Dr. Miller: CSM. What is that? We're going to talk about that next on Scope Radio.
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Dr. Miller: I'm Dr. Tom Miller and I'm here with Dr. Erica Bisson. She's a neurosurgeon and also specializes in spine surgery. What is CSM?
Dr. Bisson: CSM actually stands for Cervical Spondylotic Myelopathy, which is a lot of words, but let me just break it down. What it means is that your spinal cord is being pinched in your neck. When I say pinched, the canal is being narrowed and that causes spinal cord dysfunction. Essentially, the messages that are coming from your brain and going out to your arms and legs aren't getting there in a timely fashion.
Dr. Miller: Now, who gets that?
Dr. Bisson: So the average age for patients who have CSM is in the 50s and 60s. We do see older individuals as well, but this is a degenerative process. This is something that happens as we age.
Dr. Miller: Now, do you go in surgically and open the space around the spinal column in order to create room for it to operate and function?
Dr. Bisson: That's exactly what we do. So when we approach this surgically, our main goal is to give the spinal cord room to move. If you look at an MRI or an image of an individual who has CSM, often you see bone spurs and other abnormalities that are causing the narrowing of the spinal canal so we have to either remove the bone spurs or open up the bone in some way, shape or fashion to enlarge that spinal canal so that the spinal cord itself gets completely surrounded by fluid and has a cushion enabling it to move properly.
Dr. Miller: If a patient has spinal cord dysfunction or CSM as you've called it, what are the symptoms that they might have? How would they know if they have this particular problem?
Dr. Bisson: Well, I'll tell you, the symptoms can be a little bit vague. Having said that, there are specific questions that I tend to ask patients to try to better understand if they're having symptoms from spinal cord dysfunction. Things that we talk about are problems with balance, so patients often have balance difficulty, their walking doesn't feel quite right. The other thing that patients mostly complain of is dropping things or loss of hand strength. They also complain of loss of dexterity. You know, it's funny, some of my patients tell me, "I feel like I'm telling my hands to do something, but they're not just quite doing it." Other patients tell me, "You know, I go to pick up my pen or I go to pick up my change of the counter and it slips out because I'm not quite able to tell what I'm picking up. I'm not feeling or sensing it."
Dr. Miller: Sensation in their fingertips. But isn't that also a problem of aging? Don't we get a little bit of that with aging? How do you tell it apart?
Dr. Bisson: Great question. You absolutely . . . so all those things, balance, loss of hand strength can be a problem with aging. What I'll comment is that I often have people who come in and have an MRI and I'm trying to differentiate them. You know, nationally and internationally, we're trying to find some kind of measure or test where we can say, "Ooh. That's CSM for sure." We don't have that yet. People are inventing all sorts of tests and new techniques to try to understand that, but it's the constellation of symptoms together.
They also, patients, find that they, if you examine them their reflexes are a little brisk. That's something we call Upper Motor Neuron Disease. Or that they're having spinal cord problems so we see this thing called hyperreflexia or abnormal reflexes where their knee jerks or their arm jerks a little bit too much, relative to normal.
Dr. Miller: If you do reparative surgery on these patients, what's the chance of recovery from the symptoms that they have?
Dr. Bisson: Tom, that is a fantastic question. And historically, if you review all the literature, which I have done time and time again on this topic, we have always told patients that the ultimate goal of the surgery is to halt the progression of the disease. The natural history of this disease process is that patients will get worse over time. So when we intervene, we open up that spinal canal and give room with a hope that we stopped them from getting worse, not that we're going to improve . . .
Dr. Miller: . . . what's happened already.
Dr. Bisson: Exactly.
Dr. Miller: But there's a good chance the progression would cease.
Dr. Bisson: Yes, absolutely. And what I will also tell you is anecdotally, after having seen many, many patients through this, over the last many years that I've focused my career around this, I do notice improvement. And I constantly am amazed at the recovery that I see. So while I tell every single patient going into surgery, "My goal is to stop the progression," anecdotally I see improvement. And I see vast improvement, which is so encouraging for me.
Dr. Miller: Now, there are different approaches as I understand, we talked about this a little bit before. I mean do you tell patients that there is a best way to perform the surgery? Is that something that you talked to them about? Or do we even know that?
Dr. Bisson: That's a great question. I would tell you that in some patients there is an optimal way. When we approach the neck for spinal surgery, we can either come in through the front of the neck or from the back of the neck and each has its pluses and minuses. There are some patients that only can have surgery from the front because different issues with their neck, the alignment or how the neck is curved and there are some patients who are most appropriate for the back. The vast majority or a good majority of patients can actually do either way, front or back. That happens to be a question that PCORI, which is the Patient-Centered Outcomes Research Institute set up by the government and through the ACA funded a large study that we here at the University of Utah are participating in, looking at the answer to that exact question.
Dr. Miller: So this may tell us in the end whether one approach or the other, back or front is best?
Dr. Bisson: Absolutely and we're very much looking forward to that.
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