Rebound Myelopathy

mmglobal · Yesterday, 03:27 AM

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.

fracback · Yesterday, 12:10 PM

Mark,

Is it safe to include the T spine in these findings? After decompression surgery on T7-8 and T9-10, I have almost the same symptoms as before surgery. I waited over 2 1/2 years before being worked on by Curtis Dickman, M.D. As a matter of fact I am having pain on both sides of the spine now as opposed to the left only before the fusion.

Thanks,

Joe

nopain · Yesterday, 01:04 PM

Quote:

"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 confusing. I thought the point was to relieve symptoms - typically pain? At what point is adequate decompression reached? Does this mean an ADR will require greater decompression? Wouldnt that be a bnefit in and of itself? What good is fusion/stability if it doesn't relieve symptoms?

StillSmiling · Yesterday, 01:25 PM

I really find the name of "Rebound Myelopathy" fascinating. It's a great idea. As you said, it doesn't place the onus on the surgeon as it might have in the past - something I'm rather dealing with.

But...both inside and outside of my medical community (yes, I escaped my HMO twice for secon opinions)...the drs' feelings were the same: NO surgery. It would NOT be beneficial, and could possibly make things worse* - another item you mentioned.

I truly appreciate that you share what you learned at the medical symposium. You are such a hard working compassionate and passionate individual when it comes to spinal disorders and people with them.

I'm going to bring this along at my next visit to my Neurologist.

Thanks again, Mark.

Love, Lynnie

Cervie Barb · Yesterday, 01:33 PM

Thanks for the great post, Mark. There are some really good points in it that I never considered.

Inadequate decompression - I can see why this happens. Picture an osteophyte digging in to the cord. How much scraping and poking around does a surgeon want to do in that situation?

And the fact that ADR preserves motion is what I've always liked about the idea. Less load on adjoining disks/vertebre. But like you said, what if you have asymptomatic problems on the other side when they do the surgery, and the motion restored flares it up?

But, what other problem would be left? The entire disk is removed for ADR. Facet Joint problems?

No pain - My take on these surgeries is that it's done to stabilize the spine, or relieve pressure from the cord or nerve roots. You should get relief from symptoms if the pressure is off the nerve root. But spinal cord injury is permenant.

Thanks again, Mark!

mmglobal · Yesterday, 02:51 PM

*** all the "not a doctor" caveats apply ***

Fracback,

It is my understanding that the t-spine does not move much, so the issues of motion preservation should not be in play... or maybe to a much lesser degree. I don't know how you evaluate the possiblity that you may be in the reported 35% who's symptoms have become permanent before the surgery. I assume that Dr. Dickman looked for other reasons... if you have 2 causes and you fix one... you still have residual symptoms.

Nopain,

If you stop motion, it is less important to create space around the spinal cord because it will not be moving. If you think of an osteophyte as something that stick back into the canal area, as long as it's away from the cord and there is no mobility in that area, it will not cause irritationg. However, if you retain mobility, when you go through flexion, extension and rotation; you may be dragging the spinal cord across the osteophyte, causing irritation. So yes, I think it's true that more complete decompression is required with ADR than is required with fusion.

Barb,

Quote:

Originally Posted by Cervie Barb

And the fact that ADR preserves motion is what I've always liked about the idea. Less load on adjoining disks/vertebre. But like you said, what if you have asymptomatic problems on the other side when they do the surgery, and the motion restored flares it up?

This is why it's so important, especially if you are a difficulte case, to be with a surgeon who has a great deal of experience with cases like yours.

The can do a lot to release the posterior aspect of the disc and remove osteophytes that are up near the endplates. When osteophytes extend far towards the center of the body (as in my case), it's hard for them to get that far down around the 'corner'. At some point, the osteophytes can go too far to consider ADR because of exactly what we are talking about... leaving something sticking into the canal area and remobilizing may not be the best way to go. It may very well be the case that your situation far exceeds the ability of one surgeon, while it's well inside the range of another.

Mark

Blueberry · Yesterday, 04:43 PM

Thanks so much for this superb post. I really appreciate the info since that is exactly the group I belong to--people with myelopathy who do not have symptoms. It has always been hanging over my head, the "ticking timebomb" thing. Since my spine surgeons discharged me because I did not choose to have surgery, in my HMO I don't have much, if any, follow-up on my spinal condition. If my symptoms worsen (which they have not done), my primary care physician will approve me going back to the neurologist who will then authorize a follow-up MRI, but no one can tell me what to do in the meantime. Your post was so helpful to me.

I wish they could do a study of spine patients in the countries with socialized medicine where I've heard there is an overall lesser rate of spine surgery than in the US--and compare these folkls with spine patients in the US. I'd like to know what happens in those other countries where surgeons are not as quick to operate as US physicians. Since they do less spine surgery, do they then have a higher rate of people being paralyzed later on or going into wheelchairs, etc.? There must be a way to study people who don't have surgery. There are groups that turn down surgery due to religious reasons, and there are people who are not given spine surgery due to age. What happens long term to a large group of patients who have spinal myelopathy and don't have spine surgery? You can't be the only person asking such cogent questions. Where are the answers?

Cervie Barb · Yesterday, 08:02 PM

Great questions, Blueberry! I'd like to see a study on that too.

Myselfme · Today, 03:26 AM

The very thing I have been reading since going through fusion surgeryis. There is little difference in outcome between the surgical and non surgical group. It's quite easy to find research articles that describe the comparison. My acdf involved total disc removal....as many others here would have experienced. No disc left to rupture but osteophytes have been a post surgical problem. Osteophytes are bone shoots...as we know. What is it about ADR that can prevent this? Bone can form around the artificial disc prosthesis. Can't it? I can imagine that it can take off from many different aspects/slants. I am even wondering if motion is another good reason to offset osteophyte growth. Afterall, this is the case with failed fusion where there is movement/motion from stability. I would expect surgeons to advocate surgery. It's in their interest.

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