Cervical Spondylotic Myelopathy: A Common Cause of Spinal Cord Dysfunction in Older Persons

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WILLIAM F. YOUNG, M.D., Temple University Hospital, Philadelphia, Pennsylvania

Cervical Spondylotic Myelopathy: A Common Cause of Spinal Cord Dysfunction in Older Persons part-2

Surgical Treatment
Once frank myelopathy occurs, surgical intervention is necessary. The primary goal of surgery is to decompress the spinal cord, thus giving the neural elements more room. Traditionally, cervical laminectomy, a posterior approach, has been used for surgical treatment of CSM. However, over the past 20 years, it has been increasingly recognized that laminectomy is not appropriate for all patients. Further neurologic deterioration after laminectomy is attributed to a development of latent instability of the spine with development of kyphotic spinal deformities and to the inability of posterior approaches to directly address anterior vector compression secondary to osteophytic overgrowth.

Many surgical series show "improvement," or at least stabilization of symptoms with posterior and anterior approaches. After reviewing the surgical literature, one investigator found that the rate of successful outcome after surgery was at best 50 percent with the potential for significant postsurgical morbidity.²² The older surgical literature has been criticized because of the uncertainty of whether nonspondylotic myelopathy conditions (e.g., multiple sclerosis, ALS) had been sufficiently excluded before surgery.

A variety of factors determine success after surgery. Factors that may portend a less than satisfactory surgical outcome include severe preoperative neurologic deficits, abnormal signal changes within the spinal cord and/or spinal cord atrophy seen on MRI, and severity of cord compression seen on radiographic studies. CSM is a common cause of disability in older persons. Because spondylosis is a universal finding as patients age, it is important to correlate clinical history and neurologic findings with radiographic studies. MRI is the most useful radiographic study for quantifying the degree of stenosis and excluding other pathologies. Current treatment remains controversial with regard to surgical and nonsurgical management. In the future, prospective randomized trials may be required to definitively establish treatment guidelines. Currently, surgical decompression is appropriate for many symptomatic patients. Go to neck pain page