WEBVTT 00:00:00.000 --> 00:00:03.279 Imagine this, the single most common cause of 00:00:03.279 --> 00:00:05.940 spinal cord problems in adults, not from accidents, 00:00:06.440 --> 00:00:09.179 but developing silently, often missed, progressing 00:00:09.179 --> 00:00:12.119 almost unnoticed until, well, until function 00:00:12.119 --> 00:00:14.000 is significantly lost. We're talking about potential 00:00:14.000 --> 00:00:17.359 paralysis, a huge change in life quality. It's 00:00:17.359 --> 00:00:20.640 cervical myelopathy, or DCM, and the clock is 00:00:20.640 --> 00:00:23.420 always ticking, early diagnosis, early intervention. 00:00:24.140 --> 00:00:26.440 They're absolutely vital. It really is a race 00:00:26.440 --> 00:00:29.550 against irreversible neurological decline. Welcome 00:00:29.550 --> 00:00:32.109 to the Deep Dive. We unpack complex medical topics 00:00:32.109 --> 00:00:33.890 to give you the essential knowledge you need 00:00:33.890 --> 00:00:37.350 quickly and thoroughly. Today, we're diving deep 00:00:37.350 --> 00:00:39.649 into cervical myelopathy. It's a condition that's 00:00:39.649 --> 00:00:41.729 becoming, well, a really significant public health 00:00:41.729 --> 00:00:44.009 issue, especially with our aging population worldwide. 00:00:44.590 --> 00:00:46.829 Understanding DCM isn't just about clinical knowledge, 00:00:46.890 --> 00:00:48.869 it's fundamentally about improving lives. And 00:00:48.869 --> 00:00:50.630 we're incredibly fortunate today. We have a truly 00:00:50.630 --> 00:00:52.969 distinguished expert with us to guide us through 00:00:52.969 --> 00:00:55.409 this. He's a highly respected figure in orthopedic 00:00:55.409 --> 00:00:58.270 surgery, director of laser spine, and also chief 00:00:58.270 --> 00:01:00.789 spine surgeon at Dr. Babasaheb Ambedkar Central 00:01:00.789 --> 00:01:03.149 Railway Hospital in Mumbai. His background includes 00:01:03.149 --> 00:01:06.549 extensive fellowships globally, UK, USA Top Hospitals, 00:01:06.930 --> 00:01:08.569 and he's an executive member of the Association 00:01:08.569 --> 00:01:11.969 of Spine Surgeons of India. His expertise, particularly 00:01:11.969 --> 00:01:15.010 in minimally invasive spine surgery and, of course, 00:01:15.129 --> 00:01:18.049 cervical myelopathy, is profound. We're really 00:01:18.049 --> 00:01:20.590 keen to get his insights on this vital and sometimes 00:01:20.590 --> 00:01:23.709 quite elusive area. So to kick us off, let's 00:01:23.709 --> 00:01:25.840 get right to the heart of it. Cervical myelopathy 00:01:25.840 --> 00:01:28.019 can be tricky to spot, presentations often vague. 00:01:28.299 --> 00:01:30.140 In your view, what's the single most defining 00:01:30.140 --> 00:01:32.599 characteristic that really sets it apart from 00:01:32.599 --> 00:01:34.739 other neck conditions, the thing that helps clinicians 00:01:34.739 --> 00:01:36.640 make that crucial distinction? That's a great 00:01:36.640 --> 00:01:39.459 question. The defining thing, the one thing that 00:01:39.459 --> 00:01:42.439 really makes it stand out, is direct spinal cord 00:01:42.439 --> 00:01:45.370 compression. and that compression leads to very 00:01:45.370 --> 00:01:48.370 specific upper motor neuron signs plus these 00:01:48.370 --> 00:01:51.810 widespread often symmetrical neurological deficits. 00:01:52.450 --> 00:01:55.430 It's quite different from say a simple radiculopathy. 00:01:55.609 --> 00:01:57.629 That's just irritation of a single nerve root 00:01:57.629 --> 00:01:59.969 giving you focal pain or maybe sensory changes 00:01:59.969 --> 00:02:03.670 in one specific dermatome. Myelopathy involves 00:02:03.670 --> 00:02:05.930 the central nervous system itself so the symptoms 00:02:05.930 --> 00:02:09.210 are more diffuse. I think hand clumsiness, maybe 00:02:09.210 --> 00:02:11.810 difficulty with buttons or handwriting. And crucially, 00:02:12.150 --> 00:02:15.210 that distinct gait instability, not just localized 00:02:15.210 --> 00:02:17.729 pain. These are systemic indicators that the 00:02:17.729 --> 00:02:19.969 spinal cord itself is involved. A much broader 00:02:19.969 --> 00:02:22.050 neurological impact. Right. That makes sense. 00:02:22.250 --> 00:02:24.810 The sort of widespread non -focal nature points 00:02:24.810 --> 00:02:27.360 towards something more central, doesn't it? You 00:02:27.360 --> 00:02:29.860 mentioned it can creep up slowly, insidiously, 00:02:30.099 --> 00:02:32.479 sometimes over months or even years. What's one 00:02:32.479 --> 00:02:34.659 symptom that's perhaps surprising or maybe commonly 00:02:34.659 --> 00:02:36.719 overlooked that health care professionals really 00:02:36.719 --> 00:02:38.580 need to be sharp on, especially in those earlier 00:02:38.580 --> 00:02:40.819 stages when it could easily be mistaken for something 00:02:40.819 --> 00:02:43.919 else? Oh, yes. Without a doubt, it's a gait disturbance, 00:02:44.199 --> 00:02:47.680 that feeling of unsteadyness on the feet. It's 00:02:47.680 --> 00:02:49.400 often the most important clinical predictor, 00:02:49.580 --> 00:02:51.819 but frequently overlooked. Patients might not 00:02:51.819 --> 00:02:53.860 actually report severe neck pain initially, which 00:02:53.860 --> 00:02:56.240 can be very misleading. Instead, they might describe 00:02:56.240 --> 00:02:58.800 subtle changes, feeling a bit off balance, perhaps 00:02:58.800 --> 00:03:01.780 struggling on stairs up or down. Or maybe they 00:03:01.780 --> 00:03:04.120 can't do a tandem gait properly, you know, walking 00:03:04.120 --> 00:03:06.819 heel to toe in a line. These seemingly minor 00:03:06.819 --> 00:03:09.099 changes in balance and coordination, they're 00:03:09.099 --> 00:03:11.120 crucial red flags. They demand a closer look 00:03:11.120 --> 00:03:13.199 at the cervical spine, even if the patient isn't 00:03:13.199 --> 00:03:15.500 complaining about their neck. Spotting these 00:03:15.500 --> 00:03:17.900 early gait changes can really shift the timeline 00:03:17.900 --> 00:03:20.699 for intervention, and that directly impacts the 00:03:20.699 --> 00:03:23.379 long -term prognosis. We do see patients, unfortunately, 00:03:23.539 --> 00:03:25.900 who've been misdiagnosed. Maybe with peripheral 00:03:25.900 --> 00:03:28.199 neuropathy, we're just told it's old age for 00:03:28.199 --> 00:03:31.419 far too long. That's incredibly insightful. Shifting 00:03:31.419 --> 00:03:33.759 the focus away from just the neck to these more 00:03:33.759 --> 00:03:36.620 distal but very telling signs, you've really 00:03:36.620 --> 00:03:38.780 emphasized how crucial early intervention is. 00:03:38.840 --> 00:03:40.900 Could you just briefly explain why timing is 00:03:40.900 --> 00:03:43.039 so critical? It feels like a race against the 00:03:43.039 --> 00:03:45.560 clock with DCM. I mean, lots of conditions benefit 00:03:45.560 --> 00:03:48.020 from early diagnosis, but what makes the window 00:03:48.020 --> 00:03:50.439 for DCM particularly unforgiving, maybe more 00:03:50.439 --> 00:03:52.460 so than other spinal conditions? That's a key 00:03:52.460 --> 00:03:55.240 point. The urgency really stems from the spinal 00:03:55.240 --> 00:03:58.039 cord's very, very limited ability to regenerate. 00:03:58.620 --> 00:04:01.479 Once that spinal cord tissue is damaged, either 00:04:01.479 --> 00:04:03.620 from the chronic compression, the direct mechanical 00:04:03.620 --> 00:04:06.659 stress, or from the resulting lack of blood flow, 00:04:06.719 --> 00:04:09.800 which we call ischemic injury, well, it's incredibly 00:04:09.800 --> 00:04:11.979 difficult for it to recover. Think of it like 00:04:11.979 --> 00:04:14.780 this. Peripheral nerves, they have a better capacity 00:04:14.780 --> 00:04:17.439 to heal, to regenerate. But the spinal cord, 00:04:17.860 --> 00:04:19.759 that's central nervous system tissue. It just 00:04:19.759 --> 00:04:22.019 doesn't have that same ability. So, recognizing 00:04:22.019 --> 00:04:24.500 it early and getting treatment before that irreversible 00:04:24.500 --> 00:04:26.480 damage kicks in, that is absolutely critical. 00:04:26.740 --> 00:04:28.579 It's key for achieving good clinical outcomes 00:04:28.579 --> 00:04:30.819 and, frankly, for preventing permanent disability. 00:04:31.680 --> 00:04:33.800 Delaying treatment, unfortunately, often leads 00:04:33.800 --> 00:04:36.339 to this sort of step -wise irreversible decline 00:04:36.339 --> 00:04:39.060 in function. We're talking about a gradual, sometimes 00:04:39.060 --> 00:04:42.160 relentless, worsening of neurological deficits 00:04:42.160 --> 00:04:44.980 that, even after successful surgery, to decompress 00:04:44.980 --> 00:04:47.480 the cord often can't be fully regained. That 00:04:47.480 --> 00:04:49.860 window for maximum recovery, it's directly tied 00:04:49.860 --> 00:04:51.620 to how quickly you relieve that compression. 00:04:51.959 --> 00:04:54.500 Every month a delay can genuinely mean lost neurological 00:04:54.500 --> 00:04:56.920 function that's just gone. OK, let's unpack this 00:04:56.920 --> 00:04:59.259 a bit more then delve deeper into where it comes 00:04:59.259 --> 00:05:02.620 from. It's fascinating, isn't it? How often cervical 00:05:02.620 --> 00:05:04.740 myelopathy seems to arise from what we might 00:05:04.740 --> 00:05:07.660 just consider. Well, normal age -related changes. 00:05:07.860 --> 00:05:10.279 Everyday wear and tear. Could you elaborate on 00:05:10.279 --> 00:05:12.480 the main causes and exactly how they lead to 00:05:12.480 --> 00:05:14.519 that critical spinal cord compression and maybe 00:05:14.519 --> 00:05:16.660 touch on that dual attack mechanism you mentioned? 00:05:16.980 --> 00:05:19.660 Absolutely. The primary cause, overwhelmingly, 00:05:19.939 --> 00:05:22.600 is degenerative cervical spondylosis, or DCSM. 00:05:23.139 --> 00:05:24.879 Essentially, yes, it's the cumulative effect 00:05:24.879 --> 00:05:27.360 of wear and tear on the neck over decades. The 00:05:27.360 --> 00:05:29.740 body's natural aging process affecting the discs. 00:05:29.920 --> 00:05:32.660 the facet joints, the ligaments. For the professionals 00:05:32.660 --> 00:05:34.699 listening, this isn't just arthritis. It's a 00:05:34.699 --> 00:05:37.540 really complex interplay of biomechanical stresses 00:05:37.540 --> 00:05:40.439 and biological responses over time. Now, how 00:05:40.439 --> 00:05:43.040 does that degeneration actually compress the 00:05:43.040 --> 00:05:45.839 cord? Several key things happen. First, you get 00:05:45.839 --> 00:05:48.079 osteophytes forming. Those are bone spurs growing 00:05:48.079 --> 00:05:50.100 around the degenerating discs and facet joints. 00:05:50.680 --> 00:05:53.120 Now osteophytes are common, but in DCM, it's 00:05:53.120 --> 00:05:54.839 their specific shape and location that matter. 00:05:55.439 --> 00:05:57.740 They often grow backwards and sideways from the 00:05:57.740 --> 00:06:00.360 uncomfortable joints, or forwards from the vertebral 00:06:00.360 --> 00:06:02.519 bodies, projecting right into the spinal canal. 00:06:03.079 --> 00:06:05.459 Then you have the discosteophyte complex. That's 00:06:05.459 --> 00:06:07.519 a combination of a degenerated, often bulging 00:06:07.519 --> 00:06:09.800 disc and the bone spurs around it. Together, 00:06:09.879 --> 00:06:11.680 they form a bigger mass pushing on the cord, 00:06:12.060 --> 00:06:14.439 especially when the neck extends. We also see 00:06:14.439 --> 00:06:16.980 degenerative spondylolisthesis. That's where 00:06:16.980 --> 00:06:18.720 one vertebra can slip slightly forward on the 00:06:18.720 --> 00:06:20.980 one below, narrowing the canal front to back. 00:06:21.339 --> 00:06:24.160 Instability can make this worse, causing dynamic 00:06:24.160 --> 00:06:26.800 compression with movement. And finally, a really 00:06:26.800 --> 00:06:29.740 significant contributor is hypertrophy of the 00:06:29.740 --> 00:06:32.459 ligamentum flavum. That's the ligament at the 00:06:32.459 --> 00:06:34.889 back of the spinal canal. It can thicken and 00:06:34.889 --> 00:06:36.990 sort of buckle inwards, particularly during neck 00:06:36.990 --> 00:06:39.610 extension, eating into that precious space for 00:06:39.610 --> 00:06:42.029 the spinal cord. And it's not just plosive thickening. 00:06:42.050 --> 00:06:44.509 It can become quite fibrous, quite rigid. So 00:06:44.509 --> 00:06:46.930 it's like multiple factors converging to narrow 00:06:46.930 --> 00:06:49.910 that space. Precisely. And beyond those degenerative 00:06:49.910 --> 00:06:51.910 changes, you can have a predisposition if you're 00:06:51.910 --> 00:06:54.329 born with a naturally narrow spinal canal. That's 00:06:54.329 --> 00:06:57.209 congenital stenosis. These patients might have 00:06:57.209 --> 00:06:59.009 a canal diameter that's already quite small, 00:06:59.029 --> 00:07:02.089 say less than 13 millimeters. It might be fine 00:07:02.089 --> 00:07:04.509 for years, but then later degenerative changes 00:07:04.509 --> 00:07:07.069 come along, and that already limited space becomes 00:07:07.069 --> 00:07:09.089 critically compromised. It's like the final straw. 00:07:09.170 --> 00:07:10.470 It's the straw that breaks the camel's back. 00:07:10.589 --> 00:07:13.230 Exactly. And there are other significant causes 00:07:13.230 --> 00:07:16.029 too, though less common. Ossification of the 00:07:16.029 --> 00:07:19.370 posterior longitudinal ligament, OPLL. That's 00:07:19.370 --> 00:07:21.490 where a ligament behind the vertebrae turns into 00:07:21.490 --> 00:07:24.029 bone. It's particularly common in some Asian 00:07:24.029 --> 00:07:26.670 populations and can form a continuous sheet of 00:07:26.670 --> 00:07:29.610 bone, making surgery tricky. Then you have rarer 00:07:29.610 --> 00:07:33.509 things. Tumors, epidural abscesses, trauma causing 00:07:33.509 --> 00:07:36.550 fractures or dislocations, or even severe cervical 00:07:36.550 --> 00:07:38.910 kyphosis, that abnormal forward curve of the 00:07:38.910 --> 00:07:41.209 neck. That can stretch and compress the cord 00:07:41.209 --> 00:07:43.589 like a bowstring over time. And the dual attack. 00:07:43.990 --> 00:07:46.430 Ah yes, the mechanism of injury. It really is 00:07:46.430 --> 00:07:49.300 a dual attack. It's not just the direct mechanical 00:07:49.300 --> 00:07:52.259 squeeze on the cord causing axon damage. There's 00:07:52.259 --> 00:07:54.500 also a really significant ischemic component. 00:07:54.980 --> 00:07:57.259 The compression affects blood flow, especially 00:07:57.259 --> 00:07:59.279 to the anterior spinal artery which feeds the 00:07:59.279 --> 00:08:02.480 cord. This lack of blood flow leads to hypoxia, 00:08:02.819 --> 00:08:05.120 energy depletion within the cord cells. So it's 00:08:05.120 --> 00:08:07.879 this double whammy mechanical pressure and vascular 00:08:07.879 --> 00:08:11.100 compromise that drives progressive damage, often 00:08:11.100 --> 00:08:13.199 leading to glial scarring and demyelination. 00:08:13.470 --> 00:08:16.149 And you mentioned tandem stenosis earlier. Yes, 00:08:16.189 --> 00:08:18.410 that's important too. About 20 % of patients 00:08:18.410 --> 00:08:20.509 have compression in both the cervical and the 00:08:20.509 --> 00:08:23.649 lumbar spine. Tandem stenosis. That poses a real 00:08:23.649 --> 00:08:25.589 diagnostic and management challenge. You might 00:08:25.589 --> 00:08:28.149 have someone with gait instability from myopathy, 00:08:28.350 --> 00:08:30.829 but also neurogenic claudication from lumbar 00:08:30.829 --> 00:08:33.409 stenosis. Figuring out what's causing which symptom 00:08:33.409 --> 00:08:35.929 is crucial for planning effective surgery. Sometimes 00:08:35.929 --> 00:08:38.210 you even need staged operations. Right. So it 00:08:38.210 --> 00:08:40.870 sounds like the body's attempt to stabilize itself 00:08:40.870 --> 00:08:43.309 with age can ironically cause major problems 00:08:43.309 --> 00:08:45.029 for the court. It's not just one thing, but often 00:08:45.029 --> 00:08:48.730 this perfect storm of factors. OK, so connecting 00:08:48.730 --> 00:08:51.409 that pathophysiology to how patients actually 00:08:51.409 --> 00:08:54.250 walk into your clinic. What are the really characteristic 00:08:54.250 --> 00:08:56.330 symptoms that should set alarm bells ringing 00:08:56.330 --> 00:08:58.909 for cervical myelopathy? And what are those subtle 00:08:58.909 --> 00:09:01.690 signs that might get missed if you're not specifically 00:09:01.690 --> 00:09:03.549 looking? Perhaps you could walk us through a 00:09:03.549 --> 00:09:05.889 typical sort of patient presentation. Certainly. 00:09:06.120 --> 00:09:07.980 Let's think about a hypothetical patient. Let's 00:09:07.980 --> 00:09:10.000 call our Mrs. Davies, perhaps a 68 -year -old 00:09:10.000 --> 00:09:12.080 retired librarian. She might come in complaining 00:09:12.080 --> 00:09:14.159 less about neck pain and more that her hands 00:09:14.159 --> 00:09:16.980 just aren't working properly. And this is where 00:09:16.980 --> 00:09:19.240 clinical sharpness is so important, because the 00:09:19.240 --> 00:09:21.440 symptoms are often widespread, sometimes a bit 00:09:21.440 --> 00:09:23.919 vague, easily dismissed if you're not thinking 00:09:23.919 --> 00:09:28.460 myelopathy. So firstly, Mrs. Davies might describe 00:09:28.460 --> 00:09:31.179 extremity parasthesias, not just tingling, but 00:09:31.179 --> 00:09:33.899 often diffuse bilateral both sides and non -dermatomal 00:09:33.899 --> 00:09:36.980 numbness and tingling. It doesn't follow a neat 00:09:36.980 --> 00:09:39.120 nerve root pattern, which helps distinguish it 00:09:39.120 --> 00:09:41.620 from radiculopathy. It's more of a general pins 00:09:41.620 --> 00:09:43.759 and needles in her hands, maybe her feet too. 00:09:44.279 --> 00:09:46.259 Secondly, you'll often see weakness and clumsiness, 00:09:46.580 --> 00:09:48.659 especially in the hands. Bilateral weakness, 00:09:48.940 --> 00:09:51.379 decreased manual dexterity. Mrs. Davies might 00:09:51.379 --> 00:09:53.379 say she's dropping things more often, maybe struggling 00:09:53.379 --> 00:09:55.379 with buttons on her cardigan or her handwriting, 00:09:55.419 --> 00:09:58.159 which used to be neat, has become messy. Maybe 00:09:58.159 --> 00:10:00.340 she can't till coins apart in her purse just 00:10:00.340 --> 00:10:02.419 by feel anymore. These are often the first things 00:10:02.419 --> 00:10:04.399 that really bother patients functionally and 00:10:04.399 --> 00:10:06.039 make them seek help. We actually use scoring 00:10:06.039 --> 00:10:08.299 systems, like the Modified Japanese Orthopedic 00:10:08.299 --> 00:10:11.399 Association score, the MJOA, to quantify this. 00:10:11.659 --> 00:10:13.940 Scores below 17 often point towards functional 00:10:13.940 --> 00:10:16.740 myelopathy. And the gait issue you mentioned 00:10:16.740 --> 00:10:19.639 earlier. Yes, absolutely crucial. Gait instability. 00:10:20.029 --> 00:10:22.570 As we said, perhaps the most important predictor. 00:10:22.809 --> 00:10:24.710 Mrs. Davies might feel unsteady on her feet, 00:10:25.009 --> 00:10:27.129 struggle with balance, find stairs difficult. 00:10:27.710 --> 00:10:30.450 It can manifest as a wide -based, slightly stiff, 00:10:30.610 --> 00:10:33.009 or spastic gait. Patients might describe their 00:10:33.009 --> 00:10:35.750 legs feeling clumsy or heavy. And the really 00:10:35.750 --> 00:10:38.309 key thing here is that significant neck pain 00:10:38.309 --> 00:10:41.669 and stiffness, they can actually be absent in 00:10:41.669 --> 00:10:44.549 many myelopathy patients. That's a huge differentiator 00:10:44.549 --> 00:10:47.009 from simpler neck problems where pain is central. 00:10:47.200 --> 00:10:51.019 This lack of pain often leads to delays, as investigations 00:10:51.019 --> 00:10:53.720 might focus elsewhere, Parkinson's perhaps, or 00:10:53.720 --> 00:10:56.159 peripheral neuropathy. What about later stage 00:10:56.159 --> 00:10:58.799 symptoms? In later stages, you might see urinary 00:10:58.799 --> 00:11:01.279 retention or other bowel issues, maybe more generalized 00:11:01.279 --> 00:11:04.360 weakness. But urinary symptoms, honestly, they're 00:11:04.360 --> 00:11:06.480 rarely helpful for early diagnosis because they're 00:11:06.480 --> 00:11:09.039 so common in older people due to other causes, 00:11:09.299 --> 00:11:11.940 prostate issues in men, bladder problems. Late 00:11:11.940 --> 00:11:14.100 stage symptoms usually mean more advanced disease, 00:11:14.559 --> 00:11:16.679 more significant cord compromise, and generally 00:11:16.679 --> 00:11:19.179 point to a poor prognosis, unfortunately. So 00:11:19.179 --> 00:11:21.879 what about on physical examination? What specific 00:11:21.879 --> 00:11:24.210 signs are you looking for? Right, the examination 00:11:24.210 --> 00:11:27.049 is critical. For motor signs, overall weakness 00:11:27.049 --> 00:11:29.769 can be subtle, but look closely at the lower 00:11:29.769 --> 00:11:32.610 extremities. Weakness there is often more concerning 00:11:32.610 --> 00:11:36.750 initially. Two specific hand tests are very revealing. 00:11:37.330 --> 00:11:39.309 The finger escape sign asks the patient to hold 00:11:39.309 --> 00:11:41.389 their fingers straight and together, and the 00:11:41.389 --> 00:11:43.710 little finger might drift away into abduction 00:11:43.710 --> 00:11:47.129 due to intrinsic muscle weakness. And the grip 00:11:47.129 --> 00:11:49.190 and release test can make and release a fifth 00:11:49.190 --> 00:11:53.399 rapidly, say 20 times in 10 seconds. Myelopathic 00:11:53.399 --> 00:11:55.879 patients often struggle with this speed and coordination. 00:11:56.539 --> 00:11:59.039 It quantifies that fine motor difficulty. And 00:11:59.039 --> 00:12:01.620 sensory. Sensory signs can include proprioception 00:12:01.620 --> 00:12:03.899 problems, difficulty knowing where their limbs 00:12:03.899 --> 00:12:06.600 are in space, that points to dorsal column involvement 00:12:06.600 --> 00:12:09.399 and isn't a great sign in advanced disease, assessed 00:12:09.399 --> 00:12:11.539 joint position sense, you might find decreased 00:12:11.539 --> 00:12:14.220 pinprick sensation, maybe changes in vibration 00:12:14.220 --> 00:12:16.419 sense, though vibration usually only changes 00:12:16.419 --> 00:12:18.539 in severe long -standing cases. But the classic 00:12:18.539 --> 00:12:20.460 signs are the upper motor neuron signs, right? 00:12:20.590 --> 00:12:23.529 Exactly. Those are the hallmarks indicating spasticity 00:12:23.529 --> 00:12:25.950 and hyperreflexia from the spinal cord involvement. 00:12:26.429 --> 00:12:28.570 So you're looking for hyperreflexia exaggerated 00:12:28.570 --> 00:12:30.970 reflexes, often graded 3 plus or 4 plus date 00:12:30.970 --> 00:12:35.529 OP. The inverted radial reflex or brachioradialis 00:12:35.529 --> 00:12:38.429 reflex, tapping the brachioradialis tendon causes 00:12:38.429 --> 00:12:40.830 finger flexion instead of just elbow flexion. 00:12:41.370 --> 00:12:43.149 Hoffman's sign flicking the patient's middle 00:12:43.149 --> 00:12:45.750 finger causes the thumb and index finger to flex. 00:12:46.250 --> 00:12:48.570 This is incredibly common, often the most reliable 00:12:48.570 --> 00:12:50.899 physical sign. Sustained clonus more than three 00:12:50.899 --> 00:12:52.899 beats of rhythmic muscle contraction after a 00:12:52.899 --> 00:12:55.220 rapid stretch that's highly specific for myelopathy, 00:12:55.500 --> 00:12:57.779 but not very sensitive, meaning its absence doesn't 00:12:57.779 --> 00:12:59.899 rule it out. And the Babinski test, stroking 00:12:59.899 --> 00:13:01.799 the sole of the foot causes the big toe to extend 00:13:01.799 --> 00:13:04.240 upwards, indicates pyramidal tract issues. Are 00:13:04.240 --> 00:13:06.820 there any pitfalls with those signs? Yes, a really 00:13:06.820 --> 00:13:09.379 crucial nuance. These upper motor neuron signs 00:13:09.379 --> 00:13:12.320 can actually be absent or masked if the patient 00:13:12.320 --> 00:13:15.179 also has a peripheral nerve problem. Things like 00:13:15.179 --> 00:13:17.259 nerve root compression, lower down, diabetic 00:13:17.259 --> 00:13:19.419 neuropathy, or other peripheral neuropathies 00:13:19.419 --> 00:13:22.100 can interfere. This can really muddy the waters. 00:13:22.340 --> 00:13:25.120 That's why a full neurological exam and knowing 00:13:25.120 --> 00:13:27.480 the patient's complete medical history is absolutely 00:13:27.480 --> 00:13:30.019 essential. And gait and balance tests. Definitely 00:13:30.019 --> 00:13:32.860 assess gait directly. Look for that spastic wide 00:13:32.860 --> 00:13:35.759 -based shuffling pattern. Difficulty with tandem 00:13:35.759 --> 00:13:38.879 walking heel to toe is common. A positive Romberg 00:13:38.879 --> 00:13:41.240 test, where they lose balance standing with feet 00:13:41.240 --> 00:13:44.000 together and eyes closed, suggests post to your 00:13:44.000 --> 00:13:47.139 column dysfunction. Any provocative tests? Lermit's 00:13:47.139 --> 00:13:49.179 sign is the key one. Asking the patient to flex 00:13:49.179 --> 00:13:51.100 their neck sharply might produce an electric 00:13:51.100 --> 00:13:53.500 shock -like sensation down the spine or into 00:13:53.500 --> 00:13:55.879 the limbs. Put all these together, the history, 00:13:56.039 --> 00:13:58.559 the symptoms, these specific exam findings, and 00:13:58.559 --> 00:14:00.740 you start to build a very strong clinical picture 00:14:00.740 --> 00:14:03.379 of spinal cord compression. That's incredibly 00:14:03.379 --> 00:14:05.639 thorough, a really systematic way to approach 00:14:05.639 --> 00:14:08.440 it, moving beyond just neck pain. So once you 00:14:08.440 --> 00:14:10.980 have that strong clinical suspicion, based on 00:14:10.980 --> 00:14:12.940 the history in the exam, how do you actually 00:14:12.940 --> 00:14:15.100 confirm the diagnosis? What imaging is really 00:14:15.100 --> 00:14:17.639 essential? And what are the specific, maybe subtle 00:14:17.639 --> 00:14:19.519 findings you're looking for that seal the deal 00:14:19.519 --> 00:14:21.820 and perhaps even give you clues about prognosis? 00:14:22.059 --> 00:14:24.700 And how do these help rule out other conditions? 00:14:25.000 --> 00:14:26.879 Right, once suspicion is high, imaging becomes 00:14:26.879 --> 00:14:29.320 absolutely central to confirming the diagnosis 00:14:29.320 --> 00:14:31.639 and planning treatment. We usually start with 00:14:31.639 --> 00:14:33.860 plane radiographs x -rays, though they have limitations. 00:14:34.460 --> 00:14:36.919 We typically get AP, lateral, oblique views, 00:14:37.080 --> 00:14:39.240 and importantly, flexion and extension views. 00:14:39.879 --> 00:14:42.179 On these, you look for general degenerative changes 00:14:42.179 --> 00:14:44.620 those osteophytes we talked about, disc space 00:14:44.620 --> 00:14:47.759 narrowing. Critically, on the lateral view, we 00:14:47.759 --> 00:14:49.659 measure the sagittal diameter of the spinal canal. 00:14:49.870 --> 00:14:52.809 Less than 13 millimeters strongly suggest cord 00:14:52.809 --> 00:14:55.830 compression risk or relative stenosis. Another 00:14:55.830 --> 00:14:58.070 useful measure is the Pavlov ratio comparing 00:14:58.070 --> 00:15:00.649 the canal diameter to the vertebral body width. 00:15:01.330 --> 00:15:03.789 A ratio under 0 .8 points toward the congenitally 00:15:03.789 --> 00:15:06.879 narrow canal, a predisposing factor. We also 00:15:06.879 --> 00:15:09.940 assess alignment, the overall C2 -C7 curve, any 00:15:09.940 --> 00:15:12.620 local kyphosis. And those flexion extension views 00:15:12.620 --> 00:15:15.139 are vital for spotting instability, any abnormal 00:15:15.139 --> 00:15:17.779 slipping or angulation between vertebrae or maybe 00:15:17.779 --> 00:15:20.080 compensatory movement above or below stiff segments. 00:15:20.460 --> 00:15:22.899 Static images can miss dynamic compression. But 00:15:22.899 --> 00:15:24.919 x -rays aren't the whole story. No, definitely 00:15:24.919 --> 00:15:27.720 not. The big caveat is that degenerative changes 00:15:27.720 --> 00:15:30.139 on x -ray are incredibly common, especially as 00:15:30.139 --> 00:15:32.600 we age, maybe 70 % of 70 -year -olds show them. 00:15:32.860 --> 00:15:34.580 But they don't always correlate with symptoms. 00:15:34.830 --> 00:15:37.389 So x -rays give you bony architecture, alignment, 00:15:37.669 --> 00:15:40.129 stability, but they don't show the cord itself. 00:15:40.269 --> 00:15:43.370 They're a starting point. So MRI is key, then. 00:15:43.690 --> 00:15:46.750 MRI, magnetic resonance imaging, is unequivocally 00:15:46.750 --> 00:15:49.009 the study of choice. It's the best way to directly 00:15:49.009 --> 00:15:51.389 visualize the spinal cord and the degree of compression. 00:15:51.580 --> 00:15:55.139 On MRI, we look for effacement of the CSF, the 00:15:55.139 --> 00:15:57.600 cerebrospinal fluid, around the cord. If that 00:15:57.600 --> 00:15:59.799 space is squeezed out, it indicates functional 00:15:59.799 --> 00:16:02.379 stenosis. The most significant findings relate 00:16:02.379 --> 00:16:05.259 to signal changes within the cord itself. A bright 00:16:05.259 --> 00:16:07.220 signal on the T2 -weighted images, we call this 00:16:07.220 --> 00:16:10.659 myelomalacia, suggest edema, swelling, or gliosis, 00:16:11.080 --> 00:16:13.019 which is scarring, within the cord due to the 00:16:13.019 --> 00:16:15.360 compression. The T2 hyperintensity indicates 00:16:15.360 --> 00:16:17.820 acute or subacute injury. Even more important 00:16:17.820 --> 00:16:19.820 for prognosis, though, are signal changes on 00:16:19.820 --> 00:16:23.559 T1 -weighted images. A low signal, or T1 hypotensity, 00:16:24.000 --> 00:16:25.899 generally correlates with a poorer prognosis 00:16:25.899 --> 00:16:29.080 after surgery. Why is that? Because that T1 hypotensity 00:16:29.080 --> 00:16:31.759 usually represents more chronic, irreversible 00:16:31.759 --> 00:16:34.600 damage established myelomalacia, maybe even cavitation 00:16:34.600 --> 00:16:37.460 or cystic change within the cord, it suggests 00:16:37.460 --> 00:16:40.039 actual tissue loss, less potential for recovery. 00:16:40.740 --> 00:16:43.379 We also look at the compression ratio. the cord's 00:16:43.379 --> 00:16:45.620 smallest front -to -back diameter, divided by 00:16:45.620 --> 00:16:48.259 its widest side -to -side diameter. A ratio less 00:16:48.259 --> 00:16:51.600 than 0 .4 also carries a poorer prognosis. But 00:16:51.600 --> 00:16:54.399 MRIs aren't perfect either. No, and that's crucial 00:16:54.399 --> 00:16:57.539 to remember. MRI has a high rate of false positives. 00:16:58.039 --> 00:17:01.460 Studies show up to maybe 19 % of completely asymptomatic 00:17:01.460 --> 00:17:03.700 people can have significant -looking cervical 00:17:03.700 --> 00:17:06.240 abnormalities on their MRI. This really hammers 00:17:06.240 --> 00:17:08.559 on the point. You must interpret imaging findings 00:17:08.559 --> 00:17:10.819 in the context of the clinical picture. Never 00:17:10.819 --> 00:17:13.480 treat this scan in isolation. This clinical correlation 00:17:13.480 --> 00:17:16.240 is also key for differentiating true DCM from 00:17:16.240 --> 00:17:18.200 mimics like multiple sclerosis, where you might 00:17:18.200 --> 00:17:20.099 see T2 lesions but they have a different pattern, 00:17:20.299 --> 00:17:22.599 disseminated in space and time, or other rare 00:17:22.599 --> 00:17:24.640 things like vascular malformations. What about 00:17:24.640 --> 00:17:28.460 CT scans? CT, without contrast, is very useful 00:17:28.460 --> 00:17:31.099 for complementary bony detail. It's excellent 00:17:31.099 --> 00:17:34.019 for visualizing things like OPLL, that ossified 00:17:34.019 --> 00:17:36.740 ligament and really clearly defining osteophytes 00:17:36.740 --> 00:17:39.720 may be better than MRI sometimes. It helps where 00:17:39.720 --> 00:17:42.079 bone detail is critical, especially for surgical 00:17:42.079 --> 00:17:44.420 planning involving calcified structures. And 00:17:44.420 --> 00:17:47.519 CT myelography. CT myelography is more invasive. 00:17:47.859 --> 00:17:50.339 It involves injecting contrast dye into the spinal 00:17:50.339 --> 00:17:52.759 fluid space, usually via a lumbar puncture or 00:17:52.759 --> 00:17:56.059 sometimes a C1, C2 puncture. But it gives excellent 00:17:56.059 --> 00:17:58.599 detail on the exact degree of spinal cord compression, 00:17:59.039 --> 00:18:01.390 especially dynamic compression. We tend to use 00:18:01.390 --> 00:18:03.990 it when MRI is contraindicated. Maybe the patient 00:18:03.990 --> 00:18:06.289 has a pacemaker or certain metallic implants, 00:18:06.529 --> 00:18:08.789 or if there's a lot of artifact on the MRI, perhaps 00:18:08.789 --> 00:18:11.349 from previous spinal hardware obscuring the view, 00:18:11.609 --> 00:18:13.230 it can sometimes show the compression dynamics 00:18:13.230 --> 00:18:16.369 more clearly. And nerve conduction studies, electrophysiology. 00:18:16.789 --> 00:18:20.269 Yes, nerve conduction studies, NCS, and electromyography, 00:18:20.430 --> 00:18:23.210 EMG, they actually have a high false negative 00:18:23.210 --> 00:18:25.509 rate for myelopathy itself, so they might miss 00:18:25.509 --> 00:18:28.049 it if used alone. However, they are incredibly 00:18:28.049 --> 00:18:30.910 useful for differentiating. They help distinguish 00:18:30.910 --> 00:18:33.349 a central process like myelopathy from peripheral 00:18:33.349 --> 00:18:35.470 nerve problems that might cause similar symptoms. 00:18:36.130 --> 00:18:39.529 Think ALS, amyotrophic lateral sclerosis, severe 00:18:39.529 --> 00:18:42.549 diabetic neuropathy, or other peripheral neuropathies. 00:18:42.990 --> 00:18:45.710 For example, ALS might show both upper and lower 00:18:45.710 --> 00:18:48.549 motor neuron signs clinically, but EMG can reveal 00:18:48.549 --> 00:18:51.470 widespread denervation signals like fibrillations. 00:18:52.250 --> 00:18:53.910 Myelopathy, on the other hand, usually shows 00:18:53.910 --> 00:18:56.049 normal peripheral nerve studies but might show 00:18:56.049 --> 00:18:58.950 abnormalities on evoked potentials, SSFPs or 00:18:58.950 --> 00:19:00.950 MEPs indicating slowed conduction through the 00:19:00.950 --> 00:19:03.329 spinal cord itself. They help confirm if weakness 00:19:03.329 --> 00:19:05.900 is coming from the cord, a nerve root. peripheral 00:19:05.900 --> 00:19:07.759 nerve. So it really is about putting all the 00:19:07.759 --> 00:19:10.579 pieces together. Exactly. The key message is 00:19:10.579 --> 00:19:13.539 the need for a comprehensive evaluation. You 00:19:13.539 --> 00:19:15.619 integrate the clinical story, the detailed exam 00:19:15.619 --> 00:19:17.559 findings, and the information from the various 00:19:17.559 --> 00:19:20.799 imaging modalities. Relying solely on one piece 00:19:20.799 --> 00:19:23.200 or dismissing findings because symptoms seem 00:19:23.200 --> 00:19:25.700 subtle can lead to misdiagnosis. It needs that 00:19:25.700 --> 00:19:27.940 holistic integrated approach. Okay that gives 00:19:27.940 --> 00:19:30.900 us a really solid grasp on diagnosis navigating 00:19:30.900 --> 00:19:34.200 those potential pitfalls. Let's shift gears now 00:19:34.200 --> 00:19:36.519 to Treatment. This often involves some pretty 00:19:36.519 --> 00:19:38.759 significant decisions, doesn't it, especially 00:19:38.759 --> 00:19:40.599 given the progressive nature you've described. 00:19:40.779 --> 00:19:43.099 What are the current strategies for managing 00:19:43.099 --> 00:19:46.000 cervical myelopathy? How do you distinguish between 00:19:46.000 --> 00:19:48.279 non -operative and operative routes, and what 00:19:48.279 --> 00:19:50.640 really guides your choice for an individual patient, 00:19:50.980 --> 00:19:53.660 especially when facing those complex cases? Right, 00:19:53.740 --> 00:19:56.400 treatment. The general philosophy now strongly 00:19:56.400 --> 00:19:58.420 leans towards early intervention for most patients 00:19:58.420 --> 00:20:00.700 with confirmed myelopathy. The overarching goal, 00:20:01.380 --> 00:20:03.700 whatever technique we use, is simple. increase 00:20:03.700 --> 00:20:05.900 the space in the spinal canal, and relieve that 00:20:05.900 --> 00:20:08.259 pressure, that compression, on the spinal cord. 00:20:08.900 --> 00:20:10.900 Now, when we talk about non -operative management, 00:20:11.099 --> 00:20:12.799 it's really important to understand its very 00:20:12.799 --> 00:20:15.539 limited role. It's primarily reserved for patients 00:20:15.539 --> 00:20:18.140 with very mild disease, where there's essentially 00:20:18.140 --> 00:20:20.640 no functional impairment, their daily activities 00:20:20.640 --> 00:20:22.539 aren't significantly affected, and importantly, 00:20:22.779 --> 00:20:25.039 no clear signs of progression. Or, of course, 00:20:25.119 --> 00:20:26.819 for patients who are genuinely too medically 00:20:26.819 --> 00:20:29.619 unwell for surgery. In these mild cases, the 00:20:29.619 --> 00:20:31.559 patient's functional status, perhaps measured 00:20:31.559 --> 00:20:34.480 by that MGAOA score, is actually a more critical 00:20:34.480 --> 00:20:36.579 factor in deciding about surgery than just the 00:20:36.579 --> 00:20:38.940 physical exam findings alone. Non -operative 00:20:38.940 --> 00:20:41.500 measures might include medications, NSAIDs for 00:20:41.500 --> 00:20:44.559 pain, maybe gabapentinoids for neuropathic symptoms. 00:20:45.299 --> 00:20:47.420 Sometimes temporary immobilization with a hard 00:20:47.420 --> 00:20:49.779 collar, often in slight flexion, can give some 00:20:49.779 --> 00:20:52.119 symptomatic relief by reducing movement. Physical 00:20:52.119 --> 00:20:54.099 therapy can also play a role focusing on neck 00:20:54.099 --> 00:20:56.839 strengthening, balance exercises, gait training, 00:20:57.259 --> 00:21:00.299 trying to maintain existing function, and proprioception. 00:21:00.839 --> 00:21:03.240 But critically, therapy won't actually decompress 00:21:03.240 --> 00:21:05.779 the cord. What about things like traction or 00:21:05.779 --> 00:21:09.660 chiropractic? Good question. Generally, traction 00:21:09.660 --> 00:21:12.400 spinal manipulation chiropractic approaches are 00:21:12.400 --> 00:21:15.079 not recommended as primary treatments for myelopathy. 00:21:15.230 --> 00:21:18.170 There's no proven benefit for actually decompressing 00:21:18.170 --> 00:21:20.829 the cord, and they carry potential risks that 00:21:20.829 --> 00:21:23.049 could even worsen symptoms or cause neurological 00:21:23.049 --> 00:21:26.490 decline. While some studies show temporary symptom 00:21:26.490 --> 00:21:28.769 improvement with immobilization in very mild 00:21:28.769 --> 00:21:32.089 cases, particularly if the cord still has a decent 00:21:32.089 --> 00:21:35.069 cross -sectional area, you absolutely have to 00:21:35.069 --> 00:21:37.289 monitor these patients incredibly closely for 00:21:37.289 --> 00:21:40.279 any sign of progression. Non -operative management 00:21:40.279 --> 00:21:42.839 is rarely a definitive solution for progressive 00:21:42.839 --> 00:21:45.700 myelopathy. The evidence strongly suggests conservative 00:21:45.700 --> 00:21:47.480 treatment doesn't change the natural history, 00:21:47.660 --> 00:21:50.759 which is typically progressive decline. So choosing 00:21:50.759 --> 00:21:52.599 this route involves very careful discussion with 00:21:52.599 --> 00:21:54.599 the patient about the risks of delaying potential 00:21:54.599 --> 00:21:57.019 surgery. So surgery is often the main route then? 00:21:57.299 --> 00:21:59.859 For progressive or significant myelopathy, yes. 00:22:00.059 --> 00:22:02.039 Operative management is generally the definitive 00:22:02.039 --> 00:22:04.700 treatment. The indications are fairly clear. 00:22:04.970 --> 00:22:08.009 significant functional impairment, often reflected 00:22:08.009 --> 00:22:11.369 in that MJOA score, or clear evidence that symptoms 00:22:11.369 --> 00:22:14.190 are progressing over time. It's also generally 00:22:14.190 --> 00:22:16.730 indicated for disease affecting one or two levels, 00:22:17.130 --> 00:22:19.450 regardless of whether the neck alignment is lordotic, 00:22:19.769 --> 00:22:22.569 neutral, or even mildly kyphotic. The main goal 00:22:22.569 --> 00:22:24.589 of surgery isn't always about making symptoms 00:22:24.589 --> 00:22:26.710 dramatically better, although that's obviously 00:22:26.710 --> 00:22:29.450 the hope. Primarily it's about preventing continued 00:22:29.450 --> 00:22:32.380 neurological decline. As we keep saying, Early 00:22:32.380 --> 00:22:34.640 recognition and treatment before irreversible 00:22:34.640 --> 00:22:37.000 cord damage occurs are critical for the best 00:22:37.000 --> 00:22:39.680 possible clinical outcomes and maximizing any 00:22:39.680 --> 00:22:41.900 potential recovery. How do you choose which surgery? 00:22:41.980 --> 00:22:44.839 There seem to be quite a few options. Yes. The 00:22:44.839 --> 00:22:46.720 selection of the specific procedure is highly 00:22:46.720 --> 00:22:48.960 individualized. It really depends on several 00:22:48.960 --> 00:22:51.279 key factors. We look at the overall cervical 00:22:51.279 --> 00:22:54.500 -sagittal alignment. Is the neck curved normally? 00:22:54.779 --> 00:22:57.299 Lordotic. Straight or abnormally bent forward? 00:22:58.079 --> 00:23:00.859 How many levels are affected by stenosis? Where 00:23:00.859 --> 00:23:02.660 is the compression coming from mostly the front 00:23:02.660 --> 00:23:05.700 interior, like discs, osteophytes, or PLL? Or 00:23:05.700 --> 00:23:08.339 mostly the back posterior, like the ligamentum, 00:23:08.339 --> 00:23:11.079 flavum, or facet joints? And of course, the patient's 00:23:11.079 --> 00:23:13.420 overall medical condition and any comorbidities 00:23:13.420 --> 00:23:15.460 play a big role. Can you walk us through the 00:23:15.460 --> 00:23:17.480 main techniques, maybe starting with the anterior 00:23:17.480 --> 00:23:21.140 approaches? Certainly. Anterior cervical dissectomy 00:23:21.140 --> 00:23:24.900 and fusion, or ACDF, is a real mainstay, especially 00:23:24.900 --> 00:23:27.700 for disease affecting one or two levels. We approach 00:23:27.700 --> 00:23:29.859 from the front of the neck the Smith -Robinson 00:23:29.859 --> 00:23:32.740 approach. This gives direct access to the discs 00:23:32.740 --> 00:23:35.380 and vertebral bodies. It's excellent for correcting 00:23:35.380 --> 00:23:37.519 kyphosis because you can restore disc height 00:23:37.519 --> 00:23:40.140 and alignment, and you directly remove the anterior 00:23:40.140 --> 00:23:43.539 pathology, herniated discs, osteophytes, even 00:23:43.539 --> 00:23:46.240 segments of OPLL. You remove the problem disc 00:23:46.240 --> 00:23:48.380 of discs and then fuse the vertebrae together 00:23:48.380 --> 00:23:50.599 usually with a cage and an anterior plate for 00:23:50.599 --> 00:23:53.859 stability. Advantages, generally lower infection 00:23:53.859 --> 00:23:56.619 risk than posterior approaches, often less blood 00:23:56.619 --> 00:23:59.730 loss and maybe less post -operative pain. The 00:23:59.730 --> 00:24:01.930 main dilemma often revolves around one versus 00:24:01.930 --> 00:24:04.509 two levels. Fusion rates can drop slightly with 00:24:04.509 --> 00:24:06.269 two levels, and there's always the long -term 00:24:06.269 --> 00:24:08.690 concern about adjacent segment disease. Also, 00:24:08.809 --> 00:24:10.789 you'd avoid it in patients with significant pre 00:24:10.789 --> 00:24:13.750 -existing swallowing problems, as transient dysphagia 00:24:13.750 --> 00:24:15.589 is a common light effect. What if the problem 00:24:15.589 --> 00:24:18.309 is more extensive, or behind the vertebral body? 00:24:18.650 --> 00:24:20.690 Then we might consider an anterior carpectomy 00:24:20.690 --> 00:24:24.440 infusion, or ACF. This involves removing not 00:24:24.440 --> 00:24:27.079 just the disc, but one or more of the vertebral 00:24:27.079 --> 00:24:30.460 bodies themselves. This gives really wide decompression, 00:24:30.799 --> 00:24:32.819 especially for disease situated right behind 00:24:32.819 --> 00:24:35.079 the vertebral body, or if there's significant 00:24:35.079 --> 00:24:37.180 kyphosis that you need to correct from the front. 00:24:37.980 --> 00:24:40.059 However, corpectomies, especially multilevel 00:24:40.059 --> 00:24:43.049 ones, come with stability issues. Two -level 00:24:43.049 --> 00:24:45.230 corpectomies have a significant risk, maybe seven 00:24:45.230 --> 00:24:48.309 to 20%, of the bone graft dislodging, which can 00:24:48.309 --> 00:24:51.210 have severe consequences. Often, we try to combine 00:24:51.210 --> 00:24:53.589 a single corpectomy with an adjacent disectomy 00:24:53.589 --> 00:24:56.390 to minimize this. And critically, for three -level 00:24:56.390 --> 00:24:59.309 corpectomies or more, combined anterior and posterior 00:24:59.309 --> 00:25:02.269 fixation is generally considered mandatory. The 00:25:02.269 --> 00:25:04.109 failure rate with anterior -only fixation at 00:25:04.109 --> 00:25:06.509 three levels is just too high, potentially over 00:25:06.509 --> 00:25:10.160 70%. So the dilemma is balancing adequate decompression 00:25:10.160 --> 00:25:12.440 with maintaining spinal stability, sometimes 00:25:12.440 --> 00:25:14.500 needing a second posterior surgery. Okay, what 00:25:14.500 --> 00:25:16.420 about approaching from the back? Posterior approaches? 00:25:17.339 --> 00:25:19.539 Right. Laminectomy with posterior fusion is a 00:25:19.539 --> 00:25:21.559 common one. This is suitable for an ultilevel 00:25:21.559 --> 00:25:24.099 compression, but generally only if the cervical 00:25:24.099 --> 00:25:27.440 spine isn't significantly kyphotic. Yearly less 00:25:27.440 --> 00:25:30.539 than 10 degrees of fixed kyphosis. Why that limitation 00:25:30.539 --> 00:25:33.259 on kyphosis? Because if the spine is bent too 00:25:33.259 --> 00:25:35.799 far forward, the spinal cord is stretched taut 00:25:35.799 --> 00:25:37.759 over the front of the canal like a bowstring. 00:25:38.440 --> 00:25:40.980 Just removing the bone at the back, the lamina, 00:25:41.380 --> 00:25:43.819 won't allow the cord to drift backwards sufficiently 00:25:43.819 --> 00:25:46.680 to decompress it effectively. It might even tether 00:25:46.680 --> 00:25:50.019 the cord. In a laminectomy with fusion, we remove 00:25:50.019 --> 00:25:52.220 the lamina and then stabilize the spine with 00:25:52.220 --> 00:25:55.279 screws, usually lateral mass screws and rods. 00:25:55.549 --> 00:25:58.450 The fusion helps prevent post -laminectomy kyphosis 00:25:58.450 --> 00:26:00.809 developing later and can also help with neck 00:26:00.809 --> 00:26:03.349 pain from arthritic facet joints. I've heard 00:26:03.349 --> 00:26:05.430 a lot about laminoplasty recently. How does that 00:26:05.430 --> 00:26:08.490 fit in? Yes. Laminoplasty is gaining significant 00:26:08.490 --> 00:26:11.869 popularity. The main appeal is that it aims to 00:26:11.869 --> 00:26:14.230 preserve motion in the cervical spine, unlike 00:26:14.230 --> 00:26:16.609 fusion. It's particularly useful when you want 00:26:16.609 --> 00:26:18.789 to avoid the potential complications of fusion, 00:26:19.109 --> 00:26:22.049 like pseudoarthrosis or adjacent segment disease, 00:26:22.069 --> 00:26:24.430 maybe in younger patients, or those at high risk 00:26:24.430 --> 00:26:26.730 of fusion failing. It's also good for congenital 00:26:26.730 --> 00:26:29.849 stenosis, or sometimes for a multi -level OPLL 00:26:29.849 --> 00:26:32.309 where a big anterior operation seems too risky. 00:26:32.990 --> 00:26:35.049 The technique essentially creates a hinged door 00:26:35.049 --> 00:26:36.849 with the lamina. You cut one side and hinge it 00:26:36.849 --> 00:26:39.150 open on the other. Open door technique, or hinge 00:26:39.150 --> 00:26:42.130 both sides open. French door. This expands the 00:26:42.130 --> 00:26:44.470 volume of the spinal canal, typically from C3 00:26:44.470 --> 00:26:47.569 down to C7, decompressing the cord posteriorly 00:26:47.569 --> 00:26:49.410 while keeping the basic bony structure intact. 00:26:49.470 --> 00:26:52.589 What are the pros and cons? Advantages. Avoids 00:26:52.589 --> 00:26:55.410 post -laminectomy kyphosis. Generally has a lower 00:26:55.410 --> 00:26:57.569 complication rate than extensive multi -level 00:26:57.569 --> 00:27:00.589 ACDF, especially with OPLO, and it preserves 00:27:00.589 --> 00:27:03.690 some motion. Disadvantages. Can have higher blood 00:27:03.690 --> 00:27:06.309 loss than ACDF. There's a higher incidence of 00:27:06.309 --> 00:27:08.609 post -operative axial neck pain or stiffness. 00:27:09.130 --> 00:27:11.369 And while it preserves motion, some range is 00:27:11.369 --> 00:27:14.190 still usually lost compared to pre -op. Outcomes, 00:27:14.190 --> 00:27:16.230 though, are generally considered equivalent to 00:27:16.230 --> 00:27:18.910 multilevel ACDF or laminectomy with fusion for 00:27:18.910 --> 00:27:21.670 the right indications. The choice between laminoplasty 00:27:21.670 --> 00:27:24.230 and fusion for multilevel disease is often a 00:27:24.230 --> 00:27:26.950 key clinical debate, balancing motion preservation 00:27:26.950 --> 00:27:28.750 against the type and location of compression. 00:27:29.250 --> 00:27:31.089 There are times you need to do both front and 00:27:31.089 --> 00:27:34.309 back surgery. Yes. Combined anterior and posterior 00:27:34.309 --> 00:27:37.069 surgery is reserved for the most complex cases. 00:27:37.549 --> 00:27:39.549 Things like multi -level stenosis in a spine 00:27:39.549 --> 00:27:42.509 that's rigidly kyphotic. Or after multi -level 00:27:42.509 --> 00:27:44.549 anterior carpectomies needing extra stability. 00:27:45.269 --> 00:27:47.930 Or if someone already has kyphosis after a previous 00:27:47.930 --> 00:27:50.710 laminectomy, it offers the most robust decompression 00:27:50.710 --> 00:27:53.009 and stability. But logically, it also carries 00:27:53.009 --> 00:27:55.329 the highest overall morbidity and risk. And just 00:27:55.329 --> 00:27:58.029 laminectomy on its own. without fusion. Laminectomy 00:27:58.029 --> 00:28:00.250 alone is rarely done these days for myelopathy. 00:28:00.410 --> 00:28:02.930 There's just too high a risk anywhere from 11 00:28:02.930 --> 00:28:05.990 to 47 percent in various studies of progressive 00:28:05.990 --> 00:28:08.789 kyphosis developing afterwards, post -laminectomy 00:28:08.789 --> 00:28:10.930 kyphosis. And that can lead to the myelopathy 00:28:10.930 --> 00:28:13.230 coming back due to cord tethering. So if you 00:28:13.230 --> 00:28:15.470 do a laminectomy, you almost always add a fusion 00:28:15.470 --> 00:28:17.880 for stability. Krash, it's clear the surgical 00:28:17.880 --> 00:28:20.140 decision -making is incredibly complex, really 00:28:20.140 --> 00:28:22.180 tailored to each individual's specific anatomy 00:28:22.180 --> 00:28:25.319 and pathology. Now, with any surgery, especially 00:28:25.319 --> 00:28:28.039 complex spine surgery, complications are always 00:28:28.039 --> 00:28:30.359 a concern for the patient and the clinician. 00:28:31.079 --> 00:28:32.880 What are the key complications people should 00:28:32.880 --> 00:28:35.240 be aware of with these cervical procedures? And 00:28:35.240 --> 00:28:37.180 importantly, how are these risks minimized to 00:28:37.180 --> 00:28:39.640 keep patients as safe as possible? Maybe highlight 00:28:39.640 --> 00:28:41.700 some of the more challenging ones. Absolutely. 00:28:42.440 --> 00:28:44.460 Understanding and mitigating complications is 00:28:44.460 --> 00:28:47.359 paramount. Firstly, there are the general surgical 00:28:47.359 --> 00:28:50.200 risks that apply to almost any operation. Things 00:28:50.200 --> 00:28:52.660 like infection, interestingly, often slightly 00:28:52.660 --> 00:28:55.180 higher risk with posterior approaches due to 00:28:55.180 --> 00:28:57.339 more muscle dissection compared to anterior. 00:28:58.220 --> 00:29:00.920 Bleeding, the risk of direct nerve or spinal 00:29:00.920 --> 00:29:03.539 cord injury during the procedure itself, reactions 00:29:03.539 --> 00:29:06.099 to anesthesia, the possibility of needing more 00:29:06.099 --> 00:29:08.529 surgery down the line. failure to actually relieve 00:29:08.529 --> 00:29:10.910 the symptoms the patient came in with, dural 00:29:10.910 --> 00:29:13.750 tear, a leak of spinal fluid, and in rare cases, 00:29:14.250 --> 00:29:16.289 serious systemic complications like heart attack 00:29:16.289 --> 00:29:19.190 or stroke. These general risks tend to be higher 00:29:19.190 --> 00:29:21.430 in elderly patients, those carrying excess weight, 00:29:21.710 --> 00:29:23.930 smokers, diabetics, people with multiple other 00:29:23.930 --> 00:29:26.369 health problems. This really underscores why 00:29:26.369 --> 00:29:28.529 thorough preoperative assessment and optimizing 00:29:28.529 --> 00:29:30.369 these conditions beforehand is so important. 00:29:30.509 --> 00:29:33.490 Standard mitigation includes prophylactic antibiotics, 00:29:34.130 --> 00:29:35.809 meticulous surgical technique to control bleeding, 00:29:36.329 --> 00:29:38.589 and careful patient selection. Okay, what about 00:29:38.589 --> 00:29:41.150 risks specific to the approach, anterior first? 00:29:41.390 --> 00:29:44.349 For anterior approaches, like ACDF or carpectomy, 00:29:44.849 --> 00:29:47.170 some degree of soreness, dysphagia, difficulty 00:29:47.170 --> 00:29:49.410 swallowing, and maybe transient voice changes 00:29:49.410 --> 00:29:51.829 or hoarseness are quite common. Affecting maybe 00:29:51.829 --> 00:29:54.769 9 to 27 percent of patients initially, they usually 00:29:54.769 --> 00:29:57.670 resolve within, say, 12 weeks and are often related 00:29:57.670 --> 00:29:59.589 to the retractors used during surgery, putting 00:29:59.589 --> 00:30:02.490 pressure on the esophagus and larynx. Sometimes 00:30:02.490 --> 00:30:04.710 using local steroids near the retractors before 00:30:04.710 --> 00:30:07.859 closing can help reduce dysphagia. Recurrent 00:30:07.859 --> 00:30:10.019 laryngeal nerve injury is less common, around 00:30:10.019 --> 00:30:12.900 3 % maybe, causing more persistent hoarseness. 00:30:13.619 --> 00:30:15.039 It used to be thought right -sided approaches 00:30:15.039 --> 00:30:17.460 were riskier due to the nerves anatomy, but large 00:30:17.460 --> 00:30:20.019 studies haven't really borne that out. If it 00:30:20.019 --> 00:30:22.160 happens, we usually observe for about six weeks. 00:30:22.819 --> 00:30:25.619 If no improvement, an ENT consultation is needed 00:30:25.619 --> 00:30:27.940 for assessment, maybe vocal cord medialization 00:30:27.940 --> 00:30:30.599 procedures, and a key point for revision surgery. 00:30:30.990 --> 00:30:33.670 If there's a known or suspected presious RLN 00:30:33.670 --> 00:30:36.269 injury, you absolutely perform the revision on 00:30:36.269 --> 00:30:39.109 the same side to avoid the catastrophe of bilateral 00:30:39.109 --> 00:30:41.299 nerve injury. which would compromise the airway. 00:30:41.559 --> 00:30:43.420 What about the hardware? Hardware failure or 00:30:43.420 --> 00:30:46.059 migration is a concern, especially, as I mentioned, 00:30:46.220 --> 00:30:49.000 with two -level anterior crepectomies that 720 00:30:49.000 --> 00:30:51.880 % risk often necessitates adding posterior backup. 00:30:52.339 --> 00:30:54.779 Non -union or pseudorathrosis, where the bones 00:30:54.779 --> 00:30:57.119 don't fuse properly, is another issue. Maybe 00:30:57.119 --> 00:30:59.680 12 % risk for a single -level fusion, rising 00:30:59.680 --> 00:31:02.160 to 30 % or more for multi -level fusions. This 00:31:02.160 --> 00:31:05.819 might need repeat surgery. Smoking, NSAAD, use 00:31:05.819 --> 00:31:08.480 post -op. Poor bone quality are risk factors. 00:31:08.960 --> 00:31:11.259 And finally, a rare but serious risk is airway 00:31:11.259 --> 00:31:13.720 compromise. This risk increases with very long 00:31:13.720 --> 00:31:16.299 surgery, say over five hours, significant blood 00:31:16.299 --> 00:31:19.099 loss, or when operating high up at C2, C3, C4 00:31:19.099 --> 00:31:21.220 levels, which can cause a lot of prevertebral 00:31:21.220 --> 00:31:24.059 swelling. Careful post -op monitoring, sometimes 00:31:24.059 --> 00:31:25.980 even keeping the patient intubated for a period, 00:31:26.299 --> 00:31:28.220 is crucial in high -risk cases. Okay, and the 00:31:28.220 --> 00:31:30.660 posterior approach risks. With posterior approaches 00:31:30.660 --> 00:31:33.559 like laminectomy or laminoplasty, a notable and 00:31:33.559 --> 00:31:35.900 often quite challenging complication is postoperative 00:31:35.900 --> 00:31:39.980 C5 palsy. This affects roughly 4 .6 % of patients 00:31:39.980 --> 00:31:43.259 undergoing surgery for cervical myelopathy. It 00:31:43.259 --> 00:31:45.759 seems more common in men, and particularly after 00:31:45.759 --> 00:31:48.740 posterior laminectomy infusion. The exact cause 00:31:48.740 --> 00:31:50.700 is still debated, but a leading theory involves 00:31:50.700 --> 00:31:53.839 tethering or ischemia of the C5 nerve root as 00:31:53.839 --> 00:31:56.039 the spinal cord shifts backwards after the posterior 00:31:56.039 --> 00:31:58.960 elements are removed or opened. It causes a sort 00:31:58.960 --> 00:32:01.119 of bow -stringing effect on the nerve root as 00:32:01.119 --> 00:32:04.019 it exits. Clinically, it presents its weakness, 00:32:04.220 --> 00:32:06.920 often quite profound, in the deltoid and biceps 00:32:06.920 --> 00:32:09.279 muscles. While the prognosis for recovery is 00:32:09.279 --> 00:32:12.220 generally good, it can take 6 to 12 months, sometimes 00:32:12.220 --> 00:32:14.339 longer, which is obviously very distressing for 00:32:14.339 --> 00:32:16.980 the patient. Some surgeons perform prophylactic 00:32:16.980 --> 00:32:19.619 keyhole form monotomies at C45, widening the 00:32:19.619 --> 00:32:22.099 nerve exit hole to try and reduce the risk. Other 00:32:22.099 --> 00:32:24.960 posterior risks. The big one is post -laminectomy 00:32:24.960 --> 00:32:27.930 kyphosis. if fusion isn't performed alongside 00:32:27.930 --> 00:32:32.349 the laminectomy. That high incidence, 1147 % 00:32:32.349 --> 00:32:34.890 of the neck gradually drifting into a forward 00:32:34.890 --> 00:32:37.769 bend, potentially causing recurrent myelopathy. 00:32:38.869 --> 00:32:41.089 Axial neck pain is also more common after posterior 00:32:41.089 --> 00:32:43.490 approaches, likely due to the extensive muscle 00:32:43.490 --> 00:32:46.109 dissection and altered biomechanics. How do you 00:32:46.109 --> 00:32:48.750 mitigate all these? Mitigation is multifaceted. 00:32:48.869 --> 00:32:50.670 It starts with meticulous preoperative planning, 00:32:50.890 --> 00:32:52.470 choosing the right operation for the right patient. 00:32:53.140 --> 00:32:55.579 Then, meticulous surgical technique during the 00:32:55.579 --> 00:32:58.000 procedure itself is vital to minimize tissue 00:32:58.000 --> 00:33:01.140 damage and protect neural structures. Intraoperative 00:33:01.140 --> 00:33:04.400 neural monitoring, using SFPs and MEPs, is now 00:33:04.400 --> 00:33:06.079 standard practice in most centers to provide 00:33:06.079 --> 00:33:08.279 real -time feedback on spinal cord and nerve 00:33:08.279 --> 00:33:10.970 root function during surgery. prophylactic antibiotics 00:33:10.970 --> 00:33:13.529 or routine, early mobilization after surgery, 00:33:13.890 --> 00:33:15.970 plus measures like compression stockings help 00:33:15.970 --> 00:33:18.490 prevent blood clots, and critically, it's about 00:33:18.490 --> 00:33:21.029 vigilant post -operative monitoring and prompt 00:33:21.029 --> 00:33:24.049 management of any issue that arises. A post -operative 00:33:24.049 --> 00:33:25.950 hematoma causing airway issues, for instance, 00:33:26.069 --> 00:33:28.210 is a surgical emergency needing immediate return 00:33:28.210 --> 00:33:30.440 to theater. With such complex operations and 00:33:30.440 --> 00:33:32.819 these potential complications, it's vital to 00:33:32.819 --> 00:33:35.240 look at the bigger picture. What does a prognosis 00:33:35.240 --> 00:33:37.559 actually look like for patients after treatment? 00:33:37.880 --> 00:33:39.759 And what's exciting on the research horizon? 00:33:40.220 --> 00:33:42.279 What new developments are really shaping how 00:33:42.279 --> 00:33:44.619 we approach recovery and try to improve those 00:33:44.619 --> 00:33:46.880 long -term outcomes? This is where it gets really 00:33:46.880 --> 00:33:49.740 interesting, doesn't it? Yes. Prognosis and future 00:33:49.740 --> 00:33:53.970 directions. It's a really dynamic area. Historically, 00:33:53.990 --> 00:33:56.150 as we know, the natural history of untreated 00:33:56.150 --> 00:33:59.569 cervical myopathy is generally that slow stepwise 00:33:59.569 --> 00:34:02.309 deterioration. It rarely gets better on its own. 00:34:02.529 --> 00:34:04.690 Without treatment, patients can progress toward 00:34:04.690 --> 00:34:07.369 significant disability, even becoming wheelchair 00:34:07.369 --> 00:34:09.949 dependent in some cases if diagnosis is delayed. 00:34:10.690 --> 00:34:12.929 But with surgery, the outlook changes significantly. 00:34:13.400 --> 00:34:16.139 The typical outcomes, we quote, are roughly one 00:34:16.139 --> 00:34:18.059 -third of patients see a definite improvement 00:34:18.059 --> 00:34:20.019 in their symptoms compared to before surgery. 00:34:20.539 --> 00:34:22.400 Another third remain stable, meaning the surgery 00:34:22.400 --> 00:34:24.519 halts the progression, and unfortunately about 00:34:24.519 --> 00:34:26.539 one -third may continue to worsen somewhat over 00:34:26.539 --> 00:34:29.119 time, despite technically successful decompression. 00:34:30.039 --> 00:34:32.460 This variability is why understanding the prognostic 00:34:32.460 --> 00:34:34.699 factors is so critical when counseling patients. 00:34:36.880 --> 00:34:39.159 Several things significantly influence how well 00:34:39.159 --> 00:34:41.519 patients do. Early recognition and treatment 00:34:41.519 --> 00:34:44.260 are paramount. Patients with symptoms for less 00:34:44.260 --> 00:34:46.519 than six months generally have better outcomes. 00:34:47.199 --> 00:34:49.300 Conversely, symptom duration longer than, say, 00:34:49.380 --> 00:34:52.300 18 months is a strong poor prognostic factor. 00:34:53.019 --> 00:34:55.199 It really reflects that window before irreversible 00:34:55.199 --> 00:34:58.860 damage occurs. Age plays a role too. Younger 00:34:58.860 --> 00:35:00.559 patients tend to have better recovery potential, 00:35:00.760 --> 00:35:02.500 though it's crucial to stress that older patients 00:35:02.500 --> 00:35:04.500 can still benefit significantly and shouldn't 00:35:04.500 --> 00:35:07.000 be denied surgery based on age alone, assuming 00:35:07.000 --> 00:35:10.039 they're medically fit enough. MRI findings give 00:35:10.039 --> 00:35:13.309 us important clues. High signal on T2 images 00:35:13.309 --> 00:35:15.510 combined with low signal on T1 images within 00:35:15.510 --> 00:35:18.730 the cord, a high T2 signal intensity ratio, or 00:35:18.730 --> 00:35:20.590 that cord compression ratio being less than 0 00:35:20.590 --> 00:35:23.369 .4. These all predict poor neurological recovery 00:35:23.369 --> 00:35:26.650 after surgery. That T1 change, indicating irreversible 00:35:26.650 --> 00:35:28.969 damage, is particularly significant. Interestingly, 00:35:29.230 --> 00:35:31.269 female gender has been linked with poor prognosis 00:35:31.269 --> 00:35:33.409 in some large studies, though the exact reasons 00:35:33.409 --> 00:35:35.929 aren't fully clear yet. And finally, the severity 00:35:35.929 --> 00:35:38.300 of symptoms before surgery matters. Patients 00:35:38.300 --> 00:35:40.380 going into surgery with very significant motor 00:35:40.380 --> 00:35:44.460 weakness or profound loss of proprioception generally 00:35:44.460 --> 00:35:46.900 have less favorable outcomes in terms of recovery. 00:35:47.300 --> 00:35:49.179 Okay, so that leads us to the future. What's 00:35:49.179 --> 00:35:51.500 emerging? This is where things get really exciting. 00:35:52.199 --> 00:35:54.139 We're moving beyond just mechanical decompression 00:35:54.139 --> 00:35:56.260 towards trying to influence the biology of recovery. 00:35:57.019 --> 00:35:58.679 Medical and regenerative therapies are still 00:35:58.679 --> 00:36:01.719 relatively early days, but they represent a potential 00:36:01.719 --> 00:36:04.039 paradigm shift. The focus is on trying to halt 00:36:04.039 --> 00:36:06.099 the chemical cascade of damage within the cord 00:36:06.099 --> 00:36:09.840 and actively promote neural repair. One area 00:36:09.840 --> 00:36:11.840 generating quite a bit of interest is cerebral 00:36:11.840 --> 00:36:14.820 lysine. It's a neuroprotective drug, a mixture 00:36:14.820 --> 00:36:17.539 of amino acids and peptides, including neurotrophic 00:36:17.539 --> 00:36:20.920 factors. A pilot study published in Spine looked 00:36:20.920 --> 00:36:23.579 at patients having surgery for DCM. They found 00:36:23.579 --> 00:36:25.219 that those who received cerebral lysine showed 00:36:25.219 --> 00:36:27.440 significantly better improvement in hand function 00:36:27.440 --> 00:36:30.159 and overall neurological recovery compared to 00:36:30.159 --> 00:36:32.679 placebo at one year follow -up. The recovery 00:36:32.679 --> 00:36:36.019 rate, measured by MJOA, was about 67 % in the 00:36:36.019 --> 00:36:38.579 treatment group versus 57 % in the placebo group. 00:36:39.000 --> 00:36:41.099 And importantly, it seemed safe, with no major 00:36:41.099 --> 00:36:43.559 adverse effects reported. This suggests a real 00:36:43.559 --> 00:36:45.619 potential for agents like cerebral lysine to 00:36:45.619 --> 00:36:48.320 maybe maximize recovery after surgery. It could 00:36:48.320 --> 00:36:50.539 potentially protect neurons, enhance the cord's 00:36:50.539 --> 00:36:52.880 own repair mechanisms, reduce secondary injury 00:36:52.880 --> 00:36:56.300 after decompression. Imagine not just decompressing 00:36:56.300 --> 00:36:58.920 the cord, but actively helping it heal. That 00:36:58.920 --> 00:37:00.900 could be a game changer. That sounds incredibly 00:37:00.900 --> 00:37:03.659 promising. What else? Another fascinating and 00:37:03.659 --> 00:37:07.260 very practical area is intraoperative mean arterial 00:37:07.260 --> 00:37:10.739 pressure MAP optimization. There's growing evidence 00:37:10.739 --> 00:37:12.619 that maintaining a higher blood pressure during 00:37:12.619 --> 00:37:16.420 surgery can improve blood flow or perfusion to 00:37:16.420 --> 00:37:19.300 the compromised spinal cord. A recent pilot study 00:37:19.300 --> 00:37:22.199 found that individualizing the MAP target, specifically 00:37:22.199 --> 00:37:25.539 aiming for 20 mmHg above the patient's own preoperative 00:37:25.539 --> 00:37:28.139 average blood pressure, led to better neurological 00:37:28.139 --> 00:37:31.659 outcomes compared to a standard MAP target. This 00:37:31.659 --> 00:37:34.199 highlights how crucial, precise hemodynamic management 00:37:34.199 --> 00:37:37.099 by the anesthetic team is during surgery. Ensuring 00:37:37.099 --> 00:37:39.380 adequate oxygen delivery to the vulnerable cord 00:37:39.380 --> 00:37:41.519 might significantly reduce ischemic injury and 00:37:41.519 --> 00:37:43.619 improve recovery potential. It's a relatively 00:37:43.619 --> 00:37:45.659 simple intervention with potentially big impact. 00:37:46.159 --> 00:37:48.269 So we're finding the perioperative care. Exactly. 00:37:48.849 --> 00:37:51.329 And beyond specific drugs or techniques, there's 00:37:51.329 --> 00:37:53.650 a much broader recognition of the need for a 00:37:53.650 --> 00:37:57.050 personalized, multidisciplinary approach. Clinicians 00:37:57.050 --> 00:37:59.329 need to be really attuned to those early, subtle 00:37:59.329 --> 00:38:02.809 signs for timely diagnosis. Looking ahead, we 00:38:02.809 --> 00:38:05.429 might see advancements in chemical biomarkers, 00:38:05.610 --> 00:38:07.710 perhaps found in spinal fluid or even blood in 00:38:07.710 --> 00:38:10.349 more sophisticated ancillary tests. These could 00:38:10.349 --> 00:38:13.110 help diagnose DCM earlier, track its progression 00:38:13.110 --> 00:38:15.590 more accurately, and monitor response to treatment. 00:38:15.760 --> 00:38:18.239 Imagine a blood test indicating the degree of 00:38:18.239 --> 00:38:20.980 cord injury or inflammation. And involving patients 00:38:20.980 --> 00:38:24.340 more. Yes, that's hugely important too. The emphasis 00:38:24.340 --> 00:38:27.059 on patient -centered care is growing. Initiatives 00:38:27.059 --> 00:38:29.639 like the RICO -DCM project are fantastic examples. 00:38:29.900 --> 00:38:32.300 They bring together patients, clinicians, researchers, 00:38:32.539 --> 00:38:35.059 all stakeholders to define research priorities 00:38:35.059 --> 00:38:37.659 based on patients' lived experiences. The goal 00:38:37.659 --> 00:38:40.000 is to create a research toolkit to accelerate 00:38:40.000 --> 00:38:42.039 knowledge and improve outcomes by making sure 00:38:42.039 --> 00:38:44.139 research actually addresses what matters most 00:38:44.139 --> 00:38:46.880 to patients. This really underscores how vital 00:38:46.880 --> 00:38:49.320 it is to understand individual patient factors, 00:38:49.639 --> 00:38:52.119 their preferences, their goals, especially in 00:38:52.119 --> 00:38:54.519 those tricky cases of mild DCM where the decision 00:38:54.519 --> 00:38:57.000 between surgery and non -operative management 00:38:57.000 --> 00:38:59.780 isn't clear -cut. It's about tailoring care to 00:38:59.780 --> 00:39:02.940 the whole person, not just their MRI scan. A 00:39:02.940 --> 00:39:05.780 patient's job, hobbies, life goals, these all 00:39:05.780 --> 00:39:07.969 weigh into the decision. That's incredibly forward 00:39:07.969 --> 00:39:09.949 -looking, moving beyond just the mechanics to 00:39:09.949 --> 00:39:12.409 actual neurological recovery and patient priorities. 00:39:13.050 --> 00:39:14.670 Professor, before we go to the final quick round, 00:39:14.989 --> 00:39:17.349 what's one common misconception about DCM that 00:39:17.349 --> 00:39:19.690 you often encounter, even among experienced colleagues, 00:39:19.769 --> 00:39:22.269 and how do you usually clarify it? A very common 00:39:22.269 --> 00:39:24.829 one is the belief that significant neck pain 00:39:24.829 --> 00:39:27.829 must be present for a diagnosis of cervical myelopathy. 00:39:28.409 --> 00:39:30.650 I often see clinicians potentially dismissing 00:39:30.650 --> 00:39:32.690 myelopathy if the patient isn't complaining of 00:39:32.690 --> 00:39:35.579 severe neck pain. But as we've discussed, things 00:39:35.579 --> 00:39:38.059 like gait disturbance or hand clumsiness can 00:39:38.059 --> 00:39:40.820 absolutely be the main or even the only presenting 00:39:40.820 --> 00:39:43.920 symptoms. I clarify it by really stressing the 00:39:43.920 --> 00:39:46.239 difference between radiculopathy, which is often 00:39:46.239 --> 00:39:48.940 painful nerve root irritation, and myelopathy, 00:39:49.059 --> 00:39:50.780 which is about spinal cord dysfunction itself. 00:39:51.519 --> 00:39:53.840 The symptoms reflect where the problem is. Excellent 00:39:53.840 --> 00:39:56.530 point. Okay, let's move into our lightning round 00:39:56.530 --> 00:39:59.409 for some quick, sharp answers. What single physical 00:39:59.409 --> 00:40:01.769 exam finding, if positive, should immediately 00:40:01.769 --> 00:40:04.110 raise a massive red flag for myelopathy during 00:40:04.110 --> 00:40:06.809 your assessment? Hoffman's sign. It's easy to 00:40:06.809 --> 00:40:09.329 elicit and a strong indicator of upper motor 00:40:09.329 --> 00:40:12.710 neuron involvement. Perfect. Is non -operative 00:40:12.710 --> 00:40:15.250 treatment ever really a definitive, long -term 00:40:15.250 --> 00:40:18.449 fix for a progressive cervical myelopathy? Rarely, 00:40:18.449 --> 00:40:20.980 if ever. It might provide temporary symptom relief 00:40:20.980 --> 00:40:24.139 in very mild stable cases, but it doesn't fundamentally 00:40:24.139 --> 00:40:26.940 alter the natural history of progression in established 00:40:26.940 --> 00:40:29.599 symptomatic myelopathy. You mentioned a specific 00:40:29.599 --> 00:40:33.340 ratio on MRI that suggests a poorer prognosis. 00:40:33.519 --> 00:40:35.500 What was that again? A spinal cord compression 00:40:35.500 --> 00:40:39.780 ratio of less than 0 .4. Got it. Beyond the standard 00:40:39.780 --> 00:40:41.980 surgical techniques, what's one cutting -edge 00:40:41.980 --> 00:40:44.500 research area you're personally most excited 00:40:44.500 --> 00:40:47.039 about for potentially improving DCM outcomes 00:40:47.039 --> 00:40:49.340 in the next few years? I think the potential 00:40:49.340 --> 00:40:52.440 role of pharmacological neuroprotective agents, 00:40:52.659 --> 00:40:54.840 things like cerebellicin, used in conjunction 00:40:54.840 --> 00:40:57.380 with surgery. That's where boosting actual neurological 00:40:57.380 --> 00:41:00.219 recovery might come from. And finally, post -operatively, 00:41:00.460 --> 00:41:02.519 beyond just the wound healing, what's the most 00:41:02.519 --> 00:41:05.059 crucial aspect of care for a patient recovering 00:41:05.059 --> 00:41:07.739 from cervical myelopathy surgery? comprehensive 00:41:07.739 --> 00:41:10.360 structured physical rehabilitation. It needs 00:41:10.360 --> 00:41:12.900 to be tailored to the individual patient to really 00:41:12.900 --> 00:41:15.099 maximize their functional recovery potential. 00:41:15.420 --> 00:41:18.900 Fantastic. So wrapping all this up, what does 00:41:18.900 --> 00:41:21.460 it mean for you, the clinician, dealing with 00:41:21.460 --> 00:41:23.780 the complexities of cervical myelopathy day to 00:41:23.780 --> 00:41:27.679 day? Here are our key takeaways. First, be vigilant 00:41:27.679 --> 00:41:29.820 for cervical myelopathy. Remember, it's often 00:41:29.820 --> 00:41:32.280 vague, sometimes neck pain absent symptoms like 00:41:32.409 --> 00:41:35.570 hand clumsiness, gait instability. Though subtle 00:41:35.570 --> 00:41:37.570 balance changes are critical red flags, don't 00:41:37.570 --> 00:41:39.690 just put them down to aging. Early diagnosis 00:41:39.690 --> 00:41:42.630 is absolutely paramount for outcomes. Second, 00:41:42.750 --> 00:41:44.610 physical exam and imaging are your essential 00:41:44.610 --> 00:41:47.230 tools. Actively look for those upper motor neuron 00:41:47.230 --> 00:41:49.530 signs like Hoffman's hyperreflexia. Understand 00:41:49.530 --> 00:41:52.449 their nuances. Know the prognostic value of MRI 00:41:52.449 --> 00:41:55.070 findings, T1, T2 signal changes, chord compression 00:41:55.070 --> 00:41:57.650 ratios, but always interpret imaging in clinical 00:41:57.650 --> 00:42:00.210 context to differentiate from mimics. Third, 00:42:00.429 --> 00:42:02.989 treatment is usually surgical. and early intervention 00:42:02.989 --> 00:42:05.489 is key. While non -op has a very limited role 00:42:05.489 --> 00:42:07.590 for mild stable cases, definitive management 00:42:07.590 --> 00:42:09.349 for progressive symptoms generally means surgical 00:42:09.349 --> 00:42:11.769 decompression. Choosing the right approach anterior 00:42:11.769 --> 00:42:14.849 -posterior combined is a highly nuanced individualized 00:42:14.849 --> 00:42:17.969 decision. Fourth, stay updated on emerging insights. 00:42:18.150 --> 00:42:20.610 This field is moving fast. Things like optimizing 00:42:20.610 --> 00:42:22.989 intraoperative blood pressure, the potential 00:42:22.989 --> 00:42:26.050 of neuroprotective drugs like cerebellicin. These 00:42:26.050 --> 00:42:28.489 are actively shaping better outcomes and offer 00:42:28.489 --> 00:42:31.699 hope for enhancing neurological recovery. And 00:42:31.699 --> 00:42:34.199 finally, perhaps most importantly, embrace the 00:42:34.199 --> 00:42:36.559 multidisciplinary approach in patient -centered 00:42:36.559 --> 00:42:39.840 care. Effective management needs team surgeons, 00:42:40.159 --> 00:42:43.599 neurologists, physios, allied health. And increasingly, 00:42:43.860 --> 00:42:46.199 it demands understanding and integrating patient 00:42:46.199 --> 00:42:48.940 -specific factors, preferences, and goals into 00:42:48.940 --> 00:42:51.820 decision -making, especially for those borderline 00:42:51.820 --> 00:42:54.719 mild cases. That brings us to the end of another 00:42:54.719 --> 00:42:57.699 really insightful deep dive. We truly hope this 00:42:57.699 --> 00:43:00.099 exploration into cervical myelopathy has given 00:43:00.099 --> 00:43:02.320 you valuable perspectives and actionable knowledge 00:43:02.320 --> 00:43:05.280 for your practice, helping you identify, understand, 00:43:05.400 --> 00:43:07.699 and manage this complex condition more effectively. 00:43:08.420 --> 00:43:10.579 If you found this deep dive valuable, please 00:43:10.579 --> 00:43:12.559 do take a moment to rate and share the show with 00:43:12.559 --> 00:43:14.159 your colleagues. It genuinely helps us reach 00:43:14.159 --> 00:43:16.599 more dedicated professionals like you. Thank 00:43:16.599 --> 00:43:18.139 you so much for joining us on the deep dive. 00:43:18.599 --> 00:43:20.659 Until next time, keep learning, keep questioning, 00:43:20.880 --> 00:43:23.239 and stay well informed. Remember that in medicine, 00:43:23.539 --> 00:43:26.019 pursuing knowledge is a lifelong journey with 00:43:26.019 --> 00:43:27.219 profound impact.