Extract
Spondylosis refers to age-related degenerative changes within the
spinal column. Radiographic evidence of cervical spondylosis is frequent in
asymptomatic
adults1,2.
Approximately 25% of individuals younger than forty years of age, 50% of
individuals over forty years of age, and 85% of individuals over sixty years
of age have some degree of disc
degeneration2,3.
Occupations that place increased loads on the head predispose individuals to
the development of cervical spondylosis. Activities such as rugby, soccer, and
horseback riding and occupations such as flying fighter jets may also
predispose individuals to the development of cervical
spondylosis4-8.
Spondylosis refers to age-related degenerative changes within the
spinal column. Radiographic evidence of cervical spondylosis is frequent in
asymptomatic
adults1,2.
Approximately 25% of individuals younger than forty years of age, 50% of
individuals over forty years of age, and 85% of individuals over sixty years
of age have some degree of disc
degeneration2,3.
Occupations that place increased loads on the head predispose individuals to
the development of cervical spondylosis. Activities such as rugby, soccer, and
horseback riding and occupations such as flying fighter jets may also
predispose individuals to the development of cervical
spondylosis4-8.
Symptoms caused by cervical spondylosis can be categorized broadly into
three clinical syndromes: axial neck pain, cervical radiculopathy, and
cervical myelopathy. Patients can have a combination of these syndromes. Axial
posterior neck pain occasionally radiates to the shoulder or periscapular
region in a non-dermatomal distribution. Axial neck pain is more common in
women, has a lifetime prevalence of 66% in North American adults, and 5% of
the population has disabling pain at any given
time9-11.
Cervical radiculopathy refers to pain, sensory findings, or a
neurologic deficit in a dermatomal distribution in the upper extremity, with
or without neck pain. The annual incidence of cervical radiculopathy was
reported to be eighty-three per 100,000 population, whereas the prevalence was
found to be 3.5 per 1000 population with a peak incidence in the sixth decade
of
life12,13.
Cervical myelopathy refers to the syndrome of long-tract clinical
findings in the upper and lower extremities arising from involvement of the
spinal cord by the spondylotic changes in the cervical spinal column. The true
incidence is difficult to ascertain because of the subtle findings in its
early stages.
Neck Pain
Subaxial neck pain is most often due to muscular and ligamentous factors
related to improper posture, poor ergonomics, and muscle fatigue. Numerous
potential causes have been reported, but their contribution is unclear. Low
levels of high-energy phosphates such as adenosine triphosphate, adenosine
diphosphate, and phosphoryl creatine have been found in trapezius muscles of
patients with fibromyalgic neck
pain14. Patients
with chronic trapezius myalgia have shown lower muscle blood flow and higher
intramuscular tension on the symptomatic side when compared with the
contralateral, asymptomatic side of the same patient and with healthy
controls15. Prior
neck injury has been found to be an independent risk
factor16.
Degenerative changes at the cervical disc and facet joints can be a source of
symptoms. Nerve fibers and nociceptive nerve endings are present in the
peripheral portions of the disc and in the capsule and synovium of the facet
joints17-20.
Findings of discography and provocative injections of the facet joint have
supported the role of these structures in the causation of neck
pain21,22.
Cervical Radiculopathy
Biochemical and biomechanical changes that occur with age result in a
degenerative cascade. The intervertebral disc gradually loses height,
posterior portions of the disc bulge into the spinal canal and the
neuroforamina, the ligamentum flavum and facet joint capsule infold, and
osteophytes form. All of this leads to decreases in canal and foraminal size.
Subluxation and hypermobility between vertebral bodies may occur.
It is not clear why compression of a nerve causes pain. It is generally
believed that only an inflamed or irritated nerve root can result in radicular
pain on compression. Neurogenic chemical mediators of pain released from the
cell bodies of the sensory neurons and non-neurogenic mediators released from
disc tissue may play a role in initiating and perpetuating an inflammatory
response23,24.
Chronic edema and fibrosis within the nerve root caused by compression can
also potentially alter the response threshold and increase the sensitivity of
the nerve root to
pain25. It may be
that the dorsal root ganglion is the source of pain, as it is exquisitely
sensitive to
deformation26. In
addition to mechanical compression of the dorsal root ganglion, the prolapsed
nucleus pulposus elutes inflammatory mediators, initiating a local
inflammatory response that leads to increased permeability at the dorsal root
ganglion and
pain27.
Cervical Myelopathy
Mechanical compression of the spinal cord is widely held to be the primary
pathophysiological mechanism of cervical myelopathy. Animal studies have shown
that at least 40% cord compression was necessary to produce reversible
neurologic
deficits28.
Patients with <40% compression and myelopathy are likely to have additional
factors such as a developmentally reduced anteroposterior diameter of the
spinal canal, dynamic cord compression, dynamic changes in the intrinsic
morphology of the spinal cord, or an impaired vascular supply of the spinal
cord. The anteroposterior diameter of the subaxial spine in normal adults
measures 17 to 18 mm. Individuals with an anteroposterior diameter of the
canal of <13 mm are considered to have developmental stenosis and may be
predisposed to the development of cervical
myelopathy29. The
shape and cross-sectional area of the spinal canal are important predictors of
the development of cervical myelopathy. A cross-sectional area of the spinal
cord of <60 mm2 and a banana-shaped cord have both been found to
be associated with development of clinical signs or symptoms of
myelopathy30,31.
An anteroposterior cord compression ratio (the ratio of the anteroposterior to
the transverse cord diameter) of <40% suggested substantial flattening of
the cord and was also found to be associated with worse neurologic
dysfunction32.
Changes in the dimensions of the spinal canal during normal neck movement or
due to abnormal segmental mobility may play a role in the development of
cervical myelopathy by causing dynamic cord compression. The segmental
anteroposterior diameter as well as the volume of the cervical spinal canal
have been found to be reduced in
extension33,34.
Retrolisthesis of C3 on C4 could accentuate cord compression in elderly
individuals with
myelopathy35.
Instability at a segment cephalad to a motion segment with severe disc
degeneration may lead to dynamic cord
compression36.
Morphologic changes also occur within the spinal cord with flexion and
extension. Breig et al. previously showed that the spinal cord stretches with
flexion of the cervical spine and shortens and thickens with extension of the
cervical spine37.
Thickening of the cord in extension makes it more susceptible to pressure from
the infolded ligamentum flavum or the lamina. In flexion, the stretched cord
may be prone to higher intrinsic pressure if it abuts against a disc or a
vertebral body anteriorly.
Experimental studies have shown that ischemia of the cord has an additive
effect on the clinical manifestations of myelopathy resulting from
compression38,39.
Tenting of the anterior spinal arteries as well as reduced flow in the
anterior radicular arteries and especially the transverse intramedullary
arterioles arising from the anterior sulcal artery can lead to ischemia of the
anterior horn and the adjacent lateral
columns37,40.
Abnormal movement of a motion segment can trigger a vasospastic response that
can also compromise the cord's intrinsic blood
supply41.
Neck Pain
Localized pain and tenderness in the posterior muscles of the neck suggest
a muscle sprain or a soft-tissue injury. Deep palpation of "trigger
points" produces referred patterns of pain along the course of the
myofascial structures. Determining a position of maximal discomfort may also
provide a clue to the underlying pathological entity. Pain in the posterior
neck muscles that is worsened by flexion of the head suggests a myofascial
etiology. Pain in the posterior aspect of the neck that is aggravated by
extension and especially by rotation of the head to one side suggests a
discogenic component. Predominant suboccipital pain radiating to the back of
the ear, occiput, or neck raises the possibility of pathological involvement
of the upper cervical spine. Restricted rotation of the head to one side
suggests involvement of the ipsilateral atlanto-axial articulation.
Pain in the neck and shoulder girdle can be referred from the heart, lungs,
and abdominal viscera. Morning stiffness, polyarticular involvement, rigidity,
or cutaneous manifestations accompanying the neck pain suggest a systemic
inflammatory arthritic process. Fever, weight loss, or non-mechanical neck
pain may point to an infectious or neoplastic lesion in the cervical spine
causing neck pain.
Cervical Radiculopathy
Henderson et al. reviewed the clinical presentations in 736 patients with
cervical radiculopathy and reported that 99% had arm pain, 85% had sensory
deficits, 80% had neck pain, 71% had reflex deficits, 68% had motor deficits,
52% had scapular pain, 18% had anterior chest pain, 10% had headaches, and 1%
presented with left-sided chest and arm pain ("cervical
angina")42.
The symptoms are usually aggravated by extension or lateral rotation of the
head to the side of the pain (the Spurling maneuver). Patients with radicular
pain may obtain some relief by elevating the arm overhead (the shoulder
abduction sign) and sometimes by flexing and tilting the neck to the
contralateral
side43.
Upper cervical radiculopathies occasionally present as suboccipital pain
with referral to the back of the ear. C4 radiculopathy can present as neck and
shoulder pain with accompanying ipsilateral diaphragmatic
palsy44.
Paresthesias along the superior border of the trapezius are a clue to a
radicular etiology. Nonspondylotic pathological conditions can occasionally
simulate cervical radiculopathy (Fig.
1, Table I).
Cervical Myelopathy
Patients with cervical myelopathy generally present with clumsiness or loss
of fine motor skills in the hands. An increasingly awkward gait or difficulty
with maintaining balance may have been noted by the patient or family members.
Patients may complain of urinary urgency, hesitation, or frequency but rarely
incontinence or retention of urine. Concomitant axial neck pain and/or
radiculopathy are frequent. Motor weakness and wasting may be present in the
upper or lower extremities. Pain, temperature, proprioception and vibratory
sensations, and touch may all be diminished in the extremities and the trunk,
depending on the location of the spinal cord compromise. Abnormal reflex
findings include hyperreflexia or clonus of normal deep tendon reflexes,
absence of superficial reflexes, or the presence of pathological reflexes (the
inverted radial reflex, the Hoffmann reflex, and the extensor plantar
response) (Fig. 1).
Myelopathy hand is a term used to refer to a constellation of
findings, including loss of dexterity, diffuse numbness, wasting of the
intrinsic hand muscles, inability to rapidly grasp and release the fist, and
ulnar and flexor drift of the ulnar two digits while attempting to keep the
fingers adducted and extended (finger escape
sign)32,45.
Myelopathy resulting from a cord level cephalad to C3 may result in a
hyperactive scapulohumeral reflex—i.e., tapping of the spine of the
scapula or acromion results in scapular elevation and/or abduction of the
humerus.
Patients with warning signs and symptoms of serious pathological
involvement of the cervical spine such as tumor, infection, fracture, or
neurologic injury should undergo appropriate imaging studies without delay
(Table II). For all other
patients, imaging studies are delayed for four to six weeks to allow time for
spontaneous recovery.
Plain Radiographs
Plain radiographs should be made with the patient in an upright position
when possible. Degenerative changes such as intervertebral disc-space
narrowing, osteoarthrosis of the facet and uncovertebral joints, osteophytes,
and end-plate sclerosis are ubiquitous in the adult population and are not
diagnostic46. The
Pavlov ratio is calculated by dividing the anteroposterior diameter of the
spinal canal by the anteroposterior diameter of the vertebral body. A normal
value is 1.0. A value of <0.8 suggests developmental canal stenosis but
does not correlate with the space available for the spinal
cord47,48.
Lateral flexion-extension radiographs are used to measure the cervical range
of motion and to identify ankylosed segments and cervical instability
(translation of >3.5 mm and relative sagittal plane angulation of
>11°)49.
Computed Tomography with Myelography
Compressive osteophytes, foraminal stenosis, and ossification of the
posterior longitudinal ligament are best identified with use of computed
tomography scans. Computed tomography myelography, an invasive procedure, is
reportedly better than magnetic resonance imaging in distinguishing osseous
from soft-tissue impingement of neural structures and in detecting foraminal
stenosis50,51.
Shafaie et al. found that concordance between computed tomography and magnetic
resonance imaging findings was only moderately good in the interpretation of
degenerative cervical spine changes that led to radiculopathy or
myelopathy52.
Computed tomography myelography tended to upgrade the degree of spinal canal
compromise, neural foraminal encroachment, and cord diameter reduction. They
concluded that, while computed tomography myelography and magnetic resonance
imaging should be considered complementary studies, computed tomography
myelography may be preferable to magnetic resonance imaging because of its
superior differentiation of bone and soft
tissues52. Computed
tomography myelography also provides better imaging detail in patients with
postoperative metal artifacts or scoliotic deformity.
Magnetic Resonance Imaging
Magnetic resonance imaging is the diagnostic standard for evaluation of the
soft tissues of the cervical spine, including the neural elements, disc, joint
capsule, and ligaments. Abnormalities are frequently seen on magnetic
resonance images of adults, and it is important to correlate imaging and
clinical findings. Teresi et al. found disc degeneration on the magnetic
resonance images of five of twenty-five asymptomatic individuals between
forty-five and fifty-four years of age and those of twenty-four of forty-two
asymptomatic individuals who were more than sixty-four years of
age53. Spinal cord
compression was found on the images of nine of fifty-eight individuals who
were less than sixty-four years of age and on those of eleven of forty-two
individuals who were more than sixty-four years of
age53. Boden et al.
detected foraminal stenosis on the images of one of forty asymptomatic
subjects who were younger than forty years of age and on those of five of
twenty-three subjects who were older than forty years of
age1.
Magnetic resonance imaging also allows direct visualization of
intramedullary cord changes. Ohshio et al. reported a direct correlation
between histopathological features and intramedullary signal changes on
magnetic resonance
imaging54. Isolated
areas of high signal intensity on T2-weighted images indicate edema, which may
resolve. A combination of low signal intensity on T1-weighted images and high
signal intensity on T2-weighted images indicates severe lesions in gray matter
with necrosis, myelomalacia, or spongiform changes.
Intramedullary signal changes in the cord have been detected in >60% of
patients with symptomatic cervical
myelopathy55-57.
It is, however, not clear if the presence and the type of intramedullary
signal changes in patients with symptomatic cervical myelopathy can be used to
predict either the prognosis or the outcome of treatment with any accuracy.
High-intensity signal changes on T2-weighted images are found frequently and
can be diffuse or well demarcated, focal or multisegmental; however, their
clinical relevance is unclear (Figs.
2-A,
3,
4). Well-demarcated
high-intensity signal changes on T2-weighted images combined with
low-intensity signal changes on T1-weighted images are rare; they are usually
found in late stages of cervical myelopathy and indicate a more severe,
irreversible pathological condition such as late-stage myelomalacia and cystic
necrosis58,59.
Bednarik et al. found high-intensity intramedullary signal changes on
T2-weighted images of twenty-three of sixty-six asymptomatic patients with
cervical stenosis, but they identified no patients with a combination of
high-intensity intramedullary signal changes on T2-weighted images and
low-intensity intramedullary signal changes on T1-weighted
images58. The
presence of intramedullary signal changes does not predict a poor outcome
after nonoperative treatment in patients with mild
myelopathy56.
Morio et al. identified intramedullary signal changes in seventy-one of
seventy-three patients who underwent surgery for clinically evident
myelopathy55. They
concluded that, while low-intensity signal changes on T1-weighted images may
indicate a poor prognosis, high-intensity signal changes on T2-weighted images
can be caused by a broad spectrum of compressive myelomalacic pathological
conditions and reflect a broad spectrum of spinal cord recuperative
potentials. In another surgical series, Suri et al. identified intramedullary
signal changes in 121 of 146 symptomatic
patients57. Of
these 121 patients, 33% had changes only on the T2-weighted images and 67% had
changes on both the T1 and the T2-weighted images. Patients without
intramedullary signal changes or with changes only on T2-weighted images had
significantly better postoperative motor strength than did patients with
changes on both T1 and T2-weighted images (p < 0.05). There have also been
reports that patients with focal high-intensity intramedullary signal changes
on T2-weighted images have better clinical outcomes following surgery than do
patients with multisegmental high-intensity intramedullary signal changes on
T2-weighted
images60,61.
The transverse area and shape of the spinal cord at the compressed segment
may predict outcome, with a preoperative transverse spinal cord area of
<0.45 cm2 correlating with poor surgical
results62. With
progressive compression, the cross section of the spinal cord changes from a
boomerang shape to a teardrop shape to a triangular
shape63. The
boomerang and teardrop shapes have a better potential for recovery than does
the triangular shape.
Metabolic neuroimaging technology has recently been applied to the spinal
cord. Uchida et al. compared findings on preoperative high-resolution
18F-fluorodeoxyglucose-positron emission tomography (FDG-PET) with
JOA (Japanese Orthopaedic Association) scores and findings on magnetic
resonance imaging in twenty-three patients undergoing surgery for
myelopathy64.
FDG-PET findings correlated with preoperative JOA scores, postoperative JOA
scores, and the rate of postoperative improvement, but they had no correlation
with high-intensity intramedullary signal changes on T2-weighted images.
Currently, the major limitation of this technology is the poor resolution of
PET scans. (Accurate measurements of glucose utilization are difficult to
obtain.) Future technological advancements in PET scanning may facilitate
evaluation of early spinal cord damage and provide indications for surgical
intervention.
Electrodiagnostic Studies
Electrodiagnostic studies may help to differentiate between various causes
of symptoms, including myelopathy, radiculopathy, peripheral entrapment
syndromes, peripheral neuropathy, shoulder dysfunction, and brachial
plexopathy. Recommended investigations for neurophysiological examination of
patients with cervical myelopathy include testing of somatosensory evoked
potentials by stimulation of the tibial nerve and motor evoked potentials from
the upper and lower
extremities65. Both
motor evoked potentials and somatosensory evoked potentials can be abnormal in
patients with spinal cord compression who have no clinical features of
myelopathy66,67.
Bednarik et al. prospectively followed thirty patients with evidence of spinal
cord compression on magnetic resonance imaging, but no clinical evidence of
cervical myelopathy, by testing motor and somatosensory evoked potentials for
a period of two
years67. The
authors detected electrophysiological abnormalities in fifteen of the thirty
patients at the beginning of the study. Clinical signs of cervical myelopathy
were detected in five of these fifteen patients over the next two years, with
at least one test of evoked potentials showing deterioration at the time of
the appearance of the signs of cervical myelopathy. Myelopathy did not develop
in any of the patients with normal motor and somatosensory evoked potentials
at the beginning of the study. Bednarik et al. concluded that there was a
significant association between abnormal findings on evoked-potential studies
and the development of cervical myelopathy in patients with spinal cord
compression (p = 0.02).
Studies of motor and somatosensory evoked potentials might be useful in
detecting subclinical myelopathy. In patients with evidence of spinal cord
compression on magnetic resonance imaging and symptoms but no definitive signs
of myelopathy, motor evoked potentials are more commonly abnormal than are
somatosensory evoked
potentials66.
Clinical features of cervical myelopathy can be masked in patients with
peripheral neuropathy, and studies of evoked potentials can detect clinically
silent myelopathy in these
patients68. In
patients with diagnosed cervical spondylotic myelopathy, upper-extremity motor
evoked potentials are most commonly abnormal. Patients who have normal
preoperative median somatosensory evoked potentials may have better recovery
rates after surgery for myelopathy than patients who have abnormal
somatosensory evoked
potentials69. A
=50% decrease in motor evoked potentials correlates well with a
postoperative motor
deficit70.
Electromyography can show increased insertional activity, fibrillations,
and fasciculations and diminished motor unit recruitment, which are signs of
denervation due to pathological changes at the nerve root or anterior horn
cells. Electromyography in combination with nerve conduction studies can help
to distinguish cervical radiculopathy from peripheral neuropathy or peripheral
root entrapment syndromes in some patients. The value of electromyography as a
primary diagnostic modality for patients with clinical signs of radiculopathy
is offset by its low
sensitivity71,72.
Its concordance with magnetic resonance imaging findings in patients is low.
Nardin et al. reported that, in nineteen of forty-seven patients with cervical
radiculopathy, electromyographic results did not correlate with findings on
magnetic resonance
imaging73.
Additionally, electromyography is less likely to show abnormal findings in
patients with predominantly sensory
radiculopathy73,74.
It may be possible to improve the sensitivity of electromyography for
detecting cervical radiculopathy by the addition of paraspinal muscles to the
electromyography
screen75.
Narcotic analgesics, nonsteroidal anti-inflammatory agents,
corticosteroids, muscle relaxants, and antidepressants are commonly used to
relieve neck pain and radiculopathy. A short period of rest or cessation of
pain-provoking activities and the use of a soft collar with the neck in mild
flexion may sometimes alleviate acute pain and spasm. In a meta-analysis of
the literature, physical modalities such as heat, cold, therapeutic
ultrasound, massage, use of the TENS (transcutaneous electrical nerve
stimulator), and cervical traction were not found to have any reproducible
benefit in the treatment of acute or chronic neck
pain76. A four to
six-week program of physical therapy, including isometric exercises, active
range-of-motion exercises, aerobic conditioning, and resistive exercises, has
been found to be helpful for patients with chronic neck
pain77,78.
There have been a few reports of substantial relief of radicular pain and
improved functional outcome after the use of cervical traction for the
treatment of cervical
radiculopathy79,80.
Long-term success has been reported in 40% to 70% of patients who received
translaminar or transforaminal epidural corticosteroid injections for
treatment of cervical
radiculopathy81-83.
Rare but potentially catastrophic complications can be associated with these
injection
techniques84. In a
cohort of patients with neck pain or radicular symptoms in the upper
extremities followed for ten to twenty-five years, Gore et al. found that
nonoperative management resulted in complete resolution of symptoms in 43% of
the patients and partial resolution in 25%, whereas 32% had continued moderate
or severe
pain85.
Patients with mild myelopathy are occasionally offered a trial of
observation or nonoperative management, but nonoperative management is
generally not successful in reversing or permanently halting the progress of
myelopathy. Conservative treatment includes intermittent cervical
immobilization in a soft collar; anti-inflammatory medications and bed rest;
and active discouragement of high-risk activities, manipulation therapies, and
vigorous or prolonged flexion of the
head86. A greater
anteroposterior diameter of the spinal canal, a transverse area of the spinal
cord of >70 mm2, and an age of greater than sixty-five years
seem to be associated with a better response to conservative treatment by
patients with mild
myelopathy87.
Success rates for nonoperative management of neck pain and cervical
radiculopathy may vary depending on the patient population studied. Even in a
referral practice, 70% to 80% of patients with neck pain respond favorably to
nonoperative
treatment88,89.
Operative intervention is considered for the following patients with
predominantly axial neck pain.
Those with severely limiting pain caused by cervical degenerative disease
that is not relieved by nonoperative treatment for more than twelve months. It
is difficult to identify the symptomatic level in these patients with magnetic
resonance imaging
alone90,91,
and objective confirmation of the disc as the "pain generator"
with use of both magnetic resonance imaging and provocative discography should
be considered to improve the clinical success rates. A nonorganic component to
the pain should be absent. Anterior discectomy and fusion is the operative
intervention of choice for these patients with discogenic neck pain.Patients with C3 or C4 nerve-root impingement can present with features
simulating axial neck pain. Patients with such "pseudo-axial" neck
pain who do not respond to nonoperative measures for six to twelve weeks may
be candidates for operative intervention.Patients with pseudarthrosis of the cervical spine with graft collapse or
hardware migration and disabling axial neck pain are candidates for revision
anterior surgery. Patients without implant failure may have higher fusion
rates and superior clinical outcomes after posterior cervical fusion with
instrumentation than after anterior
revision92,93.
Those with severely limiting pain caused by cervical degenerative disease
that is not relieved by nonoperative treatment for more than twelve months. It
is difficult to identify the symptomatic level in these patients with magnetic
resonance imaging
alone90,91,
and objective confirmation of the disc as the "pain generator"
with use of both magnetic resonance imaging and provocative discography should
be considered to improve the clinical success rates. A nonorganic component to
the pain should be absent. Anterior discectomy and fusion is the operative
intervention of choice for these patients with discogenic neck pain.
Patients with C3 or C4 nerve-root impingement can present with features
simulating axial neck pain. Patients with such "pseudo-axial" neck
pain who do not respond to nonoperative measures for six to twelve weeks may
be candidates for operative intervention.
Patients with pseudarthrosis of the cervical spine with graft collapse or
hardware migration and disabling axial neck pain are candidates for revision
anterior surgery. Patients without implant failure may have higher fusion
rates and superior clinical outcomes after posterior cervical fusion with
instrumentation than after anterior
revision92,93.
Surgery is an option for patients with persistent cervical radiculopathy
following failure of a three-month trial of nonoperative measures to relieve
disabling radicular pain. These patients must have neuroimaging studies that
show a pathological condition that corresponds to the clinical features.
Surgery is also an option for patients with a progressive motor deficit or a
disabling motor deficit from the
radiculopathy94.
Studies of the natural history of cervical myelopathy suggest that most
patients with clinically established disease will have progression of
symptoms, possibly in a stepwise fashion with
time95-98.
Bednarik et al. found that clinical signs or symptoms of myelopathy developed
in thirteen of sixty-six patients with asymptomatic spinal cord compression
seen on magnetic resonance imaging in a study with a minimum two-year
follow-up58.
Patients with mild myelopathy probably do not benefit from surgery. In a
prospective randomized study with a duration of follow-up of three years,
patients with mild-to-moderate nonprogressive or slowly progressive myelopathy
were found to have similar outcomes after either nonoperative or operative
treatment86. A
trial of nonoperative treatment did not decrease the potential for ultimate
recovery of patients with mild
myelopathy99.
Patients with severe or progressive myelopathy are candidates for surgical
intervention. A number of factors are considered in the decision regarding
when to proceed with surgery in patients with myelopathy; these include the
degree of neurologic dysfunction, patient disability, findings on radiographs
and magnetic resonance imaging, duration of symptoms, and presence of
comorbidity.
The two options typically considered for the operative management of
cervical radiculopathy are (1) anterior cervical discectomy and fusion and (2)
posterior laminotomy-foraminotomy. An anterior approach is preferred for
patients with a central or bilateral disc lesion, whereas a lateral cervical
disc herniation can be approached either anteriorly or posteriorly. The
long-term results of the two procedures are comparable, but anterior cervical
discectomy and fusion is preferred for patients who have substantial neck pain
associated with the radicular
symptoms100-102.
Patients with myelopathy should be treated with anterior cervical discectomy
or corpectomy when there is pathological compression at up to three levels or
when cervical lordosis is
reversed103. A
laminectomy or laminoplasty is used in patients requiring decompression at
four or more segments, those with a developmentally narrow canal, and those in
whom the anterior column is already fused. Cervical lordosis is critical for a
posterior approach as it allows the cord to migrate dorsally after the
decompression.
Anterior Cervical Discectomy and Corpectomy
A subtotal discectomy with removal of cartilaginous end plates and anterior
osteophytes is done through a Smith-Robinson
approach104
(Fig. 5). We prefer to use a
left-sided approach as the course of the recurrent laryngeal nerve is more
sheltered within the tracheoesophageal groove on this side.
After removal of disc material within the interspace, posterior osteophytes
may need to be removed to adequately decompress the spinal cord and nerve
root. Removal of posterior osteophytes increases the risk of injury to the
spinal cord, and large osteophytes may be removed more safely with a partial
corpectomy105.
Osteophytes may resorb after a successful anterior fusion, but this theory is
controversial106,107.
Removal of the posterior longitudinal ligament similarly increases the risk of
cord contusion and postoperative epidural
hematoma108, but
it should be done if a rent in the posterior longitudinal ligament is detected
or if there is clinical or imaging-based suspicion of an extruded fragment
posterior to the ligament.
During the corpectomy, a 15 to 19-mm central trough is removed from the
anterior aspect of the vertebral body with a rongeur or a high-speed burr. A
thin residue of posterior wall and the posterior longitudinal ligament are
resected with use of a diamond-tipped burr, small curets, and a 1-mm Kerrison
rongeur as required. The adequacy of the decompression is assessed by visual
inspection of the decompressed posterior longitudinal ligament or dura.
Anterior cervical discectomy without fusion results in a higher prevalence
of postoperative neck pain, can lead to a reduction in the neuroforaminal
area, and is rarely
advised109,110.
Anterior Fusion
We remove all cartilaginous material but preserve the integrity of the
osseous end plate to provide mechanical stability to the inserted graft. Four
or five tiny perforations are created within the cephalad and caudad osseous
end plates with use of a small curet or burr to facilitate fusion across the
interspace. Some surgeons remove the osseous end plates and seat the inserted
graft within the exposed cancellous bone, with the aim of improving fusion
rates111. The
graft should be 2 mm taller than the measured height of the disc space to
maintain sagittal alignment. The graft is recessed 2 mm posterior to the
anterior cortical margin of the adjacent vertebral bodies.
Following anterior discectomy, the placement of a tricortical
horse-shoe-shaped autograft harvested from the anterior iliac crest has led to
excellent fusion
rates112-114.
Equivalent fusion rates have been reported after allografting and
autografting, combined with use of anterior plates and segmental screw
fixation, for intervertebral fusions of up to three
levels115,116.
Longer-term results are required before definite recommendations can be made
regarding the use of titanium cages, carbon-fiber cages, and PEEK
(polyetheretherketone)
cages117-119.
Tricortical iliac crest autograft struts are the best option for anterior
column reconstruction after a one or two-level anterior cervical corpectomy,
but they are associated with donor site morbidity. A fibular strut is
preferred when the iliac crest is mechanically insufficient or for corpectomy
defects that are longer than two levels. The use of longer strut grafts after
multilevel corpectomies is associated with complications. Settling of the
graft with kyphotic change in the angulation and fracture of the fibular strut
graft has been reported after the use of long fibular
grafts120,121.
Wang et al. found the risk of graft displacement and migration to be higher as
the number of removed vertebral bodies increased and when the fusion extended
down to C7122. Use
of metallic cages and synthetic spacers in conjunction with local autograft or
allograft after single or multiple-level corpectomies
(Fig. 6) have resulted in
comparable fusion rates, but the long-term results are still
unclear123,124.
High rates of early failure of the reconstruction, cage subsidence, and plate
loosening have been reported following the use of titanium-mesh cages in
multilevel
corpectomies125,126.
Anterior Cervical Plates
After either discectomy or corpectomy, anterior osteophytes are removed
from the margins of the adjacent vertebrae to prepare a flat bed for the
plate. The length of the plate is selected so that a minimum distance of 5 mm
is maintained between the ends of the plate and the adjacent discs
(Fig. 7). This helps to
decrease adjacent-level disc
ossification127.
The use of screws locked to the plate obviates the need for bicortical
purchase in the vertebral body. When multisegmental fixation is performed, an
attempt should be made to fix the plate to all vertebral levels.
The use of an anterior cervical plate in an anterior cervical discectomy
and fusion involving two or more levels improves fusion rates, reduces the
need for postoperative stabilization, reduces graft-related complications, and
is associated with less postoperative
kyphosis128,129.
Use of an anterior cervical plate after a single-level anterior cervical
discectomy and fusion with autograft bone does not improve clinical results or
fusion rates but reduces graft
collapse130,131.
An anterior plate may be beneficial when allograft bone is used for a
single-level anterior cervical discectomy and
fusion132. Fusion
occurs in approximately 90% of patients who have a single-level anterior
cervical
discectomy133,134.
The prevalence of pseudarthrosis increases with the number of levels that are
operated
on112.
The use of an anterior plate has been found to reduce pseudarthrosis rates
following single-level
corpectomy135.
Failure rates ranging from six of
twelve136 to five
of seven137 have
been reported following corpectomy involving three or more levels, even with
use of an anterior plate, and supplemental posterior instrumentation should be
considered for such patients.
Cervical Disc Replacement
Artificial disc replacement has not yet been approved by the United States
Food and Drug Administration for clinical use. Cervical disc replacement has
been proposed as an alternative to anterior cervical discectomy and fusion in
patients with pathological involvement of a cervical disc. While the causes of
deterioration of motion segments adjacent to a "stiff" fusion are
unclear, a theoretical benefit of disc replacement is a reduction in this risk
of adjacent-segment
deterioration138-140.
Cadaveric and clinical studies with a two-year follow-up have demonstrated
maintenance of motion at an operative segment following disc
replacement141,142.
Selection of patients for cervical disc replacement is currently not
standardized. Common exclusion criteria mentioned in the current literature
are substantial cervical deformity, radiographic findings of segmental
instability, isolated axial neck pain, a lack of motion at the segment
preoperatively, and severe facet
arthrosis143-145.
In a series of forty-nine patients with a one-level disc replacement,
thirty-two had an excellent result; two, a good result; ten, a fair result;
and five, a poor
result142. Coric
et al. reported comparable clinical outcomes two years following Bryan
artificial disc replacement and two years following anterior cervical
discectomy and fusion. Other early results have been
similar146,147.
In one study, the prevalence of symptomatic adjacent-level degenerative disc
disease in patients treated with fusion was reported to be significantly
higher than that in patients treated with disc replacement (p =
0.009)148.
Heterotopic ossification, persistent pain, prosthetic migration, segmental
kyphosis, and device failure have been reported following cervical disc
replacement142,145,149,150.
Posterior Laminotomy-Foraminotomy
The keyhole foraminotomy technique was originally described by Scoville and
is used for patients with unilateral radicular findings caused by a lateral or
foraminal soft cervical disc herniation or foraminal
stenosis151. The
procedure involves removal of the lateral one-third of the superior and
inferior hemilaminae with removal of the medial one-third of the facet joint.
In the case of a soft cervical disc, the foraminotomy is followed by excision
of the extruded disc fragment with use of a small blunt-tipped nerve hook.
Foraminotomy alone is adequate in patients with foraminal stenosis due to an
osteophytic
ridge152.
Microendoscopic posterior cervical foraminotomy techniques may further reduce
the postoperative pain and disability associated with the muscle stripping
during an open
foraminotomy153.
Laminoplasty
Laminoplasty increases the effective diameter of the spinal canal from C3
to C7 by shifting the laminae dorsally with use of either a so-called single
door with a single lateral hinge or a double door with lateral hinges on both
sides. In contrast to laminectomy, laminoplasty retains a covering of
posterior laminar bone and ligamentum flavum over the spinal cord, minimizes
the instability and the risk of kyphosis, limits constriction of the dura from
extradural scar formation, and obviates the need for
fusion154,155.
Intraoperatively, visible expansion of the dural sac and pulsation of the
dura after opening of the laminoplasty doors or following laminectomy suggest
good canal
expansion156. A
laminoplasty opening gap of 8 to 10 mm and an average increase in the canal
diameter of approximately 5 mm usually result in adequate
decompression157,158.
Foraminotomy is considered following a laminoplasty or laminectomy in patients
who show foraminal stenosis from a disc protrusion or foraminal osteophytes
and concordant radicular symptoms. A prophylactic C5 foraminotomy can be
performed to reduce the prevalence of C5 palsy from posterior translation of
the cord, although there is no clear evidence that it reduces the prevalence
of C5 palsy.
The laminoplasty door is held open by anchoring the spinous process to the
facet joint on the hinge side with use of suture or wire, or by insertion of
autograft, allograft, or ceramic spacers on the open side. Stabilization of
the open door with use of miniplates fixed to the lamina and the lateral mass
without major complications has been reported by multiple
authors159,160
(Fig. 8).
Laminectomy
Laminectomy can be considered when decompression is required at more than
three levels, particularly in elderly patients, in whom comorbidities increase
operative risk. All levels with radiographic evidence of stenosis should be
included in the decompression. Limiting the number of segments that are
decompressed does not influence the development of postlaminectomy kyphosis or
instability, but inclusion of C2 and T1 in the laminectomy increases the
likelihood of kyphosis and instability
developing161,162.
Concern about postlaminectomy kyphosis and instability has led to the
development of the laminectomy with fusion and posterior instrumentation.
Laminectomy without instrumentation should be restricted to patients with
preserved cervical lordosis. In patients with a flexible cervical kyphosis,
laminectomy may be combined with application of posterior instrumentation with
the neck extended to restore cervical lordosis and maximize posterior shift of
the spinal cord.
Posterior Cervical Instrumentation
Instrumentation options for posterior cervical fixation after laminectomy
include sublaminar and facet wires connected to a longitudinal rod or a
rectangular construct, and interspinous
wires163,164.
Lateral mass and cervical pedicle-based screw-fixation systems are alternative
options for patients with deficient posterior elements, but they have not yet
been approved by the Food and Drug Administration for clinical use in the
United States
165-167.
To reduce the risk of spinal cord injury during the use of lateral mass or
pedicle screws, the screw holes should be drilled prior to the laminectomy.
Pedicle screws may be preferable at C2 and C7, since the lateral masses are
poorly developed at these levels. The reported prevalence of fusion in
patients treated with instrumentation is better than that in patients treated
with bone-grafting
alone166,168,169.
Neck Pain
A large majority of patients with axial neck pain respond favorably to
nonoperative
management85,88,89,96.
Clinical outcomes in patients with predominantly axial neck pain may be
influenced by psychological
factors114,170.
The benign natural history of neck pain, difficulty in identifying an accurate
pain generator, and the lack of randomized controlled studies comparing
operative and nonoperative management have led many surgeons to recommend
nonoperative management for patients with axial neck pain, but some studies
have demonstrated a substantial decrease in pain and improved function
following anterior cervical discectomy and fusion for axial neck
pain91,171.
Use of both magnetic resonance imaging and provocative discography to
determine whether fusion should be carried out in patients with axial neck
pain has been found to reduce the number of levels that need to be fused, and
sometimes painful levels are revealed to be morphologically normal on the
magnetic resonance
imaging91.
Cervical Radiculopathy
Anterior cervical discectomy and fusion is an excellent operative option
for the treatment of cervical radiculopathy, with good to excellent clinical
results in 70% to 90% of
patients112,172,173.
The age of the patient, the duration of symptoms, and the type of disc (soft
or hard) have not been found to affect the clinical
outcome174,175.
Nonsmokers tend to have significantly more relief of arm pain and a better
clinical outcome than smokers (p <
0.01)133.
Additionally, male gender, greater segmental kyphosis, a greater preoperative
range of motion of the neck, greater right and left hand grip strength, an
organic type of pain drawing, and a low disability score on the NDI (Neck
Disability Index) have been significantly correlated with better postoperative
pain relief in patients with radiculopathy (p <
0.1)176.
Wirth et al. found no significant difference between the clinical outcomes
following anterior cervical discectomy and fusion and those following
posterior foraminotomy for the treatment of cervical
radiculopathy101.
Recurrence of radiculopathy at the same level was more common after
foraminotomy, whereas recurrence at other levels was more common after
anterior cervical discectomy and fusion. Patients treated with posterior
foraminotomy more frequently have persistent neck pain
postoperatively100.
Herkowitz et al. concluded that there was not a significant difference between
the results of anterior cervical discectomy and fusion and those of posterior
foraminotomy, although there was a trend for better clinical outcomes after
anterior cervical discectomy and
fusion102.
Cervical Myelopathy
Good restoration of spinal canal dimensions, earlier decompression, lack of
comorbidity, and either a complete lack of intramedullary cord changes or only
isolated changes on T2-weighted magnetic resonance images predict better
outcomes following anterior decompression for the treatment of cervical
myelopathy57,177,178.
Emery et al. reported on 106 patients with cervical myelopathy who had
undergone either anterior discectomy or corpectomy and fusion without
instrumentation179.
Eighty-two of these patients had preoperative gait abnormalities; thirty-eight
of them recovered normal gait, and an additional thirty-three had an
improvement in gait. Substantial improvements in hand function and sensory
deficits have also been reported after anterior decompression for the
treatment of
myelopathy177,179,180.
A meta-analysis revealed that 55% of more than 2000 patients showed some
neurologic recovery following
laminoplasty181.
The neurologic outcome was not influenced by the laminoplasty technique and
was similar after laminoplasty and laminectomy.
In a study comparing twenty-three patients treated with cervical corpectomy
and twenty-four patients treated with cervical laminoplasty for multilevel
spondylotic myelopathy, no significant difference in the neurologic recovery
was found between the groups at one year, at five years, or at the time of
final follow-up, which ranged from ten to fourteen
years182. Longer
operative times and more blood loss were reported with the anterior cervical
surgery, whereas frequent axial neck pain and more postoperative stiffness
were reported after the laminoplasties.
Neurologic Complications
Flynn reported 311 neurologic complications following more than 36,000
anterior cervical discectomy and fusion procedures done by 704
neurosurgeons183.
Radiculopathy accounted for 40% of the complications; substantial permanent
myelopathy, for 25%; and recurrent laryngeal nerve palsy, for 17%. Recurrent
laryngeal nerve palsy has been reported in 2% to 11% of patients following an
anterior cervical
approach184,185.
A prospective study in which preoperative and postoperative laryngoscopy was
performed in 123 patients who underwent single or multiple-level anterior
cervical discectomy or corpectomy with fusion demonstrated a 24% initial
prevalence of recurrent laryngeal nerve palsy with persistence of the palsy at
three months in
13%186.
Comparative studies have not shown any significant correlation between the
side of the approach and the prevalence of recurrent laryngeal nerve
palsy187.
Avoidance of prolonged retraction, knowledge of the anatomy, careful
dissection, and deflation of the endotracheal tube cuff after placement of the
retractor may all help to diminish the prevalence of this complication.
Postoperative C5 radiculopathy can occur after laminoplasty or laminectomy,
presumably as a result of traction on the short C5 nerve root due to posterior
migration of the cord after posterior decompression or as a result of closure
of the laminoplasty door causing nerve impingement. The complication is
equally frequent following anterior surgery, possibly because of impingement
of the ventral aspect of the spinal cord against the edges of a corpectomy
trough. C5 radiculopathy occurred in approximately 4% of patients after
anterior surgery or laminoplasty and in 1% of patients after
laminectomy188.
Patients with a postoperative C5 palsy were found to have more severe cord
compression at the C3-C4 and C4-C5 levels than did patients without
palsy189.
Spontaneous recovery is expected in the majority of patients, but it may be
delayed for up to twelve
months105,189.
Concurrent foraminotomy and intraoperative electromyographic monitoring of the
C5 nerve root may help to diminish the prevalence of this
condition190,191.
Injury to the superior laryngeal nerve leading to easy voice fatigue and
difficulty with high-pitched tones, and Horner syndrome from injury to the
sympathetic nerves, occur infrequently after anterior surgery.
Neck Pain
More than half of patients experience posterior neck and shoulder girdle
pain after laminoplasty, and the pain may be
severe192. The
prevalence of axial pain and stiffness following multilevel posterior
decompression has been reportedly lowered by preservation of the extensor
muscle and ligament attachments by performing partial or complete
laminectomies or interlaminar decompression at a few levels or by reattaching
osteotomized spinous processes after laminoplasty, and by early postoperative
mobilization182,193-196.
In addition, restricting the laminoplasty to the C3-C6 level and avoiding the
inclusion of C7 in the procedure reduce the prevalence of early postoperative
axial neck
pain197.
Neck Stiffness
Neck stiffness is common after laminoplasty or laminectomy with fusion and
instrumentation. In a meta-analysis of laminoplasty, approximately half of the
range of motion of the neck was found to be lost
postoperatively181.
Postoperative interlaminar osseous fusion, which occurs most frequently at
C2-C3, may be one of the major causes of restriction of the range of motion
following
laminoplasty198.
Substantial postoperative stiffness is not common following anterior cervical
discectomy and fusion. Stiffness following corpectomy and fusion is more
pronounced in patients who have undergone a three or four-level
procedure199.
Instability and Kyphosis
Laminectomy alone, especially in children and young adults or in patients
with preexisting kyphosis or segmental mobility, can result in postoperative
instability, kyphosis, and worsening of the neurologic
deficit200.
Laminectomy with fusion and instrumentation maintains lordosis that is close
to its preoperative
value165. Kyphosis
can also result following laminoplasty, especially when C2 is included, when
preoperative lordosis is <10°, and when the range of preoperative
flexion is greater than the range of preoperative
extension181,201,202.
Dysphagia
Hematoma; local edema; denervation of the pharyngeal plexus; adhesions
between the esophagus, trachea, and prevertebral fascia; and a displaced graft
or instrumentation are potential causes of dysphagia after anterior surgery. A
prevalence of dysphagia of as high as 50% at one month, but with gradual
improvement over time, has been
reported203,204.
The risk of dysphagia is higher after multilevel procedures and in patients
with long-standing neck pain, but the type of procedure (discectomy or
corpectomy) and the use of an anterior plate do not influence the prevalence
of postoperative
dysphagia203,204.
Adjacent-Segment Deterioration
The prevalence of adjacent-segment degeneration increases each year
following anterior cervical fusion, with about 25% of patients having
symptomatic adjacent-segment disease at ten
years205. The
facts that segments most prone to adjacent-segment deterioration are C5-C6 and
C6-C7, which are also most likely to naturally show degenerative changes, and
that this prevalence is similar to that found following foraminotomy without
fusion, suggest that adjacent-segment disease may be a consequence of the
natural evolution of spondylotic disease and not necessarily related to the
adjacent fusion.
Complications with Instrumentation
Breakage or loosening of a plate or screws has been reported in 35% of
patients after anterior
surgery206.
Hardware failure was more common when the screws were not locked to the
plate206.
Migration of the loosened screws into the esophagus is a potential
complication207,208.
Nerve root injury is the most common complication after posterior
instrumentation, but it occurs in fewer than 1% of patients. In one study,
cortical penetration was reported in association with 5% (ten) of 190 pedicle
screws inserted, with no resulting neurovascular complications in these
patients167.
Degenerative cervical spondylosis can present clinically as axial neck
pain, cervical radiculopathy, or cervical myelopathy. Pathoanatomic changes
are generally well visualized on imaging studies and must be correlated with
the clinical findings. Most patients with axial neck pain, cervical
radiculopathy, or mild cervical myelopathy respond well to an initial trial of
nonoperative management.
Anterior cervical discectomy and fusion and laminotomy-foraminotomy are
options for the operative management of cervical radiculopathy. The clinical
outcome after the performance of either of these procedures to treat cervical
radiculopathy is excellent. Surgical considerations in patients with cervical
myelopathy include the number of levels involved, the alignment of the
cervical spine, and the dimensions of the spinal canal. The clinical outcome
following surgery for cervical myelopathy depends primarily on the duration
since the onset of symptoms, the presence and pattern of intramedullary signal
changes on magnetic resonance imaging, and the adequacy of decompression. Both
anterior and posterior decompressions of the cervical spinal cord result in
satisfactory outcomes. Approach-related complications such as dysphagia and
injury to the laryngeal nerves are concerns with the anterior neck approach,
whereas persistent neck pain, stiffness, and the development of instability
are concerns with the posterior approach.
Instrumentation is frequently used in conjunction with anterior or
posterior fusion to increase the rigidity of the construct and to enhance the
success of the fusion. The use of a plate following anterior fusion improves
fusion rates after multilevel anterior cervical discectomy or single-level
corpectomy and can reduce the prevalence of postoperative dislodgment of the
graft and the development of kyphosis even following single-level discectomy.
The prevalence of complications remains high after multilevel anterior
cervical corpectomies, despite the addition of an anterior cervical plate, and
supplemental posterior stabilization ought to be considered for these
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