Treatment of disk and ligamentous diseases of the cervical spine

Youmans chapter 278Vladimir Y. Dadashev

Gerald E. RodtsJr

Outline

• Anatomy and pathophysiology• Clinical finding• Diagnostic studies• Nonoperative treatment• Operative management

Pathophysiology of spondylosis• Progressive biomechanical stress and strain, repetitive

trauma• Noninflammatory joint degeneration, facet joint

osteoarthritis, posterior longitudinal ligament, ligamentum flavum

• Normal aging– Proteoglycan loss of absorb water loss of water decrease

viscoelasticity and reduction in volume reduce disk height– Stress, axial load translate to annulus fibrosus tear, wear– Disrupt Sharpey’s fiber stimulate reactive bony growth

osteophyte formation – Acute dissection disk herniation

Pathophysiology of spondylosis• Osteophyte peeling of PLL• Loss of height straightening of curvature of c-spine

axial loading shift anteriorly chronic compression vertebral body kyphotic deformity hypertrophy or laxity of joint and ligamentum flavum

• C4-5,C5-6 most angular mobility

Pathophysiology of spondylosis

• Nucleus pulposus : center,water-rich gel(as a result of proteoglycan molecules)

• Annulus fibrosus : type I collagen,organized in to sheet

Pathophysiology of pain• Mild axial pain to severe cervical myelopathy• Vertebral n. form by sympathetic trunk and the stellate

ganglion ALL, anterior annulus• Small branch of ventral ramus join vertebral n. to form

sinuvertebral n. PLL, posterior annulus, dura• Dorsal rami of the cervical nerve root supply most of

innervation of cervical facet joint,rich in nociceptive nerve ending

Pathophysiology of radiculopathy

• Acute– Secondary to soft disk degeneration– Younger – Prominent motor finding

• Chronic– Older– Predominant sensory– Associated with cervical spondylosis

Pathophysiology of myelopathy• Static factor : decrease canal diameter

– Spondylosis of disk,facet,vertebral body loss of lordotic– cervical canal stenosis, cord compression– Normal saggital cervical canal diameter 17-18 mm, – canal stenosis smaller than 13 mm

• Dynamic factor– repetitive movement of the compress cord– Flexion of spine oversteching of cord– Ligamentun flavum posterior cord– Rotatory and lateral flexion not significant cause

• Final cord change : ischemia and infarct, olidendrocyte apoptosis, cytotoxic changes

Clinical finding• Cervical pain

– Common– Exaggerated by neck flexion

• Cervical radiculopathy• Cervical myelopathy

Cervical radiculopathy• Spurling test

– The examiner turns the patient's head to the affected side while extending and applying downward pressure to the top of the patient's head

– A positive Spurling's sign (i.e. the Spurling's test is positive) is when the pain arising in the neck radiates in the direction of the corresponding dermatome ipsilaterally

Cervical radiculopathy• Abduction relief sign

– Adbuction patient arm on head

Cervical radiculopathy

Cervical radiculopathy• C3 : occipital and posterior neck pain,no motor component• C4 : lower neck, medial of shoulder, medial scapular pain• C5 : lateral aspect of shoulder, upper part of arm

deltoid,supraspinatus,infraspinatus weaknessdecrease bicep reflex

• C6 : neck down to lateral of arm and forearm, thumb and index painbicep weaknessdecrease bicep and brachioradialis reflex

Cervical radiculopathy• C7 : posterior portion of shoulder to lateral forearm/arm to middle • pain

Tricep weaknessdecrease tricep reflex

• C8 : ulnar side, fourth and fifth digit painhand grip weaknessHorner’s syndrome

• T1 : rare degenerative diseaseulnar and forearm decrease sensationintrinsic muscle

Cervical myelopathy• Chronic cord compression• Progressive chronic spondylosis• LMN

• Secondary to a-motor neuron or existing nerves root• Dermatomal weakness, tingling, numbness, decrese fine motor

coordination• Atrophy and weakness of the arms or hands• Diminish pin prick sensation• Decrease DTR

Cervical myelopathy• UMN

• Long tract compression• Corticospinal tract, Spinothalamic tract, Dorsal

column ,Spinocerebellar tract• Unsteady, clumsy gait, leg rigidity, altered sensation, bowel and

bladder dysfunction• PE : lower extreme spasticity, hyperreflexia, Babinski, clonus or

Hoffman reflex

Diagnostic studies

• Plain radiograph• Computed tomography• Magnetic resonance imaging• Neurophysiologic studies• Diskography

Plain radiograph• Anatomy : fracture of vertebral body, pedicle, lamina• Pathologic : spondylosis, erosive lesion(infection,

tumour), trauma• Lateral view : alignment• Flexion, Extension : instability

Computed tomography• Sagittal, Coronal, 3D construct• Bony anatomy• Abnormal bone growth : osteophyte, ligament

ossification• Neuroforamina, spinal canal• Invaluble for cord and nerve root compression• CT-Myelography superior to MRI in postoperative scars,

instrumentation, claustrophobia, indwelling pacemaker

Magnetic resonance imaging• Highly in diagnosis surgical pathological• T1,T2 • in Myelopathy : high signal in spinal cord

Neurophysiologic studies• Not usually need if clinical syndromes and radio imaging

confirm• Nerve conduction studies

• Motor NCS, Sensory NCS, F-wave study and H-reflex

• Needle electromyography• Presence of fibrillation ,positive sharp wave muscle fiber

denervation• 3 wk after initial symptom to show

Nonoperative management• Cervical pain

– Conservative– NSAID, opioid anagelsic, muscle relaxant– Facet joint anesthesia block to identify– Physical theraphy : isometric exercise

• Cervical radiculopathy– Conservative– Rest, Medication(NSAID, steroid), Cervical collar, Physical therapy, patient

education, local injection– Opioid for severe pain– Muscle relaxant for muscle spasm– Gabapentin for neuropathy pain

• Cervical myelopathy : FU neurological examination, if progress considered for surgery

Indication for surgery• Acute worsening neurological status• Persistent or progression of neurological despite

continue conservative treatment• Persistent or recurrent arm pain longer than 6 wks with

confirmatory imaging findings

Operative management• Cervical pain• Cervical radiculopathy• Cervical myelopathy

Posterior approach for diskectomy

• For– One or two level pathology– Consider in pt with contraindication for anterior approach

• Pt of history of surgery• Dysphagia• Vocal cord paralysis

• Advantage– Direct visualization of root– Preservation of the remaining disk and motion segment– Avoidance of complication for anterior approach : recurrent

laryngeal n.– Prevent degenerative complication related to anterior fusion

Anterior cervical diskectomy with or without fusion

• Evaluate sagittal alignment• ACDF : add 5 degree of lordosis curve per level

physiologic lordotic curve of C-spine• Fusion : allograft(iliac crest), fusion cage (PEEK,

titanium)• Complication

– Early : esophageal perforation, postoperative dysphagia, postoperative hematoma, recurrenlaryngeal nerve palsy, horner’s syndrome, instrumentation backout, wound infection

– Late : adjament –segmental disease, adjacent-level ossification, pseudarthrosis, implant malfunction

Cervical myelopathy

• Dorsocaudal aspect of C2 to same C7 point

Cervical myelopathy

• Dorsocaudal aspect of C2 to same C7 point