Cervical Spondylosis

Definitions

 

Cervical spondylosis

- chronic disc degeneration & associated facet arthropathy

- cervical spine osteoarthritis

 

+/- radiculopathy / myelopathy

 

Epidemiology

 

Nakashima et al Spine 2015

- cervical spine MRI of 1211 healthy volunteers

- overall 87% of patients had evidence of significant disc bulge

- 70% of patients in their 20s had a disc bulge

- 5% of patients had evidence of spinal cord compression, mainly 50 years and over

- most common at C5/6 > C6/7 > C4/5

 

Lv et al BMC Musculoskeletal Disorders 2018

- cross sectional study 3800 patients

- symptoms of cervical spondylosis most common 40 - 60 years of age

- females > males

- associated with mental work / work posture / vibration / sleep < 7 hours

 

Pathology

 

Degenerative changes at disc / facet joints / uncovertebral joints

 

Disc dessication

- death of intervertebral disc cells

- reduced production of hydrophilic proteoglycans

- loss of disc height

 

Symptoms

 

Neck pain

Reduced ROM

 

"Atypical symptoms"

- dizziness / headache / nausea / tinnitus / palpitations / gastrointestinal disturbance / blurred vision

 

X-ray

 

Typical changes of spondylosis

- disc space narrowing

- osteophyte formation

- degenerative facet & uncovertebral joints

 

Spondylosis Xray

Severe C5/6 disc degeneration

 

CT scan

 

Spondylosis CT

2 level disc degeneration on CT

 

MRI

 

Degenerative disc changes

- dessication (loss of fluid)

- narrowing

- end plate changes

 

Cx spondylosis MRICx spondylosis 2

End plate changes                                    Disc dessication with disc bulge

 

Management

 

Non-operative

 

Education & reassurance

Simple analgesics - paracetamol / NSAIDS

Exercise program

Acupuncture

 

Exercises

 

Kay et al Cochrance Database System Rev 2012

- exercises for neck pain

- 21 RCTs

- supports use of cervical stretching and strengthening in short and intermediate term

 

Acupuncture

 

Chen et al Pain 2021

- RCT of 835 patients undergoing acupuncture for neck pain

- improved neck pain at 4 weeks compared to sham or shallow needling

 

Operative

 

Indications

 

Persistent debilitating neck pain

Disease isolated to 1 or 2 levels

 

Options

 

ACDF

Disc replacement

Posterior Instrumented fusion

 

Results

 

Single level spondylosis

 

Fallah et al PLoS One 2012

- meta-analysis of ACDF versus disc replacement for single level spondylosis

- 9 RCTS and 1700 patients

- better neck pain, arm pain, and lower neurological failure with disc replacement

 

Two level spondylosis

 

Zhao et al Medicine 2018

- meta-analysis of ACDF versus disc replacement for 2 level spondylosis

- 9 RCTs and 2700 patients

- improved outcomes for NDI and VAS scores for disc replacement

 

Zhang et al Medicine 2020

- meta-analysis

- comparison of ACDF versus hybrid surgery (ACDF and disc replacment) for multilevel spondylosis

- equivalent reduction in pain, improved neck scores, and better ROM with hybrid surgery

 

Atypical symptoms

 

Garg et al World Neurosurg 2022

- meta-analysis of success of decompression of relieving atypical symptoms

- surgery improved headache / nausea / tinnitus

- no effect blurred vision / GI upset / palpitations

 

ACDF

 

ACDF

 

Technique

 

ACDFInterbody spacer

 

Depuy Synthes surgical technique article

 

Vumedi anterior discectomy technique

 

Anterior approach / Smith Robinson

- discectomy

- decorticate end plates

- interbody fusion with bone graft +/- interbody spacer

- anterior low profile plate

 

Complications

 

Risks of Smith Robinson / Anterior Cervical Approach

 

Specific

- pseudarthrosis 0 - 4.3%

- hardware failure

- insufficient decompression

- degeneration at second level

 

Disc replacement

 

Cervical disc replacement 2Cervical disc replacement 1

 

Advantage

 

Theoretically maintain some motion and preserve other disc segments

 

Contra-indications

 

Instability / Severe deformity / kyphosis - risk prosthesis displacement

Osteoporosis - risk of subsidence

Facet joint arthropathy - continued pain with disc motion

 

Technique

 

Discover discMedtronic PrestigeMedtronic Prestige

Depuy Discover                                Medtronic Prestige

 

Vumedi disc replacement technique

 

You tube prodisc C surgical technique animation

 

Complications

 

Risks of Smith Robinson / Anterior Cervical Approach

 

Specific

- anterior displacement

- posterior displacement and spinal cord injury

- subsidence 3% - higher risk if remove or disrupt end plates

- osteolysis

- implant failure

- heterotopic ossification

 

Posterior Instrumented Fusion

 

High complication rate

 

Leckie et al, Global Spine J 2016

 - Database study of 1269 patients

 - Adverse events 3 times more likely in posterior compared to anterior

 

Cervical Pedicle Screws LateralCervical Pedicle Screws AP