1. 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

2. 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

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

4. 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

5. 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

6. 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…

7. 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

8. 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

9. 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….

10. 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

11. 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.

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

28. 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!