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DISEASES OF SPINAL CORD, PERIPHERAL NERVE, AND MUSCLE
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disease (primary lateral sclerosis type), HTLV-I myelopathy, or the carrier state of adrenoleukodystrophy or other intrinsic myelopathy When imbalance, both perceived by the patient and observed in tests of walking, is a major symptom, spondylosis must be differentiated from a number of acquired large- ber polyneuropathies, particularly in ammatory or immune types and the more benign sensory neuropathy of the aged (see page 1151) Loss of tactile sensation in the feet and loss of tendon re exes are characteristic of the latter; examination of the tendon re exes distinguishes the two Subacute combined degeneration of the spinal cord due to vitamin B12 de ciency, combined system disease of the nonpernicious anemia type, AIDS and HTLV-I myelopathy, ossi cation of the posterior longitudinal ligament, and spinal cord tumor (discussed further on) are usually listed among the conditions that might be confused with spondylotic myelopathy Adherence to the diagnostic criteria for each of these disorders and scrutiny of the radiologic studies should eliminate the possibility of error in most instances The gait abnormality produced by spondylotic myelopathy may also be mistaken for that of normal-pressure hydrocephalus; a marked increase of imbalance with removal of visual cues (Romberg sign) is a feature of spondylosis but not of hydrocephalus Also, the short stepped and magnetic quality of walking that is characteristic of hydrocephalus is not seen in cases of cervical myelopathy Incontinence occurs only in advanced cases of spondylotic myelopathy, but usually follows soon after gait deterioration in hydrocephalus The special problems of spondylotic radiculopathy, which may accompany or occur independently of the myelopathy, are discussed on pages 184 and 186 Treatment The slow, intermittently progressive course of cervical myelopathy with long periods of relatively unchanging symptomatology makes it dif cult to evaluate therapy Assuming that the prevailing opinion of the mechanisms of the cord and root injury is correct, the use of a soft collar to restrict anteroposterior motions of the neck seems reasonable This form of treatment alone may be suf cient to control the discomfort in the neck and arms Only exceptionally in our experience has arm and shoulder pain alone been suf ciently severe and persistent to require surgical decompression unless there is a laterally protruded disc or osteophytic constriction of a root foramen Most of our patients have been dissatis ed with this passive approach and are unable to wear a collar for prolonged periods If osteophytes have narrowed the spinal canal at several interspaces, a posterior decompressive laminectomy with severance of the dentate ligaments helps to prevent further injury The results of such a procedure are fairly satisfactory (Epstein and Epstein); in fully two-thirds of the patients, improvement in the function of the legs occurs, and in most of the others, progression of the myelopathy is halted The operation carries some risk; rarely, an acute quadriplegia due presumably to manipulation of the spinal cord and damage to nutrient spinal arteries has followed the surgical procedure When only one or two interspaces are the site of osteophytic overgrowths, their removal by an anterior approach has given better results and carries less risk The surgical methods and their relative advantages are reviewed by Braakman Newer techniques have been developed in which titanium cages are used to stabilize the adjacent vertebrae thereby obviating the need for bone grafts to fuse adjacent bodies; the conventional process using bone grafts requires many weeks or longer and stabilization in a hard collar Unfortunately, the long-term results after surgical treatment
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are less than ideal Ebersold and colleagues evaluated the outcomes in 84 patients in whom the median duration of follow-up was 7 years In the group of 33 patients who had undergone anterior decompressive procedures, 18 had improved, 9 were unchanged, and 6 had deteriorated Of the 51 patients who underwent posterior decompression, 19 had improved, 13 were unchanged, and 19 were worse at their last follow-up examinations These results, similar to those of most other series, indicate that the long-term outcome varies and that a signi cant proportion, even after adequate decompression and initial improvement, have persistent symptoms or undergo some degree of later functional deterioration Whether the new surgical appliances previously mentioned give more satisfactory results is not known but they certainly make recovery easier and more rapid Lumbar Stenosis This is another spondylotic abnormality, seen with particular frequency in older individuals, especially men Usually it declares itself by numbness and weakness of the legs, sometime with poor control of sphincters There is said to be generally little or no pain or only a spine ache that uctuates from day to day but in our experience the majority of patients have backache and sciatica or a smiliar back or leg pain from associated osteoarthritis or discogenic disease A notable feature is induction or aggravation of the neurologic symptoms upon standing and walking (neurologic claudication) This topic is disucssed further on page 179, which should be consulted for further discussion Ankylosing Spondylitis This rheumatologic condition of the spine is due to in ammation at the sites of ligamentous insertions into bone that leads to an intense calci cation at these and adjacent sites The sacroiliac joints and lumbar spine are most affected, as discussed on page 180, but as the disease advances, the entire spine becomes fused and rigid The biomechanics of the rigid spine make it susceptible to fracture The most common complication is a spinal stenosis and cauda equina syndrome Bartleson and associates described 14 patients (and referred to 30 others in the medical literature) who, years after the onset of spondylitis, developed sensory, motor, re ex, and sphincteric disorders referable to L4, L5, and the sacral roots Surprisingly, the spinal canal was not narrowed but instead the caudal sac was actually dilated Confavreux et al have presented evidence that enlargement of the lumbar dural sac is due to a defect in resorption of the CSF There are usually arachnoidal diverticulae on the posterior root sleeves, but no other explanation can be given for the radicular symptoms and signs Surgical decompression has not bene ted the patients, nor has corticosteroid therapy This condition occasionally occurs at higher levels and gives rise to a myelopathy Our experience includes cases with symptoms related to the cervical roots with diverticulae of dural nerve sheaths The most hazardous complication of ankylosing spondylitis is compression of the cord, from seemingly minor trauma that has resulted in fracture-dislocation of the cervical (or lumbar) vertebrae Fox and colleagues from the Mayo Clinic treated 31 such patients in a 5-year period; the majority of unstable fractures that required surgical xation were in the cervical region, and several patients had fracture-dislocations at two levels The instability at the upper spinal levels may be dif cult to detect radiologically, and caution should be observed in allowing patients to resume full activity after a neck injury if the cervical spine is seen to be involved by spondylitis Careful exion and extension x-ray views usually, but not always, demonstrate the instability
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