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|THE EDITORIAL DEBATE: PROS AND CONS
|Year : 2016 | Volume
| Issue : 1 | Page : 16-18
Surgery for multilevel cervical spondylotic myelopathy and ossified posterior longitudinal ligament
Department of Neurosurgery, King Edward VII Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Mumbai, Maharashtra, India
|Date of Web Publication||11-Jan-2016|
Department of Neurosurgery, King Edward VII Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Muzumdar D. Surgery for multilevel cervical spondylotic myelopathy and ossified posterior longitudinal ligament. Neurol India 2016;64:16-8
Dr. Leroy Abbott first suggested the anterior cervical approach in 1952, later described by Bailey and Badgley and followed by Robinson and Smith in 1955. Since then, many approaches and techniques have been described to achieve radical decompression, fusion, and fixation.,,,
Combined lesions of multilevel cervical spondylotic myelopathy (CSM) and ossified posterior longitudinal ligament (OPLL) usually involve the lower cervical spine in contradistinction to OPLL, alone, which commonly involves the upper cervical spine.,, Surgery for multilevel CSM and OPLL is formidable. It is fraught with a major risk of gross motor deficits, gait, and sphincteric disturbance. The complication rate is reported to be as high as 70%, including strut graft fracture, graft pistoning, graft dislodgment, hardware failure, and pseudarthrosis.,, The decision regarding the appropriateness of approach and extent of surgical decompression poses a dilemma for the operating surgeon. The precarious nature of the compromised spinal cord allows less room for manipulation. The choice of a surgical approach for combined CSM and OPLL is still a controversial issue. Although corpectomy is performed in a variable manner, decompression by laminectomy or multilevel anterior decompression is still being done.,
Evolution of new techniques, the introduction of microsurgery, and the use of new implants have empowered surgeons to use more aggressive techniques in patients with CSM and OPLL.,,,,, Anterior cervical discectomy and fusion procedures at one or two cervical spine levels have predictable results while procedures involving three levels are associated with increased morbidity. Vaccaro et al., demonstrated high rates of early construct failure in multilevel fusions: 9% for two-level corpectomy and 50% for three-level corpectomy. Zdeblick et al., reported a 33% construct failure rate which required a reoperation in all cases. Other authors reported similar failure rates as well. This was largely related to a biomechanical failure, which led surgeons to develop many anterior and/or posterior hybrid decompression and fixation techniques in such cases. The use of a buttress (junctional) plate alone in multilevel corpectomy was recommended, but a high rate of complication was observed due to increased stress at the lower end of the construct., It was recommended that the buttress plate be supplemented with posterior fixation. A 360° fixation using long plate is lengthy and sometimes staged procedure is necessary. The results of cadaveric biomechanical studies have shown that the longer plate generates greater motion at the fusion sites under physiological loads because of its longer lever arm.
The skip corpectomy technique is one of the novel techniques used to obtain the optimum decompression and fixation in patients with multilevel CSM and OPLL. However, it allows a slightly smaller range of motion during lateral bending and axial rotation than the standard three-level corpectomy. It helps to maintain stability of the construct without requiring an additional surgical approach. The addition of a second approach comes with the expense of increased operating time and the potential for a higher surgical morbidity.
In an oblique cervical corpectomy, the vertebral body is drilled from an anterolateral trajectory causing ventral decompression. The technique also helps to preserve an anterior buttress of the vertebral body.,, Bone grafting with or without instrumentation along with their attendant complications is avoided and spinal stability is maintained. However, the proximity to the vertebral artery and the oblique trajectory of drilling is technically challenging. The procedure has not attained the popularity that other anterior approaches have achieved. Inadequate surgical decompression may preclude optimal clinical improvement., An intraoperative imaging modality such as conducting an ultrasound during surgery on the cervical spine would help in ensuring that the decompression is complete and that the trajectory is accurate. The age at presentation, preoperative neurological status, and duration of symptoms are important factors determining long-term outcome.
Motion preservation in spine surgery is appealing because segmental fusion has been shown to increase the incidence of adjacent segment disease.,,, In predominant cases of cervical spondylosis, the support segments are already fused because of extensive osteophyte formation, joint fusion, ligamentous ossification, and diffuse idiopathic skeletal hyperostosis and may not require bony fusion. It may be of little benefit for a one- or two-level disease. However, fusion is considered essential when one is dealing with multiple levels, in the presence of subluxation, when a previous laminectomy has been performed or when an abnormal cervical alignment is encountered., 13, ,,,
There is no doubt that corpectomy, multilevel discectomy, laminectomy, and laminoplasty essentially yield results superior to nonoperative treatment in compressive myelopathy.,,,,,,,,, In poor-grade patients, myelopathy resulting from degenerative disease has repeatedly been shown to respond well to decompression in comparison to myelopathy secondary to rheumatoid arthritis. Higher age groups, prolonged symptoms of over 1 year, higher grade of disability, and poor respiratory reserve are bad prognostic indicators for surgery. In patients in whom the compression is relieved, noncompressive factors could be progressive and could be responsible for the delayed deterioration. Patients with symptoms of less than 1 year duration have the best outcome. Therefore, early decompressive surgery is offered to patients with poor-grade CSM and/or OPLL.,,,,, It is relatively well known that myelopathic patients who undergo earlier decompression have better outcomes than those who undergo later decompression. However, it has not been well documented that patients with Nurick grades of 4 and 5 would also benefit from an early decompression.
Gupta et al., in this issue have reported a retrospective study evaluating the functional and radiological outcome in 33 patients undergoing a three-level corpectomy for multilevel CSM and OPLL. They conclude that a three-level cervical corpectomy with uninstrumented fusion is a relatively safe surgery in experienced hands and can achieve excellent clinical and radiological outcomes. They have performed a three-level central corpectomy which permitted a radical excision of the OPLL. In the cervical spine, the anterior spinal support segment is partially compromised by median corpectomy while the lateral segment comprising the pedicle and facet joints and the posterior segments are intact., An interposition graft further offsets the instability. Central corpectomy along with use of autologous fibular graft provided inherent stability and obviated the need for any instrumentation in the index study. The fusion rate has been 90% and there was no permanent morbidity. A good functional outcome without any significant graft-related problems is an additional benefit, especially in patients who have osteoporosis. The above factors strengthen the scientific validity of the procedure in addition to reducing the need for a compulsive instrumentation and also help in avoiding the enormous financial burden related to instrumentation thereof. The authors also discuss the essential features regarding acute graft extrusion, postoperative spinal alignment, and stability of the strut grafts when compared to the procedure of multilevel discoidectomy and grafting. The conclusions derived from the present study assume special significance in the present era particularly since surgeons are more inclined toward instrumented fixation. This may not be a liability in developed countries but is a definite socioeconomic challenge in resource-limited countries. The limitations of the study have been highlighted but a randomized prospective study would be ideal to prove the efficacy of the procedure.
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