278 treatment of disk and ligamentous diseases of the cervical spine
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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
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