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 www.UOANJ.com

Clinical Question • What are the appropriate treatment opBons for cervical disc herniaBons in adults? www.UOANJ.com

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 www.UOANJ.com

3 Clinical Syndromes • Axial Neck Pain • Cervical Radiculopathy • Cervical Myelopathy www.UOANJ.com

3 Clinical Syndromes • Axial Neck Pain Acute Cervical • Cervical Radiculopathy * Disc Hernia8on • Cervical Myelopathy www.UOANJ.com

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) www.UOANJ.com

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 occiput or to shoulder and periscapular region (also seen with lower cervical radiculopathy) – sBffness www.UOANJ.com

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) www.UOANJ.com

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 www.UOANJ.com

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. www.UOANJ.com

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 of propriocepBon, lower extremity weakness – Severely affected individuals can be quadripareBc or quadriplegic www.UOANJ.com

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) www.UOANJ.com

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 www.UOANJ.com

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 www.UOANJ.com

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) www.UOANJ.com

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 www.UOANJ.com

Cervical Radiculopathy • PaBent presentaBon: • May be associated motor or sensory loss corresponding to the nerve root involved • Reflex acBvity may be diminished • + Spurling maneuver www.UOANJ.com

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 Cervical Angina – 1 % leK sided chest + arm pain – (Henderson, Neurosurgery, 1983) www.UOANJ.com

Common pain and neurologic patterns of radiculopathy Difficult to differenBate from axial neck pain in secng of DDD www.UOANJ.com

Cervical Radiculopathy • Radiographic evaluaBon – Plain xrays may reveal decreased disc height or osteophyte formaBon – Advanced imaging obtained in paBent not responding to nonoperaBve treatment or with severe symptoms www.UOANJ.com

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 or lesions www.UOANJ.com

Cervical Radiculopathy • Advanced Radiographic evaluaBon – CT Myelogram • If MRI contraindicated, invasive, radiaBon, may be be#er at detecBng foraminal stenosis and Spur compressing Nerve root whether nerve root compression is from hard (osteophyte/ spurring) vs soK (HNP) eBology www.UOANJ.com

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) www.UOANJ.com

Nonoperative Management • MedicaBon – NSAIDS – Muscle Relaxants – NarcoBcs – Oral Steroids • OKen administered as medrol taper • Excellent anecdotal results for acutely diminishing intensity of severe radicular pain • No long term benefit in altering the natural history has been shown www.UOANJ.com

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 www.UOANJ.com

Nonoperative Management • Cervical tracBon – Anecdotally found to temporarily relieve symptoms of axial neck pain or radiculopathy – Failed to show long term benefits – Avoid in myelopathy or cord compression to avoid stretching already compromised spinal cord www.UOANJ.com

Nonoperative Management • Cervical steroid injecBons – Cervical epidurals – SelecBve nerve root blocks • Specific targeBng of problemaBc roots, diagnosBc informaBon obtained 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 www.UOANJ.com

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 www.UOANJ.com

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 www.UOANJ.com

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 www.UOANJ.com

Surgical Management • ACDF • Disadvantages – Swallowing and speech complicaBons due to retracBon of esophagus and laryngeal nerves – Risk of pseudarthrosis – Adjacent Segment Disease www.UOANJ.com