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Overview of Cervical Disc Herniation.pptx
- 1. Cervical Disc Herniation Department of Neurosurgery Dr RE Anto 31/10/2023
- 2. Applied Anatomy of Cervical Spine • Primary function: • Mobility • Support • Protection of spinal cord and nerve roots
- 3. • Consists of 7 vertebral bodies • From the base of the skull to thoracic spine • Atypical: • C1 + C2 + C7 • Typical: • C3 – 6
- 5. Intervertebral disc • Cartilaginous structure: • Inner nucleus pulposus • Outer annulus fibrosis • Lamellae • Endplates that anchor the discs
- 6. Ligaments • Anterior longitudinal ligament • Posterior longitudinal ligament • Ligamentum nuchae • Supraspinous ligament • Interspinous/Intertransverse ligaments • Ligamentum flavum
- 8. Vasculature
- 9. Spinal canal dimension • Normal cervical spinal canal diameter from C3-C7 is 17 – 18mm in normal adults • But < 15 mm in most cases of myelopathy • Cervical cord: roughly 10mm in diameter
- 10. Etiology • Process of disc herniation: • Acute: more likely from trauma • Chronic: disc becomes degenerated or desiccated as part of an aging or osteodegenerative process
- 11. Epidemiology • Increases with age for both women and men • Most common: • Third to Fifth decade of life • Slight predominance in females (60%)
- 12. Pathophysiology • Static mechanical cord compression • Dynamic mechanical cord compression • Impaired circulation within the cord
- 13. • Encroaching upon the spinal canal space resulting in stenosis • Osteophytes • Spinal ligaments • Disc material • Can occur simultaneously Static Mechanical compression
- 14. Dynamic Mechanical Cord Compression • Flexion of the neck – compression against osteophytic bars • Extension – buckling of ligamentum flavum and compression • MICROTRAUMA
- 15. Impaired circulation within the cord • Anterior spinal artery can be compressed • Critical medullary feeders • Impaired venous drainage • NEURO-ISCHEMIC MYELOPATHY
- 16. Inflammation • Nerve irritation from herniated disc: • Inflammatory cytokines • IL-1, IL-6, substance P, bradykinin, TNF-a and prostaglandins • Trajectory of nerve root • As it exits neural foramen • Close to associated pedicle • More susceptible
- 17. Clinical evaluation • Neck pain • Myelopathy • Radiculopathy • Marginal symptoms
- 18. Physical evaluation - Myelopathy • Upper motor neuron findings: • Usually in lower extremity • Weakness with no atrophy or fasciculations • Spasticity: scissoring of legs • Sensation: any loss below the level of involvement • Complete loss • Brown-Sequard (ipsilateral vibratory and position sense loss and contralateral loss of pinprick) • Central cord sx (suspended sensory loss in UL) • Reflexes: Hoffmans reflex, Babinksi sign, Ankle clonus
- 19. Physical evaluation - Radiculopathy • Lower motor signs • Weakness usually in one myotome on one side • Atrophy + fasciculations may be present • Sensation: • Dermatomal pattern • Same as myotomal weakness • Reproduction of radicular symptoms with axial loading of the head
- 20. Provocative tests – Cervical Root Compression SPURLING TEST LHERMITTE SIGN
- 22. Nerve Root Compression Syndromes
- 23. Imaging • Xray • Look at the vertebral bodies • Quality of bone • Intervertebral disc space • Osteophytes • Calcified PLL • Dynamic views for subluxation
- 24. CT and CT Myelogram • When more in-depth bony assessment is required • Any associated fractures • Ossified PLL • Levels: • C5-6 (good) • C6-7 (artefact from shoulders) • C7-T1 (poor) • CT Myelogram: Not commonly used • Invasive
- 25. MRI • Gold Standard • Evaluate discs • T1 + T2 sagittal • T2 GRE sequence • Dark material next to disc space is bone • Disc is higher signal • CSF is high signal
- 26. Miyazaki M, Hong SW, Yoon SH, Morishita Y, Wang JC. Reliability of a magnetic resonance imaging-based Grading System For Cervical Intervertebral Disk degeneration. J Spinal Disord Tech 2008;21(4):288–292 Thompson disc degeneration staging.
- 27. Electrodiagnostic (EMG + NCS) • EMG: • Can be normal in sensory only radiculopathy • Challenging due to many muscles having shared innervation • Biceps + Deltoid + Brachioradialis + Infraspinatis + Supraspinatus (C5-6) • NCS: • Can be helpful in differentiating a peripheral neuropathy from proximal radiculopathy • Good physical exam should be the base • E.g C6 neuropathy from carpal tunnel sx
- 28. Treatment Modalities • Non-operative (Conservative) • 70 – 80 % will improve • Physical therapy • Interventional pain management • Anti-inflammatory + step wise analgesics • Facet blocks • Trigger point injections • Epidural steroid injection
- 29. Operative - Indications • Continuing or worsening symptoms consistent with nerve root or cord injury • Failure of conservative Rx (3 – 4 months) • Surgery typically avoided for isolated axial neck pain
- 30. Operative Options • Anterior cervical discectomy: • Without fusion (rarely used) • Combined with interbody fusion • With or without anterior cervical plating • Artificial disc (cervical disc arthroplasty) • Posterior approaches: • Cervical laminectomy • Without fusion • With lateral mass fusion • Keyhole laminotomy
- 31. Anterior Cervical Discectomy + Fusion • Indications • Positioning • Supine • Neck slightly extended (carefully – might need fiber-optic intubation by anesthetic team to avoid over-hyperextension) • Shoulders retracted downwards (esp to visualize with fluoroscopy) • Roll between scapula
- 32. Approach – Superficial Dissection • Incise the fascial sheath over the platysma • Split the platysma longitudinally • Anterior border of the SCM and retract laterally • Retract the tracheoesophageal structures medially Horizontal incision along Langers lines
- 33. Deep dissection • The carotid sheath is now exposed • Develop a plane between the carotid sheath and midline structures. • Retract the carotid sheath and SCM laterally. • Deep to the pre-tracheal fascia, the cervical vertebrae should be visible. • Split the longus colli muscles longitudinally • RLN is at risk during this approach; protect it with placement of retractors under the medial edge
- 35. Discectomy • Performed with curette and pituitary ronguers • Caspar pins to aid exposure • Any osteophytes can be removed • PLL is opened with blunt dissection (nerve hook) • Microscope can be used
- 36. Implants/Hardware • Bone grafts – auto or allograft • PEEK (polyetheretherketone) • Carbon fibre • Anterior cervical plates + screws
- 37. Complications • Horner’s Syndrome • Usually cervical retractors above longus colli • Hoarseness • RLN injury/irritation • Dysphagia • Pressure or retraction on esophagus • Prevent by intermittent relaxation of retractors • Partially deflating ETT cuff when retractors in • Retropharyngeal haematoma • Resp distress and tense neck mass • Prevent with portovac drain • Treatment – emergency decompression
- 38. Complications • Vertebral artery injury • CSF leak • Failure of fusion (pseudoarthrosis) • Graft extrusion/migration • Infection • Complex Regional Pain Syndrome • Pneumothorax (C7-T1)
- 39. Cervical Disc Arthroplasty • Alternative to fusion • Artificial disc to preserve motion • Surgical pointers: • Wax decorticated bone ends to prevent fusion • Height should be snug (not too big or else wont be able to flex or extend neck) • NSAIDS for 2 weeks post-op (inhibit bone growth) • No cervical collar (preserve motion)
- 40. Posterior approaches • Cervical laminectomy • Multiple levels • Posterior compression (ligamentum flavum and spinal stenosis) • Risk of RLN significant • Keyhole laminoforaminotomy • Monoradiculopathy with posterolateral soft disc sequestration • Lower C7, C8 or T1 or Upper C3, C4 cervical nerve root compression in a patient with short thick neck • Anterior approach might be difficult
- 41. References • Tew JM, Mayfield FH. Complications of Surgery of the Anterior Cervical Spine. Clin Neurosurg. 1976;23:424–434 • Gore DR, Sepic SB. Anterior Cervical Fusion for Degenerated or Protruded Discs. A Review of One Hundred and Fifty-Six Patients. Spine. 1984; 9:667– 671 • Collias JC, Roberts MP, Schmidek HH, et al. Posterior Surgical Approaches for Cervical Disc Herniation and Spondylotic Myelopathy. In: Operative Neurosurgical Techniques. 3rd ed. Philadelphia: W.B.Saunders; 1995:1805–1816 • Greenberg, Handbook of Neurosurgery, 10th edition • Spine’s Essential Handbook, 2nd edition
Editor's Notes
- An intervertebral disc is a cartilaginous structure composed of three components: an inner nucleus pulposus, outer annulus fibrosus, and endplates that anchor the discs to adjacent vertebrae. Disc herniations occur when part or all of the nucleus pulposus protrudes through the annulus fibrosus.
- Marginal symptoms are those associated with cervical spondylosis but not directly related to it – cervical migraine, dizziness, frozen shoulder
- Spurling’s sign - radicular pain reproduced when the examiner exerts downward pressure on vertex while tilting head towards symptomatic side (sometimes adding neck extension). Causes narrowing of the intervertebral foramen and possibly increases disc bulge. Used as a “mechanical sign” analogous to SLR for lumbar disc herniation. Lhermittes sign - term used that describes a transient sensation of an electric shock that extends down the spine and extremities upon flexion and/or movement of the neck.
- Bakodys test - shoulder abduction test - a sitting patient with radicular symptoms lifts their hand above their head. The reduction or disappearance of radicular symptoms is a positive finding. Moderately sensitive, fairly specific.
- The final operative position has the patient secured supine in mild neck extension with a small roll placed transversely across both shoulders. The head is toward anesthesia; the fluoroscopy machine is positioned transversely at the level of the cervical spine in preparation for localization. The shoulders are gently retracted caudally and Are taped in place for better radiographic exposure of lower cervical levels.
- The final operative position has the patient secured supine in mild neck extension with a small roll placed transversely across both shoulders. The head is toward anesthesia; the fluoroscopy machine is positioned transversely at the level of the cervical spine in preparation for localization. The shoulders are gently retracted caudally and Are taped in place for better radiographic exposure of lower cervical levels.
- The indications for cervical artificial disk replacement are single-level or multilevel disk herniations between C3–C4 and C6–C7 with radiculopathy, myelopathy, or both with minimal spondylosis and no substantial adjacent-level degeneration. The indications for cervical disk replacement are similar to those for anterior cervical diskectomy and fusion (ACDF). These are patients who present with a neural compressive lesion causing upper extremity weakness, paresthesias, and pain, with or without lower extremity hyperreflexia, who are refractory to conservative management. Disadvantages include that since motion is present, dynamic microtrauma may still persist especially in degenerative spine disease where osteophytes and bony spurs are common.