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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_31_библиотеки_им_акад_М_И_Перельмана
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a
Fig. 43.1 Cervical plain radiograph (a) and MRI (b and c) in a typical case of CSM
b
a
c
b
Fig. 43.2 CT (a) reveals OPLL.OPLL is one of the causes of spinal cord compression by MRI (b)
43 Cervical Spondylotic Myelopathy
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Fig. 43.3 CT reveals
narrowing of the spinal
canal by calcication of
the ligamentum avum
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a
Fig. 43.4 Dynamic MRI reveals spinal cord compression in extension position. (a) MRI in ex-
ion, (b) MRI in extension
b
43.5 Differential Diagnosis
Cervical cord compression is caused by spondylosis of the cervical spine and various
other pathologies, such as OPLL, spinal tumors, and epidural abscess (Chap. 42). In
addition, intrinsic neurogenic conditions are based on the primary pathology in the
spinal cord. These intrinsic pathologies, such as motor neuron disease and multiple
sclerosis, are important as differential diagnoses of compressive myelopathy.
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43.6 Treatment Options
The therapeutic strategy should be decided on the basis of the symptoms, severity
of cervical myelopathy, and general conditions. A narrative review revealed that
surgery is not superior to conservative treatment for mild and moderate forms of
CSM, whereas surgery is more suitable for patients with a clinically worse status.
Guidelines for the surgical management of cervical degenerative disease published
in the Journal of Neurosurgery Spine in 2009 stated that more severe CSM (mJOA
score≤ 12) should be considered for surgery (Video 43.4). There is controversy
concerning whether the anterior or posterior technique is preferable. The important
factors for decision-making are (1) sagittal cervical alignment, (2) the width of the
spinal canal, (3) the number of affected segments, (4) the location of the compressive abnormality, and (5) the presence of instability. Patients with one or two levels
of involvement should be managed using anterior cervical discectomy or corpectomy and fusion (Fig.43.5), whereas those with the involvement of four or more
levels should be treated using a posterior approach (Fig.43.6).
43.7 Expected Outcomes
Both anterior and posterior approaches produce favorable surgical outcomes when
effective decompression of the spinal cord is achieved. Various factors, such as age
and the preoperative severity of spinal cord dysfunction as revealed using
T2-weighted MRI, affect the surgical outcome. Patients with lordotic alignment
have better clinical results after posterior decompression than those with neutral or
kyphotic alignment. Poor surgical outcomes were reported after posterior decompression in patients with local kyphosis exceeding 13°.
Fig. 43.5 Anterior decompression and fusion surgery at C4–C5 and C5–C6 levels
b
ca
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a
Fig. 43.6 Posterior decompression surgery using cervical laminoplasty from C3 to C7
b
43.8 Potential Complications
One of the disadvantages of the anterior approach is the long-term application of a
rigid orthosis. Further, recurrent laryngeal nerve palsy, sympathetic nerve injury
resulting in Horner syndrome, dysphagia, and vertebral artery injury have been
cited as postoperative complications related to the anterior surgical approach.
Dislodgement of grafted bone might occur after anterior surgery. In long-term follow- up, adjacent segment disease above or below the fusion levels should be considered. A few possible complications are related to the posterior approach.
However, when posterior instrumentation is used, especially xation using pedicle
screws, care must be taken to not penetrate vertebral artery. Postoperative radiculopathy, or motor palsy of the C5 nerve root, is well known to occur occasionally
after posterior decompression of the spinal cord. This complication can be found
after anterior surgery. Postoperative C5 palsy is reported to occur in 5–8% of
patients on average after surgery. Other common postoperative problems of the posterior approach are axial symptoms, such as axial pain and a limited range of motion
of the cervical spine.
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43.9 What Should Patient andFamily Know?
The therapeutic strategy should be based on the severity of the symptoms. Patients
with severe or progressive cervical myelopathy associated with concordant radiologic ndings are candidates for operative treatment. Anterior or posterior decompressive surgery effectively improves the symptoms of cervical myelopathy. Both
the anterior and posterior approaches have their own advantages and
disadvantages.
Further Readings
Iyer A, etal. Cervical spondylotic myelopathy. Clin Spine Surg. 2016;29:408–14.
Nouri A, etal. Degenerative cervical myelopathy: epidemiology, genetics, and pathogenesis. Spine
(Phila Pa 1976). 2015;40:E675–93.
Rhee JM, et al. Nonoperative management of cervical myelopathy: a systematic review. Spine
(Phila Pa 1976). 2013;38:S55–67.
Thoracic Disk Herniation
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YoshiharuKawaguchi
44.1 Definition
Thoracic disk herniation (TDH) causes spinal cord compression due to the prolapse
of the thoracic disk and is associated with numbness and other clinical symptoms of
thoracic myelopathy. The incidence of TDH is 0.25% to 1% of all spinal disk herniations. TDH is a degenerative disease, rarely related to trauma, and occurs equally
in men and women, most often during middle age. The lower thoracic spine, an area
where the ribs do not attach to the sternum, is the most common injury site.
44.2 Natural History
Patients with TDH can have ill-dened back pain and a range of symptoms, depending on the location of the herniation. Involvement of the intercostal nerve results in
radicular girdle pain in the thoracic region. The symptoms of thoracic myelopathy
progress slowly and include numbness of the lower extremities, gait disturbances
(spastic gait), and vesicourethral involvement. The weakness of the lower extremities can progress rapidly after onset in some cases, and minor trauma can cause a
sudden onset of a neurological decit.
Supplementary Information The online version contains supplementary material available at
[https://doi.org/10.1007/978- 3- 030- 80356- 8_44].
Y. Kawaguchi (*)
Department of Orthopaedic Surgery, Faculty of Medicine, University of Toyama,
Toyama, Japan
e-mail: zenji@med.u-toyama.ac.jp
© The Author(s), under exclusive license to Springer Nature
Switzerland AG 2022
A. Şenköylü, F. Canavese (eds.), Essentials of Spine Surgery,
https://doi.org/10.1007/978-3-030-80356-8_44
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44.3 Physical Examination
A neurological examination is checked by deep tendon reexes, motor functions,
and the existence of sensory disturbances. Patients with thoracic myelopathy have
hyperreexia of the lower extremities. The Japanese Orthopedic Association has
developed a scoring system that can evaluate the severity of thoracic myelopathy
(Table44.1). Pathological reexes, such as Babinski and Chaddock, are positive,
and motor palsy and weakness are found in some cases. Sensory disturbance can
also be found below the affected thoracic disk (Video 44.4). Patients with TDH in
the lower thoracic region can have conus syndrome, a collection of symptoms that
includes back pain, bowel and bladder dysfunctions, spastic or accid weakness,
and bilateral sensory loss in the lower extremities.
Tab le 44.1 Modied Japanese Orthopedic Association scoring system for thoracic myelopathy
Motor function
Lower extremity
0 Unable to stand & walk by any means
0.5 Able to stand but unable to walk
1 Unable to walk w/out a cane or other support on a level surface
1.5 Able to walk w/out support but w/ a clumsy gait
2 Walks independently on a level but needs support on stairs
2.5 Walks independently when going upstairs, but needs support when going
downstairs
3 Capable of fast but clumsy walking
4 Normal
Sensory function
(I) Trunk
0 Complete loss of touch & pain sensation
0.5
1 >60% normal sensation &/or moderate pain or numbness
1.5 Subjective numbness of slight degree w/out any objective sensory decit
2 Normal
(II) Lower
extremity
0 Complete loss of touch & pain sensation
0.5
1 >60% normal sensation &/or moderate pain or numbness
1.5 Subjective numbness of slight degree w/out any objective sensory decit
2 Normal
Bladder function
0 Urinary retention &/or incontinence
1 Sense of retention &/or dribbling &/or thin stream &/or incomplete
2 Urinary retardation &/or pollakiuria
3 Normal
a
Total score for a healthy patient=11
≦50% normal sensation &/or severe pain or numbness
≦50% normal sensation &/or severe pain or numbness
continence
a
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T10
T11
Fig. 44.1 A thoracic MRI in a typical TDH case. The patient is a 77-year-old female with T10–
T11 DH suffering from incomplete paraplegia (Case 1)
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44.4 Imaging
Magnetic resonance imaging (MRI) is used to check for the existence and severity of
TDH and spinal cord compression (Fig.44.1). MRI can identify the extent of disk
degeneration, endplate damage, intramedullary changes of the spinal cord, and
appearance of Schmorl nodes (Chap. 27). Knowing the extent of spinal cord compression allows decisions to be made about decompression surgery. The herniation
type can be seen in MRI and classied as a protrusion (the most common), extrusion,
or sequestration. Computed tomography (CT) is used to detect calcied lesions
(Fig.44.2), posterior bony spurs, and coexistence of ossication of either the ossication of the posterior longitudinal ligament (OPLL) (Fig.44.3) or ligamentum avum (OLF) (Fig. 44.4). TDH is not effectively detected with the radiographic
examination. However, radiographs might identify disk space narrowing and the calcied lesions associated with TDH.Spinal alignment can also be checked with radiographs. Patients with TDH have high lumbar lordosis and low thoracic kyphosis.
44.5 Differential Diagnosis
Pathologies such as OPLL, OLF, spinal tumors, and epidural abscesses can also
cause thoracic cord compression. Patients should be checked for common disorders
of the spinal cord such as motor neuron disease and multiple sclerosis. Patients with
TDH can also have coexisting spinal lesions in the cervical and lumbar spine.
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a
b
T11
T12
c
T11
T12
Fig. 44.2 A thoracic MRI in an 80-year-old male patient with T11–T12 DH (Case 2). (a) A sagit-
tal MRI showing TDH. (b) TDH has a calcication shell (sagittal CT). (c) OLF is associated with
TDH (axial CT at T11–T12)
44.6 Treatment Options
Patients with TDH whose only symptoms are back and/or girdle pain should receive
conservative treatment, and pain-relief medication is the rst option. Surgical treatment is indicated when a patient’s persistent, severe pain cannot be relieved by
medication and/or when patients have progressive neurological symptoms. Early
surgery is necessary and urgent if thoracic myelopathy is evident, before irreversible spinal cord damage and loss of function occurs due to compression of the spinal
cord. There are three surgical approaches: posterolateral, lateral, and anterior
(Fig.44.5), each of which decompresses the spinal cord by removing the TDH.A
posterolateral approach with posterior fusion (Videos 44.3 and 44.7) is the most
common procedure to remove the TDH.This approach avoids retracting the vulnerable spinal cord (Fig.44.6). Liquorrhea should be avoided by leaving in place any
occurrence of a calcied herniated disk that is rmly attached to the dura mater. A
retropleural costotransversectomy, performed by a lateral approach, was popular in
the 1980s but is less so now because it invades bone and soft tissue. This approach
requires resection of the lateral part of the unilateral facet joint and a partial resection of the rib. More recently, minimally invasive surgery (MIS) has been introduced although it is a technically demanding procedure. An anterior approach might
be considered when a large TDH is centrally located and the patient’s general
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T4
T5
T6
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Fig. 44.3 CT of the thoracic spine showing ossication of the OPLL. MRI reveals spinal cord
compression by OPLL.A 74-year-old female with T4–T6 OPLL
T11
T12
Fig. 44.4 CT of the thoracic spine showing OLF.A 55-year-old male with T11–T12 OLF
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