Managing cervical spondylotic myelopathy

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The management of cervical spondylotic myelopathy remains controversial and the topic is the focus of a session at this year’s IMAST. The moderator of the session, K Daniel Riew, Mildred B Simon professor of Orthopedic Surgery, chief of Cervical Spine Surgery, Washington University Orthopedics, St Louis, USA, talked to Spinal News International about these controversies and the dangers of bad surgery

Conservative treatment for cervical spondylotic myelopathy is often initiated on the basis of clinician preference. Which conservative treatments do you prefer to use?

I use anti-inflammatories, neck immobilisation with a collar, and observation. 

The BMJ recently ran a debate on cervical spinal manipulation for mechanical neck pain in which one side1 argued that the practice should be abandoned because its risks outweighed its benefits. What is your view?

Most patients can receive spinal manipulation. If they have severe spinal cord compression, then I do not recommend it. However, I have seen thousands of patients who have undergone chiropractic spinal manipulation and I can count on one hand the number of patients who have been harmed by it—there are many more patients who have been harmed by bad spinal operations.

What are the main, unresolved, controversies concerning the surgical management of cervical spondylotic myelopathy?

The main controversies include anterior approach vs. posterior approach, when to operate, and how to manage patients with spinal cord compression with or without cord signal change without myelopathy.

What data are there for minimally invasive surgical techniques for CSM?

It depends on the definition of “minimally invasive”. For example, compared with fusion, laminoplasty is a minimally invasive technique and there is ample data that it works very well in indicated cases. Otherwise, as long as the decompression is adequate, minimally invasive surgery has the potential to work as well as any other approach.

However, it is very important that techniques that employ minimal visualisation and fluoroscopic guidance are done carefully as there is a great risk of harm. I have seen nerve roots injured, paralysis, inadequate decompressions, spinal instability and muscle maceration and denervation caused by “minimally invasive” posterior decompressions. These procedures, done with poor technique, can result in high doses of radiation to the patient, as well as the staff. Last week I saw a patient who had had a posterior decompression done bilaterally through two 2cm incisions. The muscles in the back of the neck were markedly atrophied. It is obvious that through these “small” incisions, the surgeon macerated the muscle. This is “minimal incision, maximal muscle killing surgery” done by someone who only paid attention to the incision size and not what is beneath the surface. A careful surgeon treats what is beneath the skin with as much respect and care as the surface, which is the only part that the patient sees. ­

As many patients with cervical spondylotic myelopathy are elderly, what are the age-related complications of surgery that surgeons need to be aware of?

Patients may have osteoporosis, which can result instrument-failure fractures, or they may have age-related balance problems as well as having myelopathy. Potential medical complications in elderly patients include cardiac, pulmonary, or renal conditions, and stroke. There is also an increased risk of dysphagia, dysphonia, and aspiration with anterior procedures. 

After an operation, patients may develop post-operative confusion. Furthermore, the effects of narcotic pain medication can be magnified with confusion, delirium, constipation, and unsteadiness of gait. There is also the issue of drug interactions with polypharmacy that can occur in an older patient. 


References
1. Wand et al. BMJ 2012;344:e3679