Is there a benefit to operating on patients (bedridden or in wheelchairs) with advanced stage cervical spondylotic myelopathy?

Abstract

Surgical treatment of cervical spondylotic myelopathy (CSM) aims to prevent or delay the progression of the disease. Many patients are diagnosed in advanced stages of the disease, presenting severe functional disability and extensive radiologic changes, which suggests clinical irreversibility. There are doubts about the real benefit of surgery in patients who are seriously ill, bedridden or in a wheelchair. The objective of the study is to evaluate the effects of surgical treatment in the clinical outcomes of patients severely affected by CSM. We analyzed patients with CSM who received an operation at a single institution between 1996 and 2008. Cases with a preoperative Nurick score equal to 5 were studied. We describe postoperative clinical improvement and compare the demographics and clinical data between the patients who improved and those who had no improvement. Radiological findings were also analyzed. We evaluated 55 patients operated on. Nine presented with preoperative Nurick score of 5 (16.3%). The mean age was 69.77 +/- 6.6 years (95% CI 64.65-79.90). The mean follow-up was 53.44 +/- 35.09 months (CI 26.46-80.42). Six patients (66.6%) achieved functional improvement when assessed by the Nurick scale, regaining the ability to walk. All patients improved on the JOAm scale, except one. The mean preoperative Nurick score was 5, while the mean postoperative Nurick score was 4.11 +/- 0.92 (95% CI 3.39-4.82) (Wilcoxon p = 0.027). The mean preoperative JOAm score was 6.4, and postoperative was 9.88 +/- 2.31 (CI 95% 8.10-11.66) (Wilcoxon p = 0.011). All spinal cords presented high-intensity signal on T2-weighted images. There was no correlation between the number of spinal cord high-intensity signal levels and clinical improvement. Three out of seven patients (whose image was adequate for analysis) had evident spinal cord atrophy, and two of them did not improve clinically. In the whole sample of patients, the mean length of disease for those who improved was 9.25 +/- 7.31 months (95% CI 1.56-16.93), and for those who did not improve was 38.00 +/- 19.28 months (95% CI 9.91-85.91) (Mann-Whitney p = 0.02). In conclusion, two-thirds of patients with CSM Nurick scores of 5 who were either bedridden or in wheelchairs at the time of diagnosis improved at least one degree on the Nurick scale after surgical treatment, thus returning to walking. The JOAm scale was more sensitive to clinical changes than the Nurick scale. Patients with longer lengths of disease had worse outcomes.

Fig. 1

Algorithm for surgical decision-making in cervical spondylothic myelopathy (based on [5])

Fig. 2

MRI of case 9. Four levels of spinal cord high-intensity signal in a patient who returned to walking after surgery

Fig. 3

Multiple levels of anterior and posterior spinal cord compression in a patient who had postoperative clinical improvement (case 4)

Fig. 4

Evident spinal cord atrophy between C4 and C5 in T1-weighted image