“A Prospective study on Functional and Radiological outcome of anterior cervical discectomy with fusion in Cervical Spondylotic
Myelopathy and Radiculopathy”
Dissertation submitted
In partial fulfillment of the regulation for the award of M.S. Degree in Orthopaedic Surgery
Registration Number: 221712307 Branch II
TIRUNELVELI MEDICAL COLLEGE THE TAMIL NADU
Dr. M.G.R MEDICAL UNIVERSITY CHENNAI-600032
Tamil Nadu – 603103, India.
MAY 2020
CERTIFICATE
This is to certify that this dissertation titled “A PROSPECTIVE STUDY ON FUNCTIONAL AND RADIOLOGICAL OUTCOME OF ANTERIOR CERVICAL DISCECTOMY WITH FUSION IN CERVICAL SPONDYLOTIC MYELOPATHY AND RADICULOPATHY’’ is a bonafide work done byDr. S. VIMALAKANNAN, Post graduate student in the department of Orthopaedics, Tirunelveli Medical College Hospital.
Date: Dr. S. M. KANNAN, M.S., Mch .,
Place: Tirunelveli. Tirunelveli Medical CollegeDean Tirunelveli.
CERTIFICATE
This is to certify that work entitled “A PROSPECTIVE STUDY ON FUNCTIONAL AND RADIOLOGICAL OUTCOME OF ANTERIOR CERVICAL DISCECTOMY WITH FUSION IN CERVICAL SPONDYLOTIC MYELOPATHY AND RADICULOPATHY ” which is being submitted for M.S. Orthopaedics, is a bonafide work of by Dr.S.VIMALAKANNAN, Postgraduate student in the department of Orthopaedics, Tirunelveli Medical College Hospital, Tirunelveli.
He has completed the necessary period of stay in the department and has fulfilled the conditions required for submission of this thesis according to university regulations. The study was undertaken by the candidate himself and the observations recorded have been periodically checked by us. Recommended and Forwarded.
Prof. N. MANIKANDAN, M.S. Ortho., Professor and HOD,
Department of Orthopaedics, Tirunelveli Medical College Hospital,
Tirunelveli.
CERTIFICATE B Y T HE G UIDE
This is to certify that the dissertation entitled “A PROSPECTIVE STUDY ON FUNCTIONAL AND RADIOLOGICAL OUTCOME OF ANTERIOR CERVICAL DISCECTOMY WITH FUSION IN CERVICAL SPONDYLOTIC MYELOPATHY AND RADICULOPATHY” is a bonafide research work done by Dr. S.
VIMALAKANNAN, Postgraduate M.S. student in Department of Orthopaedics, Tirunelveli Medical College Hospital, Tirunelveli, in partial fulfillment of the requirement for the Degree ofM.S. (Master of Surgery)inOrthopaedics.
Date: Signature of Guide
Place: Tirunelveli Assistant Professor,
Department of Orthopaedics, Tirunelveli Medical College,
Tirunelveli.
DECLARATION BY THE CANDIDATE
I solemnly declare that this dissertation titled “A Prospective study on Functional and Radiological outcome of anterior cervical discectomy with fusion in Cervical Spondylotic Myelopathy and Radiculopathy’’ was prepared by me, Registration Number 221712307, Tirunelveli Medical College Hospital under the guidance of Prof. & HOD, Dr. N. MANIKANDAN, Tirunelveli Medical College Hospital, Tirunelveli, in partial fulfillment of Dr.
M. G. R. Tamilnadu Medical University regulations for the award of M. S.
Degree in Orthopaedics.
I have not submitted this dissertation to any other university for the award of any degree or diploma previously.
Date: Signature of Candidate
Place: Tirunelveli Dr.S.VIMALAKANNAN Post Graduate in Orthopaedics,
Tirunelveli Medical College,
Tirunelveli.
ACKNOWLEDGEMENT
I am obliged to record my immense gratitude to Prof. Dr. S. M.
KANNAN M. S., Mch(Uro), Dean, Tirunelveli Medical College Hospital for providing all the facilities to conduct the study in the institution.
It gives me immense pleasure to convey my heartiest gratitude and sincere thanks to P
ROF& HOD D
R. N. MANIKANDAN and PROF. Dr. A.
SURESH KUMAR,Tirunelveli Medical College Hospital who has provided me valuable guidance, assistance with their vast knowledge and professional expertise and constant encouragement throughout the course of my study and in preparation of this dissertation.
I express my heartfelt indebtedness and thanks to Dr. BABU ALOY Assistant Professor of Orthopaedicsfor his incessant encouragement, valuable suggestions and relentless support without which this work could not have seen the present shape.
Words cannot adequately express the deep sense of indebtedness and admiration which I feel towards Dr. Mageswaran, Dr.Sundarapandian,Dr.Arokiya amalan, Dr.Dinesh,Dr. Manikandan, Dr.Chandrasekar, Dr.Balasubramanian, Dr.Eswarapandian, Dr.Palanikumar,Assistant Professor, Orthopaedics, Tirunelveli Medical College& Hospital for their generous guidance, enormous moral support and encouragement.
I express my sincere thanks to all my colleagues, staffs and other members of the department of Orthopaedics of Tirunelveli Medical College, for their assistance in patient counselling and education required for this study.
I express my immeasurable and unlimited gratitude to my parents and friends for giving me the encouragement, nurture, love and care to succeed in this endeavor.
Last but not the least I wish to thank all my patients and their relatives,
who with their excellent cooperation in conducting the present study.
CERTIFICATE –II
This is to certify that this dissertation work title “A PROSPECTIVE STUDY ON FUNCTIONAL AND RADIOLOGICAL OUTCOME OF ANTERIOR CERVICAL DISCECTOMY WITH FUSION IN SPONDYLOTIC MYELOPATHY AND RADICULOPATHY ”of the candidate Dr. S. VIMALAKANNAN, with Registration Number 221712307 for the award of M. S. Degree in the branch of Orthopedics (II). I personally verified the urkund.com website for the purpose of plagiarism check. I found that the uploaded thesis file contains from introduction to conclusion page and the result shows 3%PERCENTAGE of plagiarism in the dissertation.
SIGNATURE OF THE GUIDE Dr. BABU ALOY
Assistant Professor, Department of Orthopaedics, Tirunelveli Medical College,
Tirunelveli
S. NO. CONTENTS
PAGE NO.1. INTRODUCTION
12. AIMS AND OBJECTIVES
23. REVIEW OF LITERATURE
34. DEVELOPMENTAL,NORMAL ANATOMY OF
CERVICAL SPINE
9
5. ANATOMY OF CERVICAL SPINAL CORD
286. BIOMECHANICS
307. DEGENERATIVE DISC DISEASE
328. PATHOGENESIS
339. MATERIALS AND METHODS
5010. SURGICAL TECHNIQUES
6011. OBSERVATIONS AND RESULTS
6712. REPRESENTATIVE CASES
7613. DISCUSSION
8314. CONCLUSION
8615. ANNEXURE
BIBLIOGRAPHY
PROFORMA
CONSENT FORM
MASTER CHART
INTRODUCTION
Cervical spondylosis is a common degenerative disorder of the cervical spine which affects almost every person over 40 years, earlier or later. Pre-existing cervical canal narrowing either congenital or acquired, makes the patient vulnerable to neurological deficit with onset of cervical spondylosis.
Cervical spondylotic myelopathy (CSM) is thought to be caused by cervical canal narrowing due to disc protrusion, ossification of posterior longitudinal ligament (OPLL) or degenerative spondylosis.
Typically, patients with myelopathy have symptoms and signs for several years before seeking medical attention. Although the progression is usually slow, the course involves a progressive decline, if the disease is left untreated. A small percentage of patients exhibits a more rapid onset of progression of symptoms and signs.
Once the patient present with signs and symptoms of cervical spondylotic myelopathy, most of them will have some degree of permanent disability, little changes of symptoms resolution is possible with conservative treatment, therefore many different surgical methods have been developed to expand the cervical spinal canal anteriorly or posteriorly. Although the surgical outcome is directly associated with preoperative severity, there is little information about the role of factors which determines the outcome. Several studies has been done to determine the prognostic factors in outcome.
Many factors have been studied like, patients age, duration of symptoms, pathological changes to the spinal cord, cervical axial canal area, Anteroposterior diameter, intramedullary high signal intensity on T2 W MRI and their effect in prognosis.
AIMS & OBJECTIVES
To assess the age and sex incidence, nature of pain, presence or absence of myelopathy, motor/sensory/deep tendon reflex disturbance in case of cervical degenerative disease.
To measure the diameter of the spinal canal using MRI Cervical-spine.
To correlate with clinical findings and outcomes of various modalities of treatment and outcome of surgery.
To assess the post-operative X rays with regards to the bonyfusion and stability of ACDF.
To evaluate the clinical improvement in radiculopathy, myelopathy, neurological deficit for a follow up period of 12 months.
To assess the pre-operative and post-operative Nurick’s score and Modified JOA scale.
To assess the ODOM’s Criteria outcome.
To assess the pre-operative and post-operative pain score (WONG_BAKER pain score).
REVIEW OF LITERATURE
Reviewing the early history of cervical spinal injuries, we came to know that it is “an ailment not to be treated “As mentioned by the Egyptians in the Edwin Smith Papyrus. The traction was used during Hippocrates period.
In 1877, Boutecou was among the first to reduce fractures with weight attached by adhesive tapes to the patient face. Taylor introduced head halter traction in 1929, which was improved by Crutchfield in 1933 with the introduction of his head holding tongs.
To Nicel et al, goes the distinction of the concept and refinement of the use of halo immobilization.
The first individual to propose a more aggressive treatment ofcervical spine trauma was Hildanus (1672) who described a techniquefor reducing fracture dislocation of the cervical spine. As early as the seventeenth century, Paul of Agena, suggestedsurgical excision of fractured spinous processes for treating spinal disorders.
A French surgeon, Chipault in 1894 published perhaps the firsttextbook on spinal surgery presenting the most complete survey of pastand current spinal surgery. In 1856,he brought out specialist yearbook“travaux de neurology chirugicale” which became the first neurosurgical journal in the world. In 1904, He published manual “de orthopaedicvertebraele”, which primarily dealt with the orthopaedic treatment of spinal disorders.
Bailey and Badgley described a procedure in 1960 to treat instabilityby fusion with iliac
tumor,infection. Their technique involvedcreating an anterior trough in the vertebrae.
The canal was not routinely opened. It should be noted that this series did not include degenerative disc disease.
Verbeist et al in 1966 espoused using autogenous cortical bone.Simmon and Bhallia in 1969 described a “keystone “Graft of the iliaccrest. Whitcloud and La Rocca in 1976 advised the use of cortical fibula.
Anterior cervical fusion was first performed by Bailey and Badgley24in the early 1950s.
Cloward25,26, Smith Robinson27,and others advanced thetechniques of cervical fusion.
But pseudarthrosis rates for multilevelprocedures were as high as 40%, even when external orthotic deviceswere used. The first anterior cervical plate and screw system wasdeveloped by Bohler28 in 1964. But the widely available anterior platingsystem were the ones which were developed by Casparand Orozco29in the early 1980’s.
The next major development in ACP constructs was theSynthes CSLP, developed in Europe by Morscher30in the 1980s andintroduced into the United States by Synthes in the early 1990s, The Orionplating system was developed after the Synthes and offered variablelengthscrews, from 10 to 26 mm, allowing the surgeon to choose betweenuni and bicortical screw purchase.The Codman plate system wasdeveloped to allow for variability in screw direction and to prevent screwbackout. Acromed’s development of the DOC anterior cervical stabilization system marked the first so-called “translational”
cervical stabilizationsystem.
In 2015, Ayush Sharma et al31, showed 46 patients underwent Single level ACDF with C5-C6 the commonest level to be affected. The correlation between Duration of Symptoms to Preoperative and postoperative MJOA was statistically significant. There was a statistically significant improvement in symptoms of axial neck pain, radicular arm pain, clumsy hand, and gait disturbances post operatively at one year. Statically significant difference was noted while comparison MJOA of Preoperative to 6 months and 1 year, and 3 months to 6 months and 1 year. The fusion rate for single level ACDF was 95.65% compared to 71.42% for two levels.
In 2016, Ali Haghnegahdaret al32, evaluated 68 patients who had undergone ACDF for cervical disc herniation. With mean follow-up time of 52.93 (months) ± 31.89 SD (range: 13–131 months), they had success rates with regard to VAS for neckand radicular pain of 88.2% and 89.7%, respectively. Except QOL functional score of JOAMEQ, 100% success rate for the other 4 functional scores of JOAMEQ was achieved.
In 2017, Rouziaji Kamilijianget al33 showed, a total of 6 studies were included in our meta-analysis. No statistical difference was observed with regard to complications, degeneration of the level adjacent to the fusion, fusion rate, arm and neck VAS score, postoperative JOA score between ACCF and ACDF. Compared with ACDF group, the blood loss and operation time were significantly higher in the ACCF group, however, Cobb and fused segment height were significantly lower.
In 2017, A Saravanan et al34, study outcome was satisfactory in 29 patients with one patient with fair result in the series who had signal changes in pre-operative magnetic
resonance imaging and no patients required further surgery in the same level. Average period of fusion was 4 months except for one patient who got delayed fusion due to superficial infection. Commonly fused levels fused levels were at C5-C6 7 patients at C6-C7 4 patients remove. There were no major complications.
In 2018, Sharma et al35,study showed, 60% of patients in both the groups were male. In the autograft group, 36.7% presented with signs and symptoms of myelopathy alone and 63.3% presented with signs and symptoms of myelopathy and radiculopathy, There was statistically significant improvement noted in postoperative MJOA follow-up scores with comparison pairs of preoperative versus 6 months, preoperative versus 1 year, and 3 months versus 6 months, 3 months versus 1 year in both groups. This was most evident between 6 months and 1 year, resulting in plateauing of the improvement in MJOA score between 6 months to 1 year in the autograft group. While there was no statistical difference between fusion rates between the groups for 1 and 2 levels of ACDF, overall fusion rates were significantly better for 1-level ACDF (95.74%) when compared with 2-level ACDF (76.00%).
In 2018, Masahito Oshina36 et al showed, Ten fusion criteria were described. The 4 most common were presence of bridging trabecular bone between the endplates,absence of a radiolucent gap between the graft and endplate, absence of or minimal motion between adjacent vertebral bodies on flexion-extension radiographs, and absence of or minimal motion between the spinous processes on flexion-extension radiographs.The mean fusion rates were 90.2% at 1 year and 94.7% at 2 years.
In 2018, Hassan et al37, shows that the ages in our patient population ranged from 30 to 50 years, with a mean of 40 ± 5.9 years (mean ± standard deviation). Out of 20 patients 11(55%) were males, and 9 (45%) were females. The commonest level affected is C5- C6 level. The most common complaint of patients is neck pain andradiculopathy.
Anterior cervical discectomy followed by single level cervical fusion was done on 13 patients, while 5 patients were subjected to anterior cervical discectomy followed by double level cervical fusion and another 2 patients had anterior cervical discectomy followed by cervical artificial disc replacement at one level and zero profile implant insertion and fusion at another level.
In 2018, Paul oniet al38, There were no severe intraoperative complications such as spinal cord or vertebral artery injury or dissection.73 patients had 4, 10 patients had 5 and 2 patients had 6 anterior cervical level fixations. The visual analog scale (VAS) and Japanese Orthopedic Association (MJOA) scale scores improved (6.9 to 1.3) and 13.9 to 16.5 respectively). The Cobb angle increased from 5.7 to 17.6 postoperatively.
In 2019, Saha AC et al39,maximum patients were within 40-49 years (66.67%) with average 44.7 years. 10 (83.33%) patients were males and 2 (16.67%)females.Single level ACDF by autograft and stabilization by plate and screws was done in 10 (83.33%) patients and 2 (16.67%) patients had two level fusion. The mean follow up period was 12 months. The satisfactory result was found in 10 (83.33%) patients. Post-operative complications were donor site morbidity in2 (16.67%) patients and transient dysphagia in 1 (8.33%) patient. The fusion rate was 100% in this series.
In 2019, Deqing Penget al40. 21 patients underwent ACDF under microscope successfully with a follow-up of 6 months. 7 patients underwent 3-level ACDF, 7 patients underwent 2-level ACDF, and 7patients underwent 1-level ACDF. Study showed duration of follow-up was six months. The pre and postoperative anterior occupying rate were averagely 38.6±8.5% and 12.9±5.5%, respectively, the posterior occupying rates were averagely 27.4±7.2% and 13.1±6.6%, respectively, and JOA scores improved significantly by 59.4±34.0% at six months after surgery.
DEVELOPMENTAL ANATOMY OF CERVICAL SPINE:
The embryological development of mesoderm on either sides of the neural tube and the notochord becomes aggregated into a series of mesodermal blocks called somites1-3 occursduring third week of intrauterine life.
After its formation, each somite differentiates into a
Sclerotome, the ventromedial part.
Dermatomyotome, Dorsolateral part.
Figure 1: Schematic representation of somite development. Somite is divided into sclerotome (scl), Dermatomyotome (Derm) and myotome (Myo).Left and right sclerotomal cell migrates medially and converge around the notochord (NT).
Notochord is (NC).
During the 4th week of intrauterine life:Vertebrae, ribs and spinal ligaments are formed by the former while the latter forms the musculature and the dermis of scalp, neck and trunk.
Basilar portion of the occipital bone is formed by the fusion of caudal portion of the fourth occipital bone with the cranial half of the first cervical sclerotome. Then the caudal half of the 1stcervical sclerotome forms the 1st cervical vertebra. The same type of fusion is repeated down the length of cervical spine. Ventrally,sclerotomal cells forms vertebral bodies and discs. Dorsally, it forms pedicles and lamina of the vertebrae.
Figure 2: Schematic diagram of cranio-vertebral developmental representation with correspondence between sclerotome and occipital bone and vertebral process.
Modified from Muller and O’Rahilly4.
The apical ligament and alar ligament of the atlanto-axial articulation, the nucleus pulposus of the intervertebral discs forms from the notochord. Spinal growth occurs by enchondral ossification that is preceded by mesenchymal chondrification during fifth and sixth weeks.
Fig: 3. Illustrations showing the steps of development of vertebral bodies from sclerotome. (1) Gastrulation and formation of somatic mesoderm and notochord.
(2) Condensation of somatic mesoderm into somites. (3) Formation of Sclerotome and Dermatomyotome. (4) Formation of membranous somitesand re-segmentation with definitive vertebral formation. (5) Vertebral chondrification. (6) Vertebral Ossification.
NORMAL ANATOMY OF CERVICAL SPINE:
The vertebral column is made up of Cervical, Thoracic, Lumbar, Sacral and Coccygeal parts. The cervical vertebrae are identified by the presence of foramina transversarium.
There are 7 vertebrae, out of which first (Atlas), Second (Axis) and Seventh vertebrae are atypical, while the third-sixth are typical.
Figure 4 :Lateral view of cervical spine.
TYPICAL CERVICAL VERTEBRAE:
Each vertebra contains body, vertebral foramen, vertebral arch,attachments and relations.
Figure 6: Characteristic feature of typical vertebrae.
Body:
The body of the vertebra is small and broader from side to side than before backwards.
Superior surface :Concave transversely with upward projecting lips on each side.
Inferior surface :Convex and saddle-shaped.
Anterior broder :May be bevelled. It projects downwardsand may hide the intervertebral discs.
Lateral border: Bevelled and froms synovial joints with the projecting lips of the subsequent lower vertebrae.
Anterior and Posterior surfaces:Resembles to that of other vertebra.
Vertebral foramen:
It is larger than the body. It is triangular in shape since the pedicles are directed backwards and laterally.
Vertebral arch:
It consists of pedicle, lamina, articular processes, transverse processes and spine.
Pedicle: Directed backwards and laterally. The superior and inferior vertebral notch is of same size.
Lamina:Relatively long and narrow, being thinner above than below.
Articular processes:Forms an articular pillars which project laterally at the junction of pedicle and the lamina.
Superior articular facet: Flat, directed backwards and upwards.
Inferior articular facet: Flat, directed forwards and downwards.
Figure 7: Inferior aspect of C3 and superior aspect of C4 showing the sites of articular facet and uncovertebral articulations.
Transverse processes: Pierced by foramina transversarium. Each process has anterior and posterior roots which ends in tubercle, joined by the costotransverse bar.
The costal elements represents the anterior root, anterior tubercle, costotransverse bar and the posterior tubercle.
The anterior tubercle of the 6th vertebra is large and is called carotid tubercle,because the common carotid artery can be compressed against it.
Spine:Short and bifid. The notch is filled up by the ligamentum nuchae.
ATYPICAL VERTEBRA
ATLAS (FIRST CERVICAL VERTEBRA):
Characteristic features of Atlas:
- Ring shaped vertebra.
- Neither a body nor a spine.
- Short anterior arch.
- Long posterior arch.
- Right and left lateral masses.
- Transverse processes.
Anterior arch:
Is identified by median anterior tubercle on the anterior aspect. Its posterior surface bears an oval facet arch which articulates with the dens.
Posterior arch:
Forms about two-fifth of the ring and is much longer than the anterior arch. Its posterior surface is identified by median posterior tubercle. Its upper surface of the arch is marked behind the lateral mass by a groove.
Figure 8: Bony representation atlas C1 vertebra.
Lateral mass:
Each lateral mass shows the important features as follows:
Upper surface:
- Bear the superior articular facet, which is elongated (forward and medially), concave, and is directed upwards and medially. It articulates with the corresponding condyle to form an atlanto-occipital joint.
Figure 9: superior view of Atlas C1 Vertebrae.
Lower surface:
- Marked by the inferior articular facet which is nearly circular, more or less flat and is directed downwards, medially and backwards. It articulates with the corresponding facet on the axis vertebra to form an atlanto-occipital joint.
Medial surface: Identified by a small roughened tubercle.
Transverse process:
Projects laterally from the lateral mass. It is unusually long and can be felt on the surface of the neck between the angle of mandible and the mastoid process. Its long length allows it to act as an effective lever for rotatory movements of the head. The transverse process is pierced by the foramen transversarium.
Figure 10: Inferior view of Atlas C1 vertebrae.
AXIS (SECOND VERTEBRA):
It is identified by the presence of the dens or odontoid process which is a strong, tooth like process projecting upward from the body. The dens is usually believed to represent the centrum or body of the atlas which has fused with the centrum of the axis.
Body and Dens
Superior surface:
- Superior surface of the body is fused with the dens, and is encroached upon on each side by the superior articular facets.
- The dens articulates anteriorly with oval facet on posterior surface of the anterior arch of the atlas, and posteriorly with the transverse ligament of the atlas.
Inferior surface:Prominent anterior margin which projects downwards.
Figure 11: Bony representation of Axis C2 vertebra.
Anterior surface:Presents a median ridge on each side of which there are hollowed out impressions.
Figure 12: Anterior view of Axis C2 Vertebra.
Vertebral arch:
Pedicles: concealed superiorly by the superior articular processes. The inferiorly presents a deep and wide inferior vertebral notch, placed in front of the inferior articular
process. The superior vertebral notch is very shallow and is placed on the upper border of the lamina, behind the superior articular process.
Laminae:Thick and strong.
Figure 13: Postero-superior view of Axis C2 Vertebrae.
Articular facets:
Each superior articular facet occupies the upper surfaces of the body and of the massive pedicle. Laterally, it overhangs the foramen transversarium which is flat, large, circular facet directed upwards and laterally. It articulates with the inferior facet of the atlas vertebra to form the atlanto-axial joint. Each inferior articular facet lies posterior to the transverse process and is directed downwards and forwards to articulate with the third cervical vertebra.
Transverse processes:
Very small and represent the true posterior tubercles only. The foramen transversarium
Spine: Large, thick and very strong. It is deeply grooved inferiorly. Its tip is bifid, terminating in two rough tubercles.
SEVENTH CERVICAL VERTEBRA:
Also known as vertebra prominens because of its long spinous process, the tip of which can be felt through the skin at the lower end of the nuchal furrow.
Figure 14: Superior view of C7 vertebrae.
Spine:Thick, long and nearly horizontal. It is not bifid, but ends in a tubercle.
Transverse processes: comparatively large in size, the posterior root is larger than the anterior. Absent anterior tubercle. The foramen transversarium is relatively small, sometimes double or entirely absent. It doesn’t transmit the vertebral artery.
LOWER CERVICAL SPINE: ANTERIOR ELEMENTS:
The vertebral body is an oblong structure, with a coronal diameter that is larger than its sagittal diameter. Distinct from the normal flat end plates of the thoracic and lumbar vertebra, cervical end plates have a cup in saucer configuration.
Figure 15: Image showing anterior and posterior elements.
Viewed from the front, bilateral projections called the “uncinate processes of luschka”
extends from the lateral aspects of the superior endplates. The uncinated processes articulate with rounded infero-lateral borders of the suprajacent vertebral body.
This articulation, called the “uncovertebral joint”, is a useful surgical anatomical landmark that signals proximity to the lateral extent of the vertebral body.
Mechanically, it is believed to limit posterior translation of the cephalad vertebra5.
Figure16: Diagram of the sub-axial cervical spine viewed from the front. The
The intervertebral disc is interposed between the endplates of adjacent vertebral bodies.
The annular fibrosis is intimately related to the ALL and PLL. The longus colli muscle lie directly over and insert onto the anterolateral aspects of each cervical vertebrae. The sympathetic plexus lies on the top of the lateral longus colli, placing it at risk with overly aggressive dissection or retraction, which results in Horner’s syndrome.
A series of fascial layers invest the anterior cervical structures and separate them from the viscera. The pre-vertebral fascia separates the cervical spine from the overlying esophagus. The pre-tracheal fascia communicates with the carotid sheath, whereas the deep cervical fascia is an extension of the layer enveloping the sternocleidomastoid muscle.
Figure 17: The transverse process is made of two components. The anterior portion is actually the remnant of a costal process. The posterior portion is the true developmental transverse process. Together, they form the transverse foramen, the conduit for the vertebral artery.
Transverse processes project from the lateral aspects of the vertebral body. In contrast to their flat, solid, analogues in the thoracic, lumbar spine, cervical transverse processes
development. The anterior portion of the transverse processes is actually the remnant of a rudimentary costal process. While the costal process form ribs in the thoracic spine.
In the cervical region, each costal process fuses with the true transverse process anlage to form the foramen transversarium that transmits the vertebral artery.
At C6 there is a large accessory process in the area of the transverse foramen. This prominence, alternately called the “carotid process” or “chassaignac’s tubercle”, can be palpated directly and is a useful landmark for identifying the C6 level for anterior surgical approaches. The vertebral artery ascends to the head through the C6 to C1 foramen transversarium. It enters the C7 transverse foramen in only 5% of the population6.
Fractures that enter or displace the transverse processes suggest possible traumatic injury or occlusion, of the vertebral artery.
In addition to housing the vertebral artery, the posterior aspect of the transverse process guides the cervical spine nerves as they exit the spinal canal. The spinal nerves lies posterior to the vertebral artery. If the spine is viewed from the side, the spinal nerve appears to be cradled by the half-pipe configuration of the transverse process, as it projects in an antero-inferior direction.
Figure 18: Diagram of a side view of the cervical spine. The transverse process forms a half pipe configuration that cradles the exiting spinal nerve, while the overall alignment is normally lordotic.
POSTERIOR ELEMENTS:
The cervical pedicle projects from the vertebral body in an orientation that runs postero-lateral to antero-medial. The pedicles form the posteromedial border of the transverse foramina and the anterolateral aspect of the spinal canal. The internal morphology of the cervical pedicles, including the medial and lateral cortical thickness, can vary substantially on the basis of vertebral level and gender7,8.
Such characteristics render transpedicular screw insertion technically difficult, with a high potential for neurovascular injury.
The facet joints, also called the “Zygapophyseal articulations” are highly mobile
processes from adjacent vertebrae. These processes emanate from the posterior aspect of the pedicles and transverse processes.
The articular surfaces are angled approximately 45 degree in relation to the transverse axis of each segment. There is minimal, if any coronal angulation. The pillar of bone between the superior and inferior articular processes is commonly referred to as the lateral mass. It is useful site for posterior screw or wire stabilization of the cervical spine.
The lamina arise from the posteromedial border of the lateral masses. The lamina projects posteriorly and toward the midline, to form bifid spinous processes between C2 and C6. An elastic yellow ligament, the ligamentum flavum, spans each interlaminar space and is non-contiguous in nature. Along with the ligamentum flavum, the strong interspinous and supraspinatus ligaments from the PLC. Disruption of these structures can result in mechanical instability.
INTERVERTEBRAL DISCS:
Each vertebral body below C2 is separated from the subjacent vertebral body by a fibrocartilagenous disc. Each disc consists of inner nucleus pulposus and outer circumferential annulus fibrosus.
The nucleus pulposus has a volume 0.2ml and a diameter of 7mm. It has important property of absorbing and retaining water against pressure (imbibition). It can change its shape and can distribute it equally. A thin hyaline cartilage endplates lies between these components and adjacent subchondral portion of vertebral body.
The cartilage plays a role in growth of vertebral body and nutrition of the disc. The discs contributes 22% of the length of the cervical column. The ratio of the disc to vertebral body in the cervical spine 1:3. The disc between C6 and C7 is the thickest.
The cervical disc is thicker in front than at the back with the result that in erect posture, the anterior heights of the discs (summated) is 8mm more than posterior heights (resulting inlordosis of the cervical spine).
ATTACHMENTS AND RELATIONS:
Figure 20: A median sagittal section through the occipital bone and first to third vertebra.
ANATOMY OF CERVICAL SPINAL CORD:
Cervical spinal cord extends from, the foramen magnum where it is continuous with medulla oblongata. The anterior wall vertebral canal is formed the posterior surface of vertebra and disc covered by PL, laterally by pedicles and sequential intervertebral foramina and posteriorly by the lamina and the ligamentum flavum medially and the facet joints laterally.
The canal has greater lateral than AP width and its widest at its upper end with sagittal diameters.
Levels C1 C2 C3-C6 C7
Sizes 23mm 20mm 17mm 15mm
The spinal cord enlarges from C3 to C6 where is usually attains maximal transverse diameter of 13-14mm9.
CERVICAL NERVE ROOTS:
The roots course obliquely laterally and caudally toward intervertebral foramen. Each dorsal root presents an oval enlargement, the dorsal root ganglion as it approaches intervertebral foramen.
Just distal to the dorsal root ganglion the ventral and dorsal roots join to form corresponding spinal nerves. The cervical spinal nerve occupies 1/3rd of foramen, usually in the inferior aspect whereas the superior portion is filled with fat and veins.
The first cervical spine nerves exits between occiput and C1, C2 to C7 exit above the
the spinal nerve exits below the pedicle of corresponding numbered vertebra. C8 spinal nerves exits between C7 and T1 vertebra.
VASCULAR SUPPLY- VERTEBRAL ARTERY:
The vertebral artery is the first and the largest branch of the sub-clavian artery arising from the posterosuperior aspect of its first part. It runs upward and backward in the scalenovertebral triangle formed by scalenus anterior and longus colli muscle
Figure 25: Diagrammatic representation showing vascular supply.
It ascends anteriorly to the transverse process of the C7 vertebra, thus lateral to the transverse foramen at that level, penetrating the transverse foramen of the C6 vertebra and following ascending path always through the transverse foramina upto the C2 vertebrae.
BIOMECHANICS OF CERVICAL SPINE:
Flexion, extension, lateral bending and rotation are the movements occurs at lower cervical spine. Flexion and extension movements are more at C5-C6 and C6-C7. Neck movements diminish with increasing in age. Head deflection occurs secondarily.
A motion segment is made up of two adjacent vertebra and an intervening soft tissue. If a motion segment has all anterior and one posterior elements(or) all the posterior and one anterior element intact, than it remain stable under physiological load.
Figure 27: Normal range of motion.
The cervical spine motion can be analyzed in three different axis;
Flexion/extension.
Lateral bending
Axial rotation.
The occipital cervical junction contributes to approximately 50% of the neck flexion /extension movements.The atlantoaxial articulation contributes to approximately 50%
In subaxial cervical spine the main motion patterns are flexion/extension and lateral bending. The majority of the flexion/extension movement in the subaxial cervical spine occurs at the level of C4/C5 and C5/C6.
The majority of the lateral bending occurs from C2-C4. The least mobile segment in the cervical spine is C7/T1.
Interspace Lateral Bending Flexion-Extension Axial Rotation
C2-C3 10 10 3
C3-C4 11 15 7
C4-C5 11 20 7
C5-C6 8 20 7
C6-C7 7 17 6
C7-T1 4 9 2
CERVICAL DISC DEGENERATIVE DISORDERS
Degenerative disc disease(DDD) of the cervical spine is the most common musculoskeletal disorder with more than 65% of the population suffering from at least one major episode of neck pain in their life time.
Patients with DDD can be grouped into three different clinical syndromes and they are:
Axial neck pain
Cervical radiculopathy – due to compression and /or inflammation of the nerve root.
Cervical myelopathy – due to compression of the spinal cord.
EPIDEMIOLOGY:
Symptomatic disc disease is more common in men by ratio 1.4:1. The prevalence of neck pain is higher in educated individuals with history of injury and headaches or low back pain.
Cigarette smoking, frequent weight lifting and frequent diving are also associated with increased degeneration.
Chiu et al10 reported a higher incidence of neck pain in people with sedentary desk or computer jobs.
Jensen et al11 reported occupation specific increased risk like 54-76% in miners and 84% in butchers.
CERVICAL SPONDYLOTIC RADICULOPATHY
Cervical spondylotic radiculopathy is characterized by pain radiating from the neck due to compression of cervical roots. Sensory, motor and/or reflex abnormalities are
frequently associated.
PATHOPHYSIOLOGY:
Radiculopathy may occur from postero-lateral soft disc herniation contained by the PLL or free material extruded into and sequestrated within the canal. Foraminal stenosis and /or ligamentum flavum hypertrophy from the degenerative changes may also lead to impingement on the exiting nerve root.
Soft cervical disc herniation is divided into three types with respect to the intraspinal location of the herniated mass.
Median, Para-median - produces myelopathy Lateral herniation – produces radiculopathy.
Figure 28: Diagram depicting the zones in the central and lateral spinal canal and the definitions of the boundaries.
Figure 29: CT myelography axial sections (A) Median disc with oblique course (B) Para-median disc (C) Postero-lateral disc protrusions.
CAUSES:
1. Age and sex
2. Repeated occupational trauma (carrying axial load, professional dancing, gymnastics)
3. Prolonged occupational posture (sitting in front of the compute for software professionals).
4. Familial 5. Smoking
6. Abnormal neck posture. eg: sleeping in seated posture, driving on a 2 wheeler for long hours.
CLINICAL EVALUATION:
Examination of the patient presenting with symptoms of cervical radiculopathy demands a detailed examination of the neck, shoulder, arm and lower extremities.
Motor, sensory and reflex abnormalities localize the level of pathology.
It presents with single or multiple nerve root distribution. It consist of variable degrees of sharp, lancinating radiating arm pain, usually going down beyond the elbow associated with various degrees of dysesthesia’s, paresthesia and numbness along a dermatomal pattern of the involved nerve root.
Specific physical examination maneuvers are used to evaluate cervical spondylotic radiculopathy. With valsalva’s maneuver, pain is increased.
Spurling’s sign: Elicited by neck hyperextension and rotation towards the symptomatic side resulting in reproduction of the arm pain.
Provocative sign: A less reliable, the axial compression test, in which compression on the vertex of the skull may diminish the height of the foramen.
Shoulder abduction sign: Also known as Davidson’s test, which relieves symptoms of compression by lessening nerve root stretch with placement of the ipsilateral top of the head.
INVESTIGATIONS:
Plain X rays:
AP (antero-posterior), lateral and oblique views obtained.
Flexion-extension, dynamic lateral images in flexion should be obtained, in-case of instability is suspected.
MRI:
It gives direct information about nerve root or spinal cord compression, narrowing of disc space, developmental canal stenosis, subluxations and
The advantage of MRI in detecting direct compression is the intrinsic “contrast”
available from cerebrospinal fluid as seen on the T2 weighted images shows intramedullary cord changes that may relate to disease prognosis.
CT- Myelography:
Water soluble myelography is the next step, when MRI cannot be done.
AP view demonstrates the exiting nerve roots to the level of the pedicle where a filling defect is a typical finding of nerve root compression.
Lateral view may detect spinal cord compression disc or posterior vertebral osteophytes hypertrophied ligamentum flavum or both.
Myelographically enhanced CT improves visualization of osseous compressive structures especially neuroforamina.
CT myelography infers neural compression by deformity of the dural sac or nerve roots, however, cannot directly determine the etiology of contrast blockade.
Figure 31: Cervical myelopathy secondary to intervertebral disc protrusion at C5-
Electromyography or Nerve conduction studies:
May be used to confirmsuspected radiculopathy or may be used as an additional diagnostic method to further elucidate the cause of symptoms in a patient with atypical findings.
MANAGEMENT:
CONSERVATIVE TREATMENT:
An acute episode of unilateral radiculopathy without a major motor deficit and no evidence of spinal cord compression can be well managed by non-operative measures.
Patients with signs and symptoms of myelopathy, significant motor weakness, disabling pain and numbness or progressive neurological deficits should be considered for early surgical intervention12.
1. NSAID – Decrease inflammation/Pain relief.
2. Acetaminophen – Pain relief
3. Oral steroids -Reduce inflammation/Reduce radicular symptoms.
4. Muscle relaxants – Obviate paravertebral muscle spasm.
5. Narcotics – not routinely used/decrease acute severe pain.
6. Tricyclic Anti-depressants – Decrease radicular symptoms by altering the perception of pain.
7. Anti-convulsants – Reduces pain and radicular symptoms.
8. Bed rest may be appropriate for patients with an acute radiculopathy that is aggravated by work or moderate activity.
9. Collar may be worn for a few days only, followed by a period of warning.
Physical therapy/ Therapy/Life style modification:
a. Advice weight loss.
b. Avoidance of pre-disposing factors.
c. Muscle stretching and strengthening exercises after subsidence of acute pain.
d. Avoid lifting heavy weights and strenuous activities.
e. Heat application to decrease pain.
OPERATIVE TREATMENT
Indications:
Failure of a 2-3 month trial of conservation methods of treatment to relieve persistent or recurrent radicular arm pain with or without neurologic deficit and a progressive neurologic deficit.
Types of approaches are as follows:
Anterior decompression with discectomy with or without interbody fusion.
Anterior corpectomy with fusion.
Cervical disc replacement.
Posterior laminotomy with foraminotomy.
Laminectomy with or without fusion.
ANTERIOR APPROACHES:
Anterior surgical exposure is relatively safe and takes advantage of normal anatomic facial planes during the approach. A transverse incision is to be used for exposure in most patients when one or two discs are to be exposed. When three or more levels are
to be approached, a longitudinal incision along the anterior border of sternocleidomastoid recommended.
Anterior Cervical Discectomy with or without Fusion (ACDF/ ACD):
Disc removal is best done under microscope with good magnification and illumination.
Rent is noted or if an expected disc fragment is not identified, the PLL is removed the fragment identified. The disc spaces with relatively less movements can be alone with equally good functional outcome.
Figure 32: Restoration of the neuroforaminal height with the use of appropriate bone graft.
Different techniques of interbody fusion differ mainly in the graft configuration.
Cloward techniqueuses a Bicortical dowel shaped graft.
Simmons and Bhalla technique uses akeystone shaped graft.
Bailey and Badgley technique uses a Uni-cortical iliac crest graft.
Smith Robinson techniqueuses a Tricortical iliac crest wedge graft
Total disc replacement (TDR):
Adjacent segment degeneration is defined as new onset of myelopathy or radiculopathy significant enough to require surgery at one or two levels. This has got very limited indications and is ideally suited for a single level disc herniation causing radiculopathy.
Anterior cervical Corpectomy and Fusion (ACF):
ACF is needed in situations such as disc herniation associated with a sequestered fragment that has migrated behind the vertebral body. Subtotal anterior corpectomy and fusion is performed when two-level radiculopathy is present. Advantage of ACF over two-level ACDF is based on the number of segments that must fuse.
POSTERIOR APPROACHES
Posterior decompression for cervical radiculopathy can be by,
Laminotomy.
Foraminotomy.
Laminoforaminotomy.
Indicated rarely in the management of lateral disc protrusions. It involves removal of portions of the inferior and superior lamina at the level of the specific nerve root compression and partial facetectomy with a high speed burr. To prevent iatrogenic instability, no more than 50% of the facet is removed.
CERVICAL SPONDYLOTIC MYELOPATHY
It is the most common dysfunction of spinal cord with degenerative changes such as hypertrophic ligamentum flavum, height loss, facet and uncovertebral joint osteophytes leads to spinal cord compression and development of clinical symptoms and long tract signs13,14.
There is a decrease in the space available for the cervical spinal cord due to progressive multilevel circumferential compression. It can be produced by single or double level compression, spondylotic cervical myelopathy is often multilevel.
PATHOPHYSIOLOGY:
Final sequelae of degenerative disc disease. Osteophytes and spondylotic transverse bar form in spondylosis producing bulging of the posterior disc and stretching of the posterior longitudinal ligament (PLL).
Collapse of the anterior column height leads to buckling of the ligamentum flavum into the spinal canal (most notably during neck extension). This combination of evens may lead to spondylosis- induced compromise of the antero-posterior diameter of the canal and produce myelopathy.
Certain other factors important in the development of myelopathy are:
Congenital narrowing of spinal canal.
Dynamic cord compression.
Dynamic changes in the intrinsic morphology of the spinal cord.
Vascular supply of the spinal cord.
Sub axial spine in normal adults, antero-posterior diameter is 17 – 18 mm with the diameter of the spinal cord is approximately 10mm in this region.Individuals with an antero-posterior diameter of the spinal canal <13mm are considered to have congenital cervical stenosis.
There is a strong association between flattening of the cord within the narrowed spinal canal and the development of cervical myelopathy.
Translation or angulation between vertebral bodies in flexion or extension can result in narrowing of the space available for the cord.
Retrolisthesis of a vertebral body can result in pinching of the spinal cord between the inferior-posterior margin of a vertebral body and the superior edge of the lamina caudad to it.
This compression may be aggravated in extension, relieved in flexion. Hyperextension further narrows the spinal canal by buckling the ligamentum flavum.
CLINICAL FEATURES:
The most common cause of acquired spastic quadriparesis in adults. The patient may present with subtle findings that have been present for years or with quadriparesis that developed over the course of few hours.
Surgery is usually recommended when there is a gait disturbances and loss of fine motor control, when it presents with a combination of JOA score of < 13 and radiographic evidence of spinal cord compression. A maximum score of 17 indicates normal function and recovery rate describes the extent to which the score returns to
The clinical picture varies, depending on the anatomic portion of the cord that is primarily involved.
Ferguson and Caplan divided cervical spondylotic myelopathy into 4 syndromes.
I. Medial syndrome, consisting primarily of long tract symptoms.
II. Lateral syndrome, consisting primarily of radicular symptoms.
III. Combined medial and lateral syndromes, which is the most common clinical presentation.
IV. Vascular syndrome, which presents with rapid progressive myelopathy and is thought to represent vascular insufficiency of the spinal cord.
Patients typically present with the insidious onset of clumsiness in the hands and lower limbs. Sometimes may report worsening handwriting in the past few months or weeks, difficulty with grasping and holding or diffuse numbness in the hands.
10- 20 % of patients first notice symptoms in the lower extremities. They frequently have had increasing difficulty with balance that they attribute to age or arthritic hips and relatives may volunteer that their gait has become increasingly awkward.
Muscle weakness wasting in the lower extremities with superimposed loss of proprioception result in an unsteady, broad-based gait.
Nurick’s 15 developed a system of grading the disability in cervical spondylotic myelopathy on the basis of gait abnormality and ambulatory status.
The Lhermitte’s sign with shock sensations in the torso and limbs resulting from quick flexion and extension of the neck is present in 1/3rdof the patients.
This symptom indicates an early stage of the disease and a greater possibility improvement through operative treatment.
Clinical features:
Pain, temperature, proprioception, vibratory and dermatomal sensations may all be diminished, depending on the exact area of the cordor the nerve root that is compromised.
Patients may complain of urgency of urine, hesitation and frequency and rarely of urinary incontinence or retention.
Diminished tendon reflexes, muscle weakness and sensory disturbance in the upper extremities are signs of gray matter lesions. Exaggerated knee and ankle jerks, negative cremasteric reflex, positive Babinski’s sign and sensory disturbance found within the lower extremities or trunk are signs of white matter damage.
Hand dysfunction in CSM can present myelopathy hand. Diffuse numbness in the hands is extremely the C6-7 disc levels which accounts for only 5% of patients with cervical myelopathy. Retrolisthesis of the cervical spine seen in extension, which is a principal component of dynamic stenosis which occurs at the C6-7 discs because of its anterior tilt.
INVESTIGATIONS:
Plain X-rays:
Anteroposterior (AP view)
Lateral view.
Average sagittal diameter as measured on the lateral X-Ray, from C3 to C7 is reduced form 17 mm in normal individuals to 8-13 mm less in patients with cervical myelopathy16,17.
Diagnostic imaging helps in the diagnosis of cervical myelopathy involves the following three aspects:
Detection of pathological spinal factors responsible for the symptomatology
Evaluation of the compression and deformity of the spinal cord and
Evaluation of the intramedullary lesion MRI:
It isused to evaluate the adequacy of spinal cord decompression after surgery following seven spinal factors have been described as causative components of cervical myelopathy:
I. Developmental stenosis II. Dynamic stenosis III. Disc herniation
IV. Segmental ossification of the posterior longitudinal ligament ( OPLL ) V. Continuous OPLL
VI. Posterior spur
VII. Hypertrophy and/or calcification of the ligamentum flavum.
Myelography:
Evaluation of compression of the spinal cord before the advent of MRI. It demonstrates only the degree of obliteration of the subarachnoid space depicting a complete or
incomplete block. In contrast, MRI directly demonstrates deformities of the compressed spinal cord on both sagittal and axial views.
MANAGEMENT:
Conservative treatment:
It is helpful in the early period of the disease. Patients presenting with the new onset of subtle myelopathic findings and radiographic evidence of a soft disc herniation may be initially treated non-operatively and are followed carefully at frequent intervals to evaluate for progression or remission of symptoms.
Indicators for a poor prognosis:
Advanced age.
Duration of symptoms > 6 months.
Severity and progression of myelopathy severity of stenosis with a torg ratio of 0.8 or less or area cord measuring < 40mm2.
OPERATIVE TREATMENT
The goals of operative intervention includes as follows:
Decompression of the spinal cord.
Stabilization of the spinal column.
Reestablishment of the normal sagittal alignment.
Pre-operative findings that favor a successful surgical outcome:
Young age at presentation.
Involvement of pathology limited to fewer vertebral segments.
Presence of unilateral symptoms.
ANTERIOR PROCEDURES
An anterior approach allows the surgeon to relieve any direct compression on the anterior spinal artery which supplies the major ventral part of the spinal cord. Anterior approach is the procedure of choice and it provides adequate decompression18,19.
I. Anterior cervical discectomy and fusion II. Anterior corpectomy and fusion
Corpectomy is considered preferable to multiple ACDF, especially in higher –risk patients, such as recent smokers, diabetics or revision cases. It is an excellent alternative when there is compression behind the vertebral body usually a thickened, occasionally calcified PLL.
Midline subtotal corpectomy of the middle bodies is accomplished for two –level decompression. Static plates, buttress plates and dynamic plates have been introduced with the intended purpose of decreasing the rate of nonunion and to prevent anterior strut graft dislodgement after corpectomy.
Complications:
One of the most common sequelae of anterior procedures is postoperative dysphagia.
Etiology: It is multifactorial, including hematoma formation, prolonged retraction and degenerative plexus. Postoperative dysphonia is related to direct injury to the recurrent of retraction.
POSTERIOR APPROACH:
Posterior decompression:
Compression of the spinal cord at three levels or who have development stenosis, in those who have calcification of the ligamentum flavum and/or PLL20,21.
Two techniques of decompressing the cervical spine form a posterior approach as follows:
Laminectomy with fusion
Laminoplasty
Laminectomy and Laminoplasty for posterior decompression are popular. The C2 spinous process and the semispinalis muscles attached to it should be left intact in order to prevent post-laminectomy kyphosis. It avoid the potential for injury to the esophagus, trachea and laryngeal nerves.
Laminectomy:
It is the standard posterior procedure for the treatment of multilevel cervical myelopathy. It is a straightforward technique that provides for an extensile posterior decompression and excellent visualization of the neural elements. Postoperative cervical kyphosis after laminectomy is directly related to the amount of facet joint resection.
Laminectomy and fusion:
Concurrent lateral mass screw rod fixation has the advantage of stabilizing the decompressed segment in a lordotic posture and preventing segmental instability.
Fusion also permits a more expansive laminectomy and foraminal decompression without jeopardizing stability.
Limitations of the procedure relate principally to attempts at fusion: nonunion, hardware failure, adjacent segment degeneration loss of lordosis.
Laminoplasty:
Two forms of Laminoplasty strategies are eccentric expansion with a unilateral hinge and symmetric expansion with bilateral hingers.
The commonest purpose of all Laminoplastyprocedures is the increase in canal area through reconfiguring the posterior bony arch. Fusion of decompressed levels should be avoided. Decompression of neuroforamina may also be achieved by performing a Laminoforaminotomy before expansion of the posterior arch or through direct decompression of the neuroforamina after the expansion of the posterior arch.
Laminoplasty has also been demonstrated the management of cervical spondylotic myelopathy in the elderly, diabetics and patients on dialysis. Cord decompression occurs as the spinal cord migrates dorsally away from impinging anterior structures.
Two types of Laminoplasty:
Open - Door Laminoplasty22
French - Door Laminoplasty23 COMPLICATIONS:
Neurological complications includes iatrogenic cord or root trauma, nerve root dysfunction and late neurologic deterioration. Nerve root palsy, especially C5, has been
MATERIALS AND METHODOLOGY
Study Area: Department of Orthopaedics, Tirunelveli Medical College Hospital, Tirunelveli.
Study Population: Clinically suspected patients with cervical spondylotic myelo- radiculopathy.
Period of Study:October 2017 to September 2019
Sample Size: 20 patients with clinical suspicious of cervical spondylotic myelo- radiculopathy.
Type of Study: Prospective study.
INCLUSION CRITERIA:
Patients with persistent severe radicular pain and not corresponding to conservative management for 3 months.
Patients with cervical radiculopathy with progressive paresis.
Patients with myelopathy secondary to cervical spinal canal stenosis with disc.
Patients with posterior osteophyte complex disease.
Cases of all age groups irrespective of sex.
EXCLUSION CRITERIA:
Patients with cervical trauma.
Patients with ongoing cervical infection.
METHOD OF COLLECTION:
A standardized protocol is followed for assessment of patients after an informed consent.
Clinically patient had axial and sub-axial neck pain as their predominant complaint.
Sensory symptoms precede the motor symptoms in majority of the patients. Complete neurological examination to ascertain the motor/sensory loss and loss/brisk reflexes and any signs of myelopathy.
There is some amount of neck movement restriction as the pain progresses because of the neck muscle spasm. Impairment of the deep tendon reflexes is seen in most cause of radiculopathy – most common being Brachioradialis. Sensory changes is seen predominantly in the C6 and C7 dermatome.
Radiculopathy pain is aggravated by coughing, sneezing and lifting heavy weights.
Careful history and examination is done to rule out shoulder pathology, angina and intra spinal tumors.
Nurick’s Grading was used to evaluate the severity of cervical myelopathy preoperatively and post operatively.
NURICK’S DISABILITY SCORE:
GRADE SIGNS AND SYMPTOMS
0 Signs or symptoms of root involvement but no evidence of spinal cord disease.
1 Signs of spinal cord disease but no difficulty walking.
2 Slight difficult in walking that prevented full time employment.
3 Difficulty in walking that prevented full time employment or the ability to do all house work, but that was not so severe as to require someone’s help to walk.
4 Able to walk only with someone else’s help or with an aid of a frame.
5 Chair bound or bed ridden.
Patients age, duration of symptoms, pre-operative neurological disability (Nurick’s grade), effective canal diameter, number of levels of compression, intramedullary hyperintense signal changes in T2 MRI, were evaluated.
Wada and colleagues recommended using a combination of the patient’s clinical findings, pre-operative functional status as measured by Modified Japanese Orthopaedic Association Scale.
MODIFIED JOA SCALE:
CATEGORY SCORE (POINT)
Motor dysfunction of the upper extremity:
Unable to feed oneself.
Unable to handle chopsticks, able to eat with spoon.
Able to handle chopsticks with much difficulty.
Able to handle chopsticks with slight difficulty.
None.
0 1 2 3 4 Motor dysfunction of the lower extremity:
Unable to walk
Can walk on flat floor with walking aid.
Can walk up and for down stairs with handrail.
Lack of stability and smooth gait.
None.
0 1 2 3 4 Sensory Deficit:
Upper extremity:
Severe sensory loss or pain.
Mild sensory loss.
0 1
None.
Lower Extremity:
Severe sensory loss or pain.
Mild sensory loss.
None.
Trunk:
Severe sensory loss or pain.
Mild sensory loss.
None.
2
0 1 2
0 1 2 Sphincter dysfunction:
Unable to void.
Marked difficulty in micturition (Retention).
Difficulty in micturition (frequency, hesitation).
None.
0 1 2 3
VISUAL PAIN:
Pain is one of the major complaint in patients with myelopathy and radiculopathy.
There are many pain scales to assess the severity of pain in patients. In our study, WONG BAKERpain scale was used to assess the pre-op and post-op severity of pain.
RADIOLOGICAL EXAMINATION:
All patients clinically suspected to be suffering from cervical spondylosis are subjected to radiological imaging.
Plain X-rays:
Plain radiograph study remains the primary diagnostic spine evaluation.
The views are as follows:
- Antero-posterior view.
- Lateral view.
- Right and left oblique views
Cervical X rays should be performed in supine position. The patient is not moved to position for the various views, but the X ray beam and film position is adjusted to
Accurate interpretation of the lateral cervical spine radiographs is essential. An adequate lateral X-ray must visualize occiput to the first thoracic vertebra. Alignment of the cervical vertebra is assessed by drawing longitudinal lines along the vertebral bodies, lamina and spinous process.
Digital X-ray C-spine is taken to measure PAVLOV-TORG ratio and assess the degree of cervical stenosis. Evidence of cervical spondylosis in imaging is assessed by
presence of:
Anterior osteophytes
Disc space narrowing
Loss of lordosis
Foraminal spurs.
CT C -Spine:
CT C spine is done only in patients suspected to have ossification of posterior longitudinal ligament in the MRI.CT is not routinely done as MRI being the investigation of choice.
MRI Spine:
MRI C spine with myelogram is done for all the patients with cervical spondylosis.
MRI is done to assess the degree of root or cord compression, measure the spinal canal, disc herniation, osteophyte protrusion into the canal, ligamentum flavum hypertrophy and OPLL.
SURGICAL INSTRUMENTS:
Instruments used in Smith-Robinson Anterior Cervical Discectomy with Fusion.
GRAFT INSTRUMENTS:
CASPAR CERVICAL DISTRACTOR:
ANTERIOR CERVICAL PLATE:
OPERATIVE TREATMENT:
An anterior approach provides for direct visualization and removal of the offending pathology without manipulation of the cord. Generally recommended in patients who have spinal problems such as disc herniation and a posterior spur compressing the spinal cord at one at two levels, spondylotic bars, uncovertebral osteophytes.
Anterior Cervical Discectomy with Fusion is the technique done in our study.
