Cervical Radiculopathy and Myelopathy · PDF file•C1 Atlas •C2 Axis ... finger ext...
Transcript of Cervical Radiculopathy and Myelopathy · PDF file•C1 Atlas •C2 Axis ... finger ext...
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Cervical Radiculopathy and
Myelopathy
Wayne Cheng, MDBones and Spine
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Overview• Anatomy
• Epidemiology
• Natural History
• Clinical Presentation
• Radiology
• Treatment
– Non-Op
– Operative
• OITE Questions
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Anatomy
• Occiput
• C1 Atlas
• C2 Axis
• C3-C7
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Anatomy
• Vertebral bodies of C3-C7 are similar
– Function and appearance
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Anatomy
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Anatomy
• Occipital atlantal joint
– 50% flexion extension
• Atlantoaxial joint
– 50% cervical rotation
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Anatomy
C3C4-5
C6
Lower Mandible C2
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Anatomy
C3C4-5
C6
Lower Mandible C2
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Anatomy
C3C4-5
C6
Lower Mandible C2
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Anatomy
C3C4-5
C6
Lower Mandible C2
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Anatomy
C3C4-5
C6
Lower Mandible C2
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Anatomy
• Disc between bodies of
C2-C7
– Outer annulus fibrosus
– Inner nucleus pulposus
• Force dissipaters
• Thicker anteriorly, cervical
lordosis
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Anatomy• Cervical nerve roots exit above
corresponding vertebral body C1-C7
– C1 exits b/t occiput & C1 body
– C8 exits below C7
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AnatomyNeuroforamina
• Anteromedially uncovertebral joint
• Posterolaterally facet joint
• Superiorly pedicle of above vertebrae
• Inferiorly pedicle of below vertebrae
• Medially edge vertebral end plates &
intervertebral discs
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AnatomyNeuroforamina
• Foramina largest at C2-3
• Progressive decrease in
size to the C6-7 level
• Nerve root occupies 25-
33% foraminal space
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Definition
• Radiculopathy
– Functional disturbance of spinal nerve root
• Myelopathy
– Functional disturbance of the spinal cord
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Vs.
Radiculopathy
Incidence
Natural History
Diagnosis ?
Myelopathy
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Cervical RadiculopathyRisk Factors
• Heavy lifting
– > 25lbs repetitively
• Smoking
• Driving/operating
vibrating equipment
• Previous trauma 15%
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Cervical RadiculopathyEpidemiology
• Annual incidence
.85/1000
– Peak 4th & 5th decades
– 2.1/1000 incidence
• Prevalence 3.3/1000
– Less frequent than
lumbar spine
• M > F ?
• C6 & C7 roots
– most commonly affected
• Degenerative changes
> disc herniation
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Cervical RadiculopathyEpidemiology
• Younger patients
– “Soft” disc herniation
– Acute injury causing foraminal impingement
• Older patients
– Foraminal narrowing
from osteophytes
– More axial neck &
interscapular pain
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Natural History
• Radiculopathy
– 43% no sx after 4 wks
– 30% mild sx.
– 27% continue to have significant sx.
• Lee and Turner 1963 BMJ
• Myelopathy
– Epstein: • 36% improve
• 20% deteriorated
– Symon:• 67% relentless
progression
– Clark & Robinson:• 50% deteriorated.
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Differential Diagnosis
Cervical Radiculopathy
• Tumors
– Intracranial
– Axillary schwannoma
– Osteochondroma
• UE mononeuropathies
– Radial
– Median
– Ulnar
• Thoracic Outlet Syndrome
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Differential Diagnosis
Cervical Radiculopathy
• Brachial Plexus disorders
• Primary shoulder disease
– Rotator cuff
– Adhesive capsulitis
– Glenoid cyst
• Epidural varicose veins
• Vertebral artery dissection
• Infections
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Referred Pain Distribution
– Osteophytes
• Uncovertebral or
Facet joints
– Disc herniation
• Central or Lateral
extrusion
– Combination
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Clinical PresentationHistory
• Radiating arm pain
• Sensibility loss
• Motor deficits
• Reflex changes
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Clinical PresentationHistory
• Disc herniation after
– Trauma
– Repetitive activity
– Awaken at night
• Pain
– Severe
– Burning
– Tooth-ache quality
• Dysphagia
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Clinical PresentationHistory
• Dermatomal distribution
• Example: C5-C6 Disc
– b/t vertebral body C5 + C6
– C6 nerve root compression
• Presenting symptoms – Level of nerve compression
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HISTORY
• 65 year old male , failed
B. CTR and B. RCT
Surgery.
• 54 year old male, WC,
failed posterior
foraminotomy.
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Physical Exam
• Sensation
• Motor strength
• Range of motion
• Deep tendon reflexes
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Physical ExamC4 Radiculopathy
• C3-4 level
• Uncommon
• Weak deltoid
• Variable sensory loss
• Often severe radiating pain
– shoulder & scapula
• Rule out rotator cuff dz
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Physical ExamC5 Radiculopathy
• C4-5 level
– 3rd most common
• Weak deltoid, shoulder external rotators
– perhaps biceps
• Biceps reflex
• Pain & Sensory loss
– lateral shoulder
– lateral brachium
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Physical ExamC6 Radiculopathy
• C5-6 level
• Weak biceps & wrist extension
• Brachioradialis reflex
• Pain & sensory loss
– radial hand
– lateral brachium
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Physical ExamC7 Radiculopathy
• C6-7 level
• Weak triceps, wrist flexion, finger ext
• Triceps reflex
• Pain & sensory loss
– middle finger
– posterolateral arm
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Physical ExamC8 Radiculopathy
• C7-T1 level
– Infrequent
• Weak grip
• Pain & sensory loss
– ulnar hand
– forearm
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Physical ExamT1 Radiculopathy
• T1-2 level
– Very uncommon
• Weak hand intrinsics
• Pain & sensory loss
– ulnar forearm
– elbow
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Physical ExamProvocative Tests
• Spurling Test
• Manual Cervical Distraction
• Valsalva Maneuver
• Shoulder Abduction Sign
• L’hermitte’s Sign
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Physical ExamSpurling Test
• Extending the neck
• Rotating head
• Downward pressure on head
• Positive if pain radiates to side patient’s head is pointed– Positive Spurling in 71% football
players c recent burner (Levitz et al AM J Sp Med 1997)
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Physical ExamManual Cervical Distraction
• Supine patient
• Gentle manual axial
distraction
– Up to ~30lbs
• Positive response
reduction neck and
limb symptoms
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Physical ExamValsalva Test
• Patient bears down
• Increased intrathecal pressure
• Symptoms reproduced
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Physical ExamShoulder Abduction Sign
• While sitting, patient places hand of affected extremity on head
• Support of extremity in scapular plane
• Positive test is reduction of symptoms
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Physical ExamL’hermitte’s Sign
• Neck flexion
• Electric-like sensation radiating down spine and/or extremities
– Cervical spondylosis
– Multiple sclerosis
– Tumor
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Clinical PresentationMyelopathy
• Gait changes
• Bowel(18%) or bladder(15%)dysfunction
• Simultaneous LE changes– sensory or motor
• Diffuse hyperreflexia– Upper motor neuron changes
• 20% no neck or arm pain
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Hoffman’s ReflexMyelopathy
• Suddenly extend middle finger DIP
• Reflex finger flexion
• When asymmetric indicative spinal cord impingement
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Inverted Radial ReflexMyelopathy
• Tapping of distal brachioradialis tendon
• Spastic contraction of finger flexors
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Grip & Release TestMyelopathy
• Form fist and extend fingers rapidly
• Repeat 20x in 10 seconds
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Finger Escape SignMyelopathy
• Hold fingers adducted and extended
• Small & ring fingers fall into flexion abduction
– Usually within 30 seconds
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Radiology
• Radiographs
• Myelogram
• CT Scan
• CT Myelogram
• MRI
• Electrodiagnostics
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RadiographsCervical Radiculopathy
• Only initial screening tool
– Rule out other insidious diseases
• Osteophytes
– Oblique views• Uncovertebral hypertrophy
• Subluxation
– Lateral flexion extension
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RadiographsCervical Radiculopathy
• 30% asymptomatic individuals over 30 yo will have degenerative changes
• 70% by 70 yo will have degenerative changes on x-ray
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MyelogramCervical Radiculopathy
• Intrathecal contrast then X-ray
• Assess space occupying lesions by changes in contour
– Dural sac
– Nerve roots
– Spinal cord
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MyelogramCervical Radiculopathy
• Infection risk
• Difficulty distinguish nature of defect
– Cervical disc herniation
– Osteophyte
• Often used in conjunction with CT
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CTCervical Radiculopathy
• More sensitive than MRI to bony changes
• Limited ability to detect soft tissue lesions
• Ionizing radiation
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CT MyelogramCervical Radiculopathy
• Myelography followed by CT scan
• Better detect bony and space occupying lesions
– Better anatomic information than MRI?
• Risk radiation & infection
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MRICervical Radiculopathy
• Noninvasive, often only study needed
• More sensitive to changes disc,
spinal cord, nerve root & surrounding
soft tissues
– 25% asymptomatic patients > 40yo findings of
HNP or foraminal stenosis
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Radiology DataCervical Radiculopathy
• Blinded retrospective
• Correctly predicted cervical spine surgical pathology
– MRI 88%
– CT Myelo 81%
– Myelography alone 58%
– CT alone 50%Brown et al Am J Neuroradiology 1988
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Treatment
Non-Operative Operative• Rest
• Immobilization
• Medication
• Physical Therapy
• Cervical traction
• Injections
• Indications
• Anterior Approach
• Posterior Approach
• Results
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Non-Operative TreatmentCervical Radiculopathy
• First line therapy
– Neck pain
– Cervical radiculopathy
• Most do well in 6 weeks
– 25% persistent or worsening of symptoms
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ImmobilizationCervical Radiculopathy
• Soft cervical collar
• Limits range of motion
• Minimize nerve root irritation
• Relieve paraspinal muscle spasm
– Hopefully reduce inflammation
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MedicationsCervical Radiculopathy
• NSAIDs
– First choice
– Reduce nerve root inflammation
• Narcotics
• Oral steroids
• Local steroids
• Epidural steroids
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InjectionsCervical Radiculopathy
• Epidural steroids
• Root injections
• Facet blocks
– Less often than in lumbar spine
– Anatomic considerations
– Experienced staff
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Physical TherapyCervical Radiculopathy
• Cervical Traction
• Aerobic exercise
• Postural awareness
• Spinal extensor strengthening
• Thermotherapy
• Acupuncture
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Cervical TractionCervical Radiculopathy
• Soft disc herniations
– Often younger patients
• Less successful
– Spondylosis
– Narrow spinal canals
• 20-30lb usually effective distractive force
• Long-term basis
– select patients
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Non-Operative TreatmentCervical Radiculopathy
• Response in days to weeks
• Protracted non-op care notrecommended in presence of
– Persistent, severe pain
– Weakness
– Major sensibility loss
– Myelopathy with obvious cord findings
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Operative TreatmentIndications
• Compression of nerve root or spinal cord
• Instability
– Spondylolisthesis
– Retrolisthesis
• Deformity
• Failed medical management
• Significant neurologic deficit
– motor weakness
• Severe cervical myelopathy
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Approach
• Anterior– ACDF
– Corpectomy
– 1 or 2 level dz.
• (central or lateral)
• Hard or soft disc
– Kyphosis
• Posterior– Foraminotomy
• Soft lateral disc.
– Laminectomy
– Laminectomy + fusion
– Laminoplasty
– 3 or more levels with preservation of lordosis.
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Anterior ApproachCervical Radiculopathy
• Supine on table
• Left sided approach
– if C4-5 or lower
– Recurrent laryngeal nerve
• Can utilize either side if above C4
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Anterior ApproachCervical Radiculopathy
• Recurrent laryngeal nerve on left
– Predictable course
– Between trachea and esophagus
– Ascends from looping around aortic arch
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Anterior ApproachCervical Radiculopathy
• Once at spine level, spinal needle place into disc space
• Lateral radiograph take to confirm location
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Anterior ApproachCervical Radiculopathy
• Technique described by Robinson &
Smith 1955
– Use tricortical iliac crest graft
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Cloward Technique Cervical Radiculopathy
• Dowel type graft
• Variable size, bicortical
• Sized drill hole carefully placed into center involved disc space
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Bailey & BadgleyCervical Radiculopathy
• Trough made into vertebral bodies
– Above and below involved disc
• Unicortical
– ½ inch width
– 3/16 inch depth
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Simmons & BhallaCervical Radiculopathy
• Keyhole technique
• Beveled bicortical graft
– 14-18 degrees ideal
– Bevel up for superior vertebral body
– Bevel down for inferior vertebral body
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ACDF
• 42 yo with both C6
and C7
radiculopathy
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Posterior ApproachCervical Radiculopathy
• Described two decades b/f anterior popularized
• Utilized in numerous situations
– Lateral soft disc herniation
– Midline spondylotic myelopathy
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Posterior ApproachCervical Radiculopathy
• Radiculopathy without neck pain
• Keyhole foraminotomy
– Lateral discs
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Posterior ApproachCervical Radiculopathy
Raynor et al Neurosurg 1983
• 3-5mm nerve root exposure
• 1/3 removal facet joint
• Similar anterior decompression
– work outside direct vision
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Posterior ApproachCervical RadiculopathyRaynor et al J Neurosurg 1985
• 50% B facetectomies
• 5mm nerve root
– exposure
• Spinal stability intact
• 70% B facetectomies
• 8-10mm nerve root
– exposure
• Significant reduction
of spine stability to
shear
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ANT. CORPECTOMY &
POST FORAMINOTOMY• 59 yo businessman
with severe R. arm
pain.
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Posterior ApproachCervical Myelopathy
• Laminoplasty
– Stenosis
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Cervical Laminoplasty
• 81 year old with
quadriparesis, loss
of function of all 4,
worse with BUE
than BLE.
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Combined
• 42 year old with
progressive
quadriplegia in the
ER
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Combined
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Combined
• 64 year old male,
loss function of
right arm, unsteady
gait.
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Combined
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OITE
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OITE 2000-#73
• A 45yo man has had spontaneous neck and right arm pain for the past 2 days, and he states that the pain is relieved when he places his hand on the top of his head. Examination reveals decreased sensation on the dorsum of the first web space, weakness in the wrist extensors, and an absent brachioradialis reflex. The remainder of the exam is unremarkable. What is the most likely diagnosis?
1—Double-crush phenomenon with carpal tunnel syndrome & cervical disk herniation at C5-6
2—Cervical disk herniation at C6-7
3—Cervical disk herniation at C5-6 with myelopathy
4—Acute cervical disk herniation at C5-6
5—A shoulder impingement lesion & cervical disk herniation at C6-7
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OITE 2000-#73
• A 45yo man has had spontaneous neck and right arm pain for the past 2 days, and he states that the pain is relieved when he places his hand on the top of his head. Examination reveals decreased sensation on the dorsum of the first web space, weakness in the wrist extensors, and an absent brachioradialis reflex. The remainder of the exam is unremarkable. What is the most likely diagnosis?
1—Double-crush phenomenon with carpal tunnel syndrome & cervical disk herniation at C5-6
2—Cervical disk herniation at C6-7
3—Cervical disk herniation at C5-6 with myelopathy
4—Acute cervical disk herniation at C5-6
5—A shoulder impingement lesion & cervical disk herniation at C6-7
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SAE Spine 2000 #2
• A 60yo man underwent an anterior diskectomy and fusion for C4-5 disk disease using a left-sided approach 1 week ago. He now reports a persistent dry cough and mild horseness. Pulmonary evaluation shows evidence of a mild aspiration, and ear, nose, and throat visualization shows laxity of the vocal cord on the left side. What is the most likely explanation for these findings?
1—Traction on the recurrent laryngeal nerve
2—Traction on the superior laryngeal nerve
3—Injury to the pharyngeal nerve branches when ligating the superior thyroid artery
4—Direct trauma to the larynx from retractor blades
5—Direct injury to the vocal cords from endotracheal intubation
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SAE Spine 2000 #2
• A 60yo man underwent an anterior diskectomy and fusion for C4-5 disk disease using a left-sided approach 1 week ago. He now reports a persistent dry cough and mild horseness. Pulmonary evaluation shows evidence of a mild aspiration, and ear, nose, and throat visualization shows laxity of the vocal cord on the left side. What is the most likely explanation for these findings?
1—Traction on the recurrent laryngeal nerve
2—Traction on the superior laryngeal nerve
3—Injury to the pharyngeal nerve branches when ligating the superior thyroid artery
4—Direct trauma to the larynx from retractor blades
5—Direct injury to the vocal cords from endotracheal intubation
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OITE 1999-#24
• An otherwise healthy 79yo woman has had deteriorating function in her hands for the past 6 months when she is knitting or buttoning. She also reports neck pain and stiffness and diminished sensation in the left hand. Examination reveals a broad-based gait, weakness in the interossei in the left hand, a positive left Hoffman sign, and bilateral upgoing toes. What is the most likely diagnosis?
1—Syringomyelia
2—Pathologic fracture of C4 with incomplete spinal cord injury
3—Amytrophic lateral sclerosis
4—Multiple sclerosis
5—Cervical spondylotic myelopathy
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OITE 1999-#24
• An otherwise healthy 79yo woman has had deteriorating function in her hands for the past 6 months when she is knitting or buttoning. She also reports neck pain and stiffness and diminished sensation in the left hand. Examination reveals a broad-based gait, weakness in the interossei in the left hand, a positive left Hoffman sign, and bilateral upgoing toes. What is the most likely diagnosis?
1—Syringomyelia
2—Pathologic fracture of C4 with incomplete spinal cord injury
3—Amytrophic lateral sclerosis
4—Multiple sclerosis
5—Cervical spondylotic myelopathy
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