Neck and Arm Pain: The Result of Long-Standing Wear and Tear on the

Cervical Spine

Robert F. McLain, M.D.Robert F. McLain, M.D.Staff SurgeonStaff Surgeon

Spine and Orthopaedic InstituteSpine and Orthopaedic InstituteSt Vincent Medical GroupSt Vincent Medical Group

Common Spinal DisordersCommon Spinal Disorders

• There are lots of different spinal disorders that There are lots of different spinal disorders that may affect the cervical spine, but doctors may affect the cervical spine, but doctors typically think of the most common as falling typically think of the most common as falling into these categories:into these categories:– DegenerationDegeneration– TraumaTrauma– DeformityDeformity– Tumor and InfectionTumor and Infection

Common Degenerative ConditionsCommon Degenerative Conditions

• Herniated Nucleus Pulposus (HNP)Herniated Nucleus Pulposus (HNP)

• Cervical Stenosis (narrowing of the spinal Cervical Stenosis (narrowing of the spinal canal)canal)

• Cervical Spondylosis (arthritis)Cervical Spondylosis (arthritis)– Disc DegenerationDisc Degeneration– Facet Arthritis Facet Arthritis – Discogenic PainDiscogenic Pain

Introduction:Introduction:

• Cervical Spondylosis causes changes in Cervical Spondylosis causes changes in disc, spinal canal, and the vertebra. The disc, spinal canal, and the vertebra. The biological cause is much the same as in biological cause is much the same as in lumbar disc diseaselumbar disc disease

• As we age, chemical components of the disc As we age, chemical components of the disc change, resulting in a loss of water-holding change, resulting in a loss of water-holding capacity, and a progressive loss of elasticity capacity, and a progressive loss of elasticity and compressive strength of the discand compressive strength of the disc

The Problem:The Problem:

• As the cervical disc As the cervical disc degenerates:degenerates:– End-plates become overloaded and End-plates become overloaded and

scleroticsclerotic– Segmental motion increases, Segmental motion increases,

becomes irregular and becomes irregular and asynchronousasynchronous

– Ligaments become strained, Ligaments become strained, inflamed, painfulinflamed, painful

– Disc height is lost, spurs form, and Disc height is lost, spurs form, and alignment shiftsalignment shifts

The Problem:The Problem:

• Cervical Spondylosis:Cervical Spondylosis: • Disc space collapse and Disc space collapse and

kyphosiskyphosis• Osteophyte formation at Osteophyte formation at

facets and disc spacefacets and disc space• Disc herniationDisc herniation• Mechanical instability and Mechanical instability and

deformitydeformity• All can contribute to cord All can contribute to cord

and root compression…and root compression…

Myelopathy:Myelopathy:

• MyelopathyMyelopathy may be due to mid-central may be due to mid-central herniation, severe cervical herniation, severe cervical spondylosis, congenital or acquired spondylosis, congenital or acquired cervical stenosiscervical stenosis– Pain is less prominent;Pain is less prominent;– Poor motor control, weakness, and Poor motor control, weakness, and

spasticity are more alarming complaintsspasticity are more alarming complaints– May have root symptoms at level of May have root symptoms at level of

compression and long tract signs below compression and long tract signs below that levelthat level

X-raysX-rays

• Plain radiographs demo disc Plain radiographs demo disc space collapse, spur formation, space collapse, spur formation, spondylolisthesis, and loss of spondylolisthesis, and loss of the normal cervical lordosisthe normal cervical lordosis

• Obliques show spurs in the Obliques show spurs in the neural foramenaeneural foramenae

• Flexion / extension views show Flexion / extension views show abnormal motionabnormal motion

• Computed tomography shows Computed tomography shows bony architecture best….bony architecture best….

MRI:MRI:

• MRI gives best view of all MRI gives best view of all soft tissues involvedsoft tissues involved

• Will sometimes reveal a Will sometimes reveal a disc herniation at a level disc herniation at a level other than the obviously other than the obviously degenerated one seen on degenerated one seen on plain radiographs and CTplain radiographs and CT

• Think of MRI as a Think of MRI as a preoperative studypreoperative study

Surgical Treatment: DiscectomySurgical Treatment: Discectomy

• Treatment of cervical disc herniation, Treatment of cervical disc herniation, with nerve root compression or cord with nerve root compression or cord compression, or of disc degeneration compression, or of disc degeneration and neck pain all involve an anterior and neck pain all involve an anterior surgical approach.surgical approach.

• A transverse (side to side) incision in the A transverse (side to side) incision in the skin allows the surgeon to mobilize the skin allows the surgeon to mobilize the vital structures underneath, and reach vital structures underneath, and reach the spine with little actual cutting.the spine with little actual cutting.

Surgical Treatment: DiscectomySurgical Treatment: Discectomy

• Single level disease, or two Single level disease, or two level compression limited to level compression limited to the disc-spacesthe disc-spaces

• Central spurs don't need to Central spurs don't need to be removed, but can be if be removed, but can be if disc-space is disc-space is openopen

• Foraminal osteophytes can Foraminal osteophytes can be removed to decompress be removed to decompress rootroot

• MicroscopeMicroscope improves vision improves vision and safetyand safety

Surgical Treatment: DiscectomySurgical Treatment: Discectomy

• Adjacent level disc Adjacent level disc herniation or spondylosis:herniation or spondylosis:– When motor deficits are When motor deficits are

present, or symptoms do present, or symptoms do not improve, discectomy is not improve, discectomy is indicatedindicated

• Two-level anterior Two-level anterior discectomy discectomy

• Corpectomy and fusionCorpectomy and fusion

Discectomy with Fusion:Discectomy with Fusion:

• Anterior interbody fusionAnterior interbody fusion - - Auto- or allograft spacer Auto- or allograft spacer placed between endplates placed between endplates restores disc hieght and restores disc hieght and alignment, stops painful alignment, stops painful motionmotion– Remove disc without Remove disc without

manipulating cordmanipulating cord– Prepare and contour endplates Prepare and contour endplates – Impact graft into place, filling Impact graft into place, filling

the space and restoring heightthe space and restoring height– Soft-tissue tension-bandSoft-tissue tension-band

Discectomy with Fusion:Discectomy with Fusion:

• Anterior interbody fusionAnterior interbody fusion - - ACDFACDF– Remove painful disc and Remove painful disc and

decompress nerve roots and decompress nerve roots and cordcord

– Place properly sized graft Place properly sized graft between endplates between endplates

– Impact graft into place, filling Impact graft into place, filling the space and restoring the space and restoring heightheight

– Apply plate to restore Apply plate to restore tension-bandtension-band

Surgical Treatment: CorpectomySurgical Treatment: Corpectomy

• For multilevel compressionFor multilevel compression• When adjacent discs are When adjacent discs are

collapsed and difficult to collapsed and difficult to enterenter

• Compression extends Compression extends beyond the disc-space, beyond the disc-space, behind the vertebral bodybehind the vertebral body

• Central stenosis relievedCentral stenosis relieved• Uncovertebral joints Uncovertebral joints

decompressed as welldecompressed as well

Corpectomy and Fusion: StrutCorpectomy and Fusion: Strut

• How best to fill the segmental gap?How best to fill the segmental gap?• Allograft StrutAllograft Strut– Restores foraminal height, segmental alignmentRestores foraminal height, segmental alignment– Immobilizes the painful segment, andImmobilizes the painful segment, and– Provides permanent stabilityProvides permanent stability

• Autograft fibula - fusion rates are high and Autograft fibula - fusion rates are high and morbidity low. morbidity low.

• Titanium mesh cagesTitanium mesh cages

Corpectomy Reconstruction:Corpectomy Reconstruction:

• Anterior corpectomy and Anterior corpectomy and strut graft reconstructionstrut graft reconstruction - -

• Complete corpectomy Complete corpectomy • Meticulous decompression Meticulous decompression

and foraminotomyand foraminotomy• Remove PLL and fibrous Remove PLL and fibrous

membrane to complete membrane to complete decompressiondecompression

• Strut graft augmented with Strut graft augmented with autograft from corpectomyautograft from corpectomy

ReconstructionReconstruction

• Multisegmental Multisegmental reconstructions – reconstructions –

• Graft provides axial Graft provides axial stabilitystability

• Something else must Something else must restore torsional and restore torsional and translational stabilitytranslational stability

• Tension band needed to Tension band needed to provide stability in provide stability in extension.extension.

• Multi-level reconstructions – Multi-level reconstructions – vertebrectomy or multiple vertebrectomy or multiple discectomies – discectomies – create instabilitycreate instability

• Plating Plating

– Maintains correction, combats Maintains correction, combats deforming forcesdeforming forces

– Improves fusion rateImproves fusion rate

– Allows mobility without graft Allows mobility without graft displacementdisplacement

Corpectomy - PlatingCorpectomy - Plating

360 Fusion360 Fusion

• Why go front and back?Why go front and back?– Improved fixation inImproved fixation in• Poor bonePoor bone• Severe instabilitySevere instability• Movement disordersMovement disorders• Severe deformitiesSevere deformities

– Improved fusionImproved fusion– Anterior and Posterior Anterior and Posterior

decompressiondecompression

360 Fusion360 Fusion

• Combined decompression Combined decompression and instrumented fusionand instrumented fusion– 56 y.o. executive56 y.o. executive

• Loss of manual dexterityLoss of manual dexterity• Loss of balanceLoss of balance• Shuffling gaitShuffling gait• Diffuse motor sensory loss Diffuse motor sensory loss

BilatUE’sBilatUE’s

– Progressive myelopathyProgressive myelopathy– Neck PainNeck Pain

Conclusions:Conclusions:

• Patient selection is crucial:Patient selection is crucial:• Before offering surgery:Before offering surgery:– Imaging studies must identify the Imaging studies must identify the

treatabletreatable lesion lesion

– Findings must Findings must correlatecorrelate with clinical with clinical symptomssymptoms

– Appropriate Appropriate conservative measuresconservative measures must have been given a good try must have been given a good try before they were considered to have before they were considered to have failedfailed

Conclusions:Conclusions:

• Decompression:Decompression:• Most patients with acute radiculopathy (arm Most patients with acute radiculopathy (arm

pain) will improve with nonoperative measurespain) will improve with nonoperative measures• Pain can be intense early on – analgesics (pain Pain can be intense early on – analgesics (pain

killers) are often neededkillers) are often needed• Weakness of arms or legs, failure to improve Weakness of arms or legs, failure to improve

with time and therapy, progression of with time and therapy, progression of symptoms: these warrant surgical considerationsymptoms: these warrant surgical consideration

Conclusions:Conclusions:

• Decompression and Fusion:Decompression and Fusion:• When root compression is an isolated problem, When root compression is an isolated problem,

consider decompression aloneconsider decompression alone• When degeneration is severe, fusion is When degeneration is severe, fusion is

necessary to relieve axial neck pain as well as necessary to relieve axial neck pain as well as radiculopathyradiculopathy

• When multiple levels are involved consider When multiple levels are involved consider vertebrectomyvertebrectomy

Conclusions:Conclusions:

• We Consider Plating to:We Consider Plating to:• Immediately mobilize the patients who need to Immediately mobilize the patients who need to

stay activestay active• Completely protect the patients might not follow Completely protect the patients might not follow

all the rulesall the rules• Immobilize multiple segments and spines with Immobilize multiple segments and spines with

three column instabilitythree column instability• Improve fusion rates when more than one level Improve fusion rates when more than one level

is involvedis involved

Conclusions:Conclusions:

• 360 degree fusion:360 degree fusion:• When decompression is needed front and backWhen decompression is needed front and back• When the corrected deformity is severeWhen the corrected deformity is severe• In long anterior decompressions, revision In long anterior decompressions, revision

surgery, or marginal fixationsurgery, or marginal fixation• Patients with movement disorders, post-Patients with movement disorders, post-

laminectomy kyphosislaminectomy kyphosis

Conclusions:Conclusions:

• With careful planning With careful planning and surgical and surgical technique we can technique we can meet our goals:meet our goals:– Protect the neural Protect the neural

elementselements– Stabilize the spineStabilize the spine– Get our patients Get our patients

back to back to appropriate appropriate function ASAP!function ASAP!