Operative treatment of the cervical spine intervertebral disc

Operative treatment of the cervical spine intervertebral disc

GEORGE SAPKASASC. PROFESSOR

1st Orthopaedic DepartmentMedical School-Athens University

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 (Rothman & Rashbaum et al, 1978)al, 1978)

Neck pain – RadiculopathyNeck pain – Radiculopathy

43% complete resolution43% complete resolution

25% mild residual pain25% mild residual pain

32% moderate or severe pain32% moderate or severe pain

Radicular symptoms – less Radicular symptoms – less favourablefavourable

Treatment did not influence Treatment did not influence outcomeoutcome

(Gore et al. Spine (Gore et al. Spine 1987)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 7thth 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 Flexion and extension views can be added to evaluate the dynamic be added to evaluate the dynamic properties of the cervical spineproperties of the cervical spinePlain radiogrpaphy can Plain radiogrpaphy can demonstrate:demonstrate:

Congenital stenosisCongenital stenosisSpondylotic segmentsSpondylotic segmentsForaminal narrowingForaminal narrowingDegenerative subluxationDegenerative subluxationCongenital malformation Congenital malformation Autofused spinal segmentsAutofused spinal segmentsOsteochondrosis of the nucleous Osteochondrosis of the nucleous puplosuspuplosusSpondylosis of the annulus fibrosis Spondylosis of the annulus fibrosis Vacuum phenomenon and disk space Vacuum phenomenon and disk space height lossheight lossReactive 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 painGore et al, Spine Gore et al, Spine

19871987 Cont…

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 modalitiesdynamic 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)Anterior decompression and fusion (bone graft)

Discectomy & stabilization(cage and plate)

Discectomies & stabilization(Expandable cages 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

Post-laminectomy instabilityswan-neck deformity

Conclusions Conclusions

TreatmentTreatment

ConservativeConservative Operative Operative

Neck painNeck pain MainlyMainly Rarely Rarely

RadiculopathyRadiculopathy OftenOften OftenOften