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| Figure 1. The MRI demonstrates severe segment cord compression with deformity of the spinal cord and increased intra-spinal T2 signal |
Surgical Decision-Making for a Patient With Asymptomatic Severe Cervical Spinal Cord Compression
The patient is a 60-year-old vigorous male who enjoys cycling and inline skating. He injured his shoulder in a fall, and an MRI of the shoulder demonstrated an incidental finding of cervical stenosis. The radiology report suggested a dedicated cervical MRI, which showed significant cord compression with an anteroposterior deformity and T2 signal change. Neurosurgical consultation was requested for evaluation and clearance for general anesthesia for a rotator cuff repair.
The medical history is unremarkable: no medications, no prior illness, no prior surgeries.
The patient’s history is negative for any symptom of subtle myelopathy including no decreased dexterity or sensory change of the hands, no change in axial balance, no deterioration in bladder control, no gait abnormality or difficulty with running. The cervical spine is pain-free. Neurological examination is unremarkable except for limitation of the right shoulder joint and associated segmental strength evaluation.
The MRI (Figure 1) demonstrates severe segmental cord compression with deformity of the spinal cord and increased intraspinal T2 signal.
QUESTION: Please indicate how you would proceed for this patient by answering the five multiple choice survey questions at www.aasnneurosurgeon.org (select the Gray Matters Survey link in the tool bar and take the survey, Asymptomatic Severe Cervical Spinal Cord Compression); an optional comment field is provided at the survey’s end.
Considerations
No class I evidence exists to address the issue of surgical decision-making for a patient with asymptomatic severe cervical spinal cord compression. The prevalence of cervical stenosis in cadavers (anteroposterior view of canal diameter < 12 mm) is 6.8 percent over age 50 and 9 percent over age 70 (5). The prevalence of incidental cervical stenosis in patients undergoing MRI of the larynx is 16 percent under age 64 and 26 percent over age 64 (7). Seven percent of these patients had significant cord compression with flattening in the anteroposterior diameter.
The natural history of untreated cervical stenosis is uncertain. In athletes who participate in contact sports, cord symptoms occur at a low frequency (2, 6). The positive predictive value of a Torg ratio less than 0.8 for developing cervical cord neurapraxia was 0.2 percent (8). In the author’s experience central cord syndrome associated with low impact injuries is a familiar reason for emergent consultation particularly for patients over age 60.
Described surgical indications include a transverse spinal cord area of 40 square millimeters or less independent of the presence of clinical symptoms (4). Asymptomatic patients under 65 years of age at risk of quadriplegia with mild trauma may warrant prophylactic decompression (1). The patient’s input and his or her full awareness of potential serious complications should guide decision-making (3).
Patrick W. McCormick, MD, FACS, MBA, is associate editor of AANS Neurosurgeon. He is a partner in Neurosurgical Network Inc., Toledo, Ohio. The author reported no conflicts for disclosure.
References
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Epstein NE: Laminectomy for cervical myelopathy. Spinal Cord 41:317-327, 2003Take the Survey
- Web Address: https://www.aansneurosurgeon.org
- Take the Gray Matters Survey: Asymptomatic Severe Cervical Spinal Cord Compression
- A synopsis of all responses will be published in the next issue.
- Herzog RJ, Wiens JJ, Dillingham MF, Sontag MJ: Normal cervical spine morphometry and cervical spinal stenosis in asymptomatic professional football players. Spine 16(6 Suppl):178-186, 1991
- Hunt WE: Cervical spondylosis: natural history and rare indications for surgical decompression. Clin Neurosurg 27:466-480, 1980
- Law MD Jr, Bernhardt M, White AA III: Cervical spondylotic myelopathy: a review of surgical indications and decision making. Yale J Biol Med 66:165-77, 1993
- Lee MJ, Cassinelli EH, Riew KD: Prevalence of Cervical Spine Stenosis. Anatomic study in cadavers. J Bone Joint Surg Am 89:376-380, 2007
- Odor JM, Watkins RG, Dillin WH, Dennis S, Saberi M: Incidence of cervical spinal stenosis in professional and rookie football players. Am J Sports Med 18:507-509, 1990
- Teresi LM, Lufkin RB, Reicher MA, Moffit BJ, Vinuela FV, Wilson GM, et al.: Asymptomatic degenerative disk disease and spondylosis of the cervical spine: MR imaging. Radiology 164:83-88, 1987
- Torg JS, Naranja RJ Jr, Pavlov H, Galinat BJ, Warren R, Stine RA: The relationship of developmental narrowing of the cervical spinal canal to reversible and irreversible injury of the cervical spinal cord in football players. J Bone Joint Surg Am 78:1308-1314, 1996
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Responses: Postoperative Anticoagulation Case AANS Neurosurgeon 16(3):24, 2007 CASE: Postoperative Anticoagulation for a Patient With Surgically Treated SDH and Intermittent Atrial Fibrillation QUESTION: When and how should anticoagulation be restarted postoperatively in a patient with a surgically treated subdural hematoma and a symptomatic condition (intermittent atrial fibrillation) requiring this treatment? The following responses to the Gray Matters postoperative anticoagulation case reveal a range of decision-making factors and courses of action. Readers are invited to review and weigh in on this case by going to https://www.aansneurosurgeon.org, selecting the Gray Matters Surveys link, then taking the Postoperative Anticoagulation survey. I like to wait six weeks postoperatively. If the cardiologists are pushing me, I will go to four weeks. If the cardiologists insist on a shorter period, I insist that the cardiologist and I speak to the patient together and explain in detail the risks and benefits of restarting anticoagulation versus waiting longer, and let the patient (or family) decide. Start full dose anticoagulation postoperatively and follow with periodic CT imaging. In my experience, the risk of thromboembolism is much greater than the risk of recurrent bleeding when followed by trained caregivers and CT scans. I treat each patient differently. In the community where I practice there are many patients on anticoagulants for varying reasons. My partners and I also are the only neurosurgeons at a level 2 trauma center. I look at the underlying reason for anticoagulants. If it is strictly prophylaxis without any embolic or thrombotic events, then I tend to wait about three-to-four weeks. If patient has had history of pulmonary embolism or deep-vein thrombosis, then I will drop down to one week. I will usually tell the patient and/or the family about the risks of anticoagulants to the central nervous system. If the patient must be on warfarin, I would wait one week before restarting anticoagulant therapy. I would not bolus with heparin on the restart or bridge with Lovenox [enoxaparin]. I would simply have warfarin restarted with the INR [international normalized ratio] goal of 2-2.5 very, very strictly adhered to. Risk of bleed goes way up with INR > 4.0-4.5. Even if the patient is without symptoms, I would get a head CT scan about one-to-two weeks after anticoagulant therapy. If a recurrent bleed is present, I would discontinue anticoagulant therapy for life. Unless the use of anticoagulation is established as safe after removal of a subdural hemorrhage, neurosurgeons will not use medications like Coumadin. The downside is that a patient may rebleed into the subdural space, now with an acute subdural hemorrhage that would require a craniotomy with anticipated high morbidity or mortality along with a medical malpractice lawsuit. Unlike the orthopedic procedures, neurosurgeons have to be worried about even a small amount of bleeding in a postoperative site. Thus, we will continue to be against the use of anticoagulation in this setting. |