Degenerative Diseases Degenerative Diseases of theof the

Cervical SpineCervical Spine

Operative treatmentOperative treatment

George SapkasGeorge SapkasAsc. Professor Asc. Professor 11stst Orthop. Dpt. Orthop. Dpt.

Medical School Athens UniversityMedical School Athens University

George KelalisGeorge KelalisOrth. Surgeon Orth. Surgeon

Metropolitan HospitalMetropolitan Hospital

Neck pain, Radiculopathy, Myelopathy Neck pain, Radiculopathy, Myelopathy

PathophysiologyPathophysiology

Natural HistoryNatural History

Clinical EvaluationClinical Evaluation

Imaging StudiesImaging Studies

Conservative TreatmentConservative Treatment

Surgical IndicationsSurgical IndicationsAnterior surgical proceduresAnterior surgical procedures

Posterior surgical proceduresPosterior surgical procedures

Pathophysiology Pathophysiology

Neck pain Neck pain

MyofascialMyofascialPosture, ergonomics, chronic muscle fatiguePosture, ergonomics, chronic muscle fatigueMechanoreceptors, chemonociceptorsMechanoreceptors, chemonociceptorsBradykinin, Serotonin, KBradykinin, Serotonin, K++, CGRP, CGRP

DiscogenicDiscogenicReliable patterns with disc stimulationReliable patterns with disc stimulation

Facet jointFacet jointProvocative facet injections – pain patternsProvocative facet injections – pain patterns

HeadachesHeadachesGreater occipital nerveGreater occipital nerveSinuvertebral nervesSinuvertebral nerves

Radiculopathy Radiculopathy

- Mechanical factors- Mechanical factorsSusceptible to deformationSusceptible to deformationNervi nervorumNervi nervorumTethering – Hoffman ligamentsTethering – Hoffman ligaments

– Biologic factorsBiologic factorsChemicalsChemicalsVenular occlusion / permeabilityVenular occlusion / permeabilityFibrosis / demyelination – Fibrosis / demyelination – ectopic dischargesectopic discharges

– Dorsal root ganglionDorsal root ganglionVery sensitive to direct pressureVery sensitive to direct pressureProlonged spontaneous dischargesProlonged spontaneous dischargesNeuropeptide synthesisNeuropeptide synthesisCapillaries fenestrated – greater edemaCapillaries fenestrated – greater edema

Myelopathy Myelopathy - Canal dimensions- Canal dimensions

17 mm (13 – 20 mm) midsagital diameter17 mm (13 – 20 mm) midsagital diameter< 13 mm – congenital stenosis< 13 mm – congenital stenosis

– Cord dimensionsCord dimensions10 mm (8.5 – 11.5), 90 – 100 mm10 mm (8.5 – 11.5), 90 – 100 mm22

< 60 mm< 60 mm22 (Penning et al, 1986) (Penning et al, 1986)Better recovery > 40 mmBetter recovery > 40 mm22, A-P ratio > 0.40, A-P ratio > 0.40

– Vascular factorsVascular factorsBrieg et al, 1952 – spondylosis leads to Brieg et al, 1952 – spondylosis leads to decreased flow in anterior brancesdecreased flow in anterior brances

– Dynamic factorsDynamic factorsHyperextensionHyperextensionPincer effectPincer effectHypermobility above stiff segmentHypermobility above stiff segmentDynamic cord and vascular changesDynamic cord and vascular changes

– Cord degenerationCord degenerationIrreversible cord changes – demyelination, Irreversible cord changes – demyelination, cavitation, gliosis, wallerian degenerationcavitation, gliosis, wallerian degeneration

Natural history Natural history

Neck pain Neck pain

Lifetime incidence 50 -70%Lifetime incidence 50 -70%

Annual incidence 12 – 34%Annual incidence 12 – 34%

Population studies 90% Population studies 90% recoverrecover

23% partial – total disability at 23% partial – total disability at 5 yrs; 5 yrs; no difference with surgery no difference with surgery

(Rothman & Rashbaum et al, 1978)(Rothman & Rashbaum et al, 1978)

Neck pain – RadiculopathyNeck pain – Radiculopathy

43% complete resolution43% complete resolution

25% mild residual pain25% mild residual pain

32% moderate or severe 32% moderate or severe painpain

Radicular symptoms – less Radicular symptoms – less favourablefavourable

Treatment did not influence Treatment did not influence outcomeoutcome

(Gore et al. Spine 1987)(Gore et al. Spine 1987)

Myelopathy Myelopathy

Did not follow radiculopathy Did not follow radiculopathy

Episodic progression, static disability for yearsEpisodic progression, static disability for years

Progressive deterioration rareProgressive deterioration rare(Lees et al, BMJ 1963)(Lees et al, BMJ 1963)

Disability established early Disability established early

Static periods for many yearsStatic periods for many years(Nurick, Brain 1972)(Nurick, Brain 1972)

67% steady progressive deterioration67% steady progressive deterioration(Symon et al, Neurology 1967)(Symon et al, Neurology 1967)

Poor prognosis Poor prognosis

Non improvement if symptoms > 2 yearsNon improvement if symptoms > 2 years(Phillips, J. Neur. 1973)(Phillips, J. Neur. 1973)

Clinical evaluationClinical evaluation

Neck painNeck pain

Determine exact location of painDetermine exact location of pain

Referred pain patterns from Referred pain patterns from specific disc and facet jointsspecific disc and facet joints

Check ROM and for pain with Check ROM and for pain with specific motionspecific motion

Position of maximal discomfort Position of maximal discomfort

Watch out for:Watch out for:√ Substitution paternsSubstitution paterns√ Tumors – infectionTumors – infection√ Inflammatory arthritisInflammatory arthritis√ Pain referred from heart, viscera, and Pain referred from heart, viscera, and

T-M jointT-M joint

Radiculopathy Radiculopathy

Look for specific dermatomal distribution Look for specific dermatomal distribution to painto painShoulder abduction signShoulder abduction signSpurling signSpurling signC3, C4 – diaphragm involvementC3, C4 – diaphragm involvementC5 – dermatome – epaulet, Deltoid ? C5 – dermatome – epaulet, Deltoid ? Biceps reflexBiceps reflexC6 – dermatome – radial forearm and C6 – dermatome – radial forearm and hand, muscles, biceps reflexhand, muscles, biceps reflexC7 – dermatome – long finger – medial C7 – dermatome – long finger – medial scapula, muscles, triceps reflexscapula, muscles, triceps reflexC8 – dermatome – ulnar hand and C8 – dermatome – ulnar hand and forearm, finger flex -intrinsicsforearm, finger flex -intrinsics

Cont…

Watch out for:Watch out for:

Trauma Trauma √ Cervical sprain Cervical sprain √ Traumatic neuritisTraumatic neuritis√ Postotraumatic instabilityPostotraumatic instability

Tumors Tumors √ Pancoast tumorsPancoast tumors√ Cord tumorsCord tumors√ Metastatic diseaseMetastatic disease√ Nerve sheath tumorsNerve sheath tumors

Inflammatory Inflammatory √ Rheumatoid arthritisRheumatoid arthritis√ Ankylosing spondilitisAnkylosing spondilitis

InfectionsInfections√ DiscitisDiscitis√ OsteomyelitisOsteomyelitis√ Soft tissue abcsessSoft tissue abcsess

Watch out for:Watch out for:

Shoulder disordersShoulder disorders√ Rotator cuff tearsRotator cuff tears√ Impingement syndromeImpingement syndrome√ InstabilitiesInstabilities

Neurological conditionsNeurological conditions√ Demyelinating disease Demyelinating disease √ Anterior horn cell diseaseAnterior horn cell disease

Thoracic outlet syndromeThoracic outlet syndrome

Reflex sympathetic dystrophyReflex sympathetic dystrophy

Angina pectorisAngina pectoris

Peripheral nerve entrapmentsPeripheral nerve entrapments

Temporomandibular disordersTemporomandibular disorders

Myelopathy Myelopathy

Medial Medial Lateral Lateral CombinedCombinedVascular Vascular

(Ferguson & Caplan)(Ferguson & Caplan)

Transverse lesionTransverse lesionMotor system Motor system Central cordCentral cord

(Grandall & Bartzdorf)(Grandall & Bartzdorf)

Brachial and cord syndromeBrachial and cord syndrome(Brown & Sequard)(Brown & Sequard)

Neck pain 50%Neck pain 50%Radicular pain 38%Radicular pain 38%Radiating pain 27%Radiating pain 27%Bladder – Bowel 44%Bladder – Bowel 44%

(Grandall & Bartzdorf 62 pts)(Grandall & Bartzdorf 62 pts)

Cont…

Unsteady gaitUnsteady gait

AtaxicAtaxic

Spastic Spastic

Romberg’sRomberg’s

ReflexesReflexes

HyperflexiaHyperflexia

ClonusClonus

Absent supf reflexesAbsent supf reflexes

Pathologic reflexesPathologic reflexes

Sensory examinationSensory examination

Light touchLight touch

Sharp touchSharp touch

Vibration - proprioceptionVibration - proprioception

Cont…

MyelopathyMyelopathy’s’s hand hand

ClumsinessClumsiness

Intrinsic wasting Intrinsic wasting

Finger escape signFinger escape sign

Grip and release testGrip and release test

– Watch out for:Watch out for:Multiple sclerosisMultiple sclerosis

ALSALS

Subacute combined degenerationSubacute combined degeneration

Peripheral neuropathyPeripheral neuropathy

Tumors - infectionTumors - infection

Cervical anginaCervical anginaChronic breast painChronic breast painFacial painFacial painSpurs – dysphagia, Spurs – dysphagia, dysphonia, dyspneadysphonia, dyspneaVertebral artery thrombosisVertebral artery thrombosisHemiparesisHemiparesisSympathetic involvementSympathetic involvementCombined with lumbar Combined with lumbar stenosis – peripheral stenosis – peripheral neuropahyneuropahy

Atypical clinical presentations Atypical clinical presentations of cervical spondylosisof cervical spondylosis

Chemical mediators of spinal painChemical mediators of spinal painNeurogenicNeurogenic

Substance PSubstance PSomatostatinSomatostatinCholecystokininlike Cholecystokininlike subsctancesubsctanceVasoactive inerstinal Vasoactive inerstinal peptidepeptideGastrin releasing Gastrin releasing peptidepeptideDynorphin Dynorphin EnkephalinEnkephalinGelaninGelaninneurotensinneurotensinAngiotensin IIAngiotensin II

Non – neurogenicNon – neurogenicBradykininBradykininSerotoninSerotoninHistamineHistamineAcetylocholineAcetylocholinePGE 1 PGE 1 PGE 2PGE 2LeukotrienesLeukotrienesdiHETEdiHETE

Nurick grading of disability Nurick grading of disability based on gait abnormalitybased on gait abnormality

Grade IGrade I No difficulty in walkingNo difficulty in walking

Grade IIGrade II Mild gait involvement. Does not interfere with Mild gait involvement. Does not interfere with employmentemployment

Grade III Grade III Gait abnormality prevents employmentGait abnormality prevents employment

Grade IVGrade IV Able to ambulate only with assistanceAble to ambulate only with assistance

Grade VGrade V Chairbound or bedriddenChairbound or bedridden

Imaging studiesImaging studies

The cervical spine is a The cervical spine is a complex region with the complex region with the following elementsfollowing elements

Bone Bone

DiscDisc

LigamentsLigaments

Neural elementsNeural elements

Facet jointsFacet joints

Paraspinal musculature Paraspinal musculature

False positive imaging studies in False positive imaging studies in asymptomatic patientsasymptomatic patients

25% incidence of degenerative 25% incidence of degenerative changes on plain radiography by 5changes on plain radiography by 5 thth decadedecade

75% incidence by 775% incidence by 7 thth decade decade

No significant differences on plain film No significant differences on plain film between symptomatic and between symptomatic and asymptomatic patients asymptomatic patients

Cont…

Plain radiographyPlain radiographyA minimum 4 - week period of conservative A minimum 4 - week period of conservative treatment is recommended prior to plain x-rays treatment is recommended prior to plain x-rays with exception of:with exception of:√ TraumaTrauma√ Suspicion of neoplasmSuspicion of neoplasm√ Worsening neurologic deficitWorsening neurologic deficit

Routine cervical spine plain radiography includes:Routine cervical spine plain radiography includes:√ Anterior – posteriorAnterior – posterior√ Lateral Lateral √ obliqueoblique

Cont…

Flexion and extension views can be added to Flexion and extension views can be added to evaluate the dynamic properties of the cervical evaluate the dynamic properties of the cervical spinespinePlain radiography can demonstrate:Plain radiography can demonstrate:

Congenital stenosisCongenital stenosisSpondylotic segmentsSpondylotic segmentsForaminal narrowingForaminal narrowingDegenerative subluxationDegenerative subluxationCongenital malformation Congenital malformation Autofused spinal segmentsAutofused spinal segmentsOsteochondrosis of the nucleous puplosusOsteochondrosis of the nucleous puplosusSpondylosis of the annulus fibrosis Spondylosis of the annulus fibrosis Vacuum phenomenon and disk space height lossVacuum phenomenon and disk space height lossReactive sclerosis of the endplatesReactive sclerosis of the endplatesSchmorl´s nodes Schmorl´s nodes

M.R.IM.R.I

Progressive neurologic Progressive neurologic deficitdeficitDisabling weakness Disabling weakness Long tract signsLong tract signsCervical radiculopathy with Cervical radiculopathy with failure to improve following failure to improve following 6 – 8 weeks of conservative 6 – 8 weeks of conservative measures measures Vertebral body destruction Vertebral body destruction or instability detected on or instability detected on plain film plain film

Myelography - Computed tomographyMyelography - Computed tomographyProvides excellent details and differentiation of bone Provides excellent details and differentiation of bone versus soft tissue lesionsversus soft tissue lesionsIndicated when MRI fails to provide sufficient detail or Indicated when MRI fails to provide sufficient detail or does not match clinical findingsdoes not match clinical findingsStudy of choice in the presence of severe degenerative Study of choice in the presence of severe degenerative changes and in the presence of significant endplate changes and in the presence of significant endplate osteophytesosteophytesModic found MRI to be as sensitive as CT myelography at Modic found MRI to be as sensitive as CT myelography at detecting disease level, but less specific in terms of detecting disease level, but less specific in terms of distinguishing bony from soft tissue impingement distinguishing bony from soft tissue impingement DisadvantagesDisadvantages√ Intrathecal contrast administration and risk to spinal cord rootsIntrathecal contrast administration and risk to spinal cord roots√ Exposure to radiationExposure to radiation

CT-Myelography can be considered a complementary CT-Myelography can be considered a complementary study to a MRI scanstudy to a MRI scan

3–D3–D scan scan

Electrodiagnostic studiesElectrodiagnostic studies

Applied when clinical examination and imaging Applied when clinical examination and imaging fail to provide a clear diagnosis or perhaps fail to provide a clear diagnosis or perhaps conflicting diagnosesconflicting diagnoses

May include needle electromyelography, May include needle electromyelography, somatosensory evoked potentials or cervical root somatosensory evoked potentials or cervical root stimulationstimulation

Operator dependedOperator depended

May help differentiate primary cervical disorders May help differentiate primary cervical disorders from peripheral nerve entrapments syndromes or from peripheral nerve entrapments syndromes or pain eminating from the intrinsic shoulder pain eminating from the intrinsic shoulder pathologypathology

Radionuclide imagingRadionuclide imaging

Sensitive but non-specific exam Sensitive but non-specific exam for changes in bone metabolism for changes in bone metabolism or blood flowor blood flow

May demonstrate degenerative May demonstrate degenerative joint disease healing fracture or joint disease healing fracture or osteomyelitisosteomyelitis

Treatment Treatment

ConservativeConservative

Operative Operative

Conservative treatmentConservative treatment

Neck pain Neck pain

Most is self-limiting and will resolve with Most is self-limiting and will resolve with appropriate conservative careappropriate conservative care

The presence of severity of disease not The presence of severity of disease not related to related to √ Degenerative changesDegenerative changes√ Diameter of the spinal canal Diameter of the spinal canal √ Degree of lordosisDegree of lordosis√ Any changes in measurements of these Any changes in measurements of these

parameters over timeparameters over time

10 year follow up study in 205 cases with 10 year follow up study in 205 cases with neck pain without surgeryneck pain without surgery√ 43% free of pain43% free of pain√ 79% decreased pain79% decreased pain√ 32% moderate to severe residual pain32% moderate to severe residual pain

Gore et al, Spine 1987Gore et al, Spine 1987Cont…

Medications to address symptoms versus treatment of Medications to address symptoms versus treatment of underlying pathologyunderlying pathology√ Cosrticosteroids and NSAIDS effective in reducing Cosrticosteroids and NSAIDS effective in reducing

inflammation and paininflammation and painAcutely painful degenerative disk diseaseAcutely painful degenerative disk diseaseRadiculopathyRadiculopathyRheumatoid arthritisRheumatoid arthritis

√ Tricyclic anrtidepressantsTricyclic anrtidepressantsAmitriptyline in the treatment of chronic low back painAmitriptyline in the treatment of chronic low back pain

√ Muscle relaxantsMuscle relaxantsShort pain relief Short pain relief Act on central nervous systemAct on central nervous systemCarisoprodolCarisoprodolMetaxaloneMetaxaloneMethocarbamolMethocarbamolBenzodiazepinesBenzodiazepinesCyclobenzaprine Cyclobenzaprine

Cont…

Physical therapyPhysical therapy√ Ice and / or heatIce and / or heat√Electrical stimulationElectrical stimulation√Manual techniques / massageManual techniques / massage

After acute symptoms subside – After acute symptoms subside – dynamic modalitiesdynamic modalities√ Isometric strengthening exercisesIsometric strengthening exercises√Neck and shoulder stretchingNeck and shoulder stretching√Aerobic conditioning Aerobic conditioning

Cont…

Spinal manipulation Spinal manipulation √Manipulation has similar improvements Manipulation has similar improvements

in pain, functioning and objective in pain, functioning and objective measuresmeasures√The efficacy of spinal manipulation for The efficacy of spinal manipulation for

neck and back pain over other neck and back pain over other treatments has not been showntreatments has not been shown√Rehabilitative exercises probably are Rehabilitative exercises probably are

superior to manipulative therapy alone superior to manipulative therapy alone with gains in strength, motion and with gains in strength, motion and enduranceendurance

Cont…

Radiculopathy Radiculopathy

Non-operative treatment is the appropriate Non-operative treatment is the appropriate first step in almost all cases of cervical first step in almost all cases of cervical radiculopathyradiculopathy

Conservative measuresConservative measures√ Soft collar can reduce the acute Soft collar can reduce the acute

inflammatory response and associated paininflammatory response and associated pain√ Short period onlyShort period only√ Applied within two weeks of the onset of Applied within two weeks of the onset of

symptomssymptoms√ Prolonged immobilization is to be avoided Prolonged immobilization is to be avoided

because of deconditioningbecause of deconditioning√ Gradual weaning from the collar followed Gradual weaning from the collar followed

by physical therapyby physical therapy

Cont…

TractionTraction√ Short term reliefShort term relief√ 8 -10 pounds for 15 to 20 minutes8 -10 pounds for 15 to 20 minutes√ Optimum recommended angle is Optimum recommended angle is

2020o o to 30to 30oo of flexion of flexion √ Should not be applied until acute Should not be applied until acute

muscle spasms have subsidedmuscle spasms have subsided

Epidural steroidsEpidural steroids√Most beneficial effects in painful Most beneficial effects in painful

radiculopathyradiculopathy√ Should be administered by highly Should be administered by highly

trained individual given the risk to trained individual given the risk to the spinal cordthe spinal cord

Cont…

Cervical Myelopathy can be painless Cervical Myelopathy can be painless and have an insidious onsetand have an insidious onset..

Myelopathy Myelopathy

Conservative care of spondylotic Conservative care of spondylotic myelopathy limitedmyelopathy limitedObservation of myelopathy Observation of myelopathy caused by soft disc herniation is caused by soft disc herniation is acceptable with close attention to acceptable with close attention to progression of signs or symptomsprogression of signs or symptoms

– Options include:Options include:Immobilization of the neck with an Immobilization of the neck with an orthosis and rest to reduce neural orthosis and rest to reduce neural irritationirritationTraction or epidural steroids not Traction or epidural steroids not recommendedrecommended

Cont…

Surgical indicationsSurgical indications

Three basic goals Three basic goals

Decompression of neural elementsDecompression of neural elementsStabilization of unstable segmentsStabilization of unstable segmentsAblation of painful articulationsAblation of painful articulations

Neck painNeck pain

Surgical indicationsSurgical indicationsIntractable axial neck pain Intractable axial neck pain Cervical spondylosis Cervical spondylosis Degenerative disease of the atlanto-axial facet Degenerative disease of the atlanto-axial facet √ Intractable pain or neurologic dysfunction Intractable pain or neurologic dysfunction √ Atlanto-axial instability secondary to trauma or Atlanto-axial instability secondary to trauma or

rheumatoid arthritisrheumatoid arthritisOne third of patients with AAI and one half One third of patients with AAI and one half of those with vertical migration will develop of those with vertical migration will develop long tract signs within five years of long tract signs within five years of presentationpresentationOcciput-cervical fusion to stabilize the area Occiput-cervical fusion to stabilize the area and arrest the cranial settlingand arrest the cranial settlingCan be combined with posterior Can be combined with posterior decompression and possibly an anterior decompression and possibly an anterior resection of the odontoidresection of the odontoid

Subaxial segmental instability Subaxial segmental instability

Neck pain Neck pain

Operative treatment Operative treatment – Options Options

Fusion Fusion

Fusion and stabilizationFusion and stabilization

Artificial discArtificial disc

Radiculopathy Radiculopathy

Surgical indications Surgical indications Progressive neurologic Progressive neurologic deficit deficit Disabling motor deficit at Disabling motor deficit at presentation presentation Persistent or recurrent Persistent or recurrent radicular symptoms radicular symptoms despite at least 6 weeks despite at least 6 weeks of conservative treatmentof conservative treatmentSegmental instability Segmental instability combined with radicular combined with radicular symptomssymptoms

Radiculopathy Radiculopathy

Operative treatmentOperative treatment– Options Options

Anterior procedureAnterior procedure√ Disc excision Disc excision √ Discectomy and fusion Discectomy and fusion √ Artificial discArtificial disc

Posterior procedurePosterior procedure√ Posterior Lamino-foraminotomy Posterior Lamino-foraminotomy

MyelopathyMyelopathy

Surgical indicationsSurgical indications

A diagnosis of cervical spondylotic myelopathy is A diagnosis of cervical spondylotic myelopathy is almost always an indication for surgeryalmost always an indication for surgeryParticulary important factorsParticulary important factors

Progression of signs or symptomsProgression of signs or symptomsPresence of myelopathy for six months or longerPresence of myelopathy for six months or longerCanal – vertebral body diameter ratio approaching Canal – vertebral body diameter ratio approaching 0.40.4Difficulty walking Difficulty walking Loss of balanceLoss of balanceBowel of bladder incotinenceBowel of bladder incotinenceSignal changes within the substance of the spinal Signal changes within the substance of the spinal cordcord

In patients with rheumatoid arthritis, myelopathy In patients with rheumatoid arthritis, myelopathy caused by AAI, basilar invagination or subaxial caused by AAI, basilar invagination or subaxial instability should to be addressed surgically in a instability should to be addressed surgically in a timely manner `timely manner `

Myelopathy Myelopathy

Operative treatmentOperative treatment– OptionsOptions

Anterior procedureAnterior procedure√ Discectomy(ies) and stabilizationDiscectomy(ies) and stabilization√ Corpectomy(ies) and stabilizationCorpectomy(ies) and stabilization

Posterior proceduresPosterior procedures√ LaminectomiesLaminectomies√ Laminectomies and stabilizationLaminectomies and stabilization√ Laminoplasty Laminoplasty

Anterior proceduresAnterior procedures

Indications Indications

Better for central soft disc Better for central soft disc herniation or bilateral herniation or bilateral radiculopathy on the radiculopathy on the same levelsame level

Unilateral soft disc or Unilateral soft disc or foraminal stenosisforaminal stenosis

1 or 2 level spondylotic 1 or 2 level spondylotic myelopathymyelopathy

Contra-IndicationContra-Indication

Cervical stenosis due Cervical stenosis due to pathology of the to pathology of the posterior elementsposterior elements

Anterior decompression and fusion (bone graft)

Anterior decompression and stabilization with Mesh cylinder and plate

Anterior decompression and stabilization expandable cages and plate

Ε.Δ. F 60

20/7/99

1ST POP

Vertebrectomy and stabilization Mesh cylinder and plate

Anterior Cervical Corpectomy(ies) fusion and stabilization

Advantages

• allows for more complete cord decompression

• may be safer better visualizationless distraction

• higher fusion rate

• less levels to fuse

Disadvantages Disadvantages PseudarthrosisPseudarthrosis

Graft dislodgement Graft dislodgement

Implants failureImplants failure

Posterior proceduresPosterior procedures

Indications Indications

Unilateral disc herniation or foraminal Unilateral disc herniation or foraminal stenosisstenosisCervical spondylotic myelopathyCervical spondylotic myelopathy due to due to >> 3 level pathology3 level pathology– Congenital stenosisCongenital stenosis– Ossification of posterior longitudinal ligament Ossification of posterior longitudinal ligament

(OPLL)(OPLL)

Cervical stenosis due to degeneration – Cervical stenosis due to degeneration – hypertrophy of posterior cervical hypertrophy of posterior cervical elementselementsPrior anterior cervical procedures (Prior anterior cervical procedures (±)±)

The cervical spine must be in lordosis

Contra-Contra-indicationsindications

Pre-existed cervical Pre-existed cervical kyphosiskyphosis

Pathology of the anterior Pathology of the anterior vertebral elements (vertebral elements (±)±)

Laminoplasty

Laminoplasty

Laminectomy and stabilization

withplates – rods and screws

Γ.ΠΜ 66Ν(+)

Γ.ΠΜ 66Ν(+)

Γ.ΠΜ 66Ν(+)Γ.Π

Μ 66Ν(+)

Γ.ΠΜ 66Ν(+)

ComplicationsComplicationsPitfalls Pitfalls

Dysphagia Dysphagia Esophageal InjuriesEsophageal InjuriesVocal cord paralysis Vocal cord paralysis after anterior cervical after anterior cervical spine surgeryspine surgerySpinal cord injury Spinal cord injury Incidental durotomy Incidental durotomy Epidural HenatomaEpidural HenatomaPostolaminectomy kyphosisPostolaminectomy kyphosisCervical pseudartrhosisCervical pseudartrhosisProblems related to instrumentationsProblems related to instrumentations

Anterior procedure

Inadequate decompression

Implants failure(plate removal)

Laminoplastyfracture of the bony hinge

Post-laminectomy instability

Post-laminectomy instabilityswan-neck deformity

Conclusions Conclusions

TreatmentTreatment

ConservativeConservative Operative Operative

Neck painNeck pain MainlyMainly Rarely Rarely

RadiculopathyRadiculopathy OftenOften OftenOften

MyelopathyMyelopathy Rarely Rarely Mainly Mainly

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