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Orthopedics 5th year, 2nd lecture (Dr. Hamid)

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The lecture has been given on May 8th, 2011 by Dr. Hamid.

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Orthopedics 5th year, 2nd lecture (Dr. Hamid)

  1. 1. CERVICAL SPONDYLOSIS
  2. 2. CERVICAL SPONDYLOSIS <ul><li>􀂙 Commonest cause of; </li></ul><ul><li>- neck pain </li></ul><ul><li>- Radiculopathy </li></ul><ul><li>Myelopathy </li></ul><ul><li>both </li></ul><ul><li>- Decreased ROM </li></ul>
  3. 3. Cervical Sponylosis <ul><li>Chronic degenerative lesions of single or </li></ul><ul><li>multiple intevertebral discs and consequent </li></ul><ul><li>osteophytosis of related vertebral bodies </li></ul><ul><li>Cervical spondylosis is a leading cause of musculo- skeletal disability </li></ul><ul><li>There is no inflammation being not synovial </li></ul><ul><li>natural process of ageing </li></ul>
  4. 4. <ul><li>Cervical spondylosis is a general term encompassing a number of degenerative conditions </li></ul><ul><ul><li>Degenerative disc disease (DDD) </li></ul></ul><ul><ul><li>Spinal stenosis </li></ul></ul><ul><ul><li>With or without degenerative facet joints </li></ul></ul><ul><ul><li>With or without the formation of osteophytes </li></ul></ul><ul><ul><li>With or without a herniated disc </li></ul></ul><ul><li>One single component as a diagnosis is rare </li></ul>
  5. 5. Path--Degeneration <ul><li>-Change in osmotic properties </li></ul><ul><li>- Decrease in water content </li></ul><ul><li>- Loss of disc height&ability to expand </li></ul><ul><li>- Irregularities of end plate </li></ul><ul><li>- Sclerosis in disc interspace </li></ul><ul><li>-Formation of spures and osteophytes </li></ul>
  6. 6. CL/p <ul><li>pressure on (pss)&d,sleeve- </li></ul><ul><li>= == == = root- </li></ul><ul><li>= = = = = = =cord- </li></ul><ul><li>= = = = = = =both- </li></ul>
  7. 7. history <ul><li>A; Pain in the neck- Dull boring, difficult to localize </li></ul><ul><li>Morning stiffness </li></ul><ul><li>Headaches in some – from neck to back of head </li></ul><ul><li>B: Radicular pain- C5- Deltoid , C6 - Thumb & index finger +- weakness of afected myotoms </li></ul><ul><li>C:Instability – difficulty in walking, difficulty in </li></ul><ul><li>climbing stairs </li></ul><ul><li>D:Bladder and Bowel dysfunction </li></ul>
  8. 8. Exam <ul><li>-Gait -Look ,feel, move - neurological exam -special test </li></ul><ul><li>Neck – loss of lordosis, tender areas </li></ul><ul><li>- restricted & painful neck movements </li></ul><ul><li>Radiculopathy -Reflex changes </li></ul><ul><li>wasting of small & big muscles </li></ul><ul><li>Myelopathy - Brisk jerks in lower ext. </li></ul><ul><li>Tendency for clonus </li></ul><ul><li>Spasticity. </li></ul>
  9. 9. radiculopathy
  10. 10. Aetiology <ul><li>􀂄 Aging process </li></ul><ul><li>􀂄 Mechanical load applied to the spine </li></ul><ul><li>􀂄 Mechanical instability </li></ul><ul><li>􀂄 Abnormal movements </li></ul><ul><li>􀂄 Genetic abnormalities of cartilage protein(type IX collagen </li></ul>
  11. 11. Pridisposing factors <ul><li>Abnormalities of glucose metabolism </li></ul><ul><li>HLA related genotype aberration </li></ul><ul><li>Diabetes </li></ul><ul><li>High blood pressure </li></ul><ul><li>Smoking </li></ul>
  12. 12. Osteophite & Spure <ul><li>Disc bulge - peripheral tear within annulus </li></ul><ul><li>elevates ALL&PLL from bony rim. </li></ul><ul><li>Produces Tension which stimulates growth </li></ul><ul><li>& Proliferation of fibroblasts in outer annulus </li></ul><ul><li>and metaplasia into chondrocytes leads to cartilage, osteophite and spur formation </li></ul>
  13. 13. IMAGING <ul><li>X-ray </li></ul><ul><li>CT </li></ul><ul><li>MRI </li></ul>
  14. 15. Differential Diagnosis <ul><li>Nerve entrapment Syndromes </li></ul><ul><li>Rotator Cuff lesions </li></ul><ul><li>Cervical tumers </li></ul><ul><li>TOS </li></ul>
  15. 16. Treatment <ul><li>Conservative </li></ul>
  16. 17. <ul><li>Surgery- </li></ul><ul><li>1-progressive C,mylopathy on conservativR/ </li></ul><ul><li>2-moderate to sever mylopathy </li></ul><ul><li>3-clinical and radiological evidence of radiculopathy with progressive N, defficit. </li></ul><ul><li>4--single level with signif, pain and stiffness </li></ul><ul><li>5-diffinit foraminal narrowing with n,root compression </li></ul>
  17. 18. <ul><li>The type of surgical procedure performed will depend upon: </li></ul><ul><ul><li>Extent of the compression. </li></ul></ul><ul><ul><li>Number of vertebral levels involved. </li></ul></ul><ul><ul><li>Location : Anterior Vs. Posterior compression. </li></ul></ul><ul><ul><li>Instability .+ve or -ve </li></ul></ul><ul><ul><li>Alignment of the cervical spine;k,L </li></ul></ul>Spine Round Friday October 14, 2005 Cervical Myelopathy
  18. 19. <ul><li>Two main approaches </li></ul><ul><ul><li>. </li></ul></ul><ul><ul><li>Posterior </li></ul></ul><ul><ul><ul><li>Laminectomy. </li></ul></ul></ul><ul><ul><ul><li>Laminoplasty </li></ul></ul></ul><ul><ul><ul><li>Anterior </li></ul></ul></ul><ul><ul><ul><li>Why not like disc surgery-neucleolysis,percutaneous </li></ul></ul></ul>
  19. 20. Anterior cervical decompression <ul><li>The goal : </li></ul><ul><ul><li>To expand the spinal canal </li></ul></ul><ul><ul><li>To secure spinal stability </li></ul></ul><ul><ul><li>To preserve the protective function of the spine. </li></ul></ul><ul><li>Indication : </li></ul><ul><ul><li>Herniated disc and ostephite removal </li></ul></ul><ul><ul><li>Vertebral fusion </li></ul></ul><ul><ul><li>Access C2 - C7 Multilevel cord compression. </li></ul></ul><ul><li>Morbidities : </li></ul><ul><ul><li>complexity </li></ul></ul><ul><ul><li>of multilevel anterior </li></ul></ul><ul><ul><li>Recurrent laryngeal nerve Rt. </li></ul></ul><ul><ul><li>Sympathetic nerve </li></ul></ul><ul><ul><li>Carotid artery . </li></ul></ul>Cervical Myelopathy Spine Round Friday October 14, 2005
  20. 21. Anterior Cervical Discectomy and Fusion (ACDF) <ul><li>High success rate >90% for 1 level </li></ul><ul><ul><li>Multilevels </li></ul></ul><ul><ul><li>Disc removal/decompression </li></ul></ul><ul><ul><li>Use of microscope </li></ul></ul><ul><ul><li>Bone graft or other material for fusion </li></ul></ul><ul><ul><li>Usually with plating </li></ul></ul>
  21. 23. Cervical Myelopathy <ul><li>Definition </li></ul><ul><ul><li>Pathological process that affect primary the spine and cause spinal cord impairment : </li></ul></ul><ul><ul><li>- It is usually chronic and slowly progressive </li></ul></ul><ul><ul><li>- The main cause is spondylotic compression. </li></ul></ul><ul><ul><li>-It is quite common in advanced spinal stenosis </li></ul></ul><ul><ul><li>-Transverse myelitis ( when acute) </li></ul></ul><ul><ul><ul><ul><li>multiple sclerosis, , infectious myelitis, haemorrhage. </li></ul></ul></ul></ul>Spine Round Friday October 14, 2005 Cervical Myelopathy
  22. 24. Causes <ul><li>Compromise of the spinal cord </li></ul><ul><ul><li>Cervical spondylosis . </li></ul></ul><ul><ul><li>Acute disc herniation. </li></ul></ul><ul><ul><li>Inflammatory arthritis </li></ul></ul><ul><ul><li>Spinal stenosis. </li></ul></ul><ul><li>Trauma </li></ul><ul><li>Congenital and developmental defects </li></ul><ul><ul><li>Syringomyelia </li></ul></ul><ul><ul><li>Neural tube formation defects </li></ul></ul><ul><li>Spinal neoplasms </li></ul><ul><li>Physical agents </li></ul><ul><ul><li>Decompression sickness </li></ul></ul><ul><ul><li>Electrical injury </li></ul></ul><ul><ul><li>Radiation </li></ul></ul><ul><li>Toxins </li></ul><ul><ul><li>Nitrous oxide </li></ul></ul><ul><li>Metabolic and nutritional disorders </li></ul><ul><ul><li>Pernicious anemia </li></ul></ul><ul><ul><li>Chronic liver disease </li></ul></ul><ul><li>Remote effect of cancer </li></ul><ul><li>Arachnoiditis </li></ul><ul><li>Post infectious autoimmune disorders </li></ul><ul><ul><li>Acute transverse myelitis </li></ul></ul><ul><ul><li>Connective tissue disease </li></ul></ul><ul><li>Multiple sclerosis </li></ul><ul><li>Epidural infections </li></ul><ul><li>Primary infections (human immunodeficiency virus [HIV]) </li></ul><ul><li>Vascular causes </li></ul><ul><ul><li>Epidural hematoma </li></ul></ul><ul><ul><li>Atherosclerotic, abdominal aneurysm </li></ul></ul><ul><ul><li>Malformation </li></ul></ul>Spine Round Friday October 14, 2005 Cervical Myelopathy
  23. 25. Introduction <ul><li>Cervical Myelopathy , cervical cord compression </li></ul><ul><ul><ul><li>Cervical spondylosis. 50% . </li></ul></ul></ul><ul><ul><ul><ul><li>hypertrophy of facet joint and osteophyte formation </li></ul></ul></ul></ul><ul><ul><ul><li>Hypertrophy of the ligamenta flava. </li></ul></ul></ul><ul><ul><ul><li>Bulging (or prolapse) of a cervical disc. </li></ul></ul></ul><ul><ul><ul><li>Spinal stenosis </li></ul></ul></ul><ul><ul><ul><li>Congenital narrowing. </li></ul></ul></ul>Spine Round Friday October 14, 2005 Cervical Myelopathy
  24. 26. Spine Round Friday October 14, 2005 Cervical Myelopathy
  25. 27. Pathophysiology <ul><li>Direct pressure on the spinal cord. </li></ul><ul><li>( Mechanical Factors ) </li></ul><ul><ul><ul><li>Static </li></ul></ul></ul><ul><ul><ul><li>Dynamic. </li></ul></ul></ul><ul><li>Ischemia of the cord . </li></ul><ul><ul><ul><li>compression and obstruction of small vessels within the cord. </li></ul></ul></ul><ul><ul><ul><li>Compression of the feeding radicular arteries within the the intervertebral foramen. </li></ul></ul></ul>Cervical Myelopathy Spine Round Friday October 14, 2005
  26. 28. Phathophysiology <ul><li>The morphological changes within the cord include: </li></ul><ul><ul><li>Degeneration and loss of nerve cells </li></ul></ul><ul><ul><li>Cavitations and proliferation of glia within the grey matter. </li></ul></ul><ul><ul><li>Demyelination of the lateral and posterior columns. </li></ul></ul><ul><ul><li>Wallerian degeneration in ascending tracts above and descending tracts below the compression </li></ul></ul><ul><ul><li>Proliferation of small blood vessels with thickening of the vessel walls </li></ul></ul>Cervical Myelopathy Spine Round Friday October 14, 2005
  27. 29. Clinical syndromes <ul><li>Five Clinical syndromes of Spondylotic Myelopathy. </li></ul><ul><ul><ul><li>Posterior syndrome. </li></ul></ul></ul><ul><ul><ul><li>Anterior cord syndrome </li></ul></ul></ul><ul><ul><ul><li>Central cord syndrome </li></ul></ul></ul><ul><ul><ul><li>Brown-sequard syndrome </li></ul></ul></ul>Cervical Myelopathy Spine Round Friday October 14, 2005
  28. 30. Diagnosis <ul><li>Clinical History. And exam </li></ul><ul><li>Neurologic findings. </li></ul><ul><li>Accurate radiologic imaging studies. </li></ul>Cervical Myelopathy Spine Round Friday October 14, 2005
  29. 31. <ul><li>Age 30 – 50 </li></ul><ul><li>Duration of symptoms range from several months to several years. </li></ul><ul><ul><li>Hand sensory complaints. ( numbness and paresthesia) </li></ul></ul><ul><ul><li>Gait dysfunctions. </li></ul></ul><ul><ul><li>Impairment of hand Fine movements . </li></ul></ul><ul><ul><li>Less frequent symptomes: </li></ul></ul><ul><ul><ul><li>Sphincter and sexual dysfunction are relatively infrequent ( advance myelopathy) </li></ul></ul></ul><ul><ul><ul><li>pain. </li></ul></ul></ul><ul><ul><ul><li>Bladder dysfunction. </li></ul></ul></ul>History and Physical Cervical Myelopathy Spine Round Friday October 14, 2005
  30. 32. Neurological Examination <ul><li>Sign : </li></ul><ul><ul><li>Muscle weakness (the hand intrinsic and triceps muscles) </li></ul></ul><ul><ul><li>Lower extremity weakness (primarily affecting the iliopsoas) </li></ul></ul><ul><ul><li>Spasticity . (cause of gait dysfunction ) </li></ul></ul><ul><ul><li>Hyperreflexia . </li></ul></ul><ul><ul><li>+ ve Hoffman reflex. </li></ul></ul><ul><ul><li>Muscel wasting relatively uncommon </li></ul></ul><ul><ul><li>Grip&release,inverted radial reflex, finger escape </li></ul></ul>Spine Round Friday October 14, 2005 Cervical Myelopathy
  31. 33. <ul><li>Sometimes clinical signs do not improve after decompression </li></ul><ul><li>Sometimes myelopathy progress in spite of decompression </li></ul><ul><li>Neurological findings do not always correlate with radiological level of compression </li></ul>
  32. 34. Myelopathy in elderly <ul><li>Wasting of small muscles in hands </li></ul><ul><li>Weakness of deltoid is characteristic </li></ul><ul><li>Extension contractures of finger MP joints </li></ul><ul><li>Numbness & paraesthesiae in hands </li></ul><ul><li>Difficult to use spoon, button shirt </li></ul>
  33. 35. Radiological investigations <ul><li>Plain X-ray , ( essential firs step ) </li></ul><ul><ul><li>AP , lateral and Oblique ; narrow vertebral canal, ( 13 mm lower limit) </li></ul></ul><ul><ul><li>C anal diameter to body diameter should be greater than 0.8 </li></ul></ul><ul><ul><li>flexion-extension; mobility of the cervical spine </li></ul></ul><ul><li>CT </li></ul><ul><ul><li>Osteophytes, calcified discs, dimensions </li></ul></ul><ul><ul><li>Inadequate assessment of cord & roots </li></ul></ul><ul><li>MRI </li></ul><ul><ul><li>To confirm the nature and extent of the cord compression. ( anterior vs. posterior compression) </li></ul></ul><ul><ul><li>The severity of the disease. </li></ul></ul><ul><ul><li>T2 hyperintensity reflects myelomalacia, demyelination, or microcavities </li></ul></ul><ul><ul><li>Intense signal probably inflammation or edema. </li></ul></ul>Cervical Myelopathy Spine Round Friday October 14, 2005
  34. 37. Natural history <ul><li>Slowly progressive. </li></ul><ul><li>Periods of relative stability or accelerated functional decline. </li></ul><ul><li>Spontaneous improvement is rare. </li></ul><ul><li>Motor symptoms much more progressive and less likely to improve than sensory abnormalities. </li></ul>Cervical Myelopathy Spine Round Friday October 14, 2005
  35. 38. Surgery <ul><ul><li>Surgery </li></ul></ul>Spine Round Friday October 14, 2005 Cervical Myelopathy
  36. 39. THANK YOU

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