Neurosurgical Updates 2016 Brain & Spine Symposium: Presented by: Mary L. Dombovy, MD, MHSA Paul K. Maurer, MD Anthony L. Petraglia, MD Patrick J. Reid, MD Matthew L. Dashnaw, MD, Pharm D M. Gordon Whitbeck, Jr., MD

Cervical Spinal Disorders A Menu of Options Presented by Paul K. Maurer, MD Chief of Neurosurgery, Unity Hospital Rochester Regional Health

Universal Principles The patient just wants to get better The procedure should achieve this goal with the least friction possible… surgeon specific Anything done beyond this is “mission creep” CSM: a combination of compression and dynamic motion

What Needs to be Addressed Is substantial evidence that CSM is a synergistic combination of compression AND motion (dynamic forces) Henderson ‘05 etc, Philips 1973 etc Procedures to correct both issues MAY excel BUT… who needs decomp and fusion?... age, ROS, clean vs “dirty canal, pre-op cervical angle?

What’s the Cause of the Problem? Is fairly good evidence that CSM/R is a combination of compression AND dynamic motion: Phillips 1973…collar and improving sxs Ono et al autopsy data with lat. Region Adams and Logue…ROM pre cervical Lam Henderson 2005…thorough review of dynamic changes in the cord in CSM Maurer et al…CLF for CSM

JnSurg Comm Review “…there is a lack of Class I or II evidence to support ANY particular surgical approach in points with csm.” “…the consensus,using Class III data as a guide, is that all of the common approaches are effective…’ Angevine et al: (spine 2003) review of national hospital data found greater than 50% increase in fusion incidence in similar op vols.

JnSurg 2009 Supplement ACDF vs CL: “There is insufficient evidence to rec’d ACDF/ACCF v. CL because both approaches have produced similar results… some indication of potential late deterioration may lead to consideration of ACDF for short segment CSM…” ACDF vs CLF: “…insuff. Evidence to rec’d ACDF over CLF as both produce similar results”

Review of the literature suggests that ALL of the techniques of canal expansion, and variable degrees of motion reduction suffice: Cervical Laminectomy (CL) Cervical Lam+fusion(CLF) Cervical Laminoplasty (CL) Anter. Cerv. Disk Fusion (ACDF) Anter. Cerv. Corp. Fusion (ACCF) 360 Distraction/facet spacers + spinous fusion (no decomp) ACDA

Why Do We Fuse? Potential delayed kyphosis?… 2 most quoted articles (Kaptain and Guigi) are small series and clinical deterioration less than 8% (Benzel et al) To address the dynamic aspect of CSM..although this may vary with age

To Ponder E. Benzel”… a standard and appropriate laminectomy should not significantly diminish intrinsic spinal stability..post op instability is unusual in series in which laminectomy is extended only to the lateral most aspect of the dural sac” Kaptain et al… 21% v. <10% Pre op angle, age, condition of spine

CSM: A Spectrum of Disease? Clinical presentation of a two level CSM may = three level… BUT optimal treatment option may vary The long term result differences are marginally different…the surgical up front risks are much better defined... surgeon friction

52 y/o radiologist with 12 week progression of gait instability, loss of hand dexterity Classic DTRs, clonus etc ROS neg

48y/o music teacher Difficulty with piano dexterity over 6 months, “stumbling” Significant mechanical neck pain

66 y/o hospital administrator with loss of gait stability over months, rapid and intense left C6 region radiculopathy as well last 12 weeks ROS non contrib

Bottom Line All of the techniques work and have there own inherent risks and benefits When considered over the literature, no clear “winner” is evident for the overall case mix Careful individual case selection is key… (preop spinal angle, age and spinal motility and activity, ros, # of segments) Each surgeon will find what has the least friction for him/her

“I would rather die on my feet than live on my knees”. — E. Zapata

“The Americans will always do the right thing… after they have exhausted all the alternatives”. — Winston Churchill

Two Core Concepts The patient only wants to get better “Mission Creep” Each option (ACDF,ACCF,CL,CLP,CLF,360 etc) has a baseline procedural “friction” and an MD specific friction

To address CSM/R one could address both forces (compressive and dynamic) BUT who really needs both addressed and what is the “friction” of adding the stabilization/fusion?…”mission creep” ??? Anderson et al (JNSurg 09) extensive review of CLF literature..”Class III evidence shows consistently 70-95% improvement (JOA)” … comps related approx. 5% but vary

A small number of entry criteria are relevant: Pre-operative kyphosis Number of segments involved “Ventral Pathology” ???

Cervical Surgical Techs in Rx of CSM: JNSurg2009 (panel report) …all techniques allowed improvement with similar results. CL may have a greater frequency of delayed deterioration Comps vary with technique but clinical resolution NOT statistically different