الفهرس 
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Abstract
In this thesis, 22 Patients with cervical spondylotic myelopathy were admitted in the Neurosurgical department, Menoufiya University hospital where they were managed and operated.
The aim of this work was to evaluate the surgical outcome and complications of cervical laminectomy and lateral mass screw fixation for the operated cases.
All patients were subjected to clinical examination according to the neurological sheet applied in this study.
The mean age of our patients was 59.3 years. The vast majority of cases (10 cases, 45.5 %) were in the age group between 61 to 70 years old. In the current study, there was a significant relation between patient’s age at presentation and the post-operative neurological recovery rate. Where, younger patients had better outcome.
Male patients were affected more than females. Male to female ratio was (2.1:1).
Difficulty in fine hand movements, heaviness in lower limbs and neck pain were the main presenting symptoms. Among studied cases, difficulty in fine hand movements was present in (72.7%), heaviness in lower limbs was present in (68.2%) and neck pain in (50%) of cases.
In the current study, in decreasing order of frequency, other clinical presentations included; hyperreflexia that was found in (86.4%) of cases, positive Babinski sign in (77.2%) of cases, upper limb weakness in (72.7%) of cases, lower limb weakness in (68.2%) of cases, gait disturbances in (72.2%), upper limbs hypoesthesia in (63.6%), weakness in both upper and lower limbs in (59.1%), positive Hoffman’s sign in (50%), spasticity in (40.9%), sphincteric disturbances in (36.4%), limitation of neck movement in (31.8%), brachialgia in (22.7 %) and ankle clonus in (22.7%) of cases.
In the current study, there was significant relation between the duration of clinical presentations before surgery and the post-operative neurological recovery. Patients with short duration of myelopathy had better neurological recovery.
We used the mJOA score pre-operatively to assess the patient’s neurological functions and during the follow up period to assess their improvement.
In the current study, plain radiograph, CT and MRI were performed for all cases. Radiological findings included spondylotic changes with loss of cervical lordosis, cervical canal stenosis involving ≥ 3 levels, degenerative instability in flexion and extension radiographs and cord signal (myelomalicia) in MRI. Patients without pre-operative cord signal had better neurological recovery.
In our study, surgery was done for all patients who fulfilled the inclusion criteria. Lateral mass screws were inserted where the screw entry point was 1-2 mm medial and inferior to the mid-point of the lateral mass and the trajectory was 25 degrees lateral and parallel to the superior facet joint. Laminectomy was done for all cases after screws insertion.
We did not face any serious complications such as neurovascular injuries. Operative related complications were encountered in 5 cases (22.7%). Three patients (13.7%) had C-5 nerve root palsy, one patient (4.5%) had superficial wound infection and one patient (4.5%) had intra-operative lateral mass fracture in a single level at one site and this level was bypassed In the current study, neck pain, limitation of neck movements and lower limb weakness were the most common symptoms that were improved in the post-operative period while sphincter disturbance did not show much improvement.
In our study, the pre-operative mJOA score ranged from (5 - 13) and the mean was 9/18. One month post-operative, the mJOA score was improved where the mean became 11.5/18 and the range was (9 - 15). Three months post-operative, the mean became 13.1/18 and the range was (11 - 15). At six months post-operative, the mean became 14.6/18 and the score range was (12 - 17).
In our study, the post-operative neurological recovery rate at the end of the follow up period was excellent in 3 patients (13.7%), good in 14 patients (63.6%) and fair in 5 patients (22.7%). No patients had poor recovery rate. Both excellent and good recovery rates were considered satisfactory while fair or poor recovery rates were considered unsatisfactory. from the total number of cases, 17 patients (77.3%) had satisfactory outcome while 5 patients (22.7%) had unsatisfactory outcome.
In the final follow-up plain radiographs showed that, the cervical curvature remained good without cervical curvature changes and there was no instruments failure. Successful bone fusion was achieved in 20 patients (90%) of our cases.
Twelve patients completed one year of follow up. The pattern of neurological recovery in these patients was rapid in the first 6 months following surgery then the level of recovery stabilizes from the results of the current study, it is concluded that:
CSM occurs mainly in elderly patients but can also be seen in younger patients in cases of congenital canal stenosis.
Difficulty in fine hand movements, heaviness in lower limbs and neck pain are the main presenting symptoms in patients with CSM. Diagnosis of CSM is based on detailed history, the signs observed in clinical examination supported by radiological studies showing spinal cord compression.
MRI study is of great importance in establishing a presumptive diagnosis of CSM, delineating the cord compression and help for choosing the suitable surgical approach.
Lateral mass screws fixation can effectively restore and maintain the normal cervical lordosis and provide a stable biomechanical environment for neurological recovery.
The pattern of neurological recovery in patients with CSM is rapid in the first 6 months post-operative then the level of recovery stabilizes.
Many prognostic factors can affect the outcome in patients with CSM. Out of which are the following:
1. Proper selection and preparation of patients.
2. Patient’s age at presentation.
3. Duration of the pre-operative clinical presentations.
4. Neurological condition of the patient as reflected by the pre-operative mJOA score.
5. Cord signal (myelomalicia) in the pre-operative MRI.
6. Surgical skills, good knowledge of detailed surgical anatomy of the cervical spine and equipment availability.