operative treatment of the cervical spine intervertebral disc
DESCRIPTION
Pathophysiology Natural History Clinical Evaluation Imaging Studies Conservative Treatment Surgical Indications Anterior surgical procedures Posterior surgical proceduresTRANSCRIPT
Operative treatment of the cervical spine intervertebral disc
GEORGE SAPKASASC. PROFESSOR
1st Orthopaedic DepartmentMedical School-Athens University
Cervical Spine:Cervical Spine:Neck pain, RadiculopathyNeck pain, Radiculopathy
Neck pain, RadiculopathyNeck pain, Radiculopathy
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
Disc degeneration Disc degeneration
Neck pain Neck pain
MyofascialMyofascialPosture, ergonomics, chronic muscle Posture, ergonomics, chronic muscle fatiguefatigueMechanoreceptors, chemonociceptorsMechanoreceptors, chemonociceptorsBradykinin, Serotonin, KBradykinin, Serotonin, K++, CGRP, CGRP
DiscogenicDiscogenicReliable patterns with disc stimulationReliable patterns with disc stimulation
Facet jointFacet jointProvocative facet injections – pain Provocative facet injections – pain patternspatterns
HeadachesHeadachesGreater occipital nerveGreater occipital nerveSinuvertebral nervesSinuvertebral nerves
Radiculopathy Radiculopathy - Mechanical factors- Mechanical factors
Susceptible 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 Capillaries fenestrated – greater edemaedema
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)
Clinical evaluationClinical evaluation
Neck painNeck painDetermine 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
Chemical mediators of spinal Chemical mediators of spinal painpain
NeurogenicNeurogenicSubstance PSubstance P
SomatostatinSomatostatin
Cholecystokininlike Cholecystokininlike subsctancesubsctance
Vasoactive inerstinal peptideVasoactive inerstinal peptide
Gastrin releasing peptideGastrin releasing peptide
Dynorphin Dynorphin
EnkephalinEnkephalin
GelaninGelanin
neurotensinneurotensin
Angiotensin IIAngiotensin II
Non – neurogenicNon – neurogenicBradykininBradykinin
SerotoninSerotonin
HistamineHistamine
AcetylocholineAcetylocholine
PGE 1 PGE 1
PGE 2PGE 2
LeukotrienesLeukotrienes
diHETEdiHETE
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 False positive imaging studies in asymptomatic studies in asymptomatic patientspatients
25% incidence of degenerative 25% incidence of degenerative changes on plain radiography changes on plain radiography by 5by 5thth decade decade75% incidence by 775% incidence by 7 thth decade decadeNo significant differences on No significant differences on plain film between plain film between symptomatic and symptomatic and asymptomatic patients asymptomatic patients
Cont…
Plain radiographyPlain radiographyA minimum 4 - week period of A minimum 4 - week period of conservative treatment is conservative treatment is recommended prior to plain x-recommended prior to plain x-rays with exception of:rays with exception of:
– TraumaTrauma– Suspicion of neoplasmSuspicion of neoplasm– Worsening neurologic deficitWorsening neurologic deficit
Routine cervical spine plain Routine cervical spine plain radiography includes:radiography includes:
– Anterior – posteriorAnterior – posterior– Lateral Lateral – obliqueoblique
Cont…
Flexion and extension views can be Flexion and extension views can be added to evaluate the dynamic added to evaluate the dynamic properties of the cervical spineproperties of the cervical spinePlain radiogrpaphy can demonstrate:Plain radiogrpaphy 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 Vacuum phenomenon and disk space height losslossReactive sclerosis of the endplatesReactive sclerosis of the endplatesSchmorl´s nodes Schmorl´s nodes
C T scanC T scan
M.R.IM.R.I
Progressive neurologic deficitProgressive neurologic deficit
Disabling weakness Disabling weakness
Long tract signsLong tract signs
Cervical radiculopathy with Cervical radiculopathy with failure to improve following 6 – 8 failure to improve following 6 – 8 weeks of conservative weeks of conservative measures measures
Vertebral body destruction or Vertebral body destruction or instability detected on plain film instability detected on plain film
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
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…
MedicationsMedications to address symptoms to address symptoms versus treatment of underlying pathology versus treatment of underlying pathology
– Cosrticosteroids and NSAIDS effective in reducing inflammation and Cosrticosteroids and NSAIDS effective in reducing inflammation and painpain
Acutely 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 modalities– dynamic modalities
– Isometric strengthening exercisesIsometric strengthening exercises–Neck and shoulder stretchingNeck and shoulder stretching–Aerobic conditioning Aerobic conditioning
Cont…
Spinal manipulationSpinal 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…
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 painSurgical indicationsSurgical indications
Intractable 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
Anterior decompression and fusion (bone graft)
Discectomy & stabilization(cage and plate)
Discectomies & stabilization(Expandable cages and plate)
Disc excision – artificial discDisc excision – artificial disc
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
Post-laminectomy instabilityswan-neck deformity
Conclusions Conclusions
TreatmentTreatment
ConservativeConservative Operative Operative
Neck painNeck pain MainlyMainly Rarely Rarely
RadiculopathyRadiculopathy OftenOften OftenOften