Spinal Column - Cleveland Clinic

SPRING 2007
Spinal Column
This Issue: The Cervical Spine
In This Issue:
Conservative Treatment of Neck Pain
Minimally Invasive Cervical Laminoforaminotomy
Treating Cervical Radiculopathy and Myelopathy
Cervical Disc Arthroplasty
Cervical Deformities
Cervical Spine
Tumors
p. 2
p. 4
p. 6
p. 8
p. 10
p. 12
A Look at the Cervical Spine
A message from Edward C. Benzel, M.D.
This issue of Spinal Column focuses on cervical spine pathologies and treatment strategies. Dr.
Mroz has collected and collated a wonderful mix of papers addressing the variety of pathologies
and treatment opportunities available. This includes conservative, operative and minimally invasive
treatments for a variety of conditions.
Pathologies of the cervical spine pose the potential for
greater risk to patients than similar analogous pathologies in the lumbar spine, due to the heightened potential
for spinal cord injury and greater chance of injury to
visceral structures. Therefore, the use of less risky
diagnostic and treatment strategies are emphasized;
conservative treatment, if effective, is always preferred.
Dr. Zachary analyzes such conservative treatments on
page 2. When surgery is required, minimally invasive
techniques, when an option, are beneficial. Dr. Steinmetz
reviews the use of such techniques for a laminoforaminotomy on page 4.
The most common cause of cervical spine radiculopathy
and myelopathy is degenerative spine disease. The
‘disease’ part of ‘degenerative spine disease’ is really
a misnomer. It, in reality, is not a disease at all, but
a manifestation of the natural process of aging. The
intervertebral discs bulge and the facet joints and
ligaments hypertrophy, which causes encroachment on
the spinal canal and neuroforamina with spinal cord
and nerve root distortion and compression. Surgical
strategies designed to relieve neural compression or
to stabilize the spine have, therefore, been devised.
Both open and, when appropriate, minimally invasive
operations can be used to treat affected patients. Dr. Bell
reviews treatment options for both radiculopathy and
myelopathy on page 6.
An early-stage manifestation of cervical spine degenerative
disease is that of disc herniation. Disc herniation and
the resultant radiculopathy and/or myelopathy can be
treated surgically. Anterior cervical discectomy is usually
followed by fusion (anterior cervical discectomy and
fusion). This has been shown to be a very successful
operation over the years. Recently, the substitution of
an artificial disc for the fusion part of the operation
has been used as a strategy to stabilize the spine and to
retain segmental motion following the removal of the
disc. Dr. Mroz considers its usage in his article on page 8.
I hope you enjoy this collection of
well-illustrated articles and that they
provide insight into this interesting
and perhaps most misunderstood
aspect of spine care.
An end-stage manifestation of cervical spine degenerative
disease is spine deformation, the most common of which
is kyphosis. Contributing factors to the development of a
kyphotic deformity are the degenerative (aging) process
itself, often combined with superimposed, prior spine
surgery. The destabilizing effects of an unsuccessful
continued on page 14
Edward C. Benzel, M.D.
For more information, please
contact Dr. Benzel at
216.445.5514 or our
administrator, Kathy
Huffman, at 216.445.8442.
To refer patients,
call 216.445.2225 or
800.553.5056, ext. 42225.
Conservative Treatment of Neck Pain
By Adrian Zachary, D.O., M.P.H.
Neck pain is a prevalent and at times debilitating problem. Although not as common as low back
pain, 40 to 70 percent of the general population will experience cervical spine pain at some point
in their lives1,2 and up to 10 percent of adults will suffer from a disabling neck problem.3
Adrian Zachary, D.O., M.P.H.
Dr. Zachary can be reached
at 216.445.5061 or
[email protected].
Most cases of cervical spine pain present spontaneously
and resolve within days to weeks with little or no treatment. Some risk factors for developing cervical spine pain
include a history of headaches or low back pain, whiplash
injury, high quantitative job demands and low coworker
support. Studies suggest cervical trauma or whiplash
injury increases the likelihood of patients developing
chronic cervical pain; however, in some cases litigation
and monetary gain may be a confounding factor
influencing the duration of pain in this population.
What are the best treatment options for patients
suffering from neck pain? With evolving fields in
complementary medicine and alternative treatment
modalities, many physicians are left in a quandary
as how to best treat their patients. This article offers
an overview of many cervical treatment modalities.
Diagnosing the Problem
The key to treating cervical spine pain is a thorough
history and examination. Most cases of neck pain are
benign, but neck pain can be the presenting symptom
of more serious pathology and therefore requires an
accurate history. Recent trauma, neurologic deficits,
radicular symptoms, bowel or bladder dysfunction,
a history of malignancy, night pain or fevers should
heighten the examiner’s suspicion for further work
up. Likewise, examination should focus on identifying
neurologic deficits, gait dysfunction, upper motor
neuron signs or restricted cervical range of motion.
In the absence of neurologic deficits, radicular symptoms
and ominous red flags, treatment for cervical pain and
whiplash injuries should be conservative. Trauma
patients will usually have cervical x-rays or a CT scan
in the acute setting. Evaluation for fracture or instability
is appropriate but extensive evaluation is not indicated
in the absence of neurologic deficits. In the office
setting, an x-ray is appropriate but usually of low yield
at the initial onset of pain. The use of MRI should be
reserved for patients with neurologic deficits, symptoms suggestive of more serious pathology or patients
who do not respond to conservative treatment.
The use of non-steroidal anti-inflammatories (NSAIDs),
ice/heat, avoidance of aggravating activities and
analgesics should be the first line of treatment for
cervical spine pain. Short-term use of a soft collar may
Spinal Column | SPRING 2007
be employed, but prolonged use should be discouraged.
Studies have shown that two weeks of cervical collar use
was no more effective at relieving pain than two days of use.
Pharmacologic Treatments
For mild pain, the use of NSAIDs or acetaminophen is
recommended. However, high doses of acetaminophen
can lead to hepatotoxicity and chronic NSAID use can
cause serious gastrointestinal side effects. Therefore, close
monitoring is indicated with the use of these medications.
Opioid treatment is appropriate for acute cervical pain,
but should be monitored closely for effectiveness and side
effects. Prolonged use of opiate analgesics increases the
risk of tolerance and dependence. Much debate surrounds
the use of opiate analgesics for chronic neck pain, but
studies suggest the risk for significant abuse is highest in
patients with a prior addiction, further emphasizing the
importance of a thorough past medical history.
The use of muscle relaxants appears to be effective in
reducing cervical pain, decreasing muscle spasm and
improving sleep. Muscle relaxants are more effective
in the early course of treatment, suggesting a shorter
course of these medications is preferable. Side-effects
of drowsiness, dry mouth, nausea and vomiting are
common and, at times, limit the use of these medications. Tricyclic antidepressants have not been well
studied in the treatment of acute or chronic cervical
spine pain.
Although commonly prescribed for whiplash injuries
and cervical radiculopathy, oral corticosteroids have not
been well studied in neck pain. Literature suggests that a
short course of steroids may provide overall reduction in
pain, in analgesic usage and in number of sick days.
Physical Therapy and Manual Medicine
Physical therapy has long been the standard in the
treatment of neck pain. Literature reviews seem to
suggest moderate evidence that physical therapy is
effective in decreasing pain from acute whiplash
injuries4. Well-designed, controlled studies, however,
are also lacking for this treatment. There is evidence
that an early return to regular activities may be equally
effective at alleviating cervical pain.
Cleveland CLinic
An increasing number of patients suffering from cervical pain are pursuing manual
medical treatments from chiropractors, physiotherapists and osteopathic physicians.
There is conflicting evidence regarding the efficacy of these modalities. Recent
reviews of manipulative therapy for pain control have failed to report convincing
evidence of its effectiveness in acute or chronic neck pain, most reporting lack of welldesigned studies. There is moderate evidence that manipulation in combination
with physical therapy is more beneficial than manipulation alone, but not more
effective than conventional exercise treatment for neck pain.
Modalities and Interventional Treatments
Cervical facet joint and medial branch blocks appear to be effective in the shortterm treatment of cervical spine pain. Recent studies suggest there is evidence
that cervical medial branch radiofrequency ablation is an effective cervical pain
treatment with longer duration of action than medial branch blocks in whiplash
patients who have failed other forms of conservative treatment.5,6
Cervical traction is often employed in the treatment of neck pain. Recent reviews
suggest a lack of conclusive evidence to support the efficacy of continuous traction
in the treatment of cervical spine pain, but there is moderate evidence to support
the use of intermittent traction over continuous traction.
There is strong support in
the medical community
for the use of conservative
therapeutic options in the
treatment of acute and
chronic cervical spine
pain versus early surgical
intervention.
The use of electrotherapies, including TENS, pulsed electromagnetic field therapy
and electrical muscle stimulation with physical therapy, has been an essential
part of cervical rehabilitation. Strong evidence supporting the effectiveness of
these therapies, however, is unfortunately lacking.
There is conflicting evidence regarding the effectiveness of acupuncture in the
treatment of cervical spine pain. A recently published report shows moderate
evidence supporting acupuncture as being superior to massage and some other
alternative therapies in the treatment of cervical spine pain. However, other
studies suggest a lack of strong supporting evidence of the effectiveness of
acupuncture in the treatment of neck pain.
The effectiveness of Botox injections in subjects suffering with chronic mechanical
neck pain has not been shown to be any more effective than saline injections in
several high-quality studies.
Patient education is an important component of an effective treatment plan for
cervical spine pain. Educating patients regarding the benign nature of most neck
pain decreases the incidence of chronic pain complaints in whiplash-injured
patients. Fear of the underlying cause of pain has been shown to be a barrier to
recovery for many patients. Education also may help in a patient’s ability to
actively cope with neck pain. Studies have shown that passive coping is a strong
predictor of patients developing disabling neck pain.
Despite the paucity of quality research validating the use of commonly prescribed
modalities, there is strong support in the medical community for the use of
conservative therapeutic options in the treatment of acute and chronic cervical
spine pain versus early surgical intervention. However, patients with severe
disability, neurologic deficits or neck pain recalcitrant to conservative treatment
should be referred to a spine specialist for surgical evaluation.
1C
ote P, Cassidy JD, Carroll L. Saskatchewan health and
back pain survey: the prevalence of neck pain and related
disability in Saskatchewan adults. Spine. 1998; 23:1
1689-1698.
2L
evin KH, Covington EC, Devereaux MW, et al. Neck pain
and low back pain. Continuum. (NY) 2001; 7:1-205.
3B
ovim G, Schrader H, Sand T. Neck pain in the general
population. Spine. 1994;19:1307-1309.
4S
arig-Bahat H. Evidence for exercise therapy in
mechanical neck disorders. Man Ther. 2003;8:10-20.
5B
ogduk N. Treatment of whiplash injuries. Spine: State of
the Art Reviews. 1998;12:469-83.
6 Niemisto L, et al. Radiofrequency denervation for neck
and back pain: a systemic review within the framework of
the Cochran Collaboration Back Review Group. Spine
2003;28(16):1877-1888.
7T
rinh KV et al. Acupuncture for neck disorders. Cochrane
Database Syst Rev. 2006;3:CD004870.
Adrian Zachary, D.O., M.P.H., is a staff medical spine specialist with Cleveland Clinic.
He specializes in interventional pain management and non-surgical treatment of
spine disorders.
clevelandclinic.org/spine Minimally Invasive Cervical Laminoforaminotomy
By Michael P. Steinmetz, M.D.
Posterior cervical decompression is very successful at relieving pain and neurologic dysfunction
related to stenosis of one to a few neural foramen. It was first proposed by Spurling and Scoville
in the 1940s and is a procedure of choice for posterolateral disc herniations and focal foraminal
stenosis. It also is useful for those patients in which an anterior approach would be contraindicated.
Michael P. Steinmetz, M.D.
Dr. Steinmetz can be
reached at 216.445.4633
or [email protected].
In general, surgery consists of creating a small window
in the bone of the dorsal cervical spine — that is, the
lamina and facet joint. This procedure is commonly
referred to as a laminoforaminotomy. The classic open
posterior cervical approach necessitates a moderatesized midline incision, lateral reflection of the upper
cervical musculature and exposure of the medial facet
and lamina. Extensive muscle dissection is often
required, which frequently results in considerable neck
pain and spasticity following surgery. Moreover, a large
visible scar is often left following surgery. Minimally
invasive techniques, however, allow the surgeon to
perform the laminoforaminotomy without the need
for extensive muscle dissection or a large incision.
The success rate of the
procedure is approximately
90 percent, and the incidence
of complications is low.
Following surgery, the patient
is left with an approximately
2 cm incision and may return
to activity as soon as tolerated;
no fusion is required.
The procedure is ideal for a lateral soft disc herniation or
lateral spondylosis resulting in foraminal stenosis and
radiculopathy (Figure 1). The procedure is not used for
central stenosis due to a midline disc herniation or
bulge or to treat cervical myelopathy. It also may not be
appropriate for multi-level foraminal stenosis, but may
be utilized for bilateral disease.
Spinal Column | SPRING 2007
The patient is positioned either prone or sitting. Lateral
and/or AP fluoroscopy is used to localize the appropriate
level (Figure 2). The incision is based over the level to be
decompressed and is approximately one finger breadth
lateral to the midline (approximately 2 cm). The size of
the incision depends on the size of the tube used. An
18 mm tube or, alternatively, a 16 or 14 mm tube, may
be utilized. An incision of approximately 20 mm is made
and a series of dilators are delivered through the incision
until the working diameter is reached and the final
working tube is placed (Figure 3). A surgical microscope
is then used to clear muscle and tissue off the interior
edge of the lamina and medial facet. A small window of
bone is drilled away with a high-speed drill and cleared
with fine curettes or punches. This is done to relieve the
exiting nerve root of any compression (Figure 4). The
tube is removed and the skin is closed with fine sutures
(under the skin) and glue (Figure 5).
The success rate of the procedure is approximately
90 percent, and the incidence of complications is low.
Following surgery, the patient is left with an approximately 2 cm incision and may return to activity as
soon as tolerated; no fusion is required.
Recently, advances in this approach have afforded the
ability to perform instrumented fusion in the dorsal
cervical spine. Alterations are currently being performed
in the instrumentation sets to make this much easier.
Overall, minimally invasive laminoforaminotomy is a very
successful operation for the carefully selected patient.
Michael P. Steinmetz, M.D., is an assistant professor of
surgery with Cleveland Clinic. His clinical interests include
minimally invasive spine surgery, including decompression
and fusion; spine and spinal cord tumors; adult reconstructive surgery; and adult deformity surgery. He maintains an
active laboratory investigating spinal cord injury, regeneration and plasticity.
Cleveland CLinic
Figure 1
Figure 4
Figure 2
Figure 5
Figure 1: Axial MRI of the spine at the C5/6 level. A left-side far
lateral disc herniation is present with resultant foraminal stenosis.
Figure 2: Lateral fluoroscopy is used to localize the appropriate
level to decompress.
Figure 3: A series of dilators are used to place the working tube.
The tube is attached to the operating room bed rigidly.
Figure 4: The foraminotomy is performed under the operating
room microscope. The decompression is finished when a small
nerve hook may be passed through the foramen with no
obstruction.
Figure 5: The incision may be closed with sutures and glue.
Figure 3
clevelandclinic.org/spine Treating Cervical Radiculopathy and Myelopathy
By Gordon R. Bell, M.D.
Figure 1: Axial T2 MRI showing a right lateral disc
herniation at C5-6, which was removed by a posterior
laminotomy and discectomy.
Two spinal conditions frequently encountered in clinical practice are cervical
radiculopathy and cervical myelopathy. Cervical radiculopathy refers to radiating
arm pain with or without sensory and/or motor loss. Cervical myelopathy, on the
other hand, presents a complex — and sometimes confusing — upper motor
neuron clinical picture characterized by symptoms and signs of spinal cord
compression. Occasionally both lower motor nerve root findings and spinal cord
upper motor neuron findings may co-exist (myeloradiculopathy), which may further
complicate the clinical presentation.
The natural history, clinical presentation and expected outcome of cervical radiculopathy and
cervical myelopathy are very different; surgical treatment of each is therefore different. While
radiculopathy generally is treated by anterior decompression and fusion (unless a far lateral
herniation or foraminal stenosis exists), cervical myelopathy can be treated either by anterior
decompression and fusion or by posterior decompression and stabilization, depending upon
the alignment of the cervical spine.
Cervical Radiculopathy
Radiating arm pain is commonly due to nerve root compression from disc herniation or foraminal stenosis. The diagnosis is made by correlating the dermatomal distribution of the pain with
objective neurological findings and corroborative imaging, either by magnetic resonance
imaging (MRI) or by myelography with computed tomography (CT).
Many, if not most, patients with cervical radiculopathy will get better without surgery. The
absolute indications for surgery include progressive arm weakness or findings suggesting
concomitant spinal cord compression (myelopathy). The most common indication for surgery is
intractable arm pain that has failed to respond to conservative measures. Conservative treatment
includes anti-inflammatories, analgesics and physical therapy, which includes a McKenzie neck
program and passive modalities such as cervical traction.
Figure 2a
Surgery for cervical radiculopathy is most commonly performed anteriorly and usually involves
an anterior cervical discectomy and fusion (ACDF), in which the disc is removed, the nerve root is
decompressed and a fusion is performed. This procedure was originally described in the early
1950s. Fusion involves the use of bone and sometimes an interbody device to augment the fusion.
The bone graft may be a tricortical iliac crest graft taken from the patient (autologous graft), or it
may be cadaveric bone commercially obtained from a bone bank (allograft). Interbody devices,
made from either titanium or carbon, and filled with cancellous bone graft, also may be used.
The bone graft or interbody device commonly is held in position by a small anterior plate,
although a single-level fusion may be performed with bone graft only and without a plate.
Occasionally, a far lateral disc herniation with resultant radiculopathy can be removed
posteriorly without performing a fusion (Figure 1). This situation is uncommon but, when
present, offers the opportunity for nerve root decompression without fusion. Radiculopathy
from foraminal stenosis also can be treated with posterior foraminal decompression alone.
Figure 2b
Figure 2a: Sagittal cervical MRI showing severe cord
compression at C4-5 and C5-6. Note the severe
narrowing with loss of the white cerebrospinal fluid
surrounding the spinal cord at these levels.
Figure 2b: Post-operative lateral x-ray showing five
small laminoplasty plates from C3-7 that keep the
spinal canal hinged open at the decompressed levels.
Relief of arm pain following an anterior fusion is reliable and predictable. Good or excellent
results are reported in approximately 85 to 90 percent of patients. Complications are relatively
uncommon and can include nerve root injury, pseudarthrosis, transient airway obstruction (from
laryngospasm, hematoma, vocal cord paralysis, allergic reaction or edema), hoarseness (from
retraction or injury to the superior or recurrent laryngeal nerve), and dysphagia (from retraction
Spinal Column | SPRING 2007
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of the esophagus). Dysphagia is more common with
multilevel decompression and prolonged surgery. Less
common complications include nerve root injury, spinal
cord injury and vascular injury.
Cervical Myelopathy
kyphosis. The ability of posterior surgery to adequately
decompress the spine depends upon the presence of
preoperative cervical lordosis or neutral alignment. With
a lordotic or neutral spine, the spinal cord can “drift”
posteriorly following the posterior decompression,
thereby relieving the cord compression.
Spinal cord compression commonly occurs from a
congenitally narrowed canal, from degenerative changes
or a combination of both. This may result in a confusing
clinical picture with symptoms and signs of spinal cord
dysfunction, nerve root compression or both. When due
to age-related canal narrowing, the condition is referred
to as cervical spondylotic myelopathy (CSM).
The posterior decompressive options include laminectomy and fusion or laminoplasty, in which the spinal
canal is enlarged by “hinging” open the laminae without
actually removing them (Figure 2). This offers the dual
advantages of enlarging and decompressing the spinal
canal, as well as minimizing the risk of developing
postoperative spinal instability. The main advantage of
laminoplasty over laminectomy with fusion is that motion
Common clinical manifestations of cervical myelopathy
is preserved with a laminoplasty. The latter is ideal for the
include loss of dexterity in the upper extremities (such as
myelopathic patient with multilevel stenosis, neutral or
unexplained changes in hand writing), gait abnormalities,
lordotic alignment and minimal neck pain. If the spine is
extremity weakness and, in extreme cases, bowel and
kyphotic, laminectomy or laminoplasty is contraindibladder incontinence. Neurological examination typically
cated, since the compressing force is anterior, and
reveals long tract findings such as hyper-reflexia, spasticity
posterior decompression will therefore not address the
and clonus. Other pathological reflexes such as a Hoffman
source of compression. Under these circumstances,
sign and an extensor-plantar response (Babinski sign) also
anterior decompression and fusion is preferred.
may be present. In addition, objective weakness usually is
present, which typically is greater in the upper than the
lower extremities.
The natural history of CSM usually is characterized by
eventual neurologic deterioration, although it may have
periods of relative stability. Therefore, the treatment of
this condition generally is surgical decompression and
fusion. Depending upon the location of the compression
and the alignment of the cervical spine, surgery may be
performed either anteriorly or posteriorly. If the myelopathy is due to a focal disc herniation, the treatment involves
an ACDF. If the pathology is more diffuse and is multisegmental, treatment can involve either anterior or posterior
decompression, depending on the location of the
compression (anterior or posterior) and the alignment of
the cervical spine. If there is lordotic or neutral alignment,
surgery generally may be performed either anteriorly or
posteriorly. Anterior surgery involves either multilevel
discectomy with fusion or corpectomy — in which a large
segment of one or more vertebral bodies and intervening/
adjacent discs are removed — with fusion. With either
procedure, anterior cervical instrumentation usually is
performed. Such extensive anterior surgery is associated
with a relatively high risk of dysphagia (usually temporary),
and for that reason posterior surgery often is preferred.
Gordon R. Bell, M.D.
Dr. Bell can be reached
at 216.444.8126 or
[email protected].
Relief of arm pain following an anterior fusion
is reliable and predictable. Good or excellent
results are reported in approximately 85 to 90
percent of patients.
The outcome following spinal cord decompression for
cervical myelopathy is unpredictable. Therefore, the
patient should be told that the goal of surgery is to
stabilize his/her neurological function and to prevent
further deterioration. In general, milder degrees of
myelopathy have a better chance of improvement than
more severe myelopathy.
Gordon R. Bell, M.D., holds a primary appointment as a
Cleveland Clinic spine surgeon, with a joint appointment in
the Department of Orthopaedic Surgery, where he serves as
vice chairman. His interests include degenerative conditions
of the lumbar and cervical spine, spine fractures and athletic
spine injuries.
Posterior surgery generally involves decompression and
some form of stabilization, since laminectomy alone is
associated with a risk of developing post-operative
clevelandclinic.org/spine The Merits of Cervical Disc Arthroplasty
By Thomas E. Mroz, M.D.
Cervical spondylosis is a natural and evolving process that occurs with aging. Approximately 60
percent of asymptomatic persons over 40 years of age have radiographic evidence of spondylosis.
By age 60, 95 percent of men and 70 percent of women show similar radiographic findings.
Thomas E. Mroz, M.D.
Dr. Mroz can be reached
at 216.445.9232 or
[email protected].
Nearly 50 years ago, cervical spine fusion was introduced
as a treatment for symptomatic cervical spondylosis.
Today, anterior cervical discectomy and fusion (ACDF) is
a common surgical treatment for symptomatic cervical
spondylosis. Yet, it is widely recognized that levels
adjacent to a fused cervical segment or segments are
prone to develop accelerated degenerative changes, and
it is thought that the incidence is 3 percent per year. This
may be due to the significant forces transmitted to the
adjacent levels following segmental fusion. Adjacent
segment degeneration (ASD) is associated with clinical
deterioration in some patients, giving rise to what has
been termed adjacent segment disease.
Disc replacement, also known as cervical total disc
arthroplasty (TDA), is a novel technology designed to
replace cervical fusion. Theoretically, by maintaining
cervical motion, the adjacent level degeneration
associated with fusion may be avoided. Similar to
lumbar disc replacements, there are various cervical
discs with unique mechanical characteristics currently
being studied in this country (Figures 1–3). All are
designed to preserve motion at the surgical level.
The criteria being used for disc replacement in the FDA
Investigational Device Exemption clinical trials include:
1) radiculopathy caused by disc hernia ions or bony
foraminal stenosis, 2) myelopathy due to soft disc
herniation and/or disc/osteophyte complexes, or 3)
any combination of 1 or 2. TDA currently is not considered
a reasonable treatment for axial neck pain.
Cervical arthroplasty is an exciting new technology that
may improve clinical outcomes in patients with spondylosis and the variety of associated neurological syndromes.
The purported benefits of arthroplasty have not been
clinically proven, due to the lack of adequate long-term
follow-up from well-designed clinical trials. Considering
the current published literature, one can conclude only
that single-level arthroplasty is equivalent to single-level
ACDF at two years postoperatively. One study suggests
that arthroplasty prevents or lessens the degree of ASD at
two years postoperatively. This conclusion, however, will
need to be validated with longer-term studies.
Spinal Column | SPRING 2007
In order for cervical arthroplasty to become a standard
of care for cervical spondylosis that is refractory to nonsurgical management, several criteria must be met.
First, it must have a clinical benefit that is equal to, or
better than, the current standard, ACDF. Second, it must
be shown that it is efficacious at preventing or delaying
the progression of ASD. The latter is a critical factor
regarding the support of the argument in favor of this
technology. Third, it must be safe. Finally, arthroplasty
must be shown to be cost effective.
TDA is becoming an increasingly larger component of
the $3 billion implant industry. Arthroplasty is a new,
incompletely studied technology, about which many are
enthusiastic. Like any new spinal technology, however, it
must withstand the scrutiny of well-designed, unbiased
studies that prove its efficacy, as has laparoscopic
cholecystectomy. However, unique to arthroplasty is the
need for long-term outcome studies. This is due to the
type of devices employed, the lack of models that
simulate the clinical situation, and the nature of the
clinical problem (adjacent segment degeneration) it is
designed to remedy. Adjacent segment degeneration
occurs over a period of years and, as such, a device
designed to prevent such a problem needs long-term
data to support or refute its efficacy. This is an exciting
era of spinal surgery in general, and further research will
foster the development of technically advanced and clinically efficacious methods to treat cervical spinal
disorders using motion-preserving technology.
Thomas E. Mroz, M.D., is a spinal surgeon with Cleveland
Clinic. He is interested in cervical spine surgery and
minimally invasive spinal surgery, especially complex
cervical spine surgery, including cervical deformity,
revision surgery, cervical infections, cervical tumors, and
cervical myelopathy and radiculopathy.
Cleveland CLinic
Figure 1: Cervical discs currently
being studied in the United States
include the: (a) Bryan cervical disk
(Medtronic Sofamor Danek,
Memphis, Tenn.); (b) Prestige
cervical disc (Medtronic Sofamor
Danek, Memphis, Tenn.); (c) Porous
Coated Motion (PCM) Artificial
Cervical Disc* (Cervitech, Rockaway,
N.J.); and (d) Prodisc-C (Synthes
Spine, West Chester, Pa.).
Figure 1a
Figure 1b
Figure 1c
Figure 1d
*Caution: Investigational Device,
Limited by United States Law to
Investigational Use.
Figure 2: Illustrations from Cervitech
compare their PCM Artificial Cervical
Disc (a) to traditional fusion (b).
Figure 3: Lateral close-ups of the
PCM Artificial Cervical Disc (a) and
plate fusion (b).
Figures 1a and 1b reprinted with
permission from Medtronic Sofamor
Danek. Figures 1c, 2 and 3 reprinted
with permission from Cervitech.
Figure 1d reprinted with permission
from Synthes Spine, LLP.
Figure 2a
Figure 2b
Figure 3a
Figure 3b
clevelandclinic.org/spine Cervical Deformities
By R. Douglas Orr, M.D., FRCSC
R. Douglas Orr, M.D., FRCSC
Dr. Orr can be reached
at 216.363.2410 or
[email protected].
The cervical spine is susceptible to a number of forces that it must balance in order to maintain alignment and stability and in order to protect the spinal cord. If these forces are not balanced correctly,
deformities can occur. The human head weighs about 10 pounds and is balanced on top of the
vertebra of the neck, which are usually less than 2 inches wide and 1.5 inches front-to-back. This
configuration has been compared to balancing a bowling ball on a bowling pin. In addition to the
vertebra and discs, there are other supporting structures for the head, such as the paraspinal muscles
and three strong ligaments: the anterior and posterior longitudinal ligaments and the interspinous
ligaments. In addition to providing support, these structures must also allow mobility so that the
head can be moved. Failure of any of these structures can lead to deformity.
Cervical deformity is an uncommon but complex
problem. In many cases, non-operative management is
effective and appropriate. Surgery often is indicated and
effective, but the surgeries are complex. Patients with
symptomatic cervical deformities, therefore, should be
assessed by someone experienced in their treatment.
Figure 1
Types of Cervical Deformities
In the normal spine, a gentle curve is seen when viewed
from the side. This curve is called lordosis (Figure 1). The
most common pattern of deformity in the cervical spine
is the reversal of this curve, called kyphosis (Figure 2).
When viewed from the front or back, the cervical spine
should be straight. Scoliosis is a curve in the spine when
viewed from the front or back and is uncommon in the
cervical spine. This condition, when seen, is called
torticollis.
There are numerous causes of cervical deformities and
they can manifest themselves in many ways. Many cause
no symptoms and are picked up incidentally, while others
do lead to symptoms and require treatment. The predominant symptoms encountered are axial neck pain, arm
(radicular) pain and myelopathy (impairment of spinal
cord function). Axial neck pain often involves a positional
or fatigue pattern and occurs because of the increased
energy expended by the paraspinal muscles to hold the
head up and maintain a forward gaze when gravity is
working to pull the head forward and down. As the
deformity increases, so do the energy demands. Radicular
pain is caused by nerve root compression and can occur in
the distribution of any cervical nerve root. Myelopathy is
caused by compression of the spinal cord and can present
with gait disturbances or loss of hand function.
Treatment
Figure 2
10
Spinal Column | SPRING 2007
Treatment of cervical deformities is dependant on the
presenting symptom. If the patient is asymptomatic,
then observation alone is warranted. Axial neck pain
often will respond to a physical therapy program with an
active strengthening component. Traction seems like an
appealing method of treatment, but has not been shown
to be effective. Bracing has been advocated, but only in
very rare circumstances is it effective. Typically, not only
Cleveland CLinic
Figure 1: Lateral view of the cervical spine showing
a normal lordotic alignment.
Figure 2: Lateral view of the spine showing a
kyphotic alignment.
Figure 3: Sagittal T2 MRI showing multilevel
compression of the cervical spinal cord, both from
the posterior and anterior.
Figure 4: A post-operative lateral film of the patient
in Figure 3 after combined anterior and posterior
treatment of the myelopathy and deformity.
Figure 3
Figure 4
is it ineffective, but it may in fact worsen the condition.
When braces are effective, they unload the cervical
muscles. The unused muscles are already weak and
brace wear only exacerbates their weakness, which
contributes to axial pain. Soft cervical collars have no
role in the treatment of any cervical deformity, because
they provide no stability, do not restore alignment and
wearers tend to lose range of motion.
Radicular pain can be treated in a number of ways. Nonsteroidal anti-inflammatory drugs and narcotics each
have a role, though narcotic use should be short term.
Medications for neurogenic pain such as gabapentin
(Neurontin) and pregabalin (Lyrica) have been shown to
be effective in some patients. Cervical nerve root blocks
and epidural injections also are effective in some patients.
If a patient has persistent pain for more than three
months, in spite of conservative management, then
surgery may be a good option. The presence of a significant deformity complicates the surgical approach. In
general, decompressive procedures alone are not a good
option, as they tend to exacerbate the deformity. Similarly,
treatment of a single-level radiculopathy with single-level
surgery is only rarely indicated. As a result, the surgery for
cervical deformity often is quite extensive and may involve
combined anterior and posterior approaches.
The predominant symptoms
encountered [with cervical
deformities] are axial neck
pain, arm (radicular) pain and
myelopathy (impairment of
spinal cord function).
surgery are decompression of the spinal cord and
correction of the deformity. This usually will involve a
multi-level instrumented fusion and may again need
combined anterior and posterior approaches (Figure 4).
R. Douglas Orr, M.D., FRCSC, is a spinal surgeon with
Cleveland Clinic and also has a joint appointment in
orthopaedic surgery. His clinical interests include spinal
deformities, spinal tumors, spinal biomechanics and
biomaterials, and minimally invasive spine surgery.
Myelopathy is a common presenting symptom of cervical
deformity and has a different natural history. In general,
most cervical conditions are not progressive. Myelopathy, however, almost invariably is progressive, though
the rate of progression may be quite slow. Compression
on the cord comes from both the degenerative changes
seen in deformities and from the draping of the spinal
cord over the anterior osteophytes and discs (Figure 3).
Typically, the only effective treatment for a cervical
deformity with myelopathy is surgery. The goals of
clevelandclinic.org/spine 11
Cervical Spine Tumors
By Thomas E. Mroz, M.D.
The incidence of metastatic disease of the spine far exceeds that of primary
neoplasia, and is estimated to account for greater than 95 percent of all
spinal tumors. Primary tumors and metastatic disease of the cervical spine
are relatively rare, compared to the thoracic, lumbar and sacral regions.
Figure 1
The likelihood of malignancy is directly proportional to the age of the patient. In one
study of 23 patients with primary cervical spine tumors, all patients younger than 21
years old had benign tumors, while 71 percent of patients older than 21 years had a
malignancy. Carcinomas begin to peak in the fourth, fifth and sixth decades, and
myeloma and lymphoma begin to peak in the fifth and sixth decades. Certainly, when
a patient presents in the fourth decade with an undiagnosed cervical spine lesion, the
suspicion of malignancy must be quite high. A difference in tumor location also
provides a clue about the tumor type, with benign tumors having a predilection for
the posterior elements, and malignancies more often occurring in the vertebral body.
Figure 2
Primary Tumors
There are many primary benign tumors that affect the cervical spine. Osteochondroma
is the most common. Others include osteoblastoma, osteoid osteoma, aneurysmal
bone cyst, hemangioma, giant cell tumor and eosinophilic granuloma. Chordomas
are the most frequently accounted malignant tumor in the spinal column. However,
the cervical spine is not a common site of occurrence; most occur in the sacrum
or the clivus.
Figure 3
Case Example One
A 52-year-old female with mechanical neck
pain and no history of primary malignancy
was found to have a large tumor involving C3.
Pre-operative work-up demonstrated systemic
metastasis with a suspected pancreatic
primary. Figure 1 shows a lateral x-ray of the
cervical spine showing the C3 metastatic
lesion. Note the overall lucency and the lytic
region of the C3 vertebral body. Figure 2
shows an MRI with contrast of the cervical
spine; note the complete replacement of the
C3 vertebral body by the tumor. A C3 body
resection (corpectomy) with allograft and
plate reconstruction, followed by a posterior
instrumented fusion was necessary for
adequate resection and stabilization. Figure 3
shows a lateral post-operative x-ray. Postoperative chemotherapy and radiation therapy
were then administered.
12
Myeloma and solitary plasmacytoma are the most common primary malignancies
of the adult spine. They account for approximately 30 percent of all primary spinal
malignancies. According to the Mayo Clinic Registry, the cervical spine is involved
in 3 percent of all myeloma cases. Non-plasma cell lymphomas account for 10 percent
of spinal malignancies, but only 0.8 percent of all lymphomas occur in the cervical
spine. Chondrosarcoma also accounts for 10 percent of primary spinal malignancies,
but only 1.5 percent of chondrosarcomas affect the cervical spine. Osteosarcomas and
Ewing’s sarcomas are highly malignant bone lesions, and together account for 10
percent of the primary spinal malignancies. However, it is estimated that only 0.5
percent and 0.4 percent, respectively, of all osteosarcomas and Ewing’s sarcomas
occur in the cervical spine.
Metastatic Tumors
Skeletal metastasis is a common occurrence, and the spine represents the most
commonly affected osseous site. The thoracic spine is the most commonly involved
region, followed by the lumbar and cervical regions. The top three most common
tumors to metastasize to the spine are breast, lung and prostate. Renal, gastrointestinal, thyroid and bladder tumors also occur in the spine, but at lower rates.
Patient Presentation and Treatment Principles
Patients with cervical tumors require a thorough evaluation of their histories,
physical examinations, and laboratory and imaging studies in order to be properly
diagnosed and to formulate the most appropriate and efficacious treatment plans.
Patients with cervical tumors can present in many ways, but mechanical neck pain
is a common presentation. A pathologic fracture may be heralded by an acute onset
of neck pain with or without a neurologic deficit, depending on the fracture type
Spinal Column | SPRING 2007
Cleveland CLinic
and tumor burden. In patients with an isolated cervical
lesion without a known primary, an open biopsy often is
necessary to obtain a diagnosis.
The treatment of cervical tumors depends primarily on
the tumor type, its radio- and chemo-sensitivity, the
extent of tumor metastasis (if metastatic) and, importantly, the degree of spinal stability and neural compression. Regardless of whether a non-surgical or surgical
regimen is chosen, it is important to have a comprehensive, well-organized team that includes an internist,
oncologist, surgeon, dietitian and social worker in order
to make the treatment of these patients most efficacious.
Surgical resection and reconstruction is required in
patients who have neurologic compromise, marked bony
destruction, a significant deformity due to fracture or a
risk of developing a fracture.
The cervical spine has unique biomechanical characteristics and surrounding anatomy. Therefore, it commands more thought and diligence during the decisionmaking process. Surgery for spine tumors requires
meticulous technique with appropriate decompression
of the neural elements, restoration of normal or nearnormal cervical alignment, the provision of spinal
stability, and minimal morbidity and injury to adjacent
visceral and vascular structures.
Thomas E. Mroz, M.D., is a spinal surgeon with Cleveland
Clinic. He is interested in cervical spine surgery and
minimally invasive spinal surgery, especially complex
cervical spine surgery, including cervical deformity, revision
surgery, cervical infections, cervical tumors, and cervical
myelopathy and radiculopathy.
Thomas E. Mroz, M.D.
Dr. Mroz can be reached
at 216.445.9232 or
[email protected].
Case Example Two
An 84-year-old male with neck pain and
a history of B-cell lymphoma had a large,
destructive lesion of C2 (Figures 4–6).
He underwent an occipitocervical fusion for
stabilization followed by radiation therapy
(Figure 7). He is now three years post-op,
and doing well.
Figure 4
Figure 5
Figure 6
Figure 7
clevelandclinic.org/spine 13
A Look at the Cervical Spine
continued from page 1
Locations
surgery can accelerate the progression of deformity, and
extreme surgical measures may be required to correct the
deformity. Dr. Orr reviews the types of cervical deformities
and various treatment options on page 10.
A variety of tumors and tumor types can involve the cervical
spine. Although not a common cause of symptoms, tumor
involvement of the cervical spine can lead to major morbidity and mortality. Henceforth, their impact may be great.
Dr. Mroz reviews the instances and effects of cervical spine
tumors on page 12.
I hope you enjoy this collection of well-illustrated articles
and that they provide insight into this interesting and
perhaps most misunderstood aspect of spine care.
Edward C. Benzel, M.D., is a Cleveland Clinic spinal surgeon.
Cleveland Clinic
9500 Euclid Avenue
Cleveland, OH 44195
216.444.BACK (2225)
Solon Family Health Center
29800 Bainbridge Road
Solon, OH 44139
440.519.6800
Beachwood Family Health and Surgery Center
26900 Cedar Road
Beachwood, OH 44112
216.839.3000
Strongsville Family Health and Surgery Center
16761 SouthPark Center
Strongsville, OH 44136
440.878.2500
Euclid Hospital
18901 Lake Shore Blvd.
Euclid, OH 44119
216.692.8222
Westlake Family Health Center
30033 Clemens Road
Westlake, OH 44145
440.899.5555
Lutheran Hospital
1730 West 25th Street
Cleveland, OH 44113
216.363.2410
Outcomes Data Available
The latest outcomes data in spine care are available.
Our outcomes booklet also offers summary reviews of
medical and surgical trends and approaches. Charts,
graphs and data illustrate the scope and volume of
procedures performed in our department each year.
To view outcomes booklets for spine, as well as many
other Cleveland Clinic medical and surgical disciplines,
14visit clevelandclinic.org/quality.
Spinal Column | Winter 2007
Cleveland CLinic
Willoughby Hills Family Health Center
2570 SOM Center Road
Willoughby Hills, OH 44094
440.943.2500
Cleveland Clinic
Spine Clinical Trials
Prospective outcomes evaluation of decompression
with or without instrumented fusion for lumbar
stenosis with degenerative grade I spondylolisthesis
Edward Benzel, M.D.
216.445.5514
Comparing surgical to conservative management in
the treatment of Type II odontoid fractures among
the elderly
Edward Benzel, M.D.
216.445.5514
Anterior cervical fusion augmented with autologous
marrow: a controlled, prospective, randomized trial
Robert McLain, M.D.
216.444.2744
Pilot study assessing the use of Cortoss, a synthetic
cortical bone void filler in kyphoplasty
Isador Lieberman, M.D.
216.445.2743
Application of seating support for patients with
coccygodynia
Prospective, randomized clinical investigation of the
Cervitech, Inc., Porous Coated Motion Artificial Disc
for stabilization of the cervical spine in patients with
DDD and neurological symptoms at one level (C3–
C4 or C7–T1)
Richard Schlenk, M.D.
216.445.4318
Gaurav Kapur, M.D.
216.445.7378
Comparison of femoral ring allograft with supplemental translaminar facet screw fixation versus
stand-alone anterior lumbar interbody fusion cages
Douglas Orr, M.D.
216.363.2410
Isador Lieberman, M.D.
216.445.2743
The prediction of pain reduction in the treatment of facet joint syndrome monitored by CERSR technology
An assessment of surgical techniques for treating
cervical spondylotic myelopathy
Thomas Mroz, M.D.
216.445.9232
Daniel Mazanec, M.D.
216.444.6191
Upcoming Symposia
February 23–25, 2007
First International Symposium on
Stereotactic Body Radiation Therapy
and Stereotactic Radiosurgery
Grand Floridian Resort and Spa
Lake Buena Vista, Florida
July 18–24, 2007
Cleveland Spine Review
InterContinental Hotel & Conference Center
Cleveland, Ohio
August 3–9, 2007
Egyptian Spine Review and Hands-on Course
Cairo, Egypt
August 24–25, 2007
Innovative Spine Care: Essential
Skills for the Nursing Team
InterContinental Hotel & Conference Center
Cleveland, Ohio
Contact Martha Tobin at 216.445.3449 or 800.223.2273, ext. 53449, or at [email protected] for seminar details.
clevelandclinic.org/spine 15
Spinal Column
The Cleveland Clinic Foundation
9500 Euclid Avenue / W14
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For referrals to Cleveland Clinic spine
physicians, call 216.444.2225
Spinal Column | SPRING 2007 the cervical spine
Cleveland Clinic is ranked third in the nation in U.S.News & World Report’s
2006 Best Hospitals Survey.
Co-Editor:
Edward C. Benzel, M.D.
Co-Editor:
Daniel J. Mazanec, M.D., F.A.C.P.
Dr.Connect:
Physician Leader:
Thomas E. Mroz, M.D.
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Whether you are referring from near or far, our new e-Cleveland Clinic service,
Dr.Connect, can streamline your communication with our specialists. This new
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please call 877.224.7367 or e-mail [email protected].
Managing Editor:
Christine Coolick
Spinal Column is published by Cleveland
Clinic to provide up-to-date information
about our spine physicians’ research and
services. The information contained in this
publication is for research purposes only and
should not be relied upon as medical advice.
It has not been designed to replace a
physician’s independent medical judgment
about the appropriateness or risks of a
procedure for a given patient.
MKT 06-SPC-008