Degenerative Cervical spine Flashcards
Cervical spondylosis cervical myelopathy Cervical Radiculopathy
What is Cervical Spondylosis?
-
A chronic disc degeneration and associated facet arthropathy that can lead to
- Cervical myelopathy
- cervical radiculopathy
What is the epidemiology of cervical spondylosis?
- 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
What is the pathoanatomy of cervical spondylosis?
- 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
-
disc degeneration
What is the mechanism of neurological compression in cevrvical spondylosis?
-
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)
-
foraminal spondylolytic changes
-
Central cord compression
- when diam ( normal 17mm)
- worse during neck extension when central cord is pinched between
- degenerative disc
- Hypertrophic facets/infolded ligamentum
What investigations are useful for dx of cervical spondylosis?
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
What is the tx of cervical spondylosis?
depends on symptoms of
- cervical radiculopathy
- cervical myelopathy
Define Cervical Myelopathy?
- A clinical syndrome cause by compression of the spinal cord which is characterised by
- cluminess in hands
- Gait imbalance
What is the pathophysiology of cervcal myopathy?
-
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
Decribe the neurological injury in cervical myopathy?
- Direct Cord compression
- Ischaemia from compression of anterior spinal artery
Describe any associated conditions?
-
Lumbar spine stenosis
- tandem stenosis in cervical /lumbar in 20% pts
What is the prognosis of cervical myopathy?
- Slow Progession
- Rarely improves with nonoperative modalities
- steplike deterioation
- early recongnition and tx prior to spinal cord damage is critical for good outcomes
Can you name a classification system for cervial myopathy?
- 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
What are the symptoms of cervical myopathy?
-
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
What are the signs of cervial myopathy?
-
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
What investigations are useful to dx cervical myopathy?
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

What is the ddx of a patient with weakness, extremity dysathesia, hyperreflexia, gait imbalance?
- Normal aging
- Stroke
- Movement disorder
- Vitamin B12 deficiency
- Amyotrophic Lateral Sclerosis (ALS)
- Mutliple sclerosis
What is the tx of a patient with cervical myopathy?
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
What is the outcome of surgery for cervical myopathy?
- 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
What are the indications for anterior approach and fusion?
- 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
What are the advantages and disadvantages of anterior fusion?
Advantages
- Lower infection
- mild postoperative pain
Disadvantge
- avoid in pt with poor swallow
what are the indicaitions for laminectomy and posterior spinal fusion?
- 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

What are the indiciations for laminoplasty?
- useful in maintaining motion
- avoids complx of fusion so useful in pts with high risk of pseudoarthrosis
- CI- cervical kyphosis >13o
- severe axial neck pain
Describe the technique for laminoplasty?
- 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

Describe the advantages /disadvantages of laminoplasty?
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
What are the indications for anterior and posterior surgery
- Mutlilevel stenosis in rigid kyphosis
- Multilevel anterior cervical corpectomies
- postlaminectomy kyphosis
What are the indications in laminectomy alone?
- Rare due to risk of postlaminectomy kyphosis
- progressive kyphosis is a risk 11-47% chance if laminectomy preformed without fusion
What are the complications of surgery?
-
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
What is cervical radiculopathy?
- Clinical symptoms caused by nerve root compression in the cervical spine
- characterised by sensory and motor symptoms in the upper extremity
What is the pathophysiology of cervical radiculopathy?
-
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
What are the symptoms of cervical radiculopathy?
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
What are the signs of cervical radiculopathy?
- 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
-
Spurling Test
What investigations are useful for cervical radiculopathy?
- Xrays- ap , lateral , oblique flexion, extension
- MRI- T2 axial imaging is modality of choice and gives info about soft tissue
What is the tx of cervical radiculopathy?
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
What are the risk of surgery for cervical radiculopathy?
-
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
*
What are the different types of cervical stenosis?
- Congential
- Acquired
- traumatic
- degenerative
what are the assocaited conditions of cervical stenosis?
- Spear tackler’s spine
- A syndrome of cervical stenosis- caused by repeitive microtrauma & improper tackling technique
- CI to return to play
What is the prognosis of cervical stenosis?
- increase risk for radiculopathy/myelopathy even from minor trauma
- congenital cervical stenosis important consideration in athlete
What is the classification of cervical stenosis?
-
Absolute cervical stenosis
- canal diameter <10mm
-
Relative cervical stenosis
- Canal diameter 10-13mm
What investigations are useful in dx of cervical stenosis?
- xrays
- ap, lateral , flexion/extension
- lateral
- canal diameter <13mm
- Torg- Pavlo ratio
- canal/vertebral body width of <0.8 normal is 1.0

What are the tx for cervical stenosis?
- Non op
- observe w possible activity restrictions
- CI return to play contraversial
- Surgery
- surgical decompression and stablisation
- for radiculopathy
- myelopathy
- prophylactic measure
- surgical decompression and stablisation