Amy Hay--Cervical Surgery Flashcards
Surgical Procedures
- Decompression
- Discectomy w/ Fusion (ant/post)
- Discectomy plus Corpectomy
- Post Laminectomy
- Artificial Disc
Intractable Pain
- Spinal Cord Stimulator
- Intrathecal Pump
Cervical Disc Surgery Patient Selection
- Progressive/non-improving motor deficits
- Failure of PT and interventional pain management
- Spinal cord (spasticity/weakness LE, Numbness UE/LE, Weak legs, increased reflexes in LE)
Cervical Prolapse
Age: 25-45
S/Sx: reflex change, numbness, +foraminal compression test, +axial separation test, sagittal motions worst; partial/complete dermatome
Acute Cervical Extrusion
Age: 25-45
- Arm worse than neck pain
- severe broad radiating pain in UE
- All motions limited/pn
- neurological changes
- Negative axial separation test (can’t completely alleviate with axial separation/may increase Sx)
Anterior Cervical Discectomy
- Indication: disc pathology with nerve/spinal cord involvement
- procedure one level Sx
- Structures Affected: ALL, disc, foramen
- Go in anteriorly
- common with fusion
Discectomy Patients
- Conservative
- controlled mobility
- longus colli work
Advantages of Ant Discectomy and Fusion
- restore height
- open foramen
- decrease ligament buckling
- control segmental motion
Anterior Discectomy, Corpectomy, Fusion
- Corpectomy=removal of vertebral body (rare)
- Indications: bony stenosis with myelopathy
- Tissues affected: ALL, Disc, Vertebral Body, PLL
- Longer healing, up to 3 months neck brace
Posterior Discectomy
- Indications: disc herniations near spinal nerve (more lateral)
- position in prone and flexion
- Structures Affected: Lamina, Ligamentum Flavum, Nerve Root, Disc, muscles
Manual therapy with Corpectomy with fusion
Conservative (>12 weeks)
can do soft tissue
Advantage/Disadvantage of Post Discectomy
- Adv: don’t have to fuse
- Disadv: no increased segmental height for nerve root (3-5% chance recurrence)
Posterior Discectomy & Fusion
Indications: disc disease, fractures
-Combined with other procedures (laminotomy, discectomy, foraminotomy)
Post Laminectomy
- Indication: spinal stenosis & myelopathy
- Goal: remove lamina to give cord more room
- Often with fusion
Cervical Disc Replacement Indications
- neck/arm pain due to disc pathology
- no significant facet joint disease/bony compression on nerve
- no prior major CS surgery
- No deformity (scoliosis)
Advant/disad Disc replacement
-Adv: improved mobility, no increased stress on adjacent segments, no need of bone graft
Disc replacement
- anterior approach
- metal or metal/plastic combo
- improved neurological function
Tx for intractable spinal pain
- Spinal Cord Stimulator
- Intrathecal Pump
Spinal Cord Stimulator Indications
- Failed neck surgery
- Severe nerve related pn/Numbness
- CRPS
- Successful percutaneous trial
Spinal Cord Stimulator
- Implantable system that sends electrical pulses to dorsal spinal cord
- inhibits pain signals
- pt has tingling sensation
- laminotomy to place leads with slack to allow spinal movements
- helps with extremity pain (not as much with spinal pn)
- have paresthesia instead of pain
Spinal cord stimulator post op considerations
- no bending fwd, heavy lifting/straining for 6 weeks
- no reaching overhead, bend, twisting for 6 weeks
- resume light to normal activity 1-2 days
- walk as much as pain allows
Intrathecal pump Indications
- conservative therapy failed
- no benefit from additional surgery
- dependent on pain meds
- no phychological problems
- no medical conditions that would keep pt from undergoing implantation
- not allergic to drugs in pump
- +response to trial dose of meds
Intrathecal Pump
- gives meds directly to spinal cord placed under skin in abdomen
- direct delivery of smaller doses
- can use multiple meds (pn, numbing, Mm relaxers)
Common Cervical Interventional Procedures
- trigger point injections
- epidural steroid injections
- epidural lysis of adhesions
- facet (injections, medial branch blocks, radiofrequency ablation)
- c0-1 & C1-2 joint injections
- sympathetic block (stellate ganglion)
3 Most Common Procedures
- Ant discectomy with fusion
- post discectomy with fusion
- laminectomy with fusion
Percutaneous Adhesiolysis Indications
-chronic arm/neck pain from:
-failed neck surgery
-spinal stenosis
-disc herniation >6 months
-Intermittent/continuous pn causing functional disability
-Fail to respond to non-interventional/non-surgical
Absence of facet joint pain
Cervical Facet Pain
- parasagittal neck pain
- no arm pn, no midline pn
- pn does not cross midline
Cervical facet Synovitis
- parasagittal neck pn
- no arm pn
- most pn with rotation
- no large limits of motion
- no pn with extension with chin-tuck
- most pn with coupled 3D patterns
Medial Branch Block
- pt must be instructed to try activities that they are limited that same day to determine effectiveness
- insurance may require series of 3 MBB prior to RFA
Radiofrequency Ablation
- AKA radiofrequency thermal coagulation
- AKA radiofrequency denervation
- Application: heatet, pulsed
Headaches
- Suboccipitals
- Arthropathy
- C0-1 or C1-2 Joint arthropathy
- C2 Nerve root/DRG
- discogenic
- Disc segment (N root irritation)
Nerve Blocks for HA
C2
Gr. Occipital N
Lesser Occipital N
