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Flashcards in Degenerative Cervical spine Deck (40):
1

What is Cervical Spondylosis?

  • A chronic disc degeneration and associated facet arthropathy that can lead to 
    • Cervical myelopathy
    • cervical radiculopathy

2

What is the epidemiology of cervical spondylosis?

  • typically begins 40-50 yrs
  • most common levels C5-6 > C6-7 because they are associated with most flexion/extension in subaxial spine
  • more common men than women

Risk Factors

  • excessive drinking
  • smoking
  • lifting
  • professional athletes

3

What is the pathoanatomy of cervical spondylosis?

  • Natural aging process of spine
  • characterised by degeneration of the disc and all 4 joints of cervical motion segment
    • 2 facet joints
    • 2 uncovertebral joints of Luschka
  • The process of degeneration includes
    • disc degeneration
      • disc dessication/loss of height/disc bulge/herniation
    • Joint degeneration
      • ucinate spurring and facet arthrosis
    • ligamenous changes
      • lig flavum thickens, infolding secondary to loss of disc height
    • Deformity
      • kyphosis secondary to loss of disc height-> transfer of load to facet and uncovertebral joints-> further uncinate spurring/facet arthrosis

4

What is the mechanism of neurological compression in cevrvical spondylosis?

  • Nerve root compression
    • foraminal spondylolytic changes
      • 2ary to chondrosseous spurs of facet/ uncovertebral joints
    • posterolateral disc herniation
      • between post edge of uncinate and lateral edge of PL
    • usually affects nerve root below (C6/7- affect C7)
  • Central cord compression
    • ​when diam ( normal 17mm)
    • worse during neck extension when central cord is pinched between
      • degenerative disc
      • Hypertrophic facets/infolded ligamentum

5

What investigations are useful for dx of cervical spondylosis?

xrays- ap , lateral , oblique, flexion/extension

  • degenerative changes of uncovertebral/facet joints
  • osteophyte formation
  • disc space narrowing
  • endplate sclerosis
  • decreased sagittal diameter ( cord comp
  • changes don't always correlate with symptoms ;)
    • 70% of 70yr old deg changes on xray

MRI

  • axial key to see soft tissues
    • disc degen, spinal cord changes, 
    • high rate false positives

6

What is the tx of cervical spondylosis?

depends on symptoms of

  • cervical radiculopathy
  • cervical myelopathy

7

Define Cervical Myelopathy?

  • A clinical syndrome cause by compression of the spinal cord which is characterised by
    • cluminess in hands
    • Gait imbalance

8

What is the pathophysiology of cervcal myopathy?

  • Degenerative cervical spondylosis
    • most common cause
    • compression usually by anterior osteophytes,discophyte complex
    • degenerative spondylothesis and hypertrophy of ligamentum flavum may contribute
  • Congential stenosis
    • when congential narrowing combined with spondyltic degernative change
  • Ossification of the posterior longitudinal ligament
  • Tumour
  • Epidural abscess
  • Trauma
  • Cervical Kyphosis

9

Decribe the neurological injury in cervical myopathy?

  • Direct Cord compression
  • Ischaemia from compression of anterior spinal artery

10

Describe any associated conditions?

  • Lumbar spine stenosis
    • tandem stenosis in cervical /lumbar in 20% pts

11

What is the prognosis of cervical myopathy?

  • Slow Progession
  • Rarely improves with nonoperative modalities
  • steplike deterioation
  • early recongnition and tx prior to spinal cord damage is critical for good outcomes

12

Can you name a classification system for cervial myopathy?

  • Ranawat 
  • Class I-  Pain no neurological deficit
  • Class 2-Subjective weakness, hyperreflexia, dyssthesia
  • Class 3A- Objective weakness,long tract signs, ambulatory
  • Class 3B- Objective weakness, long tract signs, non ambulatory

13

What are the symptoms of cervical myopathy?

  • Neck pain and stiffness
    • occipital headache-common
    • axial neck pain
  • Extremity parathesia
    • diffuse NONDERMATOMAL numbness and tingling
  • Weakness and clumseyness
    • weakness and reduced manual dexterity
  • Gait instability - most important predictor
    • pt feels unsteady on feet
    • weakness up and down stairs
  • Urinary retention
    • rare, appears late in disorder

14

What are the signs of cervial myopathy?

  • Weakness
    • difficult to detect
  • Finger escape sign
    • pt holds finger extended and abducted-little finger spontaneously abducts due to weak intrinsics
  • Grip and release test
    • normal pt can grip and release 20 times in 10 seconds myopathic pt may not be able to do this

Sensory

  • Proprioception dysfunction
    • due to dorsal column involvement
    • late in disease
    • Assoc w poor prognosis
  • Decreased Pain sensation
    • pinprick test to see if global reduction or dermatomal
    • involvement of ventral spinothalamic tract
    • vibration loss only seen in long standing cases
  • UPPER MOTOR NEURONE SIGNS- spasicity
    • ​Hyperreflexia
    • inverted radial reflex
      • ​tapping distal brachioradial reflex->ipislat finger flexion
    • Hoffman's sign
      • snapping distal phalanx of middle finger- spontaneous flexion in other fingers
    • Sustained clonus
      • ​> 3 beats
    • Babsinki test
      • ​positive- extension of great toe

​​Gait analysis

  • Toe to heel walk- pt finds this difficult
  • Romberg test
    • eyes closed arms forward
    • loss of balance consistent with post column dysfunction

Provocation tests

  • Lhermitte
    • extreme cervical flexion -> shock like senation down spine to extremities

15

What investigations are useful to dx cervical myopathy?

xrays

  • Cervical AP, lateral,oblique, extension/flexion
    • osteophytes
    • disc space narrowing
    • degenerative changes of uncovertebral and facet joints
    • decreased sagittal diameter
      • cord compression when diam <13mm
  • ​​lateral radiograph
    • ​identify c2-c7 alignement- tangentail lines form c2-c7
    • local kyphosis angle
  • ​oblique
    • foraminal stenosis from uncovertebral joint arthrosis

MRI

  • best for evaluation of spinal cord and nerve root
  • spinal cord changes- bright on T2- myelomalacia
  • T1 changes poorer outcome following surgical decompression
  • Compression ratio- smallest ap diameter/ largest transverse diameter
  • compression ratio of <0.4 carries poor prognosis

CT

  • useful for osteophytes and ostephyte posterior ligament

CT myelogram

  • gives excellent degrees of compression
  • contrast  injection via lumbar spine then trendelembery /C1-C2 puncture and diffuse caudal 
  • gd for pts with pacemakers etc for which MRI artefact

 

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16

What is the ddx of a patient with weakness, extremity dysathesia, hyperreflexia, gait imbalance?

  • Normal aging
  • Stroke
  • Movement disorder
  • Vitamin B12 deficiency
  • Amyotrophic Lateral Sclerosis (ALS)
  • Mutliple sclerosis

17

What is the tx of a patient with cervical myopathy?

Non operative

  • Observations, NSAIDS, PT and lifestyle modifications
    • mild disease w no functional impairment
    • pt who are poor candidates for surgery
    • meds- naids, gabapentin
    • c collar-hard collar in slight flexion
    • PT for strenghtening muscles, back, neck
    • watch pt for progression
    • improved outcome with pt with large transverse diameter >70mm2

​​Operative

  • Surgical decompresion , restoration of lordosis and stabilisation
    • signifciant funcitonal impairment
    • 1-2 level disease
    • lordotic, neutral or kyphotic position
  • Anterior cervical discetomy/corpectomy, + fusion
  • Posterior laminectomy + fusion
  • Posterior laminoplasty
  • combined ant/post proceedure

18

What is the outcome of surgery for cervical myopathy?

 

  • prospective studies show improvement in overall pain, function, and neurologic symptoms with operative treatment
  • early recognition and treatment prior to spinal cord damage is critical for good clinical outcomes

19

What are the indications for anterior approach and fusion?

  • Most common tx with pt with single/2 level disease
  • Fixed kyphosis >10 o
  • Anterior fixation can correct kyphosis
  • Pathology is anterior- osteophytes , OPLL, soft disc

  • decompression 


    • corpectomy and strut graft may be required for multilevel spondylosis

    • two level corpectomies tend to be biomechanically vulnerable (preferable to combine single level corpectomy with adjacent level diskectomy)



    • 7% to 20% rates of graft dislodgement with cervical corpectomy with associated severe complications including death reported. 



  • fixation

    • anterior plating functions to increase fusion rates and preserve position of interbody cage or strut graft

       

20

What are the advantages and disadvantages of anterior  fusion?

Advantages

  • Lower infection
  • mild postoperative pain

Disadvantge

  • avoid in pt with poor swallow

 

21

what are the indicaitions for laminectomy and posterior spinal fusion?


  • multilevel compression with kyphosis of < 10 degrees 


  • > 13 degrees of fixed kyphosis is a contraindication for a posterior procedure   - will not fully correct the spine and bowstring anteriorly
  • in flexible kyphotic spine, posterior decompression and fusion may be indicated if kyphotic deformity can be corrected prior to instrumentation

 

 

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22

What are the indiciations for laminoplasty?

  • useful in maintaining motion
  • avoids complx of fusion so useful in pts with high risk of pseudoarthrosis
  • CI- cervical kyphosis >13o 
    • severe axial neck pain

23

Describe the technique for laminoplasty?


  • volume of canal is expanded by hinged-door laminoplasty followed by fusion 


  • usually performed from C3 to C7
     
  • open door technique

    • hinge created unilateral at junction of lateral mass and lamina and opening on opposite side 



    • opening held open by bone, suture anchors, or special plates
       
  • French door technique

    • hinge created bilaterally and opening created midline
       

 

 

 

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24

Describe the advantages /disadvantages of laminoplasty?

Advantages


  • Allows for decompression of multilevel stenotic myelopathy without compromising stability and motion (avoids postlaminectomy kyphosis) 




  • lower complication rate than multilevel anterior decompression especially in patients with OPLL

  • A motion preserving technique

    • pseudoarthrosis not a concern in patients with poor healing potential (diabetes, chronic steroid users)

  • can be combined with a subseqeunt anterior procedure

 

​Disadvantages

  • ongoing neck pain
  • still associated with loss of motion

 

 

25

What are the indications for anterior and posterior surgery

  • Mutlilevel stenosis in rigid kyphosis
  • Multilevel anterior cervical corpectomies
  • postlaminectomy kyphosis

26

What are the indications in laminectomy alone?

  • Rare due to risk of postlaminectomy kyphosis
  • progressive kyphosis is a risk 11-47% chance if laminectomy preformed without fusion

27

What are the complications of surgery?

  • Pseudoarthrosis
    • ​12% single level, 30% multi level
    • tx with post wiring/plating or rpt ant decompression
  • Post op C5 palsy
    • 4.6% incidence
    • same for ant/post decompression
    • gd prognosis for recovery but takes time
  • Recurrent laryngeal nerve palsy
    • ​right more vunerable then left
    • watch over time
    • if no improvement 6/52->ent to scope + inject teflon
  • Hardware falure and migration 
    • ​7-20% with 2 level corpectomy
  • post laminectomy kyphosis
    • ​tx with ant/post decompression
  • post op axial neck pain
  • vertebral artery injury
  • oesphageal injury
  • dysphagia and alteration in speech

28

What is cervical radiculopathy?

  • Clinical symptoms caused by nerve root compression in the cervical spine
    • characterised by sensory and motor symptoms in the upper extremity

29

What is the pathophysiology of cervical radiculopathy?

  • Degenerative Cervical Spondylosis
    • discosteophyte complex and loss of disc height
    • chondrosseous spurs of facet and uncovertebral joints
  • Disc Herniation- soft disc
    • usually posterolateral
    • between edge of uncinate and lateral edge of PL
  • ​Neural compression
    • direct
    • irration by chemical mediators
      • IL1, IL6, TNF alpha, Prostag
    • Affects nerve root below: C6/7 affect C7

30

What are the symptoms  of cervical radiculopathy?

Symptoms

  • occipital headache
  • trapezial/ interscapular pain
  • neck pain
    • radiate to shoulders
    • insidious that may worsen with vertebral motion
  • Unilateral arm pain
    • global non dermatomal
  • unilateral dermatomal numbness and tingling
    • in thumb- c6
    • In middle finger c7
  • unilateral weakness
    • grip strength/overhead activities- C7

31

What are the signs of cervical radiculopathy?

  • C5 radiculopathy
    • weak deltoid/biceps
    • diminished biceps reflex
  • C6
    • weak brachioradialis & wrist extension 
    • diminished brachioradialis reflex
    • parathesia in thumb
  • C7
    • weak triceps and wrist flexion
    • diminished triceps reflex
    • parathesia in index, middle , ring fingers
  • C8
    • weak distal phalanx flexion middle/index finger
    • parathesia- little
  • Provocation test
    • Spurling Test
      • Simultaneous extension, rotation to affected side, lateral bend adn vertical compression-> symptoms in ipislateral arm
    • Shoulder abduction test
      • lifting arms above head often relieves symptoms

32

What investigations are useful for cervical radiculopathy?

  • Xrays- ap , lateral , oblique flexion, extension
  • MRI- T2 axial imaging is modality of choice and gives info about soft tissue

33

What is the tx of cervical radiculopathy?

Non operative

  • rest, medications and rehabiliation
    • 75% improve non op tx
    • by reabsorption of disc, decrease inflammation around irritated nerves
    • immobilisation- short time <1-2wks
    • meds; Nsaids, muscle relaxants, corticosteriods
    • rehab: moist heat, isometric excercises
  • selective nerve root corticosteriod injection

​Surgery

  • Anterior cervical discectomy +fusion
    • ​persistent/disabling pain/progressive neurology
    • GOLD STANDARD
  • posterior foraminotomy (endoscopically)
    • ​for foraminal soft disc herniation casuing single level radiculopathy
    • 91% sucess
  • cervical total disc replacement
    • single level disease w minimal arthrosis of facets
    • avoids non union

 

34

What are the risk of surgery for cervical radiculopathy?

  • Pseudoarthrosis
    • 5-10% for single level fusions, 30% for multilevel
    • Risk factors
      • smoking
      • diabetes
      • multi-level fusion
    • if asymptomatic observe, if symptomatic tx with post cervical fusion
      • better chance of fusion even though > blood loss, longer hospitalisation, longer op times, increased complx rates
  • Recurrent laryngeal nerve injury
    • abberrant pathway on right
    • theoretically more at risk on right no evidence to support incidence w right sided incision
    • tx- observe
    • no improvement in 6 weeks then ENT
  • hypoglossal n injury
    • tongue deviated to side of injury
  • Vascular injury- vertebral artery- fatal
  • Dysphagia
  • Horner's syndrome
    • injury to sympathetic chain on longus collu muscle at c6
    • miosis, ptosis, anhydrosis, enophthalmos, loss pf ciliospinal reflex on side of face
  •  

35

What are the different types of cervical stenosis?

  • Congential 
  • Acquired
    • traumatic
    • degenerative

36

what are the assocaited conditions of cervical stenosis?

  • Spear tackler's spine
  • A syndrome of cervical stenosis- caused by repeitive microtrauma & improper tackling technique
  • CI to return to play

37

What is the prognosis of cervical stenosis?

  • increase risk for radiculopathy/myelopathy even from minor trauma
  • congenital cervical stenosis important consideration in athlete

38

What is the classification of cervical stenosis?

  • Absolute cervical stenosis
    • canal diameter <10mm
  • Relative cervical stenosis
    • Canal diameter 10-13mm

39

What investigations are useful in dx of cervical stenosis?

  • xrays
    • ap, lateral , flexion/extension
    • lateral 
      • canal diameter <13mm
      • Torg- Pavlo ratio
        • canal/vertebral body width of <0.8 normal is 1.0

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40

What are the tx for cervical stenosis?

  • Non op
    • observe w possible activity restrictions
    • CI return to play contraversial
  • Surgery
    • surgical decompression and stablisation
      • for radiculopathy
      • myelopathy
      • prophylactic measure