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CERVICAL  DISC DISORDER<br />LUNCH HOUR CME<br />15/12/2010<br />
Spondylosis: any or various degenerative diseases of the spine<br />Myelopathy: any disease or disorder of the spinal cord...
Cervical spondylosis<br />Cervical radiculopathy<br />Cervical myelopathy<br />
A non-specific term<br />Refers to any lesion of cervical spine of a degenerative nature (non-inflammatory disc degenerati...
Imbalance between formation & degradation of proteoglycans & collagen in disc<br />With aging, a -ve imbalance with subseq...
Degeneration -><br />Disc herniation<br />Stenosis<br />Instability<br />Spine unable to withstand physiologic loads -> si...
Cervical spinal instability<br />Radiographic criteria of White<br />>11o angulation<br />>3.5 mm translation of adjacent ...
Most people with degenerative changes of the cervical spine remain asymptomatic.<br />Symptomatic patients are usually old...
<ul><li>X-rays changes</li></ul>Narrowing of intervertebral disc<br />Sclerosis of endplates<br />Osteophyte formation<br ...
Most frequently in C5-6 & C6-7
Incidence of spondylosis on X-rays in asymptomatic patients</li></ul>80% in 51-60 age group<br />95% in 61-70 age group<br...
Incidence of Spondylosis on MRI in asymptomatic patients <br />
A condition caused by compression of a nerve root in cervical spine.<br />Involves a specific spinal level with sparing of...
C7 monoradiculopathy-most common,C6-7 level.<br />Pain post. aspect of arm, posterolateral forearm,middle finger<br />Tric...
C3 radiculopathy-involving C2C3 disk.<br />Uncommon<br />Sensory-post.neck,suboccipital and ear<br />No detectable  muscle...
C5 :deltoid muscle- difficulty in elevating of arm.<br />Weakness of supraspinatus-infraspinatus<br />Decrease bicep refle...
C8 radiculopathy-numbness small finger and medial half of the ring finger.<br />Most of intrinsic muscles of the hand.<br ...
Largely secondary to mechanical compression of nerve roots.<br />5 articulations:<br />intervertebral disc<br />2 uncovert...
Innervation of the cervical intervertebral disc<br />   ST=cervical sympathetic trunk<br />   VA=vertebral artery; <br /> ...
Half of adult population will experience neck and radicular pain.<br />Rarely progressed to myelopathic state (Less and Tu...
Varies greatly-Pain, paraesthesia and weakness.<br />Classically:significant radicular pain and refered trapezial and peri...
Exacerbation with neck hyperextension and tilted toward affected side.<br />Modified spurling test(combination of head ext...
Acute-disc herniation:Posterolateral, mid-line and intra-foraminal<br />Insidious-degenerative<br />Uncovertebral-compress...
<ul><li>Three locations of focal disc protrusions: </li></ul>(A) intraforaminal; <br />(B) posterolateral; <br />(C) midli...
Cervical myelopathy<br />Entrapment syndrome<br />Thoracic outlet syndrome<br />Intraspinal and extraspinal tumor<br />Dif...
<ul><li>X ray-instability and pathologic changes</li></ul>Flexion-extension lateral films-instability<br />Loss of disc sp...
MRI-spinal canal diameter, spinal cord, IVD </li></ul>        and  vetebral ligaments.<br />Imaging<br />
Non-operative:<br />Soft collar-<2 weeks<br />Traction(24 degree flexion)- release pressure, increase blood flow<br />Heat...
Indications: significant pain or deficits after 6 weeks or progressive neurologic deficits<br />Approach should be determi...
Options:<br /><ul><li>Anterior cervical discectomy & fusion
Anterior foraminotomy (Jho’s procedure)
Posterior foraminotomy
Cervical arthroplasty.</li></li></ul><li>Posterior cervical foraminotomy<br />For unilateral osteophytes, facet hypertroph...
<ul><li>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 level...
provides an effective elimination of the compressing herniated portion of the disc or bone spurs, while preserving the rem...
Myelopathy = Cord dysfunction<br />Cervical Spondylitic Myelopathy (CSM) introduced by Brain et. al. 1952.<br />CSM= gait ...
Pathology<br />1.Developmental stenosis: AP diameter of spinal canal of 12 mm or less .<br />2.Dynamic stenosis: defined a...
Cervical Myelopathy(Static stenosis)<br />
<ul><li>Pain usually absent.
Discomfort varies from aching to </li></ul>   sharp pain.<br /><ul><li>Gait disturbances,clumsy hands,</li></ul>   spastic...
The proximal motor groups of the legs are more involved than the distal groups (which is the opposite of the pattern with ...
Hyperreflexia, positive Hoffmann’s sign, Babinski test, clonus, sensory and motor changes.<br />Myelopathic hand syndrome:...
Many patients have evidence of significant compression on neuroradiologic imaging but are relatively asymptomatic <br />No...
Scapulohumeral reflex. (tap on scapula spine-pathology above C4)<br />L’Hermitte’s sign. (flexion on neck  Paresthesia / ...
Plain X-ray for stenosis<br />Normal = ~17 mm<br />Absolute (AP canal diameter <10 mm) or relative (10-13 mm) stenosis are...
MRI<br />Shows cervical disc prolapse well<br />Demonstrates spinal cord well<br />High intensity signal can be found in s...
Cervical Myelopathy(evaluation)<br />
Brown-Sequard syndrome.<br />Unilateral cord lesion.<br />Cross motor and sensory dysfunction.<br />Cervical Myelopathy(cl...
Central cord syndrome.<br />Typically Upper limbs are more affected than lower limbs.<br />Cervical Myelopathy(clinical sy...
Motor system syndrome.<br />Anterior cord syndrome.<br />Spinal thalamic tract.<br />Cortical spinal tract.<br />Minimal s...
Transverse lesion syndrome.<br />Posterior cord syndrome<br />Posterior Column.<br />Spinal thalamic tract.<br />Cortical ...
Mild myelopathy:<br /><ul><li>May display findings such as slight gait disturbance and mild hyper-reflexia but may have no...
Re-evaluation every 6 to 12 months to look for deterioration of neurologic function or a change in symptoms. </li></ul>Non...
Muscle relaxants<br />Analgesics<br />NSAID<br />Physiotherapy<br />Cervical support<br />Conservative management<br />
Absolute indication = neurological deficit which is progressing<br />Patients with cord compression on MRI but no objectiv...
Surgical approaches<br />No controlled prospective studies comparing anterior & posterior approaches<br />Approach depends...
Indications:<br />Generally recommended if disc herniation or posterior spur causing compression at 1 or 2 levels<br />Als...
Ant. Corpectomy strut grafting<br />better decompression<br />kyphotic deformity<br />more problem if >3 level<br />Operat...
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Cervical myelopathy cme

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Cervical myelopathy cme

  1. 1. CERVICAL DISC DISORDER<br />LUNCH HOUR CME<br />15/12/2010<br />
  2. 2. Spondylosis: any or various degenerative diseases of the spine<br />Myelopathy: any disease or disorder of the spinal cord or bone marrow<br />Radicular: of, relating to, or involving a nerve root<br />Radiculopathy: any pathological condition at the nerve roots.<br />Definitions of Spinal Disorders<br />
  3. 3. Cervical spondylosis<br />Cervical radiculopathy<br />Cervical myelopathy<br />
  4. 4. A non-specific term<br />Refers to any lesion of cervical spine of a degenerative nature (non-inflammatory disc degeneration)<br />Cervical Spondylosis<br />
  5. 5. Imbalance between formation & degradation of proteoglycans & collagen in disc<br />With aging, a -ve imbalance with subsequent loss of disc material -> degenerative changes<br />Factors influencing severity of degeneration<br />Heredity<br />Trauma<br />Metabolic<br />Other environmental effects, eg. smoking<br />Pathology<br />
  6. 6. Degeneration -><br />Disc herniation<br />Stenosis<br />Instability<br />Spine unable to withstand physiologic loads -> significant risk for neurologic injury, progressive deformity & long-term pain & disability<br />Not common in cervical spondylosis except those with stiffness in middle & lower segments who develop compensatory hypermobility at C3-4 or C4-5 -> myelopathy<br />
  7. 7. Cervical spinal instability<br />Radiographic criteria of White<br />>11o angulation<br />>3.5 mm translation of adjacent subaxial segments<br />
  8. 8. Most people with degenerative changes of the cervical spine remain asymptomatic.<br />Symptomatic patients are usually older than 40 years of age and present with symptoms that are caused by the compression of neural structures.<br />There are three main symptom complexes related to cervical spondylosis: <br />1.Neck pain<br />2.Cervical radiculopathy<br />3.Cervical myelopathy<br />Presentation <br />
  9. 9. <ul><li>X-rays changes</li></ul>Narrowing of intervertebral disc<br />Sclerosis of endplates<br />Osteophyte formation<br /><ul><li>Similar changes may occur in facet joints
  10. 10. Most frequently in C5-6 & C6-7
  11. 11. Incidence of spondylosis on X-rays in asymptomatic patients</li></ul>80% in 51-60 age group<br />95% in 61-70 age group<br />Radiological findings<br />
  12. 12.
  13. 13. Incidence of Spondylosis on MRI in asymptomatic patients <br />
  14. 14. A condition caused by compression of a nerve root in cervical spine.<br />Involves a specific spinal level with sparing of levels immediately above & below.<br />Peak age:50-54 year <br />Disc protrusion =22% spondylosis=68% <br />41% had associated lumbar radiculopathy<br />Cervical Radiculopathy<br />
  15. 15. C7 monoradiculopathy-most common,C6-7 level.<br />Pain post. aspect of arm, posterolateral forearm,middle finger<br />Tricep and fingers extensor weakness<br />Tricep reflex reduce.<br />90% not treated surgically were asymptomatic.<br />Cervical Radiculopathy<br />
  16. 16. C3 radiculopathy-involving C2C3 disk.<br />Uncommon<br />Sensory-post.neck,suboccipital and ear<br />No detectable muscle motor.<br />C4 radiculopathy-neck and shoulder pain<br />No significant motor deficit. Radiating pain-base of the neck,midshoulder and scapula.<br />No reflex changes.<br />Radiculopathy<br />
  17. 17. C5 :deltoid muscle- difficulty in elevating of arm.<br />Weakness of supraspinatus-infraspinatus<br />Decrease bicep reflex<br />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.<br />Bicep and brachoradialis reflex decrease.<br />
  18. 18. C8 radiculopathy-numbness small finger and medial half of the ring finger.<br />Most of intrinsic muscles of the hand.<br />Lose fine fingertip and grip strength.<br />
  19. 19. Largely secondary to mechanical compression of nerve roots.<br />5 articulations:<br />intervertebral disc<br />2 uncovertebral<br />2 facets joints<br />Patho-anatomy<br />
  20. 20. Innervation of the cervical intervertebral disc<br /> ST=cervical sympathetic trunk<br /> VA=vertebral artery; <br /> ALL=anterior longitudinal ligament <br /> PLL=posterior longitudinal ligament SVN=cervical sinuvertebral nerve<br />
  21. 21. Half of adult population will experience neck and radicular pain.<br />Rarely progressed to myelopathic state (Less and Turner, 1963)<br />Natural history<br />
  22. 22. Varies greatly-Pain, paraesthesia and weakness.<br />Classically:significant radicular pain and refered trapezial and periscapular pain.<br />Only 55% had pain in a strictly radicular pattern.(Henderson et al,1983,neurosurgery).<br />Other studies:60%-70% motor weakness,70% reflex changes.<br />Often described symptoms that correlate with various head position.<br />Clinical features<br />
  23. 23. Exacerbation with neck hyperextension and tilted toward affected side.<br />Modified spurling test(combination of head extension and head tilt)<br />Shoulder abduction relief sign-specific for soft disc herniation.<br />Symptoms and examination<br />
  24. 24. Acute-disc herniation:Posterolateral, mid-line and intra-foraminal<br />Insidious-degenerative<br />Uncovertebral-compress nerve root anteriorly.<br />Neuroforaminal narrowing by:osteophytes superior facet, decrease disc height <br />Cervical disc herniation and degenerative spondylosis<br />
  25. 25. <ul><li>Three locations of focal disc protrusions: </li></ul>(A) intraforaminal; <br />(B) posterolateral; <br />(C) midline<br />
  26. 26. Cervical myelopathy<br />Entrapment syndrome<br />Thoracic outlet syndrome<br />Intraspinal and extraspinal tumor<br />Differential diagnosis<br />
  27. 27. <ul><li>X ray-instability and pathologic changes</li></ul>Flexion-extension lateral films-instability<br />Loss of disc space height<br />Foraminal osteophytes<br />Kyphosis<br />Subluxution<br />Posterior compression from facet arthropathy<br /><ul><li>CT-to evaluate transverse foramina, size and shape of spinal canal, facet and uncovetebral joints
  28. 28. MRI-spinal canal diameter, spinal cord, IVD </li></ul> and vetebral ligaments.<br />Imaging<br />
  29. 29. Non-operative:<br />Soft collar-<2 weeks<br />Traction(24 degree flexion)- release pressure, increase blood flow<br />Heat and cold therapy<br />Medical- opioid, Nsaids, antispasmodic<br />Management<br />
  30. 30. Indications: significant pain or deficits after 6 weeks or progressive neurologic deficits<br />Approach should be determined by position & type of lesion<br />Soft lateral discs easily removed by posterior approach<br />Spurs & more paramedian discs via anterior approach<br />Surgical procedures<br />
  31. 31. Options:<br /><ul><li>Anterior cervical discectomy & fusion
  32. 32. Anterior foraminotomy (Jho’s procedure)
  33. 33. Posterior foraminotomy
  34. 34. Cervical arthroplasty.</li></li></ul><li>Posterior cervical foraminotomy<br />For unilateral osteophytes, facet hypertrophy, extruded disc causing unilateral radiculopathy<br />Avoids bone fusion but often does not efficiently eliminate the herniated disc materials<br />
  35. 35. <ul><li>Indications for this approach:
  36. 36. Progressive or persistent symptoms arising from unilateral or bilateral lateral disc herniations
  37. 37. Spondylotic neural foraminal compromise at one to two levels.
  38. 38. Sacrifice the spinal motion at the herniated disc level.
  39. 39. C/I-congenital stenosis, stenosis arising predominantly from posterior structures, and disease at greater than three levels</li></ul>ANTERIOR CERVICAL DISCECTOMY AND FUSION<br />
  40. 40. 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<br />Anterior cervical microforaminotomy(Jho procedure)<br />
  41. 41. Myelopathy = Cord dysfunction<br />Cervical Spondylitic Myelopathy (CSM) introduced by Brain et. al. 1952.<br />CSM= gait abnormality and weakness or stiffness of the legs which usually develop insidiously.<br />> 50% CM are CSM.<br />Other causes for myelopathy are trauma, tumour and congenital.<br />Cervical Myelopathy<br />
  42. 42. Pathology<br />1.Developmental stenosis: AP diameter of spinal canal of 12 mm or less .<br />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<br />3.Disc herniation<br />4.Segmental OPLL (Ossification of posterior longitudinal ligament)<br />5.Continuous OPLL<br />6.Posterior spur<br />7.Calcification of ligamentum flavum (CLF): tends to occur in elderly women<br /><ul><li>1 & 2 most common</li></li></ul><li>
  43. 43. Cervical Myelopathy(Static stenosis)<br />
  44. 44. <ul><li>Pain usually absent.
  45. 45. Discomfort varies from aching to </li></ul> sharp pain.<br /><ul><li>Gait disturbances,clumsy hands,</li></ul> spasticity,sphincter disturbances, <br /> motor weakness.<br />Cervical Myelopathy<br />
  46. 46. The proximal motor groups of the legs are more involved than the distal groups (which is the opposite of the pattern with lumbar stenosis) <br />Clinical Presentation<br />
  47. 47. Hyperreflexia, positive Hoffmann’s sign, Babinski test, clonus, sensory and motor changes.<br />Myelopathic hand syndrome:<br /> thenar atrophy, positive finger escape sign and grip release test.<br />Positive Lhermitte’s sign: electric shock sensation with neck flexion<br />Physical findings<br />
  48. 48.
  49. 49. Many patients have evidence of significant compression on neuroradiologic imaging but are relatively asymptomatic <br />No patient ever return to normal state.<br />75% episodic worsening.<br />20% slow and steady progression.<br />5% rapid onset with lengthy disability. <br />Myelopathy rarely developed in patient with spondylosis.<br />Generally, once moderate signs and symptoms of myelopathy develop,the ultimate prognosis is poor. <br />Cervical Myelopathy:natural history<br />
  50. 50. Scapulohumeral reflex. (tap on scapula spine-pathology above C4)<br />L’Hermitte’s sign. (flexion on neck  Paresthesia / shock down to extremities)<br />Babinski sign.<br />Cervical Myelopathy(signs)<br />
  51. 51. Plain X-ray for stenosis<br />Normal = ~17 mm<br />Absolute (AP canal diameter <10 mm) or relative (10-13 mm) stenosis are risk factors for myelopathy, radiculopathy, or both<br />Pavlov's ratio (canal/vertebral body width)<br />Should be 1.0, with <0.85 indicating stenosis<br />Ratio of <0.80 is a significant risk factor for lateral neurologic injury<br />This identifies a congenitally narrow canal<br />OPLL<br />
  52. 52. MRI<br />Shows cervical disc prolapse well<br />Demonstrates spinal cord well<br />High intensity signal can be found in spinal cord on T2, representing myelomalacia (necrosis/cavity formation)<br />CT shows OPLL & bone spurs best<br />
  53. 53. Cervical Myelopathy(evaluation)<br />
  54. 54. Brown-Sequard syndrome.<br />Unilateral cord lesion.<br />Cross motor and sensory dysfunction.<br />Cervical Myelopathy(clinical syndromes)<br />
  55. 55. Central cord syndrome.<br />Typically Upper limbs are more affected than lower limbs.<br />Cervical Myelopathy(clinical syndromes)<br />
  56. 56. Motor system syndrome.<br />Anterior cord syndrome.<br />Spinal thalamic tract.<br />Cortical spinal tract.<br />Minimal sensory complaints.<br />Cervical Myelopathy(clinical syndromes)<br />
  57. 57. Transverse lesion syndrome.<br />Posterior cord syndrome<br />Posterior Column.<br />Spinal thalamic tract.<br />Cortical spinal tract.<br />Anterior horn cells often involved.<br />Cervical Myelopathy(clinical syndromes)<br />
  58. 58. Mild myelopathy:<br /><ul><li>May display findings such as slight gait disturbance and mild hyper-reflexia but may have no functional deficits and no weakness.
  59. 59. Re-evaluation every 6 to 12 months to look for deterioration of neurologic function or a change in symptoms. </li></ul>Non-operative treatment<br />
  60. 60. Muscle relaxants<br />Analgesics<br />NSAID<br />Physiotherapy<br />Cervical support<br />Conservative management<br />
  61. 61. Absolute indication = neurological deficit which is progressing<br />Patients with cord compression on MRI but no objective symptoms or findings of myelopathy best treated non-operatively<br /><ul><li>Herniation shows better improvement after surgery, older patients & those with dynamic stenosis show less improvement.</li></ul>Indications for surgery<br />
  62. 62. Surgical approaches<br />No controlled prospective studies comparing anterior & posterior approaches<br />Approach depends on<br />Location of pathology<br />Levels of involvement<br />Stability of spine<br />Presence of kyphotic deformity<br />
  63. 63. Indications:<br />Generally recommended if disc herniation or posterior spur causing compression at 1 or 2 levels<br />Also indicated if there is kyphotic deformity, so that correction can be achieved<br />Options:<br />Anterior discectomy & interbody fusion with anterior spinal instrumentation<br />With more extensive anterior decompression involving excision of osteophytes - discectomy & corpectomy with strut graft fusion<br />Anterior Decompression & Fusion<br />
  64. 64. Ant. Corpectomy strut grafting<br />better decompression<br />kyphotic deformity<br />more problem if >3 level<br />Operative management<br />
  65. 65. Generally recommended if there is compression of spinal cord at 3 levels or more, in developmental stenosis or calcification of ligamentumflavum<br />Options<br />Laminoplasty<br />Directly decompresses cord posteriorly & indirectly decompresses cord anteriorly<br />Requirements<br />Straight or lordotic cervical spine<br />Stable spine<br />Multilevel cord compression<br /><ul><li>Laminectomy - poor outcome due to spinal instability & kyphosis</li></ul>Posterior decompression +/- fusion<br />
  66. 66. Canal expansive laminoplasty<br />decompression of spinal canal with reduced risk for kyphotic deformity<br />No fusion<br />Z-plasty (Hattori)<br />Hemi-lateral open (Hirabayashi)<br />Bilateral open (Kurokawa)<br />
  67. 67. Operative management<br />
  68. 68. Operative management<br />
  69. 69. Operative management<br />
  70. 70. Cervical Myelopathy(evaluation)<br />< 7 = severe <br />8-12 = moderate<br />13-16 mild<br />Max = 17<br />
  71. 71. Complications<br />Anterior surgery<br />anterior structures (dysphagia, hoarseness, vocal cord, sore throat, sympathetic chain)<br />non union.<br />Graft slippage (1% -2% ACDF) (6% - 29% graft)<br />
  72. 72. Posterior surgery<br />kyphosis (preservation of posterior structures)<br />reduced ROM with laminoplasty<br />General complication<br />infection (< 1%)<br />hematoma and compression<br />cord injury<br />
  73. 73. Positive prognostic value include larger transverse area of the cord. <br />Younger patient age <br />Shorter duration of symptoms, and <br />Single rather than multiple levels of involvement <br />
  74. 74. Symptoms > 6 months<br />Canal : body ratio < 0.8<br />Compression ratio < 0.4 after surgery.<br />Cervical Myelopathy;bad prognosis<br />

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