Degenerative Cervical spine

Question 1

What is Cervical Spondylosis?

Answer 1

• A chronic disc degeneration and associated facet arthropathy that can lead to
  
  • Cervical myelopathy
  • cervical radiculopathy

Question 2

What is the epidemiology of cervical spondylosis?

Answer 2

• typically begins 40-50 yrs
• most common levels C5-6 > C6-7 because they are associated with most flexion/extension in subaxial spine
• more common men than women

Risk Factors

• excessive drinking
• smoking
• lifting
• professional athletes

Question 3

What is the pathoanatomy of cervical spondylosis?

Answer 3

• Natural aging process of spine
• characterised by degeneration of the disc and all 4 joints of cervical motion segment
  
  • 2 facet joints
  • 2 uncovertebral joints of Luschka
• The process of degeneration includes
  
  • disc degeneration
    
    • disc dessication/loss of height/disc bulge/herniation
  • Joint degeneration
    
    • ucinate spurring and facet arthrosis
  • ligamenous changes
    
    • lig flavum thickens, infolding secondary to loss of disc height
  • Deformity
    
    • kyphosis secondary to loss of disc height-> transfer of load to facet and uncovertebral joints-> further uncinate spurring/facet arthrosis

Question 4

What is the mechanism of neurological compression in cevrvical spondylosis?

Answer 4

• Nerve root compression
  
  • foraminal spondylolytic changes
    
    • 2ary to chondrosseous spurs of facet/ uncovertebral joints
  • posterolateral disc herniation
    
    • between post edge of uncinate and lateral edge of PL
  • usually affects nerve root below (C6/7- affect C7)
• Central cord compression
  
  • ​when diam ( normal 17mm)
  • worse during neck extension when central cord is pinched between
    
    • degenerative disc
    • Hypertrophic facets/infolded ligamentum

Question 5

What investigations are useful for dx of cervical spondylosis?

Answer 5

xrays- ap , lateral , oblique, flexion/extension

• degenerative changes of uncovertebral/facet joints
• osteophyte formation
• disc space narrowing
• endplate sclerosis
• decreased sagittal diameter ( cord comp
• changes don’t always correlate with symptoms ;)
  
  • 70% of 70yr old deg changes on xray

MRI

• axial key to see soft tissues
  
  • disc degen, spinal cord changes,
  • high rate false positives

Question 6

What is the tx of cervical spondylosis?

Answer 6

depends on symptoms of

• cervical radiculopathy
• cervical myelopathy

Question 7

Define Cervical Myelopathy?

Answer 7

• A clinical syndrome cause by compression of the spinal cord which is characterised by
  
  • cluminess in hands
  • Gait imbalance

Question 8

What is the pathophysiology of cervcal myopathy?

Answer 8

• Degenerative cervical spondylosis
  
  • most common cause
  • compression usually by anterior osteophytes,discophyte complex
  • degenerative spondylothesis and hypertrophy of ligamentum flavum may contribute
• Congential stenosis
  
  • when congential narrowing combined with spondyltic degernative change
• Ossification of the posterior longitudinal ligament​
• Tumour
• Epidural abscess
• Trauma
• Cervical Kyphosis

Question 9

Decribe the neurological injury in cervical myopathy?

Answer 9

• Direct Cord compression
• Ischaemia from compression of anterior spinal artery

Question 10

Describe any associated conditions?

Answer 10

• Lumbar spine stenosis
  
  • tandem stenosis in cervical /lumbar in 20% pts

Question 11

What is the prognosis of cervical myopathy?

Answer 11

• Slow Progession
• Rarely improves with nonoperative modalities
• steplike deterioation
• early recongnition and tx prior to spinal cord damage is critical for good outcomes

Question 12

Can you name a classification system for cervial myopathy?

Answer 12

• Ranawat
• Class I- Pain no neurological deficit
• Class 2-Subjective weakness, hyperreflexia, dyssthesia
• Class 3A- Objective weakness,long tract signs, ambulatory
• Class 3B- Objective weakness, long tract signs, non ambulatory

Question 13

What are the symptoms of cervical myopathy?

Answer 13

• Neck pain and stiffness
  
  • occipital headache-common
  • axial neck pain
• Extremity parathesia
  
  • diffuse NONDERMATOMAL numbness and tingling
• Weakness and clumseyness
  
  • weakness and reduced manual dexterity
• Gait instability - most important predictor
  
  • pt feels unsteady on feet
  • weakness up and down stairs
• Urinary retention
  
  • rare, appears late in disorder

Question 14

What are the signs of cervial myopathy?

Answer 14

• Weakness
  
  • difficult to detect
• Finger escape sign
  
  • pt holds finger extended and abducted-little finger spontaneously abducts due to weak intrinsics
• Grip and release test
  
  • normal pt can grip and release 20 times in 10 seconds myopathic pt may not be able to do this

Sensory

• Proprioception dysfunction
  
  • due to dorsal column involvement
  • late in disease
  • Assoc w poor prognosis
• Decreased Pain sensation
  
  • ​pinprick test to see if global reduction or dermatomal
  • involvement of ventral spinothalamic tract
  • vibration loss only seen in long standing cases
• UPPER MOTOR NEURONE SIGNS- spasicity
  
  • ​Hyperreflexia
  • inverted radial reflex
    
    • ​tapping distal brachioradial reflex->ipislat finger flexion
  • Hoffman’s sign
    
    • ​snapping distal phalanx of middle finger- spontaneous flexion in other fingers
  • Sustained clonus
    
    • ​> 3 beats
  • Babsinki test
    
    • ​positive- extension of great toe

​​Gait analysis

• Toe to heel walk- pt finds this difficult
• Romberg test
  
  • eyes closed arms forward
  • loss of balance consistent with post column dysfunction

Provocation tests

• Lhermitte
  
  • extreme cervical flexion -> shock like senation down spine to extremities

Question 15

What investigations are useful to dx cervical myopathy?

Answer 15

xrays

• Cervical AP, lateral,oblique, extension/flexion
  
  • osteophytes
  • disc space narrowing
  • degenerative changes of uncovertebral and facet joints
  • decreased sagittal diameter
    
    • cord compression when diam <13mm
• ​​lateral radiograph
  
  • ​identify c2-c7 alignement- tangentail lines form c2-c7
  • local kyphosis angle
• ​oblique
  
  • ​foraminal stenosis from uncovertebral joint arthrosis

MRI

• best for evaluation of spinal cord and nerve root
• spinal cord changes- bright on T2- myelomalacia
• T1 changes poorer outcome following surgical decompression
• Compression ratio- smallest ap diameter/ largest transverse diameter
• compression ratio of <0.4 carries poor prognosis

CT

• useful for osteophytes and ostephyte posterior ligament

CT myelogram

• gives excellent degrees of compression
• contrast injection via lumbar spine then trendelembery /C1-C2 puncture and diffuse caudal
• gd for pts with pacemakers etc for which MRI artefact

Question 16

What is the ddx of a patient with weakness, extremity dysathesia, hyperreflexia, gait imbalance?

Answer 16

• Normal aging
• Stroke
• Movement disorder
• Vitamin B12 deficiency
• Amyotrophic Lateral Sclerosis (ALS)
• Mutliple sclerosis

Question 17

What is the tx of a patient with cervical myopathy?

Answer 17

Non operative

• Observations, NSAIDS, PT and lifestyle modifications
  
  • mild disease w no functional impairment
  • pt who are poor candidates for surgery
  • meds- naids, gabapentin
  • c collar-hard collar in slight flexion
  • PT for strenghtening muscles, back, neck
  • watch pt for progression
  • improved outcome with pt with large transverse diameter >70mm²

^​​Operative

• Surgical decompresion , restoration of lordosis and stabilisation
  
  • signifciant funcitonal impairment
  • 1-2 level disease
  • lordotic, neutral or kyphotic position
• Anterior cervical discetomy/corpectomy, + fusion
• Posterior laminectomy + fusion
• Posterior laminoplasty
• combined ant/post proceedure

Question 18

What is the outcome of surgery for cervical myopathy?

Answer 18

• prospective studies show improvement in overall pain, function, and neurologic symptoms with operative treatment
• early recognition and treatment prior to spinal cord damage is critical for good clinical outcomes

Question 19

What are the indications for anterior approach and fusion?

Answer 19

• Most common tx with pt with single/2 level disease
• Fixed kyphosis >10 ^o
• Anterior fixation can correct kyphosis
• Pathology is anterior- osteophytes , OPLL, soft disc
• decompression
  • ​corpectomy and strut graft may be required for multilevel spondylosis
  • two level corpectomies tend to be biomechanically vulnerable (preferable to combine single level corpectomy with adjacent level diskectomy)
  • 7% to 20% rates of graft dislodgement with cervical corpectomy with associated severe complications including death reported.
• ​fixation
  
  • ​anterior plating functions to increase fusion rates and preserve position of interbody cage or strut graft

Question 20

What are the advantages and disadvantages of anterior fusion?

Answer 20

Advantages

• Lower infection
• mild postoperative pain

Disadvantge

• avoid in pt with poor swallow

Question 21

what are the indicaitions for laminectomy and posterior spinal fusion?

Answer 21

• multilevel compression with kyphosis of < 10 degrees
• > 13 degrees of fixed kyphosis is a _contraindication f_or a posterior procedure - will not fully correct the spine and bowstring anteriorly
• in flexible kyphotic spine, posterior decompression and fusion may be indicated if kyphotic deformity can be corrected prior to instrumentation

Question 22

What are the indiciations for laminoplasty?

Answer 22

• useful in maintaining motion
• avoids complx of fusion so useful in pts with high risk of pseudoarthrosis
• CI- cervical kyphosis >13^o
  
  • severe axial neck pain

Question 23

Describe the technique for laminoplasty?

Answer 23

• volume of canal is expanded by hinged-door laminoplasty followed by fusion
• usually performed from C3 to C7
• open door technique
  
  • hinge created unilateral at junction of lateral mass and lamina and opening on opposite side
  • opening held open by bone, suture anchors, or special plates
• French door technique
  
  • hinge created bilaterally and opening created midline

Question 24

Describe the advantages /disadvantages of laminoplasty?

Answer 24

Advantages

• Allows for decompression of multilevel stenotic myelopathy without compromising stability and motion (avoids postlaminectomy kyphosis)
• lower complication rate than multilevel anterior decompression especially in patients with OPLL
• A motion preserving technique
  
  • ​pseudoarthrosis not a concern in patients with poor healing potential (diabetes, chronic steroid users)
• ​can be combined with a subseqeunt anterior procedure

​Disadvantages

• ongoing neck pain
• still associated with loss of motion

Question 25

What are the indications for anterior and posterior surgery

Answer 25

• Mutlilevel stenosis in rigid kyphosis
• Multilevel anterior cervical corpectomies
• postlaminectomy kyphosis

Question 26

What are the indications in laminectomy alone?

Answer 26

• Rare due to risk of postlaminectomy kyphosis
• progressive kyphosis is a risk 11-47% chance if laminectomy preformed without fusion

Question 27

What are the complications of surgery?

Answer 27

• Pseudoarthrosis
  
  • ​12% single level, 30% multi level
  • tx with post wiring/plating or rpt ant decompression
• Post op C5 palsy
  
  • 4.6% incidence
  • same for ant/post decompression
  • gd prognosis for recovery but takes time
• Recurrent laryngeal nerve palsy
  
  • ​right more vunerable then left
  • watch over time
  • if no improvement 6/52->ent to scope + inject teflon
• **Hardware falure and migration **
  
  • ​7-20% with 2 level corpectomy
• post laminectomy kyphosis
  
  • ​tx with ant/post decompression
• post op axial neck pain
• vertebral artery injury
• oesphageal injury
• dysphagia and alteration in speech

Question 28

What is cervical radiculopathy?

Answer 28

• Clinical symptoms caused by nerve root compression in the cervical spine
  
  • characterised by sensory and motor symptoms in the upper extremity

Question 29

What is the pathophysiology of cervical radiculopathy?

Answer 29

• Degenerative Cervical Spondylosis
  
  • discosteophyte complex and loss of disc height
  • chondrosseous spurs of facet and uncovertebral joints
• Disc Herniation- soft disc
  
  • usually posterolateral
  • between edge of uncinate and lateral edge of PL
• ​Neural compression
  
  • direct
  • irration by chemical mediators
    
    • IL1, IL6, TNF alpha, Prostag
  • Affects nerve root below: C6/7 affect C7

Question 30

What are the symptoms of cervical radiculopathy?

Answer 30

Symptoms

• occipital headache
• trapezial/ interscapular pain
• neck pain
  
  • radiate to shoulders
  • insidious that may worsen with vertebral motion
• Unilateral arm pain
  
  • global non dermatomal
• unilateral dermatomal numbness and tingling
  
  • in thumb- c6
  • In middle finger c7
• unilateral weakness
  
  • grip strength/overhead activities- C7

Question 31

What are the signs of cervical radiculopathy?

Answer 31

• C5 radiculopathy
  
  • weak deltoid/biceps
  • diminished biceps reflex
• C6
  
  • weak brachioradialis & wrist extension
  • diminished brachioradialis reflex
  • parathesia in thumb
• C7
  
  • weak triceps and wrist flexion
  • diminished triceps reflex
  • parathesia in index, middle , ring fingers
• C8
  
  • weak distal phalanx flexion middle/index finger
  • parathesia- little
• Provocation test
  
  • Spurling Test
    
    • Simultaneous extension, rotation to affected side, lateral bend adn vertical compression-> symptoms in ipislateral arm
  • Shoulder abduction test
    
    • lifting arms above head often relieves symptoms

Question 32

What investigations are useful for cervical radiculopathy?

Answer 32

• Xrays- ap , lateral , oblique flexion, extension
• MRI- T2 axial imaging is modality of choice and gives info about soft tissue

Question 33

What is the tx of cervical radiculopathy?

Answer 33

Non operative

• rest, medications and rehabiliation
  
  • 75% improve non op tx
  • by reabsorption of disc, decrease inflammation around irritated nerves
  • immobilisation- short time <1-2wks
  • meds; Nsaids, muscle relaxants, corticosteriods
  • rehab: moist heat, isometric excercises
• selective nerve root corticosteriod injection

​Surgery

• Anterior cervical discectomy +fusion
  
  • ​persistent/disabling pain/progressive neurology
  • GOLD STANDARD
• posterior foraminotomy (endoscopically)
  
  • ​for foraminal soft disc herniation casuing single level radiculopathy
  • 91% sucess
• cervical total disc replacement
  
  • single level disease w minimal arthrosis of facets
  • avoids non union

Question 34

What are the risk of surgery for cervical radiculopathy?

Answer 34

• Pseudoarthrosis
  
  • 5-10% for single level fusions, 30% for multilevel
  • Risk factors
    
    • smoking
    • diabetes
    • multi-level fusion
  • if asymptomatic observe, if symptomatic tx with post cervical fusion
    
    • better chance of fusion even though > blood loss, longer hospitalisation, longer op times, increased complx rates
• Recurrent laryngeal nerve injury
  
  • abberrant pathway on right
  • theoretically more at risk on right no evidence to support incidence w right sided incision
  • tx- observe
  • no improvement in 6 weeks then ENT
• hypoglossal n injury
  
  • tongue deviated to side of injury
• Vascular injury- vertebral artery- fatal
• Dysphagia
• Horner’s syndrome
  
  • injury to sympathetic chain on longus collu muscle at c6
  • miosis, ptosis, anhydrosis, enophthalmos, loss pf ciliospinal reflex on side of face
    *

Question 35

What are the different types of cervical stenosis?

Answer 35

• Congential
• Acquired
  
  • traumatic
  • degenerative

Question 36

what are the assocaited conditions of cervical stenosis?

Answer 36

• Spear tackler’s spine
• A syndrome of cervical stenosis- caused by repeitive microtrauma & improper tackling technique
• CI to return to play

Question 37

What is the prognosis of cervical stenosis?

Answer 37

• increase risk for radiculopathy/myelopathy even from minor trauma
• congenital cervical stenosis important consideration in athlete

Question 38

What is the classification of cervical stenosis?

Answer 38

• Absolute cervical stenosis
  
  • canal diameter <10mm
• Relative cervical stenosis
  
  • Canal diameter 10-13mm

Question 39

What investigations are useful in dx of cervical stenosis?

Answer 39

• xrays
  
  • ap, lateral , flexion/extension
  • lateral
    
    • canal diameter <13mm
    • Torg- Pavlo ratio
      
      • canal/vertebral body width of <0.8 normal is 1.0

Question 40

What are the tx for cervical stenosis?

Answer 40

• Non op
  
  • observe w possible activity restrictions
  • CI return to play contraversial
• Surgery
  
  • surgical decompression and stablisation
    
    • for radiculopathy
    • myelopathy
    • prophylactic measure