Cervical Spondylosis;Etiology, Evaluation and Management Steven D. Wray M.D.Atlanta Brain and Spine Care P.C. Piedmont Spine Center
Conclusion:Cervical nerve root or cordcompression from bone spurformation (spondylosis) is adegenerative and progressiveprocess which should be referred toa neurosurgeon early as outcome isdirectly related to the duration ofsymptoms.
Cervical Spondylosis; DefinitionAge related degeneration of thecervical spine“Osteoarthritis”Most common in persons over 40Most common cause for myelopathyin persons over 55Male>Female
Cervical Spondylosis; Pathology Age Related Degeneration and Dehydration of intervertebal Disks Decreased cartilage between adjacent vertebral bodies Developmental laxity in the spinal supportive ligaments Hyper-mobility of spinal segment Bone-on bone apposition propagates bone spur formation which narrow the cervical spinal canal and may compress the cervical nerve roots and spinal cord
Cervical Spondylosis; Spondylitic change with bone spur/disk complex formation Developmental narrowing of spinal canal with compression of spinal cord and nerve roots
Cervical Spondylosis; Cord Compression 64 Year old patient with severe symptomatic spondylitic myelopathy. Multilevel Cord compression seen on MRI.
Cervical Spondylosis; Natural HistoryPredisposition• Some individuals have a congenitally narrow spinal canal• Increased incidence of symptom development with mild to moderate spondylosis• Pre-participation screening of athletes to asses vulnerability to spinal cord injuryEvolution• Unlike soft cervical disk herniation which usually resolves, Cervical Spondylosis is progressive• May be insidious and then more rapidly progressive as Spinal Fluid “reserve” becomes depleted by enlarging bone spurs
Cervical Spondylosis Symptom PathogenesisHyper-mobility / instability of spinalsegmentsIrritation/inflammation of heavilyinnervated vertebral body endplatesDirect compression of cervical nerveroot or spinal cordRepetitive trauma to cord or rootsIschemic change to the cord
Cervical Spondylosis;Presentation with “Headache” Kyphotic Angular deformity creates added stress on the paraspinal muscles and causes severe myofascial pain and spasm and often produces suboccipital headaches where the paraspinal muscles insert on the base of the skull. For this reason, some degenerative cervical spine disease can present with “headache”.
Cervical Spondylosis;Developmental Scoliosis; Facet Arthropaty Coronal Plane angulation causes myofascial pain as well as changes of the facet joints. The added stress on joints leads to joint hypertrophy and inflammatory change which is painful.
DefinitionsRadiculopathy• Nerve Root Compression• Pain, weakness, numbness in the distribution of a nerve root (neck or back)Myelopathy• Spinal Cord Compression in the cervical or thoracic area• Symptoms Numbness, tingling of the arms/ hands Dexterity difficulty with fine motor movements Gait instability Balance and coordination difficulty Bowel/Bladder disturbances (incontinence)
Who Needs Surgery?Neurologic Compromise• Symptomatic Nerve root compression refractory to non-surgical management• Spinal Cord Compression with myelopathyBiomechanical Instability• Instability on Flexion/Extension Films• Angular deformity• Subluxation/ Listhesis
Surgical Options; ConsiderationsType of Pathology• Soft Disk• Bone Spur; SpondylosisLocation of Compression• anterior vs. posteriorAngulation of Spine• Preserved Lordosis vs. KyphosisPatient age and co-morbiditiesHealth of adjacent levelsBone DensityNumber of spinal segments involved
Surgical OptionsAnterior vs. Posterior DecompressionSimple Decompression vs. Fusionand Stabilization
Anterior Cervical Decompression and FusionPerformed through a transverse cervicalincisionMicroscopic Decompression of spinal cordby removal of compressive bone spurRestore and maintain intervertebral heightusing an intervertebral bone graft orplastic spacerStabilize spinal segment with low profiletitanium plate (promotes fusion)
Anterior Cervical Diskectomy and FusionMinimal pain as no muscle disruptionSubcuticular closureOvernight observationAddresses ventral pathology withoutany neural element retraction ormanipulation
Anterior Cervical Decompression and Fusion High fusion rate. Fusion promoted by good blood supply at the ventral moment arm of the spine.
Fusion SubstrateHistorical Gold Standard; Freshlyharvested iliac crest bone autograft• Donor site morbidity• Pain/ Infection RiskBanked Allograft• Small but present risk for disease transmissionPEEK Spacers• Plastic cement restrictors which are non- compressible and restore inter-vertebral height
Bone Morphogenic ProteinRecombinant protein with no risk ofdisease transmission and High fusionrate
Biologics to Promote FusionOsteocondustionOsteoinduction Transverse Process
Goals of SurgeryDecompress neural elementsRestore Intervertebral height which alsorestores neural foraminal patencyRestore anatomic alignment in the case ofkyphosis or scoliosisStabilize spinal segment(s) to preventbone spur propagation and repetitivenerve root irritationPromote solid arthrodesis over time
ACDF to correct Developmental Scoliosis from Spondylosis XXXXX
ACDF to Correct Developmental Kyphosis due to spondylosis xxxxxxx
Posterior Cervical FusionDecompress neural elements byremoval of the bony lamina andunderlying ligament (Laminectomy)Stabilization by posterior lateralmass screws and rodsFusion performed by on-laytechnique and inter-facet graftmaterial (laminar bone or iliac crestautograft)
Posterior Cervical DecompressionDecompression alone iscontraindicated with preexistingkyphotic deformityHigh risk of developing late swan-neck deformityPost operative PainIn case of hyperlordosis, posteriorcord migration may cause cordcompression
Surgical OutcomesAnterior or Posterior approaches thateffectively decompress spinal cordpromote improvements in outcomeHigher Risk of late kyphosis in patientswho undergo laminectomy or anteriorcervical decompression alone compared topatients in whom decompression iscombined with fusionFehlings MG, Arvin B. J Neurosurg Spine. 2009 Aug:11 (2): 97-100
Outcomes Duration of Symptoms and advanced age negatively affect outcome in patients with CSM • 50% improve if operated within a year compared with only 16% is operated after Abnormal Pre-operative SSEP/EMG Findings adversely affect outcome Cord Signal Change or the presence of spinal cord atrophy negatively affect outcomeFehlings MG, Arvin B. J Neurosurg Spine 2009 Aug;11(2):97-100
REFER EARLY!!Patients with spinal cord or nerveroot compression should be referredfor neurosurgical evaluationpromptly.