Indications for laminectomy are mainly for the management of: multilevel cervical myelopathy predominant posterior neural compression elderly CSM patients with comorbidities CSM with
Trang 1faces [218] (Case Study 3) Current indications and contraindications for TDA
include [11] (Table 7):
Table 7 Indications and contraindications for TDA
) symptomatic cervical disc disease
) one- or two-level involvement (C3–T1)
) structural correlate (i.e herniated nucleus
pulposus, cervical spondylosis)
) failed conservative therapy of 6 weeks
) age between 20 and 70 years
) no contraindications
) three vertebral levels requiring treatment ) cervical instability (translation > 3 mm and/or > 11° angulational differ-ence)
) cervical fusion adjacent to the target level ) previous surgery/fracture at target level ) known allergy to implant materials ) severe spondylosis (bridging osteophytes, disc height loss > 50 %, and absence of motion < 2°, facet joint OA)
) axial neck pain as the solitary presenting symptom ) systemic and metabolic diseases (AIDS, HIV, hepatitis B or C, insulin-dependent diabetes, infections, obesity, BMI> 40)
Outcome of TDA is not superior to conventional ACDF techniques
Preliminary outcome data demonstrated that TDA preserves segmental motion
[50, 185] in the short term and compares very favorably to ACDF in terms of
clin-ical outcome [23, 179, 184, 243] However, no convincing data was provided so far
that TDA will prevent adjacent segment degeneration [243]
Posterior Laminectomy
Cervical laminectomy was first performed by Sir Victor Horsley (1857 – 1916) for
the treatment of tumor related myelopathy [265] Laminectomy is a versatile and
technically facile approach to decompress the spinal cord [171]
Indications for laminectomy are mainly for the management of:
) multilevel cervical myelopathy
) predominant posterior neural compression
) elderly CSM patients with comorbidities
) CSM with preserved cervical lordosis
Laminectomy provides favorable results in selected cases
In elderly patients suffering from significant comorbidities and CSM due to
mul-tilevel spinal cord compression, laminectomy is a short and effective procedure
to arrest or improve neurological deficits In the presence of kyphosis, however,
laminectomy only has a limited effect since the spinal cord cannot migrate
poste-riorly and move away from osteophytes or discs compressing the spine
anteri-orly Good to excellent results have been reported in 56 – 85 % of patients after
laminectomy [171] The lateral extension of laminectomy should not include
more than 50 % of the facet joint The resection greater than 50 % compromises
joint strength significantly and can lead to segmental instability and kyphosis In
multilevel laminectomy, even 25 % resection of the facet can reduce cervical
sta-bility considerably and require fusion [189]
Laminectomy and Instrumented Fusion
Instrumented fusion prevents postoperative deformity and instability
The main drawbacks of laminectomies are progressive postoperative deformity
and instability, which may subsequently lead to neurological deterioration [109,
135, 257, 299] These limitations can be overcome by additional instrumented
fusion Most commonly lateral mass screw fixation is used allowing for a good
biomechanical stability of the decompressed segments and a high rate of solid
fusion [71, 121] The technique of screw insertion is reviewed in Chapter 13
With proper technique the risk of complications (vertebral artery or nerve root
Trang 2injury) is minimal [71, 79, 121] Pedicle cervical screw fixation (see Chapter 13)
is an alternative but is rarely needed in degenerative disorders with good bone quality [1, 2] For cases in which correction of a kyphotic deformity is attempted, pedicle screw fixation is advisable for better bony purchase [3]
Posterior Foraminotomy
Posterior foraminotomy
remains a valid treatment
alternative for CSR
A posterior foraminotomy for the treatment of cervical nerve root compression
was first described by Frykholm [88] ( Fig 7) and subsequently by Scoville [249] and Murphey [182] Despite favorable results [122, 305], this approach fell out of favor because of the limitations of treating anterior neural compression of
Figure 7 Technique of posterior foraminotomy (Frykholm)
The spine is exposed by a unilateral posterior approach Tubular retractors allow collateral damage to the neck muscles
to be minimized.aA high-speed diamond burr is used to create a keyhole laminotomy exposing the exiting nerve root.
bAfter resection of the ligamentum flavum, epidural veins may become visible which may require coagulation (low-energy bipolar).cThe exiting nerve root can gently be lifted cranially to expose the underlying pathology (disc hernia-tion, spur).dThe disc herniation or spur can be removed with a rongeur or curette.
Trang 3median pathology Many surgeons therefore prefer the anterior approach with
discectomy and osteophytectomy in conjunction with interbody fusion
How-ever, posterior foraminotomy remains a valid option in cases with CSR
predom-inantly caused by lateral recess stenosis and lateral disc herniations [159, 161]
The muscles of the neck are rich in proprioceptors that send afferents directly to
the vestibular and optical neurons controlling head position on the trunk [148,
213] This can be the major cause of postoperative persistent neck pain
Access technology makes the posterior approach appealing
Recently, minimally invasive procedures were introduced to minimize the
trauma to the neck muscles avoiding detachment of the extensor cervical
mus-cles from the lamina and spinous process [82] Burke and Caputy [43] reported
on a microendoscopic technique through a transmuscular access with only
sep-aration and dilatation of the muscles Boehm et al [30] used a working channel
of an outer diameter of 11 mm to expose the interlaminar-facet region and
reported favorable results with this technique Clarke et al [59] have shown that
posterior foraminotomy is associated with a low rate of same- and
adjacent-seg-ment disease
Laminoplasty
The potential destabilization, sagittal malalignment (kyphosis) and the lack of
spinal cord protection subsequent to multilevel cervical laminectomy led
Japa-nese surgeons to develop cervical laminoplasty techniques [127] Accordingly,
the general advantages of laminoplasty are to [297]:
) expand the spinal canal
) secure spinal cord protection
) maintain spinal stability
) preserve spinal mobility
) decrease the risk of adjacent segment degeneration
Laminoplasty has predominantly been developed to treat OPLL
Hirabayashi introduced a new surgical technique called “expansive open-door
laminoplasty” which is still widely used today [126 – 128] As an alternative, the
“French open-door laminoplasty” was introduced by Hoshi and Kurokawa [129].
Although numerous surgical modifications [117, 137, 147, 165, 174] have been
suggested, the basic concept of most of the procedures is similar to one of these
two techniques (Fig 8)
The benefits of laminoplasty are not well supported
A recent critical review concluded that the literature has yet to support the
purported benefits of laminoplasty [225] Ratcliff and Cooper [225] concluded
that neurological outcome and change in spinal alignment appear to be similar
after laminectomy and laminoplasty Patients treated with laminoplasty appear
to develop progressive limitation of cervical range of motion (ROM) similar to
that seen after laminectomy and fusion However, data is lacking on the role of
laminoplasty in young individuals with cervical myelopathy due to a congenitally
narrow spinal canal and where multilevel decompression and instrumented
fusion is not a favorable alternative
Surgical Decision-Making
When considering surgery to treat degenerative cervical disorders, the surgical
strategy must be based on patient as well as morphological factors (Table 8)
The fundamental question remains “when to operate and when not to”
Radiographic alterations are common in asymptomatic patients [29] The
most important factor in patient selection therefore is that clinical and
morpho-logical findings must match to obtain a satisfactory outcome Innumerable
arti-cles cover the outcome of surgical treatment for degenerative cervical disorders
Almost all articles cover technical aspects, and safety and early clinical results
Trang 4a b
Figure 8 Laminoplasty techniques
aExpansive open-door laminoplasty according to Hirabayashi [127] The opened lamina is fixed with a suture through the inferior articular process.bHemilateral open-door laminoplasty with interposition of a bone graft and fixation according to Itoh [137].cAlternative fixation with an AO small fragment reconstruction plate.dFrench open-door lami-noplasty according to Hoshi and Kurokawa [129] Intraspinous insertion of a bone block and fixation with a suture or cer-clage wire.
Table 8 Decision factors for surgical strategy
) predominant symptoms (neck pain vs arm pain) ) presence of neural compression
) presence of radicular symptoms ) extent and localization of neural compression
) presence of myelopathic symptoms ) soft vs hard compression
) severity and duration of symptoms ) segmental instability
) onset of symptoms (acute, insidious) ) spinal deformity (kyphosis)
Trang 5without adequate control groups Many of the anecdotal studies incorporated a
whole variety of indications, which limits conclusions on degenerative cervical
disorders However, when the scientific literature is reduced to Level A
recom-mendations (i.e consistent evidence in multiple high-quality RCTs, Level I
evi-dence), only very few RCTs can be identified The fundamental question
regard-ing treatment option is always related to the choice between surgery and
non-operative care However, the literature is equally sparse on such comparisons
These findings greatly limit treatment recommendations In this section, we
therefore try to provide as best evidence-enhanced rather than evidence-based
treatment recommendations and the reader should acknowledge this
limita-tion
Neck Pain
Scientific evidence for the effectiveness of neck pain surgery is poor
Axial neck pain is multifactorial and often lacking a structural correlate which
can be treated by surgery Therefore, surgery for neck pain is rarely indicated [15,
223, 291]
However, a certain subset of these patients present with atypical radicular pain
particularly when upper nerve roots are involved and may benefit from surgery
In this setting, compression of the C4 nerve root has been recognized as a source
of neck pain which was successfully treated by surgery [139]
In patients with severe, disabling neck pain who failed an adequate trial of
conservative care, the indication for surgery can be explored by using detailed
imaging and injection studies [223] However, the identification of the pain
source and painful levels (e.g by discography or facet joint blocks) remains
chal-lenging and often unreliable [64, 107, 150, 200, 256] Treatment of axial neck pain
by fusion is only supported by a few cohort studies [65, 92, 138, 200, 224, 290,
307] Of note, neck pain alone as the presenting symptom is listed as one of the
current contraindications for TDA [11]
Rarely, patients present with severe osteoarthritis at the craniocervical
junc-tion (Fig 2d), which may necessitate fusion In selected cases, fusion can result in
a significant improvement [284]
Cervical Radiculopathy
Conservative care compares favorably to surgery for CSR
Only one study so far systematically compared non-operative treatment and
sur-gery for radiculopathy [86] In the prospective study by Persson et al [211, 212],
81 patients were included who presented with cervicobrachial pain of at least
3 months duration due to spondylotic encroachment with or without an
addi-tional bulging disc The patients were divided into three treatment arms, i.e
sur-gery (Cloward technique), individually adapted physiotherapy or cervical collar
Pain intensity, muscle weakness and sensory loss can be expected to improve
within a few months after surgery Although a short-term benefit for the
surgi-cally treated patients was noted, there was no difference in visual analogue scale,
Sickness Impact Profile, and Mood Adjective Check List measurements among
the groups at 1 year follow-up The authors concluded that cervical collar,
physio-therapy, or surgery are equally effective in the treatment of patients with
long-lasting cervical radicular pain
ACDF remains the gold standard for treatment
of CSR
In some patients, however, radicular symptoms are so severe or persistent
despite non-operative care that they opt for a surgical solution Regarding the
cur-rent literature, ACDF still remains the gold standard for surgical treatment [45]
There is no evidence that additional anterior plate fixation influences clinical
outcome for one-level disease [105, 244, 309] and limited evidence that anterior
plating increases the fusion rate for two-level disease [47, 94, 146, 280, 281] The
Trang 6Cage fusion and TDA are
superior to ACDF only
regarding donor site pain
evidence for the superiority of cage fusions [111, 210, 233, 273] or TDA [23, 179,
184, 243] compared to ACDF is lacking except in terms of iliac crest donor site pain Particularly, the superiority of TDA in terms of adjacent segment degenera-tion studies remains unproven
Minimally invasive decompressions (anterior or posterior) for the treatment
of selected radiculopathy patients [30, 43, 140, 240, 241] remain intriguing because they preserve segmental motion and do not require instrumentation (potential cost-effectiveness) But, so far, scientific evidence is lacking for their role in the treatment of cervical radiculopathy
Treatment outcome
is primarily dependent on
nerve root decompression
In general, the treatment outcome of surgical treatment of cervical radiculo-pathy is favorable with good to excellent results in 83 – 97 % [33, 96, 102, 110] and primarily dependent on the nerve root decompression and not so much on the specific surgical technique
Cervical Spondylotic Myelopathy
There is no evidence against
surgery in moderate
to severe CSM cases
It is not known whether surgery results in better results than conservative care in mild to moderate CSM [142] In a prospective study, Kadanka et al [142] ran-domized 48 patients with mild to moderate CSM into a conservative and an oper-ative arm There was no significant deterioration in modified JOA score, recovery ratio, or timed 10-m walk within either group during the 2 years of follow-up The authors concluded that surgical treatment of mild and moderate forms of CSM, consisting of patients with no or very slow, insidious progression and a rel-atively long duration of symptoms, was not superior to conservative care [142] However, there is no controversy as to whether severe or progressive CSM should
be treated by decompression [22, 223]
The goal of surgery
is to completely decompress
the spinal cord
The primary surgical objective in CSM is the arrest or improvement of
neuro-logical deficits by spinal cord decompression In a prospective, multicenter non-randomized study, surgically treated patients had a significant improvement in functional status and overall pain, with improvement also observed in neurolog-ical symptoms [239] Conservatively treated patients had a significant worsening
of their ability to perform activities of daily living, with worsening of neurologi-cal symptoms [239] A meta-analysis of more than 2 000 patients treated by lami-noplasty revealed a mean improvement rate of 80 % [225]
The choice of the surgical
technique is dependent
on the target pathology
and patient characteristics
The decompression of the spinal cord can be achieved either by:
) anterior approach (multilevel ACDF or corpectomy ± plate fixation) ) posterior approach (laminoplasty, laminectomy ± instrumented fusion) ) combined anterior/posterior approach
Corpectomy and
anteropo-sterior instrumented fusion
results in a reliable outcome
Although innumerable studies have been reported for each of these approaches, the scientific evidence for treatment recommendations remains limited Only a few studies have provided some evidence which is helpful for surgical
decision-making There is moderate evidence that multilevel ACDFs are associated with a high non-union rate [33, 49, 78] and limited evidence that corpectomies result in
a lower non-union rate for multilevel decompression [263] In three and more level ACDFs or corpectomies, anterior plate fixation does not suffice [136, 242,
270, 281] and additional posterior fixation is recommended [73, 93, 162, 226] There is limited evidence that both multilevel corpectomy and laminoplasty are
equally effective in arresting myelopathic progression in multilevel cervical mye-lopathy and can lead to significant neurological recovery and pain reduction in a majority of patients [72] The neurological recovery appears not to be dependent
on the laminoplasty technique [225] However, there is limited evidence that patients treated with laminoplasty develop progressive limitation of cervical ROM similar to that seen after laminectomy and fusion [225]
Trang 7Factors Affecting Outcome
Spinal canal dimensions and signal intensity changes predict outcome
The outcome of surgery appears to be critically dependent on the extent of the
spinal canal stenosis and cord compression Yamazaki et al [294] analyzed the
prognostic factors by comparing younger and elderly patient groups on the basis
of preoperative radiological and clinical data The authors found that for elderly
patients, the transverse area of the spinal cord at the level of maximum
compres-sion and symptom duration were the factors that predicted an excellent recovery
In younger patients, the transverse area was the only predictor of excellent
recov-ery Age, preoperative JOA score, canal diameter, and an intensity change on the
spinal cord were not predictive in either age range [294] Fujiwara et al [89]
showed that the transverse cord area at the site of maximum compression
corre-lates significantly with the results of surgery In most patients with less than
30 mm2of spinal cord area, the results are poor Patients with high
intramedul-lary signal change on T2W images who do not have clonus or spasticity may
experience a good surgical outcome and may have reversal of the MRI
abnormal-ity [6] A less favorable surgical outcome is predicted by the presence of low
intra-medullary signal on T1W images, clonus, or spasticity [6] Based on these
find-ings, Alafifiet et al [6] suggested that there may be a window of opportunity for
obtaining optimal surgical outcomes in patients with CSM Yonenobu [297] has
indicated that surgery performed too late in a stage with already severe
myelopa-thy generally had a poor prognosis and therefore advocates early surgery
Staged combined anterior/
posterior decompression for myelopathy is safer
Some debate continues on the question of whether combined
anterior/poste-rior surgery to decompress moderate to severe myelopathy should be done
staged or in one surgery [180] There is no evidence to support one approach
over the other Anecdotally, we have seen patients admitted to our spinal cord
injury unit who experience substantial neurological deterioration after
com-bined surgery We therefore recommend performing anterior/posterior spinal
cord decompression staged in moderate to severe myelopathy cases to minimize
edema and allow blood supply to the spinal cord to readapt between the
surger-ies
Complications
A comprehensive review of complications is provided in Chapter 39 In general,
complications of surgery for CSR and CSM are uncommon but can include [45,
85, 306]:
) cerebrospinal fluid leak (0.2 – 0.5 %)
) recurrent laryngeal nerve injury (0.8 – 3.1 %)
) dysphagia (0.02 – 9.5 %)
) Horner’s syndrome (0.02 – 1.1)
) cervical nerve root injury (0.2 – 3.3 %)
) hematoma (0.2 – 5.6 %)
) tetraparesis (0.4 %)
) death (0.1 – 0.8 %)
) infection (0.1 – 1.4 %)
) esophageal perforations (0.2 – 0.3 %)
) non-union (dependent on technique)
) graft dislodgement/collapse (dependent on technique)
) instrumentation failure (dependent on technique)
Dysphagia is a common postoperative complication
Dysphagia is a quite frequent symptom after anterior cervical surgery and can be
encountered in up to 50 % of cases in the immediate postoperative period [17]
Dysphagia is dependent on the number of levels treated [227] At 12 months
Trang 8post-operatively, however, the rate of moderate to severe dysphagia decreases to about
13 % [17] The etiology of this complication is not fully understood An injury to the superior laryngeal nerve has been suggested as a potential cause [131] Papa-vero et al [202] have reported that no correlation exists between the pharynx/ esophagus retraction and postoperative swallowing disturbances
RLN injury is not dependent
on the approach site
Recurrent laryngeal nerve (RLN) palsy has been reported in 2 – 11 % [223] In
contrast to common belief, the injury rate does not appear to be related to the side of the approach [26] Postoperative laryngoscopy revealed that the true inci-dence of initial and persisting RLN palsy after anterior cervical spine surgery was much higher than anticipated [141] Jung et al [141] reported that the postopera-tive rate of clinically symptomatic RLN palsy was 8.3 %, and the incidence of RLN palsy not associated with hoarseness (i.e clinically unapparent without laryn-goscopy) was 15.9 % At 3 months postoperatively, these rates decrease to 2.5 % and 10.8 %, respectively [141]
C5 radiculopathy is a serious
complication of spinal cord
decompression
An infrequent but serious complication is a postoperative C 5 palsy which can
develop in up to 3 – 5 % of patients after posterior decompression surgery partic-ularly laminoplasty [133, 235] It has been suggested that this neural compromise
is a result of traction on the short C5 nerve root due to posterior migration of the cord after posterior decompression [223] However, a systematic review did not reveal significant differences between patients undergoing anterior decompres-sion and fudecompres-sion and laminoplasty, nor were distinctions apparent between uni-lateral hinge laminoplasty and French-door laminoplasty, or between cervical spondylotic myelopathy and ossification of the posterior longitudinal ligament [235] The pathogenesis of postoperative C5 palsy remains unclear at the present time Patients with postoperative C5 palsy generally have a good prognosis for functional recovery, but the severely paralyzed cases required significantly lon-ger recovery times than the mild cases [235]
Recapitulation
Epidemiology.Degenerative changes of the
cervi-cal spine (cervicervi-cal spondylosis) can result in cervicervi-cal
disc herniation with radiculopathy, cervical
spondy-lotic radiculopathy (CSR) and myelopathy (CSM)
Degenerative cervical spondylosis is very common
in the aging population but not necessarily
associ-ated with symptoms The prevalence of neck pain
ranges between 17 % and 34 % in a general
popula-tion More than half of the adult population suffer
from cervical radiculopathy (CR) at least once in
their lifetime The C6 and C7 nerve roots are most
frequently affected Cervical spondylosis more
fre-quently causes CR than disc herniation (3:1)
Cervi-cal spondylotic myelopathy (CSM) is the most
common cause of spinal cord dysfunction in
indi-viduals older than 55 years A special form of
cervi-cal myelopathy is caused by an ossification of the
posterior longitudinal ligament (OPLL) and is
com-mon in the Asian population
Pathogenesis. Predominant neck pain can arise
from painful degeneration of the motion segment
and can be attributed to disc degeneration, facet joint osteoarthritis and segmental instability In the vast majority of cases with subaxial neck pain the correlation of morphological alterations and neck
pain remains weak (non-specific neck pain)
Radi-culopathy due to disc herniation (so-called soft her-niations) usually occurs during early stages of disc degeneration in the 4th–5th life decades Compres-sive spondylotic spurs usually develop during later degenerative stages (so-called hard herniations)
Both mechanical and inflammatory processes cause the clinical syndrome of radiculopathy CSM is mainly
due to a compression of the spinal cord by osteophy-tes, calcified disc herniations, yellow ligament hyper-trophy or OPLL Mechanical compression and vascu-lar insufficiency lead to pathobiologic alterations re-sulting in myelopathy The clinical manifestation of CSM depends on the degree of cord compression and time course of compression The major risk
fac-tor is a congenitally narrow spinal canal (sagittal
di-ameter < 13 mm) Minor trauma can acutely increase the compression which the spinal cord cannot
Trang 9toler-ate any more, leading to sudden severe
neurologi-cal deficits Dynamic compression can aggravate
spinal cord compression Flexion lengthens the
spi-nal cord and extension leads to a buckling of the
ligamentum flavum which results in a bilateral cord
compression (pincer effect) In addition to
mechan-ical compression, vascular factors play a significant
role in the development of myelopathy Ischemia
and a cascade of cellular and molecular events
(glutamatergic toxicity, free radical cell injuries, and
apoptosis) aggravate the compromise of the spinal
cord The causes of the OPLL are not well explored
but gene polymorphisms appear to play an
essen-tial role
Clinical presentation The clinical assessment aims
to differentiate between patients with specific and
non-specific cervical disorders Patients quite
fre-quently present with pain syndrome located in the
neck-shoulder-arm region Neck pain most
fre-quently is non-specific (i.e without a clear structural
correlate) but can seldomly be part of a so-called
spondylotic syndrome (i.e painful motion segment
degeneration) The cardinal symptoms of cervical
radiculopathy are a predominant radicular arm pain
with or without sensorimotor and reflex deficits
Accompanying vegetative symptoms, dizziness,
vertigo and headaches are not uncommon A
thor-ough neurological examination and nerve root
provocation tests (e.g Spurling test) are helpful in
diagnosing radiculopathy Radiculopathy can be
associated with myelopathy because cervical
spon-dylosis not only affects the foramen but also the
spi-nal caspi-nal A myelopathic syndrome can begin very
subtly and can therefore pose a diagnostic
chal-lenge Patients with cervical myelopathy can
pre-sent with a broad spectrum of signs and symptoms
depending on the magnitude of spinal cord
dys-function and chronicity The leading symptoms are
numb, clumsy, painful hands and compromised
fine motor skills Further findings are atrophy of the
interosseous muscles, gait disturbances, ataxia, and
symptoms of progressive tetraparesis
Diagnostic work-up. Morphological alterations in
imaging studies are frequent in asymptomatic
con-trols, jeopardizing their role in identifying the pain
source Standard radiographs (anteroposterior,
lat-eral, oblique views) of the cervical spine may give
important information about spinal alignment,
spi-nal curvature, disc space narrowing, spondylophytes,
facet joint osteoarthritis, foraminal stenosis,
develop-mental anomalies, and DISH Functional radio-graphs have failed to reliably allow the diagnosis of segmental instability Therefore, instability remains a clinical diagnosis The imaging modality of choice is MRI Sagittal T2W images tend to overestimate the
spinal cord compression, favoring T1W images for
this assessment MR signal intensity changes
repre-sent structural alterations of the spinal cord and have
some prognostic value for treatment outcome CT myelography provides better information than MRI
regarding the relationship between neural
compres-sion by osteophytes or ossifications Injection stud-ies (facet joint blocks, discography) do not reliably allow identification of the pain source Neurophysio-logical studies are helpful in differentiating
radiculo-pathy and peripheral neuroradiculo-pathy Furthermore, they allow the recognition of subclinical myelopathy
Non-operative treatment.Most cases of non-spe-cific acute neck pain resolve within a few days or weeks But neck pain frequently recurs and can
become disabling in about 6 % of cases The natural history of CSR generally is benign However, CSR
has a somewhat worse course than disc related radiculopathy because disc extrusion/sequestra-tions tend to regress with time while osseous
com-pression tends to increase The natural history of CSM has a variable clinical course which is
charac-terized either by long periods of stable disability followed by episodes of deterioration or a linear progressive course In advanced stages, complete
remission to normality never occurs Non-specific neck pain and spondylosis related neck pain are
best managed with conservative care because a clear morphological correlate which could be addressed by surgery is often missing In the absence of major (MRC Grade > 3) or progressive
motor deficits, CSR should be treated with an initial
trial of non-operative care Persistence of severe pain and sensorimotor deficits despite adequate non-operative care should prompt the indication for surgery in cases with a clear morphological cor-relate Non-surgical treatment is only indicated in
mild forms of CSM In cases with circumferential
spinal cord compression, deterioration under
con-servative care must be expected The mainstay of non-surgical care consists of oral medications (e.g.
analgesics, NSAIDs, muscle relaxants, psychotropic drugs), manipulative treatment, and physical
exer-cises There is moderate evidence that spinal manipulative therapy (SMT) and mobilization is
superior to general practitioner management for
Trang 10short-term pain reduction of chronic neck pain.
There is limited evidence for the effectiveness of
spinal injections, which are more dangerous than
previously thought Radiofrequency denervation of
facet joints is only supported by limited evidence
There is no evidence for the effectiveness of
mas-sage, acupuncture, or electrotherapy
Operative treatment.In general, patients with
pro-gressive neurological symptoms and those failing
to respond to non-operative treatment should be
considered candidates for surgery Axial neck pain
is multifactorial and often lacking a structural
corre-late which can be treated by surgery Therefore,
sur-gery for neck pain is rarely indicated Anterior
cer-vical discectomy and fusion (ACDF) still remains the
gold standard for surgical treatment of CR There is
no evidence that additional anterior plate fixation
influences clinical outcome for one-level disease
and only limited evidence for the increase of the
fusion rate for two-level disease Similarly, there is
no evidence for the superiority of cage fusions or
total disc arthroplasty (TDA) compared to ACDF
with the exception of iliac crest donor site pain
Minimally invasive decompressions (anterior or
posterior) for the treatment of selected
radiculopa-thy patients remain intriguing because they
pre-serve segmental motion and do not require
instru-mentation The outcome of surgery for CR is largely
dependent on the successful decompression of the
nerve root(s) and not per se on the chosen surgical
technique The primary surgical objective in CSM
is to arrest or improve neurological deficits by
spi-nal cord decompression, which is possible in about
80 % of patients depending on the disease state Spinal decompression can be achieved by (multi-level) ACDF, corpectomy, laminectomy or lamino-plasty The surgical techniques must be tailored to the target pathology There is moderate evidence
that multilevel ACDFs are associated with a high non-union rate and limited evidence that corporec-tomies result in a lower non-union rate for
multi-level decompression In three and more multi-level
ACDFs or corpectomies, anterior plate fixation
does not suffice and additional posterior fixation is recommended There is limited evidence that both multilevel corpectomy and laminoplasty are equally effective in arresting myelopathic progres-sion in multilevel cervical myelopathy Patients
treated with laminoplasty develop progressive
lim-itation of cervical ROM similar to that seen after laminectomy and fusion The neurological recovery appears not to be dependent on the decompres-sion technique but spinal canal dimendecompres-sions and MR signal intensity changes of the spinal cord are
strong predictors of surgical outcome Dysphagia
is a quite frequent symptom after anterior cervical surgery and can be encountered in up to 50 % of cases in the immediate postoperative period How-ever, most patients (90 %) recover within 1 year
after surgery Recurrent laryngeal nerve (RLN)
injury is reported in 2 – 11 % and independently of the approach site An infrequent but serious
com-plication is a postoperative C5 palsy which can
develop in up to 3 – 5 % of patients after posterior decompression surgery, particularly laminoplasty
Key Articles
Baptiste DC, Fehlings MG ( 2006) Pathophysiology of cervical myelopathy Spine J 6(6 Suppl): 190S–197S
Excellent review of the current knowledge of the pathophysiology of cervical myelo-pathy.
Gross AR, Goldsmith C, Hoving JL, Haines T, Peloso P, Aker P, Santaguida P, Myers C ( 2007) Conservative management of mechanical neck disorders: a systematic review.
J Rheumatol 34:1083–102
This comprehensive review noted strong evidence for the benefit of exercise plus mobili-zation/manipulation in the treatment of subacute/chronic mechanical neck pain There was moderate evidence for the long-term benefit of direct neck strengthening and stretching exercises for chronic neck pain Many other treatments only demonstrated short-term effects.
Persson LC, Carlsson CA, Carlsson JY ( 1997) Long-lasting cervical radicular pain man-aged with surgery, physiotherapy, or a cervical collar A prospective, randomized study Spine 22:751–8