The following case presentation is intended to assess current practice habits for common neurosurgical challenges when class I evidence is not available.
The Case
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| This mid-sagittal image shows moderate epidural compression from spondylosis at C-4C-6 and there is a focus of increased T2 signal within the spinal cord adjacent to the C5 vertebral body. (Click to enlarge) |
The patient is a 60-year-old man who presents with a two-year history of worsening neck pain that does not radiate into his arms. The neck pain is managed well with analgesics. In the last year he has noticed slight numbness in both hands and intermittent clumsiness when performing discrete activities with his nondominant left hand. His bowel and bladder function is intact. He has normal motor bulk, tone, and power. Deep tendon reflexes are normal and not hyper-brisk. There is a positive Hoffman’s sign in the left hand and an upgoing toe (positive Babinski sign) in the left foot. There is no ankle clonus, and his gait and balance are normal.
Sensory testing reveals patchy nondermatomal alteration to pinprick in the left hand. An MRI scan of the cervical spine shows multilevel cervical spondylosis with maintained lordosis. There is moderate epidural compression from spondylosis at C4–C6 and a focus of increased T2 signal within the spinal cord adjacent to the C5 vertebral body on the mid-sagittal image (see figure).
In summary, this patient presents with minimally symptomatic cervical spondylotic myelopathy, associated with an abnormal MRI scan (increased T2 signal).
Take the Gray Matters Survey
Indicate how you would proceed for this patient by answering the four survey questions at www.aansneur osurgeon.org (select the Gray Matters Survey link in the tool bar and take the survey, Minimally Symptomatic Cervical Spondylotic Myelopathy). An optional open comment field is provided at the survey’s end.
- Web Address: https://www.aansneurosurgeon.org
- Take the Survey: Minimally Symptomatic Cervical Spondylotic Myelopathy
- Survey results and signed comments will be published in the next issue.
Considerations
The management of cervical spondylotic myelopathy remains controversial. While
most surgeons would recommend decompression for patients presenting with severe
or progressive neurological deficits, patients with nonprogressive mild impairment
or minor neurological deficits may do well with conservative treatment (5).
Indeed, a recent review indicates that there is substantial clinical equipoise
in several groups of patients with cervical spondylotic myelopathy (2). This
is especially the case for the category of patients with minimal or no symptoms
whose increased T2 signal within the cervical spinal cord was incidentally
discovered when undergoing MRI (2).
In a recent study, patients exhibiting high signal intensity on T2 alone and without much circumferential spinal cord compression did not show a significant deterioration in their myelopathy after nonsurgical treatment (6). Yet in surgical series the very patients with milder symptoms and findings such as a positive Babinski sign and hand dysfunction (but without spasticity or clonus) in association with hyperintensity on T2 had better surgical outcomes than those whose symptoms were more pronounced (1).
A recent Italian study demonstrated that results were best in patients with no cord signal change, intermediate in those with high T2 signal alone, and worst in patients with both high T2 signal and hypointensity shown on T1-weighted images (4).
Larger and more recent imaging studies demonstrate that a critically reduced cross-sectional transverse area of the spinal cord is the imaging feature that correlates best with poorer neurological status (3). Given the conflicting literature, it remains uncertain whether to recommend surgery or conservative treatment in patients with T2 signal change alone (with moderate compression) and mild or no clinical deficit.
Rajiv Midha, MD, MS, is professor and deputy head of the Department of Clinical Neurosciences and chief of the Division of Neurosurgery at the University of Calgary in Canada. The author reported no conflicts for disclosure.
References
1. Alafifi T, Kern R, Fehlings M: Clinical and MRI predictors of outcome after surgical intervention for cervical spondylotic myelopathy. J Neuroimaging 17:315–322, 2007
2. Benatar M: Clinical equipoise and treatment decisions in cervical spondylotic myelopathy. Can J Neurol Sci 34:47–52, 2007
3. Kadanka Z, Kerkovsky M, Bednarik J, Jarkovsky J: Cross-sectional transverse area and hyperintensities on magnetic resonance imaging in relation to the clinical picture in cervical spondylotic myelopathy. Spine 32:2573–2577, 2007
4. Mastronardi L, Elsawaf A, Roperto R, Bozzao A, Caroli M, Ferrante M, Ferrante L: Prognostic relevance of the postoperative evolution of intramedullary spinal cord changes in signal intensity on magnetic resonance imaging after anterior decompression for cervical spondylotic myelopathy. J Neurosurg Spine 7:615–622, 2007
5. McCormack BM, Weinstein PR: Cervical spondylosis. An update. West J Med 165:43–51, 1996
6. Shimomura T, Sumi M, Nishida K, Maeno K, Tadokoro K, Miyamoto H, et al.: Prognostic factors for deterioration of patients with cervical spondylotic myelopathy after nonsurgical treatment. Spine 32:2474–2479, 2007
Responses: Asymptomatic Severe Cervical Cord Compression Case
AANS Neurosurgeon 16(4):40, 2007–2008
The case
Surgical Decision-Making for a Patient With Asymptomatic Severe Cervical Spinal Cord Compression
Survey Results Summary
Most respondents to this online survey, 67 percent, would recommend surgery for prophylactic spinal cord compression. Extremely influential factors in this decision were the risk of neurological injury without treatment and comorbidities. Somewhat influential factors were patient lifestyle and age and the extent of surgery necessary. A majority of respondents also felt that the patient should be cleared for general anesthesia with intubation (67 percent) and should be advised to alter his lifestyle if he decides to avoid surgery (73 percent).
Respondents split when asked of what degree of spinal cord injury risk the patient should be apprised if he chooses management rather than surgery. Twenty-seven percent said to advise of a greater than 50 percent chance of spinal cord injury, and the same percentage said to advise of a less than 50 percent chance of such injury. Twenty-seven percent would warn of a less than 25 percent risk, while 13 percent would advise of a less than 5 percent risk and 7 percent, of a greater than 75 percent risk.
Case Commentary
Respondents commented that major factors in advising surgery for the patient were the patient’s overall good health and the high degree of active lifestyle he desires. They also stressed the importance of clear communication to the patient and the wisdom of obtaining a second opinion.
The presence of T2 signal abnormality indicates that the cord parenchyma is not tolerating compression well and, therefore, there is likely a greater risk that future minor trauma could result in an irreversible neurological deficit. If the patient is educated to this ill-defined relative risk, then an informed consent for or against surgery can be obtained.
Jeffrey Oppenheim, MD, Suffern, N.Y.
This case is a serious accident waiting to happen; therefore, it should be addressed surgically as soon as one can arrange it. It is quite obvious that the level of compression is bad at 5–6 and worse at 3–4. I believe anterior decompression of these two levels is absolutely necessary because this patient, regardless of age, is in danger of developing severe myelopathy with a minor incident, for example forceful sneezing or minor trauma to the head or neck. Therefore, this patient will need a prophylactic decompression. This is, of course, after everything is explained to the patient and he makes the final decision.
David A. Yazdan, MD, FACS, Brick, N.J.
Responses: Postoperative Anticoagulation Case
AANS Neurosurgeon 16(3):24, 2007
The Case
Postoperative Anticoagulation for a Patient With Surgically Treated SDH and Intermittent Atrial Fibrillation
Survey Results Summary
A majority of respondents to this online survey, 40 percent, said that they would never restart heparin given the circumstances of this case. Twenty-one percent of respondents would wait at least five days, 7 percent would wait one week, and 29 percent would restart heparin after two weeks. Two respondents commented that they would restart anticoagulation with Coumadin rather than heparin and one would consider Lovenox on the second day postsurgery. The top factors influencing decision-making in this case were the history of falls and the presence of an underlying medical condition, followed by postoperative CT, discharge disposition (home, rehabilitation, other facility), and postoperative neurological status. When asked who should make the decision about how and when to restart anticoagulation, most respondents said the neurosurgeon, followed by the cardiologist, the patient’s family, and the primary care physician.
Case Commentary
Additional comments on this case were published in AANS Neurosurgeon 16(4):41, 2007.
Teasing out a consensus for restarting anticoagulation therapy in a patient with atrial fibrillation who has just had a subdural hematoma raises several issues that must be considered in formulating a treatment plan. One must first evaluate the risk stratification for a patient carrying a diagnosis of atrial fibrillation (5). It is generally accepted that the overall risk for stroke in a non-anticoagulated patient with atrial fibrillation is approximately 5 percent per year. However, this risk may temporarily increase to 20 percent for those who have recently been diagnosed with a stroke (2, 4).
Secondly, there is a theoretical basis for how neurosurgeons time the restart of anticoagulation therapy, other than anecdotal experience. Some neurosurgeons consider restarting anticoagulation within three to five days when gliosis becomes apparent through peak production of astrocytes and GFAP at the site of injury (3). Others may wish to wait one-to-two weeks based on maturation of healing (2). Consultation with the patient and the family might include the information that risk of stroke exists, extrapolated to be approximately 0.2 percent every two weeks, and that as small as this number seems, strokes do occur (see figure).
Further complicating these decisions are the general health of this populationof patients, which includes variables such as elderly patients with a history of falling, cancer patients with coagulopathies, and patients with complicated anticoagulation histories associated with drug interactions (1, 5). Consensus, therefore, is more likely to be achieved in the “healthy” or an equivocal-risk subset of atrial fibrillation patients after subdural hematoma. In our experience, this group of “healthy” patients receives oral anticoagulation starting day five, reflecting the preoperative medication schedule.
Ann Stroink, MD, Seth Molloy, DO, Bloomington, Ill.
References
1. Gullov AL, Koefoed BG, Peterson P: Bleeding during warfarin and aspirin therapy in patients with atrial fibrillation. The AFASAK 2 study. Arch Intern Med 159:1322–1328, 1999
2. Lazio BE, Simard MJ: Anticoagulation in neurosurgical patients [current perspectives]. Neurosurgery 45:838–847, 1999
3. Norton WT, Aquino DA, Hozumi I, Chiu FC, Brosnan CF: Quantitative aspects of reactive gliosis: a review. Neurochem Res 17:877–885, 1992
4. Singer DE, Albers GW, Dalen JE, Go AS, Halperin JL, Manning WJ: Antithrombotic therapy in atrial fibrillation: The seventh ACCP conference on antithrombotic and thrombolytic therapy. Chest 126(30 spp1):429–456, 2004
5. The Stroke Risk in Atrial Fibrillation Working Group: Independent predictors of stroke in patients with atrial fibrillation: a systematic review. Neurology 69:546–554, 2007