1. Outcome of Surgical Treatment of Cervical Spondylotic Myelopathy (CSM): Experience in 120 Patients.
Lt Col Ibrahim Farooq Pasha
FCPS Ortho, Fellowship Spine AFPGMI AO Fellow Spine
Associate Prof. Spine Surg CMH RWP

2. Disclaimer
No advantage directly or indirectly has been taken from any company or person
Figures used in introduction are taken from Spinal Disorders
Figures used in study are of our own patient operated in CMH RWP

3. INTRODUCTION
Aging Spine- Degeneration
Spondylosis-Degenerative Diseases of the Spine

4. PATHOGENESIS
Static ,Dynamic & Biological / molecular factors (Bohlman)
Static factors :
Disc degeneration
Osteophytes
Joint hypertrophy..
Calcification of posterior longitudinal ligaments.
Hypertrophy of ligamentum flavum.
Stenosis of canal (congenital or post traumatic) can predispose to cervical myelopathy
Dynamic Factors.
Flexion.
Extension.
Spondylolesthesis.
Loss of lordosis and formation of kyphosis.

5. CSR- Radiculopathy ( Root compression))
CLINICAL ASSESSMENT (Aims)
Spondylosis (Axial)
CSR- Radiculopathy ( Root compression))
CSM-Myelopathy (Cord Compression)
Central causes
Poly neuropathy

6. Symptoms (CSM) Early (Good et al 1984)
Numb, clumsy painful Hands (Ono K et al 1987)
Difficulty in writing and eating.
Disturbed fine motor skills.
Difficulty walking(Ataxic)
Progressive tetra paresis (Gregorous et al 1976)
Bowel and bladder dysfunction (Lunsford LD 1980)
Late

7. Signs Sensory and motor deficits Atrophy of interosseous muscles
Positive Lhermittes sign
Spasticity, hyper reflexia and clonus
Babinski, Hoffman, Reverse sup Jerk
Gait disturbance and ataxia

8. Investigations Normal AP canal dia 14-22 (Payne 1957)
Relative Stenosis (10-13 mm)
Absolute Stenosis (<10mm)(Edwards 1983)
Pavlov's ratio (canal/body=1.0)(Pavlov H 1987)
Instability (>3.5 mm & ang >11 Deg) (White at al 1975)

9. MRI
NCS/EMGs
CT-Myelo

10. No patient ever returns to normal state
Natural History (Clark & Robinson 1956)
No patient ever returns to normal state
75% episodic worsening
20% slow and steady progression
5% rapid onset with lengthy disability
With moderate CSM prognosis is poor (Larocca 1988)

11. Indication For Surgery (Yonenobu k 2000)
Progressive Myelopathy despite Non-Operative care
Acute onset, Deterioration or Progression of Neuro Deficits
Definitive Compression with Moderate to-Severe Symptoms
Progressive Kyphosis with Neurological Deficit

12. OPERATIONS
ACDF
ACCF
Laminoplasy
Laminectomy
Combined
Decompression

13. Patients & Methods, N=120, (follow up =Min 2 years Mean 37 M)
Conducted at CMH RWP ( )
Patients Operated for CSM included
Treated Cons or Unfit or Unwilling Excluded
1-3 level with predominantly Ant comp= Ant apprch
More that 3 levels with lordosis = Post approch
No Neck Pain & Good ROM=Laminoplasty ?

14. Neurick Scale was used for neurological assessment depending upon walikng ability
(Nurick S 1972)
Grade 0- Only root involvement no difficulty in walking
Grade 1- Signs of CSM, hyper reflxia, hoffman +, no walking difficlty
Grade 2- difficulty in walking but able to perform job
Grade 3-Difficulty in walking for which has to change job
Grade 4- Able to walk with frame/ help
Grade 5- Bed bound/chair bound

15. Results N=120, Mean Age (26-82)

16. Operations 1 Anterior cervical disc excision and fusion (ACDF) 26 2
Anterior Corpectomy & fusion with BG or a cage (ACCF) 21 3
Laminoplasty 9 4
Laminectomy with LMP (37) or rod (24) 61 5
Decompressive laminectomy

17. Outcome Neurick Scale

18. Outcome Neurick Scale

19. ACDF C3-4 (57 M)

20. ACDF C5-6-7 (45 F)

21. ACDF C (55 M)

22. ACCF C4-5-6 (61 M)

23. ACCF C (55M)

24. Laminoplasty C (56 M)

25. Laminectomy with LMP C3-6 (64 F)

26. Complications Incidental durotomy in 3 (2.5%),
Wound infection in 2 (1.67%)
Deterioration of neurological status in 3 (2.5%)

27. Conclusions
The operative treatment in CSM should be done early before neurological deficits get fixed .
When there is less neurological deficit the recovery is more with better functional outcome.