Cervical Spine Surgery - Sydney Adventist Hospital

Cervical Spine Surgery
Orthopaedic Nursing Seminar
Dr Michelle Atkinson
Friday October 21st 2011
The Sydney and Dalcross
Adventist Hospitals
Cervical disc herniation
The most frequently treated surgical
pathology in the spine
Cervical Disc Herniation
• at any disc level from C2 to
the sacrum,
C4-5
C5-6
L3-4
C6-7
• most frequently involved are
those segments with great
range of motion
L4-5
• or axial loading forces.
L5-S1
Cervical Disc Herniation
Disc Herniation
– L3-4,
– L4-5,
– L5-S1 are most
frequently involved
in the lumbar spine.
– In the cervical spine,
C4-5
C5-6,
C5-6
– C6-7 and
L3-4
C6-7
– C4-5
L4-5
– are the most frequent
discs (in that order) to L5-S1
herniate.
L4-5
– Thoracic disc herniation
is much less common
Cervical Disc Herniation
Protrusions most frequent at
posterolateral margins of the disc
•
The structural changes of disc
herniation are not the same as those
seen with degenerative disc disease.
–
•
•
Central posterior protrusions
are often limited by the
fibers of the PLL.
The anterior longitudinal
ligament (ALL) generally
contains anterior and
anterolateral protrusions.
L5-S1
Disc Anatomy Review
PLL
•
C4-5
C5-6
L3-4
C6-7
Disc herniation is thought to be the
culmination of a series of acute
traumatic events to the disc.
ALL
PLL
Nuclear herniation
Disc Anatomy Review
•
The intervertebral disc is the largest
avascular structure in the body.
•
It receives nutrition by way of
passive diffusion through the central
vertebral endplates.
•
Because the disc is avascular, it
cannot heal itself the way other
normal tissues do.
Internal disruption and damage to
the disc are permanent.
•
arteries
Four Degrees of Herniation
veins
• There are four degrees of
disc herniation:
– Nuclear herniation
This occurs when the nucleus ruptures through the
innermost fibers of the annulus fibrosus but does not cause
any disruption or distortion of the outer annular fibers.
Nuclear herniation
Four Degrees of Herniation
– Disc protrusion
Also known as a “bulging disc,” this occurs when the
ruptured nucleus distorts the outermost fibers of the
annulus causing them to bulge outward. The term
“prolapsed disc” is synonymous with protrusion or bulging.
Disc protrusion
Four Degrees of Herniation
– Nuclear extrusion
This describes a complete split in the annulus that allows
nuclear material to leak out into the surrounding spaces. In
this type of herniation, the protruded material remains
attached to the nuclear material remaining inside the disc.
Nuclear extrusion
Four Degrees of Herniation
– Sequestered nucleus
The extruded nuclear substance is no longer attached to the
material
remaining inside of the disc. The sequestered
.
fragment(s) may float around the spinal canal and become
totally remote from the site from which it originally
extruded.
Cervical Disc Herniation
Cervical discs are slightly different in
anatomical form than lumbar discs:
• The nucleus is smaller
•well supported on the lateral
margins from the uncinate
processes.
• Most occur in the postero-lateral
margins
• Aging decreases the proteoglycan
and water content of the disc, more
Nucleus pulposus
prolapse after the third decade of life.Uncinate processes
Herniation
• Major or minor trauma more
susceptible to herniation later in life.
Sequestered
nucleus
Clinical Presentation and Patient
Assessment
symptoms:
neck pain
radicular arm pain
myelopathy
paralysis or paraesthesiae of the upper
extremities.
Clinical Presentation and Patient
Assessment
• Symptoms may
begin abruptly or
insidiously.
• There may be a
history of episodes
that resolved .
Radiographic and Diagnostic
Evaluation
• plain cervical radiographs
provide a general assessment of
alignment and the extent of
degenerative changes.
• MRI is generally considered the
study of choice in evaluating
cervical disc herniations
• CT scan and cervical myelogram
occasionally.
• Discography of the cervical
spine
• Nerve conduction and EMG
studies are rarely indicated
Treatment of Cervical Disc Herniations
• Conservative treatment
– There is a high likelihood that
cervical radiculopathy will
resolve without the need for
surgery.
Large disc
herniation
Treatment of Cervical Disc Herniations
• Surgical treatment
– Continued pain
– anterior discectomy without
fusion,
– partial anterior discectomy
– discectomy with fusion
– posterior laminectomy
– posterior laminotomy
– posterior laminoplasty
Treatment of Cervical Disc Herniations
Left
foraminal
stenosis
C5
Disc herniation
C6
Left foraminal stenosis
caused by an acute
herniated cervical disc
as seen on axial CT
scan.
Sagittal MRI confirms
herniation at C5-6.
Anterior
cervical
plate
Neurologic Injury to the Spinal Cord
Sagittal cross section of a
spondylotic spine.
This close-up view shows endplate
osteophyte (O) and
ligamentum flavum (LF)
compressing the spinal cord (SC)
and leading to complete neurologic
loss below the injury.
Note the spinal cord hemorrhage
(H).
Disc Anatomy Review
– Degenerative disc disease, which is
part of the normal aging process,
– is a long-term process involving all
the components of the motion
segment.
Reduced disc height and
motion segment degeneration
as a result of the normal aging
process.
Degenerative Disc Disease
Degenerative Disc Disease
• The following changes to the motion segment may occur from
degenerative disc disease:
This disease is actually a degenerative
process of the entire motion segment.
Degenerated disc disease – cervical spine
C4
Extruded disc material
osteophytes
Degenerated discs
Vertebral artery
C5
More information
Spinal Stenosis
• Degenerative disc disease may be found in every spinal level.
However, the most frequently affected levels by region are:
– Cervical 5-6
– Lumbar 4-5
– Lumbar 5-S1
Back
Spinal Stenosis
Spinal canal (tube) created
by spinal foramina
The word
stenosis is derived
from the Greek
stenos: narrow,
– The disc loses water causing it to shrink in volume
– The disc space begins to narrow. Concurrently, the facet joints begin to
override and wear away at the hyaline cartilage surfaces.
– Compressive loads are transferred away from the nucleus/central
endplate interface to the peripheral annulus/vertebral endplate margins
– Sclerosis of the central endplate further reduces disc nutrition
– The motion segment becomes hypermobile due to the narrowed space
and overriding of the facets
– Osteophytes develop in an attempt to stabilize excessive motion
– Osteophytes may encroach on neurological structures
Spinal stenosis can be either developmental or acquired. Developmental forms are
present at birth, while acquired forms occur after birth. The most common form of spinal
stenosis is the acquired degenerative type. Although stenosis may occur anywhere in the
spinal canal, the most frequently involved regions for degenerative spinal stenosis are in the
lower cervical and lower lumbar areas. These areas also correlate with the more common
sites associated with degenerative disc disease.
Thickened ligamentum
flavum
Central stenosis
Stenosis may occur in the central spinal canal
(central stenosis) where the spinal cord or
cauda equina are located, in the tract where
the nerve root exits the central canal (lateral
recess stenosis) or in the lateral foramen
(foraminal stenosis) where the individual
nerve roots exit out to the body.
Lateral recess
stenosis
Foraminal stenosis
Stenosis of the Cervical Spine
Spinal Stenosis
The actual cause of degenerative spinal stenosis is unknown. However,
changes in the three-joint complex of the motion segment are thought to lead to
narrowing of the canal and nerve tracts. Degenerative changes may begin in the
disc, in either facet joint, or in all three places simultaneously. Eventually, all
three joints are involved.
spinal cord
Exiting nerve root
Osteophyte causing lateral
recess stenosis
• • One
unique
degenerative
change
noted
Degeneration
of the
three-joint complex
is the most
cause
of spinal
stenosis
in the cervical of
in thecommon
cervical
spine
is the
development
region. The anatomic changes noted in the cervical
spine are similar
to those
lumbar
spine. These
osteophytes
in the
areaofofthethe
uncinate
include disc degeneration, hypertrophy of the facet
processes.
These lateral
osteophytes
may be
joints, thickening
and redundancy
of the ligamentum
flavum and formation of traction osteophytes.
a source
of pain and they can cause
Together, these degenerative changes may lead to
the development
of spinal
stenosisartery,
which maywhich
be
compression
of the
vertebral
is
central, lateral or foraminal.
in close proximity to the uncovertebral joint.
Obstruction of the vertebral artery may
result in reduced circulation to the brain and
Nerve root
osteophytes
Spinal cord
Thickened ligamentum
flavum
can lead to fainting spells.
Vertebral
body
Foraminal stenosis
Axial cross section of stenotic
cervical spine
Vertebral
artery
Treatment
•
Radiographic Studies
A-P and lateral plain films should be done initially. Oblique films may be helpful in
evaluating osteophytes in the foramina. Flexion and extension films can be used to
check for segmental instability. CT scan with myelography is excellent for determining
lateral recess stenosis. However, MRI is done more routinely as it is not as invasive as
myelography and does not expose the patient to radiation.
•
DECOMPRESSION surgery may be done from the anterior, posterior or combined
•
LAMINECTOMY and LAMINOPLASTY are the most common posterior surgical
approaches.
Anterior
discectomy,
withtoorindividuals
without fusion,
is usually
done for single level
•
Conservative
care is generally
whoinvolves
suffer
radicular
treatments
for degenerative
cervicallimited
stenosis.
Laminectomy
partial orsymptoms
complete
stenosis.
It maytreatment
also be done
for multiple
level immobilization
lesions. Multipleinlevel
stenosis
may be
only.
Non-operative
options
may increased
include
a cervical
collar,
removal of the posterior
elements
allowing
space for the neural
structures.
treated
by
anterior
corpectomy
with
structural
bone
grafting
and
stabilization.
Microflexibility and is
strengthening
exercises, pain of
medications
andelements
anti-inflammatory
Laminoplasty
the surgical reconstruction
the posterior
that allowsagents.
for
Patients
with frankeither
myelopathy
degenerative
be considered
foremployed
surgical to
discectomy,
open orfrom
through
minimallystenosis
invasive should
technique,
may also be
increased
canal
spaceasbut
maintains
the posterior
arch.
There are
numerous
techniques
for
intervention
as
soon
possible.
Additionally,
those
individuals
with
significant
deformity
remove a disc causing a stenosis. Finally, patients who exhibit symptoms of vertebral artery
laminoplasty.
and/or
instability may
surgical
candidates.
compression
maybe
benefit
from
a decompression of the offending osteophytes in the
uncovertebral joint complex.
degeneration
ration of
Preoperative radiographic studies showing severe cervical degene
C4C4-5, C5C5-6, and C6C6-7.
Lateral recess
Lateral
revealsat
significant
Axial
CTx-ray
myelogram
C5-6 reveals
stenosis
Lateral MRI shows canal
disc
and anteriorwith
canal compromise
compromise from disc materialsignificant
at degeneration
bone spurs
on stenosis
C4, C5, and
C6. right.
lateral
recess
on the
C5-6 and C6-7.
Degenerated
discs
Bone spurs
Dye in the
thecal sac
Retropulsed
disc material
Lateral view
Cut lamina
Laminoplas
B. Posterior laminectomy at
ty done
those levels allows for
from
Notched lamina to form
decompression of the spinal
posterior
a
hinge
cord.
approach
Superior view
creating a
hinge on
one side of
the lamina
allowing
the
opposite
Two methods of an anterior
corpectomy are
side to
be a procedure
illustrated: the lateral view
shows
using rongeurs, and theraised
axial view shows a burr
away from
being used. Either technique
can be done to
the
spinal
decompress the neural structures.
cord. This
allows for
decompres
sion of the
central
A. Shows spinal cord
compression from
ossification of the
posterior longitudinal
ligament at the C4,
C5, and C6 levels.
Cervical Stenosis Case
Study
Bone
graft
Anterior
cervical
plate
Cervical
plate
A.
B.
Posterior lateral (A.) and AP (B.) x-rays of the same patient following a two-level corpectomy
(C5 and C6) with structural anterior bone graft and anterior plating C4-C7. The preoperative
images can be seen in the “Radiographic Evaluation” section.
Thank You