning his shirt and fine motor movement. He denies any bowel bladder dysfunction. He was not using any assistive device before his fall but is now using a wheelchair when out and a walker at home. He underwent imaging and this was concerning for cervical stenosis ( Figs. 14.1–14.2 ).
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Medications: amlodipine, aspirin 81 mg, pravastatin, sertraline, tacrolimus, tamsulosin
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Allergies: lorazepam
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Past medical and surgical history: alcoholic cirrhosis, early-stage dementia, hypertension, hyperlipidemia, depression, skin cancer, cervical myelopathy, liver transplant
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Family history: noncontributory
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Social history: retired professor, previous alcohol dependency, remote history of smoking
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Physical examination: awake, alert, and oriented to person, place, and time; cranial nerves II–XII intact; bilateral deltoids/biceps/triceps 5/5; interossei 5/5; iliopsoas/knee flexion/knee extension/dorsi, and plantar flexion 5/5
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Reflexes: 3+ in bilateral biceps/triceps/brachioradialis; 3+ in bilateral patella/ankle no clonus or Babinski, left Hoffman; sensation increased in bilateral lower extremities
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| Preoperative | ||||
| Additional tests requested |
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| Surgical approach selected | C3-7 laminoplasty | C3-4, C4-5, C5-6 ACDF | C3-5 laminectomy | C3-7 laminectomy |
| Goal of surgery | Spinal cord decompression | Spinal cord decompression, fusion | Spinal cord decompression | Spinal cord decompression |
| Perioperative | ||||
| Positioning | Prone with Gardner-Wells tongs on Jackson table with 10–15 lb of traction | Supine, no pins | Prone with Mayfield pins | Prone with Mayfield pins |
| Surgical equipment |
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Fluoroscopy | Fluoroscopy |
| Medications | Tranexamic acid, steroids, MAPs 85–90 | None | Steroids, maintain MAP | None |
| Anatomical considerations | Spinal cord, C5 nerve roots, insertion of spinal extensors | Spinal cord | Dura, vertebral arteries | Spinal cord, facets |
| Complications feared with approach chosen | Pseudoarthrosis, incomplete decompression, junctional segment compression, hardware failure, dysphagia | Durotomy, CSF leak | Durotomy, CSF leak, vertebral artery injury | Durotomy, CSF leak, spinal instability, dysphagia |
| Intraoperative | ||||
| Anesthesia | General | General | General | General |
| Exposure | C3-7 | C3-6 | C2-6 | C3-7 |
| Levels decompressed | C3-7 | C3-6 | C3-5 | C3-7 |
| Levels fused | None | C3-6 | None | None |
| Surgical narrative | Position prone with Gardner-Wells tongs, keep head neutral to flexed with bivector traction robes, expose C3-7 lateral masses bilaterally, partial laminectomy at caudal end of C3 and rostral end of C7, full trough bilaterally at C4-6 on opening side that is more symptomatic and compression, thin contralateral side trough C4-6, open full trough side, place plates and fixed lamina then spinous process, apply hemostatic agent and steroids on cord, bur down dominant spinous process, five-layer closure | Intubated, supine position, fluoroscopy to identify correct level, right transverse neck incision, incise platysma, work between trachea and esophagus medially and carotid sheath laterally, expose C3-6, start at top level and remove disk, curette disc space, open PLL, use blunt nerve hook behind disc space to ensure adequate decompression, insert PEEK, repeat at C4-5 and C5-6, insert plate, AP and lateral x-rays to confirm good location of interbody grafts and plate, standard closure with subplatysmal drain | Intubated, x-ray to confirm level, midline incision, subperiosteal bilateral exposure of C2-6, C3-5 laminectomy, yellow ligament removal until dural visualized | GlideScope intubation, supine SSEP/MEP, position prone with pins in head neutral, confirm baseline IOM, exposure spine, confirm levels based on lateral fluoroscopy, open ligamentum flavum at C2-3 and C7-T1, drill troughs at C3-7 lamina-facet junction, open ligamentum flavum in the troughs with a 1 mm Kerrison rongeur, lift C3-7 lamina away from spine in one piece, confirm spinal levels with fluoroscopy, layered closure with drain |
| Complication avoidance | Laminoplasty, opening side of laminoplasty on more symptomatic side, bur down spinous processes | Anterior approach, right side to avoid recurrent laryngeal nerve injury, preserve lordosis, x-ray to confirm | No fusion | Preflip IOM, en bloc laminectomy, no fusion |
| Postoperative | ||||
| Admission | Stepdown unit vs. floor | ICU | ICU | Floor |
| Postoperative complications feared | C5 palsy | Neurological deterioration | CSF leak, spinal instability, vertebral artery injury, medical complications | C5 nerve palsy, hematoma, CSF leak, medical complication |
| Anticipated length of stay | 1–3 days | 2 days | 5 days | 3 days |
| Follow-up testing |
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Cervical x-rays 2 months, 6 months, 12 months after surgery | C-spine CT 1 day, 3 months after surgery, C-spine MRI 3 months after surgery | None |
| Bracing | Soft collar for 2 weeks | Soft collar for 6 weeks | Philadelphia collar for 3 months | None |
| Follow-up visits | 2–3 weeks after surgery | 2 weeks, 2 months, 6 months, 12 months after surgery | 3 weeks after discharge | 2 weeks, 6 weeks, 3 months, 6 months, 1 year after surgery |
ACDF , Anterior cervical decompression and fusion ; AP , anteroposterior; CSF , cerebrospinal fluid; EMG , Electromyogram; ESI , epidural spinal injections; ICU , intensive care unit; IOM , intraoperative monitoring; MAP , mean arterial pressure; MEP , motor evoked potentials; MRI , magnetic resonance imaging; PEEK , polyetheretherketone; PLL , posterior longitudinal ligament; SSEP , somatosensory evoked potentials.
Differential diagnosis
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Cervical myelopathy
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Transverse myelitis
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Multiple sclerosis
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