Baghdad College of Medicine / 5
th
grade
Student’s Name :
Dr. Muneer K. Faraj
Lec. 1
Cervical Spondylosis
Wed. 19 / 10 / 2016
DONE BY : Ali Kareem
مكتب اشور لالستنساخ
2016 – 2017
Cervical Spondylosis Dr. Muneer
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©Ali Kareem 2016-2017
CERVICAL SPONDYLOSIS
Definition
o Degenerative alterations of the cervical spine
Pathogenesis
o
It is an aging process (“wear and tear”, degeneration) which may be
accelerated due to trauma or disease e.g. Rheumatoid arthritis.
o It represents a mixed group of pathologies involving the intervertebral discs,
vertebrae, and/or associated joints.
o The disc height decreases leading to disc bulging.
o Micro instability results in reactive hyperostosis with formation of
osteophytes at the vertebral endplates which can penetrate into the spinal
canal and compromise the spinal cord and nerve roots.
o Osteophytes of the uncovertebral and facet joints reduce the mobility of the
segment.
o Segmental instability leads to a hypertrophy of the yellow ligament and
causes a narrowing of the spinal canal and foramen
o Cervical Kyphosis may occur in late stages
Cervical Spondylosis Dr. Muneer
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©Ali Kareem 2016-2017
Epidemiology
o The prevalence of neck pain ranges between 17%and 34%in a general
population.
o Cervical Spondylosis mainly affects individuals in the 4th and 5th decades
of life .
Clinical Features : HISTORY
A. The spondylotic syndrome
o The pain arises from the motion of the degenerated segment accentuated by
movement and during specific positions (e.g. reading, computer work,
driving).
o Pain during the night may indicate severe facet joint osteoarthritis
o Pain is often associated with non-dermatomal shoulder girdle pain.
o Patients often report vague numbness, thermal sensations, and tingling.
o vertigo and dizziness are not uncommon but their causes are not well
explored
o Headaches are frequent concomitant symptom.
B. Radicular Syndrome:
o radicular pain, i.e. pain following a dermatomal distribution. The sensory,
motor and reflex deficits are dependent on the affected nerve root.
o It is important to note that the pain not only radiates into the skin
(dermatome) but also into the muscles (myotomes) and bone (sclerotomes
C. Myelopathic Syndrome:
o can begin very subtly. The leading symptoms are numbness, clumsy,
painful hands with disturbed fine motor skills (particularly writing skills).
o Later they presents with long tract signs, gait disturbance and sphincter
disorders
Cervical Spondylosis Dr. Muneer
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Clinical Features : SIGNS
In patients with spondylotic syndrome, findings are:
o stiff neck with limited range of cervical motion
o neck pain on extension and rotation
o referred pain on motion (occiput, shoulder, upper limb)
o chronic trapezius myalgia
In patients with radiculopathy, frequent findings are :
o sensory deficit
o motor deficit
o reflex deficits
o positive Spurling test or neck compression test which is performed with the
patient in the sitting position. The neck is extended and rotated to the side of
the pain. Then, a careful axial compression of the head is applied; if positive,
the patient reports pain radiating along the compromised nerve root
In patients with cervical myelopathy, frequent findings are:
o atrophy of the interosseous muscles
o muscle weakness
o spasticity, hyperreflexia, and clonus
o pathologic reflexes, positive Babinski sign
o sensory and vibratory deficits
o gait disturbances (broad, abrupt and jerky)
Investigations
o Plain Cervical spine X- Ray:
o sagittal profile (e.g. loss of lordosis, kyphosis)
o sagittal spinal canal diameter (<10mm at risk of developing Cervical
myelopathy .
o spinal alignment and bony relationship (e.g. spondylolisthesis)
o disc space narrowing
o bony vertebral structures (vertebral collapse, osteophytes)
o facet joint osteoarthritis
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o Narrow intervertebral foramen on oblique views
o MRI: will shows detailed disc and neuronal element changes.
o CT- Scan: will shows bony pathologies
Neurophysiological studies (EMG, NCS) : Helpful in differentiating
radiculopathy from peripheral neuropathy. They allow the recognition of
subclinical myelopathy
Differential Diagnosis
o nerve entrapment syndromes
o shoulder girdle disorders (rotator cuff tears, impingement syndrome,
tendinitis)
o acute brachial plexopathy ,brachial plexitis/neuritis (e.g. herpes zoster)
o thoracic outlet syndrome
o amyotrophic lateral sclerosis
o tumors (e.g. Pancoast tumors)
o coronary heart disease
Treatment
General objectives of treatment:
o relieve pain
o prevent neurological deterioration
o improve functional limitations
o reverse or improve neurological deficits
Oral Medications
Drug treatment for neck pain disorders consists of:
analgesics
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NSAIDs
muscle relaxants
psychotropic drugs
Cervical Collar
The treatment effect of cervical collars is unproven in acute neck pain.
Manipulative therapy particularly, traction has been reported to result in short-
term relief of radiculopathy
Surgical Therapy : Indications
o progressive, functionally important motor deficit
o persistent pain despite non-surgical treatment for at least 6 weeks
o progressive myelopathy despite non-operative care
o progressive kyphosis with neurological deficits
The goal of Cervical Spondylotic myelopathy treatment primarily is to arrest
progression
Anterior Cervical Approach is indicated :
1- Cervical disc lesion
2- predominant anterior compression elements
3- Cervical myelopathy with kyphosis
Types :
1- Anterior cervical discectomy and fusion: remains the gold standard for
Cervical Spondylotic Radiculopathy
2- Anterior cervical corpectomy with fusion
Cervical Spondylosis Dr. Muneer
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Posterior cervical approach is indicated:
1- multilevel cervical myelopathy
2- predominant posterior neural compression
3- cervical myelopathy with preserved cervical lordosis
Types:
1- Laminectomy
2- Foramenotomy
3- laminoplasty:
Postoperative complications
o cerebrospinal fluid leak (0.2–0.5%)
o recurrent laryngeal nerve injury (0.8–3.1%)
o dysphagia (0.02–9.5%)
o Horner’s syndrome (0.02–1.1)
o cervical nerve root injury (0.2–3.3%)
o hematoma (0.2–5.6%)
o Tetra paresis (0.4%)
o death (0.1–0.8%)
o infection (0.1–1.4%)
o esophageal perforations (0.2–0.3%)
o non-union (dependent on technique)
o graft dislodgement/collapse (dépendent on technique , instrumentation
failure (dependent on technique
#END of this Lecture …