This document provides an overview of the pathophysiology, clinical presentation, diagnosis, and treatment of cervical disk and ligamentous diseases. It discusses the degenerative changes that occur with spondylosis including loss of disk height and osteophyte formation. Clinical findings are outlined for cervical radiculopathy including positive Spurling's and abduction relief signs, and for cervical myelopathy including upper and lower motor neuron signs. Diagnostic studies including plain radiographs, CT, MRI, and electrodiagnostic testing are covered. Nonoperative treatments include rest, medication, and physical therapy. Surgical indications and techniques for anterior cervical diskectomy with or without fusion and posterior cervical foraminotomy are summarized.

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