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J
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Editor-in-Chief : Atul Goel (INDIA)
Open Access HTML Format
For entire Editorial Board visit : http://www.jcvjs.com/editorialboard.asp
Journal of Craniovertebral Junction and Spine
Editorial
Is it necessary to resect osteophytes in degenerative spondylotic myelopathy? Atul Goel Department of Neurosurgery, K.E.M. Hospital and Seth G.S. Medical College, Parel, Mumbai, Maharashtra, India Corresponding author: Prof. Atul Goel, Department of Neurosurgery, King Edward VII Memorial Hospital, Parel, Mumbai - 400 012, Maharashtra, India. E-mail: [email protected] Journal of Craniovertebral Junction and Spine 2013, 4:1
Osteophytes are commonly referred to as bone spurs that form along the joint margin. In the spine, osteophytes are universally considered to be the principal agents that compress the spinal cord or roots and result in symptoms of radiculopathy and of myelopathy. The primary aim during surgery for degenerative spine has been either removal of osteophyte for direct decompression of the neural structures or indirectly to perform surgical procedures that will increase the spinal canal dimension and reduce the pinching effect of the osteophyte. Goel hypothesized that the primary event in spinal degeneration is weakness of the muscles of nape of the neck and vertical spinal instability related to standing human position.[1-3] Ligamentous buckling, disc space reduction, osteophyte formation and spinal canal or root canal size reduction are secondary phenomenon and related to the primary feature of facetal over-riding. It appears that osteophyte formation is not a primary pathological event and is secondary to spinal instability. The instability is “vertical” in nature and its primary or initial pathogenetic effect is evident on the facets that tend to slip over the one inferior to it, the process being labeled as retrolisthesis in the cervical and dorsal spine and facetal over-riding in the lumbar spine. The entire phenomenon of spinal degeneration or spondylosis is based on or initiated by the primary phenomenon of instability. The pathological effects of degeneration in the form of disc space reduction, osteophyte formation, ligamental buckling and spinal and root canal space reduction are all secondary effects related to primary vertical instability. Addressing the primary Access this article online Quick Response Code:
Website: www.jcvjs.com
DOI: 10.4103/0974-8237.121615
factor of spinal instability may potentially result in resolution or disappearance of osteophytes. Instability is primary and the rest of the processes are all secondary or may even be protective in nature. The presence of osteophyte by itself suggests the presence of instability and may direct the need for surgical fixation. If surgical resection of the osteophytes can be avoided, the surgical procedure for degenerative spine can be relatively straight-forward and safe. It is important that one attempts to understand this pathogenetic concept so that a philosophically correct form of treatment can be initiated. Osteophytes are frequently observed in spinal imaging of an elderly. The primary aim of surgical treatment is to resect the osteophytes as widely as possible and to decompress the cord of indentation. Osteophyte formation is usually at multiple levels and essentially circumferential around the entire spinal and root canal, around the vertebral body and around the facets. Osteophytes result in focal neural compression and as a consequence of wide and circumferential presence, in the spinal canal stenosis. Osteophyte formation is related to the vertical height reduction related to telescoping effect on spinal segments. Disc space height reduction results in buckling and subsequent separation of intervertebral ligaments from the bone. Bone neoformation or osteophyte formation in the region is similar to “callous-formation” related to periosteal separation or reaction in long bone fractures. Osteophyte formation is a relentlessly progressive process that develops over several months and years. The slow and progressively increasing phenomenon of osteophyte formation results in deformation of spinal cord and roots. Frequent identification of large and indenting osteophytes without any neural symptoms is testimony of the slow and long-standing pathogenic process and demonstrates the accommodation of the compression by the natural neural elasticity. Some of the authors feel that formation of osteophytes is a phenomenon of additional bone formation that could assist in 1
Journal of Craniovertebral Junction and Spine 2013, 4:1
providing stability to the unstable region of the spine. Presence of osteopytes is almost universal in the elderly. Multi-level spinal cord compression by the osteophytes can be frequently or always observed. Modern imaging can demonstrate the status of facets remarkably clearly when compared with imaging that was primarily focused on the bulk of the disc and more recently on the status of the spinal cord. Osteophytes can be identified around the facets. Presence of osteophytes anywhere in the spine can be a clear evidence of presence of local vertical spinal instability. Presence of osteophytes by themselves has no clinical relevance unless it has associated symptoms. Symptom of local neck pain can be due to several causes that include muscle stress, ligamental tear and similar such cause. However, when symptoms are progressive, are related to neck movements, are long-standing and when associated with radicular pain, suspicion of instability can be on the mind. And when radiological images show the presence of osteophytes, the suspicion of instability can be strengthened. Presence of osteophytes can provide an evidence of instability and when the symptoms of radiculopathy or myelopathy co-exist, the need for treatment of instability becomes necessary. The need for directly handling and removal of the osteophytes can be avoided. Osteophytes arise and grow secondary to local spinal instability as soon as the issue of instability is addressed, there is a potential of osteophyte regressing in size. Similar event is clearly seen in the craniovertebral junction. Retro-odontoid process ligamentous hypertrophy is not a primary event, but it is secondary to posterior longitudinal ligament buckling that is secondary to instability of the atlantoaxial joint. Goel first hypothesized that the presence of retro-odontoid ligamentous hypertrophy is a clear indication of atlantoaxial instability and suggests the need for atlantoaxial fixation.[4-8] Goel hypothesized that retroodontoid ligamentous hypertrophy need not be directly handled surgically. Regression of the retro-odontoid ligamentous hypertrophy is possible after atlantoaxial stabilization and has been demonstrated by several authors. The pathogenesis of retro-odontoid ligmentous hypertrophy simulates that of osteophyte formation in the subaxial spine. Instability is clearly the cause of formation of osteophytes and needs to be treated
Goel: Osteophytes and degenerative spine
when associated with symptoms. Distraction of facets by the introduction of spacers within the joint confines and arthrodesis of spinal segment by the technique described by Goel can result in stabilization of the spinal segment and unbuckling of the ligaments.[9,10] The procedure results in an immediate increase in the spinal canal and neural canal dimensions. Restoration of the tautness of the intervertebral ligaments has the potential of spontaneous regression of the osteophytes. Direct handling of the osteophytes can be counter-productive.
REFERENCES 1.
2. 3. 4.
5.
6.
7.
8.
9.
10.
Goel A. Facet distraction spacers for treatment of degenerative disease of the spine: Rationale and an alternative hypothesis of spinal degeneration. J Craniovertebr Junction Spine 2010;1:65-6. Goel A. Facet distraction-arthrodesis technique: Can it revolutionize spinal stabilization methods? J Craniovertebr Junction Spine 2011;2:1-2. Goel A. ‘Only fixation’ as rationale treatment for spinal canal stenosis. J Craniovertebr Junction Spine 2011;2:55-6. Goel A, Sharma P. Craniovertebral realignment for basilar invagination and atlantoaxial dislocation secondary to rheumatoid arthritis. Neurol India 2004;52:338-41. Goel A, Pareikh S, Sharma P. Atlantoaxial joint distraction for treatment of basilar invagination secondary to rheumatoid arthritis. Neurol India 2005;53:238-40. Goel A, Dange N. Immediate postoperative regression of retroodontoid pannus after lateral mass reconstruction in a patient with rheumatoid disease of the craniovertebral junction. Case report. J Neurosurg Spine 2008;9:273-6. Goel A, Shah A, Gupta SR. Craniovertebral instability due to degenerative osteoarthritis of the atlantoaxial joints: Analysis of the management of 108 cases. J Neurosurg Spine 2010;12:592-601. Goel A. Letter to Editor. Resolution of cystic deterioration of the C1-C2 articulation with posterior fusion: treatment implications for asymptomatic patients. World Neurosurg 2013. {Epub ahead of print} Goel A, Shah A. Facetal distraction as treatment for single- and multilevel cervical spondylotic radiculopathy and myelopathy: A preliminary report. J Neurosurg Spine 2011;14:689-96. Goel A, Shah A, Jadhav M, Nama S. Distraction of facets with intraarticular spacers as treatment for lumbar canal stenosis: Report on a preliminary experience with 21 cases. J Neurosurg Spine 2011;[Epub ahead of print].
How to cite this article: Goel A. Is it necessary to resect osteophytes in degenerative spondylotic myelopathy?. J Craniovert Jun Spine 2013;4:1-2.
Announcement
“QUICK RESPONSE CODE” LINK FOR FULL TEXT ARTICLES The journal issue has a unique new feature for reaching to the journal’s website without typing a single letter. Each article on its first page has a “Quick Response Code”. Using any mobile or other hand-held device with camera and GPRS/other internet source, one can reach to the full text of that particular article on the journal’s website. Start a QR-code reading software (see list of free applications from http://tinyurl.com/yzlh2tc) and point the camera to the QR-code printed in the journal. It will automatically take you to the HTML full text of that article. One can also use a desktop or laptop with web camera for similar functionality. See http://tinyurl.com/2bw7fn3 or http://tinyurl.com/3ysr3me for the free applications. 2
Copyright of Journal of Craniovertebral Junction & Spine is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
C
V
J
S
Editor-in-Chief : Atul Goel (INDIA)
Open Access HTML Format
For entire Editorial Board visit : http://www.jcvjs.com/editorialboard.asp
Journal of Craniovertebral Junction and Spine
Editorial
Is it necessary to resect osteophytes in degenerative spondylotic myelopathy? Atul Goel Department of Neurosurgery, K.E.M. Hospital and Seth G.S. Medical College, Parel, Mumbai, Maharashtra, India Corresponding author: Prof. Atul Goel, Department of Neurosurgery, King Edward VII Memorial Hospital, Parel, Mumbai - 400 012, Maharashtra, India. E-mail: [email protected] Journal of Craniovertebral Junction and Spine 2013, 4:1
Osteophytes are commonly referred to as bone spurs that form along the joint margin. In the spine, osteophytes are universally considered to be the principal agents that compress the spinal cord or roots and result in symptoms of radiculopathy and of myelopathy. The primary aim during surgery for degenerative spine has been either removal of osteophyte for direct decompression of the neural structures or indirectly to perform surgical procedures that will increase the spinal canal dimension and reduce the pinching effect of the osteophyte. Goel hypothesized that the primary event in spinal degeneration is weakness of the muscles of nape of the neck and vertical spinal instability related to standing human position.[1-3] Ligamentous buckling, disc space reduction, osteophyte formation and spinal canal or root canal size reduction are secondary phenomenon and related to the primary feature of facetal over-riding. It appears that osteophyte formation is not a primary pathological event and is secondary to spinal instability. The instability is “vertical” in nature and its primary or initial pathogenetic effect is evident on the facets that tend to slip over the one inferior to it, the process being labeled as retrolisthesis in the cervical and dorsal spine and facetal over-riding in the lumbar spine. The entire phenomenon of spinal degeneration or spondylosis is based on or initiated by the primary phenomenon of instability. The pathological effects of degeneration in the form of disc space reduction, osteophyte formation, ligamental buckling and spinal and root canal space reduction are all secondary effects related to primary vertical instability. Addressing the primary Access this article online Quick Response Code:
Website: www.jcvjs.com
DOI: 10.4103/0974-8237.121615
factor of spinal instability may potentially result in resolution or disappearance of osteophytes. Instability is primary and the rest of the processes are all secondary or may even be protective in nature. The presence of osteophyte by itself suggests the presence of instability and may direct the need for surgical fixation. If surgical resection of the osteophytes can be avoided, the surgical procedure for degenerative spine can be relatively straight-forward and safe. It is important that one attempts to understand this pathogenetic concept so that a philosophically correct form of treatment can be initiated. Osteophytes are frequently observed in spinal imaging of an elderly. The primary aim of surgical treatment is to resect the osteophytes as widely as possible and to decompress the cord of indentation. Osteophyte formation is usually at multiple levels and essentially circumferential around the entire spinal and root canal, around the vertebral body and around the facets. Osteophytes result in focal neural compression and as a consequence of wide and circumferential presence, in the spinal canal stenosis. Osteophyte formation is related to the vertical height reduction related to telescoping effect on spinal segments. Disc space height reduction results in buckling and subsequent separation of intervertebral ligaments from the bone. Bone neoformation or osteophyte formation in the region is similar to “callous-formation” related to periosteal separation or reaction in long bone fractures. Osteophyte formation is a relentlessly progressive process that develops over several months and years. The slow and progressively increasing phenomenon of osteophyte formation results in deformation of spinal cord and roots. Frequent identification of large and indenting osteophytes without any neural symptoms is testimony of the slow and long-standing pathogenic process and demonstrates the accommodation of the compression by the natural neural elasticity. Some of the authors feel that formation of osteophytes is a phenomenon of additional bone formation that could assist in 1
Journal of Craniovertebral Junction and Spine 2013, 4:1
providing stability to the unstable region of the spine. Presence of osteopytes is almost universal in the elderly. Multi-level spinal cord compression by the osteophytes can be frequently or always observed. Modern imaging can demonstrate the status of facets remarkably clearly when compared with imaging that was primarily focused on the bulk of the disc and more recently on the status of the spinal cord. Osteophytes can be identified around the facets. Presence of osteophytes anywhere in the spine can be a clear evidence of presence of local vertical spinal instability. Presence of osteophytes by themselves has no clinical relevance unless it has associated symptoms. Symptom of local neck pain can be due to several causes that include muscle stress, ligamental tear and similar such cause. However, when symptoms are progressive, are related to neck movements, are long-standing and when associated with radicular pain, suspicion of instability can be on the mind. And when radiological images show the presence of osteophytes, the suspicion of instability can be strengthened. Presence of osteophytes can provide an evidence of instability and when the symptoms of radiculopathy or myelopathy co-exist, the need for treatment of instability becomes necessary. The need for directly handling and removal of the osteophytes can be avoided. Osteophytes arise and grow secondary to local spinal instability as soon as the issue of instability is addressed, there is a potential of osteophyte regressing in size. Similar event is clearly seen in the craniovertebral junction. Retro-odontoid process ligamentous hypertrophy is not a primary event, but it is secondary to posterior longitudinal ligament buckling that is secondary to instability of the atlantoaxial joint. Goel first hypothesized that the presence of retro-odontoid ligamentous hypertrophy is a clear indication of atlantoaxial instability and suggests the need for atlantoaxial fixation.[4-8] Goel hypothesized that retroodontoid ligamentous hypertrophy need not be directly handled surgically. Regression of the retro-odontoid ligamentous hypertrophy is possible after atlantoaxial stabilization and has been demonstrated by several authors. The pathogenesis of retro-odontoid ligmentous hypertrophy simulates that of osteophyte formation in the subaxial spine. Instability is clearly the cause of formation of osteophytes and needs to be treated
Goel: Osteophytes and degenerative spine
when associated with symptoms. Distraction of facets by the introduction of spacers within the joint confines and arthrodesis of spinal segment by the technique described by Goel can result in stabilization of the spinal segment and unbuckling of the ligaments.[9,10] The procedure results in an immediate increase in the spinal canal and neural canal dimensions. Restoration of the tautness of the intervertebral ligaments has the potential of spontaneous regression of the osteophytes. Direct handling of the osteophytes can be counter-productive.
REFERENCES 1.
2. 3. 4.
5.
6.
7.
8.
9.
10.
Goel A. Facet distraction spacers for treatment of degenerative disease of the spine: Rationale and an alternative hypothesis of spinal degeneration. J Craniovertebr Junction Spine 2010;1:65-6. Goel A. Facet distraction-arthrodesis technique: Can it revolutionize spinal stabilization methods? J Craniovertebr Junction Spine 2011;2:1-2. Goel A. ‘Only fixation’ as rationale treatment for spinal canal stenosis. J Craniovertebr Junction Spine 2011;2:55-6. Goel A, Sharma P. Craniovertebral realignment for basilar invagination and atlantoaxial dislocation secondary to rheumatoid arthritis. Neurol India 2004;52:338-41. Goel A, Pareikh S, Sharma P. Atlantoaxial joint distraction for treatment of basilar invagination secondary to rheumatoid arthritis. Neurol India 2005;53:238-40. Goel A, Dange N. Immediate postoperative regression of retroodontoid pannus after lateral mass reconstruction in a patient with rheumatoid disease of the craniovertebral junction. Case report. J Neurosurg Spine 2008;9:273-6. Goel A, Shah A, Gupta SR. Craniovertebral instability due to degenerative osteoarthritis of the atlantoaxial joints: Analysis of the management of 108 cases. J Neurosurg Spine 2010;12:592-601. Goel A. Letter to Editor. Resolution of cystic deterioration of the C1-C2 articulation with posterior fusion: treatment implications for asymptomatic patients. World Neurosurg 2013. {Epub ahead of print} Goel A, Shah A. Facetal distraction as treatment for single- and multilevel cervical spondylotic radiculopathy and myelopathy: A preliminary report. J Neurosurg Spine 2011;14:689-96. Goel A, Shah A, Jadhav M, Nama S. Distraction of facets with intraarticular spacers as treatment for lumbar canal stenosis: Report on a preliminary experience with 21 cases. J Neurosurg Spine 2011;[Epub ahead of print].
How to cite this article: Goel A. Is it necessary to resect osteophytes in degenerative spondylotic myelopathy?. J Craniovert Jun Spine 2013;4:1-2.
Announcement
“QUICK RESPONSE CODE” LINK FOR FULL TEXT ARTICLES The journal issue has a unique new feature for reaching to the journal’s website without typing a single letter. Each article on its first page has a “Quick Response Code”. Using any mobile or other hand-held device with camera and GPRS/other internet source, one can reach to the full text of that particular article on the journal’s website. Start a QR-code reading software (see list of free applications from http://tinyurl.com/yzlh2tc) and point the camera to the QR-code printed in the journal. It will automatically take you to the HTML full text of that article. One can also use a desktop or laptop with web camera for similar functionality. See http://tinyurl.com/2bw7fn3 or http://tinyurl.com/3ysr3me for the free applications. 2
Copyright of Journal of Craniovertebral Junction & Spine is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
