neurosurgery resident presentation

1. DR MUMTAZ ALI NAREJO
JPMC KARACHI

2. OUTLINE
 NORMAL ALIGNMENT
 DEFINITION
 PATHOPHYSIOLOGY
 CLINICAL FEATURES
 GRADING SYSTEMS
 WORKUP
 MANAGEMENT
 WHIPLASH INJURY
 SCIWORA

3. Cervical Spine Curvature
 Normal cervical spine has
lordotic curve
 Increased lordotic curve
(forward head) indicative of
poor posture and muscular
weakness or imbalance
 Lessened lordotic curve
indicative of muscular
spasm/guarding and/or
nerve root impingement

4. SPONDYLOSIS
 Widespread age-related degenerative condition of the
cervical spine including various combinations of the
following:
 Congenital spinal stenosis (“shallow cervical canal”)
 Degeneration of the intervertebral disc producing a
focal stenosis due to a “cervical bar” which is usually a
combination of:
 a) osteophytic spurs (“hard disc”)
 b) and/or protrusion of intervertebral disc material
(“soft disc”)

5.  3. hypertrophy of any of the following (which also contributes to
canal stenosis):
 a) lamina
 b) dura
 c) articular facets
 d) ligaments, including
 ● increased stenosis in extension is more common than with
flexion largely due to posterior inbuckling of ligamentum
flavum
 ● posterior longitudinal ligament: may include ossification of
the posterior longitudinal ligament
 4. subluxation: due to disc and facet joint degeneration
 5. altered mobility: severely spondylotic levels may be fused and
are usually stable, however there is often hypermobility at
adjacent or other segments

6.  6. telescoping of the spine due to loss of height of VBs
→“shingling” of laminae
 7. alteration of the normal lordotic curvature
 a) reduction of lordosis: including
 ● straightening
 ● reversal of the curvature (kyphosis): may cause
“bowstringing” of the spinal cord across osteophytes
 b) exaggerated lordosis (hyperlordosis): the least
common variant (may also cause bowstringing)

7. SPONDYLOSIS
 Cervical spondylosis is the most common cause of
myelopathy in patients > 55 yrs of age.
 CSM is rare in patients <40 years of age.
 Cervical spondylotic myelopathy (CSM) develops in
almost all patients with ≥30% narrowing of the cross-
sectional area of the cervical spinal canal

8. CANAL DIAMETER
 Normal canal diameter on lateral C-spine x-ray (rom
spinolaminar line (SLL) to posterior vertebral body : 17
± 5 mm.
 In the presence of osteophytic spurs, measure from the
back of the spur to the SLL.
 Cervical spinal stenosis: various cutoffs for the normal
minimum AP diameter have been suggested.
 Most authors agree that stenosis is present when the
AP diameter is <12 mm in an adult.

9. PATHOPHYSIOLOGY
Theories include the following alone or in combination:
 Direct cord compression between osteophytic bars and
hypertrophy or infolding of the ligamentum flavum,
 Ischemia due to compression of vascular structures
(arterial deprivation and/or venous stasis)
 Repeated local cord trauma by normal movements in the
presence of protruded discs and/or osteophytic
(spondylotic) bars

10.  Degeneration of the cervical spine motion segments
results from an accumulation of repeated movement,
stress and strain on the osseoligamentous structures.
 Genetic and developmental factors may have an
influence on the vulnerability of the cervical spine to
degenerative change.
 Although all the mobile components of the cervical
spine are susceptible to degenerative change, the
subaxial cervical spine is most often (and
severely) affected compared to the atlantoaxial
complex.

11.  In particular, the lower cervical motion segments at
C5–C6, C6–C7 typically incur maximal degenerative
change.
 These segments are most vulnerable because they
incur the widest degree of range of motion and the
maximal amount of axial stress of the cervical spine
motion segments.
 The precise pathogenesis of cervical spondylosis is not
clearly understood.

12. SIGNS & SYMPTOMS

14. DIFFERENTIAL DIAGNOSIS

15. GRADING
 The modified Japanese Orthopaedic Association scale
 Neck Disability Index:
 a 10 question survey. Mild disability is defin ed as a score of
10–28%, moderate =30– 48%, severe =50–68%, complete ≥
72%
 Other commonly used scales :
 a) Nurick
 b) Harsh

16. JOA SCORING

17. WORKUP
 PLAIN X RAYS
 MRI
 CT 3D
 CT/MR MYELOGRAM

18. OTHERS
EMG
 Not routinely useful. EMG has poor sensitivity in cervical
radiculopathy and is not reliable in predicting outcome
from surgery for CSM.
 EMG is most helpful in suspicious cases to eliminate
etiologies such as peripheral neuropathy.
Sensory evoked potentials (SEPs)
 SSEPs are of limited usefulness, although a normal pre-op
SEP or normalization of SEPs in the early post-op period
are associated with better outcome.

19. IMPORTANT
As part of the work-up for the cause of
axial arm pain or neurological deficit,
one must consider intrathoracic
pathology, appendicular joint
osteoarthritis and peripheral
entrapment neuropathies in the
differential diagnosis.

24. TREATMENT GOALS
 The goals of treating patients with symptomatic
cervical spondylitic disease include
 diminishing pain,
 restoring neurological function
 re-establishing spinal stability.

25. MANAGEMENT
 NON SURGICAL (Conservative)
 SURGICAL

26. CONSERVATIVE
TREATMENT
 Analgesics
 Muscle relaxants
 Physiotherapy

27. POSTERIOR APPROACH
Options include:
 1. laminectomy alone laminectomy/arthrodesis (i.e.
laminectomy + lateral mass fusion):
 2. laminoplasty
 3. multilevel foraminotomies: usually not adequate for
central canal stenosis

28. ANTERIOR APPROACH
 2-level ACDF with anterior plate
 1-level corpectomy with plate
 1-level corpectomy without plate
 2-level ACDF without plate

31. CERVICAL
INJURY

32. WHIPLASH INJURY
Caused due to sudden
deceleration injury
 Sudden stopping of a
moving vehicle
The head goes into
hyperflexion and then
hyper extension

34. DAMAGE
 Rupture of interspinous ligaments in the posterior side
of c-spine
 Unlocking of facet joints
 Rupture of disc or fracture of vertebrae anteriorly

37. Clinical features
 Severe neck pain and stiffness
 May present with quadreplegia
 X-ray may be normal
 MRI – may show the soft tissue injury and
hemorrhage below the longitudinal ligaments
 May present with quadreplegia with out any
radiological changes – due to cord contusion

38. Treatment
 Cervical traction
 Immobilization
 Analgesics
 Wait for the neurological recovery

39. SCIWORA
 Spinal cord injury without radiographic abnormality
(SCIWORA) refers to spinal injuries, typically located
in the cervical region, in the absence of identifiable
bony or ligamentous injury on complete, technically
adequate plain radiographs or computed tomography

40.  Since the advent of magnetic resonance imaging
(MRI) approximately two-thirds of cases described as
SCIWORA in the literature actually have demonstrable
injury to the spinal cord, soft tissue components of the
spinal column (ligaments, capsules, or muscles), or
vertebral body endplate

41.  Occurs most often in pediatric population <8y
 Thought to be due to elasticity of pediatric cervical
spine
 Is diagnosis of exclusion and needs MRI to evaluate for
cord edema vs. ligamental injury
 May have up to a 4 day delay in presentation
 Needs admission and observation
 Keep neck immobilized till improvement.