export_cervical surgeries poweroint dr wofford - from study blue - need to re-format Flashcards
on what are the superior and inferior articular facets found on?
The articular processes (superior and inferior, respectively)
What is the other name for the Transverse Foramen found in the cervical spine?
Foramen Transversarium
7 Common Cervical Pathologies described by Dr. Wofford
- Cervical Sprain or Strain 2. Cervical Spondylosis (NOT spondylolysis or Spondylolithesis!) 3. Cervical OA 4. Cervical Spine Instability 5. Facet Joint Syndrome 6. Disk Herniation 7 Spinal Stenosis
Details about a Cervical Strain/Sprain :
* Usually occurs after trauma (may involve hyeperextension and/or hyperflexion injury) * Is generally accompanied by loss of mvmt and characterized by pain with/without c/o HA * May involve SCM, Scalines, U Traps, levator, & suboccipitals * Thoracic spine may also be involved (always assess thorax spine when evaling cervical injuries
What muscles may a cervical strain/sprain likely involve? (5)
- SCM 2. Scalines 3. Upper Traps 4. Levator Scapulae 5. Subocciptial Muscles
What is a Cervical Strain/Sprain often accompanied by and characterized by?
* accompanied by loss of movement * Characterized by pain with or without head ache
Details about Cervical Spondylosis (NOT spondylolysis or spondylolithesis!):
- Age-related , degenerative condition 2. Implies a loss of the mechanical integrity of the invertebrate disk and may lead to instability and/or nerve root/cord compression 3. May eventually lead to arthritis of the c-spine 4. S/S may include pain restriction of motion , and possible radicular s/s in later stages.
T/F: Spondylosis is an age-related condition.
True
T/F: Spondylosis is a degenrative condition.
True.
Spondylosis may lead to ________ in the cervical spine.
Osteoarthritis
S/S of Cervical Spondylosis (3)
- Pain 2. Restriction of motion 3. possible radicular s/s in later stages
What is characteristic of redicular pain?
Sharp, shooting, lancinating
What condition is sort of the precursor to Osteoarthritis?
Cervical Spondylosis
What does Cervical Spondylosis?
Loss of the mechanical integrity of the intervertebral disk and may lead to instability and/or nerve root/cord compression
Details on Cervical Osteorarthritis
* Essentially the later stages of spondylosis * Progressive degeneration of the disk & facet joints * Changes may include osteophyte formation, decreased intervertebral disk space, hypertrophy of the ligamentum flava, facoet joint degeneration * May lead to osteophyte encroachment of IVF & possible encroachment of spinal cord or vert artery * Symptoms vary widely, but are commonly aggravated with cervical motion
What two things is Cervical Osteoarthritis a combination of?
DDD DJD
In OA does the disk start to dry up and decrease height?
Yes
T/F: In OA hypertrophy of the ligamentum flava doesn’t cause any problems itself.
False. It does cause problems of itself
What are four changes often found in cervical OA?
- Osteophyte formation 2. decreased intervertebral disk space 3. hypertrophy of the ligamentum flava 4. facet joint degenration
Details about Cervical Spine Instability
* May occur secondary to trauma, surgery, systemic disease, or tumors * Most commonly occurs secondary to degenerative changes * Poor Motor control is generally a major component to cervical instability * There is a difference between bony vs. muscular instability. Could be either.
What should we always consider patients with RA or Down Syndrome positive for?
Cervical Spine Instability Also, never do cervical mobs on these patients
What should we think about (anywhere in body) when we hear the word “instability”?
Think about LIGAMENTS!
What is muscular instability?
Poor motor control. In the neck it is very analogous to core stability in the trunk. Weakness comes o gradually
Bony Instability is associated with _____.
Traumatic injury
Four Facet Joint Disorders:
- Acute Synovitis/Hemarthrosis 2. Stiffness 3. Capsular Entrapment: 4. Degenerative Arthrosis:
Facet Joint Disorders: Describe Acute Synovitis/Hemarthrosis:
Acute strain to the facet joint may result in effusion and sometimes bleeding into the joint
Facet Joint Disorders: Describe Stiffness:
Can occur after an acute injury. Results from collagen corss binding or laying down of fibrous adhesions following an acute injury.
Facet Joint Disorders: Describe Capsular Entrapment:
Acute one-sided neck pain that stops the individual from holding his/her spine erect. Generally occurs from a sudden awkward movement.
Facet Joint Disorders: Describe Degenerative Arthrosis:
“wear and tear” on the facet joint. ARe generally stiff and painful, especially in the early mornings.
What is an acute facet problem usually caused by (such as when you wake up with crick in the neck or if you turn head really quickly).
Usually a capsular entrapment in the facet joint
Acute synovitis/hemarthrosis, Stiffness, capsular entrapment, and degenerative arthrosis. Which are more acute/sub-acute and which are more chronic.
More acute/sub-acute: Acute synovitis/hemarthrosis, Stiffness, and capsular entrapment More (very) chronic: Degenerative arthrosis
What is the deal with cervical collars?
Unless you have had a traumatic injury that has caused bony instability, there is no good evidence to support wearing a cervical collar. Cervical collar has a lot of negative side effects, so only use it under these circumstances.
Describe the structure of the IVD:
“the jelly donut” * Outermost layer is composed of tough, fibrous annular plates (annulus fibrosus) * Innermost area is the nucleus pulposus, a protein-water complex * Transition zone: the area between the outermost and innermost areas. Acts as a buffer between the annulus and the nucleus
Functions of the IVD include the following:
* Spacing: Provides spacing for the segment ot allow the nerve root to pass through the foramen without being compromised * Motion: Permits, guides and restrains motion in all direction
What is the three types of disk herniation that Dr. Wofford presented?
- Protrusion: intact annular wall (disk bulge) 2. Extrusion: annular wall has been breached and intra-discal mass protrudes through , but still remains in contact 3. Sequestration: annular wall has been breached and the intra-discal mass has separated from the disk
Use the Jelly Donut Example to describe Disk Herniation types to a patient.
Imagine Jelly donut If you squeeze one side a little, jelly would migrate a little to the other side, but it will push and bulge a bit on that side. Increases pressure on one side, but is not migrating outside of annulus fibrosis. Annulus fibrosus is intact. This is a protrusion. If we keep squeezing, the jelly will come out but will not fall on floor. Nucleus pulposis has breached the annular wall (annular tear), but the nucleus pulposis is still attached. An Extrusion If we squeeze hard enough, the jelly will fall on floor and no longer be attached. This is a sequestation . There will be nucleus pulposus fragments outside of the disk
Where do almost all Cervical and LUmbar HNPs occur?
The posterior side (usually go poterior-lateral)
HNP
HNP = herniated nucleus pulposus
Can Disk protrusions push on the nerve root?
Yes! they vary in size and can be very large. The important thing is there is no annular tear in a disk protrusion
What appears dark in a T1 MRI?
“Water, CSF, acute hemorrhage, and soft tissue tumors appear dark on T1, and bright on T2 studies” – Dr. Davies’ slide.
Label each picture with herniation type:
A: normal disk B: Protrusion C: Extrusion D: Sequestration
Draw the three different types of disk herniation
https://classconnection.s3.amazonaws.com/297/flashcards/2750297/png/disk_herniation_pic-148B928371F7D84D17C.png
Which direction do Disk Herniations usually occur? What direction produces the most clinical s/s?
Disc herniations may occur in any direction, but present the most clinical s/s when they occur posterior or posterior-lateral
What is common S/S for disk herniation
* Referred or Redicular * Commonly Display Limited ROM
What % of patients without back pain had some protrusion showing in an MRI (in a study conducted in the 90’s)
80%
What should the place of an MRI be in clinical decision making
MRI can show anything, but it is up to us to decide if it is clinically important. It can be very very scary for a patient to hear they have a disk bulge, so it can be helpful to tell them that 80% of pts can have cervical disk bulge but asymptomatic. Also keep in mind that an MRI is a static picture at a point in time. Not a series.
what age group do disk bulges usually occur in and why?
Disk bulges usually occurs between 30-50 while water content is high – nucleus pulposus is more pliable during these times so time of day and recent activities can effect where it is during MRI
Details about Spinal Stenosis
* Generally Occurs secondary to degeneration or trauma * May be central or lateral in nature * Central stensosis is characterized by
What is central stenosis characterized by?
What three things may Spinal Stenosis be due to?
- Disk herniation 2. Osteophytes 3. Hypertrophy of the lamina or facet joints
What is Spinal Stenosis, and what are the two sub-categories
Spinal Stenosis = A narrowing of the spinal column 1. Central Stenosis = central foramen narrowing 2. Lateral Stenosis = intervertebral foramina narrowing
What two things is Spinal Stenosis usually secondary to (broad categories)?
- Trauma 2. Degeneration
What are the two Common Cervical Surgeries that we learned about?
- Anterior Cervical Discectomy and fusion (ACDF) 2. Cervcial Disk Replacement
ACDF
Anterior Cervical Discectomy and fusion
Who may benefit from an ACDF?
- Patients with a cervical radiculopathy 2. Patients with cervical myelopathy
What is the difference between myelopathy, radiculopathy, and neuropathy?
* Myelopathy = CNS, spinal cord compression * Radiculopathy = peripheral nerve compression at the nerve root * Neuropathy = peripheral nerve compression distal to the nerve root
When is an ACDF for radiculopathy indicated? (3 criteria proposed in the literature)
- Persistent or recurrent rm pain of more than 3 months in duration 2. Neurological deficits that interfere with function and/or are progressive in nature 3. Failure of conservative treatments
Does a lower motor neuron problem cause a hyperreflexive response or a hyporeflexive response?
HypOreflexive (Upper motor neuron problems can cause hyper-reflexiveness)
In absence of upper neuron symptoms, should someone undergo a ADCF for radiculopathy?
they should undergo conservative treatments before ACDF
In true radiculopathy, myotomes and dermatomes must show positive?
Only sometimes can just myotomes be positive for a true radiculopathy. Reflexes are also important.
What are the advantages of performing ACDF for persons with Radiculopathy?
- Stopping further osteophyte formation 2. Distracting the disk space to enlarge the neuroforamen and create decompression 3. Regression and remodeling of existing osteophytes after fusion.
What are two conditions a ACDF could be useful for?
- Radiculopathy 2. Myelopathy
When is an ACDF (Anterior Cervical Disectomy and Fusion) for myelopathy indicated? (4)
- Moderate or severy symptoms that affect the pt’s quality of life or ability to work 2. Unsteady gait 3. Hand dysfunction 4. Neurogenic bowel or bladder (none of these can be caused by lower motor neuron problems except maybe hand dysfunction)
Unsteady gate and neurogenic bowl or bladder are considered _______.
RED Flags!
What are the advantages of performing an ACDF for persons with cervical myelopathy? (2)
- Stop the neurological progression 2. Reduce pain
What is an ACDF?
* Is generally performed using an anterior approach on side of symptoms * After incision, SCM & carotid sheath are moved laterally & trachea, espophagus , & thyroid medially * disk space is identified & the annulus/disk material are excised * Either allograft or autograft placed into disk space * Instrumentation (plate & screws) to secure the graft
What is the benefits for the use of instrumentation during an ADCF?
Benefits for the use of instrumentation include: immediate stability, increased fusion rate, prevention of loss of graft fixation/position, and improved post-operative rehabilitation
What is an autograph in relation to an ACDF?
tissue from the self to be placed into the disk space
ACDF: Allograph is ___.
Allograph from somewhere else – cadaver or some sort of synthetic (allograph is what she has seen most common).
how big is the incision usually for an ACDF?
1 inch
Does the fusion in one ACDF usually create a large deficit in cervical ROM?
no, it usually only creates a small rotation deficit if only one level is fused.
Is ACDF an outpatient or inpatient procedure?
outpatient procedure that takes 45-60 minutes.
How long does an ACDF normally take?
45-60 minutes
How soon may we see a patient after an ACDF?
as early as one week later
Which two professionals can perform an ACDF?
Orthopedic Surgeon Neuro Surgeon
Would an ortho or neuro surgeon be more preferable to perform your ACDF?
The individual with the most successful experience performing that procedure would be the best choice
History of cervical disk replacement
* first total disc implanted in Jan 2000 (Belgium) - also year of first European clinical trial * First clinical trial in US was May 2002 * Approved by FDA on July 16, 2007 We have no long-term outcome data
Approximately how long has ACDF been performed?
at least 50 years
Cervical Disk Replacement procedure
- Perform anterior Disectomy like ACDF ( anterior approach from side of symptoms. SCM and carotid sheath are moved laterally and the trachea, espophagus , and thyroid are moved medially . The disk space is identified and the annulus/disk material are excised) 2. Implant cervical prosthesis 3. no need for instrumentation
Why did Cervical Disk Replacement come about
There were problems with the fusions, especially at the level above and below the fusion which had to move more and therefore developed more wear and tear
What are 3 advantages of Cervical Disc Replacement?
- Maintains spinal motion 2. Less potential for degenerative changes of adjacent segments 3. Quicker recovery time and return to prior level of function
What are three disadvantages of a cervical TDR?
- No long term outcome studies (although Lumbar TDR has been around since 2004) 2. Very specific group of patients who may benefit 3. Risk for subluxation/dislocation of prosthesis
What are three advantages of ACDF?
- Long term outcome studies available - has been performed for over 50 years 2. No risk of subluxation/dislocation 3. May be performed on multiple levels
What are two disadvantages of ACDF?
- potential loss of spinal motion 2. Increased degeneration of adjacent segments
To perform a cervical TDR pt must have a ____ at one level.
HNP (herniated nucleus pulposus?)
When does initial and full fusion occur for ACDF?
Initial: 12 weeks Full: 1 year
How long does healing take for TDR?
not as much data on how long it takes, just know it is short. There is nothing to heal or fuse. It is just in there.
