Degenerative Cervical Spine

Cervical Spondylosis

  • degenerative changes
  • facet arthropathy
  • begins @ 40 years of age, by 60-70 years most men and women have it
  • symptoms can be discogenic neck pain, radiculopathy, and/or myelopathy
  • As disc ages
    • decrease in disk hydration
    • decreased chondroitin sulfate
    • increased keratin sulfate
    • Inflammatory mediators
      • IL-1
      • TNF-alpha
  • Most common at C5-6, next at C4-5

How to Classify Stenosis

  • acquired or traumatic
  • absolute or relative
    • absolute: cervical spine canal <10mm
    • relative: cervical spine canal between 10-13mm
  • PADI

    • posterior atlanto dens interval at C1-C2 level
    • useful only in patients with rheumatoid arthritis (RA)
    • <14mm: think about surgery
  • Pavlov or Torg’s ratio 

    syrinx spondylosis radiculopathy myelopathy disk arthroplasty disc herniation disc arthroplasty disc ACDF

    Torg-Pavlov Ratio = A/B; if Ratio <0.8, Patient Must Avoid Collision Sports

    • more of a sports concept
    • measure the canal diameter on the lateral view
    • divide by vertebral body
    • if <0.8, then restrain patient from contact sports
    • canal A-P width divided by vertebral body A-P width

Myelopathy vs. Radiculopathy

  • Myelopathy

    • progressive stepwise deterioration
    • symptoms include hyper-reflexia, cord signal changes, dropping things, unable to button shirt, etc
    • worst symptom is lower extremity weakness, ataxia – this indicates significant involvement
    • central stenosis caused by ligamentum flavum hypertrophy, canal stenosis, central disc herniation
    • treatment for myelopathy is almost always surgical
      • ACDF probably the best board answer
      • recent OITE listed disc replacement or disk arthroplasty as the correct answer, so it may be heading that way
    • remember Wartenberg finger escape sign – cord injury and hand intrinsics go first because they are smaller, but ECU still fires and causes abduction
    • remember Charcot shoulder – caused by syrinx – order cervical spine MRI if you see a dusted shoulder in the x-ray
  • Radiculopathy

    • foraminal stenosis caused by uncovertebral hypertrophy and facet hypertrophy
    • symptoms include pain radiating down arm, weakness, tingling sensation, discogenic neck pain, scalp pain
    • lower nerve root is usually the one affected
      • C5-6 would be C6 root affected
      • note, concept of far lateral disc does not apply in cervical spine as it does in the lumbar spine
    • nonoperative treatment is initial management
    • differentiate between soft and hard herniation
      • soft is better because it could resorb
  • Surgical Treatments

    • For multi-level involvement, multilevel ACDF, laminoplasty, and laminectomy and fusion are all decent options
    • they used to say that laminoplasty was not the right answer, but it is now accepted as a reasonable option except when the patient is kyphotic
    • ACDF

      • Carotid artery lies most medial during anterior approach
      • sympathetic chain on longus colli
      • recurrent laryngeal n. – runs in tracho-esophageal groove
        • risk is same on both sides
        • higher risk the lower you go
      • dysphagia – retracting the esophagus
        • the higher up you go, the greater the risk (the esophagus is tethered at the hypopharynx
      • more levels you do, the greater the risk of nonunion – 5-10% per level
  • Other considerations

    • C5 radiculopathy – consider frozen shoulder or bursitis
    • C8 symptoms – consider ulnar neuropathy
    • C6-7 symptoms – consider carpal tunnel
    • Pain going down arm, patient is a smoker – consider Pancoast tumor