Cervical Spondylosis Cervical disc Cervical Spondylotic myelopathy Anatomy

Cervical Spondylosis Cervical disc Cervical Spondylotic myelopathy

Anatomy Of The Cervical Spine Adult cervical spine dimensions have considerable variation. Normal size: ü Antero-posterior (at C 5): 14 mm minimum ü Width: 25 mm (average) ü Spinal cord: AP 8 mm /width 13 mm at C 5 (Remainder of the canal is occupied by dura, CSF , epidural fat and veins. ) Normal cervical disc: ü Formed of nucleus bulposes and anulus fibrosus. ü 88% water in infancy, 65% in elderly. ü Height 45% of vertebral body.

Anatomy Of The Cervical Spine

Cervical Spondylosis (definition) A non specific chronic degenerative condition affecting the cervical spine components (vertebrae, discs, ligaments, joints, blood vessels, nerve roots and spinal cord) which may result in deformity , instability, myelopathy and radiculopathy.

(Cervical disc disease (definition Rupture of fibrocartilagenous material (annulus fibrosis) that surrounds the intervertebral disk. This rupture involves the release of the disk's center portion containing a gelatinous substance called the nucleus pulposus. Pressure from the vertebrae above and below may cause the nucleus pulposus to be forced outward, placing pressure on a spinal nerve and causing considerable pain and damage to the nerve (compression of the cord or root)

Cervical Spondylosis (incidence) Radiographic evidence in 20 -25% of population by the age of 50 y and 70% by the age of 65 y Cervical spondylotic myelopathy is the commonest cause of acquired spstic paraparesis in middle and old age. Starts earlier in men than women C 5/6 &C 6/7 levels are commonest to be involved C 5&C 6 roots are comonly affected.

Cervical Spondylosis (pathology) Vertebrae: § Marginal osteophytes: ü Anterior (may lead to dysphagia if extensive) ü Posterior &lateral (leads to Neural foraminal encroachment and canal stenosis. § Spontaneous fusion: between osteophytes and adjacent vertebrae.

Cervical Spondylosis (pathology)

Cervical disc (pathology) • Discs: üDehydration. üFragmentation. üLoss of disc height. üDisc herniation. bulging, protrusion or extrusion

Cervical disc (pathology)

Cervical disc (pathology)

Cervical Spondylosis (pathology) • Ligaments: üThickening üOssification üBuckling ? üRupture.

Cervical Spondylosis (pathology)

Cervical Spondylosis (pathology)

Cervical Spondylosis (pathology) • Joints: üReduced mobility üHypertrophy üSublaxation. üInflamation.

Cervical Spondylosis (pathology)

Cervical Spondylosis (pathology) • Neural foramina üNarrowing. üRoot compression. üRoot ischemia. üRadicular artery and vein compression

Cervical Spondylosis (pathology) • Spinal cord: üThecal indentation. üCord compression üischemia / edema / infarction üGliosis. üSyrinx.

Clinical presentation • History : üThe course may be slowly progressive , the patient may be asymptomatic or has mild neck pain. üAcute on top of chronic deterioration may occurs , and may be predisposed by trauma.

Clinical (cont. ) • Presentation: ü Muscloskeletal : Ø Pain (neck pain, occipital pain, headache, shoulder pain). Ø Diminished cervical range of motion. Ø Dysphagia. ü Radiculopathy : (in upper limbs) Ø Sensory : ( with dermatoms) Radicular pain (brachialgia) Parathesia. Ø Motor: Weakness Atrophy ü Myelopathy : (in upper and lower limbs) Ø weakness Ø Spasticity and gait disturbance. Ø Impaired fine motor movements. Ø Sphincter dysfunction and impotence.

Clinical (cont. )

Clinical (cont. ) • Examination: ü Local: Ø Decreased range of motion especially with neck extension Ø L’hermitte sign. ü Neurological : Ø Motor: - Spastic quadriparisis or paraparisis (below the level of compression) - Weakness taking myotomal distribution (according to level of compression) Ø Reflexes: - Hyper-reflexia , clonus (below the level). - Pathological reflexes (hoffman sign, pectoralis reflex, adductor reflex, babiniski reflex) - Hypo-reflexia (at the level) Ø Sensory: Hypothesia with dermatomal distribution or with sensory level

• Differential diagnosis

Correlation between radiological and clinical findings is mandatory.

Imaging • PXR

Imaging • CT Scan

Imaging • CT Scan reconstruction

Imaging • MRI

Imaging

Management • Conservative management: ü For relief of symptoms ØBed rest, neck massage, heat application, analgesics, anti-inflamatory medications, muscle relaxants. ØNeck immobilization (neck collar). ØPhysiotherapy ? ü Minor neurological deficit can also be treated. ü Frequent monitoring is required. • Surgical management.

Management Surgical management • Indications: ü ü Intractable pain due to identified cause. Progressive neurologic deficite. Root compression clinicaly correlated to radiological finding. Instability • Aim of surgery ü Relieve pain and neuronal compression. ü Achieve stability. • Choice of procedure ü Depends upon findings on imaging ü Level of disease process. ü Extent of pathological changes.

Management • Surgical procedures ü Posterior approaches: Ø Laminectomy. Ø Posterior foraminotomy. Ø Laminoplasty. Ø With or without fixation with plate and screws. NB. Posterior approaches for posterior pathology. ü Anterior approaches: Ø Anterior cervical discectomy/osteophytectomy and fusion. Ø Corpectomy with fusion and fixation. Ø Anterior foraminotomy. Ø Cervical arthroplasty. (artificial disc and dynamic implants) ü Percutaneous facet injection or radiofrequency.

Management

Management

Management

Take home messages • Correlation • Diffrenttial • Different approaches acc to path