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Tratado de Cirurgia da Coluna Vertebral
SECTION 5 • Degenerative Diseases
Chapter48

Cervical Stenosis, Degenerative Cervical Myelopathy and OPLL

Authors:Fernando Luiz Rolemberg Dantas•François Dantas•Victor Kelles Tupy da Fonseca
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Sec. 5Degenerative Diseases
Cap. 48Clinical Chapter
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Chapter Summary

• Context: A cervical myelopathy degenerativa (MCD) representa uma das principais causas de disfunção medular no adulto. Degeneração discal, osteófitos, hipertrofia facetária, alterações ligamentares, instabilidade e ossificação do ligamento longitudinal posterior (OLLP) podem reduzir progressivamente o espaço disponível para a medula. A fisiopatologia combina compressão estática, fatores dinâmicos relacionados aos movimentos cervicais e alterações vasculares e histopatológicas secundárias. O diagnóstico pode ser tardio porque os sintomas iniciais — perda de destreza, parestesias ou alteração discreta da marcha — são facilmente atribuídos a outras condições. A RM é fundamental, mas compressão cervical também pode existir em pessoas assintomáticas, tornando o exame neurológico indispensável. Escalas funcionais auxiliam na avaliação de gravidade. O tratamento depende da intensidade e progressão da mielopatia, do número de níveis, da localização da compressão, do alinhamento e, nos casos de OLLP, de suas características morfológicas.
• Chapter Objective: understand the pathophysiology e a apresentação da MCD, reconhecer precocemente a síndrome medular, utilizar escalas clínicas e métodos de imagem, compreender a classificação e importância da OLLP e selecionar conceitualmente entre abordagens anterior, posterior ou combinada conforme compressão, extensão e alinhamento cervical.
• Compressão estática, dinâmica e dano neuralO capítulo organiza a fisiopatologia em componentes estruturais, movimentos cervicais repetitivos e consequências vasculares e histológicas. Isso ajuda a explicar por que a magnitude da compressão em uma única imagem estática não representa toda a doença.
• O diagnóstico começa na funçãoPerda de destreza manual, alteração da marcha, hiper-reflexia, parestesias e comprometimento progressivo da coordenação são manifestações centrais. As escalas JOA modificada e Nurick, apresentadas nas Tabelas 48.1 e 48.2, ajudam a documentar gravidade e evolução. A Figura 48.4 ilustra elementos do exame neurológico, incluindo sinais de trato longo, equilíbrio e destreza manual.
• OLLPA OLLP pode apresentar diferentes padrões morfológicos, demonstrados na Figura 48.1, e associação com ossificação dural, ilustrada na Figura 48.2. A K-line, apresentada na Figura 48.3, integra alinhamento e volume da ossificação e auxilia no raciocínio sobre a capacidade de decompression posterior indireta.
• ImagemRadiografias ajudam a avaliar alinhamento e mobilidade. A TC define particularmente bem a anatomia óssea e a OLLP. A RM demonstra compressão e alterações intramedulares. A Figura 48.10 ilustra um ponto importante: exames dinâmicos podem revelar compressão relacionada à posição não evidente na aquisição neutra.
• TratamentoMielopatia moderada ou grave e deterioração progressiva favorecem cirurgia. Casos leves podem ser individualizados e acompanhados cuidadosamente em situações selecionadas. Via anterior, laminectomy com fusão, laminoplasty e procedimentos combinados apresentam vantagens e limitações distintas. O capítulo enfatiza que número de níveis, localização da compressão, sagittal alignment, instabilidade e comorbidades devem determinar a escolha. Estudos comparativos discutidos pelos autores não demonstram uma superioridade universal da via anterior ou posterior quando a indicação é adequadamente individualizada.
• Clinical Application: Um paciente que passa a deixar objetos cair, apresenta mudança de caligrafia, dificuldade para abotoar roupas ou alteração inexplicada da marcha merece investigação de MCD mesmo quando a neck pain não é proeminente. A ausência de Hoffmann ou Babinski não exclui doença. Polineuropatias podem inclusive mascarar hiper-reflexia. A RM deve confirmar um quadro clínico compatível e demonstrar nível e extensão da compressão. TC ganha importância especial diante de OLLP e para planejamento anatômico. Na decisão cirúrgica, “anterior ou posterior?” não deve ser respondido apenas pelo número de níveis. O alinhamento da coluna, localização do elemento compressivo e possibilidade de a medula migrar posteriormente após uma decompression influenciam a escolha. Nos casos de OLLP, características morfológicas e eventual ossificação dural também alteram o risco e a estratégia. Assim, o objetivo não é aplicar uma operação padrão à MCD, mas selecionar uma decompression que respeite a anatomia, mantenha ou restaure estabilidade e minimize o risco de complicações.
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Keywords

Preferred DeCS/MeSH Descriptors:
Coluna VertebralProcedimentos Cirúrgicos OperatóriosDiagnóstico por ImagemArtrodeseBiomecânicaQualidade de VidaReabilitação
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Why this chapter matters

O atraso diagnóstico pode significar perda neurológica progressivamente menos reversível. Ao mesmo tempo, compressão cervical na RM não basta para diagnosticar mielopatia. O capítulo ensina a unir função, exame neurológico e imagem e fornece a base para uma das decisões mais importantes da cirurgia cervical degenerativa: quando operar e qual corredor oferecerá decompression adequada com menor custo biomecânico e neurológico.

“cervical myelopathy degenerativa é uma síndrome clínica progressiva associada a compressão e sofrimento medular. Reconhecimento precoce é essencial. A RM caracteriza a medula, enquanto radiografia e TC acrescentam informações sobre alinhamento, mobilidade e OLLP. Quando a cirurgia é indicada, não existe uma via universalmente superior: localização da compressão, número de níveis, alinhamento e características individuais devem orientar a estratégia.”
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Chapter Highlights

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Card 1 — Mielopatia pode começar discretamente. Alteração da caligrafia, perda de destreza ou desequilíbrio podem anteceder sinais neurológicos exuberantes. A ausência de neck pain intensa não deve reduzir a suspeição diante de sintomas de disfunção medular.

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Card 2 — O alinhamento escolhe a via. Número de níveis é apenas parte do planejamento. Localização da compressão, lordose ou kyphosis, instabilidade e OLLP determinam se uma estratégia anterior, posterior ou combinada oferece a melhor decompression.

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Card 3 — OLLP exige planejamento próprio. Morfologia da ossificação, relação com a dura e alinhamento cervical modificam tanto a eficácia da decompression indireta quanto o risco de complicações. OLLP não deve ser tratada como simples estenose espondilótica.

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Treatise in Debate

Official videocast derived from the treatise chapters.

Episode 1 – Chapter 8: Sagittal Plane Spinal Alignment

Discussion with the authors on fundamental concepts of sagittal alignment, radiographic parameters, and clinical significance.

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