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

1. Neck and Arm Pain: The Result of Long-Standing Wear and Tear on the Cervical Spine Robert F. McLain, M.D. Staff Surgeon Spine and Orthopaedic Institute St Vincent Medical Group

2. Common Spinal Disorders • There are lots of different spinal disorders that may affect the cervical spine, but doctors typically think of the most common as falling into these categories: • Degeneration • Trauma • Deformity • Tumor and Infection

3. Common Degenerative Conditions • Herniated Nucleus Pulposus (HNP) • Cervical Stenosis (narrowing of the spinal canal) • Cervical Spondylosis (arthritis) • Disc Degeneration • Facet Arthritis • Discogenic Pain

4. Introduction: • Cervical Spondylosis causes changes in disc, spinal canal, and the vertebra. The biological cause is much the same as in lumbar disc disease • As we age, chemical components of the disc change, resulting in a loss of water-holding capacity, and a progressive loss of elasticity and compressive strength of the disc

5. The Problem: • As the cervical disc degenerates: • End-plates become overloaded and sclerotic • Segmental motion increases, becomes irregular and asynchronous • Ligaments become strained, inflamed, painful • Disc height is lost, spurs form, and alignment shifts

6. The Problem: • Cervical Spondylosis: • Disc space collapse and kyphosis • Osteophyte formation at facets and disc space • Disc herniation • Mechanical instability and deformity • All can contribute to cord and root compression…

7. Myelopathy: • Myelopathy may be due to mid-central herniation, severe cervical spondylosis, congenital or acquired cervical stenosis • Pain is less prominent; • Poor motor control, weakness, and spasticity are more alarming complaints • May have root symptoms at level of compression and long tract signs below that level

8. X-rays • Plain radiographs demo disc space collapse, spur formation, spondylolisthesis, and loss of the normal cervical lordosis • Obliques show spurs in the neural foramenae • Flexion / extension views show abnormal motion • Computed tomography shows bony architecture best….

9. MRI: • MRI gives best view of all soft tissues involved • Will sometimes reveal a disc herniation at a level other than the obviously degenerated one seen on plain radiographs and CT • Think of MRI as a preoperative study

10. Surgical Treatment: Discectomy • Treatment of cervical disc herniation, with nerve root compression or cord compression, or of disc degeneration and neck pain all involve an anterior surgical approach. • A transverse (side to side) incision in the skin allows the surgeon to mobilize the vital structures underneath, and reach the spine with little actual cutting.

11. Surgical Treatment: Discectomy • Single level disease, or two level compression limited to the disc-spaces • Central spurs don't need to be removed, but can be if disc-space is open • Foraminal osteophytes can be removed to decompress root • Microscope improves vision and safety

12. Surgical Treatment: Discectomy • Adjacent level disc herniation or spondylosis: • When motor deficits are present, or symptoms do not improve, discectomy is indicated • Two-level anterior discectomy • Corpectomy and fusion

13. Discectomy with Fusion: • Anterior interbody fusion - Auto- or allograft spacer placed between endplates restores disc hieght and alignment, stops painful motion • Remove disc without manipulating cord • Prepare and contour endplates • Impact graft into place, filling the space and restoring height • Soft-tissue tension-band

14. Discectomy with Fusion: • Anterior interbody fusion - ACDF • Remove painful disc and decompress nerve roots and cord • Place properly sized graft between endplates • Impact graft into place, filling the space and restoring height • Apply plate to restore tension-band

15. Surgical Treatment: Corpectomy • For multilevel compression • When adjacent discs are collapsed and difficult to enter • Compression extends beyond the disc-space, behind the vertebral body • Central stenosis relieved • Uncovertebral joints decompressed as well

16. Corpectomy and Fusion: Strut • How best to fill the segmental gap? • Allograft Strut • Restores foraminal height, segmental alignment • Immobilizes the painful segment, and • Provides permanent stability • Autograft fibula - fusion rates are high and morbidity low. • Titanium mesh cages

17. Corpectomy Reconstruction: • Anterior corpectomy and strut graft reconstruction - • Complete corpectomy • Meticulous decompression and foraminotomy • Remove PLL and fibrous membrane to complete decompression • Strut graft augmented with autograft from corpectomy

18. Reconstruction • Multisegmental reconstructions – • Graft provides axial stability • Something else must restore torsional and translational stability • Tension band needed to provide stability in extension.

19. Corpectomy - Plating • Multi-level reconstructions – vertebrectomy or multiple discectomies – create instability • Plating • Maintains correction, combats deforming forces • Improves fusion rate • Allows mobility without graft displacement

20. 360 Fusion • Why go front and back? • Improved fixation in • Poor bone • Severe instability • Movement disorders • Severe deformities • Improved fusion • Anterior and Posterior decompression

21. 360 Fusion • Combined decompression and instrumented fusion • 56 y.o. executive • Loss of manual dexterity • Loss of balance • Shuffling gait • Diffuse motor sensory loss BilatUE’s • Progressive myelopathy • Neck Pain

22. Conclusions: • Patient selection is crucial: • Before offering surgery: • Imaging studies must identify the treatable lesion • Findings must correlate with clinical symptoms • Appropriate conservative measures must have been given a good try before they were considered to have failed

23. Conclusions: • Decompression: • Most patients with acute radiculopathy (arm pain) will improve with nonoperative measures • Pain can be intense early on – analgesics (pain killers) are often needed • Weakness of arms or legs, failure to improve with time and therapy, progression of symptoms: these warrant surgical consideration

24. Conclusions: • Decompression and Fusion: • When root compression is an isolated problem, consider decompression alone • When degeneration is severe, fusion is necessary to relieve axial neck pain as well as radiculopathy • When multiple levels are involved consider vertebrectomy

25. Conclusions: • We Consider Plating to: • Immediately mobilize the patients who need to stay active • Completely protect the patients might not follow all the rules • Immobilize multiple segments and spines with three column instability • Improve fusion rates when more than one level is involved

26. Conclusions: • 360 degree fusion: • When decompression is needed front and back • When the corrected deformity is severe • In long anterior decompressions, revision surgery, or marginal fixation • Patients with movement disorders, post-laminectomy kyphosis

27. Conclusions: • With careful planning and surgical technique we can meet our goals: • Protect the neural elements • Stabilize the spine • Get our patients back to appropriate function ASAP!