Spine and Orthopaedic Institute St Vincent Medical Group Neck and Arm Pain: The Result of Long-Standing Wear and Tear on the Cervical Spine Robert F. McLain, M.D. Staff Surgeon Spine and Orthopaedic Institute St Vincent Medical Group

Common Spinal Disorders There are lots of different spinal disorders that may affect the cervical spine, but doctors typically think of the most common as falling into these categories: Degeneration Trauma Deformity Tumor and Infection

Common Degenerative Conditions Herniated Nucleus Pulposus (HNP) Cervical Stenosis (narrowing of the spinal canal) Cervical Spondylosis (arthritis) Disc Degeneration Facet Arthritis Discogenic Pain

Introduction: Cervical Spondylosis causes changes in disc, spinal canal, and the vertebra. The biological cause is much the same as in lumbar disc disease As we age, chemical components of the disc change, resulting in a loss of water-holding capacity, and a progressive loss of elasticity and compressive strength of the disc

The Problem: As the cervical disc degenerates: End-plates become overloaded and sclerotic Segmental motion increases, becomes irregular and asynchronous Ligaments become strained, inflamed, painful Disc height is lost, spurs form, and alignment shifts

The Problem: Cervical Spondylosis: Disc space collapse and kyphosis Osteophyte formation at facets and disc space Disc herniation Mechanical instability and deformity All can contribute to cord and root compression…

Presenting Symptoms: Cervical DDD - symptoms include Axial neck pain - neck stiffness, pain, headache; Referred pain - symptoms over the trapezius, rhomboids, and scapulae Radicular pain - pain in the spinal nerve distribution Myelopathy - poor motor control, weakness, spasticity – this is due to spinal cord compression, and needs to be evaluated urgently

Myelopathy: Myelopathy may be due to mid-central herniation, severe cervical spondylosis, congenital or acquired cervical stenosis Pain is less prominent; Poor motor control, weakness, and spasticity are more alarming complaints May have root symptoms at level of compression and long tract signs below that level

X-rays Plain radiographs demo disc space collapse, spur formation, spondylolisthesis, and loss of the normal cervical lordosis Obliques show spurs in the neural foramenae Flexion / extension views show abnormal motion Computed tomography shows bony architecture best….

MRI: MRI gives best view of all soft tissues involved Will sometimes reveal a disc herniation at a level other than the obviously degenerated one seen on plain radiographs and CT Think of MRI as a preoperative study

Surgical Treatment: Discectomy Treatment of cervical disc herniation, with nerve root compression or cord compression, or of disc degeneration and neck pain all involve an anterior surgical approach. A transverse (side to side) incision in the skin allows the surgeon to mobilize the vital structures underneath, and reach the spine with little actual cutting.

Surgical Treatment: Discectomy Single level disease, or two level compression limited to the disc-spaces Central spurs don't need to be removed, but can be if disc-space is open Foraminal osteophytes can be removed to decompress root Microscope improves vision and safety

Surgical Treatment: Discectomy Adjacent level disc herniation or spondylosis: When motor deficits are present, or symptoms do not improve, discectomy is indicated Two-level anterior discectomy Corpectomy and fusion

Discectomy with Fusion: Anterior interbody fusion - Auto- or allograft spacer placed between endplates restores disc hieght and alignment, stops painful motion Remove disc without manipulating cord Prepare and contour endplates Impact graft into place, filling the space and restoring height Soft-tissue tension-band

Discectomy with Fusion: Anterior interbody fusion - ACDF Remove painful disc and decompress nerve roots and cord Place properly sized graft between endplates Impact graft into place, filling the space and restoring height Apply plate to restore tension-band

Surgical Treatment: Corpectomy For multilevel compression When adjacent discs are collapsed and difficult to enter Compression extends beyond the disc-space, behind the vertebral body Central stenosis relieved Uncovertebral joints decompressed as well

Corpectomy and Fusion: Strut How best to fill the segmental gap? Allograft Strut Restores foraminal height, segmental alignment Immobilizes the painful segment, and Provides permanent stability Autograft fibula - fusion rates are high and morbidity low. Titanium mesh cages

Corpectomy Reconstruction: Anterior corpectomy and strut graft reconstruction - Complete corpectomy Meticulous decompression and foraminotomy Remove PLL and fibrous membrane to complete decompression Strut graft augmented with autograft from corpectomy

Reconstruction Multisegmental reconstructions – Graft provides axial stability Something else must restore torsional and translational stability Tension band needed to provide stability in extension.

Corpectomy - Plating Multi-level reconstructions – vertebrectomy or multiple discectomies – create instability Plating Maintains correction, combats deforming forces Improves fusion rate Allows mobility without graft displacement

360 Fusion Why go front and back? Improved fixation in Improved fusion Poor bone Severe instability Movement disorders Severe deformities Improved fusion Anterior and Posterior decompression

360 Fusion Combined decompression and instrumented fusion 56 y.o. executive Loss of manual dexterity Loss of balance Shuffling gait Diffuse motor sensory loss BilatUE’s Progressive myelopathy Neck Pain

Conclusions: Patient selection is crucial: Before offering surgery: Imaging studies must identify the treatable lesion Findings must correlate with clinical symptoms Appropriate conservative measures must have been given a good try before they were considered to have failed

Conclusions: Decompression: Most patients with acute radiculopathy (arm pain) will improve with nonoperative measures Pain can be intense early on – analgesics (pain killers) are often needed Weakness of arms or legs, failure to improve with time and therapy, progression of symptoms: these warrant surgical consideration

Conclusions: Decompression and Fusion: When root compression is an isolated problem, consider decompression alone When degeneration is severe, fusion is necessary to relieve axial neck pain as well as radiculopathy When multiple levels are involved consider vertebrectomy

Conclusions: We Consider Plating to: Immediately mobilize the patients who need to stay active Completely protect the patients might not follow all the rules Immobilize multiple segments and spines with three column instability Improve fusion rates when more than one level is involved

Conclusions: 360 degree fusion: When decompression is needed front and back When the corrected deformity is severe In long anterior decompressions, revision surgery, or marginal fixation Patients with movement disorders, post-laminectomy kyphosis

Conclusions: With careful planning and surgical technique we can meet our goals: Protect the neural elements Stabilize the spine Get our patients back to appropriate function ASAP!