Cervical

Cervical
Spondylosis
Spondylosis
;
;
Etiology, Evaluation and
Etiology, Evaluation and
Management
Management
Steven D. Wray M.D.
Steven D. Wray M.D.
Atlanta Brain and Spine Care P.C.
Atlanta Brain and Spine Care P.C.
Piedmont Spine Center
Piedmont Spine Center
Conclusion:
Conclusion:

Cervical nerve root or cord
Cervical nerve root or cord
compression from bone spur
compression from bone spur
formation (
formation (
spondylosis
spondylosis
) is a
) is a
degenerative and progressive
degenerative and progressive
process which should be referred to
process which should be referred to
a neurosurgeon early as outcome is
a neurosurgeon early as outcome is
directly related to the duration of
directly related to the duration of
symptoms.
symptoms.
Cervical
Cervical
Spondylosis
Spondylosis
; Definition
; Definition

Age related degeneration of the
Age related degeneration of the
cervical spine
cervical spine

Osteoarthritis
Osteoarthritis

Most common in persons over 40
Most common in persons over 40

Most common cause for
Most common cause for
myelopathy
myelopathy
in persons over 55
in persons over 55

Male>Female
Male>Female
Cervical
Cervical
Spondylosis
Spondylosis
;
;
Pathology
Pathology
Age Related Degeneration and
Dehydration of intervertebal Disks
Decreased cartilage between
adjacent vertebral bodies
Developmental laxity in the spinal
supportive ligaments
Hyper-mobility of spinal segment
Bone-on bone apposition
propagates bone spur formation
which narrow the cervical spinal
canal and may compress the
cervical nerve roots and spinal cord
Cervical
Cervical
Spondylosis
Spondylosis
;
;
Clinical Presentation

Mechanical
Mechanical

Pain
Pain

Stiffness
Stiffness

Muscle Spasm
Muscle Spasm

Pop and Crack

Pop and Crack

Neurologic
Neurologic

Nerve Root Compression

Nerve Root Compression

Spinal Cord Compression

Spinal Cord Compression
Cervical
Cervical
Spondylosis
Spondylosis
;
;
Spondylitic change with bone
spur/disk complex formation
Developmental narrowing of
spinal canal with
compression of spinal cord
and nerve roots
Cervical
Cervical
Spondylosis
Spondylosis
;
;
Cord Compression
Cord Compression
64 Year old patient
with severe
symptomatic
spondylitic
myelopathy.
Multilevel Cord
compression seen on
MRI.
Cervical
Cervical
Spondylosis
Spondylosis
;
;
Natural History
Natural History
Predisposition Predisposition
Some individuals have a Some individuals have a congenitally narrow spinal congenitally narrow spinal
canal canal
Increased incidence of symptom development with mild Increased incidence of symptom development with mild
to moderate to moderate spondylosis spondylosis
Pre Pre- -participation screening of athletes to asses participation screening of athletes to asses
vulnerability to spinal cord injury vulnerability to spinal cord injury
Evolution Evolution
Unlike soft cervical disk Unlike soft cervical disk herniation herniation which usually which usually
resolves, Cervical resolves, Cervical Spondylosis Spondylosis is progressive is progressive
May be insidious and then more rapidly progressive as May be insidious and then more rapidly progressive as
Spinal Fluid Spinal Fluid reserve reserve becomes depleted by enlarging becomes depleted by enlarging
bone spurs bone spurs
Cervical
Cervical
Spondylosis
Spondylosis
Symptom Pathogenesis
Symptom Pathogenesis

Hyper
Hyper
-
-
mobility / instability of spinal
mobility / instability of spinal
segments
segments

Irritation/inflammation of heavily
Irritation/inflammation of heavily
innervated vertebral body endplates
innervated vertebral body endplates

Direct compression of cervical nerve
Direct compression of cervical nerve
root or spinal cord
root or spinal cord

Repetitive trauma to cord or roots
Repetitive trauma to cord or roots

Ischemic change to the cord
Ischemic change to the cord
Cervical
Cervical
Spondylosis
Spondylosis
;
;
Presentation with
Presentation with

Headache
Headache

Kyphotic Angular deformity

creates added stress on the
paraspinal muscles and causes
severe myofascial pain and
spasm and often produces
suboccipital headaches where
the paraspinal muscles insert on
the base of the skull.
For this reason, some
degenerative cervical spine
disease can present with
headache.
Cervical
Cervical
Spondylosis
Spondylosis
;
;
Developmental Scoliosis; Facet
Developmental Scoliosis; Facet
Arthropaty
Arthropaty
Coronal Plane angulation
causes myofascial pain as
well as changes of the facet
joints. The added stress on
joints leads to joint
hypertrophy and inflammatory
change which is painful.
Cervical Spine Dynamic Instability;
Cervical Spine Dynamic Instability;
Flexion/Extension Radiographs!
Flexion/Extension Radiographs!
Nonsurgical Treatment
Nonsurgical Treatment

NSAIDS
NSAIDS

Traction
Traction

PT
PT
Ultrasound for trigger points Ultrasound for trigger points
Neuromuscular massage Neuromuscular massage
TENS TENS
Traction Traction

Interventional
Interventional
Selective nerve root block Selective nerve root block
ESI ESI
Facet block/ RFA Facet block/ RFA
Definitions
Definitions

Radiculopathy
Radiculopathy
Nerve Root Compression Nerve Root Compression
Pain, weakness, numbness in the distribution Pain, weakness, numbness in the distribution
of a nerve root (neck or back) of a nerve root (neck or back)

Myelopathy
Myelopathy
Spinal Cord Compression in the cervical or Spinal Cord Compression in the cervical or
thoracic area thoracic area
Symptoms Symptoms
Numbness, tingling of the arms/ hands Numbness, tingling of the arms/ hands
Dexterity difficulty with fine motor movements Dexterity difficulty with fine motor movements
Gait instability Gait instability
Balance and coordination difficulty Balance and coordination difficulty
Bowel/Bladder disturbances (incontinence) Bowel/Bladder disturbances (incontinence)
Cervical Nerve Root
Cervical Nerve Root
Symtoms
Symtoms
C4 C4- -5 5 C5 C5- -6 6 C6 C6- -7 7 C7 C7- -T1 T1
Incidence Incidence 2% 2% 19% 19% 69% 69% 10% 10%
Root Root
Affected Affected
C5 C5 C6 C6 C7 C7 C8 C8
Motor Motor Deltoid Deltoid Biceps/ Biceps/
BR BR
Triceps Triceps Intrinsics Intrinsics
Sensory Sensory Shoulder Shoulder Upper Upper
arm/ arm/
Thumb Thumb
2 2
nd nd
3 3
rd rd
finger/ all finger/ all
fingertips fingertips
4 4
th th
and 5 and 5
th th
finger finger
Incidence of
Incidence of
Myelopathy
Myelopathy
is Related
is Related
to Canal Diameter
to Canal Diameter
xxxx
xxxxxx
Canal Diameter <13mm increases
risk for myelopathy
Canal Diameter <10mm almost
always results in symptomatic
cord compression
Differential Diagnoses
Differential Diagnoses

ALS
ALS
Exclusively Motor Exclusively Motor
Tongue Tongue Fasciculations Fasciculations

Multiple Sclerosis
Multiple Sclerosis
Relapsing/remitting symptoms Relapsing/remitting symptoms
Demyelinating Demyelinating plaques on Brain MRI plaques on Brain MRI

Subacute
Subacute
Combined Degeneration
Combined Degeneration
Macrocytic Macrocytic Anemia Anemia
B12 deficiency B12 deficiency
Who Needs Surgery?
Who Needs Surgery?

Neurologic Compromise
Neurologic Compromise

Symptomatic Nerve root compression

Symptomatic Nerve root compression
refractory to non
refractory to non
-
-
surgical management
surgical management

Spinal Cord Compression with

Spinal Cord Compression with
myelopathy
myelopathy

Biomechanical Instability
Biomechanical Instability

Instability on Flexion/Extension Films

Instability on Flexion/Extension Films

Angular deformity
Angular deformity

Subluxation
Subluxation
/
/
Listhesis
Listhesis
Surgical Options; Considerations
Surgical Options; Considerations

Type of Pathology
Type of Pathology
Soft Disk Soft Disk
Bone Spur; Bone Spur; Spondylosis Spondylosis

Location of Compression
Location of Compression
anterior vs. posterior anterior vs. posterior

Angulation
Angulation
of Spine
of Spine
Preserved Preserved Lordosis Lordosis vs. vs. Kyphosis Kyphosis

Patient age and co
Patient age and co
-
-
morbidities
morbidities

Health of adjacent levels
Health of adjacent levels

Bone Density
Bone Density

Number of spinal segments involved
Number of spinal segments involved
Surgical Options
Surgical Options

Anterior vs. Posterior Decompression
Anterior vs. Posterior Decompression

Simple Decompression vs. Fusion
Simple Decompression vs. Fusion
and Stabilization
and Stabilization
Anterior Cervical Decompression
Anterior Cervical Decompression
and Fusion
and Fusion

Performed through a transverse cervical
Performed through a transverse cervical
incision
incision

Microscopic Decompression of spinal cord
Microscopic Decompression of spinal cord
by removal of compressive bone spur
by removal of compressive bone spur

Restore and maintain
Restore and maintain
intervertebral
intervertebral
height
height
using an
using an
intervertebral
intervertebral
bone graft or
bone graft or
plastic spacer
plastic spacer

Stabilize spinal segment with low profile
Stabilize spinal segment with low profile
titanium plate (promotes fusion)
titanium plate (promotes fusion)
Anterior Cervical Decompression
Anterior Cervical Decompression
and Fusion
and Fusion
Anterior Cervical
Anterior Cervical
Diskectomy
Diskectomy
and
and
Fusion
Fusion

Minimal pain as no muscle disruption
Minimal pain as no muscle disruption

Subcuticular
Subcuticular
closure
closure

Overnight observation
Overnight observation

Addresses ventral pathology without
Addresses ventral pathology without
any neural element retraction or
any neural element retraction or
manipulation
manipulation
Anterior Cervical Decompression
Anterior Cervical Decompression
and Fusion
and Fusion
High fusion rate.
Fusion promoted by good blood supply
at the ventral moment arm of the spine.
Fusion Substrate
Fusion Substrate

Historical Gold Standard; Freshly
Historical Gold Standard; Freshly
harvested iliac crest bone
harvested iliac crest bone
autograft
autograft
Donor site morbidity Donor site morbidity
Pain/ Infection Risk Pain/ Infection Risk

Banked Allograft
Banked Allograft
Small but present risk for disease transmission Small but present risk for disease transmission

PEEK Spacers
PEEK Spacers
Plastic cement restrictors which are non Plastic cement restrictors which are non- -
compressible and restore inter compressible and restore inter- -vertebral height vertebral height
Bone
Bone
Morphogenic
Morphogenic
Protein
Protein

Recombinant protein with no risk of
Recombinant protein with no risk of
disease transmission and High fusion
disease transmission and High fusion
rate
rate
Biologics to Promote Fusion
Biologics to Promote Fusion

Osteocondustion
Osteocondustion

Osteoinduction
Osteoinduction
Transverse Process
BMP and Fusion
BMP and Fusion
Goals of Surgery
Goals of Surgery

Decompress neural elements
Decompress neural elements

Restore
Restore
Intervertebral
Intervertebral
height which also
height which also
restores neural
restores neural
foraminal
foraminal
patency
patency

Restore anatomic alignment in the case of
Restore anatomic alignment in the case of
kyphosis
kyphosis
or scoliosis
or scoliosis

Stabilize spinal
Stabilize spinal
segment(s
segment(s
) to prevent
) to prevent
bone spur propagation and repetitive
bone spur propagation and repetitive
nerve root irritation
nerve root irritation

Promote solid
Promote solid
arthrodesis
arthrodesis
over time
over time
ACDF to correct Developmental
ACDF to correct Developmental
Scoliosis from
Scoliosis from
Spondylosis
Spondylosis
XXXXX
ACDF to Correct Developmental
ACDF to Correct Developmental
Kyphosis
Kyphosis
due to
due to
spondylosis
spondylosis
xxxxxxx
Posterior Cervical Fusion
Posterior Cervical Fusion

Decompress neural elements by
Decompress neural elements by
removal of the bony lamina and
removal of the bony lamina and
underlying ligament (
underlying ligament (
Laminectomy
Laminectomy
)
)

Stabilization by posterior lateral
Stabilization by posterior lateral
mass screws and rods
mass screws and rods

Fusion performed by on
Fusion performed by on
-
-
lay
lay
technique and inter
technique and inter
-
-
facet graft
facet graft
material (laminar bone or iliac crest
material (laminar bone or iliac crest
autograft
autograft
)
)
Posterior Cervical Fusion
Posterior Cervical Fusion
Posterior Cervical Decompression
Posterior Cervical Decompression

Decompression alone is
Decompression alone is
contraindicated with preexisting
contraindicated with preexisting
kyphotic
kyphotic
deformity
deformity

High risk of developing late swan
High risk of developing late swan
-
-
neck deformity
neck deformity

Post operative Pain
Post operative Pain

In case of
In case of
hyperlordosis
hyperlordosis
, posterior
, posterior
cord migration may cause cord
cord migration may cause cord
compression
compression
Surgical Outcomes
Surgical Outcomes

Anterior or Posterior approaches that
Anterior or Posterior approaches that
effectively decompress spinal cord
effectively decompress spinal cord
promote improvements in outcome
promote improvements in outcome

Higher Risk of late
Higher Risk of late
kyphosis
kyphosis
in patients
in patients
who undergo
who undergo
laminectomy
laminectomy
or anterior
or anterior
cervical decompression alone compared to
cervical decompression alone compared to
patients in whom decompression is
patients in whom decompression is
combined with fusion
combined with fusion
Fehlings MG, Arvin B. J Neurosurg Spine. 2009 Aug:11 (2): 97-100
Outcomes
Outcomes
Duration of Symptoms Duration of Symptoms and advanced age and advanced age
negatively affect outcome in patients with CSM negatively affect outcome in patients with CSM
50% improve if operated within a year 50% improve if operated within a year
compared with only 16% is operated after compared with only 16% is operated after
Abnormal Pre Abnormal Pre- -operative SSEP/EMG Findings operative SSEP/EMG Findings
adversely affect outcome adversely affect outcome
Cord Signal Change or the presence of spinal Cord Signal Change or the presence of spinal
cord atrophy negatively affect outcome cord atrophy negatively affect outcome
Fehlings MG, Arvin B. J Neurosurg Spine 2009 Aug;11(2):97-100
REFER EARLY!!
REFER EARLY!!

Patients with spinal cord or nerve
Patients with spinal cord or nerve
root compression should be referred
root compression should be referred
for neurosurgical evaluation
for neurosurgical evaluation
promptly.
promptly.
Thank You