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Cervical myelopathy cme
 

Cervical myelopathy cme

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    Cervical myelopathy cme Cervical myelopathy cme Presentation Transcript

    • CERVICAL DISC DISORDER
      LUNCH HOUR CME
      15/12/2010
    • Spondylosis: any or various degenerative diseases of the spine
      Myelopathy: any disease or disorder of the spinal cord or bone marrow
      Radicular: of, relating to, or involving a nerve root
      Radiculopathy: any pathological condition at the nerve roots.
      Definitions of Spinal Disorders
    • Cervical spondylosis
      Cervical radiculopathy
      Cervical myelopathy
    • A non-specific term
      Refers to any lesion of cervical spine of a degenerative nature (non-inflammatory disc degeneration)
      Cervical Spondylosis
    • Imbalance between formation & degradation of proteoglycans & collagen in disc
      With aging, a -ve imbalance with subsequent loss of disc material -> degenerative changes
      Factors influencing severity of degeneration
      Heredity
      Trauma
      Metabolic
      Other environmental effects, eg. smoking
      Pathology
    • Degeneration ->
      Disc herniation
      Stenosis
      Instability
      Spine unable to withstand physiologic loads -> significant risk for neurologic injury, progressive deformity & long-term pain & disability
      Not common in cervical spondylosis except those with stiffness in middle & lower segments who develop compensatory hypermobility at C3-4 or C4-5 -> myelopathy
    • Cervical spinal instability
      Radiographic criteria of White
      >11o angulation
      >3.5 mm translation of adjacent subaxial segments
    • Most people with degenerative changes of the cervical spine remain asymptomatic.
      Symptomatic patients are usually older than 40 years of age and present with symptoms that are caused by the compression of neural structures.
      There are three main symptom complexes related to cervical spondylosis:
      1.Neck pain
      2.Cervical radiculopathy
      3.Cervical myelopathy
      Presentation
      • X-rays changes
      Narrowing of intervertebral disc
      Sclerosis of endplates
      Osteophyte formation
      • Similar changes may occur in facet joints
      • Most frequently in C5-6 & C6-7
      • Incidence of spondylosis on X-rays in asymptomatic patients
      80% in 51-60 age group
      95% in 61-70 age group
      Radiological findings
    • Incidence of Spondylosis on MRI in asymptomatic patients
    • A condition caused by compression of a nerve root in cervical spine.
      Involves a specific spinal level with sparing of levels immediately above & below.
      Peak age:50-54 year
      Disc protrusion =22% spondylosis=68%
      41% had associated lumbar radiculopathy
      Cervical Radiculopathy
    • C7 monoradiculopathy-most common,C6-7 level.
      Pain post. aspect of arm, posterolateral forearm,middle finger
      Tricep and fingers extensor weakness
      Tricep reflex reduce.
      90% not treated surgically were asymptomatic.
      Cervical Radiculopathy
    • C3 radiculopathy-involving C2C3 disk.
      Uncommon
      Sensory-post.neck,suboccipital and ear
      No detectable muscle motor.
      C4 radiculopathy-neck and shoulder pain
      No significant motor deficit. Radiating pain-base of the neck,midshoulder and scapula.
      No reflex changes.
      Radiculopathy
    • C5 :deltoid muscle- difficulty in elevating of arm.
      Weakness of supraspinatus-infraspinatus
      Decrease bicep reflex
      C6:herniation bt.C5C6. top of neck,along the bicep into lat. Aspect of the forearm and onto dorsal surface of hand between thumb and index finger.
      Bicep and brachoradialis reflex decrease.
    • C8 radiculopathy-numbness small finger and medial half of the ring finger.
      Most of intrinsic muscles of the hand.
      Lose fine fingertip and grip strength.
    • Largely secondary to mechanical compression of nerve roots.
      5 articulations:
      intervertebral disc
      2 uncovertebral
      2 facets joints
      Patho-anatomy
    • Innervation of the cervical intervertebral disc
      ST=cervical sympathetic trunk
      VA=vertebral artery;
      ALL=anterior longitudinal ligament
      PLL=posterior longitudinal ligament SVN=cervical sinuvertebral nerve
    • Half of adult population will experience neck and radicular pain.
      Rarely progressed to myelopathic state (Less and Turner, 1963)
      Natural history
    • Varies greatly-Pain, paraesthesia and weakness.
      Classically:significant radicular pain and refered trapezial and periscapular pain.
      Only 55% had pain in a strictly radicular pattern.(Henderson et al,1983,neurosurgery).
      Other studies:60%-70% motor weakness,70% reflex changes.
      Often described symptoms that correlate with various head position.
      Clinical features
    • Exacerbation with neck hyperextension and tilted toward affected side.
      Modified spurling test(combination of head extension and head tilt)
      Shoulder abduction relief sign-specific for soft disc herniation.
      Symptoms and examination
    • Acute-disc herniation:Posterolateral, mid-line and intra-foraminal
      Insidious-degenerative
      Uncovertebral-compress nerve root anteriorly.
      Neuroforaminal narrowing by:osteophytes superior facet, decrease disc height
      Cervical disc herniation and degenerative spondylosis
      • Three locations of focal disc protrusions:
      (A) intraforaminal;
      (B) posterolateral;
      (C) midline
    • Cervical myelopathy
      Entrapment syndrome
      Thoracic outlet syndrome
      Intraspinal and extraspinal tumor
      Differential diagnosis
      • X ray-instability and pathologic changes
      Flexion-extension lateral films-instability
      Loss of disc space height
      Foraminal osteophytes
      Kyphosis
      Subluxution
      Posterior compression from facet arthropathy
      • CT-to evaluate transverse foramina, size and shape of spinal canal, facet and uncovetebral joints
      • MRI-spinal canal diameter, spinal cord, IVD
      and vetebral ligaments.
      Imaging
    • Non-operative:
      Soft collar-<2 weeks
      Traction(24 degree flexion)- release pressure, increase blood flow
      Heat and cold therapy
      Medical- opioid, Nsaids, antispasmodic
      Management
    • Indications: significant pain or deficits after 6 weeks or progressive neurologic deficits
      Approach should be determined by position & type of lesion
      Soft lateral discs easily removed by posterior approach
      Spurs & more paramedian discs via anterior approach
      Surgical procedures
    • Options:
      • Anterior cervical discectomy & fusion
      • Anterior foraminotomy (Jho’s procedure)
      • Posterior foraminotomy
      • Cervical arthroplasty.
    • Posterior cervical foraminotomy
      For unilateral osteophytes, facet hypertrophy, extruded disc causing unilateral radiculopathy
      Avoids bone fusion but often does not efficiently eliminate the herniated disc materials
      • Indications for this approach:
      • Progressive or persistent symptoms arising from unilateral or bilateral lateral disc herniations
      • Spondylotic neural foraminal compromise at one to two levels.
      • Sacrifice the spinal motion at the herniated disc level.
      • C/I-congenital stenosis, stenosis arising predominantly from posterior structures, and disease at greater than three levels
      ANTERIOR CERVICAL DISCECTOMY AND FUSION
    • provides an effective elimination of the compressing herniated portion of the disc or bone spurs, while preserving the remaining disc between the vertebrae and maintaining spinal motion
      Anterior cervical microforaminotomy(Jho procedure)
    • Myelopathy = Cord dysfunction
      Cervical Spondylitic Myelopathy (CSM) introduced by Brain et. al. 1952.
      CSM= gait abnormality and weakness or stiffness of the legs which usually develop insidiously.
      > 50% CM are CSM.
      Other causes for myelopathy are trauma, tumour and congenital.
      Cervical Myelopathy
    • Pathology
      1.Developmental stenosis: AP diameter of spinal canal of 12 mm or less .
      2.Dynamic stenosis: defined as Penning’s jaw diameter - distance from posterior inferior corner of vertebral body, to anterior margin of subjacent lamina, 12 mm or less, a/w 2 mm of retrolisthesis with neck in extension
      3.Disc herniation
      4.Segmental OPLL (Ossification of posterior longitudinal ligament)
      5.Continuous OPLL
      6.Posterior spur
      7.Calcification of ligamentum flavum (CLF): tends to occur in elderly women
      • 1 & 2 most common
    • Cervical Myelopathy(Static stenosis)
      • Pain usually absent.
      • Discomfort varies from aching to
      sharp pain.
      • Gait disturbances,clumsy hands,
      spasticity,sphincter disturbances,
      motor weakness.
      Cervical Myelopathy
    • The proximal motor groups of the legs are more involved than the distal groups (which is the opposite of the pattern with lumbar stenosis)
      Clinical Presentation
    • Hyperreflexia, positive Hoffmann’s sign, Babinski test, clonus, sensory and motor changes.
      Myelopathic hand syndrome:
      thenar atrophy, positive finger escape sign and grip release test.
      Positive Lhermitte’s sign: electric shock sensation with neck flexion
      Physical findings
    • Many patients have evidence of significant compression on neuroradiologic imaging but are relatively asymptomatic
      No patient ever return to normal state.
      75% episodic worsening.
      20% slow and steady progression.
      5% rapid onset with lengthy disability.
      Myelopathy rarely developed in patient with spondylosis.
      Generally, once moderate signs and symptoms of myelopathy develop,the ultimate prognosis is poor.
      Cervical Myelopathy:natural history
    • Scapulohumeral reflex. (tap on scapula spine-pathology above C4)
      L’Hermitte’s sign. (flexion on neck  Paresthesia / shock down to extremities)
      Babinski sign.
      Cervical Myelopathy(signs)
    • Plain X-ray for stenosis
      Normal = ~17 mm
      Absolute (AP canal diameter <10 mm) or relative (10-13 mm) stenosis are risk factors for myelopathy, radiculopathy, or both
      Pavlov's ratio (canal/vertebral body width)
      Should be 1.0, with <0.85 indicating stenosis
      Ratio of <0.80 is a significant risk factor for lateral neurologic injury
      This identifies a congenitally narrow canal
      OPLL
    • MRI
      Shows cervical disc prolapse well
      Demonstrates spinal cord well
      High intensity signal can be found in spinal cord on T2, representing myelomalacia (necrosis/cavity formation)
      CT shows OPLL & bone spurs best
    • Cervical Myelopathy(evaluation)
    • Brown-Sequard syndrome.
      Unilateral cord lesion.
      Cross motor and sensory dysfunction.
      Cervical Myelopathy(clinical syndromes)
    • Central cord syndrome.
      Typically Upper limbs are more affected than lower limbs.
      Cervical Myelopathy(clinical syndromes)
    • Motor system syndrome.
      Anterior cord syndrome.
      Spinal thalamic tract.
      Cortical spinal tract.
      Minimal sensory complaints.
      Cervical Myelopathy(clinical syndromes)
    • Transverse lesion syndrome.
      Posterior cord syndrome
      Posterior Column.
      Spinal thalamic tract.
      Cortical spinal tract.
      Anterior horn cells often involved.
      Cervical Myelopathy(clinical syndromes)
    • Mild myelopathy:
      • May display findings such as slight gait disturbance and mild hyper-reflexia but may have no functional deficits and no weakness.
      • Re-evaluation every 6 to 12 months to look for deterioration of neurologic function or a change in symptoms.
      Non-operative treatment
    • Muscle relaxants
      Analgesics
      NSAID
      Physiotherapy
      Cervical support
      Conservative management
    • Absolute indication = neurological deficit which is progressing
      Patients with cord compression on MRI but no objective symptoms or findings of myelopathy best treated non-operatively
      • Herniation shows better improvement after surgery, older patients & those with dynamic stenosis show less improvement.
      Indications for surgery
    • Surgical approaches
      No controlled prospective studies comparing anterior & posterior approaches
      Approach depends on
      Location of pathology
      Levels of involvement
      Stability of spine
      Presence of kyphotic deformity
    • Indications:
      Generally recommended if disc herniation or posterior spur causing compression at 1 or 2 levels
      Also indicated if there is kyphotic deformity, so that correction can be achieved
      Options:
      Anterior discectomy & interbody fusion with anterior spinal instrumentation
      With more extensive anterior decompression involving excision of osteophytes - discectomy & corpectomy with strut graft fusion
      Anterior Decompression & Fusion
    • Ant. Corpectomy strut grafting
      better decompression
      kyphotic deformity
      more problem if >3 level
      Operative management
    • Generally recommended if there is compression of spinal cord at 3 levels or more, in developmental stenosis or calcification of ligamentumflavum
      Options
      Laminoplasty
      Directly decompresses cord posteriorly & indirectly decompresses cord anteriorly
      Requirements
      Straight or lordotic cervical spine
      Stable spine
      Multilevel cord compression
      • Laminectomy - poor outcome due to spinal instability & kyphosis
      Posterior decompression +/- fusion
    • Canal expansive laminoplasty
      decompression of spinal canal with reduced risk for kyphotic deformity
      No fusion
      Z-plasty (Hattori)
      Hemi-lateral open (Hirabayashi)
      Bilateral open (Kurokawa)
    • Operative management
    • Operative management
    • Operative management
    • Cervical Myelopathy(evaluation)
      < 7 = severe
      8-12 = moderate
      13-16 mild
      Max = 17
    • Complications
      Anterior surgery
      anterior structures (dysphagia, hoarseness, vocal cord, sore throat, sympathetic chain)
      non union.
      Graft slippage (1% -2% ACDF) (6% - 29% graft)
    • Posterior surgery
      kyphosis (preservation of posterior structures)
      reduced ROM with laminoplasty
      General complication
      infection (< 1%)
      hematoma and compression
      cord injury
    • Positive prognostic value include larger transverse area of the cord.
      Younger patient age
      Shorter duration of symptoms, and
      Single rather than multiple levels of involvement
    • Symptoms > 6 months
      Canal : body ratio < 0.8
      Compression ratio < 0.4 after surgery.
      Cervical Myelopathy;bad prognosis