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RSD and Concomitant Neuropathies - Part I

© Les Abrams

Author's Opening Note: This is the first article of a new series describing the concomitant neuropathies that often accompany RSD and Diabetic Neuropathies. We begin with the diseases of the spine. These include Radiculopathy and Myelopathy.

Surgical Decisions for Cervical Spondylotic Myelopathy

Originally authored by: Sait Naderi, M.D., Edward C. Benzel, M.D., and Nevan G. Baldwin, M.D

Department of Neurosurgery, Marmara University, School of Medicine, Istanbul, Turkey; and Division of Neurosurgery, University of New Mexico, School of Medicine, Albuquerque, New Mexico

INTRODUCTION

Cervical spondylotic myelopathy can produce a variety of clinical signs and symptoms secondary to neural compromise and biomechanical involvement of the spine. The surgical treatment of cervical spondylotic myelopathy remains a controversial issue after many years of study, evolution, and refinement. Several ventral, dorsal, or combined approaches have been defined. The complications associated with ventral approaches and the concerns about kyphosis following dorsal approaches led to the development of a variety of laminoplasty procedures. This paper reviews the biomechanical basis of cervical spondylotic myelopathy and its effect on choosing the appropriate surgical approach.

Cervical spondylotic myelopathy (CSM) occurs secondary to cervical spondylosis and is characterized by degeneration of the cervical intervertebral discs, with subsequent changes in the bones and soft tissues. Cervical spondylotic myelopathy often has an accelerated pattern of progression,[44] and results in three clinical manifestations: 1) myelopathy; 2) radiculopathy; and 3) myeloradiculopathy. The rational for this categorization scheme is based on the differing clinical manifestations (that is, myelopathy vs. radiculopathy) and surgical approaches (that is, decompression of the spinal cord vs. decompression of the nerve root) associated with each. Many surgical approaches have been proposed for patients with CSM; however, there are no standard methods for determining which is preferable. These approaches include: 1) laminectomy, with or without fusion; 2) laminoplasty; 3) medial (central) corpectomy with grafting, with or without fusion; and 4) ventral discectomy.

These multiple surgical options raise many questions regarding the decision-making process. The following pages address these questions by outlining the surgical component of the decision-making process.

A SURGICAL APPROACH TO CSM

Both ventral and dorsal surgical approaches play a role in the management of CSM. The advantages and disadvantages of each must be considered in nearly all cases. It is imperative that one determines which patients are most likely to benefit from any given surgical approach while minimizing the risk/benefit ratio.

Dorsal surgical approaches to spinal canal decompression appear to be safe and effective.[2,8,10­14,20,21,40,41,60,62­64] Laminectomy, and to a certain extent laminoplasty, are relatively simple operations. The complications

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