AAOS Comprehensive Orthopaedic Review 4: Print + Ebook (AAOS - American Academy of Orthopaedic Surgeons)

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15 | Degenerative Conditions of the Cervical Spine

laminectomy, the right and left sides of the spine become disconnected from each other, creating an extremely unstable biomechanical environment. 3. Supplemental posterior fixation is recommended to improve construct stability. 4. Supplemental posterior fixation and fusion should be considered in patients with substantial kypho sis requiring multilevel anterior decompression. N. OPLL 1. Overview and epidemiology a. OPLL is a potential cause of cervical myelopathy. b. OPLL is common in (but not limited to) the Asian population. c. The cause of OPLL remains unclear but is most likely multifactorial, with genetic, hormonal, and environmental influences. Factors impli cated include diabetes, obesity, a high-salt and low-meat diet, poor calcium absorption, and mechanical stress on the posterior longitudinal ligament. 2. Patient presentation a. Patient presentation is variable. b. Patients may be completely asymptomatic or have severe myelopathy. 3. Patient considerations a. The same general guidelines that apply to the choice of approach in CSM apply to OPLL.

b. In patients with severe OPLL, a posterior approach may be preferable and safer, irrespec tive of the number of stenotic levels involved. 4. Treatment—As with CSM, the management of myelopathy resulting from OPLL is typically surgical. a. Direct resection via an anterior approach— Troublesome dural tears can be avoided by allow ing the adherent OPLL to float anteriorly after corpectomy without necessarily removing it. b. Interbody fusion without decompression • This technique is suggested for the patient with dynamic myelopathic symptoms. By immobilizing and fusing the stenotic areas, repeated trauma to the cord by the ossified mass can be avoided. • A posterior approach with a laminoplasty also can be used to achieve cord decompres sion without resection of the OPLL. 5. Complications a. Anterior approaches with floating of the OPLL or complete excision have been touted to avoid postoperative growth of the OPLL. b. Posterior procedures, in contrast, are associ ated with a tendency for radiographic enlarge ment of the OPLL postoperatively. The OPLL will continue to grow with nonfusion proce dures, but the growth is slowed (but not neces sarily stopped) with a fusion procedure.

2 | Spine

KEY LEARNING POINTS

Cervical Radiculopathy 1. Cervical nerve roots exit above their corresponding numbered pedicles (eg, C6 exits between C5 and C6). 2. Nonsurgical treatment should be attempted for most patients with cervical radiculopathy. Many forms of nonsurgical treatment relieve pain but may not alter the natural history of the disease. 3. Surgical management provides excellent and predictable outcomes in patients with progressive neurologic dysfunction or improvement despite time and nonsurgical treatment. Either an anterior or a posterior approach can be used, depending on the circumstances, understanding that neither is perfect. 4. Complications associated with ACDF include persistent speech and swallowing problems. Cervical Myelopathy 1. Cervical myelopathy is typically a surgical disorder. 2. Early treatment, before the onset of permanent cord injury, is recommended. 3. An anterior approach is indicated in patients with myelopathy arising from one or two disk segments or in a cervical spine with rigid kyphosis because the alignment precludes the float back of the spinal cord following posterior-only decompression. 4. Laminoplasty is indicated in patients with multilevel involvement (three or more disk spaces). 5. A combined anterior-posterior approach is indicated in patients with multilevel stenosis and kyphosis or in patients with postlaminectomy kyphosis. Copyright © Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. 2023

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AAOS Comprehensive Orthopaedic Review 4