CERVICAL SPONDYLOSIS AND CERVICAL SPONDYLOTIC MYELOPATHY
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1 CERVICAL SPONDYLOSIS AND CERVICAL SPONDYLOTIC MYELOPATHY A NEUROSURGEON S VIEW A Preventable Journey to a wheelchair bound-life Dr H. BOODHOO F.C.S (Neurosurgery)
2 Cervical Spondylosis Spinal Osteoarthritis / Spinal Arthritis Degenerative cervical disc disease 90% of the world population above 65 but about 10% only have symptoms <40 years: 25% >40 years: 50%
3 A N A T O M Y
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15 Cervical Spondylosis : Definition Age related degeneration of the cervical spine Osteoarthritis Most common in persons over 40 Most common cause for myelopathy in persons over 55 Male > Female
16 PATHOPHYSIOLOGY
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18 Cervical Spondylosis Hyper-mobility/ Instability of spinal segments Irritation/inflammation of heavily innervated vertebral body endplates Direct compression of cervical nerve root or spinal cord Repetitive trauma to cord or roots Ischemic change to the cord
19 X -Ray Cervical Spondylosis
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21 ACUTE HYPERFLEXION ROTATION (OR BOTH) Rupture of Disc annulus and PLL Nucleolus herniate into spinal cord Cord or Nerve Root compression
22 Cervical Spondylosis - Pathology
23 Cervical Spondylosis Spondylitic change with bone spur/disk complex formation Developmental narrowing of spinal canal with compression of spinal cord and nerve roots
24 Cervical Spondylosis Clinical Presentation Mechanical Pain Stiffness Muscle Spasm Pop and Crack Neurologic Nerve Root Compression Spinal Cord Compression
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26 Clinical Symptoms and Signs
27 Cervical Spondylosis Causes Cumulation of all these - Bumps, Fall, Injuries, Accidents, Bad posture, Sitting and looking down, Forward position, Incorrect sleep position Congenitally narrow vertebral canal Athletic person :Rugby, horse riding, soccer Genetic
28 Cervical Spondylosis- Presentation with Headache
29 Cervical Spondylosis 3 Clinical Syndromes: Axial neck pain Cervical Radiculopathy Cervical Myelopathy
30 Neck Pain
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33 Cervical Radiculopathy C 6 /C 7 most common Radicular pain: compression of inflamed or irritated nerve root Increase substance P in Dorsal nerve root Neurogenic pain mediator Mechanical deformation of the Dorsal nerve root cause reduction of blood flow to the sensory nerve cells bodies resulting in pain Local inflammatory mediators; examples TNFα causing pain
34 On Examination
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36 Shoulder Abduction Test for Radiculopathy
37 Autumn dry leaves Oil on canvas x 107 cm
38 CERVICAL SPONDYLOTIC MYELOPATHY
39 Definition CERVICAL SPONDYLOTIC MYELOPATHY is a neurological disorder caused by the narrowing of the spinal canal as a result of degenerative changes in the cervical spine. Symptoms and signs may be subtle in early manifestations Can be easily missed or incorrectly diagnosed as the natural process of ageing
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42 Subtle changes in balance or hand dexterity Cervical Spondylotic Myelopathy (CSM) Clumsiness or slowness with activities: Buttoning buttons Using keys Change in handwriting Difficulty with common tasks using computer keyboard Pushing buttons on a cellphone Texting Messages
43 Balance Problem Recent necessity to use handrail while negotiating stairs Paresthesia and weakness in upper limbs May have concomitant radicular signs & Symptoms Change in bowel or bladder dysfunction
44 Myelopathy Hand Test of hand dexterity - 15 seconds grip and release test Loss of Motor Strength Sensory Changes Wasting of the intrinsic muscles Spasticity
45 Myelopathy Hand Finger Escape Signs Ulnar two digits drift into abduction and flexion after the patient hold the hand in the extended position
46 Sensory Vibration in upper & lower limbs Hyper reflexia Abnormal long tract signs Hoffmans Babinski
47 Plain Xray C.Spine. AP + LAT views Narrowing of Disc Space Facet Joint Arthrosis Bone Spurs Cervical Spondylotic Myelopathy (CSM) - Evaluations Ossification of Post Longitudinal ligament (OPLL) Kyphotic Alignment PAVLOV Ratio For Stenosis Flexion Extension Views + Oblique Views
48 MRI Cervical Spine Disc Herniation Facet Joint Hypertrophy Folding of Ligamentum Flavum Cord Oedema/ Signal Changes Sagittal diameter of cord
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52 CT Scan C. Spine Presence of bone spurs Or any ossification of post longitudinal ligament (OPLL)
53 CT Scan Neck
54 Canal Stenosis Absolute Stenosis Sagittal Canal Diameter <10mm Critical Stenosis < 8mm Relative Stenosis < 13mm Normal diameter mm Genetic Variation
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56 Acute Hypertension
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58 PAVLOV RATIO = A / B STENOSIS IF <0.8
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60 Diagnosis of CSM History Physical Examination Imaging For each individual patient
61 Pathologic long tract signs :- Hoffman s Babinski Clonus Finger Escape L hermitte s Signs Hypereflexia On examination
62 CSM
63 CSM L hermitte s Signs Neck flexion causing electric shock sensation and paraesthesia radiating to the upper and lower extremities
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66 Natural History Several studies Mixed Course Not clearly defined Tendency to progress to more severe disease Quiescent period Slow stepwise decline Stable neurological dysfunction and a rapid decline
67 The natural history of is one of the stepwise progression. Early recognition and treatment is essential for optimum patient outcome before irreversible spinal cord damage.
68 Cervical Spondylotic Myelopathy Differential diagnosis Amyotrophic Lateral Sclerosis Multiple Sclerosis Carpal Tunnel Syndrome Syringomyelia Guillian Barre Syndrome Spino Cerebellar degeneration Traumatic myelopathy
69 Progression of Cervical Spondylosis to Cervical Spondylotic Myelopathy Several studies Highly variable and difficult to predict Relatively benign form to severe disease with neurological deficit
70 Brachialgia and Cord syndrome Syndromes seen in CSM patients Complete lesions: Transverse lesion syndrome Incomplete lesions: Motor system syndrome: Central cord syndrome: Brown-Sequard syndrome
71 Indication for Surgery Patient Age Baseline Function Rate of Deterioration Severity of Symptoms Overall Health and Morbidity
72 Indication for Surgery Ongoing Symptoms refractory to conservative treatment Progressive symptoms bowel and bladder dysfunction Overt weakness
73 Surgery To prevent further decline May not result in substantial spontaneous improvement Early surgery for patients with myelomalacia or severe radiographic stenosis Intramedullary high signal changes -> poor prognosis
74 Myelopathy V/S Radiculopathy Myelopathy : Any pathological condition of the spinal cord Upper motor neuron signs Motor weakness, positive Babinski sign, spasticity, hypereflexia, clonus Radiculopathy: Pathological condition of a spinal nerve root Lower motor neuron sign Motor weakness, Muscle fasciculation, Muscle atrophy, hyporeflexia
75 Prognosis Condition does not improve without surgery. It tends to be progressive and get worse in a stepwise detoriation with period of stable symtoms
76 Nurick Classification
77 Saggital CT reconstruction: Osteophyte present C3/4
78 NON-SURGICAL TREATMENT Usually steady deterioration Trail of non-surgical management indicated in non-acute patients Various modalities: - Medications - Immobilization - Physiotherapy - Traction - Manual therapies - Cervical exercises - Passive modalities - Occupational therapy - Recreational Therapy - Lifestyle changes - Other modalities
79 Controversial Indications Goals Approaches SURGICAL TREATMENT Anterior Posterior Combined
80 ISOLATED NECKPAIN IS NOT AN INDICATION FOR SURGERY
81 LORDOSIS EFFECTIVE KYPHOSIS STRAIGHT
82 ANTERIOR APPROACHES Anterior Cervical Discectomy without graft fusion Anterior Cervical Discectomy with graft fusion Anterior cervical Discectomy with graft fusion and plating Discectomy & Corpectomy with graft fusion +/- plating Interbody fusion with cages Oblique Corpectomy Prosthetics
83 POSTERIOR APPROACHES Laminectomy Hemi-Laminectomy Laminoplasty Keyhole Foraminotomy / Lamino-foraminotomy +/- posterior spinal fusion Posterior cervical stabilization: Spinous process wiring / Interfacet wiring / Facet wiring / Lateral Mass plates
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104 Peek Cages
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106 CORPECTOMY
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109 Corpectomy
110 Corpectomy Spinal Cord
111 Corpectomy & Prosthesis
112 Plating
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119 Foraminotomy
120 Disc Herniation With Nerve Root Compression
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122 Foraminotomy
123 Axial T2-weighted MRI
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126 LAMINOPLASTY Popular technique for the treatment of cervical myelopathy due to multilevel canal stenosis Many variations Open door cervical Expansile laminoplasty
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128 Expansile Laminoplasty
129 Summary Cervical Spondylosis and the progression to Cervical Spondylotic Myelopathy is highly variable and difficult to predict. 3 clinical syndromes of Cervical Spondylosis are: 1) Axial Neck Pain 2) Radiculopathy 3) Myelopathy It is important to diagnose Cervical Myelopathy early (50% improved surgery v/s 16% late surgery after 1 year)
130 Summary (cntd) Cervical Spondylosis Osteoarthritis of the neck Axial Neck Pain Cervical Radiculopathy Cervical Spondylotic Myelopathy Cold Compression Myelopathy Early Surgical Treatment
131 Signs Radiculopathy Spurling Sign Abduction Test Hyporeflexia LMN Myelopathy Hoffman Test Babinski Finger Escape L hermitte s Signs Hypereflexia Clonus UMN
132 Summary (Cntd) Cervical Myelopathy can present in 5 different syndromes. Investigations MRI is the investigation of choice, X-Rays C.Spine in flexion, extension for instability. CT Scan occasionally used for bone anatomy.
133 Diagnosis of CSM Be aware and suspect CSM History Examination MRI Diagnose early Refer early A Preventable Journey to a wheelchair bound-life
134 Good surgeons know how to get out of trouble Better surgeons know how to avoid it. Thank you
Daniel J. Blizzard, MD, MS
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