Transcription:
Exploring Treatment Options for Cervical Myelopathy

Melanie Cole (Host):  Welcome to Better Edge, a Northwestern Medicine Podcast for Physicians. I'm Melanie Cole, and I invite you to listen as we explore treatment options for cervical myelopathy. Joining me is Dr. Geoffrey Stricsek. He's an Assistant Professor of Neurosurgery and a practicing Spine Surgeon at Northwestern Medicine. Dr. Stricsek, it's a pleasure to have you join us today. Before we get into the topic, tell us a little bit about yourself and how long you've been with Northwestern Medicine.

Geoffrey P. Stricsek, MD (Guest): Well, thank you for inviting me to join you guys today. I joined the Northwestern team in August of 2020. Prior to that I completed neurosurgery residency training in Philadelphia at Thomas Jefferson University. While there, I did a dedicated year focusing on complex spinal surgery and then following graduation from residency, I did another year of a Spinal Surgery Fellowship at Emory University in Atlanta.

Host: Well, thank you for that. So, let's talk about our topic, cervical myelopathy. Tell us a little bit about what causes it, whether we're talking about ossification or hardening of ligaments, you know, tell us a little bit about how this happens.

Dr. Stricsek: Sure. So, I think of cervical myelopathy as being a diagnosis, that means somebody has symptomatic compression or pressure on the cervical spinal cord. And there's sort of two different components that can lead to that compression. There can be static factors and then dynamic factors. So, some of the static factors that can cause spinal cord compression, is really sort of a, confluence of degenerative changes.

So, as we age, our intervertebral discs start to dry out. So, as they dry out, they start to lose height a little bit, and then that loss of height of the intervertebral disc ends up putting increased stress and increased pressure on the uncinate or uncovertebral joints at the level of the vertebral bodies, as well as additional stress on the facet joints, posteriorly.

So, as the discs dry out and that disc height decreases, that increased pressure on the uncinate and facet joints causes osteophyte formation. And because the spinal canal is a rigid confined space, as somebody starts to develop those osteophytes, it'll decrease the available room for the cervical spinal cord.

And as those osteophytes progress in size, they can start to cause symptomatic spinal cord compression. Another part of that is as we lose that disc height, there can be in folding of the ligaments around the spinal cord. So, it's a combination of that ligament in folding as well as the osteophyte formation that can cause compression on the spinal cord. That's sort of the general degenerative pathology.

Sometimes people can have other diagnoses like ossification of the posterior longitudinal ligament. And that's not as much a degenerative disease as a separate entity, but that can also cause compression on the spinal cord because it's growth of sort of bone abnormally within that fixed space for the spinal canal. And as we get something that comes into the canal, the only thing that can move within that bony ring ends up being the spinal cord. So, that's what ends up yielding to the encroachment of these abnormal pathologies.

Host: Isn't that interesting? So, Dr. Stricsek, tell us a little bit about the clinical presentation. What symptoms do patients with cervical myelopathy typically present with? How is it diagnosed and what imaging do you use?

Dr. Stricsek: So, I think the most common presentation that people have is often some degree of clumsiness in their hands, or a lot of times people have gait instability, or gait imbalance. People will frequently come in and they'll say, I have trouble walking or feels like I'm drunk when I'm walking, but they haven't been drinking. Another common thing is maybe it's not so much, they've had several falls or they feel unsteady on their feet, they almost find themselves tripping over their feet a little bit more often, you know, the corner of the rug catches them more frequently than it used to. And it's the result of the nerves in the neck run all the way down and supply the nerves in the leg too.

So, even though we have compression in the neck, it can impact the entire body. Another thing people notice they're just a little bit more clumsy, maybe holding a cup of coffee or a cup of tea in the morning. They tend to spill things a little bit more often, or maybe they drop a glass a little bit more often than they used to. And those are some of the kind of the early signs that I hear people say when they come in, they end up getting diagnosed with cervical myelopathy. So, you know, if somebody has some of these concerning findings on their history, the first step to really better understand what's happening from a structural standpoint is to get an MRI of the cervical spine.

And it can be an MRI without contrast. And the goal here is to look to see is there a narrowing of the spinal canal. Is there compression on the spinal cord? So it can help us start to put the clinical picture together. We want to merge both what people are having from a symptom standpoint, with what we see radiographically.

There definitely can be overlap with pathologies. MS tends to have a more relapsing and remitting course, meaning sometimes people develop symptoms and then it'll kind of get better and then they'll have another flare and then it'll get better. There's certainly some overlap with other neurodegenerative diseases like ALS. The MRI and kind of the clinical history, as well as the physical exam are really the three critical components, you know, we want to see what somebody is saying they've been having from a symptom standpoint, put that together with their clinical exam, you know, where we're looking for weakness or maybe pathological reflexes, like a Hoffman's reflex or elevated patellar reflexes, or elevated biceps reflexes. And then put that in with the MR imaging to try to yield a suitable diagnosis.

Host: Well, thank you for that. So, talk us through the treatment process for cervical myelopathy and what's involved.

Dr. Stricsek: Once we've established a diagnosis, we consider somebody's underlying health, their medical comorbidities, their age, and then we discuss treatment options. So, first question we always have to ask ourselves is surgery the right choice in this situation. And what we know is we can go back and look at the literature and there have been a lot of actually pretty good published reports, looking at the treatment of cervical myelopathy. And what we know from those studies is that the majority of people do well with surgery. Surgery tends to yield a positive benefit, meaning that people derive functional improvement or functional gains from the surgery.

So, surgical options include surgery approaching the spine from the front or from the back. And there's really risks and benefits to each. And the specific decision-making is somewhat dependent on where the worst of the pathology is located. There's also some consideration too, have they had neck surgery before. Have they had neck radiation before? Something that makes the surgical approach more challenging? Surgery from the front tends to have less postoperative pain because there's fewer muscles that we have to come through for that surgery, but there's a slightly higher risk of dysphasia or some swallowing difficulties after surgery. Surgery from the back, we avoid being in contact with the trachea and the esophagus.

There's not that sore throat or some of that difficulty swallowing afterwards, but there's a higher risk of wound infection because it's a longer deeper incision when we do surgery from the back. There's also more postoperative pain because we have to separate the paraspinal muscles. So, that tends to cause a little bit more discomfort. One of the posterior approaches that tends to have a slight advantage as opposed to the anterior approaches, there's fusion and non-fusion surgeries. So, surgery from the front tends to be a fusion operation. Most of the time when we do surgery from the back, it's also a fusion operation, but there is a procedure called a cervical laminoplasty, where we don't have to put in screws and rods and fuse those bones together.

And the laminoplasty is a technique where we actually put in a small plate at each level where there's stenosis and basically increase the space around the spinal cord. And people will still get some of the immediate postoperative muscular pain because we still have to come through those muscles. But over time they actually tend to have less neck stiffness and less neck pain because those bones haven't been fused together.

Host: So, then tell us a little bit about the multidisciplinary approach that might be used for these patients and because it involves the spine and central nervous system Doctor, I'm assuming that there are different specialties involved. Do you collaborate with colleagues in say, orthopedics, rehabilitation, tell us about this multidisciplinary approach?

Dr. Stricsek: So, we do work with orthopedic surgery colleagues here as well. This is something that even though we're working around the spinal cord, can be addressed by both the spinal neurosurgeon and a spinal orthopedic surgeon. I view the approach to cervical myelopathy as really a multi-step process. You know, step one is diagnosis. Step two is treatment. Step three is recovery. The first step and sometimes the biggest hill to climb is the surgery. But to achieve the maximum benefit or the maximum gains from surgery, it's important for us to work closely with the physical therapist and occupational therapist, after surgery.

I've used surgery as a way for us to put somebody in as good a position as possible to derive the optimal benefit from surgery. But that's really step one. Step two is going through physical therapy, retraining those nerves, trying to re-recruit some of those nerves that have been injured from the pressure on the spinal cord. That's our goal is we want to save as many of those injured nerves as possible. And having somebody really work closely and aggressively with physical therapy is the best sort of complimentary tool to derive the most benefit from surgery.

Host: So, then tell us a little bit more about the research you did looking at how age, medical comorbidities and even smoking status can impact the surgical outcomes for this. And how should these factors impact your surgical decision making?

Dr. Stricsek: One of the important things that we think about in any patient that we see is, is surgery the right choice and what are the relative risks and benefits of surgery for anybody? It's interesting looking at the sort of epidemiological data. We know that approximately 90% of people over the age of 65, have some degree of spondylosis or osteophyte formation, some degree of degenerative disease in their spinal cord, but it doesn't mean everybody has cervical myelopathy. However, we also know that people who have asymptomatic or minimally symptomatic spinal cord compression, approximately 8% of those people will start to develop worsening symptoms per year.

And it jumps to just under 25% at about four years. As our population continues to age and as people live longer, the number of people who are over 65 that have symptomatic cervical spinal cord compression is going to start to go up or will continue to go up. So, the question is how best do we manage the people and is surgery still an appropriate option?

And the answer is yes. You know, certainly as we age, we tend to have more medical co-morbidities, which will increase somewhat risks associated with surgery. But even within that context, we still see that people who are older, still derive significant benefit from surgery. And the same thing with some of the other medical comorbidities like hypertension or diabetes, or even tobacco use. Age is a complicated one because it's a non-modifiable risk factor.

You know, there's not much, we can't change somebody's age, but we can look at some of these other things. Like if somebody has elevated blood pressure, we want that to be well-controlled prior to surgery. If somebody has diabetes, same thing, we know that poorly controlled diabetes, meaning they have an elevated hemoglobin A1C. Those patients tend to not recover as much as people who have either no diabetes or well controlled diabetes. So, if we can get somebody's blood sugar under better control before surgery, we know that that'll improve their outcomes post-operatively and similarly thing with tobacco use. From a wound healing standpoint, from a spinal cord recovery standpoint, tobacco use tends to adversely impact people, but if we can optimize somebody before surgery so that they're no longer smoking and then they don't resume smoking after surgery, we know that those people also get benefit. It's a problem that will continue to face us as a population as a surgical specialty. But we know that appropriately selected patients will do well regardless of age. And if we can control some of these other factors like hypertension, diabetes, and tobacco use, that even people in those settings, maybe their benefit won't be as great as somebody who is otherwise healthy and younger, but they still will derive significant benefit and significant functional improvement with surgery.

Host: Such an interesting topic, Dr. Stricsek, as we wrap up, what would you like other providers to know about your program at Northwestern Medicine? When you feel it's important for them to refer and any developments or innovations on the horizon that could better treat or prevent cervical myelopathy.

Dr. Stricsek: I think, anytime somebody there's a question as to could it be cervical myelopathy, is it symptomatic spinal cord compression or is this something we can just watch, it's appropriate to either call us or send somebody in to be evaluated. I would much rather see somebody in clinic be able to have a conversation with them and show them their MRI and be like, oh, you know, this is what we see inside your body. This is how it correlates with the symptoms you're having. And these are the options available to us, rather than waiting. Because even if we see somebody and we say, okay, maybe surgery isn't necessary right now, we know that we can follow up and see them in again, in a couple of months to see if there's been any change.

And it's important to see these people early because we know that the worse the deficits get over time, the less good or less closer to "normal" they'll be after surgery. So, people who have surgery sooner after they develop symptoms of cerebral myelopathy, they tend to do better.

So, I'd rather see somebody sooner rather than later. And then in terms of research or future developments, you know, certainly people have been doing a lot of work trying to figure out what can we do to improve outcomes. We look at things from a surgical standpoint, surgical technique standpoint, but I think in the longrun, what will make the most difference is when we finally figure out how to control or reverse some of the degenerative changes in the spin. You know, imagine can we plump that disk back up again? Can we rehydrate that disk? Unfortunately, there's nothing commercially available for that right now, but I think that'll be one of the big things in the future that'll help reduce the incidence of symptomatic cervical spinal cord compression.

Host: Thank you so much, Dr. Stricsek. What a great topic and so informative. Thank you for joining us. And to refer your patient or for more information, please visit our website. nm.org to get connected with one of our providers. That concludes this episode of Better Edge, a Northwestern Medicine Podcast for Physicians. Please remember to download, subscribe, rate, and review this podcast and all the other Northwestern Medicine podcasts. I'm Melanie Cole.