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156
14 Dege nerative Cervical Spine Disorders
3. Physical exam ndings:
a. Hyperre exia.
b. Positive Ho man’s sign: pressing the dorsal surface of the middle nger
elicits a re ex contraction of the thumb and index ngers.
c. Inverted brachioradialis re ex: brachioradialis tendon tap elicits a re ex
exion of the ngers.
d. Positive Babinski’s sign: lateral stimulation of the plantar surface of the
foot elicit s toe exte n sion .
e. Positive Lhermitte’s sign: tapping the posterior neck in neck exion
elicits paresthesia down the back and into the extrem ities.
f. Myelopat h ic h an d syn d rom e:
(1) Thenar atrophy.
(2) Positive nger escape sign: the patient cannot keep the fourth and
fth digit of the hand in extension.
(3) Positive grip release test: patient has trouble making a st and fully
extending ngers—normal is 20 times in 10 seconds.
(4) Dysdiadochokinesia: loss of coordination and dexterity of the hands
during rapid movement.
III. Diagn o st ic im agin g (Fig. 14.2 an d Fig. 14.3).
A. Pla in r a d io g r a p h s .
1. Anteroposterior, lateral, and oblique views.
a. Overall alignment:
(1) Patients with spondylosis may have a loss of lordosis or a
spondylolisthesis.
Fi g . 1 4 . 2 Sch em at ic o f an a xia l cu t thro u g h t h e ce rvica l spin e . The sha d e d are a in se c t ion I re pre s e n t s
the lamina that is removed in a laminectomy. Section II represents the bone removed to perform a
thorough foraminotomy.
14 Dege nerative Ce rvical Spine Disorders 157
Fi g . 1 4 . 3 Cro ss-se ct io n al vie w o f a ce rvica l ve r t eb ra . Th e n e u ro fo ra m e n is d ivid e d in t o t hre e a re as:
the medial zone, the middle zone, and the lateral zone.
b. Narrowing of the intervertebral disk space.
c. Degenerative changes in the zygapophyseal joints and the presence of
osteophytes.
d. Foraminal narrowing is observed on the oblique views (Fig. 14.4).
B. Co m p u te d t o m o g ra p hy w it h m ye lo gr a p hy.
1. Modality of choice for those who cannot undergo magnetic resonance
im aging (MRI).
2. Good for postoperative imaging if instrumentation present.
3. Invasive procedure that involves intradural injection of radiopaque dye.
C. M RI (Fig. 14.5).
1. Imaging modality of choice for cervical disk disease.
2. Good for evaluating space available for the cord:
a. Less than 13 mm is relative stenosis.
3. Particularly useful to rule out spinal cord lesions, such as syringomyelia,
tumors, and myelomalacia.
4. Correlation with clinical symptoms is critical, because the false-positive rate
is high.
158
14 Dege nerative Cervical Spine Disorders
Fi g . 1 4 . 4 An o b l iq u e c e r v ic a l s p i n e
radiograph demonstrating neuroforamina l st e nosis se co n dar y t o oste o p hyt e
form at ion a t the u n cin at e proce sse s.
IV. Di eren t ia l d iagn osis (Table 14.2).
V. Tr e a t m e n t f o r c e r v i c a l r a d i c u l o p a t h y .
A. Co n se r va t ive t r e at m e n t : a 7 0 t o 8 0 % s u ccessfu l ou t co m e is e xp e ct e d w it h 2 t o 3
months of conservative treatment.
1. Acute phase ( rst 2 weeks).
a. Nonsteroidal anti-in ammatory medications.
b. Oral steroids.
c. Short-term analgesics (limited use of narcotics).
d. Ice or heat application.
e. Activity modi cation.
(1) Soft collar.
(2) Home traction.
2. Intermediate healing phase (3–4 weeks).
a. Stretching and isometric exercises.
b. Physical therapy:
(1) Modalities if the patient is not improving.
c. Epidural steroids may be considered for persistent radicular pain.
3. Rehabilitation phase (> 4 weeks).
a. Cardiovascular conditioning.
b. Vigorous strengthening exercise program.
B. Op e r at ive in d ic at io n s:
1. Progressive signs of root or cord dysfunction.
2. Failure of conservative treatment in relieving radicular pain or neurological
de cits.
14 Dege nerative Ce rvical Spine Disorders 159
ab
Fi g . 1 4 . 5 ( a – c ) Sa g it tal m ag n et ic re so -
nance imaging of the cervical spine. (From
Uh le nb ro ck D. MR Im a g ing o f t h e Sp ine
and Spinal Cord. Stuttgart, Germany: Georg
Th ie m e Ve rla g ; 2 00 4: Fig . 4 .7 0. Re pro du ce d
c
with permission.)
3. Axial pain without radiculopathy should be treated conservatively as long as
possible, because surgical results are less predictable.
VI. Su rgica l t e ch n iq u es .
A. An t e r io r ce r vica l su r ge r y.
1. Indications.
a. Central soft disk herniation.
b. Bilateral radiculopathy at the same level.
c. Unilateral soft disk or foram inal stenosis.
(1) Anterior approach is preferred in patients with signi cant neck pain
in addition to radiculopathy.
d. One- or two-level spondylotic myelopathy.
e. Kyphotic sagittal alignment.
160
14 Dege nerative Cervical Spine Disorders
Ta b l e 1 4 . 2 Di e rent ial diag n o sis of cervical sp in e patho log y
Pat h o lo g y Di erential
Tr a u m a – C e r v i c a l s p r a i n
– Traumatic neuritis (brachial plexus)
– Posttraumatic instability
Tu m o r – S u p e r i o r s u l c u s ( P a n c o a s t ) t u m o r w i t h C 8 r a d i c u l o p a t h y a n d
Horner’s syndrom e
– Spinal cord tumors
– Metastatic disease
– Primary bone tumors
In a m m a t o ry
conditions
– Rheumatoid arthritis
– Ankylosing spondylitis
In fe ct io n s – Diskit is
– Osteomyelitis
– Soft tissue abscess
– Shoulder disorders
– Rotator cu tears
– Impingement syndrome
Neuro lo gical
conditions
– Demyelinating disease (Guillain–Barré syndrome)
– Amyotrophic lateral sclerosis
Others – Thoracic outlet syndrome
– Re ex sympathetic dystrophy
– Angina pectoris
– Peripheral nerve entrapments
– Multiple sclerosis
– Acute brachial neuritis (Parsonage–Turner syndrome)
2. Anterior cervical diskectomy and fusion (ACDF).
a. Allograft with local autograft may be used for fusion with
instrum entation.
(1) No iliac crest graft site morbidity.
(2) Recom binant hum an bone morphogenetic protein-2 (rhBMP-2) was
used o label as an allograft to adjunct arthrodesis in the anterior
cervical spine.
(a) In 2007, the Food and Drug Adm inistration (FDA) issued public
health noti cations regarding the risk of dysphagia and severe,
sometimes fatal, soft tissue swelling causing airway compromise
with the use of rhBMP-2 in the setting of an ACDF.
(b) Subsequ ently, the rate of rhBMP-2 use in the an terior cer vical
spine has declined substantially.
14 Dege nerative Ce rvical Spine Disorders 161
b. Interbody cage devices:
(1) Can hold graft materials.
(2) Provide structural stability.
(3) Maintain foram inal height.
(4) Titanium and carbon ber cages were popularized.
(a) These metallic cages had a greater modulus of elasticity than
bone, resulting in cage subsidence.
(b) Disk height collapse an d kyphot ic deform ity.
(5) Polyetheretherketone (PEEK) cages were subsequently introduced
(Fig. 14.6):
(a) Radiolucent.
(b) Nonabsorbable and biocompatible.
(c) Com parable modus of elasticity to bone.
(d) Reduced risk of cage subsidence.
(6) PEEK cages are produced as nonexpandable, expandable, and
stackable models.
(a) Nonexpandable PEEK cages have prede ned dim ensions, end
plate angles, and heights.
i. Risk for im plan t displacem en t .
Fi g . 1 4 . 6 Illu st r a t io n o f a p o lye t he re t h e r ke t o n e
(PEEK) cage. (From Albert TJ, Lee JY, Lim MR. Ce rvical Spine Surgery Challenges. New York, NY:
Th ie m e Me d ic a l Pu b lish e r s ; 2 0 08 : Fig . 1 8 . 5 . Re p ro duced with permission.)
162
14 Dege nerative Cervical Spine Disorders
(b) Expan dable PEEK cages con tour to the patien t’s anatomy with
minimal intraoperative modi cations.
i. Particularly advantageous for corpectom y defect s.
c. Use of anterior instrum entation (plating):
(1) Single-level interbody fusion is quite stable, and fusion rates are
excellent, with no need for postoperative bracing.
(2) Instrum entation is recomm ended in the following:
(a) Single-level fusions with allograft.
(b) Avoid postoperative bracing.
(c) Multiple-level interbody fusions.
(d) High-risk patients:
i. Revision fusion .
ii. Sm okers.
3. Anterior cervical corpectomy and fusion.
a. Strut allograft and anterior plate instrumentation for stability.
(1) Avoids postoperative halo vest.
b. Expandable cages (PEEK/titanium).
(1) Easier to contour and t to the corpectomy trough.
B. Ce r vi c a l d is k a r t h r op la st y ( CDA) .
1. Replacement of an intervertebral disk with an arti cial disk device.
2. Purpose was to design motion-sparing devices in an e ort to reduce
adjacent segment degeneration.
3. Currently ve are FDA-approved:
a. Bryan Disc (Medtronic Sofamor Danek).
b. Prestige Disc (Medtronic Sofamor Danek).
c. ProDisc-C (Synthes Spine).
d. Secure C disc (Globus Medical, Inc.).
e. PCM disc (NuVasive, Inc.).
4. Several FDA investigative device exemption trials as well as other prospective
studies have demonstrated the long-term noninferiority of CDA when
compared w ith ACDF for the m an agem ent of degen erat ive disk disease.
5. The rates of adjacent segment degeneration between CDA and ACDF are still
subject to controversy.
a. Similarly, the rates of revision and reoperation have also been scrutinized
due to author and industry bias.
C. Po st er io r ce r vica l s u r ge r y.
1. Indications.
a. Unilateral soft disk herniation or foraminal stenosis in patients with
radiculopathy and no signi cant axial symptoms (positive Spurling’s sign
and no segmental kyphosis).
b. Cervical spondylotic myelopathy (more than three levels of pathology).
c. Ossi cation of the posterior longitudinal ligam ent (OPLL).
d. Neutral or lordotic sagittal alignment.
2. Laminoforaminotomy (Fig. 14.7).
a. Motion-preserving procedure.
b. Treatment of cervical radiculopathy w ith minimal axial symptoms.
14 Dege nerative Ce rvical Spine Disorders 163
b
a
c
Fi g . 1 4 . 7 St e p -b y st ep m e t ho do lo gy fo r p e r fo r m in g a p ost erio r ce rvic a l fo r a m in ot o m y. (a) A cut t in g
bur is used to thin the lamina (labeled I) at the junction of the lateral mass–lamina. (b) Twenty- ve
percent of the lateral mass is removed, exposing the lamina (II), superior articular process of the inferior lam ina (V), facet joint (IV), and ligam entum avum (VI). (c) A cure t te is used t o re m ove t he supe rior articular process overlying the nerve root.
3. Laminoplasty (Fig. 14.8).
a. Comparable outcomes and complications when compared with
lam in ectom y an d fusion and ACDF.
b. Motion-preserving procedure.
c. Sam e indications as laminectomy and fusion (lam inoplasty is preferred
in patients w ith minim al axial neck pain and no signi cant instability).
d. Technique with or without instrumentation: instrumentation allows for
earlier mobilization and theoretically reduced rates of postoperative axial
neck pain.
(1) French door.
(a) Midline opening.
(b) Bilateral hinges.
(2) Open door (more com m on).
(a) Opening side.
(b) Hinge side.
164
14 Dege nerative Cervical Spine Disorders
a
b
cd
Fi g . 1 4 . 8 ( a ) Pre op e rat ive ce r vica l m a g n e t ic re so n a nce im a g ing de m on st rat in g sp inal ste nosis e xt e n d -
ing fro m C3 t o C7 . (b) A laminoplasty from C3 to C7 was performed (postoperative lateral radiograph
demonstrating the placement of titanium cervical plates and allograft). (c) Po st o pe ra t ive axial co mp u t ed
tomography demonstrating placement of the titanium plate. (d) Postoperative axial computed tomography demonstrating placem ent of the machined allograft.
4. Laminectomy and fusion with instrumentation (same indications as
lam inoplast y and preferred for pat ients with signi can t neck pain , bilateral
foram in a l ste n osis re q u ir ing for a m in otom ies in a dd it io n t o la m in ectom y a n d
instabilities such as spondylolisthesis).
a. Stabilization is recommended when performing laminectomy to prevent
postlaminectomy kyphosis.
(1) Lateral mass screw xation.
(2) Pedicle screw (C2, C7, T1).
(3) C2 Translam inar screw xation.
(a) Screws are placed in between the inner and outer tables of the
lam ina.
(b) Potential option if the posterior elem ent s of C2 are int act .
(c) Indications include the following:
i. Atlantoaxial inst abilit y.
ii. Osteoarth ritis.
iii. Failed C1–C2 ar throdesis.
VII. Co m p licat io n s.
A. Ant e r io r ce r vica l su r ge r y.
1. Pseudarthrosis.
14 Dege nerative Ce rvical Spine Disorders 165
2. Graft dislodgment, resorption, or collapse.
3. Dysphagia.
4. Hoarseness.
5. Vertebral or carotid artery injury.
6. Dural tears.
7. Esophageal or tracheal injury.
8. Nerve injury: C5 nerve root palsy also occurs in anterior surgery; the rates of
C5 p a ls y a r e s lig h t ly d e cr e a s e d r ela t ive t o p o st e r io r c e r v i c a l s u r g e r y.
B. Po st e r io r c e r vic a l s u r ge r y.
1. Neurological de cit.
2. Axial neck pain.
3. C5 nerve root palsy.
a. Believed to occur secondary to posterior cord migration and stretch
injur y to the C5 nerve root.
b. C5 palsy occurs with all cervical approaches, including anterior
techniques. The rates of C5 palsy are greatest with posterior
lam in ectom y/fusion and lam inoplasty. Nevertheless, C5 palsy m ay occur
follow in g a n t er io r ce r vica l fu sio n s.
VIII. Po s t op e r at ive m a n a ge m e n t.
A. No r igid co lla r is n ee d e d a ft e r in st ru m e n t e d p ro ce d u re s .
1. The patient may begin range of motion exercises in the immediate
postoperative period.
2. Soft collars may be used for patient comfort.
Sugg este d Reading
An d e r so n PA, Ma t z PG, Gr o M W , e t a l; Jo in t Se ct io n o n Dis o r d e r s o f t h e Sp in e a n d Pe -
ripheral Nerves of the American Association of Neurological Surgeons and Congress of
Neu rological Surgeon s. Lam in e ctom y an d fu sion for the t reat m e n t of cervical d egen erat ive m yelop at h y. J Neurosu rg Spin e 2009;11(2):15 0–156
Hear y RF, Kheter p al A, Mam m is A, Kum ar S. St acka ble carbon ber cages for t h oracolu m -
bar interbody fusion after corpectomy: long-term outcome analysis. Neurosurgery
2011;68(3):8 10– 818, d iscu ssion 818–819
Ka n d z i o r a F, P u g m a ch e r R, Sc h a e fe r J, e t a l. Bio m e c h a n i ca l c om p a r i s o n o f e x p a n d a b le
cages for vertebral body replacem ent in the cervical spine. J Neurosurg 2003;99(1,
Su p p l): 91– 9 7
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