Youmans Neurological Surgery

1. Treatment of disk and ligamentous
diseases of the cervical spine
Youmans chapter 278
Vladimir Y. Dadashev
Gerald E. RodtsJr

2. Outline
• Anatomy and pathophysiology
• Clinical finding
• Diagnostic studies
• Nonoperative treatment
• Operative management

3. Pathophysiology of spondylosis
• Progressive biomechanical stress and strain, repetitive
trauma
• Noninflammatory joint degeneration, facet joint
osteoarthritis, posterior longitudinal ligament,
ligamentum flavum
• Normal aging
– Proteoglycan loss of absorb water  loss of water  decrease
viscoelasticity and reduction in volume  reduce disk height
– Stress, axial load translate to annulus fibrosus  tear, wear
– Disrupt Sharpey’s fiber  stimulate reactive bony growth 
osteophyte formation
– Acute dissection  disk herniation

4. Pathophysiology of spondylosis
• Osteophyte  peeling of PLL
• Loss of height  straightening of curvature of c-spine 
axial loading shift anteriorly  chronic compression
vertebral body  kyphotic deformity  hypertrophy or
laxity of joint and ligamentum flavum
• C4-5,C5-6 most angular mobility

5. Pathophysiology of spondylosis
• Nucleus pulposus :
center,water-rich gel(as a
result of proteoglycan
molecules)
• Annulus fibrosus : type I
collagen,organized in to
sheet

6. Pathophysiology of pain
• Mild axial pain to severe cervical myelopathy
• Vertebral n. form by sympathetic trunk and the stellate
ganglion  ALL, anterior annulus
• Small branch of ventral ramus join vertebral n. to form
sinuvertebral n.  PLL, posterior annulus, dura
• Dorsal rami of the cervical nerve root supply most of
innervation of cervical facet joint,rich in nociceptive nerve
ending

8. Pathophysiology of radiculopathy
• Acute
– Secondary to soft disk degeneration
– Younger
– Prominent motor finding
• Chronic
– Older
– Predominant sensory
– Associated with cervical spondylosis

9. Pathophysiology of myelopathy
• Static factor : decrease canal diameter
– Spondylosis of disk,facet,vertebral body  loss of lordotic
– cervical canal stenosis, cord compression
– Normal saggital cervical canal diameter 17-18 mm,
– canal stenosis smaller than 13 mm
• Dynamic factor
– repetitive movement of the compress cord
– Flexion of spine  oversteching of cord
– Ligamentun flavum  posterior cord
– Rotatory and lateral flexion not significant cause
• Final cord change : ischemia and infarct, olidendrocyte
apoptosis, cytotoxic changes

10. Clinical finding
• Cervical pain
– Common
– Exaggerated by neck flexion
• Cervical radiculopathy
• Cervical myelopathy

11. Cervical radiculopathy
• Spurling test
– The examiner turns the patient's head to the affected side while
extending and applying downward pressure to the top of the
patient's head
– A positive Spurling's sign (i.e. the Spurling's test is positive) is
when the pain arising in the neck radiates in the direction of the
corresponding dermatome ipsilaterally

12. Cervical radiculopathy
• Abduction relief sign
– Adbuction patient arm on head

13. Cervical radiculopathy

14. Cervical radiculopathy
• C3 : occipital and posterior neck pain,no motor component
• C4 : lower neck, medial of shoulder, medial scapular pain
• C5 : lateral aspect of shoulder, upper part of arm
deltoid,supraspinatus,infraspinatus weakness
decrease bicep reflex
• C6 : neck down to lateral of arm and forearm, thumb and index pain
bicep weakness
decrease bicep and brachioradialis reflex

15. Cervical radiculopathy
• C7 : posterior portion of shoulder to lateral forearm/arm to middle
• pain
Tricep weakness
decrease tricep reflex
• C8 : ulnar side, fourth and fifth digit pain
hand grip weakness
Horner’s syndrome
• T1 : rare degenerative disease
ulnar and forearm decrease sensation
intrinsic muscle

16. Cervical myelopathy
• Chronic cord compression
• Progressive chronic spondylosis
• LMN
• Secondary to a-motor neuron or existing nerves root
• Dermatomal weakness, tingling, numbness, decrese fine motor
coordination
• Atrophy and weakness of the arms or hands
• Diminish pin prick sensation
• Decrease DTR

17. Cervical myelopathy
• UMN
• Long tract compression
• Corticospinal tract, Spinothalamic tract, Dorsal column
,Spinocerebellar tract
• Unsteady, clumsy gait, leg rigidity, altered sensation, bowel and
bladder dysfunction
• PE : lower extreme spasticity, hyperreflexia, Babinski, clonus or
Hoffman reflex

18. Diagnostic studies
• Plain radiograph
• Computed tomography
• Magnetic resonance imaging
• Neurophysiologic studies
• Diskography

19. Plain radiograph
• Anatomy : fracture of vertebral body, pedicle, lamina
• Pathologic : spondylosis, erosive lesion(infection,
tumour), trauma
• Lateral view : alignment
• Flexion, Extension : instability

20. Computed tomography
• Sagittal, Coronal, 3D construct
• Bony anatomy
• Abnormal bone growth : osteophyte, ligament
ossification
• Neuroforamina, spinal canal
• Invaluble for cord and nerve root compression
• CT-Myelography superior to MRI in postoperative scars,
instrumentation, claustrophobia, indwelling pacemaker

21. Magnetic resonance imaging
• Highly in diagnosis surgical pathological
• T1,T2
• in Myelopathy : high signal in spinal cord

22. Neurophysiologic studies
• Not usually need if clinical syndromes and radio imaging
confirm
• Nerve conduction studies
• Motor NCS, Sensory NCS, F-wave study and H-reflex
• Needle electromyography
• Presence of fibrillation ,positive sharp wave  muscle fiber
denervation
• 3 wk after initial symptom to show

23. Nonoperative management
• Cervical pain
– Conservative
– NSAID, opioid anagelsic, muscle relaxant
– Facet joint anesthesia block to identify
– Physical theraphy : isometric exercise
• Cervical radiculopathy
– Conservative
– Rest, Medication(NSAID, steroid), Cervical collar, Physical
therapy, patient education, local injection
– Opioid for severe pain
– Muscle relaxant for muscle spasm
– Gabapentin for neuropathy pain
• Cervical myelopathy : FU neurological examination, if progress
 considered for surgery

24. Indication for surgery
• Acute worsening neurological status
• Persistent or progression of neurological despite
continue conservative treatment
• Persistent or recurrent arm pain longer than 6 wks with
confirmatory imaging findings

25. Operative management
• Cervical pain
• Cervical radiculopathy
• Cervical myelopathy

26. Posterior approach for diskectomy
• For
– One or two level pathology
– Consider in pt with contraindication for anterior approach
• Pt of history of surgery
• Dysphagia
• Vocal cord paralysis
• Advantage
– Direct visualization of root
– Preservation of the remaining disk and motion segment
– Avoidance of complication for anterior approach : recurrent
laryngeal n.
– Prevent degenerative complication related to anterior fusion

27. Anterior cervical diskectomy
with or without fusion
• Evaluate sagittal alignment
• ACDF : add 5 degree of lordosis curve per level 
physiologic lordotic curve of C-spine
• Fusion : allograft(iliac crest), fusion cage (PEEK,
titanium)
• Complication
– Early : esophageal perforation, postoperative dysphagia,
postoperative hematoma, recurrenlaryngeal nerve palsy,
horner’s syndrome, instrumentation backout, wound infection
– Late : adjament –segmental disease, adjacent-level ossification,
pseudarthrosis, implant malfunction

28. Cervical myelopathy
• Dorsocaudal aspect of C2 to same C7 point

29. Cervical myelopathy

30. • Dorsocaudal aspect of C2 to same C7
point