KNS Main Topic Session Spine Surgery : Case-Based Lecture of Spinal Disease Cervical Degenerative Disease - Surgical Approaches to CSM 가톨릭의대인천성모병원척추센터 김종태
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
Indications Drawbacks Anterior 3분절미만전방에주병소 Kyphosis Foraminal pathology Narrow diameter Esophageal injury Recurrent laryngeal N. injury Post. ( safer than Ant. ) 3 분절이상 주병소가후방 Congenital canal stenosis Unable to ant. approach Swan neck deformity, Instability Postop. Neck pain High incidence of C5 palsy
CASE 1 70/M PNP with occipital headache, severe Both shoulder and arm pain & numbness Both arms and hands weakness - 젓가락질힘들다. Ataxia, mild Progressive for 1-2 decades EMG & SSEP bilateral posterior tibial somatosensory dysfunction -- cervical lesion myelopathy
PREOP. X-Ray
4-5 5-6
CASE 1 가장적절한수술법은? 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 2 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
PREOP. X-RAY
PREOP. MRI 3-4 4-5 5-6 6-7
CASE 2 가장적절한수술법으로고려될방법은? 1) Ant. cervical discectomy with fusion (ACDF) 2) Ant. cervical corpectomy with fusion (ACCF) 3) Post. laminoforaminotomy 4) Post. laminectomy with fusion 5) Laminoplasty
POSTOP. 6Mo. MRI 3-4 4-5 5-6 6-7
POSTOP. 6Mo. X-Ray
CASE 3 66/M Both legs weakness, grade 3 Ataxia, severe after slip down ( slowly progression ) LBP, BOTH LEGS PAIN, NUMBNESS FOR 6-7 YRS
PREOP. MRI 3-4 4-5 5-6 6-7
PREOP. MDCT RT LT 3-4 4-5 5-6 6-7
L-MRI
Case 3 이환자에있어가장적절한수술적접근법은무엇이라고생각하십니까? 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 4 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
Preop. MRI 3-4 4-5 5-6 6-7
CASE 4-1 환자의임상증상및증후, 방사선소견으로보아적절한수술법은? 1) Ant. Discectomy with fusion (ACDF) 2) Ant. Corpectomy with fusion (ACCF) 3) Post. Laminectomy with fusion 4) Laminoplasty 5) Post. Laminoforaminotomy
수술후 당일 Progressive Quadriparesis within 1-2hous Right postop. Left U/Ex 2-3 1-2 L/Ex 2 1 C2-3 3-4 4-5 T2-3 2-3 3-4 4-5 T2-3
CASE 4-2 상부경추부터상부흉추까지광범위하고상부경추강전방애심한혈종및경수압박이있는이러한경우수술적접근법은? 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
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!!!