Degenerative Diseases Degenerative Diseases of the of the Cervical Spine Cervical Spine Operative treatment Operative treatment George Sapkas George Sapkas Asc. Professor Asc. Professor 1 st st Orthop. Dpt. Orthop. Dpt. Medical School Athens University Medical School Athens University George Kelalis George Kelalis Orth. Surgeon Orth. Surgeon Metropolitan Hospital Metropolitan Hospital
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Degenerative Diseases Degenerative Diseases of theof the
Cervical SpineCervical Spine
Operative treatmentOperative treatment
George SapkasGeorge SapkasAsc. Professor Asc. Professor 11stst Orthop. Dpt. Orthop. Dpt.
Medical School Athens UniversityMedical School Athens University
George KelalisGeorge KelalisOrth. Surgeon Orth. Surgeon
17 mm (13 – 20 mm) midsagital diameter17 mm (13 – 20 mm) midsagital diameter< 13 mm – congenital stenosis< 13 mm – congenital stenosis
– Cord dimensionsCord dimensions10 mm (8.5 – 11.5), 90 – 100 mm10 mm (8.5 – 11.5), 90 – 100 mm22
< 60 mm< 60 mm22 (Penning et al, 1986) (Penning et al, 1986)Better recovery > 40 mmBetter recovery > 40 mm22, A-P ratio > 0.40, A-P ratio > 0.40
– Vascular factorsVascular factorsBrieg et al, 1952 – spondylosis leads to Brieg et al, 1952 – spondylosis leads to decreased flow in anterior brancesdecreased flow in anterior brances
– Dynamic factorsDynamic factorsHyperextensionHyperextensionPincer effectPincer effectHypermobility above stiff segmentHypermobility above stiff segmentDynamic cord and vascular changesDynamic cord and vascular changes
32% moderate or severe 32% moderate or severe painpain
Radicular symptoms – less Radicular symptoms – less favourablefavourable
Treatment did not influence Treatment did not influence outcomeoutcome
(Gore et al. Spine 1987)(Gore et al. Spine 1987)
Myelopathy Myelopathy
Did not follow radiculopathy Did not follow radiculopathy
Episodic progression, static disability for yearsEpisodic progression, static disability for years
Progressive deterioration rareProgressive deterioration rare(Lees et al, BMJ 1963)(Lees et al, BMJ 1963)
Disability established early Disability established early
Static periods for many yearsStatic periods for many years(Nurick, Brain 1972)(Nurick, Brain 1972)
67% steady progressive deterioration67% steady progressive deterioration(Symon et al, Neurology 1967)(Symon et al, Neurology 1967)
Poor prognosis Poor prognosis
Non improvement if symptoms > 2 yearsNon improvement if symptoms > 2 years(Phillips, J. Neur. 1973)(Phillips, J. Neur. 1973)
Clinical evaluationClinical evaluation
Neck painNeck pain
Determine exact location of painDetermine exact location of pain
Referred pain patterns from Referred pain patterns from specific disc and facet jointsspecific disc and facet joints
Check ROM and for pain with Check ROM and for pain with specific motionspecific motion
Position of maximal discomfort Position of maximal discomfort
Watch out for:Watch out for:√ Substitution paternsSubstitution paterns√ Tumors – infectionTumors – infection√ Inflammatory arthritisInflammatory arthritis√ Pain referred from heart, viscera, and Pain referred from heart, viscera, and
T-M jointT-M joint
Radiculopathy Radiculopathy
Look for specific dermatomal distribution Look for specific dermatomal distribution to painto painShoulder abduction signShoulder abduction signSpurling signSpurling signC3, C4 – diaphragm involvementC3, C4 – diaphragm involvementC5 – dermatome – epaulet, Deltoid ? C5 – dermatome – epaulet, Deltoid ? Biceps reflexBiceps reflexC6 – dermatome – radial forearm and C6 – dermatome – radial forearm and hand, muscles, biceps reflexhand, muscles, biceps reflexC7 – dermatome – long finger – medial C7 – dermatome – long finger – medial scapula, muscles, triceps reflexscapula, muscles, triceps reflexC8 – dermatome – ulnar hand and C8 – dermatome – ulnar hand and forearm, finger flex -intrinsicsforearm, finger flex -intrinsics
Nurick grading of disability Nurick grading of disability based on gait abnormalitybased on gait abnormality
Grade IGrade I No difficulty in walkingNo difficulty in walking
Grade IIGrade II Mild gait involvement. Does not interfere with Mild gait involvement. Does not interfere with employmentemployment
Grade III Grade III Gait abnormality prevents employmentGait abnormality prevents employment
Grade IVGrade IV Able to ambulate only with assistanceAble to ambulate only with assistance
Grade VGrade V Chairbound or bedriddenChairbound or bedridden
Imaging studiesImaging studies
The cervical spine is a The cervical spine is a complex region with the complex region with the following elementsfollowing elements
Bone Bone
DiscDisc
LigamentsLigaments
Neural elementsNeural elements
Facet jointsFacet joints
Paraspinal musculature Paraspinal musculature
False positive imaging studies in False positive imaging studies in asymptomatic patientsasymptomatic patients
25% incidence of degenerative 25% incidence of degenerative changes on plain radiography by 5changes on plain radiography by 5 thth decadedecade
75% incidence by 775% incidence by 7 thth decade decade
No significant differences on plain film No significant differences on plain film between symptomatic and between symptomatic and asymptomatic patients asymptomatic patients
Cont…
Plain radiographyPlain radiographyA minimum 4 - week period of conservative A minimum 4 - week period of conservative treatment is recommended prior to plain x-rays treatment is recommended prior to plain x-rays with exception of:with exception of:√ TraumaTrauma√ Suspicion of neoplasmSuspicion of neoplasm√ Worsening neurologic deficitWorsening neurologic deficit
Flexion and extension views can be added to Flexion and extension views can be added to evaluate the dynamic properties of the cervical evaluate the dynamic properties of the cervical spinespinePlain radiography can demonstrate:Plain radiography can demonstrate:
Congenital stenosisCongenital stenosisSpondylotic segmentsSpondylotic segmentsForaminal narrowingForaminal narrowingDegenerative subluxationDegenerative subluxationCongenital malformation Congenital malformation Autofused spinal segmentsAutofused spinal segmentsOsteochondrosis of the nucleous puplosusOsteochondrosis of the nucleous puplosusSpondylosis of the annulus fibrosis Spondylosis of the annulus fibrosis Vacuum phenomenon and disk space height lossVacuum phenomenon and disk space height lossReactive sclerosis of the endplatesReactive sclerosis of the endplatesSchmorl´s nodes Schmorl´s nodes
M.R.IM.R.I
Progressive neurologic Progressive neurologic deficitdeficitDisabling weakness Disabling weakness Long tract signsLong tract signsCervical radiculopathy with Cervical radiculopathy with failure to improve following failure to improve following 6 – 8 weeks of conservative 6 – 8 weeks of conservative measures measures Vertebral body destruction Vertebral body destruction or instability detected on or instability detected on plain film plain film
Myelography - Computed tomographyMyelography - Computed tomographyProvides excellent details and differentiation of bone Provides excellent details and differentiation of bone versus soft tissue lesionsversus soft tissue lesionsIndicated when MRI fails to provide sufficient detail or Indicated when MRI fails to provide sufficient detail or does not match clinical findingsdoes not match clinical findingsStudy of choice in the presence of severe degenerative Study of choice in the presence of severe degenerative changes and in the presence of significant endplate changes and in the presence of significant endplate osteophytesosteophytesModic found MRI to be as sensitive as CT myelography at Modic found MRI to be as sensitive as CT myelography at detecting disease level, but less specific in terms of detecting disease level, but less specific in terms of distinguishing bony from soft tissue impingement distinguishing bony from soft tissue impingement DisadvantagesDisadvantages√ Intrathecal contrast administration and risk to spinal cord rootsIntrathecal contrast administration and risk to spinal cord roots√ Exposure to radiationExposure to radiation
CT-Myelography can be considered a complementary CT-Myelography can be considered a complementary study to a MRI scanstudy to a MRI scan
Applied when clinical examination and imaging Applied when clinical examination and imaging fail to provide a clear diagnosis or perhaps fail to provide a clear diagnosis or perhaps conflicting diagnosesconflicting diagnoses
May include needle electromyelography, May include needle electromyelography, somatosensory evoked potentials or cervical root somatosensory evoked potentials or cervical root stimulationstimulation
Operator dependedOperator depended
May help differentiate primary cervical disorders May help differentiate primary cervical disorders from peripheral nerve entrapments syndromes or from peripheral nerve entrapments syndromes or pain eminating from the intrinsic shoulder pain eminating from the intrinsic shoulder pathologypathology
Radionuclide imagingRadionuclide imaging
Sensitive but non-specific exam Sensitive but non-specific exam for changes in bone metabolism for changes in bone metabolism or blood flowor blood flow
May demonstrate degenerative May demonstrate degenerative joint disease healing fracture or joint disease healing fracture or osteomyelitisosteomyelitis
Treatment Treatment
ConservativeConservative
Operative Operative
Conservative treatmentConservative treatment
Neck pain Neck pain
Most is self-limiting and will resolve with Most is self-limiting and will resolve with appropriate conservative careappropriate conservative care
The presence of severity of disease not The presence of severity of disease not related to related to √ Degenerative changesDegenerative changes√ Diameter of the spinal canal Diameter of the spinal canal √ Degree of lordosisDegree of lordosis√ Any changes in measurements of these Any changes in measurements of these
parameters over timeparameters over time
10 year follow up study in 205 cases with 10 year follow up study in 205 cases with neck pain without surgeryneck pain without surgery√ 43% free of pain43% free of pain√ 79% decreased pain79% decreased pain√ 32% moderate to severe residual pain32% moderate to severe residual pain
Gore et al, Spine 1987Gore et al, Spine 1987Cont…
Medications to address symptoms versus treatment of Medications to address symptoms versus treatment of underlying pathologyunderlying pathology√ Cosrticosteroids and NSAIDS effective in reducing Cosrticosteroids and NSAIDS effective in reducing
inflammation and paininflammation and painAcutely painful degenerative disk diseaseAcutely painful degenerative disk diseaseRadiculopathyRadiculopathyRheumatoid arthritisRheumatoid arthritis
√ Tricyclic anrtidepressantsTricyclic anrtidepressantsAmitriptyline in the treatment of chronic low back painAmitriptyline in the treatment of chronic low back pain
√ Muscle relaxantsMuscle relaxantsShort pain relief Short pain relief Act on central nervous systemAct on central nervous systemCarisoprodolCarisoprodolMetaxaloneMetaxaloneMethocarbamolMethocarbamolBenzodiazepinesBenzodiazepinesCyclobenzaprine Cyclobenzaprine
Cont…
Physical therapyPhysical therapy√ Ice and / or heatIce and / or heat√Electrical stimulationElectrical stimulation√Manual techniques / massageManual techniques / massage
After acute symptoms subside – After acute symptoms subside – dynamic modalitiesdynamic modalities√ Isometric strengthening exercisesIsometric strengthening exercises√Neck and shoulder stretchingNeck and shoulder stretching√Aerobic conditioning Aerobic conditioning
Cont…
Spinal manipulation Spinal manipulation √Manipulation has similar improvements Manipulation has similar improvements
in pain, functioning and objective in pain, functioning and objective measuresmeasures√The efficacy of spinal manipulation for The efficacy of spinal manipulation for
neck and back pain over other neck and back pain over other treatments has not been showntreatments has not been shown√Rehabilitative exercises probably are Rehabilitative exercises probably are
superior to manipulative therapy alone superior to manipulative therapy alone with gains in strength, motion and with gains in strength, motion and enduranceendurance
Cont…
Radiculopathy Radiculopathy
Non-operative treatment is the appropriate Non-operative treatment is the appropriate first step in almost all cases of cervical first step in almost all cases of cervical radiculopathyradiculopathy
Conservative measuresConservative measures√ Soft collar can reduce the acute Soft collar can reduce the acute
inflammatory response and associated paininflammatory response and associated pain√ Short period onlyShort period only√ Applied within two weeks of the onset of Applied within two weeks of the onset of
symptomssymptoms√ Prolonged immobilization is to be avoided Prolonged immobilization is to be avoided
because of deconditioningbecause of deconditioning√ Gradual weaning from the collar followed Gradual weaning from the collar followed
by physical therapyby physical therapy
Cont…
TractionTraction√ Short term reliefShort term relief√ 8 -10 pounds for 15 to 20 minutes8 -10 pounds for 15 to 20 minutes√ Optimum recommended angle is Optimum recommended angle is
2020o o to 30to 30oo of flexion of flexion √ Should not be applied until acute Should not be applied until acute
muscle spasms have subsidedmuscle spasms have subsided
Epidural steroidsEpidural steroids√Most beneficial effects in painful Most beneficial effects in painful
radiculopathyradiculopathy√ Should be administered by highly Should be administered by highly
trained individual given the risk to trained individual given the risk to the spinal cordthe spinal cord
Cont…
Cervical Myelopathy can be painless Cervical Myelopathy can be painless and have an insidious onsetand have an insidious onset..
Myelopathy Myelopathy
Conservative care of spondylotic Conservative care of spondylotic myelopathy limitedmyelopathy limitedObservation of myelopathy Observation of myelopathy caused by soft disc herniation is caused by soft disc herniation is acceptable with close attention to acceptable with close attention to progression of signs or symptomsprogression of signs or symptoms
– Options include:Options include:Immobilization of the neck with an Immobilization of the neck with an orthosis and rest to reduce neural orthosis and rest to reduce neural irritationirritationTraction or epidural steroids not Traction or epidural steroids not recommendedrecommended
Cont…
Surgical indicationsSurgical indications
Three basic goals Three basic goals
Decompression of neural elementsDecompression of neural elementsStabilization of unstable segmentsStabilization of unstable segmentsAblation of painful articulationsAblation of painful articulations
Neck painNeck pain
Surgical indicationsSurgical indicationsIntractable axial neck pain Intractable axial neck pain Cervical spondylosis Cervical spondylosis Degenerative disease of the atlanto-axial facet Degenerative disease of the atlanto-axial facet √ Intractable pain or neurologic dysfunction Intractable pain or neurologic dysfunction √ Atlanto-axial instability secondary to trauma or Atlanto-axial instability secondary to trauma or
rheumatoid arthritisrheumatoid arthritisOne third of patients with AAI and one half One third of patients with AAI and one half of those with vertical migration will develop of those with vertical migration will develop long tract signs within five years of long tract signs within five years of presentationpresentationOcciput-cervical fusion to stabilize the area Occiput-cervical fusion to stabilize the area and arrest the cranial settlingand arrest the cranial settlingCan be combined with posterior Can be combined with posterior decompression and possibly an anterior decompression and possibly an anterior resection of the odontoidresection of the odontoid
Surgical indications Surgical indications Progressive neurologic Progressive neurologic deficit deficit Disabling motor deficit at Disabling motor deficit at presentation presentation Persistent or recurrent Persistent or recurrent radicular symptoms radicular symptoms despite at least 6 weeks despite at least 6 weeks of conservative treatmentof conservative treatmentSegmental instability Segmental instability combined with radicular combined with radicular symptomssymptoms
A diagnosis of cervical spondylotic myelopathy is A diagnosis of cervical spondylotic myelopathy is almost always an indication for surgeryalmost always an indication for surgeryParticulary important factorsParticulary important factors
Progression of signs or symptomsProgression of signs or symptomsPresence of myelopathy for six months or longerPresence of myelopathy for six months or longerCanal – vertebral body diameter ratio approaching Canal – vertebral body diameter ratio approaching 0.40.4Difficulty walking Difficulty walking Loss of balanceLoss of balanceBowel of bladder incotinenceBowel of bladder incotinenceSignal changes within the substance of the spinal Signal changes within the substance of the spinal cordcord
In patients with rheumatoid arthritis, myelopathy In patients with rheumatoid arthritis, myelopathy caused by AAI, basilar invagination or subaxial caused by AAI, basilar invagination or subaxial instability should to be addressed surgically in a instability should to be addressed surgically in a timely manner `timely manner `
Anterior procedureAnterior procedure√ Discectomy(ies) and stabilizationDiscectomy(ies) and stabilization√ Corpectomy(ies) and stabilizationCorpectomy(ies) and stabilization
Posterior proceduresPosterior procedures√ LaminectomiesLaminectomies√ Laminectomies and stabilizationLaminectomies and stabilization√ Laminoplasty Laminoplasty
Anterior proceduresAnterior procedures
Indications Indications
Better for central soft disc Better for central soft disc herniation or bilateral herniation or bilateral radiculopathy on the radiculopathy on the same levelsame level
Unilateral soft disc or Unilateral soft disc or foraminal stenosisforaminal stenosis
1 or 2 level spondylotic 1 or 2 level spondylotic myelopathymyelopathy
Contra-IndicationContra-Indication
Cervical stenosis due Cervical stenosis due to pathology of the to pathology of the posterior elementsposterior elements
Anterior decompression and fusion (bone graft)
Anterior decompression and stabilization with Mesh cylinder and plate
Anterior decompression and stabilization expandable cages and plate
Ε.Δ. F 60
20/7/99
1ST POP
Vertebrectomy and stabilization Mesh cylinder and plate
Anterior Cervical Corpectomy(ies) fusion and stabilization
Advantages
• allows for more complete cord decompression
• may be safer better visualizationless distraction
Unilateral disc herniation or foraminal Unilateral disc herniation or foraminal stenosisstenosisCervical spondylotic myelopathyCervical spondylotic myelopathy due to due to >> 3 level pathology3 level pathology– Congenital stenosisCongenital stenosis– Ossification of posterior longitudinal ligament Ossification of posterior longitudinal ligament
(OPLL)(OPLL)
Cervical stenosis due to degeneration – Cervical stenosis due to degeneration – hypertrophy of posterior cervical hypertrophy of posterior cervical elementselementsPrior anterior cervical procedures (Prior anterior cervical procedures (±)±)