Degenerative Cervical Myelopathy (DCM) formally referred to as Cervical Spondolytic Myelopathy (CSM)

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1 Degenerative Cervical Myelopathy (DCM) formally referred to as Cervical Spondolytic Myelopathy (CSM) Douglas B Moreland, MD Patrick Jowdy, MD Lindsay Guzzetta, RPA Carly Domes, RPA

2 Disclosure Statement No Significant Financial, General, or Obligation Interest to Report.

3 Disclosure Statement No Significant Financial, General, or Obligation Interest to Report. This lecture is dynamic and in evolution

4 Session Objectives Definition of Degenerative Cervical Myeloradiculopathy Pathophysiology Differential Diagnosis Treatment Options

5 Session Objectives If you leave this session with a clear understanding of the standard-of-care for DCM then

6 Session Objectives If you leave this session with a clear understanding of the standard-of-care for DCM then I have not done my job

7 Outline Definition Pathophysiology Clinical Presentation Differential Diagnosis Treatment Options Summary

8 DCM- Definition Spinal Cord or Nerve Root Dysfunction From anatomical compression as a result of spine column degeneration Disc herniation Spondylosis, spurs, arthritis, osteophytes, facet hypertrophy May be predisposed to someone with congenitally small spinal canal (short pedicles) Vascular compromise Combination of the above

9 Demographics Rarely under the age of 50 Incidence 2002 = 10 per 100, = 21 per 100,000 United Kingdom = 1.6 per 100,000 Cost in US Hospital Charges 5.3 B, Physician 1.32 B Leading indication for surgery on the CNS.

10 Pathophysiology Cervical Spondylosis (Arthritis) and disc degeneration- A natural Consequence of Aging. Genetics also play a role Know these Spinal cord compression = Myelopathy Nerve Root Compression= Radiculopathy

rotation, load distribution, shock absorption Osteophytes (spurs)- Form as a natural response of the spine to

11 Pathophysiology Disc- Annulus Fibrosis (outer layer) - fibrous, rich in collagen, tensile strength Nucleus Pulposus (inner layer)- compression strength Both are necessary for seamless integration of the disc functionbending, rotation, load distribution, shock absorption Osteophytes (spurs)- Form as a natural response of the spine to accommodate to repetitive physiologic loads (the more weight you carry, the quicker all this occurs) Nerve Root Compression=Radiculopathy

12 Dermatomes You should have a good command of these

13 Clinical Presentation- Myelopathy Symptoms Gait disturbance falling, imbalance, unsteadiness Neck Pain and Stiffness Unilateral/ Bilateral Limb Body Pain Upper extremity weakness, numbness, loss of dexterity Lower extremity stiffness (spasticity), weakness, sensory loss Paresthesias (pins and needles sensation) Autonomic Symptoms bowel and bladder dysfunction, erectile dysfunction (rare) Bilateral Carpal Tunnel Syndrome is unusual and DCM should be considered in the face of this presentation.

14 Hypereflexia/Spasticity

15 Gait Disturbance COMPREHENSIVE NEUROSCIENCE CLINICS

16 Natural History Mixed- and variable, no consistent pattern. may manifest as a slow, stepwise decline or there may be a long period of quiescence Long periods of severe stenosis are associated with demyelination and may result in necrosis (myelomalacia) of both gray and white matter. With severe and/or long lasting DCM symptoms, the likelihood of improvement with non-operative measures is low. Objectively measurable deterioration is rarely seen acutely in patients younger than 75 years of age with mild DCM (modified Japanese Orthopaedic Association scale score > 12; Class I). In patients with cervical stenosis without myelopathy, the presence of abnormal electromyography findings or the presence of clinical radiculopathy is associated with the development of symptomatic DCM in this patient population (Class I). Conclusions. The natural history of DCM is variable, which may affect treatment decisions. (DOI: / SPINE08716)

17 Natural History Indolent, insidious, pernicious course Incidental spinal cord compression- 59% ages (range 32% in 40 s, to 67 % in 70 s) 22% of asymptomatic individual will develop DCM within 4 years. Delay in diagnosis is significant problem due to insidious course- average 2.2 yrs., average 5 consultations before diagnosis is made. Poor awareness of disease Overlap with natural history of aging, other diseases Delay in treatment means poorer outcomes Optimal outcomes- if diagnosed within 3-6 months of onset of symptoms.

18 Natural History The symptoms may precede objective exam findings. Similar to other CNS disorders, examination features in DCM have a low sensitivity- i.e.- normal findings do NOT exclude the disease. This is of note in our case example, and demonstrates the lack of sensitivity of our exam for subtle neurologic changes. She complained of loss of fine coordinated movement, conspicuous spasticity Yet my rudimentary exam of her proprioception was unremarkable Take home messages- listen, do a full exam, scan and test when in doubt On the other hand, abnormal findings are highly suggestive of the disease.

19 Clinical Presentation- Radiculopathy The myotome and dermatome correspond to each other.

20 Outcome Measures NDI Neck Disability Index SF Item Short Form Health Survey VAS- Visual Analog Scale 0-10 mjoa modified Japanese Orthopaedic Association

21 Neck Disability Index

22 Neck Disability Index Continued

23 Neck Disability Index Continued

24 Diagnostic Workup- Imaging MR- most valuable CT Radiographs Flexion/Extension Subluxation (slippage) Osteophytes Fractures Previous surgery Instrumentation EMG (Electromyogram)/NCV (Nerve Conduction Velocity) Rule out other causes (ALS, MS) High false negative rate

25 Diagnostic Workup- Imaging to refresh your anatomy

26 Diagnostic Workup- Imaging to refresh your anatomy

27 Diagnostic Workup- MR normal

28 Diagnostic Workup- MR Disc Bulge/ Early Disc Degeneration

29 Diagnostic Workup- MR Herniated Disc

30 Small Group Case Presentation Complaints- unable to identify pocket change yet proprioception normal Life and Medicine are full of inconsistencies The symptoms may precede objective exam findings. Similar to other CNS disorders, examination features in DCM have a low sensitivity- i.e.- normal findings do NOT exclude the disease. On the other hand, abnormal findings are highly suggestive of the disease. There are significant limits to our ability to test and identify subtle neurologic deficits. Psychometrics- 1/1000 of a second.

31 Differential Diagnosis

32 Differential Diagnosis- Syringomyelia

33 Differential Diagnosis B12 Deficiency

34 Differential Diagnosis- Spinal Cord Tumors, Vascular Malformations

35 Differential Diagnosis- Metabolic Syndromes Alcoholic B12 Difficiency Transverse Myelitis Diabetes Multiple Sclerosis Aging (idiopathic) ALS

36 Why is the differential diagnosis important? % of imaging pathology in asymptomatic patients by age Disc Degeneration 30 s 40 s 50 s 60 s 70 s 52% 68% 80% 88% 93% Disc Bulge 40% 50% 60% 69% 77% Annular Tear 20% 22% 23% 25% 27% Facet Degeneration 9% 18% 32% 50% 69% Spondylolisthesis 5% 8% 14% 23% 35% Take Home Message Treat the patient not the image Do NOT assume imaging pathology is clinically relevant in spine disease. This is why the clinical correlation is so important

Guideline Development Multidisciplinary Collaboration Reviewers trained before project started Conflicts of Interest Disclosed Level of Evidence Grades of Recommendation A: Good Evidence (Level I

37 Guideline Development Multidisciplinary Collaboration Reviewers trained before project started Conflicts of Interest Disclosed Level of Evidence Grades of Recommendation A: Good Evidence (Level I studies with consistent findings) B: Fair Evidence (Level II or III studies w consistent evidence) C: Poor Quality Evidence (Level IV or V studies) I: Insufficient or conflicting evidence Guideline Development Process Quite labor intensive- Identify question, assign study group, search literature, analyze, formulate recommendations May 2009, NASS (North American Spine Society)

38 Disclaimer Take Home message- Guidelines are NOT standard of Care They do not apply to every scenario, good clinical judgment remains critical

39 Guideline Summary 24 Questions asked 179 Pages A- 1 (Outcome Measures) B- 13 C - 4 I (Insufficient Evidence)- 4 Consensus Required as no studies met any standard- 2 i.e.- Working Definition Definition and Natural History of Cervical Radiculopathy and Degenerative Disorders Minimum of 30 Maximum of 315 articles reviewed for each questions

40 Guideline Summary Take Home Message Much of what we accept as fact should not be Personal Bias

41 Pharmacotherapy A systematic review of the literature yielded no study to adequately address the role of pharmacotherapy in the management of cervical radiculopathy from degenerative disorders

42 Conservative Options Physical Therapy- Insufficient Evidence Chiropractic Therapy- No studies adequately address the role of chiropractic manipulation. Warning- it may do harm, so proceed with caution Epidural Steroid Injections- C Not without risk, short term benefits Others- Bracing, traction, electric stimulation, acupuncture, TENS (transcutaneous electrical nerve stimulation) all I insufficient evidence. My personal Bias- they are a waste of time money and effort (for myelopathy)

43 Buyer Beware

44 Many options Surgery- Anterior Cervical Discectomy and Fusion (ACDF) Is it better that conservative care? Yes- - B ACDF (Anterior Cervical Discectomy and Fusion, with instrumentation) Debatable if plate is necessary Posterior Lamino-foraminotomy- Work Group Consensus- for single level disease Anterior is better that posterior approach However

45 Surgery- Confusion abounds as to correct technique

46 On Line Contemporary Case History

47 On Line Contemporary Case History- Continued Imaging

48 On Line Contemporary Case History- Continued Surgeon Options

49 Positioning Anterior Approach

50 Prep and Drape

51 Operative Technique- Orb Eye

52 Operative Technique

53 Operative Technique

54 Operative Technique

55 Operative Technique

56 Operative Technique

57 Operative Technique

58 Operative Technique

59 Operative Technique

60 Operative Technique

61 Operative Technique

62 Complications General- Infection (rare) Related to the manifold anatomy of the neck Bleeding- venous more common (and more difficult to address) Jugular, facial, Arterial- Carotid, Vertebral Nerves- Cervical Plexus Horner s Syndrome Nerve root Spinal cord Esophagus- perforation, tear, stretch Lung Apex

63 Outcomes Outpatient Procedure min. 75%-90% success rate Expectations- abate progression of disease Complications less than 4%

64 Operative Technique- Posterior Approach

65 Operative Technique- Posterior Approach

66 Operative Technique- Posterior Approach

67 Operative Technique- Posterior Approach

68 Radiographs Post-op anterior posterior Cervical fusion

69 MR Spondylosis (Pre and Post op)

Misteaks Made While you wate Wrong level Identified in the text- The disc pathology is clearly at thec5-c6 level C2 C3 C4 C5 C6 It is the simple thing, which we all take for

71 Misteaks Made While you wate Wrong level Identified in the text- The disc pathology is clearly at thec5-c6 level C2 C3 C4 C5 C6 It is the simple thing, which we all take for granted that gets us into trouble Operating at the wrong level is inexcusable If Contemporary Spine Surgery- peer reviewed, often referenced can make this mistake- we all can.

72 Misteaks Made While you wate

73 Misteaks Made While you wate Money back guarantee

74 Summary If you have a clear understanding of the treatment guidelines I have not done my job.

76 December 1, 2018

Neck Pain: Help! Eric M. Massicotte, MD, MSc, MBA, FRCSC Associate Professor University of Toronto

Neck Pain: Help! Eric M. Massicotte, MD, MSc, MBA, FRCSC Associate Professor University of Toronto Copyright 2017 by Sea Courses Inc. All rights reserved. No part of this document may be reproduced, copied,