Cervical Myelopathy

Soft collar for symptom relief during acute exacerbation. Avoid prolonged use (causes muscle atrophy and stiffness). Not a long-term solution for cord compression.

• Neuropathic pain: Gabapentin, pregabalin (for coexisting radiculopathy)
• Spasticity: Baclofen, tizanidine (for UMN spasticity)
• No role for NSAIDs or steroids in chronic degenerative myelopathy (unlike acute cord injury)

Goal: Maintain ROM, strengthen supporting musculature, gait training

• Does NOT halt progression of cord compression
• Avoid manipulation or traction - risk of worsening cord compression

Clinical assessment: Nurick grade, mJOA score, gait, UMN signs Repeat MRI if worsening: Assess progression of cord compression Threshold for surgery: If symptoms progress, convert to surgical management

Clinical myelopathy (UMN signs, gait disturbance) + MRI cord compression = Surgical indication

• Ensure progressive symptoms (not static or radiculopathy alone)
• Rule out mimics: MS, ALS, B12 deficiency, copper deficiency (all can cause UMN signs)

Anterior approach (ACDF, corpectomy):

• 1-2 level anterior compression (disc, osteophyte)
• Direct decompression of ventral pathology
• Advantages: Direct visualization, immediate stability with fusion
• Disadvantages: Dysphagia (10-20%), RLN injury (1-2%), pseudarthrosis (5-10%)

Posterior approach (laminoplasty, laminectomy + fusion):

• Multilevel compression (more than 3 levels)
• Circumferential stenosis or congenital stenosis
• OPLL (avoids anterior CSF leak risk)
• Advantages: Multilevel decompression, preserves motion (laminoplasty)
• Disadvantages: Axial neck pain (20-30%), C5 palsy (5-10%), kyphosis risk (if laminectomy without fusion)

Combined approach:

• Severe multilevel compression with kyphotic deformity
• Anterior corpectomy + posterior fusion for stability

Optimal timing: Nurick 1-2 (early disease) - best outcomes Acceptable timing: Nurick 3-4 (moderate to severe) - still benefit, but less recovery Poor prognosis: Nurick 5 (severe disability, more than 18 months symptoms, T2 hyperintensity) - surgery still halts progression but recovery limited

Day 1: Mobilize out of bed, collar if anterior fusion Week 1-6: Neck ROM exercises, avoid heavy lifting Week 6-12: Progressive strengthening, return to activities Long-term: Monitor for adjacent segment disease (5-10% per decade)

Supine, head neutral or slight extension, shoulder roll to extend neck Smith-Robinson approach: Transverse or oblique incision along anterior border SCM, typically left side (less risk to RLN) Dissection: Medial to carotid sheath, lateral to trachea/esophagus, retract medially

Localization: Fluoroscopy to confirm level (C6 has prominent anterior tubercle) Discectomy: Remove disc completely, including posterior annulus and posterior osteophytes Decompress cord: Remove PLL if ossified, ensure adequate canal decompression Foraminotomy: If coexisting radiculopathy, decompress nerve root laterally

Options:

• PEEK cage + autograft/allograft (most common)
• Structural allograft (femoral ring, fibula)
• Cage size: Trial to ensure adequate height restoration and lordosis

Plate fixation: Anterior cervical plate with screws into vertebral bodies above and below Rationale: Increases fusion rate (95% vs 85% without plate), prevents cage subsidence

Closure: Layer closure, drain optional (controversial) Collar: Soft collar for comfort, not structural (plate provides stability) Diet: NPO until swallow assessment (dysphagia risk), advance as tolerated

Prone, head in Mayfield clamp, neutral neck position (avoid excessive flexion/extension) Midline incision C2-T1, subperiosteal dissection, preserve C2 and C7 spinous processes Expose lateral masses to lateral edge of facet joints bilaterally

Hinge side (usually left): Thin lamina with high-speed burr to create greenstick fracture (do not penetrate dura) Open side (usually right): Complete trough at lamina-lateral mass junction, detach ligamentum flavum Lift door: Elevate lamina at hinge, opens like a door, increases canal diameter by 4-5mm

Spacer placement: Titanium miniplate with spacer, hydroxyapatite block, or suture (older technique) Goal: Maintain 5-7mm opening, prevent door closure Check decompression: Visualize dural pulsation, ensure adequate space for cord drift

Muscle reattachment: Reattach extensor musculature to C2 and C7 spinous processes (preserve to reduce axial pain) Drain: Subfascial drain for 24-48 hours No collar needed: Laminoplasty inherently stable

Remove laminae C3-7 (or targeted levels): Osteotome or Kerrison rongeurs Remove ligamentum flavum: Complete excision to decompress dura posteriorly Preserve facet joints (especially more than 50% of facet) to maintain stability

Lateral mass screws (C3-C6): Magerl or Roy-Camille technique, 3.5mm screws, 14-16mm length Pedicle screws (C7, T1): Larger pedicles, allow better fixation Rod contouring: Contour rods to match cervical lordosis (or correct kyphosis)

Decorticate lateral masses and facets: Burr to bleeding bone Bone graft: Local bone (from laminae), allograft, or BMP Place over decorticated surfaces for fusion mass

Monitoring: Neurological checks Q2H (motor/sensory), swallow assessment before PO Collar: Soft collar for comfort (not structural - plate provides stability) Mobilization: Out of bed Day 1, early ambulation reduces DVT risk Diet: NPO until swallow cleared, advance as tolerated (soft diet if dysphagia) Pain control: Multimodal analgesia (acetaminophen, gabapentin, PRN opioids)

Activity: Avoid heavy lifting (more than 5kg), no driving while in collar or on opioids Collar: Wean at 2-4 weeks (earlier if single-level, longer if multilevel) Physical therapy: Gentle ROM exercises, posture training Imaging: X-rays at 6 weeks to assess alignment, hardware position

Activity advancement: Gradual return to activities, progressive strengthening Fusion assessment: X-rays or CT at 12 weeks if concern for pseudarthrosis Functional goals: Most patients independent in ADLs by 3 months

Surveillance: Annual X-rays for 2 years, then PRN if symptomatic Adjacent segment disease: Monitor for new symptoms (5-10% per decade) Return to full activity: 3-6 months depending on occupation

Drain management: Subfascial drain for 24-48 hours (remove when less than 30mL/24h) C5 palsy monitoring: Check deltoid/biceps strength Q4H in first 72 hours (peak incidence) Mobilization: Out of bed Day 1 (earlier than anterior approach, no dysphagia risk) No collar needed: Laminoplasty/fusion inherently stable

Axial pain management: Common (20-30%), NSAIDs, muscle relaxants, heat/ice ROM exercises: Gentle active ROM to prevent stiffness Avoid flexion: Limit neck flexion in first 6 weeks to protect posterior fusion

Strengthening: Progressive resistance exercises for neck extensors Fusion check: X-rays at 12 weeks if fusion performed Functional improvement: Most patients plateau by 6 months

ROM assessment: Expect 30-50% loss of flexion/extension (counsel preoperatively) No adjacent segment disease: Benefit of laminoplasty (no fusion) or fusion protects