Cervical Myelopathy (CSM) is a common spinal cord dysfunction often seen in individuals over 55, characterized by symptoms such as loss of dexterity, neck stiffness, and leg weakness. Diagnosis involves clinical evaluation and imaging studies, while treatment options range from conservative management to surgical intervention, depending on symptom severity and progression. The document emphasizes the importance of recognizing and treating CSM early to improve patient outcomes and decrease the risk of severe disability.

1. CCeerrvviiccaall MMyyeellooppaatthhyy
““AAllwwaayyss IIggnnoorreedd””!!!!
WWhhaatt ccoouulldd OOrrtthhooppaaeeddiicc ssuurrggeeoonn ddoo??

2. CCeerrvviiccaall SSppoonnddyylloottiicc
MMyyeellooppaatthhyy ((CCSSMM))
Def:
Spinal cord dysfunction secondary to:-
- Extrinsic compression of the cord.
- Blood supply interferance.
- Both
(Parke, Spine. 1988)

3. CSM Syndrome.
- Sir Russel Brain : Neurologist.
- D. North Field : Neuro Surgeon.
- Marcia Wilkinson : Pathologist.
(Brain etal. 1952).

4. This is one more condition which has been
taken out of the scrap basket into which
we used to put MS or spinal degenerative
disease.
(Gilbert Horrax, 1954).

5. Cervical Myelopathy :
A complication of Cervical
Spondylosis (CSM).
* (Brain etal. 1952).
* (Clarke & Robinson 1956).

6. PPaatthhoopphhyyssiioollooggyy ooff CCSSMM
* Pre existing cong. or developmental stenosis.
* Degenerative changes in the disc, producing
secondary changes on nearby structures
* Osteophyte of facet Joint.
* Ligamentum flavum thickening.

7. CCSSMM
Most common type of spinal cord
dysfunction above 55y old.
(Simeone etal. 1982)

8. CSM
* frequently under diagnosed, under
treated, often leading to increased
disability.
Law etal, (JBJS - A, 1994)
Bernhardt etal. (JBJS-A, 1993)
* The single most common under
diagnosed spinal disorder.
(Dillin etal, 1989).

9. CClliinniiccaall EEvvaalluuaattiioonn
A- Common Symptoms : Above 55y.
* Loss of dexterity of the U.L.
(Clumsy or weak hands).
* Neck stiffness, difficulty in walking,
* Leg weakness or stiffness
* Pain in shoulders or arms
* Radicular nerve roots symptoms.

10. B - Physical Examination.
1. U.M.N.L. : L.L. ( Hyperreflexia)
2. U.M.N.L./L.M.N.L. : U.L. (Atrophy of the
hand musculature)
3. Hoffmann`s sign + (Neck extension).
4. Inverted B. Radialis reflex.
5. Neck flexion  Electric shock –
sensation down the back &L.L.
(Lhermitte sign).

11. 6. Changes in deep sensation.
- Position.
- Vibration.
7. Abnormal gait.
8. Early DisdiadochoKinesia
(Uncoordinated alternating movement).

12. DDiiaaggnnoossttiicc SSttuuddiieess
1. C. spine x-ray - Routine.
- Instability.
- Pavlov ratio.
2. MRI.
3. Myelogram for dynamic instability.
4. CT myelogram for OPLL.

13. DDiiffffeerreennttiiaall DDxx ooff CCSSMM
1. Multiple sclerosis.
2. Amyotrophic lateral sclerosis.
3. Spinal cord tumor.
4. Subacute combined degeneration.
5. Cervical disc herniation.
6. Cerebral lesion.
7. Syringomyelia

14. NNaattuurraall HHiissttoorryy ooff CCSSMM
* Most becomes worse clinically if untreated.
* > 50% progress to severe disability.
* Surgery best.
= 6-12M symptoms.
= Early myelopathic findings.

15. DDiissaabbiilliittyy CCllaassssiiffiiccaattiioonn ooff
CCSSMM
((NNuurriicckk 11997722))
* Grade O : Radicular S & S only.
* Grade 1 : Signs of cord involvement.
* Grade 2 : Mild gait involvement.
* Grade 3 : Gait problem affecting work.
* Grade 4 : Ambulation with assistance.
* Grade 5 : Chairbound or bedridden.

16. DDaannggeerroouuss CCoonnsseerrvvaattiivvee
ttrreeaattmmeenntt
1. Cervical traction.
2. Manipulation of C. Spine will cause:
* Narrowing of spinal canal.
* “ “ foramina.
* Irritation to the facet joints &
produce further swelling.

17. WWhheenn ttoo ccoonnssiiddeerr
ccoonnsseerrvvaattiivvee ttrreeaattmmeenntt??..
* Mild symptoms.
* 13 points or more in JOA score.

18. CCoonnsseerrvvaattiivvee ttrreeaattmmeenntt
* How long?.
* Firm orthosis/NSAIDs.
* Isometric muscle strengthening.
* Ice, heat, massage.
* Monthly follow up.

19. OOppeerraattiivvee mmaannaaggeemmeenntt
Absolute indications
1. Neurological defecit which are
progressive or have already developed.
2. Failure of non-operative methods to
improve the neurological findings.
3. Severe myelopathy.
4. 7 points or less in JOA score.

20. WWhhoo wwiillll bbeenneeffiitt ffrroomm ssuurrggeerryy??
1. Severe tingling in the fingers & legs.
2. Poor handling of knife and fork.
3. difficulty in buttoning shirts.
4. Symptoms less than one year.
5. Patients with 8-12 point in JOA score.

21. WWhhiicchh aapppprrooaacchh??..
* Anterior decompression!.
* Posterior decompression!.
* Anterior + Posterior!.

22. PPrree ooppeerraattiivvee
ccoonnssiiddeerraattiioonnss
* Avoid hyper extension of the neck
during positioning.
* Left sided approach to avoid inj. to
RLN.
* Pre op 120mg prednisolone to be
repeated after 4hrs.

23. WWhheenn ttoo ddoo aanntt..
aapppprrooaacchh??
1. Soft disc herniation 1 to 2 levels.
2. Spondylosis 1 to 4 levels.
3. Developmental narrowing of the canal.
4. Kyphotic deformity.
5. Localized OPLL.

24. WWhhaatt yyoouu sshhoouulldd ddoo
aanntteerriioorrllyy??
1. ACDF + plates!!!.
2. Corpectomy + graft.
3. Corpectomy + strut graft.

25. WWhheenn ttoo ddoo ppoosstteerriioorr
ddeeccoommpprreessssiioonn??
1. Compression of > 4 levels.
2. Calcification of lig. flavum.
3. Developmental stenosis : (< AP
13mm).
4. Extensive OPLL.

26. PPoosstteerriioorr ddeeccoommpprreessssiioonn
pprroocceedduurreess
1. Laminectomy.
2. Bilat. Open door laminectomy (Kirita’s).
3. Expanding laminoplasty.
* Spinous process splitting.
* Hemilat. open.
* Z-Plasty.

27. CCoommbbiinneedd aapppprrooaacchheess!!!!!!!!
* Cervical instability.
* Dominant, localized ventral lesion.
e.g cervical disc, OPLL with canal stenosis.
* Dominant, localized vental lesion with
extensive CS or OPLL.

28. PPoooorr pprrooggnnoossiiss aafftteerr
ddeeccoommpprreessssiioonn
1. Atrophy of the spinal cord on MRI
(Severe cord malacia).
2. Weakness of peroneal muscles
(Kozo etal. 1991).
3. Worse pre op. neurological function
(Emery etal 1998).
4. Loss of vibration & propriocepition
(Montgomery 1992).

29. CCoommpplliiccaattiioonnss ooff ssuurrggeerryy ffoorr
CCSSMM
1. Graft problems.
a. Dislodgment.
b. Non union.
c. Graft site morbidity.
2. Spinal instability.
3. Spinal cord injury.
4. Injury to nearby structures.
5. Technical.

30. 110088 ppaattiieenntt CCSSMM ,,11997744 --
11999933
((EEmmeerryy eettaall.. JJBBJJSS--AA 11999988))
Procedure : Ant. decompression + graft.
2 Patients died (MI, Pneumonia).
Follow up (2-17 years).

31. 8877 pptt.. hhaadd mmoottoorr ddeeffeecciitt pprree
oopp..
54 pt.  Complete recovery post op.
26 pt.  Partial recovery post op.
06 pt. No change.
01 pt. Worse deficit.

32. GGaaiitt iimmpprroovveemmeenntt
82 pt. : Had abn. gait pre op.
*************************************
38 Normal gait post op.
33 Improved gait post op.
06 No change.
04 Temporary improvement.
01 Worse gait.

33. Pre op. Nurick score : 2.4
Post op. = = = = = : 1.2
(Average 0.0 to 5.0).

34. Complications No. of pts.
Complete quadriplegia. 1
Upper air way edema 3
pneumonia (Died). 1
M.I (Died). 1
C.S.F. leak 4
Graft dislogement. 6
Oesophygeal erosion 1

35. CCoonncclluussiioonn
1. CSM is under diagnosed and under treated.
2. Surgery will improve the gait and neurology.
3. Surgical approach depends on the site of
the pathology and surgeon experience.

36. CCoonncclluussiioonn
4. Atrophy of the spinal cord is a poor
prognostic indicator.
5. Complications of surgery is minimal in
comparison with the functional
improvement of disability.

37. SSppiinnaall TTrraaccttss SSyynnddrroommeess iinn
CCSSMM
1. Transverse lesion : Most common.
* AHC.
* Spino. Th. Tract.
* Cortico spinal tract.
* Lately : Post column.
2. Motor system synd.
* Cortico spinal tract.
* Weak U.L. + L.L.
* Spasticity.

38. 3. Central cord syndrome.
* U.L. weaker than L.L.
* Prominant hand weakness.
* Rarely post column.
4. Brown-Sequard Syn:Early form of
CSM..
* Cortico spinal tract (Unilat.)
- Hemi paresis.
- Pain & Temp. analgesia.
* Best prognosis for recovery.

39. 5. Brachialgia cord syndrome.
* U.L. root compression : Radicular
symptoms with paraesthesia &
hyporeflexia.
* Long tract signs, weakness.
* Gait disturbance.