Degenerative Cervical spine Flashcards by Sally-Anne Phillips

What is Cervical Spondylosis?

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

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

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)
Central cord compression
- when diam ( normal 17mm)
- worse during neck extension when central cord is pinched between
  - degenerative disc
  - Hypertrophic facets/infolded ligamentum

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

What is the tx of cervical spondylosis?

depends on symptoms of

cervical radiculopathy
cervical myelopathy

How well did you know this?

Not at all

Perfectly

Define Cervical Myelopathy?

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

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

Decribe the neurological injury in cervical myopathy?

Direct Cord compression
Ischaemia from compression of anterior spinal artery

How well did you know this?

Not at all

Perfectly

Describe any associated conditions?

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

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

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

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

How well did you know this?

Not at all

Perfectly

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

How well did you know this?

Not at all

Perfectly

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 >13^o
- 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

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

Degenerative Cervical spine Flashcards

Cervical spondylosis cervical myelopathy Cervical Radiculopathy