The Journal of Bone and Joint Surgery, Vol 73, Issue 3 352-364, Copyright © 1991 by Journal of Bone and Joint Surgery, Inc
Treatment of cervical spondylotic myelopathy by enlargement of the spinal canal anteriorly, followed by arthrodesis
K Okada, N Shirasaki, H Hayashi, S Oka and T Hosoya
Department of Orthopaedic Surgery, Kagawa Medical School, Japan.
Thirty-seven patients who had enlargement of the spinal canal anteriorly
and stabilization of the spine for cervical spondylotic myelopathy were
followed for an average of forty-nine months (range, twenty-eight to
seventy months). Myelography and computed tomographic myelography were
performed preoperatively on all patients to determine the location and
features of the areas of decompression. The canal was enlarged by
discectomy; by subtotal corpectomy and removal of the anteromedial parts of
the pedicles; or by removal of osteophytes or of the posterior longitudinal
ligament, or both. Partial corpectomy and interbody arthrodesis was
performed in nine patients; subtotal corpectomy, including removal of the
posterior parts of the vertebral bodies and of the posterior longitudinal
ligament, and strut bone-grafting, in fifteen patients; and subtotal
corpectomy, with detachment of the remaining thin posterior parts of the
vertebral bodies and of the posterior longitudinal ligament, and strut
bone-grafting, in thirteen patients. Postoperatively, radiographic
examinations, including myelography and computed tomographic myelography,
were performed for thirty-six patients and magnetic resonance imaging, for
twenty-eight. A satisfactory neurological result was obtained in
twenty-nine patients. Atrophy of the spinal cord, as seen on preoperative
computed-tomographic myelograms, was predictive of an unsatisfactory result
of the decompression, as was weakness of the peroneal muscles. All but one
of the thirty-seven patients had improved walking ability at the most
recent follow-up examination: seventeen patients improved by 1 point;
fourteen, by 2 points; four, by 3 points; and one, by 4 points. The
remaining patient reverted to the preoperative status after an initial
improvement. The ability to walk at the interim examinations was compared
with that at the most recent examination; three patients had continuing
improvement, while three others had deterioration. The main cause of
deterioration was new spondylotic changes associated with stenosis of the
spinal canal, occurring at the level of the disc just cephalad to the fused
levels. We concluded that anterior decompression followed by a secure
arthrodesis should be an extensive procedure for patients who have cervical
spondylotic myelopathy, as determined preoperatively from a myelogram or
computed tomographic myelogram. Excision of the vertebral bodies should
also be wide and should include the anteromedial parts of the pedicles. The
third or fourth cervical vertebra should be included in the arthrodesis
prophylactically in patients who have stenosis of the spinal canal when
either of these vertebrae is adjacent to the level of fusion.
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