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Degenerative myelopathy — Clinical Guidelines

Overview

Degenerative myelopathy, often manifesting as degenerative lumbar scoliosis, is a 3-dimensional spinal deformity characterized by a coronal deviation greater than 10°, typically affecting elderly individuals and causing significant pain and disability 24.

Diagnosis

Clinical Presentation: Severe back pain, radiculopathy, and spinal claudication 19.

Radiographic Evaluation: Full-length standing spine radiographs are commonly used; coronal Cobb angle measurement is crucial 18.

MRI and CT: Coronal MRI images can better identify nerve root compromise compared to standard axial and sagittal views 12.

Biomechanical Assessment: Evaluating intervertebral disc degeneration and facet joint orientation aids in understanding curve rigidity and progression 27 32.

Management

Nonoperative Management: Physical therapy and conservative treatments are often initial approaches, showing efficacy comparable to arthroscopic surgery for some patients 9 23.

Surgical Interventions:

- Minimally Invasive Surgery (MIS): Techniques like MIS decompression and limited correction are favored for mild-to-moderate cases 26. - Fusion Procedures: Short-segment versus long-segment fusions debated; sagittal alignment and patient-specific factors crucial 34. - Selective Nerve Root Block: Precision treatment option for managing symptoms without extensive fusion 21.

Interdisciplinary Care: Reduces intensive care unit use post-surgery, beneficial for elderly patients 22.

Special Populations

Elderly Patients: Interdisciplinary management improves outcomes; careful consideration of balance and sagittal alignment in surgical planning 22 34.

Comorbidities: Presence of conditions like osteoporosis influences surgical technique and outcomes, necessitating tailored approaches 39.

Key Recommendations

Utilize full-length standing spine radiographs for preoperative assessment of degenerative lumbar scoliosis to guide surgical decisions 18.

Consider minimally invasive surgical techniques for decompression and limited correction in managing mild-to-moderate degenerative scoliosis to minimize complications 26.

Implement interdisciplinary care teams to optimize outcomes and reduce perioperative complications in elderly patients undergoing surgical correction 22.

(Evidence: Moderate)

References

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Degenerative myelopathy