Cervical Disc Herniations Ma#hew McDonnell, M.D. October 27, 2015 - - PowerPoint PPT Presentation

Cervical Disc Herniations

Ma#hew McDonnell, M.D. October 27, 2015

Disclosures

• No Relevant Financial Disclosures

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Clinical Question

• What are the appropriate treatment opBons for

cervical disc herniaBons in adults?

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Background

• A significant number of sports related injuries

involved the spine and prevalent among these are cervical and lumbar disc herniaBons.

• DegeneraBve changes of the cervical spine are

ubiquitous in the adult populaBon

– Natural consequence of aging – OKen asymptomaBc unBl injury – Very common over age of 40

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3 Clinical Syndromes

• Axial Neck Pain
• Cervical Radiculopathy
• Cervical Myelopathy

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3 Clinical Syndromes

• Axial Neck Pain
• Cervical Radiculopathy *
• Cervical Myelopathy

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Acute Cervical Disc Hernia8on

Axial neck pain

• EBology:

– Sprains and strains – muscular/ligamentous imbalance related to poor posture, faulty ergonomics, muscle faBgue or stress – DegeneraBve disc or facet joints, spondylosis (subaxial) – C1-C2 degeneraBve/inflammatory condiBons (suboccipital)

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Axial neck pain

• Clinical presentaBon:

– Pain along posterior neck/trapezius muscles without radiaBon to the extremity – Pain may refer along paraspinal muscles of neck to

• cciput or to shoulder and periscapular region (also

seen with lower cervical radiculopathy) – sBffness

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Axial neck pain

• Typically responds to

nonsurgical treatment

• OKen resolves spontaneously
• Axial neck pain from cervical

spondylosis

– 3 months nonoperaBve treatment – 78 % total symptoms relief or improved – 22 % not improved – (Depalma, Clin Orthop Rel Res, 1965)

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Axial neck pain

• Surgery

– Chronic neck pain failing 6-12 months nonoperaBve treatment – Mixed results – PaBent selecBon challenging

• Pain generators?
• Number of involved levels?
• Advanced studies/discogram?
• Psychosocial consideraBons?

– ACDF (standard), disc replacement

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Cervical Myelopathy

• More commonly seen secondary to advanced cervical

spondylosis with resulBng stenosis and spinal cord compression (Cervical spondyloBc myelopathy

• Can occur in secng of cervical disc herniaBon due to

spinal cord compression and significant cervical stenosis.

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Cervical Myelopathy

• Results in spinal cord dysfuncBon leading to:

– Upper extremity sensory impairment, weakness, loss of FMS funcBon, clumsiness of hands, difficulty grasping objects – Clumsy, unsteady gait, difficulBes with balance, loss

• f propriocepBon, lower extremity weakness

– Severely affected individuals can be quadripareBc or quadriplegic

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Cervical Myelopathy

• Natural history

– 5 % rapid onset followed by long periods of remission – 20 % gradual decline in funcBon without periods of remission – 75 % stepwise deterioraBon in funcBon followed by episodic periods of remission. – (Clark and Robinson, 1956)

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Cervical Myelopathy

• Physical exam

– hyperreflexia – pathologic reflexes (Hoffman reflex, inverted radial reflex, Babinski sign) – clonus – difficulty with gait – Various pa#erns of sensory disturbances and pa#erns of weakness

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Cervical Myelopathy

• Treatment is surgical
• Goals

– Decompress spinal cord, prevent further funcBonal decline – Stabilize spinal column – Restablish normal sagi#al alignment

• disc herniaBon à ACDF
• Anterior discectomy or

corpectomy and fusion, posterior laminectomy and fusion, posterior laminoplasty for CSM

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Cervical Radiculopathy

• Result of cervical nerve root compression/

impingement from:

• 1. SoK disc herniaBon posterolateral or intraforaminal
• 2. Disc bulging with osteophyte spurring

(uncovertebral) in secng of degeneraBve disc disease (also associated with facet overgrowth and foraminal narrowing)

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Cervical Radiculopathy

• PaBent presentaBon:
• Neck pain and referred/radiaBng symptoms in a

specific dermatomal distribuBon in the upper extremity (frequently unilateral)

– Sharp pain, burning, Bngling sensaBons

• Difficult Bme finding comfortable posiBon
• SomeBmes present with head cocked to opposite

side or arm elevated overhead (shoulder abducBon sign)

• SubjecBve numbness or weakness common

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Cervical Radiculopathy

• PaBent presentaBon:
• May be associated motor or

sensory loss corresponding to the nerve root involved

• Reflex acBvity may be

diminished

• + Spurling maneuver

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Cervical Radiculopathy

• PaBent presentaBon:
• Review of 736 paBents with cervical radiculopathy

– 95 % arm pain – 85 % sensory deficits – 79 % neck pain – 71 % reflex deficit – 68 % motor deficit – 52 % scapular pain – 17 % anterior chest pain – 9 % headaches – 6 % anterior chest + arm pain – 1 % leK sided chest + arm pain – (Henderson, Neurosurgery, 1983)

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Cervical Angina

Common pain and neurologic patterns of radiculopathy

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Difficult to differenBate from axial neck pain in secng

• f DDD

Cervical Radiculopathy

• Radiographic evaluaBon

– Plain xrays may reveal decreased disc height or

• steophyte formaBon

– Advanced imaging obtained in paBent not responding to nonoperaBve treatment or with severe symptoms

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Cervical Radiculopathy

• Advanced Radiographic

evaluaBon

– MRI

• Current standard,

noninvasive, no radiaBon, good at idenBfying disc herniaBons (central and foraminal), quality of intervertebral disc, spinal cord signal abnormaliBes

• r lesions

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Cervical Radiculopathy

• Advanced Radiographic

evaluaBon

– CT Myelogram

• If MRI contraindicated, invasive,

radiaBon, may be be#er at detecBng foraminal stenosis and whether nerve root compression is from hard (osteophyte/ spurring) vs soK (HNP) eBology

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Spur compressing Nerve root

Nonoperative Management

• Cervical Collar

– Diminish inflammaBon around irritated nerve root – Diminish muscle spasm – Nighcme collar may maintain proper alignment to diminish nighBme postural symptoms

• No significant benefit in reducing the duraBon or

severity of symptoms (radiculopathy) (Naylor, Br J Rheum, 1991)

• Long term use associated with muscle atrophy

(limit to less than 2 weeks)

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Nonoperative Management

• MedicaBon

– NSAIDS – Muscle Relaxants – NarcoBcs – Oral Steroids

• OKen administered as medrol taper
• Excellent anecdotal results for acutely diminishing intensity
• f severe radicular pain
• No long term benefit in altering the natural history has

been shown

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Nonoperative Management

• Physical Therapy

– Commonly prescribed aKer iniBal period of rest and acute pain has resolved – Has not been shown to alter the natural history of cervical radiculopathy (Levine, JAAOS, 1996 and Tan Orthop Clin North Am, 1992)

• Cervical ManipulaBon

– Short term benefits for axial neck pain – Should not be performed in paBent with cord compression or myelopathy due to risk of catastophic injury (complicaBon rate 5-10 per 10 million) – No solid evidence supporBng clinical effecBveness

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Nonoperative Management

• Cervical tracBon

– Anecdotally found to temporarily relieve symptoms

• f axial neck pain or radiculopathy

– Failed to show long term benefits – Avoid in myelopathy or cord compression to avoid stretching already compromised spinal cord

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Nonoperative Management

• Cervical steroid injecBons

– Cervical epidurals – SelecBve nerve root blocks

• Specific targeBng of problemaBc roots, diagnosBc informaBon
• btained for surgical planning
• Number of retrospecBve and prospecBve studies

demonstraBng 50-80% good to excellent results for short term relief in cervical radiculopathy

– Lack control groups – Natural history favors resoluBon of symptoms with Bme – Rowlingson 1986, Ferrante 1993, Slipman 2001, Vallee 2001, Sasso 2005

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Surgical Management

• IndicaBons:

– Significant pain that fails to respond to nonsurgical treatment – Severe or progressive neurologic deficit OpBons: – Anterior cervical decompression and fusion (ACDF) – Posterior laminoforaminotomy – Cervical disc replacement

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Surgical Management

• ACDF
• Advantages

– Allows direct visualizaton and removal of lesions causing radiculopathy (disc herniaBon, uncovertebral spur) without neural retracBon – Anterior bone graK allows opening of neuroforamen and indirect decompression of nerve root – Fusion may provide relief of neck pain associated with disc degeneraBon/spondylosis

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Surgical Management

• ACDF
• Advantages

– Low infecBon and wound complicaBon rates – CosmeBc scar – Minimal perioperaBve pain – li#le muscle dissecBon – Numerous studies documenBng good outcomes and effecBveness for relief of radicular and neck pain

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Surgical Management

• ACDF
• Disadvantages

– Swallowing and speech complicaBons due to retracBon of esophagus and laryngeal nerves – Risk of pseudarthrosis – Adjacent Segment Disease

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Surgical Management

• ACDF Fusion Rates

– Historically, literature reports rates ranging from 0-20% for 1- or 2-level ACDFs and as high as 50-60% for 3- and 4-level ACDFs – More recent studies demonstrate very favorable results – 2015 systemaBc review and meta-analysis: – 2.6 % overal rate of pseudarthrosis for 1-, 2-, and 3- level ACDFs aKer ACDF with plate fixaBon – Shriver, Spine J, 2015

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Surgical Management

• Adjacent segment disease

– Cervical fusion may lead to accelerated degeneraBon of a segment adjacent to a fusion due increased stress and altered biomechanical forces – Adjacent segment degeneraBon can become symptomaBc resulBng in neck pain, stenosis, radiculopathy or myelopathy

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Surgical Management

• Adjacent segment disease

– Annual incidence approx 3 % – Prevalence approximately 25 % at 10 yr followup – (Hilibrand, 1999) – Approximately 17% reoperaBon rate for ASD – (Yue 2005, Ishihara 2004)

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Surgical Management

• Cervical Disc Replacement

– Similar decompression of neural elements as ACDF – Preserve moBon, minimizing risk of adjacent segment disease

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Surgical Management

• Cervical Disc Replacement

– Disadvantages

• Recurrent stenosis (re-development of
• steophytes secondary to conBnued

moBon

• Segmental kyphosis
• Mechanical failure of devices over Bme

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Surgical Management

• Cervical Disc Replacement

Most current studies demonstrate equivalent outcomes at 1 and 2 year followup to ACDF. No long term data yet for long term followup, actual impact on adjacent segment disease, and rates of long term mechanical failure. Being performed selecBvely

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Surgical Management

• Posterior Laminoforaminotomy

– Ideal for far lateral or foraminal disc herniaBon – Posterior approach, no destabilizaBon

• f spine, no fusion required

– Disadvantages:

• Possibility for incomplete decompression
• Does not address disc issues, no foraminal

height restoraBon

• Recurrence or deterioraBon or results with

Bme if progressive degeneraBon occurs

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What about athletes?

• Small retrospecBve series of 16 NFL players with

MRI confirmed cervical disc herniaBons

• Most common presentaBon was radiculopathy

aKer single traumaBc event (9/16)

• 3/16 presented with transient quadraparesis

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What about athletes?

• 8/16 treated nonoperaBvely and returned to sport

– Normal exam – ResoluBon of symptoms

• 3/16 failed nonsurgical treatment or had spinal cord

compression with signal change on MRI and had 1-level ACDF

– Only 1/3 returned to sport

• 5/16 treated non-op did not return to sport

– 2 had cord compression but reBred rather than have surgery – 3 were cleared to return based on improvement but were released by the team

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What about athletes?

• RetrospecBve cohort study of 99 NFL athletes with

cervical disc herniaBons and 2 year followup.

• opera8ve group: 38 of 53 (72%) players

successfully returned to play for 29 games over a 2.8-year period, which was significantly greater than nonopera8ve group: only 21 of 46 (46%) players successfully returned to the field to play aKer treatment for 15 games over a 1.5-year period (P < 0.04).

• Defensive backs have poorer prognosis

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What about athletes?

• 40 MLB pitchers from 1984 to 2009 with a cervical disk

herniaBon or lumbar disk herniaBon were idenBfied

• Cervical disk herniaBon was idenBfied in 11 pitchers, 8 of

which were treated operaBvely.

• The majority of pitchers with cervical disk herniaBon

(8/11) returned to play at an average of 11.6 months

• Lumbar disk herniaBon was idenBfied in 29 pitchers, 20
• f which were treated operaBvely
• All pitchers with lumbar disk herniaBon (29/29) returned

to play at an average of 7.3 months aKer diagnosis.

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Conclusion

• TOUGHNESS !!

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>

Athletes return to play after cervical disc herniation

• OK to return to play:

– Known cervical disc herniaBon, now asymptomaBc – Previous 1 level ACDF – Posterior laminoforaminotomy

• RelaBve contraindicaBon:

– Previous 2 level ACDF

• Absolute contraindicaBon

– SymptomaBc disc herniaBon – Spinal cord compression – Cervical myelopathy – Previous 3 or more level ACDF

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Clinical Question

• Based on current literature..
• What are the appropriate treatment opBons for

cervical disc herniaBons in adults with radiculopathy?

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Clinical Question

• 1. IniBal treatment with conservaBve treatment

modaliBes.

– Natural history shows good prognosis for resoluBon

• f symptoms and good clinical results

– OpBons include medicaBons

• NSAIDS, muscle relaxants, opiates, oral steroids

– therapy (cervical tracBon) – injecBons

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Clinical Question

• 2. Surgery is an excellent treatment opBon for

paBents with severe debilitaBng pain, progressive weakness, or persistent symptoms despite nonsurgical treatment

– ACDF (most common)

• Excellent clinical outcomes with low complicaBon rates
• Adjacent segment disease

– Cervical disc replacement

• Favorable short and intermediate term results equivalent to

ACDF

• Long term results and risks of long term mechanical failure to

be determined

– Posterior laminoforaminotomy

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Bibliography

• Roh JS, Teng AL, Yoo JU et al: DegeneraBve disorders of the lumbar and cervical spine. Orthop Clin

North Am 36:255-262, 2005.

• Truumees E, Herkowitz HN: Cervical spondyloBc myelopathy and radiculopathy. Intr Course Lect

49:339-360, 2000.

• Henderson CM, Hennessy RG, Shuey HM, et al: Posterior lateral foraminotomy as an exclusive
• peraBve technique for cervical radiculopathy. Neurosurgery 13:504-512, 1983.
• DePalma AF, Subin DK: Study of the cervical syndrome. Clin Orthop Rel Res 38:135-142, 1965.
• Naylor JR, Mulley GP: Surgical collars: A survey of their prescripBon and use. Br J Rheumatol

30:282-284, 1991.

• Levine MJ, Albert TJ, Smith MD: Cervical Radiculopathy: Diagnosis and nonoperaBve management.

J Am Acad Orthop Surg 4:305-316, 1996.

• Tan JC, Nordin M: Role of physical therapy in the treatment of cervical disk disease. Orthop Clin

North Am 23:435-449, 1992.

• Rowlingson JC, Kirschenbaum LP: Epidural analgesic techniques in the management of cervical

pain, Anesth Analg 65:938-942.

• Ferrante FM, Wilson SP, Iacobo C: Clinical classificaton as a predictor of therapeuBc outcome aKer

cervical epidural injecBon. Spine 18:730-736, 1993.

• Slipman CW, Lipetz JS, Plastaras CT, TherapeuBc zygapophyseal joint injecBons for headaches

emanaBng from the C2-C3 joint. Am J Phys Med Rehab 80:182-188,2001.

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Bibliography

• Vallee JN, Feydy A, Carlier RY: Chronic cervical radiculopathy: Lateral-approach periradicular

corBcosteroid injecBon. Radiology 218:886-892, 2001.

• Sasso RC, Macadaeg K, Nordmann D: SelecBve nerve root injecBons can predict surgical outcome

for lumbar and cervical radiculopathy: Comparison to magneBc resonance imaging. J Spinal Disorder Tech 18:471-478, 2005.

• Shriver Et al: Pseudoarthrosis rates in anterior cervical discectomy and fusion: a meta-analysis,

Spine J, 2015.

• Hilibrand AS, Carlson GD, Palumbo MA, et al. Radiculopathy and myelopathy at segments adjacent

to the site of a previous anterior cervical arthrodesis. J Bone Joint Surg Am 1999;81:519–28.

• Yue WM, Brodner W, Highland TR. Long-term results aKer anterior cervical discectomy and fusion

with allograK and plaBng: a 5- to 11-year radiologic and clinical follow-up study. Spine (Phila Pa 1976) 2005;30:2138–44.

• Ishihara H, Kanamori M, Kawaguchi Y, et al. Adjacent segment diseaseaKer anterior cervical

interbody fusion. Spine J 2004;4(6):624–8.

• Cark E, Robinson P: Cervical Myelopathy: A complicaBon of cervical spondylosis. Brain 79:483,

1956.

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