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Originally Posted by mmglobal on Braintalk
Last week, I attended the Spine Arthroplasty Society’s 6th Annual Global Symposium on Motion Preservation Technology. It ran Tuesday through Saturday in Montreal. I’ll be blogging my experience there on the GPN website, but it will take me a while to catch up. I’ll do at least one article there every day until I’m done.
Because I have several cervical clients with substantial cord compression with myelopathy, I was on a mission to gather more information about their situations and options. Some of these people have substantial symptoms that must be addressed. I’ve been told that with compressive myelopathy, there is a 35% chance that symptoms will not be relieved when the source of the compression is relieved and that symptoms may be permanent. The patients who have a really tough time with their surgical decision are the ones who have severe cord compression, but with mild or no symptoms. These people are often told that they must do surgery even with no symptoms because they are at risk for rapid onset of severe symptoms and serious permanent damage (even paralysis.) Other doctors tell them to wait.
We’ve been discussing the concept of “rebound myelopathy”. This term is sometimes used to describe new or worse symptoms after surgery. The theory is that changing the situation by relieving the source of the compression, restoring blood flow to tissues that have been blood deprived, moving things around and/or remobilizing or increasing the mobility of a segment may actually cause new symptoms or make existing symptoms worse. I spoke to several top surgeons about this… specifically about ADR in the presence of compressive myelopathy. Some surgeons are recommending against ADR in this situation because of these fears.
Other surgeons would not embrace the concept of “rebound myelopathy” being caused by removing the source of compressions or increasing mobility the segment. One surgeon told me, “What they are doing is describing new or worsening symptoms and putting a label on it. This label makes it sound as if it has nothing to do with the surgery, just bad luck. In reality, many things can adequately explain the symptoms without such a label. It could be trauma to the cord caused by too aggressive use of tools in the surgery. It could be inadequate decompression. The amount of decompression required for a fusion is much less than what is required if the motion is restored. Calling it rebound myelopathy instead of inadequate decompression takes the pressure off the surgeon.”
This is consistent with data presented in sessions about cervical ADR complications. Cases were reported where patients went into surgery with arm or shoulder pain on one side. The surgery relieved that pain, but when activity levels increased as the patient recovered from the surgery. In some of these cases it was explained by the surgeons decompressing the side in which symptoms existed, as they would for a traditional spine surgery. ASYMPTOMATIC stenosis caused by osteophytes, calcified ligament, disc bulges, etc. on the other side may BECOME symptomatic after the patient increases activity levels or because motion at the segment may be increased.
As for the decision to wait in the absence of symptoms, some will still recommend not doing surgery. Depending on the severity of the cord compression, they may recommend MRI’s every year, 6-months or even 3-months to insure that things aren’t progressing… not only the compression, but changes to the myelon too. One surgeon said, “even in the absence of symptoms, moderate to severe cord compression is like a ticking bomb. The risk of waiting can be much greater than the risk surgery. Yes, it can be dangerous to have someone go to defuse the bomb, but we still do it because the risks involved in leaving it alone are greater than the risks of the surgery.”
If you are considering cervical surgery, especially with motion preservation technology, and you have spinal cord compression; you might want to discuss these issues with your surgeon. This may be one of those cases where some surgeons have substantial poor experience while others have few problems… with the difference being explained by surgical technique, differences in patient selection, diligence in follow-up or patient tracking, or other factors. This may be one of those situations in which you should be with a surgeon who has high experience with cases like yours.
Mark
*** Remember, I’m not a doctor. These writings relate my recollections and impressions which may be completely wrong.
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