European Journal of Cardiovascular Medicine

The cervical spine is a bioengineering marvel which provides strength, flexibility and at the same time protection to the underlying neural elements. The cervical spine is at constant motion during action. Being the most mobile segment of the whole spine, it is subjected to significant wear and tear. This explains why cervical spine degenerates early, particularly in persons doing heavy manual work. These changes are ubiquitous in the elderly population. No surgical procedure can cure the natural progression of cervical degeneration, which is a normal part of ageing process.

Cervical spondylosis is a chronic degenerative condition of the cervical spine that affects the vertebral bodies and inter vertebral discs of the neck (e.g disc herniation, spur formation), as well as the contents of the spinal canal (nerve roots and/or spinal cord). It also include the degenerative changes in the facet joints, longitudinal ligaments and ligamentum flavum.

Spondylosis progresses with age and often develops at multiple levels. Chronic cervical degeneration is the most common cause of progressive spinal cord and nerve root compression.  Spondylotic changes can result in spinal canal, lateral recess, and foraminal stenosis. Spinal canal stenosis can result in myelopathy, whereas the latter two can cause radiculopathy. When cord compression is caused by degenerative changes it is referred to as cervical spondylotic myelopathy (CSM). Spondylosis may initially cause neck pain or a radiculopathy those progresses to a myelopathic syndrome when the cord becomes involved, though such progression is rare ³.

Surgical procedures have been proposed by which the neural components can be decompressed by either an anterior approach (anterior cervical discectomy with or without fusion or corpectomy) or a posterior approach (decompressive cervical laminectomy or cervical laminoplasty). Anterior cervical discectomy is reserved for cervical radiculopathy or cervical myelopathy due to prolapsed cervical disc at one or two and very rarely at three levels. This procedure has to be followed by fusion by putting a bone graft in the disc space and may require instrumentation to keep the graft in position. Corpectomy is a procedure for cervical spondylotic myelopathy due to multiple prolapsed adjacent cervical discs, cervical ossified posterior longitudinal ligament (OPLL). The middle one third of the vertebral bodies are excised along with the adjacent and intervening discs, which is followed by fusion using an iliac or fibular bone graft. It is usually followed by instrumentation. Cervical decompressive laminectomy are reserved for cervical spondylotic myelopathy for any pathology posterior to the cord, more than three level discs or anterior pathology and often in continuous OPLL.

Decompressive laminectomy for the treatment of cervical spondylotic myelopathy has been accepted as a standard procedure for years. It is most commonly indicated in patients who have a compressive myelopathy with an effective cervical lordosis. In these cases the laminae are to be removed one level proximal and one level distal to the involved segments. In wide laminectomy up to 25% of involved facet joint can be excised. This provides more space for spinal cord and hence improvement. Cervical laminoplasty has become the choice of treatment for CSM in many countries, but even today it is been commonly practiced in India. This procedure has been recommended for CSM and OPLL. The theory behind laminoplasty in CSM is to prevent kyphosis and instability, post laminectomy membrane formation, arachnoiditis and restenosis. The main goal of laminoplasty is to enlarge the spinal canal and in turn to increase the cross sectional area of the spinal cord without compromising stability. Cases with a straightened spine may be treated by either a ventral or dorsal decompressive operation.

The present study is a prospective study comprising of 70 cases of cervical spondylotic myelopathy. Studied over a period from June 2016 to March 2018 in the department of neurosurgery, GMC, GGH, GUNTUR.

The cases included in this study were cases of cervical spondylotic myelopathy with ventral compression 1or 2or 3 levels.

Inclusion Criteria: All ages and both genders patients of only cervical compressive myelopathy are taken

Exclusion Criteria: Patients with associated compression at different spinal levels like thoracic, lumbar, Patients with gross subluxation grade and infective pathology were excluded from this study.

Nurick’s Grading

Grade 0 – Signs And Symptoms Of Root Involvement, Spinal Cord Not Involved.

Grade I – Signs Of Spinal Cord Disease. No Difficulty In Walking.

Grade Ii – Slight Difficulty In Walking. Full Employment Not Prevented.

Grade Iii – Difficulty In Walking. Prevents Fulltime Employment Or Do All The House Hold Works.                                                      

Grade Iv – Able To Walk Only With Help

Grade V – Chair Bound Or Bed Ridden.

Grade I And Ii Are Taken As Mild, Grade Iii And Iv As Moderate And Grade V As Severe Grade.

All basic investigations done in all patients. All the patients were evaluated as per age group, sex, presence of various symptoms, duration of symptoms, nurick’ grading and MRI findings. All these patients underwent anterior cervical discectomy and followed by fusion with bone graft from iliac crest and fixation with titanium cervical plates and screws. Corpectomy and discectomy with fixation are done in cases where significant retrovertebral compression is present over the spinal cord. Outcome was recorded for Improvement, no change (Static) and Deterioration.

The age incidence of 70 patients with CSM is analyzed.

Table-1: Demographic details in present study

The youngest patient in our study was 19 years old; whereas the eldest patient was 75 years old. The mean age in our study was 44.02 years. Males outnumbered females with 91.42% of patients in our study were male and only 8.58% of patients were female, which shows preponderance of cervical spondylotic myelopathy in male. The commonest clinical presentation in our study was motor symptoms. Most of the patients in our study had symptoms for more than 12 months. The mean duration of symptoms in our study was 22 months. All the cases were analyzed according to level of lesion. Most of the patients have 1 level involvement.

Table-2: Cases were classified as per Nurick’s grading and JAO scoring system.

       Most of the patients i.e 55/70 in our study were of grade II and III. That is   presented only when there is difficulty in walking.

Table-3: Neurological status after 1 and 6 months of surgery

Table-4: Outcome as per nurick’s grading after 1 and 6 months of surgery

Out of 36 grade I and II (mild) cases, 75% (27 cases) had improvement and 25% were remained as such after 1 month of surgery. In moderate cases (grade III and IV) 50% cases improved, 46.66%cases remained static & 3.33%(1 case) developed MI in post op period. In 4 severe cases, 2 cases remained as such where as 2 cases expired on 7^th and 15th post operative day because of respiratory failure. Among mild cases (grade I and II), 100% improvement was seen after 6 months of surgery. In moderate cases (grade III and IV), 65.51% improved, 31.03% remained as such and 3.44% cases deteriorated. Out of 4 severe cases (grade V),2 cases expired on 7^th,and 11th post operative days due to respiratory failure and the rest 1 case  remained as such after 6 months of surgery and other landed in septicemia due to bed sore. The overall improvement in our study in six months duration was 78.57%. The p value was 0.046902, which is statistically significant.

Table-5: The clinical outcome analyzed as per the age group were as follows

Clinical improvement was favorable in younger patients compared to elderly age group. At the end of 1month 88.88% patients improved in 3^rd decade. At the end of 6months 100% patient improved in 4^th decade .out of 70 patients 42 patients improved in the 1^st month, 55 patients in the 6^th month. In our study patients with symptoms for shorter duration fared better compared to those with symptoms for more than 12 months. The p value was 0.018702, which is statistically significant.

Patients who are operated for single level lesion showed 84% improvement after 6months followed by 2 level lesion it showed an improvement of 66.66% after 6 months and 3 level lesion with 60 % after 6months.

Table-6: The clinical outcome of the patients as per the MRI findings were as follows

Out of 70 Patients a total of 31 patients have shown myelomalacia changes, of these 20 patients have improve on post operative MRI. Similarly out of 39 patients without myelomalacia 35 patients as shown significant improvement. This clearly infers that the improvement as proved by MRI is better in patients without myelomalacia changes.

Our study is a prospective study comprising of 70 cases studied over a period from June 2016 to September 2018 in the Department of Neurosurgery, Government General Hospital, Guntur. These are all  . All these patients were decompressed or approached anteriorly either by Discectomy i.e., ACD with Fusion or Corpectomy and fusion followed by fixation with cervical plate and cortical screws

Age incidence ranged from 19-75years with a mean age of 44.02. In our study males outnumbered the females (91.42% males). Commonest clinical presentation is motor symptoms – clumsiness of hands, quadriparesis, bladder disturbances etc., only 22/70 (31%) have presented with radiculopathy. Similarly majority of the patients 38/70 (54%) have long standing symptoms of more than 1year. The mean duration was 16 months. The delay in presentation is because of vague symptoms in the beginning, which were ignored by most of our patients, who are manual laborers. However, these patients have immediately attended the OPD once serious symptoms like loss of power impairing their daily activity 55/70 approximately 78% have presented in Nurick’s grade II & III. Majority of patients have I level involvement (50/70) i.e 71%. 50 single level discectomy and fusion was done with fixation. II level discectomy & corpectomy was done in 10 patients and remaining 5 patients underwent two level discectomy, fusion with plates and screws. III level ACDF is performed in 5 patients. In all cases a tricorticate bone graft harvested from iliac crest patients. Clinically improvement was assessed at the end of 1^st month & 6months using Nurick’s grading. Clinical improvement was compared with post operative MRI findings. The patients without pre-operative myelomalacia have better improvement (89%). The patients with myelomalacia have relatively less improvement (64.00%).

In our study 70% of patients were more than 40 years of age. The mean age of the study was 44.02 years, which is comparable to Rajasekhar et al.⁵ The outcome was better in younger age group. In patients up to 4^th decade there was 100% improvement whereas in persons more than 60 years of age there was only 53% improvement. Sex incidence in our study was showing a high preponderance among Males with Male is to Female ratio is around 12:1. The other International studies were showing the same as 4:1. This shows the degenerative changes in working males and the negligence towards regular health checkups and occupational rehabilitation in our country.

Most of the patients (54%) in our study have symptoms for more than a year. The mean duration of symptoms in our study was (16 months) which is comparable with 18.2 months by Jain et al.⁶ The outcome was also better in those with symptoms for less than 1 year. In our study 100% improvement was noticed in as early as 1 month following surgery in 3^rd decade. In patients with symptoms for less than 6 months duration whereas in patients with symptoms for more than 1 year only 68.42% shown improvements even after 6   months of follow up. The overall improvement in our study was 78.57% which was better than study by Jain et al ⁶ (61%) and Herkowitz et al ⁷ (56%) and it is comparable to Hirai .T et al⁸ (73%)

Motor symptoms were the most common presentation in our study 84% of the patients had clumsiness of hand with weak hand grip. 45.71% of patients had bladder disturbances following surgery. Motor symptoms improved early and significantly compared to bladder symptoms. 83% patients had improvement in their hand grip and 53%hadimproved bladder symptoms. Most patients in this study were in Nurick grade II, III ie., 41% and 37% respectively. The improvement was better in grade I and II compared to grade V. In our study 100% patients in grade I and II improved over a period of 6 months following surgery  and grade V 50% had no change and rest 50% deteriorated. Most patients in this study had 1 level lesion (71%). Single level lesions had 94% recovery over a period of 6 months following surgery whereas 2 level and 3 level lesions had 73% and 60% recovery after 6 months of surgery. MRI of the patient without myelomalacia changes in the spinal cord fair better compared to those with myelomalacia changes. 89.74% of patients without myelomalacia changes improved clinically after 6 months compared to only 64% of patients with myelomalacia.

Table-7: Comparision of parameters with other studies

Table-8: Surgical Results in CSM  due to multiple levels of pathology in other studies

There is an increase in the incidence of cervical spondylotic myelopaty due to increase in geriatric population. Life expectancy has gone higher worldwide. This is a condition commonly seen in elderly age group except traumatic cervical spondylotic myelopathy which is more common in younger age group. It affects mostly males.

The earliest symptoms like clumsiness of hands, mild weakness of limbs are usually overlooked by the patient. 56% of patients presented after gait disturbance (Nurick’s Grade II&III). By the time moderate to severe weakness of limbs and sphincter disturbances appear it is already late. The prognosis is related to duration of symptoms, cord changes, Nurick’s Grade, Level of lesions. Age of patient & associated metabolic comorbid also are important. Proper health education and understanding of the disease at the bottom level of health care, is more important for better prognosis. Compared to posterior approach, anterior approach has got better compliance. As post operative quality of life is significantly improved in anterior surgeries maybe as safe or safer than posterior surgery and most cost effective.

In cervical spondylotic myelopathy with anterior compression, decompression by posterior surgery is ineffective as you can’t remove osteophytes more over multilevel cervical spondylotic myelopathy is accompanied by various levels of nerve root compression and posterior surgery is ineffective for the decompression of nerve roots resulting in persistence of post operative symptoms.

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