(2)
Department of Orthopedics, Front Range Orthopedic Center, 1551 Professional Ln Suite 200, Longmont, CO 80501, USA
Take-Home Message
Degenerative Cascade
Degenerative disc changes and facet arthrosis
Can lead to stenosis
Changes of aging vs. pathologic change
Definition
Disc degeneration and facet arthropathy leading to a variety of changes which can cause axial and radicular pain can cause neurologic changes
Etiology
Age related
Motion and wear and tear over time
Injuries
Smoking
Occupation
Genetic
Pathophysiology
Degenerative cascade
DDD with instability, micro or macro
Annular tearing
Facet degeneration leading to stenosis
Radiographs
X-rays: Disc narrowing, endplate sclerosis, marginal osteophytes, uncal hypertrophy, and foraminal narrowing seen on obliques, subluxation
CT: Defines bony anatomy but not good at seeing stenosis unless done with myelography
MRI: Disc desiccation, foraminal stenosis, central stenosis, disc herniation
Discography controversial
Classification
Subjective
Mild, moderate, severe
Treatment
Natural history favorable
Nonoperative
Physical therapy
Chiropractic care
Massage
NSAIDs
Relative rest
Operative – depends on pathoanatomy
Decompression
Fusion
Instrumentation
Complications
DVT: PE
Infection
Neurologic injury
Covered in other sections
Bibliography
1.
Kelly JC, Groarke PJ, Butler JS, Poynton AR, O’Byrne JM. The natural history and clinical syndromes of degenerative cervical spondylosis. Adv Orthop. 2012;2012:393642.
2 Cervical Disc Herniation
Samuel E. Smith3
(3)
Department of Orthopedics, Front Range Orthopedic Center, 1551 Professional Ln Suite 200, Longmont, CO 80501, USA
Take-Home Message
Typically causes radiculopathy with nerve compression in the foramen, i.e., C6 nerve root in the C5/C6 foramen
Central herniations can cause spinal cord compression and myelopathy
Herniations with axial pain only do not do well with surgery
Definition
Disruption of the annulus fibrosis of the intervertebral disc leading to displacement of the nucleus pulposus away from the center of the disc
Etiology
Degenerative cascade
Microtrauma leading to annular tearing
Genetic predisposition
Pathophysiology
Annular tearing as a repetitive phenomenon
Tears coalesce into a larger annular fissure
Nucleus displaces from the center of the disc into the canal or foramen or both
Most commonly cause radiculopathy but can cause myelopathy
Radiographs
Sometimes normal
Degenerative disc space narrowing sometimes seen
CT does not show herniation in the cervical spine well
MRI “gold standard” for diagnosis
Myelogram/CT for when MRI not possible
Classification
No accepted classification
Treatment
Natural history of cervical radiculopathy is favorable
Nonoperative
Bracing
Traction: Controversial as to whether it helps or not
Manipulation
Medication
PT
Spinal injections
Operative
Anterior cervical discectomy with or without fusion. Most favor fusion to prevent collapse of disc into kyphosis
Fixation vs. stand-alone graft
Plates or interlocking cages
Disc arthroplasty
Posterior foraminotomy avoids fusion and results can be comparable to ACD/ACF and is amenable to less invasive approach
Complications
Dysphagia
Aspiration
Esophageal injury
Injury to recurrent laryngeal nerve-latest information suggests equal risk from right or left sided approach, review the anatomy as it relates to the aortic arch for the RLN
Dural tear
Infection
DVT/PE
Bibliography
1.
Lees F, Turner JW. Natural history and prognosis of cervical spondylosis. Br Med J. 1963;2(5373):1607–10.
2.
Rhee JM, Yoon T, Riew KD. Cervical radiculopathy. J Am Acad Orthop Surg. 2007;15(8):486–94.
3 Cervical Spinal Stenosis
Samuel E. Smith4
(4)
Department of Orthopedics, Front Range Orthopedic Center, 1551 Professional Ln Suite 200, Longmont, CO 80501, USA
Take-Home Message
Can be congenital, developmental with degenerative disease, or associated with OPLL
Most common source degenerative osteophytes from margins of disc, facet hypertrophy, and degenerative hypertrophy of the uncovertebral “joint”
Vertebral subluxation a potential factor
Can cause radiculopathy, myelopathy, or both
Definition
Decreased space for the spinal cord and exiting nerve roots of the cervical spine from a variety of causes
Congenital stenosis defined by Torg ratio or a sagittal diameter of less than 10 mm
Not everyone with stenosis has symptoms
Etiology
Degenerative marginal osteophytes and hypertrophy of the abovementioned structures decrease the space available for the cord and nerve roots
Congenital stenosis can have superimposed degenerative stenosis
Familial tendency
Smoking
Occupational factors
OPLL ethnic and genetic factors
Pathophysiology
Degenerative cascade of Kirkaldy-Willis
OPLL dealt with separately
Can lead to spinal cord compromise and signs of myelopathy (Hoffman’s, clonus, poor tandem walking, hyperactive reflexes, incoordination)
Radiculopathy (Spurling’s)
Radiographs
X-rays: May show osteophytes, deformity, subluxation, and congenital stenosis
MRI good with canal dimensions and direct visualization of cord and nerve roots
Detects signal change in cord
Defines operative anatomy, limited diagnostically but very useful if used with myelography
Treatment
Nonoperative
Physical therapy
Chiropractic care
NSAIDs
Opioid therapy for only brief periods
Operative
Approach depends on specific pathoanatomic problemsRelated posts:
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