I.

Cervical Spondylosis (British Medical Journal, Best Practice) Pathophysiology The spine includes 2 basic cartilaginous joints: o the disc, which contains a complex hydrogel material o the facet joints, which are synovial joints The disc hydrogel is poorly maintained with maturity due to the loss of the primary disc cells and sclerosis of the end plates preventing diffusion of nutrients. The disc joint becomes dehydrated and narrows. At a certain degree of narrowing, the annulus of the disc, which is normally without nerve endings, can become innervated and develop osteophytes at the margins, similar to any type of mobile joint. Because the function of the facet joints is primarily prevention of rotation and flexion/extension, their degeneration is enhanced with more axial loading as the disc joint narrows, placing more stress on the facet joints. The cervical joint degeneration or spondylosis is entirely asymptomatic in many people, except perhaps for decreased cervical range of motion. However, a number of patients experience axial neck pain with mild degenerative changes. For this reason, the degree of spondylosis on cervical radiographs or MRI does not necessarily correlate with the syndrome of axial neck pain. The perception of the pattern of pain with cervical spondylosis is that the joint receptor signals (including those of abnormal nerve fibres innervating the annulus with degeneration) are routed to cervical paraspinal muscles in particular, resulting in paraspinal muscle spasm and characteristic interscapular and lateral neck pain. Cervical spondylotic radiculopathy (CSR) results if the nerve exiting the spinal cord and the spinal canal is pinched by either disc degeneration alone (i.e., herniated disc, wherein an annular weak spot allows displacement of disc nucleus contents to be adjacent to the nerve root) or with moderate to severe degenerative changes, narrowing the root exit at the foraminal level. Cervical spondylotic myelopathy (CSM) usually involves severe disc and facet degeneration with changes in the alignment of the spine, such as kyphosis or spondylolisthesis, along with osteophyte formation. These lead to a significantly narrowed spinal canal and secondary spinal cord deformation. Treatment approach In patients with symptomatic cervical spondylosis, there are 3 main clinical syndromes: o Axial neck pain o Cervical spondylotic radiculopathy (CSR) o Cervical spondylotic myelopathy (CSM). The last 2 syndromes may overlap and both include degrees of axial neck pain. Pain may be acute or chronic, is the most common symptom, and may occur with or without neurological symptoms due to radiculopathy and/or myelopathy. Axial neck pain o First-line treatment of acute (<6 weeks), non-traumatic axial neck pain is physiotherapy, including cervical traction. The degree of axial neck pain can be assessed by simple outcome measures to determine the effects of subsequent treatment. [23] It is unclear whether patient education alone is helpful for treatment. o Depending on the severity of pain, the additional use of NSAIDs may be beneficial in individual patients.

o If muscle spasm is a feature of the pain, muscle relaxants and manoeuvres (including heat, massage, and cervical pillows) may be beneficial in some patients. The addition of trigger-point and/or facet joint injections and transcutaneous electrical nerve stimulator (TENS) units may also be beneficial. o Additional treatment modalities include various forms of cervical epidural injections, chiropractic treatment, acupuncture, and other, less orthodox approaches, particularly electrotherapy, laser therapy, and cervical spine manipulation therapy. These therapies may entail additional risks and are not supported by evidence. o All of these treatments are symptomatic, to relieve specific parts of the patient's complaints, and none have any effect on the underlying cervical spondylosis or affect the long-term nature of the cervical degenerative changes. Very few treatments have any effect beyond 6 weeks. o Chronic neck pain (>6 weeks) may be managed by continuing these symptomatic treatments if they improve the patient's discomfort. Axial neck pain is starting to receive consideration for cervical arthroplasty, although this procedure is not yet approved for axial neck pain alone by organisations such as the FDA. Physicians should refer to local consultants on indications for the procedure in their region. Cervical spondylotic radiculopathy o Radiating arm pain can be severe and is initially managed with oral analgesia combined with physiotherapy and cervical traction. Oral corticosteroid therapy may also benefit individual patients. Because patients initially have severe pain, a combination of these treatments is suggested at the outset to curtail the nerve irritation. o Depending on the timing and outcome of these initial treatments, subsequent more invasive treatments may consist of epidural corticosteroids or cervical nerve root block at the suspected level to maintain a positive effect from the oral corticosteroids. o In most patients (around 75%), the severe arm pain will spontaneously relent by 4 to 6 weeks. The pain eventually resolves with conservative measures, but it may take 1 to 2 years to completely disappear. o If the pain does not resolve and if all symptoms, signs and diagnostic studies converge to indicate pressure on a single nerve root, then surgical nerve decompression may be helpful. There are a variety of technical aspects to nerve decompression (which continue to be debated) but either anterior discectomy or posterior nerve decompression procedures are generally selected, based on the patient's symptoms, number of levels of involvement, and specific anatomy from the cervical MRI scan. Because significant weakness or neurological change is rarely associated with radiculopathy, the primary decision for considering surgical decompression is the patient's subjective degree of pain and the significance of the discomfort. Cervical spondylotic myelopathy o Surgical decompression is the preferred first-line acute treatment in patients with severe symptoms who are good surgical candidates, although 2 RCTs do not show any shortterm benefit for mild to moderate myelopathy. Surgical decompression would ideally provide significant space for the spinal cord while retaining mobility of the cervical spine without leading to instability; this ideal treatment does not exist. Usually, adequate treatment of the severe underlying degenerative joint disease (DJD) requires fusion or

immobilisation of the segments, leading to loss of range of motion of the cervical spine. With anterior approaches, adjacent segments often develop DJD over time, leading to adjacent segment stenosis. With posterior approaches there can be either instability (following laminectomy alone) or near complete loss of cervical range of motion, with the typical extensive posterior fusion needed. Furthermore, decompression surgery typically only stabilises spinal cord function (with only mild improvement in symptoms), because there is usually existing permanent damage to the spinal cord at the time of surgery. The trend is consequently towards earlier surgery, while the patient has more of a chance of returning to normal function, or surgery while the patient is asymptomatic. o Conservative treatment consists of immobilisation in a hard cervical collar. This is the preferred treatment for patients who are poor surgical candidates or who have mild, chronic symptoms. This conservative treatment has been shown in mild to moderate myelopathy to be equivalent (over 1 to 3 years) to surgical decompression. There are no long-term drugs that are helpful in management of cervical spondylotic myelopathy; short-term steroids may be used as a bridge prior to possible surgical decompression, but for <2 weeks due to their side-effects profile. o Surgical treatment of all levels of cervical myelopathy is considered the standard of care in some countries, despite no existing specific evidence supporting this option. Surgical decompression is therefore typically offered to patients on presentation, though there is variability between individual surgeons. Due to this bias and the worry that patients may experience irreversible deterioration if surgical decompression is delayed, it is very unlikely that any randomised surgical trials for cervical myelopathy will be planned. One on-going prospective (but not randomised) trial of cervical spondylotic myelopathy has been concluded, but full data are not available as of June 2011. II. Timeline of Events (Philippine Inquirer) Friday, July 29th, 2011 GMA underwent surgery, four days after she was brought to the hospital due to severe pain in the upper limbs, which doctors said was a result of nerves being compressed in the neck area. Prior to the operation, she was undergoing pain management and physical therapy for a portion of her spine that had become misaligned, an age-related condition called cervical spondylosis Doctors then put titanium plates to correct four afflicted levels of her spine. She was discharged a week later. Dr. Juliet Cervantes (main AP) said the operation at the St. Lukes Medical Center in Fort Bonifacio, Taguig City took seven hours. Wednesday, August 10th, 2011 GMA underwent a second surgery to remove an infected implant on her cervical spine Doctors attempted to replace the plates after these were dislodged. The infection had caused fluid to collect in Arroyos cervical spine and dislodged the plates. Doctors said the weakening of Arroyos bones was also a reason why the implants were dislodged even after these were screwed into place. GMA would undergo a third operation for a new implant once her condition improves. Dr. Juliet Gopez-Cervantes said that the surgery would involve reinforcing the titanium plates with a mesh made from the same metal to hold the screws in place.

Bone grafts from Arroyos pelvis would also be placed on the mesh, which the doctors hope to grow in order to add stability to the implant

Thursday, August 25th, 2011 GMA went under the knife for the third time. Doctors at St. Lukes Medical Center (SLMC) in Taguig City repaired the metal implant on Arroyos neck on Wednesday morning, a procedure initially scheduled on Tuesday but was postponed after she developed a fever over the weekend. Surgeons proceeded with the operation at around 8 a.m. and finished at around 2 p.m. Wednesday, October 19th, 2011 Dr. Juliet Gopez-Cervantes, along with the team of physicians who attend to the former president, said their patient was showing signs of recovery from her most recent operation. Dr. Mario Ver, Arroyos orthopedic surgeon said his patients clinical condition showed progress after the post-operative consultation earlier Tuesday. He said Arroyo showed a remarkable improvements of her neurologic status and that she no longer suffered from pains she earlier felt in her neck, arms, hands or weakness and numbness in her upper extremities. The medical bulletin added Arroyos implant was seen as stable in her x-ray results. St. Lukes Medical Centers Radiology Institute Director, Dr. Bernie Laya, supported Arroyos physicians in saying that the Pampanga representative was showing signs of recovery Laya said there were signs of bone growth in the anterior column from C3 to C7 of Arroyos cervical spine. The doctors added the halo vest that was screwed into Arroyos skull has been replaced with a less rigid brace three weeks ago. They said they have also advised the former president to do some neck movements to help in her recovery. Tuesday, November 8th, 2011 GMA was also diagnosed to be suffering from hypoparatyhroidism. A spokesperson for Arroyo said her treatment depended ultimately on a bone biopsy, which the family wanted to avail of abroad. PMA governor Dr. Leo Olarte said the radio isotope scan or bone scan was a ready alternative, adding that it was noninvasive compared to a bone biopsy. Like a bone biopsy, a bone scan can also detect a bone tumor or cancer and determine if a cancer that began somewhere in the bodysuch as the thyroid, breast, lung or kidneyhad spread to the bones. Olarte, also an orthopedic surgeon, said bone scans were readily available in the country. In my personal opinion, a bone biopsy is just an option but we have the radio isotope scan that can take the place of the bone biopsy, said Olarte. He said he would highly recommend a bone scan which would not require Arroyo to undergo an operation. These metabolic experts belong to the Philippine Society of Endocrinology and Metabolism, a specialty component of the PMA which is also the proper body to declare whether or not there exists a metabolic expert physician in the country, said Olarte. Olarte said both the proceduresbone biopsy and bone scancan be done in the Philippines.

Saturday, November 19, 2011 The Pasay City Regional Trial Court's warrant of arrest against GMA saved the country from a brewing constitutional crisis. Jose Cabrera, Integrated Bar of the Phil (IBP) national executive director, said that the order of the lower court broke the standoff between the executive and the judiciary over Mrs. Arroyo's plan to leave the country for medical treatment. Cabrera said that the executive branch should not weaken the judiciary with its defiance of the Supreme Courts (SC) order. Once you weaken the Supreme Court, everybody suffers... We are inviting a revolt and civil war here, he said. He stressed that the government cannot just defy the orders of the Supreme Court simply because it is not popular. Still the rule of law must be the rule and not the rule of men, he said. On Tuesday, the high court issued a temporary restraining order (TRO) on the Department of Justice's watchlist order (WLO), which prevents Mrs. Arroyo from leaving the country. Instead of abiding by the TRO, Justice Secretary Leila de Lima announced that the WLO was still in effect and ordered immigration officers to prevent Mrs. Arroyo and her husband, Jose Miguel Arroyo, from leaving the country. De Lima's order prevailed on Tuesday night, as the Arroyo couple was denied by immigration officers to board a plane bound for Hong Kong. Cabrera said that refusing to abide by the TRO was an open defiance of the high court. He also said that the SC should also consider as an "insult" Malacaang's obedience to the lower court's order while refusing to acknowledge its TRO. The executive must be consistent. It must not choose which order to follow. It must set an example, especially that Justice Secretary Leila de Lima is the symbol of the law in the executive branch, he added. Friday, November 25, 2011 The Pasay City Regional Trial Court subpoenaed yesterday the three doctors of GMA at the St. Lukes Medical Center in Taguig City so they can tell the court the true state of health of the former president. Pasay RTC Judge Jesus Mupas of Branch 112 summoned Dr. Juliet Gopez-Cervantes, Dr. Mario Ver and Dr. Roberto Mirasol to attend the 8:30 a.m. hearing today in connection with the motion of Comelec investigation and prosecution division chief Maria Juana Valeza asking about the medical condition of Mrs. Arroyo. Around 1 p.m. yesterday court sheriff Rodelio Buenviejo and court process server Ismael Cuerdo brought the subpoena to the office of Marilen Lagniton, Vice President of Corporate Affairs at St. Lukes Medical Center. Atty. Joel Pelicano, clerk of court of branch 112, said the court ordered the doctors of the former president to submit before the court all documents, particularly medical records, medical abstract and the result of their examination to have a better knowledge on the true state of health of the accused in the electoral sabotage case filed by Commission on Elections. If summoned, the doctors of former Mrs. Arroyo are willing to appear before the Supreme Court or any investigating agency.

Lagniton, SLMC vice president for corporate affairs, gave this assurance adding that they are willing to cooperate with the proceedings and testify on the real medical condition of the former president. According to Lagniton, the doctors would only speak based on their medical findings on the condition of Arroyo. If summoned, of course they will appear, Lagniton said in an interview, adding that they are already preparing the medical abstract and other pertinent documents in case they will appear before the SC. They will always stick with the truth, only and always based on clinical evidence, she added. Earlier, Justice Secretary Leila de Lima through the Office of Solicitor General has filed an urgent motion asking the SC to summon Arroyos doctors.

Tuesday, November 29th, 2011 The Supreme Court on Tuesday blocked the move of the Department of Justice to summon the attending physicians of Gloria Macapagal Arroyo in a bid to justify Justice Secretary Leila de Limas decision to bar the former President from leaving the country. Voting unanimously, the 15-member high tribunal ruled that there was no need to compel the doctors to appear on Thursday during the continuation of the oral arguments on the constitutionality of De Limas watch-list order against Arroyo and her husband, Jose Miguel Mike Arroyo. The motion has been denied because the doctors have already appeared before the Pasay (City) regional trial court which is hearing the (electoral sabotage) case against the former President, Midas Marquez said during a news briefing. De Lima stressed the importance of compelling the doctors to appear at the oral arguments, arguing that the magistrates would have a better understanding of the medical abstract that Arroyos lawyers submitted to the high tribunal if her doctors would explain their findings. De Lima said while the doctors had already appeared before the Pasay RTC, their testimony was limited. I think they were only asked if (Arroyo) needs continuing confinement. The issue in the Supreme Court is different. Their testimony would let the justices understand that I denied her (travel request) with good reasons, she said. In its urgent motion on Nov. 23, the OSG argued that it was important for Arroyos doctors to inform the justices of her actual physical condition in order to help them decide on her pending motion challenging DOJ Circular No. 41. The circular, issued during Arroyos presidency, authorizes the justice secretary to issue watchlist and hold-departure orders on persons facing criminal investigation. Estelito Mendoza, Arroyos lawyer, argued that the doctors testimony would be irrelevant to the debate on the constitutionality of the watch-list order and the DOJ circular.