Rebound Myelopathy

[mmglobal]

In order to answer necknoses question on the Removal of bone spurring thread, I have resurrected a post from Google's cache of lost Braintalk archives.

The post and part of the discussion can be found here.

Originally Posted by mmglobal on Braintalk

Last week, I attended the Spine Arthroplasty Society’s 6th Annual Global Symposium on Motion Preservation Technology. It ran Tuesday through Saturday in Montreal. I’ll be blogging my experience there on the GPN website, but it will take me a while to catch up. I’ll do at least one article there every day until I’m done.

Because I have several cervical clients with substantial cord compression with myelopathy, I was on a mission to gather more information about their situations and options. Some of these people have substantial symptoms that must be addressed. I’ve been told that with compressive myelopathy, there is a 35% chance that symptoms will not be relieved when the source of the compression is relieved and that symptoms may be permanent. The patients who have a really tough time with their surgical decision are the ones who have severe cord compression, but with mild or no symptoms. These people are often told that they must do surgery even with no symptoms because they are at risk for rapid onset of severe symptoms and serious permanent damage (even paralysis.) Other doctors tell them to wait.

We’ve been discussing the concept of “rebound myelopathy”. This term is sometimes used to describe new or worse symptoms after surgery. The theory is that changing the situation by relieving the source of the compression, restoring blood flow to tissues that have been blood deprived, moving things around and/or remobilizing or increasing the mobility of a segment may actually cause new symptoms or make existing symptoms worse. I spoke to several top surgeons about this… specifically about ADR in the presence of compressive myelopathy. Some surgeons are recommending against ADR in this situation because of these fears.

Other surgeons would not embrace the concept of “rebound myelopathy” being caused by removing the source of compressions or increasing mobility the segment. One surgeon told me, “What they are doing is describing new or worsening symptoms and putting a label on it. This label makes it sound as if it has nothing to do with the surgery, just bad luck. In reality, many things can adequately explain the symptoms without such a label. It could be trauma to the cord caused by too aggressive use of tools in the surgery. It could be inadequate decompression. The amount of decompression required for a fusion is much less than what is required if the motion is restored. Calling it rebound myelopathy instead of inadequate decompression takes the pressure off the surgeon.”

This is consistent with data presented in sessions about cervical ADR complications. Cases were reported where patients went into surgery with arm or shoulder pain on one side. The surgery relieved that pain, but when activity levels increased as the patient recovered from the surgery. In some of these cases it was explained by the surgeons decompressing the side in which symptoms existed, as they would for a traditional spine surgery. ASYMPTOMATIC stenosis caused by osteophytes, calcified ligament, disc bulges, etc. on the other side may BECOME symptomatic after the patient increases activity levels or because motion at the segment may be increased.

As for the decision to wait in the absence of symptoms, some will still recommend not doing surgery. Depending on the severity of the cord compression, they may recommend MRI’s every year, 6-months or even 3-months to insure that things aren’t progressing… not only the compression, but changes to the myelon too. One surgeon said, “even in the absence of symptoms, moderate to severe cord compression is like a ticking bomb. The risk of waiting can be much greater than the risk surgery. Yes, it can be dangerous to have someone go to defuse the bomb, but we still do it because the risks involved in leaving it alone are greater than the risks of the surgery.”

If you are considering cervical surgery, especially with motion preservation technology, and you have spinal cord compression; you might want to discuss these issues with your surgeon. This may be one of those cases where some surgeons have substantial poor experience while others have few problems… with the difference being explained by surgical technique, differences in patient selection, diligence in follow-up or patient tracking, or other factors. This may be one of those situations in which you should be with a surgeon who has high experience with cases like yours.

Mark

*** Remember, I’m not a doctor. These writings relate my recollections and impressions which may be completely wrong.

[rob_zzz]

Mark - just read this article again and it has me wondering about whether ADR is appropriate for my own situation.

Just wondering what your general experience has been for clients with cervical myelopathy that have had ADR? I've had some fusion surgeons opposed to ADR for myelopathy (they oppose ADR for everything though), and I haven't seen any really useful studies on it.

Also my understanding is that myelopathy is a difficult situation for surgeons to address regardless of technique (the success rate for myelopathy for fusions is far less predictable than for pure radiculopathy as I understand it.).

e.g. the standard figures I've heard from surgeons for surgery for myelopathy are 20% continue to get worse, 40% stabilise and 40% improve.

Most people with myelopathy are looking for stabilisation of symptoms at the minimum - is ADR proving to be succesful in stabilising myelopathic symptoms?

Another sort of related question - how difficult is a revision to fusion for an ADR patient?


thanks,
Rob

[mmglobal]

Rob...

I see too many cases with conflicting opinions of surgeons. More traditional or more conservative is not always safer or better. Yesterday I was contacted by someone who wants info about Bradley... the 6-level cervical guy. It caused me to rekindle contacts and he's still doing great. EVERY other surgeon he went to told him that the not fusing his skull to his thoracic spine was nuts. We are not talking about surgeons in Podunk,,, we are talking about the best in the US.

Many will say that agressive application of technology is not safe... maybe they are right... maybe it's because they don't have any experience in that arena or cannot offer such options?

I don't remember enough about your case to comment, but I'd gather opinions and evaluate everything. These are tough decisions.

The numbers I've heard are that 1/3 of the patients with myelopathic symptoms will not get relief from decompressing the spinal cord.

Your question prompted me to contact my one client who had severe and long-standing myelopathic symptoms prior to his 2-level cervical ADR, now almost 2 years ago. He had waited too long with SEVERE gait problems for more than a year before his surgery. He was not in pain, so it was easy for him to wait. He considers the surgery a success even though he still has his severely altered gait. His symptoms did not get worse, although his gait did not improve. He still has no pain from his c-spine, but feels like he's not longer at risk of paralysis from a minor fall or auto accident. The cord compression is resolved, but unfortunately, the damage appears to be permanent. I'm not sure how this relates to your question except that in this one extreme case, there is no 'rebound myelopathy'.

I've seen increases in radicular symptoms in some cervical procedures, as we do in some lumbar procedures. I think that the incidence in cervical is lower and like lumbar, it almost always fades in a few days, weeks, or months. I've not seen increases in myelopathic symptoms in my clients, but the number of folks with real myelopathy has been low, so I don't know how relevant my experience is.

Remember all the "I'm not a doctor" diclaimer stuff... I'm just sharing my limited experience... take everything I say with a grain of salt, check it out and make your own decisions...

All the best.

Mark

[rob_zzz]

Mark,

Thanks for the reply. There's always plenty of conflicting opinions about ADR vs fusion, but then add to that the conflicting opinions about whether surgery is indicated at all as well and it makes it very difficult for the patient.

It would also be easy for the fusion proponents to point to failed ADR for myelopathy situations as an example, but the reality is (from what I can tell in the various studies I've looked through) that fusion also often fails for these situations as well.

The conflicting opinions have caused me a lot of trouble - particularly when well regarded surgeons strongly express an opinion, its difficult to ignore it even though your gut, knowledge of your own symptoms, and your own research is telling you otherwise.

With this complex situation its easy to see why cord compression patients often end up leaving it far too long to have surgery.

Rob.