Microscopic Cervical Laminectomy In Shifa Medical Complex For Cervical Spondylotic Myelopathy (C S M) DR : HAZEM KUHEIL Consultant NEUROSURGEON

Abstract   Cervical spondylotic myelopathy (CSM) is common disorder which can lead to significant clinical morbidity. Conservative management is the preferred and often only required intervention. Surgical intervention is reserved for those patients who have intractable pain or progressive neurological symptoms. The goals of surgical treatment are decompression of the spinal cord and nerve roots and deformity prevention .

Numerous surgical techniques exist to alleviate symptoms, which are achieved through different approaches. Under most circumstances, one approach will produce optimal results. The objective of this paper is to analyze the major surgical treatment options for cervical myelopathy and focusing on our surgical option (cervical laminectomy) outcomes.

Introduction   Cervical Spondylosis is the most common cause of neural dysfunction in the cervical spine and is becoming more prevalent as the average life-expectancy increases [1]. The degenerative changes associated with ageing include disc herniation, osteophyte formation, hypertrophy of facet joints, and hypertrophy of ligaments. This condition is often asymptomatic, but in 10% to 15% of cases it compresses the cervical spinal cord and roots to present symptomatically as myelopathy or radiculopathy [2, 3].

One of the most common causes of cervical myelopathy is Extradural compression of the cord, which can occur as a result of # Spinal trauma # Mass lesions # Degenerative changes of the Spine, or other factors. When cord compression is caused by degenerative changes it is cervical spondylotic myelopathy (CSM), which will be the focus .

How spondylosis lead to cord compression?

Spondylosis may lead to cord damage in three ways Static-mechanical compression of the cord by # Osteophytes # Spinal ligaments # Disc material which encroach upon the canal space resulting in stenosis of the canal Those with a congenitally narrowed spinal canal are especially vulnerable to static-mechanical compression

2. Dynamic-mechanical cord compression NECK MOVEMENTS Neck flexion Reduces the AP diameter of the spinal canal by 2-3 mm AP compression by osteophytes  Neck extension Ligamentum flavum to pinch the cord against anterior osteophytes Lateral neck movements Nerve root compression Radicular symptoms

3.Impairing the circulation within the cord Osteophytes can compress the Anterior Spinal Artery or a critical medullary feeder, or can compress venous drainage leading to a neuroischemic myelopathy usually affecting the anterior cord

Clinical presentation Most commonly Sensory symptoms including Upper extremity numbness, Pain, and paraesthesia initially, followed by lower extremity sensory changes Motor dysfunction may be unilateral or bilateral depending on the extent and location of cord damage, -- quadriplegia .

Role Of Radiological Investigations 1 Plain X ray disc space narrowing Osteophytosis Kyphosis Joint subluxation Stenosis of the spinal canal

2- CT Spine A CT scan is helpful in assessing Canal stenosis May show osteophytes better than plain radiography Good at defining the neural foramina Useful in diagnosing Ossification of PLL

3-MRI C SPINE MRI remains the imaging modality of choice for CSM MRI allows for clear visualization of cord impingement or compression to accurately measure space within the spinal canal Signal intensity may be increased at the level of cord damage, particularly on T2-weighted images, due to Inflammation , edema, ischemia, gliosis, or myelomalacia 

Can MRI Predict The Prognosis Of CSM? The low-signal intensity changes on T1-weighted sequences indicated a poor prognosis Morio et al., 2001, Correlation Between Operative Outcomes of Cervical Compression Myelopathy and MRI of the Spinal Cord

CSM Management Non - Surgical Surgical

Non Operative treatment Provides symptomatic relief in patients with CSM  Should avoid activities that exacerbate symptoms Long term cervical immobilization with a cervical collar or neck brace is commonly used, but little evidence for its efficacy Role of Physiotherapy 

Non Surgical treatment Drugs: NSAIDs  GABA analogue Tricyclic antidepressants Muscle relaxants Opioids can be used for pain relief

Surgical Treatment Patients who are operated on early (within a year of the onset of symptoms) have better outcomes than those who are operated on more than a year after the onset of symptoms Several studies have shown that many patients treated surgically have good outcomes  Ebersold M et al., J Neurosurg 2015;82(5):745-751

Decompression by anterior or posterior?

Surgical Treatment AIM: To decompress the spinal cord Decompression can be accomplished by removing bone, disc, or ligamentous material that is encroaching on the space within the spinal canal.

Posterior approach Laminectomy Laminoplasty The laminal arch along with the ligamentum flavum are removed to create room within the spinal canal The lamina are reconstructed in a way that creates more room within the spinal canal but are not removed Relatively less complicated procedure More Complicated procedure The Lamina are removed, a kyphotic deformity can develop postoperatively Improved neck stability and mobility and less kyphosis after a laminoplasty (structural integrity of the vertebrae are maintained)

Cervical Laminectomy Sagittal view Axial view

Laminoplasty Laminoplasty

Anterior Approach Anterior discectomy is indicated for single-level and some multi-level disc herniation's causing cord damage  Fusion is almost always performed along with discectomy because spinal instability is common if this is not done  discectomy

Corpectomy Vertebral body and disc are removed at one or more levels and the vertebrae above and below the corpectomy are fused It is often favoured when three or more cord levels are involved as it may provide superior decompression and a higher rate of successful fusion in these cases  Corpectomy

Posterior approach Favoured in cases in which compression is mainly posterior, for example by Posterior osteophytes, Thickened ligamentum flavum. And in Multilevel deg. disc with stenosis.

Anterior Approach Preferred in patients with predominately anterior compression from Disc material Anterior osteophytes, or a Thick or ossified Posterior longitudinal ligament Either approach can create space within the spinal canal regardless of the anatomical location of compression

During 2016 In Shifa medical complex three cases of cervical myelopathy was operated with excellent outcome ,and three cases of upper dorsal lesions with myelopathy .Two were improved significantly and one case had a mild improvement due to late presentation .

Female patient 60years old with progressive quadriparesis during last two weeks before presentation. She was admitted in medical department for the treatment of general fatigue and ataxia ,brain CT was within normal . After neurosurgical consultation MRI cervical spine was done

Pre op . MRI

Urgent microscopic laminectomy was done Urgent microscopic laminectomy was done . Second post operative day the patient can walk with min. assistance. After one month the patient walk alone ,with out neurological deficit . MRI post op. showed significate improvement .

Post op . MRI

Conclusion Microscopic Cervical laminectomy is a safe and effective surgical option in patients with multilevel CSM. It usually results in improvement of the neurological deficits and the radicular pain in these patients with a reasonably low incidence of postoperative clinical deterioration and cervical instability.

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