Cervical Degenerative Disease

- Surgical Approaches to CSM

KNS Main Topic Session

Spine Surgery :

Case-Based Lecture of Spinal Disease

가톨릭의대 인천성모병원 척추센터

김 종 태

Cervical Spondylotic Myelopathy

( CSM ) (1984, Brain )

Impaired function of the spinal cord caused by

advanced degenerative changes of the discs and

facet joints acquired in adult life

Pathophysiology

Direct compression of spinal cord

Ischemia

Repeated microtrauma to cord by neck motion

( Dynamic factor )

Surgery for CSM

Decompression of the spinal cord

-- resolve direct compression & Ischemia

Maintain the spinal stability

-- elimination of dynamic factor ( microtrauma )

Correction of instabililty, deformity

Surgical approaches for CSM

Anterior Approaches : Direct resection

of compressive lesion

Posterior Approaches : widening spinal canal ( SAC )

ACDF

ACCF

Ant. Microforaminotomy

Oblique partial corpectomy

Laminectomy

Laminectomy with fusion

Laminoplasty

Post. lamino-foraminotomy

Combined approach

: Ant. ( short segment maximal compressive ventral lesion )

Post. – long segment spacious SAC

Surgical Decision Makings

Cervical curvature (Kyphosis, Lordosis )

Extents to be decompressed & exposed

( less or more than 3 level ??)

Magnitude of ventral compressive lesion

Foraminal stenosis, combined

Dynamic cord compression

Osteoporosis

Anterior Post.

( safer than Ant. )

Indications 3분절 미만

전방에 주병소

Kyphosis

Foraminal pathology

3분절 이상

주병소가 후방

Congenital canal stenosis

Unable to ant. approach

Drawbacks Narrow diameter

Esophageal injury

Recurrent laryngeal N.

injury

Swan neck deformity,

Instability

Postop. Neck pain

High incidence of C5 palsy

70/M

PNP with occipital headache , severe

Both shoulder and arm pain & numbness

Both arms and hands weakness - 젓가락질 힘들다.

Ataxia , mild

Progressive for 1-2 decades

EMG & SSEP

bilateral posterior tibial somatosensory dysfunction

-- cervical lesion myelopathy

CASE 1

PREOP. X-Ray

4-5 5-6

1) Ant. cervical discectomy with fusion (ACDF)

2) Ant. cervical corpectomy with fusion (ACCF)

3) Post. lamino-foraminotomy

4) Post. laminectomy with fusion

5) Laminoplasty

CASE 1

가장 적절한 수술법은 ?

47/M

Quadriparesis

Both extremities tingling sensation

after head trauma

DTR : increased

Hoffman , Babiski sign : positive

EMG/SSEP

: Both median somatosensory pathway

abnormality maybe due to CSM

CASE 2

PREOP. X-RAY

PREOP. MRI

3-4

5-6

4-5

6-7

1) Ant. cervical discectomy with fusion (ACDF)

2) Ant. cervical corpectomy with fusion (ACCF)

3) Post. laminoforaminotomy

4) Post. laminectomy with fusion

5) Laminoplasty

CASE 2 가장 적절한 수술법으로 고려될 방법은 ?

POSTOP. 6Mo. MRI

3-4

6-7

5-6

4-5

POSTOP. 6Mo. X-Ray

66/M

Both legs weakness, grade 3

Ataxia, severe

after slip down ( slowly progression )

LBP , BOTH LEGS PAIN , NUMBNESS

FOR 6-7 YRS

CASE 3

PREOP. MRI

3-4

5-6

4-5

6-7

PREOP. MDCT

3-4 4-5 5-6 6-7

RT LT

L-MRI

1) Ant. Discectomy with Fusion , multilevel (ACDF)

2) Ant. Corpectomy with Fusion (ACCF)

3) Post. Laminectomy with Fusion

4) Expansive Laminoplasty

5) Lumbar decompression with Fusion

Case 3 이 환자에 있어 가장 적절한 수술적 접근법은 무엇이라고 생각하십니까?

68/M

Unsteady gait & Left hemiparesis grade 3,

progressive for several yrs Bilateral arms and hands numbness and paresthesia

P/Hx : HBP ,

Both ICA wall arteriosclerosis – ASA, CLOPD

EMG/SSEP :

Rt cerviacal radiculopathy C5 -- chronic

bilateral posterior tibial SEP dysfunction -- cervical myelopathy

CASE 4

Preop. MRI

3-4

5-6

4-5

6-7

1) Ant. Discectomy with fusion (ACDF)

2) Ant. Corpectomy with fusion (ACCF)

3) Post. Laminectomy with fusion

4) Laminoplasty

5) Post. Laminoforaminotomy

CASE 4-1

환자의 임상 증상 및 증후, 방사선 소견 으로 보아 적절한 수술법은 ?

수술 후

당일

C2-3 3-4 4-5 T2-3

T2-3 4-5 3-4 2-3

Progressive Quadriparesis

within 1-2hous postop.

Right Left

U/Ex 2-3 1-2

L/Ex 2 1

1) Ant. Revision with hematoma removal

2) Extended ant. Decompression with hematoma removal

3) Laminectomy with fusion, limited to upper cervical

4) Laminectomy with fusion from upper cervical to upper

thoracic

5) Combined Ant. and Post. approach with hematoma removal

CASE 4-2

상부 경추부터 상부 흉추까지 광범위하고

상부 경추강 전방애 심한 혈종 및 경수 압박이 있는

이러한 경우 수술적 접근법은 ?

Post. Decompression with fixation

+ Ant. hematoma removal

Postop. 10 days

Surgical Decision Makings For CSM

Cervical Alignment (Kyphosis, Lordosis )

Extents to be decompressed & exposed

Magnitude of ventral compressive lesion

CASE BY CASE !!!