Cervical Degeneration

Cervical Myelopathy

DefinitionCervical Myelopathy MRI


Spinal cord dysfunction
- extrinsic compression of the cord or its vascular supply
- caused by degenerative disease of spine




Most common spinal cord dysfunction in patients > 55 years old

C5/6 commonest level




- congenital / developmental stenosis
- decreased space available for cord
- average mid cervical spine is 17 – 18 mm



1. HNP

2. Osteophytes from facet and uncovertebral joints
3. Ligamentum Flavum

4. Instability

5. Kyphosis
- stretches spinal cord over posterior vertebral bodies and discs
- dictates an anterior approach

6. Ossification of PLL
- more common in certain Asian populations i.e. Japanese



Need to exclude other causes of spinal cord dysfunction


- CVA / AVM / Tumour / Hydrocephalus

- Metabolic or alcoholic encephalopathy


- demyelinating disease / MS / MND
- syringomyelia / Tabes dorsalis

- myopathy / peripheral neuropathy




Neck pain


- global, non dermatomal distribution over upper extremities


Difficulty walking / unsteadiness on feet



- have central cord like presentation
- distal worst than central


- pain , numbness and weakness
- clumsiness of hands common
- difficulty with fine motor function
- may also have radicular symptoms


Bladder dysfunction uncommonly occurs


May present acutely with central cord syndrome




UMN in extremities below lesion

LMN signs at level of lesion




Wide based gait

Unable to heel toe


Poor proprioception

1.  Finger escape sign
- deficient adduction or extension of ulnar digits of affected hand


2.  Romberg Positive




1.  Hoffman Reflex
- flexion of ipsilateral IPJ of index and thumb when long finger DIPJ flexed

- extension of neck increases sensitivity


2.  Inverted Brachioradial Reflex

- spontaneous flexion of digits when BR reflex elicited
- indicates cord compression at C5 and C6 / commonest levels


3.  Babinski Reflex



Narrowed joint space
- C5/6 commonest level followed by C6/7


Osteophytic lipping
- foraminal and uncovertebral osteophytes seen


- lordosis v kyphosis

Cervical Stenosis Kyphotic AlignmentLordotic Cervical SpineCervical Spinal Kyphosis Flexion View


Ossification PLL


Cervical Spine OPLL


Flexion / Extension views show instability
- > 3 o
- > 11 mm


Pavlovs Ratio
- AP diameter of spinal canal divided by the AP diameter of body at same level
- indicator of developmental stenosis
- should be 1.0

- < 0.8 is narrowed and stenotic


AP diameter / SAC
- normal (17mm)
- relative (13mm)
- absolute stenosis (10mm)


NB: X-ray estimates of space available for cord

- do not take into account ST i.e. discs and ligamentum flavum




Helps distinguish disc from osteophytes

- soft v hard disc




OPLL Cervical Spine




Disc herniation

- high incidence of asymptomatic findings
- 19% of asymptomatic patients have abnormality on MRI


Cervical Myelopathy Herniated Discs


Cord changes
- cord oedema with signal change seen


Cervical Myelopathy Cord Changes


AP diameter thecal sac < 10 mm


Compression Ratio
- banana cord
- divide the smallest AP diameter by largest transverse diameter at same level of spinal cord
- ratio of < 0.4 after decompression particularly with myelopathy > 6 months has poor prognosis


Cervical Myelopathy Compression Cord Ratio


Cross sectional area of spinal cord
- < 30 mm2 poor prognosis




Natural history suggests that > 50% of patients become worse if not treated
- some stable
- most slowly progressive
- < 5% acute deterioration




Non operative


Cervical collar
Physiotherapy with isometric strengthening
Ice , heat and massage

Follow up every 6-12 weeks initially followed by yearly if no progression

Traction and manipulation contraindicated

Must counsel them to the risks of trauma




Absolute Indications


1. Progressive neurological deficit
2. Failure of symptoms to improve with 6 months of non operative treatment
- base on severity of clinical neurological fingings


Relative indications


1. Compression ratio < 0.4
2. Transverse spinal cord diameter of < 40 mm2
3. Increased signal intensity of cord on T2 of MRI
4. Acute central cord syndrome
- initially collar and methylprednisolone
- no operation if near full recovery
- decompress if residual neurological deficit




The patient with cervical and lumbar stenosis

- should have the cervical spine decompressed first

- risk of intubation damage to cervical spine
- reduces need for lumbar surgery
- leg symptoms may improve after the cervical decompression




Surgery can be expected to halt progression

- may improve motor, sensory and gait disturbance


The best spinal cord recovery seen in those treated
- decompression within 6 - 12 months
- early, mild myelopathic signs
- transverse area of cord greater than 40 mm2 postoperatively
- age < 60


Preoperative Considerations


NSAIDS ceased 2 weeks prior to surgery


Positioning should avoid hyperextension of the cervical spine

- may need awake fibreoptic intubation




1.  Laminectomy & fusion

2.  Laminoplasty

2.  ACDF

3.  Corpectomy


1. Laminectomy & Fusion


Cervical Myelopathy Posterior Decompression InstrumentedCervical Myelopathy Posterior Decompression Instrumentation




Any posterior decompression procedure is an indirect technique

- requires posterior shifting of the cord in the thecal sac

- to diminish the effect of the anterior compression



Lordotic cervical spine / no kyphotic deformity

Ossification of PLL

- dura may be adhered

- high risk of irreparable dural tears with anterior approach


Indications for fusion





Positioning for the posterior approach
- prone
- Mayfield head tongs in neutral

- protect eyes / elbows (ulna nerve) / knees (CPN)
- pneumatic compression stockings
- infiltration of skin with adrenaline solution



- wide laminectomy +/- foraminotomy


- avoids progressive kyphotic deformity
- lateral mass screws


Cervical Myelopathy Posterior Decompression




Postoperative instability / kyphosis
- > 50% facet resection = instability
- avoid by fusion or laminoplasty


2.  Laminoplasty



- divide lamina unilaterally

- elevate to decompress

- insert device to keep lamina elevated



- maintains stability

- no need to insert pedicle screws



- no kyphotic deformity


3. ACDF / Corpectomy and Arthrodesis





- anterior cord compression

- pathology primarily at disc level

- kyphotic deformity


removes entire disc

- can maintain / restore lordosis

- restores foramina / decompresses nerve root


- difficulty decompressing the nerve roots in foramen from front
- difficult access to the posterior osteophytes




Smith - Robinson approach


- supine with interscapular roll
- head turned slightly to right for left sided approach


Disc removal in full
- MRI reviewed carefully to exclude free disc lying behind the PLL
- resect the disc until the longitudinal fibres of PLL seen

- inspect carefully for defect
- if no defect on MRI findings then should not routinely remove the PLL


Insertion cage 

- contains autograft / allograft / BMP & collagen
- sized first, check on x-ray
- insert cage, ensuring not too posterior
- aiming to decompress foramina


Anterior plate for stability


4.  Corpectomy and strut Graft





- multilevel disease

- soft and hard disc causing compression

- kyphotic deformity




Anterior approach
- decompression of disc above and below

- resection of vertebral body with burr
- leave lateral walls to protect vertebral artery
- typical midline channel is 16 – 18 mm


Bone Grafting Technique
- single level, iliac crest
- multiple level, fibular strut
- autograft superior to allograft


- maintains alignment / improves graft stability

Post op
- usually require HTB




1. Transient sore throat or difficulty swallowing

- most common complication

- superior laryngeal nerve


2. Recurrent Laryngeal Nerve paralysis
- more common in right sided approach
- post operative hoarseness


3. Respiratory compromise
- drains
- strict monitoring

- emergency release of wound stitches if haematoma


4. Neurological injury 1 – 2%


5. Injury vertebral artery


6. Dural tears
- more common if OPLL
- fibrin glue, fascial patch


7. Graft related
- dislodgement
- fracture
- severe settling
- pseudoarthrosis

Cervical Radiculopathy



Clinical diagnosis

- based on a sclerotomal distribution of motor &/or sensory symptoms or signs


Caused by impingement of exiting nerve roots


- zygo-apophyseal / facet joint hypertrophy

- neuro-central joint hypertrophy


May be acute or chronic






Peak age 50-54


C7 > C6


Natural History


Mayo Clinic Natural History Radiculopathy

- 50% of population at some stage

- ~50% recurrent

- 90% asymptomatic at 5 years




Each subaxial C-spine motion segment has 5 articulations


A. Intervertebral disc


B.  2 neurocentral / uncovertebral joints

- along posterolateral vertebral body / Joint of Luschka

- lie between disc & nerve root

- each body has upturned postero-lateral uncinate process

- pedicle is attached below uncinate process


C.  2 facet joints

- angulated 30-50° to transverse plane


Intervertebral foramina boundaries


A. Anterior

- both vertebral bodies, uncinate process & disc


B.  Posterior

- facet joints


C.  Above & below

- pedicles


Foramina are 45° to sagittal plane


Transverse process


3 elements

1. Embryological TP to posterior tubercle

2. Embryological rib to anterior tubercle

3. Tubercles joined by intertubercular lamella


Foramen transversarium in middle with vertebral artery

Dorsal root ganglion and ventral ramus spinal nerve on intertubercular lamella




Posterior tubercle

- Scalenus medius


Anterior tubercle

- Scalenus anterior, longus coli & capitus

- progressively enlarge from C3 down to C6

- C6 Chassaignacs tubercle


Cervical Nerve Roots


Each cervical root exits above the pedicle for which it is named except C8

- C5/6 – C6

- C6/7 – C7

- C7/T1 – C8


Pathophysiology Nerve root compression


1.  HNP

- in contrast to lumbar spine

- both posterolateral and central HNP compress exiting nerve root

- inflammatory and ischaemic components


A. Central - myelopathy

B. Posterolateral - mainly motor weakness

C. Intraforaminal - most common / often dermatomal distribution


Cervical Spine Central Disc HerniationCervical MRI Posterolateral Disc


2.  Spondylosis / Disc degeneration

- loss of height / annular bulging

- foraminal compression


3.  Bony 


A.  Uncovertebral osteophytes / hard discs

- compress nerve root anteriorly


B.  Superior articular facet osteophyte

- extend from ventral surface to compress the neural foramen

- are less common




Pain / parasthesia

- often don’t follow dermatomal distribution



- 60-70% motor deficiency


Spurling maneuver

- hyperextension with tilt toward affected side 

- stimulates radiculopathy symptoms


Nerve root signs (C6 and C7 most common)


C2 Posterior occipital headaches

C3 Occipital headache

C4 Neck and trapezial pain +/- shoulder / scapula pain

C5 Pain lateral upper arm (epaulet) / deltoid weakness / biceps jerk decreased

C6 Radial forearm and hand pain / weak biceps and wrist extension / BR reflex decreased

C7 MF pain / weak triceps / absent triceps jerk

C8 Pain ring and little fingers / weak finger flexors

T1 Ulna forearm pain / weak hand intrinsics


DDx Myopathy


Entrapment syndromes (ulna / median nerves)

Thoracic outlet syndrome

RC disease




Demonstrate loss of disc height and degeneration





- 19% of asymptomatic patients will have evidence of nerve root compression

- difficult to distinguish between hard and soft discs




Adds complementary information to MRI in C spine


Demonstrates the posterolateral impingement is from “hard” disc

- i.e. uncovertebral spur 


Cervical nerve root injections


Confirm diagnosis

- should get some temporary symptomatic relief





- concern re peripheral nerve entrapment



- are usually normal because lesion proximal to DRG



- amplitude decreased proportional to muscle atrophy


Nerve conduction velocity

- not abnormal unless severe demyelination of axons



- best for differentiating peripheral nerve root compression from central

- fibrillations




Non operative





Pharmaceutical / NSAIDS


- hot / cold

- electrical stimulation

- ROM / stretching

- isometric strengthening exercises 

Cervical traction


HCLA / nerve root injections




Lellad et al Ann Phys Rehabil Med 2009

- RCT demonstrating benefit of reducing symptoms with cervical traction


Cervical Traction


Kuijper et al BMJ 2009

- RCT demonstrating benefit of wearing semi-hard collar for 3 weeks 





- severe pain

- severe neurological impairment

- failure non operative treatment





Disc replacement










Anterior Cervical Discectomy and Fusion



- anterior approach

- interbody fusion

- iliac crest bone graft / synthetic bone graft / allograft / cage

- anterior plate / eliminates need for brace



- deal with HNP and uncovertebral osteophytes

- opens up the neuroforamina and decompresses the nerve

- fusion relieves pain of spondylosis

- anterior approach dissects little muscle and has little pain

- scar very cosmetically acceptable




Smith & Robinson / anterior approach

- divide platysma and deep cervical fascia

- SCM laterally

- divide pretracheal fascia / carotid sheath laterally

- divide prevertebral fascia in midline, separate longus colli



- decorticate end plates

- excision of osteophytes controversial

- generally only if causing compression

- otherwise will absorb with stability



- pseudarthrosis

- graft / cage displacement posteriorly

- wrong level

- insufficient decompression

- neurological injury (quadriplegia /  nerve root / RLN / Superior Laryngeal Nerve)

- injury to other structures (carotid artery / oesophagus)

- degeneration at second level


Cervical Disc Degeneration Above Fusion




2. Disc replacement



- as above

- insert disc replacement

- no anterior plate



- maintain some motion

- preserve other disc segments




Murrey et al Spine 2009

- RCT of ACDF v disc replacement

- disc replacement maintained 4o of motion

- significant reduced reoperation rate in disc replacement (1 v 8%)


3. Corpectomy



- multilevel hard and soft compression

- can remove body with disc above and below

- decompress 2 levels


Cervical HNP 2 Levels


Cervical Corpectomy APCervical Corpectomy


4. Laminoforaminotomy



- posterior approach

- deroofing of foramina




Herkowitz et al Spine 1990

- compared ACDF with posterior laminotomy / foraminotomy

- patients with both central and posterolateral discs

- combination of radiculopathy and myelopathy symptoms

- 4 year followup

- 95% vs 75% G/E


Johnson et al Spine 2000

- prospective study of patients with posterolateral disc and radiculopathy

- patients had no neck pain

- removal of HNP + uncovertebral osteophytes

- 91% improved or resolved

- 9% revision (ACDF / repeat posterior foraminotomy)





Cervical Spondylosis



Cervical spondylosis

- chronic disc degeneration & associated facet arthropathy


Cervical myelopathy

- spinal cord dysfunction

- secondary to extrinsic compression of cord or its vascular supply


Cervical radiculopathy

- sclerotomal distribution of motor &/or sensory symptoms or signs

- due to compression of nerve root




Usually begins at age 40-50




Most common at C5/6 > C6/7 > C4/5






Degenerative changes at disc / facet joints / uncovertebral joints


Clinical Features


Neck pain / headaches / local tenderness


Reduced ROM




Typical changes of spondylosis

- disc space narrowing

- osteophyte formation

- degenerative facet & uncovertebral joints


May be present in asymptomatic individuals


Cervical Spine Degeneration


CT scan


Degenerative changes


Cervical Spondylosis CT




Degenerative disc changes

- dessicated (loss of fluid), narrowed, end plate changes


Space available for cord


Neural compression

- intrinsic cord changes

- cord compression / ratio / cross sectional area


Cervical Spine Degeneration MRI






Education & Reassurance

- analgesics

- local modalities

- exercise programme

- traction







- failure non operative treatment

- disease isolated to 1 or 2 levels




Posterior Instrumented Fusion


Cervical Pedicle Screws LateralCervical Pedicle Screws AP







- restores disc height and aligment

- decompresses foramina



- autograft

- allograft

- cage


Jacobs et al Cochrane Database Review 2011

- autograft superior to discectomy alone

- autograft superior to cage in fusion rate but with higher complications


Disc Replacement



- elevate / decompress foramin

- maintain motion / decrease degeneration at subsequent levels


Burkus et al J Neurosurg Spine 2010

- prospective multicentred RCT 541 patients with single level disc degeneration

- disc replacement v ACDF

- improved outcome scores and neurological outcome in disc replacement

- no difference in rates of subsequent level surgery


PLOS One March 2015

- meta-analysis of 19 RCT of ACDF v disc replacement

- disc replacement had better scores, better pt outcome, better ROM, and decreased secondary degeneration



Technique ACDF

Anterior Cervical Discectomy and Fusion






Place the patient in the supine position

- small roll placed under the shoulder blades to drop the shoulders from the field

- exposes the anterior neck

- strap the shoulders at the side with minimal traction 

- allows visualization of the lower cervical spine on lateral radiographs

- apply skull traction with Gardner-Wells tongs

- keep head rotation to a minimum because deep dissection will depend on identifying the vertebrae midline

- prevents inadvertent injury to adjacent structures

- reverse Trendelenburg position facilitates venous drainage and results in less bleeding during surgery




Anatomic landmarks for incision 

- hyoid bone overlying C3

- thyroid cartilage overlying the C4/5 interspace

- cricoid cartilage overlying the C6 level


Use transverse incision for exposure in most cases

- more cosmetic

- from the midline to the anterior border of SCM in Langer's lines

- divide the deep cervical fascia and platysma muscle exposing the middle layer of the cervical fascia

- bluntly dissect the pretracheal fascia and palpate the carotid pulse


When three or more levels are approached, use a longitudinal incision


Dissection through the pretracheal fascia places several structures at risk

- superior and inferior thyroid arteries extend through the pretracheal fascia from the carotid artery to the midline

- travel at the C3/4 and C6/7 levels, respectively

- intervening area provides a relatively avascular plane for dissection


Recurrent laryngeal nerves

- right recurrent laryngeal nerve ascends in the neck after passing around the subclavian vessels

- courses medially and cranially at the C6–C7 level, often along with the inferior thyroid artery

- left recurrent laryngeal nerve ascends after curving around the aortic arch along the tracheoesophageal groove

- more midline and protected position

- left-sided procedure may be safer, especially when lower cervical segments are approached

- the thoracic duct is often visible on the left at the C7–T1 level and must be protected


Retract the sternocleidomastoid muscle and the carotid sheath medially

- contents (common carotid artery, internal jugular vein, and vagus nerve)


Retract the midline structures, including the trachea, esophagus, and thyroid gland medially

- complete blunt dissection through the deeper levels to the prevertebral fascia and vertebral bodies


Once the midline is identified, incise the prevertebral fascia

- elevate the medial edges of the longus colli muscles

- place blunt self-retaining retractors under the leading edges of the muscle

- Tramline retractor is used (Medial Lateral)

- take care to avoid dissecting along the longus colli muscle because of injury to the cervical sympathetic plexus

- screws in vertebral bodies for vertebral distraction





- vertebral bodies by their concave appearance 

- the discs by their more convex contour


Localize the disc space with a radiopaque marker and lateral radiograph


Remove disc

- incise the disc with an annulotomy blade

- cut lateral to medial away from the vertebral artery

- remove the disc contents and endplate cartilage to the PLL

- use thorough evaluative preoperative imaging to determine the presence of a sequestered disc behind the PLL

- palpate the PLL for the presence of a rent that may also indicate a sequestered fragment

- in the event that a rent is noted, or if an expected disc fragment is not identified, remove the PLL with Kerrison rongeurs

- beware of routine removal of the PLL, because reports of postoperative epidural hematoma have been associated with this technique


Removal of endplate and uncovertebral osteophytes is controversial

- disc space distraction reduces ligamentum flavum buckling and increases neuroforaminal area

- it is believed that fusion will arrest spur progression, and stability may allow for resorption over time

- however, this is not a consistent phenomenon

- the location and size of the offending spur must be carefully considered when performing decompression

- exposure of the uncinate processes is critical to safely remove osteophytes

- utilize a high-speed burr to excise the spur from medial to lateral



- judge the adequacy of foraminotomy

- ability to place the tip of a curret anterior to the exiting nerve root without significant resistance




Atlantoaxial Instability



Loss of ligamentous stability between atlas and axis


Spectrum of conditions

1.  Subluxation AP / insufficiency transverse ligament

2.  Rotatory / insufficiency apical ligament




Most common older children and adolescents






Secondary to laxity of transverse ligament


- Larsen's / Marfans




1. Infection

- retropharyngeal abscess / Grisel's syndrome


2. Trauma


3. Hypoplasia

- Down's Syndrome (15%)


- Achondroplasia

- Morquio


4. Inflammatory

- Rheumatoid arthritis


5. Developmental

- Os Odontoideum

- Klippel Feil




Cruciform ligament

A. Transverse ligament

- tubercles medial aspect lateral mass C1

B. Longitudinal bands from transverse ligament

- up to occiput

- down to C2


Alar ligament

- side of the dens up to the lateral margins foramen magnum

- prevent excessive lateral rotation


Apical ligament

- dens to occiput


Tectorial membrane

- extension of PLL

- behind transverse and alar ligaments




Neck pain

Occipital neuralgia

Rarely vertebro-basilar insufficiency




Atlanto-Axial Rotatory Subluxation (AARS)

- Cock Robin Tilt

- Torticollis

- facial asymmetry in children





- fibrosis SCM


Ondontoid fracture


Os ondontoid




Flexion / Extension views


ADI < 3.5 mm in flexion – transverse ligament intact

ADI 3-5 mm – transverse ligament insufficient / type II injury

ADI > 5mm – failure alar ligaments / type III rotatory subluxation


Open mouth xray


Lateral mass C1 rotated & asymmetric

Wink Sign - C1 facet locked over C2


CT Scan


Confirms above diagnosis




Assess transverse ligament


Classification Fielding & Hawkins


Type I



- rotary subluxation with no anterior displacement (ADI < 3mm)

- transverse ligament intact



- often resolves spontaneously

- soft collar and analgesics

- may need correction with halter traction with application HTB


Type II



- rotation about one intact facet with increase ADI 3-5 mm

- transverse ligament insufficient & unilateral capsular tear

- alar ligs intact

- one lateral mass displaced

- other lateral mass acts as pivot



- holter traction till reduced + application HTB


Type III



- bilateral anterior subluxation with ADI > 5mm

- failure of the alar ligament

- Wink sign positive / C1 facet locks over C2



- traction till reduced

- C1/2 fusion


Type IV



- complete posterior displacement of the atlas

- really a posteriorly displaced type II dens fracture

- rare 




Specific Conditions



- often no history of trauma

- reasonable to observe for 1-2/52 as often corrects spontaneously


Down's Syndrome

- may have peg hypoplasia

- increased ADI secondary to transverse ligamentous laxity more common

- ADI > 5mm & asymptomatic = avoid contact sports

- ADI > 5mm & symptomatic = fusion



- transverse ligament incompetent

- often zygapophyseal fusion has occurred

- rarely peg base can be eroded


Operative Management



- neglected fixed deformity

- failure to correct with nonoperative management

- type III & IV

- instability

- neurological problems

- ADI > 10 mm




Posterior C1-C2 arthrodesis

- Gallie / Brooks

- Magerl's screws / transarticular

- Harms



Lower Cervical Spine Fractures


Anatomy Lower Cervical Spine



- 50% of cervical rotation

- 60% of cervical flexion / extension


Uncovertebral joint

- lateral projections of body 

- medial to vertebral artery


Facet joints

- sagittal orientation 30 – 45o


Spinous processes

- bifid C3-5

- prominent C7




Awake, alert, neurologically normal & no neck pain very unlikely to have C-spine injury


Lateral C-Spine C1-T1

- will detect 85% of fractures

- need swimmers view if cannot visualise T1


Swimmers View


AP + Lateral + Peg view

- 92% of fractures


C-spine fracture

- 10% risk another cervical spine fracture

- 30% risk fracture other level in spine (may be masked by neurological injury)




The ability of the spine under physiological loads to maintain the relationship between vertebrae

- without neurological compromise


Instability  / Panjabi & White Spine 1976



- Anterior elements destroyed    2

- Posterior elements destroyed   2

- Sagittal translation >3.5 mm   2

- Sagittal rotation >11°             2

- Positive Stretch Test > 1.7mm 2

- Medullary cord damage           2

- Root damage                          1

- Abnormal disc narrowing         1

- Dangerous loading anticipated  1


Total of 5 or more = Unstable


Stretch Test

- medical supervision / tongs + roll under head

- add 3lb / wait 5 min / add 2lb to max 40lb / xray

- repeat until weight a third body weight / neurological changes / abnormal separation occurs >1.7mm


Mechanism of Injury / Allen & Ferguson Classification


Determined by

1. Position of the neck at the time of injury - flexion / extension / neutral

2. Direction of the force - compression / distraction / lateral bending


6 Types

- flexion compression / wedge

- vertical compression / burst

- flexion distraction / facet dislocation

- extension compression

- extension distraction 

- lateral flexion


Subaxial Injury Classification Scoring System / SLIC


Dvorak et al Spine vol 32 no 23


1. Injury Morphology / Pattern injury

No abnormality                        0       

Compression                            1 

Burst                                       2          

Distraction / facet perch            3         

Rotation / translation                 4


2. Discoligamentous complex

Intact                                        0                     

Indeterminate (MRI change only) 1   

Disrupted                                   2


3. Neurological status

Intact                                        0                     

Root Injury                                1                                   

Complete cord injury                  2            

Incomplete cord injury               3    

Continuous cord compression    +1


5 or more - surgery                   3 or less - non operative                4 - equivocal



- burst + disrupted ligaments + intact nerves = 4 / equivocal




Burst Fractures




Burst fractures

- injury to anterior and middle columns +/- posterior column




Vertical compression




10% cervical fractures

Most commonly C5/6




Anterior & middle columns fail

- if severe, posterior ligament complex fails


Canal compromise / neurological injury

- retropulsed fragments

- typically one or two main retropulsed fragments




Neck pain


Complete / incomplete cord lesion





- widening between pedicles is hallmark on AP



- > 50% anterior column loss of height very suspicious

- loss of posterior vertebral height




Assess retropulsion / canal compromise




Assess integrity of posterior column


Non operative Management




< 50% height loss

Minimal kyphosis 

Nil neurology

Posterior column intact / nil instability


SLIC score 4+




Collar for 6 weeks


Operative Management









Incomplete cord lesion (urgent / good prognosis)

Complete cord lesion (may gain 1 or 2 levels recovery which is very significant)




Decompression of retropulsed fragments and stabilisation




Tongs + Traction

- incomplete neurology / will decompress canal


Anterior corpectomy / discectomy and fusion

- tricortical graft + anterior plate

- may sometimes need supplemental posterior fixation / cervical lateral mass screws




Complete v Incomplete lesion is best prognostic predictor




Facet Joint Dislocation



Facet joint dislocations secondary flexion distraction injury








1. Unifacet subluxation - interspinous process widening

2. Unifacet dislocation - 25% anterolisthesis

3. Bifacet dislocation - 50% anterolisthesis

4. Complete vertebral translation - 100% anterolisthesis


Unilateral Facet Joint Dislocation




C5/6 or C6/7




Flexion / Distraction / Rotation about contralateral intact facet




Unilateral facet subluxation

- widening of interlaminar or interspinous spaces


Unilateral facet dislocation

- 25% subluxation on lateral X-ray (<50%)


C56 Unilateral Facet Dislocation




Unilateral Facet Joint Dislocation CT


Management Principles


1.  Exclude Herniated Nucleated Pulposis



- large disc could worsen neurology with tong traction

- indication for anterior approach / discetomy / fusion



- disc always looks injured on MRI

- look for herniation


2.  Reduce and fuse


Will improve partial neurology

May gain 1 or 2 levels of recovery in complete

Unreduced unifacet dislocations painful

Facet joint dislocation is a ligamentous injury / poor healing potential


Treatment Algorithm


1.  No neurology

- MRI to exclude HNP

- awake tong traction reduction if conscious and non obtunded


2.  Stable Neurology

- complete or non progressive incomplete neurology

- MRI to exclude HNP

- awake tong traction reduction if conscious and non obtunded

- if successful reduction / collar / fusion when able

- unsuccessful /  reduce in OT and fuse


3. Progressive Neurology

- MRI to exclude HNP

- emergent open reduction and fusion


4.  HNP

- anterior approach / discectomy / fusion





- tong traction


- open reduction


MUA v tong traction


Lee 1994 JBJS

- 210 patients MUA vs traction

- traction more success 88%vs 73%

- traction safer as patient awake & can monitor neurology


Tong traction



- no HNP on MRI

- patient awake and able to communicate if neurology worsening



- obtunded patient



- Gardener Wells tongs 1" above  and behind pinna

- below equator / maximum diameter of skull to prevent slippage

- place towels under head to recreate flexion deformity

- best performed in OT, can use cross table II

- start 10 lb for head, then 5 lb for each cervical level every 10 min

- repeat X-ray after each weight increase

- monitor neurological status

- if neurology worsens, release all traction

- maximum 40% body weight

- once facet unlocked, removed towels to extend head


Successful reduction

- place in HTB

- fusion when able





- experienced surgeon

- failure closed reduction

- intention to proceed to open reduction + fusion if required


Open reduction



- failure closed reduction

- herniated disc

- reduction + fusion



- GA + II + Tongs

- head flexed 45° & rotated 45° away from side of facet dislocation

- traction in above position, then rotate to side of facet dislocation

- should hear click on reduction

- gently extend to stabilize

- similar method if bilateral, but no rotation (flexion / traction / extension)


MRI Post Closed Reduction


MRI Post C5 Unilateral Facet Dislocation






1.  ACDF

- remove herniated disc / anterior plate

ACDF post C56 Unilateral Facet Dislocation


2.  Posterior stabilisation

Unilateral Facet Dislocation Posterior Stabilisation


Bilateral Facet Joint Dislocation




>50% forward subluxation


Cervical Bilateral Facet Joint Dislocation Xray




Evidence of bilateral facet joint dislocation


Cervical Bilateral Facet Dislocation CTCervical Bilateral Facet Dislocation CT 2




Cervical Cord Injury Post Unilateral Facet Dislocation


Cord injury common


HNP 47%


Unstable - posterior & middle ligament failure




As for unilateral facet joint dislocation

- MRI first to exclude HNP

- closed reduction with traction if safe with elective anterior / post fusion

- open reduction if HNP / failure closed reduction


Other fractures

Extension distraction



- 20%

- common with ankylosing spondylitis / DISH




1. Anterior ligament failure

– disc space widening (or transverse fracture of vertebral body)


2. Posterior ligament failure with retrolisthesis of superior vertebral body


Articular process fracture


Superior process fracture


Cervical Spine Facet FractureCervical Superior Articular Facet Fracture0001Cervical Superior Articular Facet Fracture0002


Can allow superior vertebrae to dislocate anteriorly

- incidence of spinal injury



- undisplaced - hard collar

- displaced - anterior fusion


Superior Articular Process Fracture


Inferior process fracture

- don’t allow significant displacement

- Stable ->Orthosis


Clay Shoveller's


Spinous process avulsion C7 secondary to Ligamentum Nuchae

- sudden single overload 

- treat symptomatically

Teardrop Fracture




- diving into swimming pool type injury

- 3 column injury

- high incidence of spinal cord injury


Xray / CT


Large antero-inferior body fragment

- > 20 %

- stays attached to  ALL


Posterior superior fragment retropulsed into canal


Sagittal fracture on CT




Extension tear drop injury

- fragment much smaller

- stable injury




Reduction with tong traction

- improves canal / aids neurology 


Anterior corpectomy + plate

- may need posterior stabilisation as well





Wedge Fracture




Anterior compression / wedge fractures

- injury to anterior column




Flexion compression





Most common at C4/5/6




Usually stable

- rule out burst fracture

- suspicious if > 50% anterior height loss

- CT scan



ORIF Cervical Spine Fractures

C1/2 fusion




1. Sublaminar wiring

- Gallie / Brooks

2.  Transarticular / Magerl screws

3.  Harms technique

- C1 lateral mas screws

- C2 pedicle screws


Gallie Fusion


Gallie Fusion C12



- C1/2 instability

- peg fracture with anterior displacement

- rupture of transverse ligament



- relatively easy technique

- graft firmly fixed between two arches of C1 and C2

- aids in reduction of the anterior subluxation



- sublaminal wiring technique

- can't use with C1 arch fracture

- not suitable for posterior peg displacement




Prone position

- head in line traction with tongs

- midline incision occiput to C4

- soft tissue dissection from midline

- no further than 1.5cm from midline to avoid vertebral artery and venous plexus

- clear soft tissues of posterior arch C1 circumferentially to allow passage of wire

- 1.2mm wire is fashioned as loop with a hook

- loop is passed deep to C1 arch from inferior to superior

- then passed over arch superficially so loop ends up around C2 spinous process

- unless C1 and 2 are reduced significant risk of injury to cord at this point

- decorticate arch of C1 and C2

- corticocancellous rectangular graft 3x4cm removed from post iliac crest

- fashioned into a "H" to fit snugly around SP's

- fashion cancellous surface to fit snugly on post arches

- notch graft laterally to fit wire 

- tie wire over graft to secure in place

- pack with cancellous graft around op site



- HTB for 3/12


Brooks and Jenkins



- C1/2 fusion with sublaminar wiring

- biomechanically superior to Gallie technique

- more rotational control

- able to use with posterior displacement of peg



- clear C1 and C2 post arches circumferentially

- 2 lateral wire loops around each lamina 

- 1.5 x 3.5cm wedged corticocancellous grafts between lamina C1 and C2 both sides


Trans-articular / Magerl Screws



- C1/2 fusion

- acute and chronic atlanto-axial instability

- suitable for posterior arch fracture and posterior dislocation



- technically difficult


Preop CT

- determine sufficient bone for 3.5 mm screw / sagittal reconstructions

- exclude overriding vertebral artery / axial view



- patient prone

- ensure reduction with II

- flex neck

- approach midline occiput to C7

- expose posterior elements C1-C3 as above

- persistent anterior dislocation may be reduced by pushing on C2 SP or pulling on C1

- expose C2 lamina not out to vertebral artery

- under lateral image control pass 2.5mm drill C2 to C1

- entry at lower edge of caudal articular process C2 

- 3mm from inferior surface and 2mm lateral to medial edge

- drill passing through posteromedial surface of lateral mass atlas

– 25o cranially, under II

- drill to anterior cortex and place appropriate 3.5mm cortical screw

- following screw fixation posterior fusion performed



- Collar 6-10 weeks


Harms Technique


Harms Technique C12 fusion





- C1 lateral mass screws

- C2 lateral mass screws




Dens Screw



- maintain motion

- less blood loss



- technically difficult 

- 17% major complication rate 



- obesity

- short fat necks

- irreducible fracture

- reverse obliquity

- comminution

- delayed or nonunion / unable to debride or bone graft





- anterior approach at level C5/6

- this allows correct angle for wire insertion

- split platysma, open deep fascia

- SCM and carotid sheath laterally

- blunt dissect to prevertebral fascia medially

- split prevertebral fascia / between longus colli

- palpate inferior aspect of C2



- anterior displacement easy: extend neck

- posterior displacement more difficult: traction and bring head forward


Cannulated wire insertion

- need good AP and lateral x-rays

- wire inserted at C5/6 disc

- need sufficient anterior bone in C2 to prevent cut out

- 2 wires inserted for rotation control

- 1 single 3.5 mm cortical screw just penetrating tip for extra fixation


Lower C spine


Posterior Wiring C2-T1


Many techniques

- interspinous wiring simplest

- TBW of posterior elements

- Sublaminar wires here have high neurology rate




Midline posterior approach

- essential to identify correct level with II

- hole drilled in each side of spinous process of upper vertebrae of injured segment

- junction upper and middle 1/3's

- connect holes with towel clip

- 1.2mm wire is passed through hole and around inferior spinous process leaving interspinous soft tissue intact

- wires pulled tight then passed around inferior spinous process and tied superiorly

- lamina are decorticated and cancellous graft applied


Triple Spinous process wire



- through spinous process

- about bone graft each side




First wire through transverse hole base SP

- two rectangular graft blocks each side

- second wire through superior SP & each end into superior holes blocks 

- third wire through lower SP & bottom block holes 

- tie ends second and third wires together

- decorticate post laminae


Screw Fixation


Cervical Pedicle Screws


Lateral mass screws

- poly axial heads


Preoperative CT

- location and orientation of foramen and vertebral artery


Entry point

- middle of lateral mass / 1 mm medial to centre

- aim 10 - 15o lateral 

- parallel to superior articular facet




Upper Cervical Spine Fractures

Atlas Fractures

3 types


1. Posterior Arch



- axial compression with hyperextension



- 50% incidence other C1/2 fracture

- i.e. ondontoid fracture



- stable

- soft / philadelphia collar


2. Isolated lateral mass fracture



- asymmetrical axial compression / lateral bend

- fracture runs anterior, posterior or through articular surface


3. Jefferson (3 or 4 part)


Jefferson Fracture 4 Part Axial CT


Jefferson Fracture




Symmetrical axial compression


Management depends on integrity of transverse ligament


Ruptured transverse ligament


1. Peg view


C1 lateral mass displacement

- C1 overlapping on C2 bilaterally

- > 6.9 mm displacement of both lateral masses in total

-  rupture of transverse ligament likely


Jefferson CT Peg View


2. > 5mm ADI on dynamic flexion / extension xray


3. Avulsed fragment on CT




Transverse ligament

- avulsion

- midsubstance tear




1. Undisplaced


Manage with collar


2. Displaced


Reduce with ligamentotaxis / traction tongs



- 8 weeks

- check flexion / extension views


Jefferson HTB XrayJefferson Fracture Flexion Extension Views Stabe0001Jefferson Fracture Flexion Extension Views Stabe0002


B.  Fuse if midsubstance tear transverse ligament

- unlikely to heal

- as opposed to avulsion


3. Peg + Jefferson


Unstable & requires fusion


NB Elderly > 70

- increased mortality with HTB 20 – 36%

- often don’t tolerate hard collar

- soft collar / trial of life




Bony Occiput / Atlas / Axis




Occiput / atlas joint

- occipital condyles - lateral masses

- synovial joint

- often flatter in children which explains increased incidence of injury in children


Atlas / axis

- 3 synovial joints

- posterior atlas and dens

- lateral facet joints




1.  Extrinsic

- anterior tubercle attaches ALL and longus colli

- posterior tubercle attaches ligamentum nuchae


2.  Intrinsic (dorsal to ventral)


A. Tectorial Membrane

- continuation of PLL 

- posterior body of axis to anterior foramen magnum


B. Cruciate ligaments

- anterior to tectorial membrane / behind odontoid

- transverse ligament (posterior odontoid to anterior arch of atlas)

- vertical bands (from axis to foragmen magnum)


C. Odontoid ligaments

- from tip of odontoid

- paired alar ligs to occipital condyles (strong)

- small apical ligament to foramen magnum



- Tectorial

- Alar



- 40 – 45o flexion / extension (equal between C0/1 and C1/2)

- 40 – 45o rotation (mainly C1/2)





- 3 parts 

- 2 neural arches and one body



- 4 parts

- dens + 2 neural arches and one body


Goals of treatment


Protect the neural structures

Reduce and stabilise injured segment

Provide long term stability




Neck pain

Paraesthesia / Paralysis

Head / scalp lacerations

Palpate spine / Step-off Tenderness




3 trauma series


Anterior Soft Tissue

- "6 at 2 and 2 at 6"

- 6 mm at C2 normal

- 2 cm at C6 normal

- not applicable in children


SAC / Space available for Cord


- 1/3 Peg 1/3 Cord 1/3 Space

- if < 10mm cord compression



- children < 5mm

- Adults < 3mm


Stress Xray


High suspicion posterior ligamentous injury

- stretch test

- > 1.7mm increased disc space

- > 11° angle


Low suspicion ligamentous injury

- supervised flexion / extension view

- contra-indicated in decreased consciousness


CT Scan


To define bony fractures

- more sensitive upper cervical spine




To detect HNP prior to attempted reduction with incomplete lesion

Demonstrate oedema i.e. suspicious of C0-1 dislocation



Dens Fracture

Classification Anderson & D'alonzo


Type 1


Tip avulsion

- alar ligament avulsion

- fracture off one side of tip of dens



- associated with atlantoaxial instability

- manage in collar


Type 2


Fracture of base of dens


Dens Fracture Type 2 Undisplaced0001Dens Fracture Type 2 Undisplaced0002


Type 3


Fracture through body of axis

- union rates 95%


Type 3 Dens Fracture Coronal CTType 3 Dens Fracture CT Coronal



- elderly / Philidelphia collar

- young / HTB


Type 2 Dens Fracture




Undisplaced v displaced

- risk of nonunion 30% higher with displacement




Risk factors

- > 65 years

- > 5 mm displaced

- >10° angulation

- posterior displacement

- comminution

- delay in treatment

- smoker


Type 2 Dens Fracture Displaced


Management Acute Fracture


1. Undisplaced 


HTB 3/12


Platzer et al Neurosurgery 2007

- 90 patients average age 69 years treated in HTB

- union in 84%

- non union associated with elderly / displacement / delay in treatment


2. Displaced


A.  Traction

- reduces dens


B.  Ondontoid screw


C.  C1/2 Fusion


Gallie / Brooks fusion


Magerl fusion

- trans-articular screws


Harms fusion

- poly axial screw and rod fixation

- C1 lateral mass screws

- C2 pedicle screws


Dens Nonunion C12 fusion


3.  Elderly



- high risk of failure of fixation due to poor bone

- risk of HTB

- risk of non union


Koech et al Spine 2008

- 42 patients > 70 treated in HTB or collar

- 50% osseous fusion and 90% fracture stability in collar

- 37% osseous fusion and 100% fracture stability in HTB


Ondontoid Screw Fixation



- preserves motion compared to C1/2 fusion

- 50% rotation from C1/2



- irreducible fracture

- comminution

- osteopenia

- ondontoid + transverse ligament injury / will remain unstable

- oblique fracture configuration / need to place screw perpendicular to fracture




Platzer et al Spine 2007

- ondontoid screw fixation in 102 patients

- nonunion rate 4% in patients < 65

- nonunion rate 10% in patients > 65


Management Nonunion



- pain

- instability / myelopathy / risk sudden death


Type 2 Dens NonunionType 2 Dens Nonunion Coronal CT


1.  Patients < 65 years


C1/2 fusion


Dens Nonunion Instability0001Dens Nonunion Instability0002Dens Nonunion C12 fusion


2.  Elderly


Most patiens have a fibrous nonunion

- stable on flexion / extension views


Hart et al Spine 2000

- series of elderly patients with unstable nonunions

- treated non operatively

- no development of myelopathy or sudden death







Bilateral Pars Fracture C2

- traumatic axis spondylolisthesis




Neurological injury uncommon

- fragments separate and decompress


Different to judicial hanging where spinal cord is severed




Hangmans Fracture XrayHangmans Xray


Levine & Irving Classification


Type I


Vertical pars fracture with no displacement / <3mm


Hangmans CT Undisplaced0001Hangmans CT Undisplaced0002Hangmans CT Undisplaced0003


Type II


Vertical pars fracture translated anteriorly > 3mm

- hyperextension injury / windshield


Hangmans Fracture Type 2Hangman's Fracture Type 2 Axial


Type IIA


Oblique fracture pars with angulation and displacement

- flexion & distraction injury

- entire C2/3 Disc avulsed & fails in flexion

- only ALL left intact


Type III


Bilateral facet dislocation C2/3 and pars fracture






Type I

- manage in semi-rigid collar 8/52

- flexion / extension views to ensure stability


Type II

- traction + extension

- application HTB 8/52

- flexion / extension views


Type IIA

- traction contra-indicated

- extension and HTB

- some centres advocated fusion if high level angulation



- reduction / HTB or fusion




Vaccaro et al Spine 2002

- HTB treatment of 27 type II and 4 type IIA

- all type IIA went on union

- 21 type II went on to union

- high initial degree angulation associated with failure treatment


Operative Management




C2/3 instrumented fusion

C2 transpedicle stabilisation

Anterior cage and plate construct




Ma et al Spine 2011

- C2/3 pedicle screw fusion for unstable hangman's fracture

- 35 patients, solid and stable union achieved in all patients


Hangmans Fracture Non Union Posterior Fusion




Occipital Condyle Fractures




- unilateral

- bilateral





Lateral Compression





Skull base pain

Cock Robin

Cranial nerve injury


Classification Anderson & Montesano


Type I


Impaction of a condyle 



- Stable / Brace 8/52


Type II


Condyle fracture associated with basilar / skull fracture



- Stable / Brace 8/52

- Displaced / HTB 8/52


Type III


Condyle avulsions fracture secondary to rotation

- rupture strong alar ligaments



- unstable 

- HTB / fusion (C0 - C2)




Maserati et al J Neurosurg Spine 2009

- follow up of 104 occipital condyle fractures

- occipital-cervical fusion in 2 who had evidence of craniocervical malalignment

- remainder all treated with collar

- no late instability / malalignment / nerve compression



Occipito Atlantal Dislocation



Deadly & rare

- usually post mortem


More common in children due to

- immature joints 

- larger head to body ratio

- relative ligamentous laxity




High velocity trauma




- hyperextension, distraction & rotation




Pure ligament injury usually



- anterior occipital displacement (most common / head anterior)

- vertical

- posterior (rare)




Basion anterior to tip ondontoid

- most common is anterior occipital displacement

- should be located at tip of ondontoid


Basion-Dens Interval / BDI

- most sensitive

- from basion to dens

- assesses vertical displacement

- should be less than 12 mm


Basion-Axial Interval / BAI

- distance to posterior axial line / line posterior border ondontoid

- increased > 12 mm with anterior displacement


Power's Ratio BC/AO > 1 

- head goes anterior

- basion to posterior arch / opisthion to anterior arch




Reduction / HTB


Reduce in OT

- II

- putting sandbags under thorax

- allows head to reduce posteriorly

- assess with II

- apply HTB

- add compression


HTB 3 months

- assess stabilty with flexion / extension views




Is a ligamentous injury and inherently unstable

- may require atlanto-occipital fusion



Pseudo subluxation



Subluxation in children up to 8

- C 2/3 in 40% children

- C 3/4 14%

- up to 4 mm




Horizontal facet joints

- flat orientation of paediatric facets and laxity of ligaments


Become more vertical with age




1. Swischuk's Line

- drawn along spinolaminar line C1 & C3

- C2 should be within 1.5 - 2mm of this line


2. Pseudosubluxation will reduce with extension


Rheumatoid Neck



Neck involved in 86%

- second most common site after hands and feet

- closely associated with MCPJ subluxation




Males / Steroid use / Seropositivity Nodules / Severe long standing disease




Atlanto-axial subluxation

Subaxial subluxation

Superior migration ondontoid


1.  Atlanto - Axial subluxation (AAI / AAS)




A. Attrition of transverse ligament

B. Erosion of peg




Most common of RA cervical deformities

- occurs in up to 50% of patients


May cause myelopathy




1.  Lateral view AADI

- anterior atlantodental interval

- AADI > 3 mm


Cervical Flexion Instability Increased AADI


2.  AADI


A.  Instability : > 3 mm difference in flexion / extension views


RA neck Flexion View AADA /> 3 mmRA Neck Extension View AADI 1 mm


B.  Severe instability: > 7 mm difference


AADI greater than 5 mm


3.  PADI

- posterior atlantodental interval / SAC (space available for cord)

- > 14 mm 94% predictive no neural deficit

- < 14 mm 97% predictive neural compression


2.  Superior Migration of Odontoid / Pseudobasilar Invagination / Atlantoaxial vertical subluxation


Superior Migration Ondontoid CT CoronalSuperior Migration Ondontoid CT Sagittal



- vertical translocation of Dens into foramen magnum

- compresses medulla



- due to erosion of lateral masses of atlas and occipital condyles

- can lead to compression of brain stem

- risk of myelopathy / sudden death



- seen in 40% of RA patients



- C1/C2 compression gives occipitocervical pain

- ventral pressure can compress respiratory centre and cause sudden death




Superior Migration Ondontoid Lateral XraySuperior Migration Ondontoid Lateral Xray Close Up


Ranawat measurement < 13 mm

- line between anterior and posterior arch atlas

- centre of pedicle of C2


SMO Ranawat Measurement



- line of foramen magnum

- tip of dens should not protrude above this line


SMO McCrae LineSMO McCrae Line CT


McGregor line > 4.5 mm

- line hard palate to posterior occiput

- if tip of dens > 4.5 mm above this line = vertical settling

- severe > 8 men or > 10 women


SMO McGregor Line


Redlund-Johnell measurement

- assesses entire occiput to C2 complex

- base of dens to McGregor line

- men <34mm & women <29mm = abnormal

- if abnormal -> highly correlated with severe disease & neurology


SMO Redlund-Johnell


3.  Subaxial Subluxation (SAS)



- anterior subluxation of one vertebral body on another


Rheumatoid Arthritis Subaxial InstabilityRheumatoid Arthritis Subaxial Instability Extension View




A.  Instability on Flexion / Extension views

- > 3mm

- > 11o


B.  Space available for cord / SAC

- subaxial canal diameter on lateral

- < 13 mm high incidence neurology


RA Subaxial Subluxaton SAC



- facet erosions / ligament incompetence



- 10-20% of RA patients



- may see at multiple levels with stepladder type deformity & kyphosis

- occurs beneath previous cervical fusions

- anterior subluxation / destructive changes of facet joints / destruction of disc

- can result in 2° canal stenosis


Cervical Spine MRI Subaxial Subluxation


Neurological Classification Ranawat


I        No neurological deficit

II      Subjectively weak / hyperreflexia & dysesthesia

IIIA   Objectively weak / ambulatory

IIIB   Objectively weak / non ambulatory


Clinical Features



- neck radiating to shoulders / occipital headaches

- occipital neuralgia / greater occipital nerve compression

- ear pain / greater auricular nerve compression

- facial pain / trigeminal





- most common & earliest symptom 

- pain & temp / spinothalamic tract compression




Frequency or retention / constipation




Incidence of cervical involvement increases with duration of disease

- after 10 years 60% will have AAS


Postmortem study of 104 patients with RA

- 10% died 2° medullary compression

- impossible to predict which patients will progress




Supplanted CT

- site of compression

- accurate SAC / account for soft tissue



1.  Foramen magnum SAC < 14 mm = neurological compression

2.  C1-2 SAC < 13mm

3.  Subaxial spine SAC < 12mm


Rheumatoid Arthritis Limited Space Available for Cord


Cervicomedullary angle (MRI)

- long axis brainstem to long axis cord

- normal angle is 135-175°

- <135° = vertical settling & is correlated with myelopathy




Goals of Treatment


1. Prevent development of neurologic deficit

2. Prevent sudden death due unrecognised neurological compromise
- 10% of deaths in RA occur suddenly due neurological complications




Cervical spine flexion / extension xray

- mandatory in all patients pre-operatively




2 Groups 

1.  Intractable pain or neurologic compromise -> fuse

2.  No pain & no neurology – controversial





1. PADI >14mm -> observe

2. PADI < 14mm MRI

3. Cervicomedullary angle <135° / SAC < 13 - fusion




1.  C1/2 fusion

- if instability reducible / no decompression needed


2.  Occipito-cervical fusion

- instability irreducible

- must decompress / remove lamina C1


C1/2 fusion

- fusion in situ if reducible and no neurology

- laminectomy C1 + fusion if fixed deformity with neurology


A. Gallie / Brooks fusion

- contra-indicated if any displacement or neurology

- unable to perform decompression / laminectomy


C1 C2 Posterior Spinous Process WiringC1 C2 Posterior Spinous Process Wiring


B.  Transarticular / Mageryl screws

- 95% fusion rates

- +/- laminectomy of C1 if displaced or with neurology

- pannus resorbed in 19 of 22 patients with fusion


Occipitocervical fusion


C0 C3 fusion AAI Rheumatoid




90% of pts improve 1 Ranawat grade if have neurology pre-op

- PADI < 10mm predicts patinet unlikely to improve



- due to bone erosion may be insuffiency bone quality for C1/2 fusion

- may need C0 - C3




More serious & should be treated more aggressively

- xray screening

- MRI in flexion to evaluate cord compression



1. No symptoms & no cord compression on MRI

-  observe

2. Cord compression

- occipitocervical fusion

- +/- C1 laminectomy +/- anterior dens excision if fixed deformity & neurology



- 75% improve


Occipital Cervical Fusion LateralOccipito Cervical Fusion AP





- SAS >14mm & no symptoms -> observe

- SAS < 14, MRI for true SAC

- SAC < 13 or instability - surgery



1.  Anterior decompression and fusion


Subaxial Stabilisation


2.  Posterior laminectomy and fusion

- may need long fusion to prevent SAS above and below


Cervical Spine Posterior Fusion for SASCervical Spine Posterior Fusion for SAS



Smith Robinson Approach

Via the carotid triangle


SCM / posterior belly digastric / superior belly omohyoid




Exposes inferior body C2 - T1




1.  Supine in tongs

2.  Sit on head board with head taped and slightly extended


Table 30° up

Turn head away from side of incision


Which Side


Most surgeons approach from the left

- the course of the Recurrent Laryngeal Nerve / RLN is more predictable on left


Right sided approach

- used sometimes for C7/T1 to avoid thoracic duct


Recurrent Laryngeal Nerve


Right side

- given off the vagus at the level of the subclavian artery

- slopes from lateral to medial across lower part of wound to reach the oesophagus / trachea interval

- crosses the surgical approach in 50% of cases

- usually at C6/7

- may be at C5/6


Left side

- arises at the level of the aortic arch

- doesn't slope across the wound


3 Fascial layers


1.  Deep Cervical Fascia

- under the subcutaneous fat

- invests neck like collar

- clavicle / sternum / spine scapula - mandible / base of skull

- invests SCM & trapezius

- Have to incise so can retract SCM


2.  Pretracheal

- covers trachea

- deep to the strap muscles

- extends from hyoid into chest

- splits to enclose thyroid

- fuses laterally with carotid sheath

- have to divide to retract carotid sheath laterally


3.  Prevertebral

- base of skull to T3

- invests longus colli and sympathetics

- divide to separate longus colli muscles to approach verebrae




Medial border SCM

Carotid Artery lateral to SCM



- Hyoid = C3

- Thyroid Cartilage = C4/5

- Cricoid = C6

- Carotid Tubercle = C6




Inject LA with adrenaline

Transverse incision at level required from midline to posterior border SCM


Superficial Dissection


Divide Platysma vertically at anterior border SCM


Superficial plane

- through investing layer of deep cervical fascia

- between strap muscles (Sternohyoid & Sternothyroid) & anterior border SCM


Deep Dissection


Palpate the Carotid Artery 

- divide the pretracheal fascia medial to the Carotid Sheath

- open plane between carotid sheath & medial structures

- medially oesphagus, trachea & thyroid

- note that anterior carotid sheath fuses to pretracheal fascia

- retract the carotid sheath & SCM laterally





- superior thyroid artery / superior laryngeal nerve behind

- common venous trunk of superior thyroid / lingual / facial vein



- ligate middle thyroid vein

- inferior thyroid artery


Blunt dissection medially

- behind the oesophagus

- expose the vertebrae covered by Longus Colli, prevertebral fascia & ALL

- sympathetic chain lies on the Longus Colli, just lateral to the vertebrae

- incise the Longus Colli in the midline

- subperiosteally expose the Vertebrae

- place retractors under Longus Colli


Check level with II




1. Recurrent Laryngeal Nerve

- lies between trachea & oesphagus

- on right crosses field from subclavian artery at C6/7 with inferior thryoid artery


2. Superior Thyroid Artery/ Superior Laryngeal Nerve

- C3/4

- superior thyroid artery pass from the Carotid Sheath medially to the midline structures

- superior laryngeal nerve runs with artery

- can divide artery but must preserve nerve

- otherwise get dysphagia


3.  Inferior Thyroid Artery

- lower approach may pass from lateral to medial


4. Sympathetic Chain on transverse processes

5. Vertebral Artery

6. Carotid Sheath with Vagus inside

7. Oesophagus

8. Trachea

9. Thoracic duct on left at C7 / T1 level