SlideShare a Scribd company logo
Pablo Pazmi ño, MD
Orthopaedic Surgery American Academy of Orthopaedic Surgeons Clinical Faculty Olympia Medical Center Cedars Sinai Medical Center Century City Doctors Hospital Education The University of California, Los Angeles The University of Michigan, Ann Arbor
History Epidemiology, Natural History Pathophysiology Pathoanatomic Theories New Theories Diagnosis Symptoms Exam Findings Studies Treatment Non Operative Decision Making Process Operative Cases Dr. V.A.H. Horsley   (1857-1916)
Cervical Spondylosis: Progressive degenerative changes that develop slowly over time, this alters the spinal biomechanics from the loss of shock absorption properties of intervertebral discs. This leads to secondary changes in surrounding structures.  Dysfunction  Instability  Stabilization (Marginal Osteophytes)
Type I:  Cervical Radiculopathy: Cmprsn +Inflammation  of Spinal Nerve with symptoms that correspond  to the level involved Type II:  Cervical Myelopathy: Cord involvement Type III:  Axial Joint Pain (Mechanical neck pain,  “discogenic pain”, facet syndrome, painful  instability
Sex: Radiographic changes are more severe in men than in women.  Cervical Spondylosis present in 50% of population at 50 years of age.   Kellgren  Ann Rheum Dz 1958 Irvine et al defined the prevalence of Spondylosis using radiographic evidence.  Lancet 1965 ♂   prevalence was 13% in the third decade   100% by age 70 years.  ♀  prevalence ranged from 5% in the fourth    96% > 70 years.  In 1992, Rahim and Stambough noted that spondylotic changes are most common in those older than 40 years. Eventually, more than 70% of men and women are affected    Orthop Clin North Am 1992   By age 60-65 95% of nonsymptomatic men and 70% of asymptomatic women develop at least one degenerative change on Xray  Gore Spine 1986  Moore and Blumhardt series, 23.6% of patients presenting with nontraumatic myelopathic symptoms had CSM.  Spinal Cord 1997  CSM is the most common cause of nontraumatic spastic paraparesis and quadriparesis.
This study found that No patient ever returned to normal state 75% Had episodic worsening/progression 20% Slow steady progression 5% Rapid onset followed by lengthy disability  Motor changes tended to persist and progress with time Sensory/bladder changes were transient Soft collar improved gait and Nroot syx for 50% pts Clark E, Robinson PK Cervical Myelopathy: a complication of cervical spondylosis Brain 56:79:483-70 (120 patients)
Patients develop  Stepwise degeneration with periods of stability between exacerbations. 45% of patients with non myelopathic symptoms have good resolution after onset, the remaining 55% continue to have moderate long term morbidity  Lees Turner BMJ 63:2:1607 (44pts/ CSM 3-40yrs)
Found Overall Poor outcome of Nonsurgical Management of CSM The study looked at 43pts 23 Medical treatment: Decrease in ability to perform ADLs, worsening of Neurologic symptoms 20 Surgical treatment: Decreased neurologic symptoms,overall pain, and improved functional status Sampath P et al Spine 2000: 25:670
Gowers (1892) He first noticed the changes associated with Cervical Spondylosis . He called these “Vertebral Exostoses” and thought they were exceedingly rare and their chief characteristic was chronicity.
October 24,1892   20 YO “builder who under the influence of alcohol, fell off his van on to the road striking his right shoulder.” Over 2month this man gradually lost control of legs and sphincters Dr Horsley performed the First Laminectomy of 6 th  Cervical Vertebra. Oct 1892 During surgery he saw the Spinal cord was compressed by a ridge projecting backwards from the body of the vertebra. After surgery the patient had a  Complete  recovery by September of that year
Cervical spondylosis and cord impingement was originally described by Stookey in 1928  He attributed compression of the cord by “extradural chondromas” cartilaginous nodules . Which he thought was similar to these enlargements seen on ears  It was not until 1934 Peet, MM and Echols, DH showed that these “chondromas” were actually disc protrusions Lord Brain, F.R.S., D.M., F.R.C.P. (1895-1966)
In 1952 Lord Brain was the first person who recognized myelopathy and radiculopathy as a clinical disorder
Association between a narrowed, spondylotic cervical spinal canal and the development of CSM has previously led to the formulation of a relatively simple pathoanatomic concept that a narrowed spinal canal causes compression of the enclosed cord, leading to local tissue ischemia, injury, and neurological impairment.  However, this simple mechanism fails to explain the entire spectrum of clinical findings observed in CSM, particularly the development of significant neurological signs in patients without evidence of static spinal cord compression.
Mechanical Factors Static Canal Stenosis Severity Cmprsn Dynamic Changes Flexion Changes Extension Role of Ischemia Pathological Evidence Central gray and medial white most severely affected Relative sparing of anterior columns Progression with severity Lateral CSpinal Tracts most vulnerable  Ant Horn Cells less infarction Extensive Infarct Gray and White with AP Cmpr<20% Cellular and molecular mechanisms Free radical mediated cell injury Cation-mediated cell injury (Na + /Ca ++ ) Glutamatergic toxicity/cell injury Apoptosis
Biomechanical Shear/ Stretch related, Dynamic Stenosis, Pincer Effect, Euler’s Theorum Shear /Stretch Principle (Out of Plane Loading  Poisson’s Effect Dentate Tension Theory
Anteriorly   disc degeneration and osteophytes ,PLL Anterolaterally   uncovertebral joint, and facet hypertrophy  Posteriorly  Ligamentum flavum buckling  Parke WW. Spine 1988  Bernhardt et al JBJS 1993 Progressive cervical spondylotic changes result in circumferential narrowing of the cervical canal
The normal cervical canal diameter from C3 to C7 in Caucasians is  17-18 mm  (< Asians) Cervical cord   varies little in size from C1 to C7,  measuring approximately  10 mm  in diameter (range, 8.5-11.5 mm). 2/3 unoccupied by the spinal cord from C1 to C3 ¼ C4 to C7.   Payne, Brain  ’57 Normal spinal canal can accommodate the development of spondylotic changes CSM is more likely to develop in a congenitally narrowed
Cord compression ratio remains<0.4 Smallest AP Diam/Largest Trans Fujiwara JBJS BR ‘89
The transverse area of the spinal cord was measured to determine the severity of cervical cord compression and was related to prognosis with surgical intervention.  Transverse area  ≠  preoperative neurologic status Transverse area  ≈  response to surgery after decompression  ≥ 30 mm2, functional recovery was favorable. ≤ 30 mm2 a poor response  Penning L, AJR Am J Roentgenol 1986.
With an anteroposterior compression ratio < 20% extensive infarction of all the gray matter occurred.  Ogino et followed 9 patients with CSM were observed clinically, radiographically, and, at time of death, neuropathologically. Histological Changes
1. Early involvement of the corticospinal  tracts  2. Later destruction of anterior horn cells,  demyelination of lateral and  dorsolateral tracts 3. Relative preservation of anterior  columns and dorsal  regions of dorsal columns (Involved Severe CSM). Ogino H, Spine 1983;8:1-15.
Less severe myelopathy Changes confined largely to the  lateral funiculi More severe myelopathy Involvement of the  medial gray area and ventral aspect of the dorsal columns ( including gliosis and anterior horn cell dropout.)
Advanced CSM. Anterior columns and the subpial axons in the dorsal columns were relatively preserved Breig A,  J Neurosurg  1966
Histopathologic observations support the concept of ischemic injury to gray matter and medial white matter Oligodendroglia may be particularly vulnerable to ischemic injury, accounts for  Demyelination in chronic CSM  Demyelination of the corticospinal tracts is one of the first pathologic changes in CSM  Ogino H Spine 1983 First proposed by Lord Brain in 1948
Dynamic Stenosis Pincer Effect Euler’s Theorum Shear /Stretch Principle (Out of Plane Loading  Poisson’s Effect Dentate Tension Theory
1) Clinical studies of cervical mobility in patients with CSM,  2) Histopathological studies of spinal cord tissue from CSM patients 3)Biomechanical studies : an improved understanding of the material properties and biomechanical behavior of spinal cord tissue under various physiological and pathological conditions.
Functional canal diameter may be reduced to a critical level or less  White and Panjabi  Flexion,cord lengthens (more anterior path) resulting in axial tension and, potentially, ischemia. In the presence of anterior osteophytes, the spinal cord can be stretched over the anterior bars.
Progressive encroachment on the spinal canal by ventral and dorsal anatomic structures may first lead to spinal cord compression that  occurs only transiently during physiological cervical range of motion .  The appearance of clinical signs and symptoms arising from this condition has been described as “dynamic stenosis.”  With progressive narrowing of the spinal canal, dynamic stenosis evolves into static compression of the spinal cord and leads to CSM. Burnhardt et al JBJS 1993
Extension 1. Ligamentum flavum buckles inward,which results in the  maximal reduction in cross-sectional area  of the cervical canal.  2.   Spinal cord shortens, and its cross-sectional area increases. Combination places the cord at significant risk in extension.  A pincer effect :  spinal cord is compressed in extension between the posteroinferior margin of one vertebral body and the lamina or ligamentum flavum of the next caudal level.
Euler’s Theorum Spinal cord ( a viscoelastic cylinder) when compressed from the sides, exhibits net tissue creep, bulging axonal membranes, and fluid flow to the free ends of the cylinder  Longitudinal Tension forces  are created within the neuraxis perpendicular to the plane of compression.
A ventral compression force (stenosis) results in increased axial cord tension and fissuring on the side opposite the compression “ Out-of-plane loading”  Shear
Mild compressive deformation of the spinal cord resulted in viscoelastic stretch when the ventral-dorsal diameter < 20-30% Axial tension forces exceeded the material properties of the tissue and resulted in the tearing of axial fibers
Common materials become narrower in cross section when they are stretched.  Inter-atomic bonds realign with deformation.  Stretching of honeycomb by vertical forces, illustrates the concept.  Normal “in-plane” strain can result in “out-of-plane” stresses. This is called Poisson’s effect, and  it accounts for lateral contraction accompanying longitudinal extension. Poisson’s Effect:   Most materials resist a change in volume (as (determined by the bulk modulus) more than they resist a change in shape (shear modulus)
The addition of forces from a ventral spondylotic bar results in maximal stress in the lateral funiculi as the cord is pulled laterally (flattened) by the dentate ligaments (tighten in flexion, anchored by dural root sleeves and dural ligaments). Flexion of the neck increases dural tension and should be avoided in the conservative treatment of CSM.  Both anterior and posterior extradural surgical operations can diminish dentate tension, which may explain their usefulness in CSM.
The role of the dentate ligaments in this model provides an explanation 1) Characteristic histological findings of  the less severe cases of CSM  2) Explains why histopathological  changes can be found remote  from the point of compression
 
At the lower cervical and upper thoracic spine, where the amount of flexion tends to be greatest, the spinal cord stretches up to 24% of its length with a corresponding increase in length of the spinal cord of 17.6 mm at the level of the cervicothoracic junction during flexion  The increased stretching occurring locally at the cervicothoracic junction translates into a significant increase in strain and stress in the white matter and a higher stress in gray matter Reid J Neur 1960
Look how much the spinal cord moves with flexion of the neck Notice the strain on the nerves as well
 
Impairment of intracellular energy metabolism increases neuronal vulnerability to glutamate which, even at nl concentrations can damage neurons. This mechanism of slow excitotoxicity thought to be involved in neuronal death in chronic neurodegenerative diseases  Riluzole, a glutamate antagonist, has therapeutic efficacy in human ALS
Free radicals released from activated microglia may initiate MN injury by increasing the susceptibility of the MN AMPA/kainate receptor (white matter injury) and NMDA (anterior horn injury) to the toxic effects of glutamate.  Bunge RP Adv Neurol 1993.  Fehlings, M  Spine 1998
Show similar pathophysiology of cell injury with traumatic and ischemic injury to the CNS  Both: Delayed anterior horn cell loss, gliosis
Amyotrophic lateral sclerosis  Extrinsic neoplasia (metastatic tumors) Hereditary spastic paraplegia Intrinsic neoplasia (tumors of spinal cord parenchyma)  Multiple sclerosis  Normal/Low pressure hydrocephalus  Spinal cord infarction  Syringomyelia  Vitamin B12 deficiency  SCIWORA syndrome Spinal cord tumor Cerebral hemisphere lesion            
Lhermitte’s sign Paresthesias: Global non dermatomal Fine motor control Clumsy or weak hands  Handwriting  Zippers/Buttons Leg weakness or stiffness (Chair/Stairs) Proximal>>Distal LExtr Chronic suboccipital headache Suboccipital and may radiate to the  base of the neck and the vertex of the  skull.   Changes bowel/bladder (severe, Rare)
Asymptomatic Intermittent neck and shoulder pain  1/3 present with headache  >2/3  present with unilateral or bilateral shoulder pain. A significant amount of these patients also present with arm, forearm, and/or hand pain.  Radicular signs Often not dermatomal. More pain proximally in their limbs, while paresthesias dominate distally.
Radiculopathy ,most commonly 6th 7th roots from C5-6 or C6-7 spondylosis,  Patients usually present with pain, paresthesias, weakness, or a combination of these symptoms.  Pain usually is in the cervical region, upper limb, shoulder, and/or interscapular region.
First described by Pierre Marie and Chatelin in 1917. Lhermitte reported on this symptom in 1920, and in 1924  A sudden electrical sensation down the neck and back triggered by neck flexion  27% of patients CSM  Crandall Batzdorf J Nsx 66:25:57-66 A lesion in the posterior columns of the cervical spinal cord is the cause of Lhermitte's sign in multiple sclerosis .   Anatomic-radiologic basis of Lhermitte's sign in multiple sclerosis J. A. Gutrecht Archives Neurol Aug 93  Les douleurs à type discharge éléctrique consécutives à la flexion cephalique dans la sclérose en plaques. Un cas de la sclérose multiple.   Revue neurologique, Paris, 1924
Upper motor dysfunction Hyperactive deep tendon reflexes Ankle and/or patellar clonus Increased Tone/Spasticity ( especially of the  lower extremities, bladder wall  frequency and nocturia ) Pathological reflexes are also present .  Babinski sign Hoffman sign. Pectoralis muscle reflex. Jaw jerk  may distinguish an upper cervical cord compression from lesions that are above the foramen magnum.
Weakness  is most commonly seen in the triceps and/or hand intrinsic Muscle atrophy  in the following muscles: supraspinatus, infraspinatus, deltoid, triceps, and the first dorsal interosseus muscle. Proximal motor weakness, most commonly in the iliopsoas followed by the quadriceps femoris Gait  stiff or spastic gait Sensory abnormalities  variable pattern Loss of vibratory sense or proprioception in the extremities can occur (feet) Spinothalamic sensory loss may be asymmetric. Romberg test  stands with the arms held forward and the eyes closed (test for position sense; loss of balance consistent with posterior-col dysfunction.
Babinski’s  extension of the big toe and fanning of the other toes in response to stroking the sole of the foot
Hyperextension and lateral rotation toward the symptomatic side Works by narrowing the ipsilateral neural foramina during lateral flexion and rotation, while the initial extension aggravates posterior disk bulging. While this maneuver has a low sensitivity for cervical radiculopathy, it has a specificity of nearly 100%.  Roy Glenwood Spurling American neurosurgeon, born September 6, 1894, Centralia, Missouri; died February 7, 1968, La Jolla, California.  Spurling’s Maneuver for Radiculopathy  1935  Practical Neurological Diagnosis, with Special Reference to Problems of Neurosurgery
Only valuable if it is associated with other upper motor neuron–related findings.  The Hoffman sign :  Hand at rest, stabilize the proximal phalanx between the examiner's index and middle finger. With the examiner's thumb distal middle finger is flicked   reflex contraction of the thumb and index finger  The sensitivity of this examination maneuver may be increased by examining the patient during multiple full flexion or extension of the neck (Dynamic Hoffman sign). Ohne Zusammenfassung
Finger-escape sign.   The patient holds his fingers extended and adducted. In patients with cervical myelopathy, the two ulnar digits will flex and abducted usually in less than 1 minute.  Ono K  JBJS ‘87
Inverted radial reflex.  Tapping the distal brachioradialis tendon produces a hypoactive brachioradialis reflex plus hyperactive finger flexion, this is a positive radial reflex.  This correlates with cord and C5 root lesions that produce spasticity distal to the compression and a hypoactive response at the level of the root/ant horn cells.
Grip-and-release test.  Normal adults can perform rapid complete grip and release to full finger extension 20 times in 10 seconds. This not only becomes slower but, in advanced cases, exaggerated wrist flexion occurs with attempted finger extension and exaggerated wrist extension occurs with finger flexion.
Vladimir Mikhailovich Bekhterev  1902  This reflex involves the lateral and medial pectoral nerves (innervation from the C-5 through T-1 roots).  Tapping of the tendon of the pectoralis major in the deltopectoral groove In the normal state, contraction may be felt, but gross contraction and movement are not seen. A hyperactive response causes  adduction and internal rotation of the shoulder
It suggests compression in the upper cervical spine (C2-C4). Concept that compression of the spinal cord  above the level of the innervating roots of the  reflex should prevent the normal descending  inhibition of the spinal reflexes, resulting in  hyperreflexia. It does not exclude coexisting compression at lower levels
The main clinical features are localized wasting and weakness of the extrinsic and intrinsic hand muscles, but not accompanied by either sensory loss or spastic quadriparesis.   Ono K, Ebara S, Fuji T: Myelopathy hand. New clinical signs of cervical cord damage. J Bone Joint Surg Br 1987; 69 (2): 215-219
Plain film (AP), Lateral :Overall sagittal alignment (lordosis versus kyphosis) Flexionextension: Instablility, a compensatory subluxation one or two levels above the stiffer levels. Oblique views: foraminal narrowin due to uncovertebral joint spurring CT/ CT Myelography better definition of bone spurs and OPLL. The exact degree of cord deformation in the transverse plane MRI Indications: Persistent neck or arm pain (present for more than 2 or 3 months), neurologic findings, or a worsening symptomatic picture warrants neuroradiologic investigation. If evidence of myelopathy is present on physical examination, Electromyographic–nerve conduction : carpal tunnel syndrome, ulnar cubital tunnel syndrome, or thoracic outlet syndrome. Electrodiagnostic modalities may also help elucidate the confusing clinical presentations of amyotrophic lateral sclerosis, multiple sclerosis, and severe peripheral neuropathy.
Myodil Column Displacement Central and Lateral Filling defects, Root sheath obliteration
Conservative Surgical Complex decision making
Patients with neuroradiologic evidence of spinal cord compression but no symptoms or signs of myelopathy should generally be observed. Exception would be a patient with such severe compression that even low-energy trauma (rear-end motor vehicle impact or a fall) result in SCI
Natural history of cervical myelopathy for most patients is  slow deterioration over time . Typically, this is in a  stepwise fashion  with variable periods of stable neurologic function. Extent of myelopathy is reflected predominantly by physical examination findings (balance deficits, gait, motor weakness, long-tract signs, and changes in function=motor)
If the patient is in a plateau period without recent exacerbation, nonoperative treatment may be indicated.  Reevaluation every 6 to 12 months to look for deterioration of neurologic function or a change in symptoms may be appropriate.
The amount of pain experiencing Degree of change of fcn that can be tolerated, Evaluation of symptoms. Severity of compression evident on neuroradiologic studies (Worsening: cord area, cord atrophy, myelomalacia kyphotic deformity) Ex Rapid neurologic deterioration should undergo earlier operative intervention. Positive Prognositic Factors Larger transverse area of the cord,  Younger patient age Shorter duration of symptoms Single rather than multiple levels of involvement. Fujiwara J Bone Joint Surg Br 1989;71: 393-398.  Koyanagi T, Hirabayashi K, Spine 1993
Address 3 goals 1. Pain relief 2. Improved Function 3. Prevention of recurrence
1. Pain relief PT, Rehabilitation, Medication, Injection therapy,  Manipulation all differ in approaches. 2. Improved Function CSM major physical capacity deficits Disuse Change in endurance/aerobic fitness Each pain episode increases fear
3. Prevention of recurrence “ Cycling down” : Disuse leads to  decreasing physical capacity which makes  the now less protected area subject to  overload from even less stress of the initial  injury. Chronic reinjury and recurrence. Develop protective mechanisms: Condition, strengthen muscles acting around spinal construct. Forms basis of PT. Intensive exercise program of >3mo effective  Manniche  Lancet ‘88 ,Pain ‘91 Repeated PT, Manipulation is generally unsuccessful in treating chronic cond.
Disease Education Information (Re: resp pain, anatomy,ergonomics,Wt rdxn, Lifestyle  changes) Nutritional, Activity avoidance Rest Shorter periods of bed rest 2d are as good as longer 7d periods. Prolonged    Negative N balance, deconditioning, loss of BMD, Strength Modalities: Hot packs, Cryotherapy, US, Traction, Massage (Psychological and physical benefit) Isometrics: Static muscle training (Prevent loss of muscle tone, resistance to atrophy) Lat Dorsi, Rhomboid, Sh Abd, Trapezius (4 supporters neck and shoulder girdle). Cervical Flexor, ext, lat bend, rotator musculature Daily for 1 week, then Aerobic conditioning Aerobic Conditioning: Beneficial effect on pain, Weight reduction will decrease spinal loading. Avoid impact aerobics. Focus treadmill/stationary bicycle. Max 30 min 3x/wk
Flexibility Exercises:  Maintenance of adequate ROM. Upper back, trunk, shoulders and neck during aerobic phase. Active and AAROM No passive ROM or manipulation Progressive Resistive Exercises: Change from static to dynamic training.  Medication Nsaids, Narcotics, Muscle Relaxants, Antidepressants
Injection Therapy Trigger Point, Selective Nerve Root block Manipulation
Can be expected to halt progression in deterioration of neurologic function and may improve motor, sensory, and gait disturbance.  The degree of recovery depends largely on the severity of at the time of intervention.  Fujiwara J Bone Joint Surg Br 1989;71: 393-398.  Koyanagi T, Hirabayashi K, Spine 1993
Decompression of Neural elements Stabilization of unstable segments Ablation of painful articulations via fusion
Progressive Neurologic signs or symptoms Presence of Myelopathy for >6 months Canal/Vertebral Body diameter approaching 0.4  Law Bernhardt ICL 1995 Severe Spinal cord compression  Bohlman ’97 Cord Signal Changes with any signs CSM recommend earlier intervention before permanent deficits arise Atlantoaxial Instability (RA) 1/3-1/2 Vertical Migr dvlp LTS/5yrs  N Hx Death Subaxial Segmental Instability  Difficulty Walking Loss of Balance Bowel / Bladder Incontinence Neck Pain (absence of neural deficit) less defined {Intractable correlated with radiologic studies}
Anterior Options Single/Multiple anterior diskectomies with fusion and/or corpectomy (ACDF) Strut fusion techniques with or without the use of anterior instrumentation. Posterior Options   Single/multilevel laminectomy  Laminoplasty Laminectomy plus fusion procedures.
Factors to be considered Number of involved levels Overall sagittal alignment Direction of compression Presence of instability Clinical symptoms. Weigh Advantages and Disadvantages Ant vs Post (1) Approach-related, (2) Decompression-related (3) Graft related, (4) Long-term.
Anterior Approach Direct decompression  Stabilization with arthrodesis Correction of deformity Axial lengthening of spinal column Good axial pain relief Posterior Approach Less loss of motion Not as technically demanding Less bracing needed 4.  Avoids graft complications
Anterior 1. Technically demanding 2. Graft complications  (dislodgment, fracture, and severe settling into the cancellous VB) 3. Need for postoperative bracing limitations 4. Loss of motion  5.  Vertebral artery, Dysphagia, Upper airway compromise Posterior Indirect decompression 2.  Preoperative kyphosis and/or instability Late instability Adjacent segment degeneration Laminectomy  procedures :increased risk of postlaminectomy kyphosis, swanneck deformity, or instability with late neurologic deterioration. Laminoplasty  techniques decrease these risks, but add the potential complication of inadvertent closure of the opened lamina with recurrent stenosis. 7. Inconsistent axial pain results
 
Yonenobu et al  prefer the anterior approach for patients with pathologic changes at one or two levels and posterior surgery for those with involvement at three or more levels. Yonenobu K, Fuji T, Ono K, Okada K, Yamamoto T, Harada N: Choice of surgical treatment for multisegmental cervical spondylotic myelopathy.  Spine  1985;10:710-716.
42 yo High school Math teacher Slip and fall onto right side of body while at work in October 2005 C/o neck pain and radiating Right arm pain 8/10 Now on temporary disability Rx Vicodin Robaxin Pex Painful Rom : Flexion 5 deg, ext 10 Spurlings + Right side Reflexes: Diminished Rt biceps 1+ Hoffmans negative Motor sensory normal
 
Axial C5-6 2 3 4 5 6
Doing well Feels resolution of neck pain improvement right arm pain  Off all narcotic Rx
73 yo female neck and arm pain 2 nd  opinion: 1 st  rec ACDF Failed conserv therapy Tried Lyrica, Tegretol Worsening pain +Lhermittes’s Neck and arm pain with extension and rotation to right Denies B/Bladder Pmhx Trigem Neuralgia, TMJ sx,Osteoperosis PEx Weak Bilat Shoulder abduction, wrist flexion Absent Tri,Bi,Brad reflexes,Lextemities +Bilat Hoffmans +Spurlings to Right and Left
 
2 4-5 4 5 6 5-6
s/p ACDF C45 C56
59 yo male s/p Two level ACDF C 5-6 6-7 Now with significant axial neck pain Had a Pain modulating unit inserted with no improvement in syx Weakness: Wrist E/F, Finger E/F, Bi,Tri +Hoffmans 2+ Reflexes Brad Bi Tri Patellar Achilles
 
4
 
C 3,4,5 Laminoplasty:Plating, Rib graft Bilateral foraminotomies C6-7 C7-T1
Resolution of Axial neck pain Resolution of Lextremity pain Immediate Improvement in Upper Extremity Strength Wrist F/E Finger F/E Biceps Triceps
 
 
 
Brazilian Now with significant axial neck pain, instability, wearing a brace Had a previous ASF,HWR,PSF, decompression Weakness: Wrist E/F, Finger E/F, Bi,Tri, Interossei +Hoffmans 2+ Reflexes Brad Bi Tri Patellar Achilles
 
 
 
 
Hoffmans + Gait  Weakness Prox  Neck Pain Hyper reflexic Myelo Hand Babinski
 
 
 
 
 
Laminoplasty Oct 2005 C4-7
 
 
 
Patient underwent a laminoplasty  Patient has done well and since returned to work as an accountant 3 months afterwards
Surgery should be a last resort, when conservatives measures fail. In some cases surgery needs to be done sooner than later, or even urgently, depending on the physical exam, history, neural deficits, and size of the herniation.
 
All our procedures are peformed in  a minimally invasive manner. All patients receive a plastics closure and are followed closely afterwards
Payne EE, Spitlani JD. An anatomicopathologic study of 70 specimens (using a special technique) with particular reference to the problem of cervical spondylosis. Brain 1957;80:571-96  Parke WW. Correlative anatomy of cervical spondylotic myelopathy. Spine 1988;13:831-7  Penning L, Wilmink JT, van Woerden HH, Knol E. CT myelographic findings in degenerative disorders of the cervical spine: Clinical significance. AJR Am J Roentgenol 1986;146:793-801.  Panjabi M, White AD. Biomechanics of nonacute cervical spinal cord trauma. Spine 1988;13:838-42.  Ogino H, Tada K, Okada K, et al. Canal diameter, anteroposterior compression ratio, and spondylotic myelopathy of the cervical spine. Spine 1983;8:1-15.  Nurick S. The pathogenesis of the spinal cord disorder associated with cervical spondylosis. Brain 1972;95:87-100.  J Neurol Sci. 1967 May-Jun;4(3):607-8  The Rt. Hon. The Lord Brain, F.R.S., D.M., F.R.C.P. (1895-1966). Bunge RP, Puckett WR, Becerra JL, et al. Observations on the pathology of human spinal cord injury. A review and classification of 22 new cases with details from a case of chronic cord compression with extensive focal demyelination. Adv Neurol 1993;59:75-89.  Choi DW. Excitotoxic cell death. J Neurobiol  Lord Brain, M. Wilkinson. Cervical Spondylosis and other disorders of the cevical spine. 1967. Irvine DH, Foster JB, Newell DJ: Prevalence of cervical spondylosis in a general practice. Lancet 1965 May 22; 14: 1089-92  Holt S, Yates PO: Cervical spondylosis and nerve root lesions. Incidence at routine necropsy. J Bone Joint Surg Br 1966 Aug; 48(3): 407-23  Rahim KA, Stambough JL: Radiographic evaluation of the degenerative cervical spine. Orthop Clin North Am 1992 Jul; 23(3): 395-403  Fujiwara K, Yonenobu K, Ebara S, Yamashita K, Ono K: The prognosis of surgery for cervical compression myelopathy: An analysis of the factors involved. JBJS BR 1993 Koyanagi, Toyama Y, Fujimura Y: Predictability of operative results of cervical compression myelopathy based on preoperative computed tomographic myelography.  Spine  1993;18:1958-1963.
Thank you for your time. If you know someone who could benefit from a consultation for Neck Pain, Neck Arthritis or Cervical Spondylotic Myelopathy please refer them to our online website or call toll free to schedule an appointment 1-8SPINECAL-1 www.beverlyspine.com www.santamonicaspine.com

More Related Content

What's hot

Surgical approaches to hip joint
Surgical approaches to hip jointSurgical approaches to hip joint
Surgical approaches to hip joint
adityachakri
 
Congenital scoliosis
Congenital scoliosisCongenital scoliosis
Congenital scoliosis
siddharth438
 
Hallux valgus.pptx
Hallux valgus.pptxHallux valgus.pptx
Hallux valgus.pptx
Siwaporn Khureerung
 
Odontoid and hangman fracture
Odontoid and hangman fractureOdontoid and hangman fracture
Odontoid and hangman fracture
Dikpal Singh
 
Fortis lecture High Grade Spondylolisthesis
Fortis lecture High Grade SpondylolisthesisFortis lecture High Grade Spondylolisthesis
Fortis lecture High Grade Spondylolisthesis
Sumit2018
 
Classification & management of legg calve perthes disease
Classification & management of legg calve perthes diseaseClassification & management of legg calve perthes disease
Classification & management of legg calve perthes disease
Sitanshu Barik
 
Lumbar Disc Replacement
Lumbar Disc ReplacementLumbar Disc Replacement
Lumbar Disc Replacement
Pablo Pazmino
 
Imaging Cervico-vertebral junction: AAD with BI .pptx
Imaging Cervico-vertebral junction: AAD with BI .pptxImaging Cervico-vertebral junction: AAD with BI .pptx
Imaging Cervico-vertebral junction: AAD with BI .pptx
Dr. Shahnawaz Alam
 
Failed back surgery syndrome - A comprehensive overview
Failed back surgery syndrome  - A comprehensive overviewFailed back surgery syndrome  - A comprehensive overview
Failed back surgery syndrome - A comprehensive overview
SpineCenterAtlanta
 
Perthes disease ADOLESCENT COXA VARA
Perthes disease ADOLESCENT COXA VARAPerthes disease ADOLESCENT COXA VARA
Perthes disease ADOLESCENT COXA VARA
Dr ashwani panchal
 
Braces scoliosis
Braces scoliosisBraces scoliosis
Braces scoliosis
George Sapkas
 
Brachial plexus injury
Brachial plexus injuryBrachial plexus injury
Brachial plexus injury
Paudel Sushil
 
Subaxial spine
Subaxial spineSubaxial spine
Subaxial spine
SHAMEEJ MUHAMED KV
 
Recurrent Dislocation of patella
Recurrent Dislocation of patellaRecurrent Dislocation of patella
Recurrent Dislocation of patella
sabir khadka
 
Lumbar canal stenosis
Lumbar canal stenosisLumbar canal stenosis
Lumbar canal stenosis
DrHimanshu Bansal
 
Spondylolisthesis
SpondylolisthesisSpondylolisthesis
Spondylolisthesis
ratish mishra
 
Ostetomies around hip by hemant mamc
Ostetomies around hip by hemant mamcOstetomies around hip by hemant mamc
Ostetomies around hip by hemant mamc
Hemant Pippal
 
Spinal Cord Injury Without Radiology Abnormality (SCIWORA)
Spinal Cord Injury Without Radiology Abnormality (SCIWORA)Spinal Cord Injury Without Radiology Abnormality (SCIWORA)
Spinal Cord Injury Without Radiology Abnormality (SCIWORA)
Ade Wijaya
 
Spine Instrumentation.pptx
Spine Instrumentation.pptxSpine Instrumentation.pptx
Spine Instrumentation.pptx
Sairamakrishnan Sivadasan
 
Neck Pain and Arm Pain : Cervical Radiculopathy by Pablo Pazmino MD
Neck Pain and Arm Pain : Cervical Radiculopathy by Pablo Pazmino MDNeck Pain and Arm Pain : Cervical Radiculopathy by Pablo Pazmino MD
Neck Pain and Arm Pain : Cervical Radiculopathy by Pablo Pazmino MD
Pablo Pazmino
 

What's hot (20)

Surgical approaches to hip joint
Surgical approaches to hip jointSurgical approaches to hip joint
Surgical approaches to hip joint
 
Congenital scoliosis
Congenital scoliosisCongenital scoliosis
Congenital scoliosis
 
Hallux valgus.pptx
Hallux valgus.pptxHallux valgus.pptx
Hallux valgus.pptx
 
Odontoid and hangman fracture
Odontoid and hangman fractureOdontoid and hangman fracture
Odontoid and hangman fracture
 
Fortis lecture High Grade Spondylolisthesis
Fortis lecture High Grade SpondylolisthesisFortis lecture High Grade Spondylolisthesis
Fortis lecture High Grade Spondylolisthesis
 
Classification & management of legg calve perthes disease
Classification & management of legg calve perthes diseaseClassification & management of legg calve perthes disease
Classification & management of legg calve perthes disease
 
Lumbar Disc Replacement
Lumbar Disc ReplacementLumbar Disc Replacement
Lumbar Disc Replacement
 
Imaging Cervico-vertebral junction: AAD with BI .pptx
Imaging Cervico-vertebral junction: AAD with BI .pptxImaging Cervico-vertebral junction: AAD with BI .pptx
Imaging Cervico-vertebral junction: AAD with BI .pptx
 
Failed back surgery syndrome - A comprehensive overview
Failed back surgery syndrome  - A comprehensive overviewFailed back surgery syndrome  - A comprehensive overview
Failed back surgery syndrome - A comprehensive overview
 
Perthes disease ADOLESCENT COXA VARA
Perthes disease ADOLESCENT COXA VARAPerthes disease ADOLESCENT COXA VARA
Perthes disease ADOLESCENT COXA VARA
 
Braces scoliosis
Braces scoliosisBraces scoliosis
Braces scoliosis
 
Brachial plexus injury
Brachial plexus injuryBrachial plexus injury
Brachial plexus injury
 
Subaxial spine
Subaxial spineSubaxial spine
Subaxial spine
 
Recurrent Dislocation of patella
Recurrent Dislocation of patellaRecurrent Dislocation of patella
Recurrent Dislocation of patella
 
Lumbar canal stenosis
Lumbar canal stenosisLumbar canal stenosis
Lumbar canal stenosis
 
Spondylolisthesis
SpondylolisthesisSpondylolisthesis
Spondylolisthesis
 
Ostetomies around hip by hemant mamc
Ostetomies around hip by hemant mamcOstetomies around hip by hemant mamc
Ostetomies around hip by hemant mamc
 
Spinal Cord Injury Without Radiology Abnormality (SCIWORA)
Spinal Cord Injury Without Radiology Abnormality (SCIWORA)Spinal Cord Injury Without Radiology Abnormality (SCIWORA)
Spinal Cord Injury Without Radiology Abnormality (SCIWORA)
 
Spine Instrumentation.pptx
Spine Instrumentation.pptxSpine Instrumentation.pptx
Spine Instrumentation.pptx
 
Neck Pain and Arm Pain : Cervical Radiculopathy by Pablo Pazmino MD
Neck Pain and Arm Pain : Cervical Radiculopathy by Pablo Pazmino MDNeck Pain and Arm Pain : Cervical Radiculopathy by Pablo Pazmino MD
Neck Pain and Arm Pain : Cervical Radiculopathy by Pablo Pazmino MD
 

Viewers also liked

Cervical Myelopathy 2016
Cervical Myelopathy 2016Cervical Myelopathy 2016
Cervical Myelopathy 2016
George Sapkas
 
Symptoms of Cervical Myelopathy
Symptoms of Cervical MyelopathySymptoms of Cervical Myelopathy
Symptoms of Cervical Myelopathy
Ra'Kerry Rahman
 
Myelopathy management
Myelopathy managementMyelopathy management
Myelopathy management
SpinePlus
 
The cervical myelopathy.
The cervical myelopathy.The cervical myelopathy.
The cervical myelopathy.
Sokolowski Specialist Hospital
 
Cervical Compressive Myelopathy
Cervical Compressive MyelopathyCervical Compressive Myelopathy
Cervical Compressive Myelopathy
Sivaraj Sadhasivam
 
Compressive Myelopathy
Compressive MyelopathyCompressive Myelopathy
Durrani eds talk_8-10-12
Durrani eds talk_8-10-12Durrani eds talk_8-10-12
Durrani eds talk_8-10-12
DrSusanS
 
Cervical spondylosis
Cervical spondylosisCervical spondylosis
Cervical spondylosis
Emanuel Doffay
 
Spondylosis
SpondylosisSpondylosis
Spondylosis
Khairul Nizam
 
Cervical spondylosis
Cervical spondylosisCervical spondylosis
Cervical spondylosis
NeurologyKota
 
Spinal cord& its lesions,compressive myelopathy
Spinal cord& its lesions,compressive myelopathySpinal cord& its lesions,compressive myelopathy
Spinal cord& its lesions,compressive myelopathy
govt. medical college, kozhikode
 
Spondylosis
SpondylosisSpondylosis
Spondylosis
Monster Gaga
 
Cervical fractures
Cervical fracturesCervical fractures
Cervical fractures
Tarek ElHewala
 
Cervical Spondylosis.ppt
Cervical Spondylosis.pptCervical Spondylosis.ppt
Cervical Spondylosis.ppt
Shama
 
Spinal cord lesions module
Spinal cord lesions moduleSpinal cord lesions module
Spinal cord lesions module
Harun Muhammad
 
cervical canal stenosis with hypothyroidism
cervical canal stenosis with hypothyroidismcervical canal stenosis with hypothyroidism
cervical canal stenosis with hypothyroidism
Dr B Naga Raju
 
Case Review #13: 13 year old female softball player with Adolescent Idiopathi...
Case Review #13: 13 year old female softball player with Adolescent Idiopathi...Case Review #13: 13 year old female softball player with Adolescent Idiopathi...
Case Review #13: 13 year old female softball player with Adolescent Idiopathi...
Robert Pashman
 
Feet Take Care Of Your Feet
Feet Take Care Of Your FeetFeet Take Care Of Your Feet
Feet Take Care Of Your Feet
Netporium LLC
 
Footwear Prescription Workshop (Fitness.Inc)
Footwear Prescription Workshop (Fitness.Inc)Footwear Prescription Workshop (Fitness.Inc)
Footwear Prescription Workshop (Fitness.Inc)
Vasanth Kumar
 
Heel pain treatment
Heel pain treatmentHeel pain treatment
Heel pain treatment
Mednick
 

Viewers also liked (20)

Cervical Myelopathy 2016
Cervical Myelopathy 2016Cervical Myelopathy 2016
Cervical Myelopathy 2016
 
Symptoms of Cervical Myelopathy
Symptoms of Cervical MyelopathySymptoms of Cervical Myelopathy
Symptoms of Cervical Myelopathy
 
Myelopathy management
Myelopathy managementMyelopathy management
Myelopathy management
 
The cervical myelopathy.
The cervical myelopathy.The cervical myelopathy.
The cervical myelopathy.
 
Cervical Compressive Myelopathy
Cervical Compressive MyelopathyCervical Compressive Myelopathy
Cervical Compressive Myelopathy
 
Compressive Myelopathy
Compressive MyelopathyCompressive Myelopathy
Compressive Myelopathy
 
Durrani eds talk_8-10-12
Durrani eds talk_8-10-12Durrani eds talk_8-10-12
Durrani eds talk_8-10-12
 
Cervical spondylosis
Cervical spondylosisCervical spondylosis
Cervical spondylosis
 
Spondylosis
SpondylosisSpondylosis
Spondylosis
 
Cervical spondylosis
Cervical spondylosisCervical spondylosis
Cervical spondylosis
 
Spinal cord& its lesions,compressive myelopathy
Spinal cord& its lesions,compressive myelopathySpinal cord& its lesions,compressive myelopathy
Spinal cord& its lesions,compressive myelopathy
 
Spondylosis
SpondylosisSpondylosis
Spondylosis
 
Cervical fractures
Cervical fracturesCervical fractures
Cervical fractures
 
Cervical Spondylosis.ppt
Cervical Spondylosis.pptCervical Spondylosis.ppt
Cervical Spondylosis.ppt
 
Spinal cord lesions module
Spinal cord lesions moduleSpinal cord lesions module
Spinal cord lesions module
 
cervical canal stenosis with hypothyroidism
cervical canal stenosis with hypothyroidismcervical canal stenosis with hypothyroidism
cervical canal stenosis with hypothyroidism
 
Case Review #13: 13 year old female softball player with Adolescent Idiopathi...
Case Review #13: 13 year old female softball player with Adolescent Idiopathi...Case Review #13: 13 year old female softball player with Adolescent Idiopathi...
Case Review #13: 13 year old female softball player with Adolescent Idiopathi...
 
Feet Take Care Of Your Feet
Feet Take Care Of Your FeetFeet Take Care Of Your Feet
Feet Take Care Of Your Feet
 
Footwear Prescription Workshop (Fitness.Inc)
Footwear Prescription Workshop (Fitness.Inc)Footwear Prescription Workshop (Fitness.Inc)
Footwear Prescription Workshop (Fitness.Inc)
 
Heel pain treatment
Heel pain treatmentHeel pain treatment
Heel pain treatment
 

Similar to Cervical Arthritis / Cervical Spondylotic Myelopathy / Cervical Stenosis by Pablo Pazmino MD

Cervical spondylosis
Cervical spondylosisCervical spondylosis
Cervical spondylosis
ranjan mishra
 
Lubar Arthritis : Lumbar Stenosis by Pablo Pazmino, MD
Lubar Arthritis : Lumbar Stenosis by Pablo Pazmino, MDLubar Arthritis : Lumbar Stenosis by Pablo Pazmino, MD
Lubar Arthritis : Lumbar Stenosis by Pablo Pazmino, MD
Pablo Pazmino
 
Shoulder Impingement Diagnosis And Rehabilitat
Shoulder Impingement Diagnosis And RehabilitatShoulder Impingement Diagnosis And Rehabilitat
Shoulder Impingement Diagnosis And Rehabilitat
zagstdc
 
Thoracic Outlet Syndrome
Thoracic  Outlet  SyndromeThoracic  Outlet  Syndrome
Thoracic Outlet Syndrome
guestb1ae585c
 
Avascular Necrosis of the Femoral Head
Avascular Necrosis of the Femoral HeadAvascular Necrosis of the Femoral Head
Avascular Necrosis of the Femoral Head
Qazi Manaan
 
OPLL - SPINE
OPLL - SPINE OPLL - SPINE
OPLL - SPINE
MedArzun
 
Keinbocks disease
Keinbocks disease Keinbocks disease
Keinbocks disease
Pandian New
 
Hyperextension Injury
Hyperextension InjuryHyperextension Injury
Hyperextension Injury
Ahmed Shammasi
 
Basics Cervical myelopathy - البروفيسور فريح ابوحسان - استشاري جراحة العظام و...
Basics Cervical myelopathy - البروفيسور فريح ابوحسان - استشاري جراحة العظام و...Basics Cervical myelopathy - البروفيسور فريح ابوحسان - استشاري جراحة العظام و...
Basics Cervical myelopathy - البروفيسور فريح ابوحسان - استشاري جراحة العظام و...
Prof Freih Abu Hassan البروفيسور فريح ابوحسان
 
Cervical spondylosis
Cervical spondylosisCervical spondylosis
Cervical degenerative disease and injuries
Cervical degenerative disease and injuriesCervical degenerative disease and injuries
Cervical degenerative disease and injuries
Neurosurgeon Mumtaz Ali Narejo
 
Clavicle fractures
Clavicle fractures Clavicle fractures
Clavicle fractures
Hardik Pawar
 
avn-131221141653-phpapp02 (1).pdf
avn-131221141653-phpapp02 (1).pdfavn-131221141653-phpapp02 (1).pdf
avn-131221141653-phpapp02 (1).pdf
MohammedTauheed5
 
Principles of effective dynamic stabilizations
Principles of effective dynamic stabilizationsPrinciples of effective dynamic stabilizations
Principles of effective dynamic stabilizations
Alexander Bardis
 
Pra625 cervical spine
Pra625 cervical spinePra625 cervical spine
Pra625 cervical spine
Hans Cifuentes
 
LAMINOPLASTY FINAL
LAMINOPLASTY FINALLAMINOPLASTY FINAL
LAMINOPLASTY FINAL
Sanjoy Biswas
 
Spondyloptosis
SpondyloptosisSpondyloptosis
Spondyloptosis
George Sapkas
 
Spasticity
SpasticitySpasticity
Spasticity
Prashant Makhija
 
Ecr2017 c 0909
Ecr2017 c 0909Ecr2017 c 0909
Ecr2017 c 0909
MarintamaIndra
 
Osteochondroma
OsteochondromaOsteochondroma
Osteochondroma
GIRIDHAR BOYAPATI
 

Similar to Cervical Arthritis / Cervical Spondylotic Myelopathy / Cervical Stenosis by Pablo Pazmino MD (20)

Cervical spondylosis
Cervical spondylosisCervical spondylosis
Cervical spondylosis
 
Lubar Arthritis : Lumbar Stenosis by Pablo Pazmino, MD
Lubar Arthritis : Lumbar Stenosis by Pablo Pazmino, MDLubar Arthritis : Lumbar Stenosis by Pablo Pazmino, MD
Lubar Arthritis : Lumbar Stenosis by Pablo Pazmino, MD
 
Shoulder Impingement Diagnosis And Rehabilitat
Shoulder Impingement Diagnosis And RehabilitatShoulder Impingement Diagnosis And Rehabilitat
Shoulder Impingement Diagnosis And Rehabilitat
 
Thoracic Outlet Syndrome
Thoracic  Outlet  SyndromeThoracic  Outlet  Syndrome
Thoracic Outlet Syndrome
 
Avascular Necrosis of the Femoral Head
Avascular Necrosis of the Femoral HeadAvascular Necrosis of the Femoral Head
Avascular Necrosis of the Femoral Head
 
OPLL - SPINE
OPLL - SPINE OPLL - SPINE
OPLL - SPINE
 
Keinbocks disease
Keinbocks disease Keinbocks disease
Keinbocks disease
 
Hyperextension Injury
Hyperextension InjuryHyperextension Injury
Hyperextension Injury
 
Basics Cervical myelopathy - البروفيسور فريح ابوحسان - استشاري جراحة العظام و...
Basics Cervical myelopathy - البروفيسور فريح ابوحسان - استشاري جراحة العظام و...Basics Cervical myelopathy - البروفيسور فريح ابوحسان - استشاري جراحة العظام و...
Basics Cervical myelopathy - البروفيسور فريح ابوحسان - استشاري جراحة العظام و...
 
Cervical spondylosis
Cervical spondylosisCervical spondylosis
Cervical spondylosis
 
Cervical degenerative disease and injuries
Cervical degenerative disease and injuriesCervical degenerative disease and injuries
Cervical degenerative disease and injuries
 
Clavicle fractures
Clavicle fractures Clavicle fractures
Clavicle fractures
 
avn-131221141653-phpapp02 (1).pdf
avn-131221141653-phpapp02 (1).pdfavn-131221141653-phpapp02 (1).pdf
avn-131221141653-phpapp02 (1).pdf
 
Principles of effective dynamic stabilizations
Principles of effective dynamic stabilizationsPrinciples of effective dynamic stabilizations
Principles of effective dynamic stabilizations
 
Pra625 cervical spine
Pra625 cervical spinePra625 cervical spine
Pra625 cervical spine
 
LAMINOPLASTY FINAL
LAMINOPLASTY FINALLAMINOPLASTY FINAL
LAMINOPLASTY FINAL
 
Spondyloptosis
SpondyloptosisSpondyloptosis
Spondyloptosis
 
Spasticity
SpasticitySpasticity
Spasticity
 
Ecr2017 c 0909
Ecr2017 c 0909Ecr2017 c 0909
Ecr2017 c 0909
 
Osteochondroma
OsteochondromaOsteochondroma
Osteochondroma
 

More from Pablo Pazmino

Lumbar Decompression
Lumbar DecompressionLumbar Decompression
Lumbar Decompression
Pablo Pazmino
 
Cervical Laminoplasty by Pablo Pazmino MD
Cervical Laminoplasty by Pablo Pazmino MDCervical Laminoplasty by Pablo Pazmino MD
Cervical Laminoplasty by Pablo Pazmino MD
Pablo Pazmino
 
Cervical Arthritis, Cervical Spondylotic Myelopathy by Pablo Pazmino MD
Cervical Arthritis, Cervical Spondylotic Myelopathy by Pablo Pazmino MDCervical Arthritis, Cervical Spondylotic Myelopathy by Pablo Pazmino MD
Cervical Arthritis, Cervical Spondylotic Myelopathy by Pablo Pazmino MD
Pablo Pazmino
 
TLIF by Pablo Pazmino MD
TLIF by Pablo Pazmino MDTLIF by Pablo Pazmino MD
TLIF by Pablo Pazmino MD
Pablo Pazmino
 
XLIF by Pablo Pazmino MD
XLIF by Pablo Pazmino MDXLIF by Pablo Pazmino MD
XLIF by Pablo Pazmino MD
Pablo Pazmino
 
Intraoperative Monitoring
Intraoperative MonitoringIntraoperative Monitoring
Intraoperative Monitoring
Pablo Pazmino
 
Cervical Hybrid Arthroplasty by Pablo Pazmino MD
Cervical Hybrid Arthroplasty by Pablo Pazmino MDCervical Hybrid Arthroplasty by Pablo Pazmino MD
Cervical Hybrid Arthroplasty by Pablo Pazmino MD
Pablo Pazmino
 
Fusion Principles by Pablo Pazmino MD
Fusion Principles by Pablo Pazmino MDFusion Principles by Pablo Pazmino MD
Fusion Principles by Pablo Pazmino MD
Pablo Pazmino
 
Lumbar Fusion : A New Anterior Only Option. The STALIF
Lumbar Fusion : A New Anterior Only Option. The STALIFLumbar Fusion : A New Anterior Only Option. The STALIF
Lumbar Fusion : A New Anterior Only Option. The STALIF
Pablo Pazmino
 

More from Pablo Pazmino (9)

Lumbar Decompression
Lumbar DecompressionLumbar Decompression
Lumbar Decompression
 
Cervical Laminoplasty by Pablo Pazmino MD
Cervical Laminoplasty by Pablo Pazmino MDCervical Laminoplasty by Pablo Pazmino MD
Cervical Laminoplasty by Pablo Pazmino MD
 
Cervical Arthritis, Cervical Spondylotic Myelopathy by Pablo Pazmino MD
Cervical Arthritis, Cervical Spondylotic Myelopathy by Pablo Pazmino MDCervical Arthritis, Cervical Spondylotic Myelopathy by Pablo Pazmino MD
Cervical Arthritis, Cervical Spondylotic Myelopathy by Pablo Pazmino MD
 
TLIF by Pablo Pazmino MD
TLIF by Pablo Pazmino MDTLIF by Pablo Pazmino MD
TLIF by Pablo Pazmino MD
 
XLIF by Pablo Pazmino MD
XLIF by Pablo Pazmino MDXLIF by Pablo Pazmino MD
XLIF by Pablo Pazmino MD
 
Intraoperative Monitoring
Intraoperative MonitoringIntraoperative Monitoring
Intraoperative Monitoring
 
Cervical Hybrid Arthroplasty by Pablo Pazmino MD
Cervical Hybrid Arthroplasty by Pablo Pazmino MDCervical Hybrid Arthroplasty by Pablo Pazmino MD
Cervical Hybrid Arthroplasty by Pablo Pazmino MD
 
Fusion Principles by Pablo Pazmino MD
Fusion Principles by Pablo Pazmino MDFusion Principles by Pablo Pazmino MD
Fusion Principles by Pablo Pazmino MD
 
Lumbar Fusion : A New Anterior Only Option. The STALIF
Lumbar Fusion : A New Anterior Only Option. The STALIFLumbar Fusion : A New Anterior Only Option. The STALIF
Lumbar Fusion : A New Anterior Only Option. The STALIF
 

Recently uploaded

Amygdala Medi-Trivia Quiz (Prelims) | FAQ 2024
Amygdala Medi-Trivia Quiz (Prelims) | FAQ 2024Amygdala Medi-Trivia Quiz (Prelims) | FAQ 2024
Amygdala Medi-Trivia Quiz (Prelims) | FAQ 2024
Anindya Das Adhikary
 
1130712-肺阻塞照護新趨勢-講師:鄭孟軒社主任-社團法人高雄市醫師公會.pdf
1130712-肺阻塞照護新趨勢-講師:鄭孟軒社主任-社團法人高雄市醫師公會.pdf1130712-肺阻塞照護新趨勢-講師:鄭孟軒社主任-社團法人高雄市醫師公會.pdf
1130712-肺阻塞照護新趨勢-講師:鄭孟軒社主任-社團法人高雄市醫師公會.pdf
Ks doctor
 
General Endocrinology and mechanism of action of hormones
General Endocrinology and mechanism of action of hormonesGeneral Endocrinology and mechanism of action of hormones
General Endocrinology and mechanism of action of hormones
MedicoseAcademics
 
Post infectious bronchiolitis obliterans
Post infectious bronchiolitis obliteransPost infectious bronchiolitis obliterans
Post infectious bronchiolitis obliterans
drfardosy
 
Article - Design and evaluation of novel inhibitors for the treatment of clea...
Article - Design and evaluation of novel inhibitors for the treatment of clea...Article - Design and evaluation of novel inhibitors for the treatment of clea...
Article - Design and evaluation of novel inhibitors for the treatment of clea...
Trustlife
 
MEDICAL PROFESSIONALISM Class of compassionate care
MEDICAL PROFESSIONALISM Class of compassionate careMEDICAL PROFESSIONALISM Class of compassionate care
MEDICAL PROFESSIONALISM Class of compassionate care
Debre Berhan University
 
GAIRIKA.pptx for Rasashastra and Bhaisajya kalpana
GAIRIKA.pptx for Rasashastra and Bhaisajya kalpanaGAIRIKA.pptx for Rasashastra and Bhaisajya kalpana
GAIRIKA.pptx for Rasashastra and Bhaisajya kalpana
AparnaNandakumar12
 
2024 07 12 Do you share my autistic traits_ - Google Sheets.pdf
2024 07 12 Do you share my autistic traits_ - Google Sheets.pdf2024 07 12 Do you share my autistic traits_ - Google Sheets.pdf
2024 07 12 Do you share my autistic traits_ - Google Sheets.pdf
CarriePoppy
 
FIRST 1000 DAYS NI BABY PAHALAGAHAN PARA SA MALUSOG NA KINABUKASAN
FIRST 1000 DAYS NI BABY PAHALAGAHAN PARA SA MALUSOG NA KINABUKASANFIRST 1000 DAYS NI BABY PAHALAGAHAN PARA SA MALUSOG NA KINABUKASAN
FIRST 1000 DAYS NI BABY PAHALAGAHAN PARA SA MALUSOG NA KINABUKASAN
angelicarrot0827
 
World Population Day 2024_Overview_Dr Bijan Das
World Population Day 2024_Overview_Dr Bijan DasWorld Population Day 2024_Overview_Dr Bijan Das
World Population Day 2024_Overview_Dr Bijan Das
srmnchatripura
 
Yoga talk & yoga slides by Flametree Yoga 11 July 2024.pdf
Yoga talk & yoga slides by Flametree Yoga 11 July 2024.pdfYoga talk & yoga slides by Flametree Yoga 11 July 2024.pdf
Yoga talk & yoga slides by Flametree Yoga 11 July 2024.pdf
Stuart McGill
 
intermine.bio2rdf.org : A QLever SPARQL endpoint
intermine.bio2rdf.org : A QLever SPARQL endpointintermine.bio2rdf.org : A QLever SPARQL endpoint
intermine.bio2rdf.org : A QLever SPARQL endpoint
François Belleau
 
Hemodialysis: Chapter 10, AVF and AVG - Complications (Diagnosis and Manageme...
Hemodialysis: Chapter 10, AVF and AVG - Complications (Diagnosis and Manageme...Hemodialysis: Chapter 10, AVF and AVG - Complications (Diagnosis and Manageme...
Hemodialysis: Chapter 10, AVF and AVG - Complications (Diagnosis and Manageme...
NephroTube - Dr.Gawad
 
PICTURE TEST IN OBSTETRICS AND GYNAECOLOGY-Aloy Okechukwu Ugwu.pptx
PICTURE TEST IN OBSTETRICS AND GYNAECOLOGY-Aloy Okechukwu Ugwu.pptxPICTURE TEST IN OBSTETRICS AND GYNAECOLOGY-Aloy Okechukwu Ugwu.pptx
PICTURE TEST IN OBSTETRICS AND GYNAECOLOGY-Aloy Okechukwu Ugwu.pptx
Aloy Okechukwu Ugwu
 
High Class Girls Call Delhi 9711199171 Provide Best And Top Girl Service And ...
High Class Girls Call Delhi 9711199171 Provide Best And Top Girl Service And ...High Class Girls Call Delhi 9711199171 Provide Best And Top Girl Service And ...
High Class Girls Call Delhi 9711199171 Provide Best And Top Girl Service And ...
sonamrawat5631
 
Interpretation of ECG - Cardiac Arrhythmias
Interpretation of ECG - Cardiac ArrhythmiasInterpretation of ECG - Cardiac Arrhythmias
Interpretation of ECG - Cardiac Arrhythmias
MedicoseAcademics
 
BCBR MCQs with Answers.pdf for exam for NMC promotions
BCBR MCQs with Answers.pdf for exam for NMC promotionsBCBR MCQs with Answers.pdf for exam for NMC promotions
BCBR MCQs with Answers.pdf for exam for NMC promotions
sathya swaroop patnaik
 
Safeguarding Reproductive Health- Preventing Fallopian Tube Blockage After a ...
Safeguarding Reproductive Health- Preventing Fallopian Tube Blockage After a ...Safeguarding Reproductive Health- Preventing Fallopian Tube Blockage After a ...
Safeguarding Reproductive Health- Preventing Fallopian Tube Blockage After a ...
FFragrant
 
Introduction to Dental Implant for undergraduate student
Introduction to Dental Implant for undergraduate studentIntroduction to Dental Implant for undergraduate student
Introduction to Dental Implant for undergraduate student
Shamsuddin Mahmud
 
Definition of Radiotherapy Treatment Planning.pptx
Definition of Radiotherapy Treatment Planning.pptxDefinition of Radiotherapy Treatment Planning.pptx
Definition of Radiotherapy Treatment Planning.pptx
Dr. Dheeraj Kumar
 

Recently uploaded (20)

Amygdala Medi-Trivia Quiz (Prelims) | FAQ 2024
Amygdala Medi-Trivia Quiz (Prelims) | FAQ 2024Amygdala Medi-Trivia Quiz (Prelims) | FAQ 2024
Amygdala Medi-Trivia Quiz (Prelims) | FAQ 2024
 
1130712-肺阻塞照護新趨勢-講師:鄭孟軒社主任-社團法人高雄市醫師公會.pdf
1130712-肺阻塞照護新趨勢-講師:鄭孟軒社主任-社團法人高雄市醫師公會.pdf1130712-肺阻塞照護新趨勢-講師:鄭孟軒社主任-社團法人高雄市醫師公會.pdf
1130712-肺阻塞照護新趨勢-講師:鄭孟軒社主任-社團法人高雄市醫師公會.pdf
 
General Endocrinology and mechanism of action of hormones
General Endocrinology and mechanism of action of hormonesGeneral Endocrinology and mechanism of action of hormones
General Endocrinology and mechanism of action of hormones
 
Post infectious bronchiolitis obliterans
Post infectious bronchiolitis obliteransPost infectious bronchiolitis obliterans
Post infectious bronchiolitis obliterans
 
Article - Design and evaluation of novel inhibitors for the treatment of clea...
Article - Design and evaluation of novel inhibitors for the treatment of clea...Article - Design and evaluation of novel inhibitors for the treatment of clea...
Article - Design and evaluation of novel inhibitors for the treatment of clea...
 
MEDICAL PROFESSIONALISM Class of compassionate care
MEDICAL PROFESSIONALISM Class of compassionate careMEDICAL PROFESSIONALISM Class of compassionate care
MEDICAL PROFESSIONALISM Class of compassionate care
 
GAIRIKA.pptx for Rasashastra and Bhaisajya kalpana
GAIRIKA.pptx for Rasashastra and Bhaisajya kalpanaGAIRIKA.pptx for Rasashastra and Bhaisajya kalpana
GAIRIKA.pptx for Rasashastra and Bhaisajya kalpana
 
2024 07 12 Do you share my autistic traits_ - Google Sheets.pdf
2024 07 12 Do you share my autistic traits_ - Google Sheets.pdf2024 07 12 Do you share my autistic traits_ - Google Sheets.pdf
2024 07 12 Do you share my autistic traits_ - Google Sheets.pdf
 
FIRST 1000 DAYS NI BABY PAHALAGAHAN PARA SA MALUSOG NA KINABUKASAN
FIRST 1000 DAYS NI BABY PAHALAGAHAN PARA SA MALUSOG NA KINABUKASANFIRST 1000 DAYS NI BABY PAHALAGAHAN PARA SA MALUSOG NA KINABUKASAN
FIRST 1000 DAYS NI BABY PAHALAGAHAN PARA SA MALUSOG NA KINABUKASAN
 
World Population Day 2024_Overview_Dr Bijan Das
World Population Day 2024_Overview_Dr Bijan DasWorld Population Day 2024_Overview_Dr Bijan Das
World Population Day 2024_Overview_Dr Bijan Das
 
Yoga talk & yoga slides by Flametree Yoga 11 July 2024.pdf
Yoga talk & yoga slides by Flametree Yoga 11 July 2024.pdfYoga talk & yoga slides by Flametree Yoga 11 July 2024.pdf
Yoga talk & yoga slides by Flametree Yoga 11 July 2024.pdf
 
intermine.bio2rdf.org : A QLever SPARQL endpoint
intermine.bio2rdf.org : A QLever SPARQL endpointintermine.bio2rdf.org : A QLever SPARQL endpoint
intermine.bio2rdf.org : A QLever SPARQL endpoint
 
Hemodialysis: Chapter 10, AVF and AVG - Complications (Diagnosis and Manageme...
Hemodialysis: Chapter 10, AVF and AVG - Complications (Diagnosis and Manageme...Hemodialysis: Chapter 10, AVF and AVG - Complications (Diagnosis and Manageme...
Hemodialysis: Chapter 10, AVF and AVG - Complications (Diagnosis and Manageme...
 
PICTURE TEST IN OBSTETRICS AND GYNAECOLOGY-Aloy Okechukwu Ugwu.pptx
PICTURE TEST IN OBSTETRICS AND GYNAECOLOGY-Aloy Okechukwu Ugwu.pptxPICTURE TEST IN OBSTETRICS AND GYNAECOLOGY-Aloy Okechukwu Ugwu.pptx
PICTURE TEST IN OBSTETRICS AND GYNAECOLOGY-Aloy Okechukwu Ugwu.pptx
 
High Class Girls Call Delhi 9711199171 Provide Best And Top Girl Service And ...
High Class Girls Call Delhi 9711199171 Provide Best And Top Girl Service And ...High Class Girls Call Delhi 9711199171 Provide Best And Top Girl Service And ...
High Class Girls Call Delhi 9711199171 Provide Best And Top Girl Service And ...
 
Interpretation of ECG - Cardiac Arrhythmias
Interpretation of ECG - Cardiac ArrhythmiasInterpretation of ECG - Cardiac Arrhythmias
Interpretation of ECG - Cardiac Arrhythmias
 
BCBR MCQs with Answers.pdf for exam for NMC promotions
BCBR MCQs with Answers.pdf for exam for NMC promotionsBCBR MCQs with Answers.pdf for exam for NMC promotions
BCBR MCQs with Answers.pdf for exam for NMC promotions
 
Safeguarding Reproductive Health- Preventing Fallopian Tube Blockage After a ...
Safeguarding Reproductive Health- Preventing Fallopian Tube Blockage After a ...Safeguarding Reproductive Health- Preventing Fallopian Tube Blockage After a ...
Safeguarding Reproductive Health- Preventing Fallopian Tube Blockage After a ...
 
Introduction to Dental Implant for undergraduate student
Introduction to Dental Implant for undergraduate studentIntroduction to Dental Implant for undergraduate student
Introduction to Dental Implant for undergraduate student
 
Definition of Radiotherapy Treatment Planning.pptx
Definition of Radiotherapy Treatment Planning.pptxDefinition of Radiotherapy Treatment Planning.pptx
Definition of Radiotherapy Treatment Planning.pptx
 

Cervical Arthritis / Cervical Spondylotic Myelopathy / Cervical Stenosis by Pablo Pazmino MD

  • 2. Orthopaedic Surgery American Academy of Orthopaedic Surgeons Clinical Faculty Olympia Medical Center Cedars Sinai Medical Center Century City Doctors Hospital Education The University of California, Los Angeles The University of Michigan, Ann Arbor
  • 3. History Epidemiology, Natural History Pathophysiology Pathoanatomic Theories New Theories Diagnosis Symptoms Exam Findings Studies Treatment Non Operative Decision Making Process Operative Cases Dr. V.A.H. Horsley (1857-1916)
  • 4. Cervical Spondylosis: Progressive degenerative changes that develop slowly over time, this alters the spinal biomechanics from the loss of shock absorption properties of intervertebral discs. This leads to secondary changes in surrounding structures. Dysfunction  Instability  Stabilization (Marginal Osteophytes)
  • 5. Type I: Cervical Radiculopathy: Cmprsn +Inflammation of Spinal Nerve with symptoms that correspond to the level involved Type II: Cervical Myelopathy: Cord involvement Type III: Axial Joint Pain (Mechanical neck pain, “discogenic pain”, facet syndrome, painful instability
  • 6. Sex: Radiographic changes are more severe in men than in women. Cervical Spondylosis present in 50% of population at 50 years of age. Kellgren Ann Rheum Dz 1958 Irvine et al defined the prevalence of Spondylosis using radiographic evidence. Lancet 1965 ♂ prevalence was 13% in the third decade  100% by age 70 years. ♀ prevalence ranged from 5% in the fourth  96% > 70 years. In 1992, Rahim and Stambough noted that spondylotic changes are most common in those older than 40 years. Eventually, more than 70% of men and women are affected Orthop Clin North Am 1992 By age 60-65 95% of nonsymptomatic men and 70% of asymptomatic women develop at least one degenerative change on Xray Gore Spine 1986 Moore and Blumhardt series, 23.6% of patients presenting with nontraumatic myelopathic symptoms had CSM. Spinal Cord 1997 CSM is the most common cause of nontraumatic spastic paraparesis and quadriparesis.
  • 7. This study found that No patient ever returned to normal state 75% Had episodic worsening/progression 20% Slow steady progression 5% Rapid onset followed by lengthy disability Motor changes tended to persist and progress with time Sensory/bladder changes were transient Soft collar improved gait and Nroot syx for 50% pts Clark E, Robinson PK Cervical Myelopathy: a complication of cervical spondylosis Brain 56:79:483-70 (120 patients)
  • 8. Patients develop Stepwise degeneration with periods of stability between exacerbations. 45% of patients with non myelopathic symptoms have good resolution after onset, the remaining 55% continue to have moderate long term morbidity Lees Turner BMJ 63:2:1607 (44pts/ CSM 3-40yrs)
  • 9. Found Overall Poor outcome of Nonsurgical Management of CSM The study looked at 43pts 23 Medical treatment: Decrease in ability to perform ADLs, worsening of Neurologic symptoms 20 Surgical treatment: Decreased neurologic symptoms,overall pain, and improved functional status Sampath P et al Spine 2000: 25:670
  • 10. Gowers (1892) He first noticed the changes associated with Cervical Spondylosis . He called these “Vertebral Exostoses” and thought they were exceedingly rare and their chief characteristic was chronicity.
  • 11. October 24,1892 20 YO “builder who under the influence of alcohol, fell off his van on to the road striking his right shoulder.” Over 2month this man gradually lost control of legs and sphincters Dr Horsley performed the First Laminectomy of 6 th Cervical Vertebra. Oct 1892 During surgery he saw the Spinal cord was compressed by a ridge projecting backwards from the body of the vertebra. After surgery the patient had a Complete recovery by September of that year
  • 12. Cervical spondylosis and cord impingement was originally described by Stookey in 1928 He attributed compression of the cord by “extradural chondromas” cartilaginous nodules . Which he thought was similar to these enlargements seen on ears It was not until 1934 Peet, MM and Echols, DH showed that these “chondromas” were actually disc protrusions Lord Brain, F.R.S., D.M., F.R.C.P. (1895-1966)
  • 13. In 1952 Lord Brain was the first person who recognized myelopathy and radiculopathy as a clinical disorder
  • 14. Association between a narrowed, spondylotic cervical spinal canal and the development of CSM has previously led to the formulation of a relatively simple pathoanatomic concept that a narrowed spinal canal causes compression of the enclosed cord, leading to local tissue ischemia, injury, and neurological impairment. However, this simple mechanism fails to explain the entire spectrum of clinical findings observed in CSM, particularly the development of significant neurological signs in patients without evidence of static spinal cord compression.
  • 15. Mechanical Factors Static Canal Stenosis Severity Cmprsn Dynamic Changes Flexion Changes Extension Role of Ischemia Pathological Evidence Central gray and medial white most severely affected Relative sparing of anterior columns Progression with severity Lateral CSpinal Tracts most vulnerable Ant Horn Cells less infarction Extensive Infarct Gray and White with AP Cmpr<20% Cellular and molecular mechanisms Free radical mediated cell injury Cation-mediated cell injury (Na + /Ca ++ ) Glutamatergic toxicity/cell injury Apoptosis
  • 16. Biomechanical Shear/ Stretch related, Dynamic Stenosis, Pincer Effect, Euler’s Theorum Shear /Stretch Principle (Out of Plane Loading Poisson’s Effect Dentate Tension Theory
  • 17. Anteriorly  disc degeneration and osteophytes ,PLL Anterolaterally  uncovertebral joint, and facet hypertrophy Posteriorly  Ligamentum flavum buckling Parke WW. Spine 1988 Bernhardt et al JBJS 1993 Progressive cervical spondylotic changes result in circumferential narrowing of the cervical canal
  • 18. The normal cervical canal diameter from C3 to C7 in Caucasians is 17-18 mm (< Asians) Cervical cord varies little in size from C1 to C7, measuring approximately 10 mm in diameter (range, 8.5-11.5 mm). 2/3 unoccupied by the spinal cord from C1 to C3 ¼ C4 to C7. Payne, Brain ’57 Normal spinal canal can accommodate the development of spondylotic changes CSM is more likely to develop in a congenitally narrowed
  • 19. Cord compression ratio remains<0.4 Smallest AP Diam/Largest Trans Fujiwara JBJS BR ‘89
  • 20. The transverse area of the spinal cord was measured to determine the severity of cervical cord compression and was related to prognosis with surgical intervention. Transverse area ≠ preoperative neurologic status Transverse area ≈ response to surgery after decompression ≥ 30 mm2, functional recovery was favorable. ≤ 30 mm2 a poor response Penning L, AJR Am J Roentgenol 1986.
  • 21. With an anteroposterior compression ratio < 20% extensive infarction of all the gray matter occurred. Ogino et followed 9 patients with CSM were observed clinically, radiographically, and, at time of death, neuropathologically. Histological Changes
  • 22. 1. Early involvement of the corticospinal tracts 2. Later destruction of anterior horn cells, demyelination of lateral and dorsolateral tracts 3. Relative preservation of anterior columns and dorsal regions of dorsal columns (Involved Severe CSM). Ogino H, Spine 1983;8:1-15.
  • 23. Less severe myelopathy Changes confined largely to the lateral funiculi More severe myelopathy Involvement of the medial gray area and ventral aspect of the dorsal columns ( including gliosis and anterior horn cell dropout.)
  • 24. Advanced CSM. Anterior columns and the subpial axons in the dorsal columns were relatively preserved Breig A, J Neurosurg 1966
  • 25. Histopathologic observations support the concept of ischemic injury to gray matter and medial white matter Oligodendroglia may be particularly vulnerable to ischemic injury, accounts for Demyelination in chronic CSM Demyelination of the corticospinal tracts is one of the first pathologic changes in CSM Ogino H Spine 1983 First proposed by Lord Brain in 1948
  • 26. Dynamic Stenosis Pincer Effect Euler’s Theorum Shear /Stretch Principle (Out of Plane Loading Poisson’s Effect Dentate Tension Theory
  • 27. 1) Clinical studies of cervical mobility in patients with CSM, 2) Histopathological studies of spinal cord tissue from CSM patients 3)Biomechanical studies : an improved understanding of the material properties and biomechanical behavior of spinal cord tissue under various physiological and pathological conditions.
  • 28. Functional canal diameter may be reduced to a critical level or less White and Panjabi Flexion,cord lengthens (more anterior path) resulting in axial tension and, potentially, ischemia. In the presence of anterior osteophytes, the spinal cord can be stretched over the anterior bars.
  • 29. Progressive encroachment on the spinal canal by ventral and dorsal anatomic structures may first lead to spinal cord compression that occurs only transiently during physiological cervical range of motion . The appearance of clinical signs and symptoms arising from this condition has been described as “dynamic stenosis.” With progressive narrowing of the spinal canal, dynamic stenosis evolves into static compression of the spinal cord and leads to CSM. Burnhardt et al JBJS 1993
  • 30. Extension 1. Ligamentum flavum buckles inward,which results in the maximal reduction in cross-sectional area of the cervical canal. 2. Spinal cord shortens, and its cross-sectional area increases. Combination places the cord at significant risk in extension. A pincer effect : spinal cord is compressed in extension between the posteroinferior margin of one vertebral body and the lamina or ligamentum flavum of the next caudal level.
  • 31. Euler’s Theorum Spinal cord ( a viscoelastic cylinder) when compressed from the sides, exhibits net tissue creep, bulging axonal membranes, and fluid flow to the free ends of the cylinder Longitudinal Tension forces are created within the neuraxis perpendicular to the plane of compression.
  • 32. A ventral compression force (stenosis) results in increased axial cord tension and fissuring on the side opposite the compression “ Out-of-plane loading” Shear
  • 33. Mild compressive deformation of the spinal cord resulted in viscoelastic stretch when the ventral-dorsal diameter < 20-30% Axial tension forces exceeded the material properties of the tissue and resulted in the tearing of axial fibers
  • 34. Common materials become narrower in cross section when they are stretched. Inter-atomic bonds realign with deformation. Stretching of honeycomb by vertical forces, illustrates the concept. Normal “in-plane” strain can result in “out-of-plane” stresses. This is called Poisson’s effect, and it accounts for lateral contraction accompanying longitudinal extension. Poisson’s Effect: Most materials resist a change in volume (as (determined by the bulk modulus) more than they resist a change in shape (shear modulus)
  • 35. The addition of forces from a ventral spondylotic bar results in maximal stress in the lateral funiculi as the cord is pulled laterally (flattened) by the dentate ligaments (tighten in flexion, anchored by dural root sleeves and dural ligaments). Flexion of the neck increases dural tension and should be avoided in the conservative treatment of CSM. Both anterior and posterior extradural surgical operations can diminish dentate tension, which may explain their usefulness in CSM.
  • 36. The role of the dentate ligaments in this model provides an explanation 1) Characteristic histological findings of the less severe cases of CSM 2) Explains why histopathological changes can be found remote from the point of compression
  • 37.  
  • 38. At the lower cervical and upper thoracic spine, where the amount of flexion tends to be greatest, the spinal cord stretches up to 24% of its length with a corresponding increase in length of the spinal cord of 17.6 mm at the level of the cervicothoracic junction during flexion The increased stretching occurring locally at the cervicothoracic junction translates into a significant increase in strain and stress in the white matter and a higher stress in gray matter Reid J Neur 1960
  • 39. Look how much the spinal cord moves with flexion of the neck Notice the strain on the nerves as well
  • 40.  
  • 41. Impairment of intracellular energy metabolism increases neuronal vulnerability to glutamate which, even at nl concentrations can damage neurons. This mechanism of slow excitotoxicity thought to be involved in neuronal death in chronic neurodegenerative diseases Riluzole, a glutamate antagonist, has therapeutic efficacy in human ALS
  • 42. Free radicals released from activated microglia may initiate MN injury by increasing the susceptibility of the MN AMPA/kainate receptor (white matter injury) and NMDA (anterior horn injury) to the toxic effects of glutamate. Bunge RP Adv Neurol 1993. Fehlings, M Spine 1998
  • 43. Show similar pathophysiology of cell injury with traumatic and ischemic injury to the CNS Both: Delayed anterior horn cell loss, gliosis
  • 44. Amyotrophic lateral sclerosis Extrinsic neoplasia (metastatic tumors) Hereditary spastic paraplegia Intrinsic neoplasia (tumors of spinal cord parenchyma) Multiple sclerosis Normal/Low pressure hydrocephalus Spinal cord infarction Syringomyelia Vitamin B12 deficiency SCIWORA syndrome Spinal cord tumor Cerebral hemisphere lesion            
  • 45. Lhermitte’s sign Paresthesias: Global non dermatomal Fine motor control Clumsy or weak hands Handwriting Zippers/Buttons Leg weakness or stiffness (Chair/Stairs) Proximal>>Distal LExtr Chronic suboccipital headache Suboccipital and may radiate to the base of the neck and the vertex of the skull. Changes bowel/bladder (severe, Rare)
  • 46. Asymptomatic Intermittent neck and shoulder pain 1/3 present with headache >2/3 present with unilateral or bilateral shoulder pain. A significant amount of these patients also present with arm, forearm, and/or hand pain. Radicular signs Often not dermatomal. More pain proximally in their limbs, while paresthesias dominate distally.
  • 47. Radiculopathy ,most commonly 6th 7th roots from C5-6 or C6-7 spondylosis, Patients usually present with pain, paresthesias, weakness, or a combination of these symptoms. Pain usually is in the cervical region, upper limb, shoulder, and/or interscapular region.
  • 48. First described by Pierre Marie and Chatelin in 1917. Lhermitte reported on this symptom in 1920, and in 1924 A sudden electrical sensation down the neck and back triggered by neck flexion 27% of patients CSM Crandall Batzdorf J Nsx 66:25:57-66 A lesion in the posterior columns of the cervical spinal cord is the cause of Lhermitte's sign in multiple sclerosis . Anatomic-radiologic basis of Lhermitte's sign in multiple sclerosis J. A. Gutrecht Archives Neurol Aug 93 Les douleurs à type discharge éléctrique consécutives à la flexion cephalique dans la sclérose en plaques. Un cas de la sclérose multiple. Revue neurologique, Paris, 1924
  • 49. Upper motor dysfunction Hyperactive deep tendon reflexes Ankle and/or patellar clonus Increased Tone/Spasticity ( especially of the lower extremities, bladder wall  frequency and nocturia ) Pathological reflexes are also present . Babinski sign Hoffman sign. Pectoralis muscle reflex. Jaw jerk may distinguish an upper cervical cord compression from lesions that are above the foramen magnum.
  • 50. Weakness is most commonly seen in the triceps and/or hand intrinsic Muscle atrophy in the following muscles: supraspinatus, infraspinatus, deltoid, triceps, and the first dorsal interosseus muscle. Proximal motor weakness, most commonly in the iliopsoas followed by the quadriceps femoris Gait stiff or spastic gait Sensory abnormalities variable pattern Loss of vibratory sense or proprioception in the extremities can occur (feet) Spinothalamic sensory loss may be asymmetric. Romberg test stands with the arms held forward and the eyes closed (test for position sense; loss of balance consistent with posterior-col dysfunction.
  • 51. Babinski’s extension of the big toe and fanning of the other toes in response to stroking the sole of the foot
  • 52. Hyperextension and lateral rotation toward the symptomatic side Works by narrowing the ipsilateral neural foramina during lateral flexion and rotation, while the initial extension aggravates posterior disk bulging. While this maneuver has a low sensitivity for cervical radiculopathy, it has a specificity of nearly 100%. Roy Glenwood Spurling American neurosurgeon, born September 6, 1894, Centralia, Missouri; died February 7, 1968, La Jolla, California. Spurling’s Maneuver for Radiculopathy 1935 Practical Neurological Diagnosis, with Special Reference to Problems of Neurosurgery
  • 53. Only valuable if it is associated with other upper motor neuron–related findings. The Hoffman sign : Hand at rest, stabilize the proximal phalanx between the examiner's index and middle finger. With the examiner's thumb distal middle finger is flicked  reflex contraction of the thumb and index finger The sensitivity of this examination maneuver may be increased by examining the patient during multiple full flexion or extension of the neck (Dynamic Hoffman sign). Ohne Zusammenfassung
  • 54. Finger-escape sign. The patient holds his fingers extended and adducted. In patients with cervical myelopathy, the two ulnar digits will flex and abducted usually in less than 1 minute. Ono K JBJS ‘87
  • 55. Inverted radial reflex. Tapping the distal brachioradialis tendon produces a hypoactive brachioradialis reflex plus hyperactive finger flexion, this is a positive radial reflex. This correlates with cord and C5 root lesions that produce spasticity distal to the compression and a hypoactive response at the level of the root/ant horn cells.
  • 56. Grip-and-release test. Normal adults can perform rapid complete grip and release to full finger extension 20 times in 10 seconds. This not only becomes slower but, in advanced cases, exaggerated wrist flexion occurs with attempted finger extension and exaggerated wrist extension occurs with finger flexion.
  • 57. Vladimir Mikhailovich Bekhterev 1902 This reflex involves the lateral and medial pectoral nerves (innervation from the C-5 through T-1 roots). Tapping of the tendon of the pectoralis major in the deltopectoral groove In the normal state, contraction may be felt, but gross contraction and movement are not seen. A hyperactive response causes adduction and internal rotation of the shoulder
  • 58. It suggests compression in the upper cervical spine (C2-C4). Concept that compression of the spinal cord above the level of the innervating roots of the reflex should prevent the normal descending inhibition of the spinal reflexes, resulting in hyperreflexia. It does not exclude coexisting compression at lower levels
  • 59. The main clinical features are localized wasting and weakness of the extrinsic and intrinsic hand muscles, but not accompanied by either sensory loss or spastic quadriparesis. Ono K, Ebara S, Fuji T: Myelopathy hand. New clinical signs of cervical cord damage. J Bone Joint Surg Br 1987; 69 (2): 215-219
  • 60. Plain film (AP), Lateral :Overall sagittal alignment (lordosis versus kyphosis) Flexionextension: Instablility, a compensatory subluxation one or two levels above the stiffer levels. Oblique views: foraminal narrowin due to uncovertebral joint spurring CT/ CT Myelography better definition of bone spurs and OPLL. The exact degree of cord deformation in the transverse plane MRI Indications: Persistent neck or arm pain (present for more than 2 or 3 months), neurologic findings, or a worsening symptomatic picture warrants neuroradiologic investigation. If evidence of myelopathy is present on physical examination, Electromyographic–nerve conduction : carpal tunnel syndrome, ulnar cubital tunnel syndrome, or thoracic outlet syndrome. Electrodiagnostic modalities may also help elucidate the confusing clinical presentations of amyotrophic lateral sclerosis, multiple sclerosis, and severe peripheral neuropathy.
  • 61. Myodil Column Displacement Central and Lateral Filling defects, Root sheath obliteration
  • 62. Conservative Surgical Complex decision making
  • 63. Patients with neuroradiologic evidence of spinal cord compression but no symptoms or signs of myelopathy should generally be observed. Exception would be a patient with such severe compression that even low-energy trauma (rear-end motor vehicle impact or a fall) result in SCI
  • 64. Natural history of cervical myelopathy for most patients is slow deterioration over time . Typically, this is in a stepwise fashion with variable periods of stable neurologic function. Extent of myelopathy is reflected predominantly by physical examination findings (balance deficits, gait, motor weakness, long-tract signs, and changes in function=motor)
  • 65. If the patient is in a plateau period without recent exacerbation, nonoperative treatment may be indicated. Reevaluation every 6 to 12 months to look for deterioration of neurologic function or a change in symptoms may be appropriate.
  • 66. The amount of pain experiencing Degree of change of fcn that can be tolerated, Evaluation of symptoms. Severity of compression evident on neuroradiologic studies (Worsening: cord area, cord atrophy, myelomalacia kyphotic deformity) Ex Rapid neurologic deterioration should undergo earlier operative intervention. Positive Prognositic Factors Larger transverse area of the cord, Younger patient age Shorter duration of symptoms Single rather than multiple levels of involvement. Fujiwara J Bone Joint Surg Br 1989;71: 393-398. Koyanagi T, Hirabayashi K, Spine 1993
  • 67. Address 3 goals 1. Pain relief 2. Improved Function 3. Prevention of recurrence
  • 68. 1. Pain relief PT, Rehabilitation, Medication, Injection therapy, Manipulation all differ in approaches. 2. Improved Function CSM major physical capacity deficits Disuse Change in endurance/aerobic fitness Each pain episode increases fear
  • 69. 3. Prevention of recurrence “ Cycling down” : Disuse leads to decreasing physical capacity which makes the now less protected area subject to overload from even less stress of the initial injury. Chronic reinjury and recurrence. Develop protective mechanisms: Condition, strengthen muscles acting around spinal construct. Forms basis of PT. Intensive exercise program of >3mo effective Manniche Lancet ‘88 ,Pain ‘91 Repeated PT, Manipulation is generally unsuccessful in treating chronic cond.
  • 70. Disease Education Information (Re: resp pain, anatomy,ergonomics,Wt rdxn, Lifestyle changes) Nutritional, Activity avoidance Rest Shorter periods of bed rest 2d are as good as longer 7d periods. Prolonged  Negative N balance, deconditioning, loss of BMD, Strength Modalities: Hot packs, Cryotherapy, US, Traction, Massage (Psychological and physical benefit) Isometrics: Static muscle training (Prevent loss of muscle tone, resistance to atrophy) Lat Dorsi, Rhomboid, Sh Abd, Trapezius (4 supporters neck and shoulder girdle). Cervical Flexor, ext, lat bend, rotator musculature Daily for 1 week, then Aerobic conditioning Aerobic Conditioning: Beneficial effect on pain, Weight reduction will decrease spinal loading. Avoid impact aerobics. Focus treadmill/stationary bicycle. Max 30 min 3x/wk
  • 71. Flexibility Exercises: Maintenance of adequate ROM. Upper back, trunk, shoulders and neck during aerobic phase. Active and AAROM No passive ROM or manipulation Progressive Resistive Exercises: Change from static to dynamic training. Medication Nsaids, Narcotics, Muscle Relaxants, Antidepressants
  • 72. Injection Therapy Trigger Point, Selective Nerve Root block Manipulation
  • 73. Can be expected to halt progression in deterioration of neurologic function and may improve motor, sensory, and gait disturbance. The degree of recovery depends largely on the severity of at the time of intervention. Fujiwara J Bone Joint Surg Br 1989;71: 393-398. Koyanagi T, Hirabayashi K, Spine 1993
  • 74. Decompression of Neural elements Stabilization of unstable segments Ablation of painful articulations via fusion
  • 75. Progressive Neurologic signs or symptoms Presence of Myelopathy for >6 months Canal/Vertebral Body diameter approaching 0.4 Law Bernhardt ICL 1995 Severe Spinal cord compression Bohlman ’97 Cord Signal Changes with any signs CSM recommend earlier intervention before permanent deficits arise Atlantoaxial Instability (RA) 1/3-1/2 Vertical Migr dvlp LTS/5yrs  N Hx Death Subaxial Segmental Instability Difficulty Walking Loss of Balance Bowel / Bladder Incontinence Neck Pain (absence of neural deficit) less defined {Intractable correlated with radiologic studies}
  • 76. Anterior Options Single/Multiple anterior diskectomies with fusion and/or corpectomy (ACDF) Strut fusion techniques with or without the use of anterior instrumentation. Posterior Options Single/multilevel laminectomy Laminoplasty Laminectomy plus fusion procedures.
  • 77. Factors to be considered Number of involved levels Overall sagittal alignment Direction of compression Presence of instability Clinical symptoms. Weigh Advantages and Disadvantages Ant vs Post (1) Approach-related, (2) Decompression-related (3) Graft related, (4) Long-term.
  • 78. Anterior Approach Direct decompression Stabilization with arthrodesis Correction of deformity Axial lengthening of spinal column Good axial pain relief Posterior Approach Less loss of motion Not as technically demanding Less bracing needed 4. Avoids graft complications
  • 79. Anterior 1. Technically demanding 2. Graft complications (dislodgment, fracture, and severe settling into the cancellous VB) 3. Need for postoperative bracing limitations 4. Loss of motion 5. Vertebral artery, Dysphagia, Upper airway compromise Posterior Indirect decompression 2. Preoperative kyphosis and/or instability Late instability Adjacent segment degeneration Laminectomy procedures :increased risk of postlaminectomy kyphosis, swanneck deformity, or instability with late neurologic deterioration. Laminoplasty techniques decrease these risks, but add the potential complication of inadvertent closure of the opened lamina with recurrent stenosis. 7. Inconsistent axial pain results
  • 80.  
  • 81. Yonenobu et al prefer the anterior approach for patients with pathologic changes at one or two levels and posterior surgery for those with involvement at three or more levels. Yonenobu K, Fuji T, Ono K, Okada K, Yamamoto T, Harada N: Choice of surgical treatment for multisegmental cervical spondylotic myelopathy. Spine 1985;10:710-716.
  • 82. 42 yo High school Math teacher Slip and fall onto right side of body while at work in October 2005 C/o neck pain and radiating Right arm pain 8/10 Now on temporary disability Rx Vicodin Robaxin Pex Painful Rom : Flexion 5 deg, ext 10 Spurlings + Right side Reflexes: Diminished Rt biceps 1+ Hoffmans negative Motor sensory normal
  • 83.  
  • 84. Axial C5-6 2 3 4 5 6
  • 85. Doing well Feels resolution of neck pain improvement right arm pain Off all narcotic Rx
  • 86. 73 yo female neck and arm pain 2 nd opinion: 1 st rec ACDF Failed conserv therapy Tried Lyrica, Tegretol Worsening pain +Lhermittes’s Neck and arm pain with extension and rotation to right Denies B/Bladder Pmhx Trigem Neuralgia, TMJ sx,Osteoperosis PEx Weak Bilat Shoulder abduction, wrist flexion Absent Tri,Bi,Brad reflexes,Lextemities +Bilat Hoffmans +Spurlings to Right and Left
  • 87.  
  • 88. 2 4-5 4 5 6 5-6
  • 90. 59 yo male s/p Two level ACDF C 5-6 6-7 Now with significant axial neck pain Had a Pain modulating unit inserted with no improvement in syx Weakness: Wrist E/F, Finger E/F, Bi,Tri +Hoffmans 2+ Reflexes Brad Bi Tri Patellar Achilles
  • 91.  
  • 92. 4
  • 93.  
  • 94. C 3,4,5 Laminoplasty:Plating, Rib graft Bilateral foraminotomies C6-7 C7-T1
  • 95. Resolution of Axial neck pain Resolution of Lextremity pain Immediate Improvement in Upper Extremity Strength Wrist F/E Finger F/E Biceps Triceps
  • 96.  
  • 97.  
  • 98.  
  • 99. Brazilian Now with significant axial neck pain, instability, wearing a brace Had a previous ASF,HWR,PSF, decompression Weakness: Wrist E/F, Finger E/F, Bi,Tri, Interossei +Hoffmans 2+ Reflexes Brad Bi Tri Patellar Achilles
  • 100.  
  • 101.  
  • 102.  
  • 103.  
  • 104. Hoffmans + Gait Weakness Prox Neck Pain Hyper reflexic Myelo Hand Babinski
  • 105.  
  • 106.  
  • 107.  
  • 108.  
  • 109.  
  • 111.  
  • 112.  
  • 113.  
  • 114. Patient underwent a laminoplasty Patient has done well and since returned to work as an accountant 3 months afterwards
  • 115. Surgery should be a last resort, when conservatives measures fail. In some cases surgery needs to be done sooner than later, or even urgently, depending on the physical exam, history, neural deficits, and size of the herniation.
  • 116.  
  • 117. All our procedures are peformed in a minimally invasive manner. All patients receive a plastics closure and are followed closely afterwards
  • 118. Payne EE, Spitlani JD. An anatomicopathologic study of 70 specimens (using a special technique) with particular reference to the problem of cervical spondylosis. Brain 1957;80:571-96 Parke WW. Correlative anatomy of cervical spondylotic myelopathy. Spine 1988;13:831-7 Penning L, Wilmink JT, van Woerden HH, Knol E. CT myelographic findings in degenerative disorders of the cervical spine: Clinical significance. AJR Am J Roentgenol 1986;146:793-801. Panjabi M, White AD. Biomechanics of nonacute cervical spinal cord trauma. Spine 1988;13:838-42. Ogino H, Tada K, Okada K, et al. Canal diameter, anteroposterior compression ratio, and spondylotic myelopathy of the cervical spine. Spine 1983;8:1-15. Nurick S. The pathogenesis of the spinal cord disorder associated with cervical spondylosis. Brain 1972;95:87-100. J Neurol Sci. 1967 May-Jun;4(3):607-8 The Rt. Hon. The Lord Brain, F.R.S., D.M., F.R.C.P. (1895-1966). Bunge RP, Puckett WR, Becerra JL, et al. Observations on the pathology of human spinal cord injury. A review and classification of 22 new cases with details from a case of chronic cord compression with extensive focal demyelination. Adv Neurol 1993;59:75-89. Choi DW. Excitotoxic cell death. J Neurobiol Lord Brain, M. Wilkinson. Cervical Spondylosis and other disorders of the cevical spine. 1967. Irvine DH, Foster JB, Newell DJ: Prevalence of cervical spondylosis in a general practice. Lancet 1965 May 22; 14: 1089-92 Holt S, Yates PO: Cervical spondylosis and nerve root lesions. Incidence at routine necropsy. J Bone Joint Surg Br 1966 Aug; 48(3): 407-23 Rahim KA, Stambough JL: Radiographic evaluation of the degenerative cervical spine. Orthop Clin North Am 1992 Jul; 23(3): 395-403 Fujiwara K, Yonenobu K, Ebara S, Yamashita K, Ono K: The prognosis of surgery for cervical compression myelopathy: An analysis of the factors involved. JBJS BR 1993 Koyanagi, Toyama Y, Fujimura Y: Predictability of operative results of cervical compression myelopathy based on preoperative computed tomographic myelography. Spine 1993;18:1958-1963.
  • 119. Thank you for your time. If you know someone who could benefit from a consultation for Neck Pain, Neck Arthritis or Cervical Spondylotic Myelopathy please refer them to our online website or call toll free to schedule an appointment 1-8SPINECAL-1 www.beverlyspine.com www.santamonicaspine.com