Cervical Myelopathy - Nitin Bhatia, MD
Dr. Sechrest: Hello, I’m Dr. Randale Sechrest, your host for eOrthopod.TV. Today I have with me, Dr. Nitin Bhatia. Dr. Bhatia is a spine surgeon, who is the Chief of Spine Surgery, at the University of California Irvine. Dr. Bhatia did his undergraduate training at Stanford. He then went on to Baylor College of Medicine where he completed his M.D. degree. From there, he did orthopaedic surgery training at UCLA. From there, he finished a spine fellowship at the University of Miami. Today, he practices complex spine surgery at University of California Irvine. Good day, Dr. Bhatia.
Dr. Nitin Bhatia: Thank you for having me.
Dr. Sechrest: Dr. Bhatia, today what I would like to discuss is a concept that we’re familiar with but I don’t think patients are sometimes familiar with; and that’s when we have a condition called cervical myelopathy. Now for you and I that means there’s too much pressure on the spinal cord and we begin to see problems in the body, throughout the whole body, because of that increased pressure. But, tell us a little bit about what causes that problem, how it presents, and how you begin to look at patients who have this problem.
Dr. Nitin Bhatia: Sure. That’s a great question. Cervical myelopathy is a problem caused by abnormal pressure on the spinal cord. The reason it becomes such a problem is because it can be very difficult to diagnose. It doesn’t frequently show up as shooting pain in the neck, or down the arms, but rather it can slowly progress and cause dysfunction of somebody’s hands, arms, legs, and feet. Usually it takes months or even years to gradually progress where people go from being completely normal to gradually losing some function of their hands and legs. Some of the classic signs we see are problems using fine motor function of the hands. For example, buttoning your buttons on a shirt, holding a knife or fork. In Japan, the classic sign is that people can no longer use chopsticks that they’ve used since they were 2 or 3 years old. Other common signs are numbness of both hands and people can also have severe balance problems. I actually had a patient one time who had such bad myelopathy, before he had surgery, that he was walking down the sidewalk and the police pulled over to arrest him thinking he was drunk in public because his balance had gotten so bad. Usually it’s caused by a problem of cervical spinal degeneration, what we call spondylosis.
Dr. Sechrest: Now let’s go back and define a few terms. One is the whole concept of cervical. We’re really talking about the neck.
Dr. Nitin Bhatia: Exactly.
Dr. Sechrest: And we’re talking about the 7 vertebrae that make up the neck. This term spondylosis, tell us about that, what is spondylosis?
Dr. Nitin Bhatia: Spondylosis is a fancy medical term for essentially arthritic changes of the neck. Just with time the discs and the joints and the other parts of the neck slowly degenerate and wear out a little, and that’s what we call spondylosis.
Dr. Sechrest: Okay. And arthritis, when you say degenerative arthritis, we probably ought to distinguish that between rheumatoid arthritis or some folks think of arthritis as a systemic disease that affects all the joints. But what we’re talking about really is wear and tear arthritis for the most part.
Dr. Nitin Bhatia: Exactly, and that’s the most common arthritis that we see, we call it osteoarthritis, and it’s the typical arthritis that affects most people just as we get older. Now you mentioned some people do have problems like rheumatoid arthritis, but those are much more uncommon and affect people somewhat differently. So, yes, it’s the wear and tear type of arthritis.
Dr. Sechrest: And, you know, lots of patients come to us with neck pain, for example, and we tell them they have arthritis. What makes the patient who develops cervical myelopathy different than the person that we see every day that has just neck pain from arthritis?
Dr. Nitin Bhatia: You know, patients who come to me with myelopathy ask me that all the time. “How come I have this myelopathy and this problem with my hands but my spouse doesn’t?” They also have neck pain. And unfortunately we don’t have a lot of good answers why. One of the answers is just a little more unlucky. Their arthritis may cause more pressure on the spinal cord by constricting the space of the spinal canal more than other people with arthritis of the same age. Some people are also born with slightly smaller spinal canals than others. Just like my hands or fingers may be longer, shorter, fatter, skinnier than yours, our spinal canals that our spinal cord travels down can be a little larger or smaller than everyone else’s. So if you’re born with a slightly smaller spinal canal, which we call congenital spinal stenosis, you’re more prone to having pressure on the spinal cord and spinal nerves earlier than if you’re born with a regular size spine.
Dr. Sechrest: When I’m a patient, when should I become concerned, what symptoms should I start thinking about, “oh gosh, maybe this is cervical myelopathy”.
Dr. Nitin Bhatia: The classic warning signs are problems with the fine motor function of the hands, numbness in both arms or hands, and problems with balance. Those problems are probably the early onset of them. Later on in the problem, you may actually see significant weakness or problems even opening the hands as well as bowel and bladder problems.
Dr. Sechrest: Okay. So it really does, it can affect the whole spinal cord and pretty much the whole body.
Dr. Nitin Bhatia: For sure.
Dr. Sechrest: Does this ever get to point to where you’re completely quadriplegic? Where you can actually be paralyzed from the neck down?
Dr. Nitin Bhatia: You can, and the way we grade it, one of the classic grading scales grades from 0-5 and 5, which is the severe end, is actually quadriplegia where you’re paralyzed from the arthritis and the compression on the spinal cord and the resultant myelopathy.
Dr. Sechrest: And this occurs slowly, over a period of time – not all of the sudden at one time?
Dr. Nitin Bhatia: Usually it’s fairly slowly. People may get the first symptoms say one year and then 6 months later they get a little worse and they stay at that level and then they get a little worse, and it’s what we call a stepwise fashion. Occasionally, people can have a rapidly progressive form of it. Unfortunately, just this week I saw a patient in my office who, over the past 2 weeks, has gone from completely normal to wheelchair bound because it was rapidly progressive cervical myelopathy.
Dr. Sechrest: Really. It was just from the arthritis type. It just got worse and worse?
Dr. Nitin Bhatia: Exactly.
Dr. Sechrest: We talked a little bit about balance and you mentioned the patient who actually looked like he was drunk. Define balance. Is this where I’m just not quite as good on my snow skis anymore? Or is this something that is really apparent to me?
Dr. Nitin Bhatia: You know, it becomes more and more apparent. The cervical myelopathy tends to be a problem as we get older because it’s an arthritis degenerative related problem, so we see it more in older patients than younger patients. And even without myelopathy, as we get older, our balance gets a little off, but people with the balance problems from myelopathy kind of walk like they’re drunk. Their gait, instead of being normal with what we call a narrow-based gait with their feet together becomes wider. They tend to kind of lurch back and forth. They may even find themselves needing a cane or a walker to balance themselves when they’re walking.
Dr. Sechrest: So let’s say that I’m concerned. I’m starting to have some of these symptoms and I’ve decided it’s time for me to see a physician and probably a spine surgeon, or maybe I’ve seen my primary care physician and they said we need to send you to a spine specialist. How do you address that patient when you see them in your office? What’s the tip-off for you and what do you do next?
Dr. Nitin Bhatia: One of the most important things is getting that patient to my office. One of the hardest parts about cervical myelopathy is that these symptoms are kind of vague. People say, “Oh, I’m getting a little more clumsy or have some numbness”, but it’s not always a distinct neck pain or shooting pain so people forget to think about the neck and unfortunately, a lot of times, I see people who had symptoms 6 months ago or 8 months ago and it’s taken them that long to be diagnosed with a neck problem and end up in my office. Once they get to my office we do a full history to make sure that the symptoms make sense and fit with what our thoughts are and then do a physical exam; and we’re looking for abnormal neurologic findings that are compatible with pressure on the spinal cord. People can have abnormal reflexes. They can have weakness. They can have numbness. They could have ataxia, which just means poor balance when walking. Frequently, we’ll get x-rays that will show arthritic change of the neck, but many people have that and that in itself by no means diagnoses cervical stenosis, which is the nerve compression, or myelopathy, which is the nerve problem. So usually you end up with an MRI scan that actually shows us the spinal cord and the space around it or lack thereof which is very important in making the diagnosis.
Dr. Sechrest: Now is that usually enough to decide what needs to be done in treatment or are there any electrical tests or any other radiologic test that you typically will get?
Dr. Nitin Bhatia: Usually that’s enough. Sometimes, on patients who have a lot of other things going on, we may get other tests like an EMG test or even a specialized CT scan. But usually the MRI scan gives us a very picture of what’s going on in regards to the nerve compression.
Dr. Sechrest: Tell me a little bit about the patients that you see. You had mentioned that it’s usually the older patient that you begin to see cervical myelopathy. What’s the youngest you could expect? Can you start to think about this in middle age? Or is it really an elderly problem?
Dr. Nitin Bhatia: You can. Like I mentioned, we see it more commonly as we get older. So, in patients over the age of 60 years old, it occurs in about 1 in 1000 people. Younger than that, especially than 40 it’s quite rare, although some people are unfortunate in that they have this congenital spinal stenosis, or spinal canals that are narrower than they should be, and even small amounts of degeneration can lead them to have these symptoms. That’s quite rare but we do see it, and I’ve seen it in patients as young as their early 20s.
Dr. Sechrest: Once you’ve made this diagnosis and you’ve done the MRI scan, and you’re relatively certain that the problems you’re seeing, the neurological problems, are a result of the cervical myelopathy. What are my choices as a patient? Is this something that can be treated without surgery; or us this something that’s going to require surgery?
Dr. Nitin Bhatia: The only permanent solution is surgery. We have to take the pressure off of the spinal cord to stop the ongoing damage. Physical therapy doesn’t change that although it may help some neck pain and may provide some improvement in the dexterity of the hands. It doesn’t fix the compression on the spinal cord, that’s really the problem. A lot of people won’t even offer injections such as epidural injections in someone who has this because adding that extra fluid around the already tight spinal cord can make it even worse. So surgery really is the only option for this problem.
Dr. Sechrest: When you recommend surgery what are my expectations as a patient from the standpoint of what the surgery can do? Is this going to reverse the problem?
Dr. Nitin Bhatia: The sooner we get to it the better the reversal. So, if somebody comes in and they mild symptoms in their hands and we catch it early, they can probably get back to normal. But if somebody comes in later where they’re having to use a walker to walk or maybe even in a wheelchair, they’ll likely get better but they won’t go back to normal.
Dr. Sechrest: So you can stop the progression of the disease, but you can’t really guarantee that they’ll have improvement and probably not complete reversal.
Dr. Nitin Bhatia: Right, and most studies show that the progression of the disease stops very well. So the official goal of the surgery is to stop progression. But most studies also show that most of the patients get one or two grades better. So if you come in as a Grade 2, which is kind of mild, you can probably go back to being normal at Grade 0 or 1. But if you come in as a Grade 4 you’ll probably go to a Grade 2 and still have some mild symptoms. So you’ll improve somewhat.
Dr. Sechrest: Okay. You mentioned a grading system. Could you define that grading system in a way that I, as a patient, can understand it? How many grades are there and what’s a Grade 0 versus a Grade 2?
Dr. Nitin Bhatia: Sure. The numbers we use for people with myelopathy are officially 0-5, but the numbers that matter are 1-5, 1 being just some mild pain; and it’s graded based on how much we walk. So 2 is you’re having some problems walking. 3 is you’re having problems walking and you require some sort of cane or walker, but you can probably still work. 4 means that the walking has now become so bad that you probably can’t work, and 5 means that you’re essentially wheelchair-bound.
Dr. Sechrest: Okay. It sounds like anybody who has a diagnosis of cervical myelopathy is going to end up with an operation, unless there are other reasons not to operate that make is riskier to operate than not operate. Let’s move on to procedures that can be used to treat cervical myelopathy. What are my options in terms of surgery? What type of surgery is available to treat this problem?
Dr. Nitin Bhatia: There are a variety of surgeries that are available. The fundamental goal of all of them is to take the pressure off of the spinal cord. Usually we divide the surgeries into surgeries from the front of the neck, which we call anterior surgeries, or surgeries from the back of the neck called posterior surgeries. A kind of general rule of thumb, and this doesn’t hold true for everybody, is that if it involves two or less levels in the neck, for example, two disc spaces, the front of the neck probably provides better results with less complications. But if it involves three or more levels, surgery from the back of the neck likely provides better results with less complications. Now obviously each patient is a little different and their compression is a little different, that’s a general idea of how the surgeries are done.
Dr. Sechrest: Okay. Well, let’s divide them into the front and the back I guess and sort of look at it first from the front. What are we talking about? What do you actually do when you try to go in and relieve this pressure from the front?
Dr. Nitin Bhatia: When we come in from the front, we want to take the structures that are pushing on the spinal cord out. Usually it involves the discs, which are like the shock absorbers in between the vertebral bodies, which are the bones in the neck. In between each bone and the bone next to it, there is a disc. With time those discs tend to collapse and as they collapse and bulge out. It’s that bulging that then pushes towards the spinal cord and causes the problems. So we need to go in and remove those discs in what we call a discectomy to open up the space for the spinal cord. Now, sometimes, there’s actually pressure behind the vertebral bodies as well because they sit in front of the spinal cord. Some people actually have ligaments, we all have ligaments, but some people’s ligaments become ossified, or actually turn into bone and cause significant pressure on it, and then we have to take those ligaments away. To do that we take out that small piece of bone of the vertebral body that’s blocking, and that’s called a corpectomy. These procedures are very well tolerated. It’s the kind of the surgery, if it’s just a discectomy; frequently the hospital stay is at most just overnight. Some people even go home the same day, and even if it’s a corpectomy, which sounds like a much bigger procedure, most people go home the next morning. Depending on your surgeon, people may not even wear a neck collar and some surgeons put patients in neck collars for 2 months. I tend to put them in for about 2 weeks, just until the skin is nicely healed, and then they usually don’t need a neck collar after that at all.
Dr. Sechrest: So, after you take out the disc, or if you have to do a corpectomy, you take out the corpus, what do you do at that point? Obviously, you’ve got a big gap there.
Dr. Nitin Bhatia: Exactly, and we have to do something with that gap. We know if we take out the disc or even part of it and don’t fill it with something, over time that disc will collapse because the stabilizing force is collapsed, and maybe over 6 months, 1 year, or 2 years, the neck gradually falls forward and you end up with more and more problems. So we have to reconstruct that area that we’ve opened up, and that’s what we call a fusion. Usually what we do is we take bone from the bone bank, or bone from the patient’s hip, or a mechanical device that replaces the disc and the bones that we’ve removed that allows the bones to have rebuilt stability and allows them to heal together with essentially, once they’re healed, as much strength as they had before surgery if not more.
Dr. Sechrest: So, basically, if I can paraphrase what you’re saying, is that you take out anything that appears to be causing pressure on the spinal cord, and then you come back and replace that with bone graft or something that is narrower than what you took out, so that you’ve made that space bigger for the spinal cord.
Dr. Nitin Bhatia: Exactly.
Dr. Sechrest: Now, do you use metal plates or any hardware when you do that or do you just put the bone graft in?
Dr. Nitin Bhatia: I use metal plates and hardware because we know the results, especially if you have to do more than one disc, are better if you use the metal plates and hardware.
Dr. Sechrest: Okay, so you’re using the metal plate mainly to hold everything in place while it heals? Do you ever go back in and take those plates out?
Dr. Nitin Bhatia: Sometimes you can. Rarely patients will want them taken out because they just don’t want them, and very, very rarely they’ll cause some problems with swelling, especially in patients who have had problems swelling before that. In that case we may take them out. But it’s extremely rare to need them taken out.
Dr. Sechrest: Okay. It’s not something you tell patients then, and you would discourage that I’m assuming.
Dr. Nitin Bhatia: Yeah, if they don’t need it taken out we just leave it in.
Dr. Sechrest: So, I think I understand that piece. Let’s move to the back now and what’s available from the back? Are we doing the same thing?
Dr. Nitin Bhatia: The procedures from the back of the neck are a little different. Instead of going in and taking the discs out, we can’t do that from the back of the neck, mainly because it’s somewhat unsafe. But what we do is we open up the space for the spinal cord and allow it to move away from the discs and the things in the front of the neck that are pushing on it. It’s what we call an indirect decompression and it works wonderfully well. There are really two main kinds of it for myelopathy. One is called a laminectomy where we actually cut away the bones over the areas where the spinal cord has pressure on it; and nowadays, when we do a laminectomy, we usually do a fusion as well and a fusion is where we put the screws and rods in to hold it in place. The reason we do that is we know if you don’t do the fusion with the laminectomy, the neck again will fall into that forward position over a years and you’re making it a lot more than you started in. A second procedure, which I tend to prefer, is called a laminoplasty. In that we don’t actually remove the bone. What we do is cut the bone and create a hinge, kind of like in a door. So one side is partially cut whereas the other side is cut through and through. We then open it, like you would open the hinge of a door, allowing the spinal cord more space to move away from the compression. The real benefit of it is you don’t need a fusion because we’ve maintained the bone, and the neck doesn’t fall into that forward position or kyphosis. You don’t need the screws or rods, and it works very well and is a very rapid procedure. It’s actually not that commonly done in the US simply because many surgeons are not trained in it. It’s very commonly done in Japan where they see many, many cases of this myelopathy because of some genetic predisposition that they have to it, and it works wonderfully well for them.
Dr. Sechrest: Do you think that’s changing? Do you think more US surgeons are beginning to adopt the laminoplasty technique now that they see how it works?
Dr. Nitin Bhatia: Undoubtedly, and, in fact, our group has published and presented some of the biggest series of patients with laminoplasty and, after we first presented them, I got calls from my friends, who are very good surgeons around the country, who said, “Thank you for showing that, because it’s not something that we’re taught or even talk about very much in the US; and it really provides another great option for treating these patients”.
Dr. Sechrest: You mentioned that the difference between whether you choose going from the front to the back really is determined more about how long a segment of the neck is really involved. Like the shorter segments you do better from the front, and the longer – Why is that? Why do you tend to do better from the front than you do in the back? Any explanations for why?
Dr. Nitin Bhatia: The main reason for that is that, when we come in from the front of the neck, there’s not a lot of muscle that we have to get to, to get there. In fact, if you push on your neck here, you feel kind of a firm structure. That’s the spine. It’s fairly close to the front of the neck, which surprised me the first time I found that out 10-15 years ago in medical school. So, because there’s not a lot of muscle there, there’s not a lot of soreness after surgery, in fact, most patients say that it doesn’t hurt them at all. There are very low complication rates when you’ve got only one or two levels to do, because the healing of the reconstruction and fusion part heals very nicely. Once we go more than two levels, though, it’s harder for the body to heal all those levels of reconstruction consistently. So, even if two out of those three levels may heal, the third one may not, and that can lead to problems down the future although it doesn’t always.
Dr. Sechrest: So, in that case then, going through the back and damaging that muscle is probably less of a problem than trying to get all that bone to heal in front.
Dr. Nitin Bhatia: Exactly.
Dr. Sechrest: I see. I see. Well, you’d mentioned that the primary goal of either one of these operations from the front or the back is primarily to stop the process. Let’s talk a little bit about results from all of these things. What is the expectation if I’m a patient and I decide I’m going to have to have surgery? Let’s just summarize what a reasonable expectation, realistic expectations, of what you can from this surgery? And corollary to that is – Does it last?
Dr. Nitin Bhatia: Great questions. The expectations are that the progression of the myelopathy will stop, once the pressure is taken off of the spinal cord. Most people tend to get significantly better within 6 months of the surgery, and usually even much faster in that 6 weeks – 3 months; and the improvement will continue for 18 months after surgery. Most people don’t have problems again at the areas that were operated on. Now sometimes, for example, if we only do one level in the front of the neck, there’s nothing that saying that problems can’t occur above and below that just because of the patients’ predisposition to it. But, for the areas we operate on rarely, very rarely, do the problems come back.
Dr. Sechrest: Okay. You mentioned that you’re going to begin to see improvement for 6 months, maybe even longer?
Dr. Nitin Bhatia: Yes.
Dr. Sechrest: Then at one point it will stabilize and you sort of are as good as you’re going to get at that point.
Dr. Nitin Bhatia: Exactly.
Dr. Sechrest: Let’s move to something that obviously we, as surgeons, don’t like to talk about a lot, and that is, potential complications. What can go wrong with this procedure?
Dr. Nitin Bhatia: Sure. I think the first complication everyone worries about when we talk about spine surgery is paralysis: “Oh my gosh, what’s the risk of me waking up and having an injury to my spinal cord?” Fortunately, nowadays with our new technologies including great operating room microscopes so we can see everything we need to do, and spinal cord monitoring which actually a patient’s spinal cord throughout the surgery and can tell us if anything’s going wrong as well as the improvements in the anesthesia and surgical training. Surgeons, who are fellowship trained and only do spine surgery, tend to have a fair amount of experience with this. The complication rates are extremely, extremely low. The risk of something like paralysis is likely 1 in 2000 give or take a little and depending on the severity of the problem. The other kind of complications are the typical surgery kinds of complications – maybe bleeding a few tablespoons, most patients do not require any sort of transfusion from this. As with any surgery there is a minimal risk of an infection that is usually well taken care of with some antibiotics. Usually from the surgery in the front the throat is a little sore for a few days afterwards, sometimes up to a few weeks. Rarely, people can have problems with their voice for extended periods after surgery, because there’s a nerve that goes to the voice box that’s near the spinal cord there. That’s why I always do my incisions on the left side of the neck because the nerve on that side is a little more protected than the nerve on the right side of the neck, although either way you go in the risks are quite low. Probably, in general, if you put all of the risks together, they’re probably less than half a percent for significant ongoing complications after a procedure like this.
Dr. Sechrest: Well, it sounds like, clearly given a very serious condition, that the surgical risks are very acceptable, I think, especially given the new techniques we have today. Do you have any advice that you would give to a patient who is faced with making this decision? Obviously this is a serious decision and a serious problem. Anything we haven’t talked about that you would want to convey to patients that are faced with trying to either decide whether they need an evaluation or faced with the decision about whether to proceed on with surgery or not?
Dr. Nitin Bhatia: Well, I think the first question is, if you’ve seen our discussion, and have some of these symptoms, it’s worthwhile pursuing the evaluation of the neck and getting that MRI scan, because the diagnosis is one of the hardest things. Then getting in to see a good fellowship trained spine surgeon is really important. I would make sure that the patient and that surgeon have a good relationship and develop a good understanding; and, if patients are uncomfortable for whatever reason, and want to make sure that surgery is really the right option, get a second opinion to check. Go to your local University. Go to the local other spine practitioner who has a good reputation and see if they agree, but make sure you’re comfortable, and if this really is a problem that if you’re having symptoms, you will need to have surgery and the sooner we get to it, the better the results.
Dr. Sechrest: One final question, and that is, a lot of patients end up going to their regular medical physicians for problem. So, if I’m a patient and I think that I might have these symptoms and I go to my regular primary care physician, who may not be as familiar with this and I’m reassured that the primary care physician says, “Well, you know, I don’t think there’s anything wrong. Let’s watch this.” I think, from our discussion that we’ve just had, you would probably say that’s probably a bad idea.
Dr. Nitin Bhatia: I would say that’s a bad idea. You know, it’s not the primary care physician’s fault.
Dr. Sechrest: Right.
Dr. Nitin Bhatia: I mean, they have such a phenomenal breadth of knowledge. Unfortunately, this is one of those problems that really, there’s so much to learn in medical school, that it’s one of those problems that’s not really touched upon and, if it is, it’s 15 minutes in 4 years of schooling. It’s the spine surgeon’s job to know and, if you think you have these symptoms, make an appointment with your spine surgeon, have a good evaluation, have him listen to your history, and then have him figure it out. We’re really it out. We’re really the experts for this sort of problem. We’re the ones who should be making the diagnostic and therapeutic treatment decisions.
Dr. Sechrest: Yeah. I think that’s good advice, and I like the way you put it. I think that you’re right. We can’t all know everything, and this is one thing that not moving quickly or not being prudent can result in permanent damage.
Dr. Nitin Bhatia: Exactly.
Dr. Sechrest: Thanks. Thanks a lot for helping us understand this better and thanks for taking such good care of your patients.
Dr. Nitin Bhatia: My pleasure. Thanks for having me.
Dr. Sechrest: Thanks for watching today. If you have questions about the topic that we discussed today, or any orthopaedic topic, be sure to visit eOrthopod.com. If you’re an orthopaedic surgeon or healthcare provider interested in participating as a guest on eOrthopod TV, you’ll also find instructions on how to apply to become a guest on eOrthopod TV. Thanks for watching.