Cervical Cervical SpondylosisSpondylosis; ; Etiology, Evaluation and Etiology, Evaluation and

ManagementManagement

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 CenterPiedmont Spine Center

Conclusion:Conclusion:

Cervical nerve root or cord Cervical nerve root or cord compression from bone spur compression from bone spur formation (formation (spondylosisspondylosis) 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 SpondylosisSpondylosis; Definition; Definition

Age related degeneration of the Age related degeneration of the cervical spinecervical spine““OsteoarthritisOsteoarthritis””Most common in persons over 40Most common in persons over 40Most common cause for Most common cause for myelopathymyelopathyin persons over 55in persons over 55Male>FemaleMale>Female

Cervical Cervical SpondylosisSpondylosis;;PathologyPathology

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 SpondylosisSpondylosis;;Clinical Presentation

MechanicalMechanical•• PainPain•• StiffnessStiffness•• Muscle SpasmMuscle Spasm•• ““Pop and CrackPop and Crack””

NeurologicNeurologic•• Nerve Root CompressionNerve Root Compression•• Spinal Cord CompressionSpinal Cord Compression

Cervical Cervical SpondylosisSpondylosis;;

Spondylitic change with bone spur/disk complex formation

Developmental narrowing of spinal canal with compression of spinal cord and nerve roots

Cervical Cervical SpondylosisSpondylosis;;Cord CompressionCord Compression

64 Year old patient with severe symptomatic spondyliticmyelopathy. Multilevel Cord compression seen on MRI.

Cervical Cervical SpondylosisSpondylosis;;Natural HistoryNatural History

PredispositionPredisposition•• Some individuals have a Some individuals have a congenitally narrow spinal congenitally narrow spinal

canalcanal•• Increased incidence of symptom development with mild Increased incidence of symptom development with mild

to moderate to moderate spondylosisspondylosis•• PrePre--participation screening of athletes to asses participation screening of athletes to asses

vulnerability to spinal cord injuryvulnerability to spinal cord injury

EvolutionEvolution•• Unlike soft cervical disk Unlike soft cervical disk herniationherniation which usually which usually

resolves, Cervical resolves, Cervical SpondylosisSpondylosis is progressiveis progressive•• May be insidious and then more rapidly progressive as May be insidious and then more rapidly progressive as

Spinal Fluid Spinal Fluid ““reservereserve”” becomes depleted by enlarging becomes depleted by enlarging bone spursbone spurs

Cervical Cervical SpondylosisSpondylosisSymptom PathogenesisSymptom Pathogenesis

HyperHyper--mobility / instability of spinal mobility / instability of spinal segmentssegmentsIrritation/inflammation of heavily Irritation/inflammation of heavily innervated vertebral body endplatesinnervated vertebral body endplatesDirect compression of cervical nerve Direct compression of cervical nerve root or spinal cordroot or spinal cordRepetitive trauma to cord or rootsRepetitive trauma to cord or rootsIschemic change to the cordIschemic change to the cord

Cervical Cervical SpondylosisSpondylosis;;Presentation with Presentation with ““HeadacheHeadache””

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 SpondylosisSpondylosis;;Developmental Scoliosis; Facet Developmental Scoliosis; Facet ArthropatyArthropaty

Coronal Plane angulationcauses 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 TreatmentNonsurgical TreatmentNSAIDSNSAIDSTractionTractionPTPT•• Ultrasound for trigger pointsUltrasound for trigger points•• Neuromuscular massageNeuromuscular massage•• TENSTENS•• TractionTractionInterventionalInterventional•• Selective nerve root blockSelective nerve root block•• ESIESI•• Facet block/ RFAFacet block/ RFA

DefinitionsDefinitionsRadiculopathyRadiculopathy•• Nerve Root CompressionNerve 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)MyelopathyMyelopathy•• Spinal Cord Compression in the cervical or Spinal Cord Compression in the cervical or

thoracic areathoracic area•• SymptomsSymptoms

Numbness, tingling of the arms/ handsNumbness, tingling of the arms/ handsDexterity difficulty with fine motor movementsDexterity difficulty with fine motor movementsGait instabilityGait instabilityBalance and coordination difficultyBalance and coordination difficultyBowel/Bladder disturbances (incontinence)Bowel/Bladder disturbances (incontinence)

Cervical Nerve Root Cervical Nerve Root SymtomsSymtomsC4C4--55 C5C5--66 C6C6--77 C7C7--T1T1

IncidenceIncidence 2%2% 19%19% 69%69% 10%10%

Root Root AffectedAffected

C5C5 C6C6 C7C7 C8C8

MotorMotor DeltoidDeltoid Biceps/ Biceps/ BRBR

TricepsTriceps IntrinsicsIntrinsics

SensorySensory ShoulderShoulder Upper Upper arm/ arm/ ThumbThumb

22ndnd 33rdrd

finger/ all finger/ all fingertipsfingertips

44thth and 5and 5thth

fingerfinger

Incidence of Incidence of MyelopathyMyelopathy is Related is Related to Canal Diameterto Canal Diameter

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Canal Diameter <13mm increases risk for myelopathy

Canal Diameter <10mm almost always results in symptomatic cord compression

Differential DiagnosesDifferential Diagnoses

ALS ALS •• Exclusively MotorExclusively Motor•• Tongue Tongue FasciculationsFasciculations

Multiple SclerosisMultiple Sclerosis•• Relapsing/remitting symptomsRelapsing/remitting symptoms•• DemyelinatingDemyelinating plaques on Brain MRIplaques on Brain MRI

SubacuteSubacute Combined DegenerationCombined Degeneration•• MacrocyticMacrocytic AnemiaAnemia•• B12 deficiencyB12 deficiency

Who Needs Surgery?Who Needs Surgery?

Neurologic CompromiseNeurologic Compromise•• Symptomatic Nerve root compression Symptomatic Nerve root compression

refractory to nonrefractory to non--surgical managementsurgical management•• Spinal Cord Compression with Spinal Cord Compression with

myelopathymyelopathy

Biomechanical InstabilityBiomechanical Instability•• Instability on Flexion/Extension FilmsInstability on Flexion/Extension Films•• Angular deformityAngular deformity•• SubluxationSubluxation/ / ListhesisListhesis

Surgical Options; ConsiderationsSurgical Options; Considerations

Type of PathologyType of Pathology•• Soft DiskSoft Disk•• Bone Spur; Bone Spur; SpondylosisSpondylosisLocation of Compression Location of Compression •• anterior vs. posterioranterior vs. posteriorAngulationAngulation of Spine of Spine •• Preserved Preserved LordosisLordosis vs. vs. KyphosisKyphosisPatient age and coPatient age and co--morbiditiesmorbiditiesHealth of adjacent levelsHealth of adjacent levelsBone DensityBone DensityNumber of spinal segments involved Number of spinal segments involved

Surgical OptionsSurgical Options

Anterior vs. Posterior DecompressionAnterior vs. Posterior DecompressionSimple Decompression vs. Fusion Simple Decompression vs. Fusion and Stabilizationand Stabilization

Anterior Cervical Decompression Anterior Cervical Decompression and Fusionand Fusion

Performed through a transverse cervical Performed through a transverse cervical incisionincisionMicroscopic Decompression of spinal cord Microscopic Decompression of spinal cord by removal of compressive bone spurby removal of compressive bone spurRestore and maintain Restore and maintain intervertebralintervertebral height height using an using an intervertebralintervertebral bone graft or bone graft or plastic spacerplastic spacerStabilize 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 Fusionand Fusion

Anterior Cervical Anterior Cervical DiskectomyDiskectomy and and FusionFusion

Minimal pain as no muscle disruptionMinimal pain as no muscle disruptionSubcuticularSubcuticular closureclosureOvernight observationOvernight observationAddresses ventral pathology without Addresses ventral pathology without any neural element retraction or any neural element retraction or manipulationmanipulation

Anterior Cervical Decompression Anterior Cervical Decompression and Fusionand Fusion

High fusion rate.

Fusion promoted by good blood supply at the ventral moment arm of the spine.

Fusion SubstrateFusion Substrate

Historical Gold Standard; Freshly Historical Gold Standard; Freshly harvested iliac crest bone harvested iliac crest bone autograftautograft•• Donor site morbidityDonor site morbidity•• Pain/ Infection RiskPain/ Infection Risk

Banked AllograftBanked Allograft•• Small but present risk for disease transmissionSmall but present risk for disease transmission

PEEK SpacersPEEK Spacers•• Plastic cement restrictors which are nonPlastic cement restrictors which are non--

compressible and restore intercompressible and restore inter--vertebral heightvertebral height

Bone Bone MorphogenicMorphogenic ProteinProtein

Recombinant protein with no risk of Recombinant protein with no risk of disease transmission and High fusion disease transmission and High fusion raterate

Biologics to Promote FusionBiologics to Promote Fusion

OsteocondustionOsteocondustionOsteoinductionOsteoinduction

Transverse Process

BMP and FusionBMP and Fusion

Goals of SurgeryGoals of Surgery

Decompress neural elementsDecompress neural elementsRestore Restore IntervertebralIntervertebral height which also height which also restores neural restores neural foraminalforaminal patencypatencyRestore anatomic alignment in the case of Restore anatomic alignment in the case of kyphosiskyphosis or scoliosis or scoliosis Stabilize spinal Stabilize spinal segment(ssegment(s) to prevent ) to prevent bone spur propagation and repetitive bone spur propagation and repetitive nerve root irritationnerve root irritationPromote solid Promote solid arthrodesisarthrodesis over timeover time

ACDF to correct Developmental ACDF to correct Developmental Scoliosis from Scoliosis from SpondylosisSpondylosis

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ACDF to Correct Developmental ACDF to Correct Developmental KyphosisKyphosis due to due to spondylosisspondylosis

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Posterior Cervical FusionPosterior 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 (LaminectomyLaminectomy))Stabilization by posterior lateral Stabilization by posterior lateral mass screws and rodsmass screws and rodsFusion performed by onFusion performed by on--lay lay technique and intertechnique and inter--facet graft facet graft material (laminar bone or iliac crest material (laminar bone or iliac crest autograftautograft))

Posterior Cervical FusionPosterior Cervical Fusion

Posterior Cervical DecompressionPosterior Cervical Decompression

Decompression alone is Decompression alone is contraindicated with preexisting contraindicated with preexisting kyphotickyphotic deformitydeformityHigh risk of developing late swanHigh risk of developing late swan--neck deformityneck deformityPost operative PainPost operative PainIn case of In case of hyperlordosishyperlordosis, posterior , posterior cord migration may cause cord cord migration may cause cord compressioncompression

Surgical OutcomesSurgical OutcomesAnterior or Posterior approaches that Anterior or Posterior approaches that effectively decompress spinal cord effectively decompress spinal cord promote improvements in outcomepromote improvements in outcome

Higher Risk of late Higher Risk of late kyphosiskyphosis in patients in patients who undergo who undergo laminectomylaminectomy 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 fusioncombined with fusion

Fehlings MG, Arvin B. J Neurosurg Spine. 2009 Aug:11 (2): 97-100

OutcomesOutcomesDuration of SymptomsDuration of Symptoms and advanced age and advanced age negatively affect outcome in patients with CSMnegatively 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 aftercompared with only 16% is operated afterAbnormal PreAbnormal Pre--operative SSEP/EMG Findings operative SSEP/EMG Findings adversely affect outcomeadversely affect outcomeCord Signal Change or the presence of spinal Cord Signal Change or the presence of spinal cord atrophy negatively affect outcomecord 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