9.1.1 Normal Anatomy and Significant Clinical Findings

Although the scenario in which the anatomy is normal or unimpressive in the face of significant clinical findings is relatively uncommon, it is common enough that the surgeon should be prepared for such challenging encounters. A case in point is exemplified by an unimpressive imaging finding in the region of the suspected pathology (left L4–5 region; Fig. 9.1). In this case, the patient presented with left lumbar radiculopathy with no neurologic deficit, but with significant tension findings (positive straight leg raising test at 45 degrees) and incapacitating pain. Magnetic resonance (MR) imaging demonstrated no overt pathology on the left side. There was no correlation between the imaging studies and the patient’s symptoms and physical findings. A herniated disc was present, but it was contralateral to the clinical findings (see Fig. 9.1). Such was confirmed by a repeated study. Hence, no correlation (no concordance) existed between the anatomy and the clinical findings. The surgeon’s urge to operate, and the patient’s desire to undergo surgery, may be significant. The rationale for such surgery, however, is lacking—particularly in view of the fact that there exists no evidence that ipsilateral surgery improves contralateral symptoms. Furthermore, nonoperative management is, in general, associated with good outcomes in such clinical situations. In fact, the long-term results of surgery and those of nonoperative management are equivalent (see Chapter 37). Hence, this decision-making process is relatively simple, with the patient aggressively counseled regarding the use of nonoperative strategies.

9.1.2 Significant Anatomy and Unimpressive Clinical Findings

A more difficult and challenging scenario is that associated with significant anatomical/imaging findings but unimpressive or absent clinical findings. Such may be encountered when imaging studies are obtained for “other reasons” and an “incidental imaging finding” is identified. Such a situation is typified by the case presented in Fig. 9.2. This 55-year-old patient underwent MR imaging of the cervical spine following the identification of significant stenosis with signal change on localization MR imaging obtained for back pain. The patient had no neurologic deficit, no Lhermitte sign, and no pathologic long-tract findings. He did have intermittent neck pain that was relieved by mild analgesics. He was told that surgery was imperative and should be performed soon (urgently) because even mild trauma could result in paralysis. What to do? Does information exist that helps with the decision-making process?

Well, the answer to the latter question is yes. Perhaps the most important factor here is the fact that the patient was essentially asymptomatic, so that surgery, if indicated, would be indicated for prophylactic reasons only. If surgery were not performed initially and the patient subsequently became symptomatic (i.e., myelopathic), surgery could then be performed for clinical reasons. Surgical risk data might help with the decision-making process for the asymptomatic patient at hand. Surgical risk data for such pathology suggest that catastrophe (paralysis or death) results in approximately 1 per 200 to 1 per 400 operations. This implies that surgery is associated with a surprisingly high risk for an unacceptable outcome—as high as 0.5%. Obviously, other, less substantial complications occur at a much higher rate.

What, though, is the risk for paralysis if a nonoperative approach is used? This is somewhat predicated on the natural history of the pathology. Because we do not know if the offending mass is new or has been present for years, or even decades, determination of the natural history becomes even more difficult. It is safe to assume, though, that in this case, the compression is relatively chronic because an acute compression of the spinal cord of such magnitude would most likely result in substantial neurologic deficit. Therefore, if the compression is chronic and has been present for some time, perhaps even decades, the patient has withstood a “test of time.”

Now, we must ascertain the risk for spinal cord injury in the general population. Let us assume that for a 50-year-old man, the chance of spinal cord injury in his lifetime is about 1 per 100,000. The stenosis depicted in Fig. 9.2 increases his risk, without question. Does it increase the risk 10-fold? If so, his risk for spinal cord injury in his lifetime is 1 per 10,000. Or, does it increase the risk 100-fold? In such a case, his risk for spinal cord injury in his lifetime is 1 per 1,000. Both risks are substantially less than the risk for catastrophe associated with surgery (1/200 to 1/400). Only if the risk for spinal cord injury in his lifetime is increased 1,000-fold by the presence of this imaging finding is the risk for catastrophic injury with surgery (1/200) less, from a statistical perspective, than that associated with the natural history (1/100). Obviously, we do not know the increase in risk associated with this stenosis, but the risk is likely not 1,000 times greater. Furthermore, many other factors are at play here, so that the decision-making process is not as simple as portrayed. Regardless, the employment of such data and logic can assist the surgeon in making decisions in tough cases such as this one. It is emphasized that the patient has the final say. Only the patient can truly assimilate the hard data presented by the surgeon and relate them to his or her own fears and expectations.