Article
Cervical myelopathy: surgical techniques and indications
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Published: | May 4, 2005 |
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Outline
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Objective
The aim is to analyse different surgical techniques and indications concerning recalibration of the stenotic spinal canal in cervical myelopathy.
Methods
Decompression of the cervical spinal cord may be achieved different routes according to dominant anatomical lesions. The anterior approach allows enlarged discectomy with foraminotomy. Interbody fusion gives stability to motion segments reinforced by plating required in case of kyphosis or lithesis. More extended compression demands vertebral body resection with or without reconstruction. Posterior approaches include classical or instrumented laminectomy and numerous techniques of laminoplasty.
Results
Anterior approaches address directly the offending lesions in 75%, and allow sagittal balance conservation or restoration contrary to posterior decompression more frequently complicated by postoperative kyphosis and secondary reaggravation of myelopathy. Short segment stenosis up to 3 levels, loss of lordosis and dominance of upper limbs lesion are good indications. Enlarged discectomy relieves neural compression, with a fear of secondary kyphosis avoided by interbody fusion. Kyphosis correction is best achieved with anterior plating. In severe stenosis and OPLL, corpectomy fulfils excellent decompression at the price of a long graft or adapted spacers and anterior plating. An intermediate fixation enhances stability and reduces failure. Posterior approaches are favoured in multilevel stenosis with dominant cordonal signs (lower limbs). Traditional laminectomy is a straight procedure in the more morbid elderly population. Laminoplasties of different types achieve same decompression with less kyphotic deformity, less instability, and some protection of degeneration in adjacent levels. Mixed approaches are indicated in severe stenosis of congenital origin, failed surgeries by insufficient decompression.
Conclusions
Decompression of the spinal cord is the primary goal as long as the operation is timely indicated. Recalibration of the stenotic canal may be achieved by different techniques owing to anatomical location of dominant lesion, number of affected segments, clinical condition of the patient and experience of the surgeon. A sound reasoning should avoid expectable complications, using micro-techniques and modern instrumentation.