Orthopedics 5th year, 2nd lecture (Dr. Hamid)
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Cervical spondylosis is a common cause of neck pain, radiculopathy, and myelopathy. It involves chronic degenerative changes in the cervical discs and vertebrae due to aging. Common symptoms include neck pain, headaches, and radiating arm pain. Diagnosis involves clinical exam showing signs of radiculopathy or myelopathy as well as imaging like x-rays, CT, and MRI to identify areas of nerve root or spinal cord compression. Treatment options include conservative measures or surgery to decompress the spinal cord if conservative treatment fails.
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Orthopedics 5th year, 2nd lecture (Dr. Hamid)
- 2. CERVICAL SPONDYLOSIS Commonest cause of; - neck pain - Radiculopathy Myelopathy both - Decreased ROM
- 3. Cervical Sponylosis Chronic degenerative lesions of single or multiple intevertebral discs and consequent osteophytosis of related vertebral bodies Cervical spondylosis is a leading cause of musculo- skeletal disability There is no inflammation being not synovial natural process of ageing
- 4. Cervical spondylosis is a general term encompassing a number of degenerative conditions Degenerative disc disease (DDD) Spinal stenosis With or without degenerative facet joints With or without the formation of osteophytes With or without a herniated disc One single component as a diagnosis is rare
- 5. Path--Degeneration -Change in osmotic properties - Decrease in water content - Loss of disc height&ability to expand - Irregularities of end plate - Sclerosis in disc interspace -Formation of spures and osteophytes
- 6. CL/p pressure on (pss)&d,sleeve- = == == = root- = = = = = = =cord- = = = = = = =both-
- 7. history A; Pain in the neck- Dull boring, difficult to localize Morning stiffness Headaches in some – from neck to back of head B: Radicular pain- C5- Deltoid , C6 - Thumb & index finger +- weakness of afected myotoms C:Instability – difficulty in walking, difficulty in climbing stairs D:Bladder and Bowel dysfunction
- 8. Exam -Gait -Look ,feel, move - neurological exam -special test Neck – loss of lordosis, tender areas - restricted & painful neck movements Radiculopathy -Reflex changes wasting of small & big muscles Myelopathy - Brisk jerks in lower ext. Tendency for clonus Spasticity.
- 10. Aetiology Aging process Mechanical load applied to the spine Mechanical instability Abnormal movements Genetic abnormalities of cartilage protein(type IX collagen
- 11. Pridisposing factors Abnormalities of glucose metabolism HLA related genotype aberration Diabetes High blood pressure Smoking
- 12. Osteophite & Spure Disc bulge - peripheral tear within annulus elevates ALL&PLL from bony rim. Produces Tension which stimulates growth & Proliferation of fibroblasts in outer annulus and metaplasia into chondrocytes leads to cartilage, osteophite and spur formation
- 13. IMAGING X-ray CT MRI
- 15. Differential Diagnosis Nerve entrapment Syndromes Rotator Cuff lesions Cervical tumers TOS
- 17. Surgery- 1-progressive C,mylopathy on conservativR/ 2-moderate to sever mylopathy 3-clinical and radiological evidence of radiculopathy with progressive N, defficit. 4--single level with signif, pain and stiffness 5-diffinit foraminal narrowing with n,root compression
- 18. The type of surgical procedure performed will depend upon: Extent of the compression. Number of vertebral levels involved. Location : Anterior Vs. Posterior compression. Instability .+ve or -ve Alignment of the cervical spine;k,L Spine Round Friday October 14, 2005 Cervical Myelopathy
- 19. Two main approaches . Posterior Laminectomy. Laminoplasty Anterior Why not like disc surgery-neucleolysis,percutaneous
- 20. Anterior cervical decompression The goal : To expand the spinal canal To secure spinal stability To preserve the protective function of the spine. Indication : Herniated disc and ostephite removal Vertebral fusion Access C2 - C7 Multilevel cord compression. Morbidities : complexity of multilevel anterior Recurrent laryngeal nerve Rt. Sympathetic nerve Carotid artery . Cervical Myelopathy Spine Round Friday October 14, 2005
- 21. Anterior Cervical Discectomy and Fusion (ACDF) High success rate >90% for 1 level Multilevels Disc removal/decompression Use of microscope Bone graft or other material for fusion Usually with plating
- 23. Cervical Myelopathy Definition Pathological process that affect primary the spine and cause spinal cord impairment : - It is usually chronic and slowly progressive - The main cause is spondylotic compression. -It is quite common in advanced spinal stenosis -Transverse myelitis ( when acute) multiple sclerosis, , infectious myelitis, haemorrhage. Spine Round Friday October 14, 2005 Cervical Myelopathy
- 24. Causes Compromise of the spinal cord Cervical spondylosis . Acute disc herniation. Inflammatory arthritis Spinal stenosis. Trauma Congenital and developmental defects Syringomyelia Neural tube formation defects Spinal neoplasms Physical agents Decompression sickness Electrical injury Radiation Toxins Nitrous oxide Metabolic and nutritional disorders Pernicious anemia Chronic liver disease Remote effect of cancer Arachnoiditis Post infectious autoimmune disorders Acute transverse myelitis Connective tissue disease Multiple sclerosis Epidural infections Primary infections (human immunodeficiency virus [HIV]) Vascular causes Epidural hematoma Atherosclerotic, abdominal aneurysm Malformation Spine Round Friday October 14, 2005 Cervical Myelopathy
- 25. Introduction Cervical Myelopathy , cervical cord compression Cervical spondylosis. 50% . hypertrophy of facet joint and osteophyte formation Hypertrophy of the ligamenta flava. Bulging (or prolapse) of a cervical disc. Spinal stenosis Congenital narrowing. Spine Round Friday October 14, 2005 Cervical Myelopathy
- 26. Spine Round Friday October 14, 2005 Cervical Myelopathy
- 27. Pathophysiology Direct pressure on the spinal cord. ( Mechanical Factors ) Static Dynamic. Ischemia of the cord . compression and obstruction of small vessels within the cord. Compression of the feeding radicular arteries within the the intervertebral foramen. Cervical Myelopathy Spine Round Friday October 14, 2005
- 28. Phathophysiology The morphological changes within the cord include: Degeneration and loss of nerve cells Cavitations and proliferation of glia within the grey matter. Demyelination of the lateral and posterior columns. Wallerian degeneration in ascending tracts above and descending tracts below the compression Proliferation of small blood vessels with thickening of the vessel walls Cervical Myelopathy Spine Round Friday October 14, 2005
- 29. Clinical syndromes Five Clinical syndromes of Spondylotic Myelopathy. Posterior syndrome. Anterior cord syndrome Central cord syndrome Brown-sequard syndrome Cervical Myelopathy Spine Round Friday October 14, 2005
- 30. Diagnosis Clinical History. And exam Neurologic findings. Accurate radiologic imaging studies. Cervical Myelopathy Spine Round Friday October 14, 2005
- 31. Age 30 – 50 Duration of symptoms range from several months to several years. Hand sensory complaints. ( numbness and paresthesia) Gait dysfunctions. Impairment of hand Fine movements . Less frequent symptomes: Sphincter and sexual dysfunction are relatively infrequent ( advance myelopathy) pain. Bladder dysfunction. History and Physical Cervical Myelopathy Spine Round Friday October 14, 2005
- 32. Neurological Examination Sign : Muscle weakness (the hand intrinsic and triceps muscles) Lower extremity weakness (primarily affecting the iliopsoas) Spasticity . (cause of gait dysfunction ) Hyperreflexia . + ve Hoffman reflex. Muscel wasting relatively uncommon Grip&release,inverted radial reflex, finger escape Spine Round Friday October 14, 2005 Cervical Myelopathy
- 33. Sometimes clinical signs do not improve after decompression Sometimes myelopathy progress in spite of decompression Neurological findings do not always correlate with radiological level of compression
- 34. Myelopathy in elderly Wasting of small muscles in hands Weakness of deltoid is characteristic Extension contractures of finger MP joints Numbness & paraesthesiae in hands Difficult to use spoon, button shirt
- 35. Radiological investigations Plain X-ray , ( essential firs step ) AP , lateral and Oblique ; narrow vertebral canal, ( 13 mm lower limit) C anal diameter to body diameter should be greater than 0.8 flexion-extension; mobility of the cervical spine CT Osteophytes, calcified discs, dimensions Inadequate assessment of cord & roots MRI To confirm the nature and extent of the cord compression. ( anterior vs. posterior compression) The severity of the disease. T2 hyperintensity reflects myelomalacia, demyelination, or microcavities Intense signal probably inflammation or edema. Cervical Myelopathy Spine Round Friday October 14, 2005
- 37. Natural history Slowly progressive. Periods of relative stability or accelerated functional decline. Spontaneous improvement is rare. Motor symptoms much more progressive and less likely to improve than sensory abnormalities. Cervical Myelopathy Spine Round Friday October 14, 2005
- 38. Surgery Surgery Spine Round Friday October 14, 2005 Cervical Myelopathy
- 39. THANK YOU
Editor's Notes
- X
- C5-6 level confirming spondylotic osteophytic cord compression, with likely L. C6 root compression. T2-weighted sagittal MR scan of the cervical spine. Compression of the cord is seen at 2 levels, C5-6 and C6-7 with high signal in the cord
- Although there is a