What is the difference in cervical radiculopathy vs lumbar radiculopathy?
There is pedicle/ nerve root mismatch. Cervical spine root is above the Vertebrae. Also, nerve root anatomy is more horizontal in cervical spine β so central and foraminal disc will affect the same nerve root
In lumbar spine, e.g. L4/L5 disc, central disc will affect traversing root L5, and far lateral disc will affect exiting root L4
In cervical spine, C4/C5 disc will affect C5 exiting root
C7/T1 will affect C8.
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What is the natural history of cervical myelopathy?
When close eyes, left with 2 - vestibular and proprioception and normally patient can balance
When proprioception is not present, patient will have positive Romberg's
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What if you find that upper limb symptoms are not matching?
Double crush syndrome
Such patients may have double crush syndrome (DCS) with compression of nerve fibers at 2 distinct sites: 1 proximal in the C-spine, and 1 distal in the cubital tunnel, carpal tunnel, or elsewhere
I will order NCS/ EMG
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How do you classify severity in cervical myelopathy?
mJOA score - based on UL, LL, Sensory and Urinary symptoms out of 18!
THe lower the score, the more severe.
< 11 = severe, Moderate 12-14, Mild > 15
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What are you looking for on the XR in cervical myelopathy?
"looking for 4 factors that will influence my surgical approach and technique" = alignment, presence of instabiliity, number of levels and presence of OPLL.
K-line Mid point of canal at C2 and canal at C7 - lordosis or kyphosis [Positive means lordosis]
Number of levels involved
Presence of OPLL? - posterior approach due to risk of dural leak
Presence of POSSIBLE Instability - listhesis confirm with flex extension views
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What other invx?
Flex extension views - instability is present if change in translation > 3.5mm, angulation > 11
MRI C-spine - myelomalaciae
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What is the difference between cord edema and myelomalacia?
Myelomalacia = associated with focal cord atrophy; softening of the cord
Myelomalacia appears hypointense to the cord (but hyperintense than CSF) on T1WI, and hyperintense to the cord (can be similar to CSF) on T2WI
Cord Edema - no atrophy but swelling around cord due to inflammation
Risk of dural injury which I can further quanity with CT scan looking at single layer or double layer signs
Sway towards Posterior approach to prevent dural leak if max occupational ratio < 60% and K-line lordosis.
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How do you evaluate OPLL? Impact on management?
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Maximum Occupancy ratio = size of OPLL / Spinal canal
if it is > 60%, posterior procedures likely will not work due to extensive anterior component β will need to risk anterior approach
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CT scan - evaluate C-signs
C sign indicates that the lateral dura had become imbricated in the OPLL mass
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Does OPLL continue to progress after laminoplasty?
Yes. Younger age and mixed- or continuous-type OPLL are associated with increased risk of OPLL progression.
Fortunately, despite relatively high rates of progression in OPLL, there is a low rate of late neurological deterioration among patients managed both nonoperatively and operatively
Why neurological function is preserved after laminoplasty in some patients despite radiographic evidence of OPLL growth has yet to be answered definitively.