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domingo, 21 de marzo de 2010

Cervical Spine

Cervical Spine


Content


Dear Patient
The following information was put together to help in the decision-making process. The graphs show the answers of the members of EuroSpine, the Spine Society of Europe, considered to be the European experts in the field of treatment of spine pathology. This information should help you to learn and understand what most of the experts in the field would do in each specific situation. The information reflects a “common sense” approach to treatment of the members of EuroSpine, yet does not replace a careful evaluation of your individual situation. Therefore, if you find a significant difference between the answers below and you doctor’s opinion, ask your doctor what made him/her reach this decision.

Each specific situation has to be evaluated on an individual basis. EuroSpine and its members cannot be held responsible for any misunderstandings (or misdiagnosis) based on the information provided here, which in no way attempts to replace a targeted evaluation.


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THE HEALTHY CERVICAL SPINE

General aspects

The cervical spine (CS) is the connection between the head and body. Its mobility allows three-dimensional movement of the head, which in turn allows the orientation in space in all directions. It was probably this mobility, together with the erect position and the development of the brain that allowed mankind to fight and defend themselves efficiently in the early days of evolution.

The soft tissues of the neck consist of elements for the transportation of food and air, which provide the body and muscles with the basic energy supply to control the above-mentioned motion. Vessels ensure the oxygen supply to the brain. The nervous system running through the cervical spinal canal carries information from the functioning body to the brain and transports signals from the brain to the periphery.

Anatomy of the CS

Spine: The CS comprises seven vertebrae, of which five (C3–C7) follow a principle schematic design of all the vertebrae of the spine and two (C1–C2) have a different anatomical build.

Normal anatomy of the cervical spine
Fig 1
Together, all cervical vertebrae make up the CS and form the bony support of the neck. Mobility is assured by the intervertebral connections such as discs, facets and ligaments. Rotation of the head is made possible by the specific anatomical design of the first two vertebrae (C1/C2), called atlas (C1) and axis (C2), while flexion, extension and lateral bending are performed in the lower CS.

Flexion / extension
Fig 2
C1/2 rotation
Fig 3
Vertebral arches, which are interconnected with the ligamentum flavum, form the cervical spinal canal. Together with the ventrally located vertebral bodies and intervertebral discs, a canal with segmental lateral openings is formed. Running through this canal is the spinal cord, with nerve roots exiting bilaterally to the upper extremities.


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PATHOLOGY OF THE CERVICAL SPINE

JUVENILE CERVICAL SPINE
Congenital pathologies

C1/2 (atlantoaxial) instability
One source of instability in the atlantoaxial segment is the pathological development of the dens axis. This can appear as a non-formation (aplasia) or a separated ossicle (os odontoideum). These conditions lead to an increased range of motion or subluxation between the axis and atlas, which may lead to repetitive trauma and damage of the spinal cord.

Diagnosis: This condition may be diagnosed using radiographs of the neck in flexion/extension, by computer tomography (CT) or magnetic resonance imaging (MRI).

Treatment: Therapeutic options in severe atlantoaxial instability in children, as seen by the members of SSE, include:

Specialist's opinion:
1) Preferred treatment for fixed rotatory subluxation
Non-operative

8 votes
Operative, if non-operative is unsuccessful

26 votes
Surgical

4 votes
Total: 38 Specialists answered
2) Preferred treatment for atlantoaxial subluxation/instability
Non-operative

3 votes
Operative, if non-operative is unsuccessful

11 votes
Surgical

22 votes
Other

1 votes
Total: 37 Specialists answered
3) Surgical fixation of fixed rotatory subluxation
Wires C1/2

10 votes
Screws C1/2

24 votes
No internal fixation

1 votes
Total: 36 Specialists answered
4) Surgical fixation of fixed rotatory subluxation
With iliac bone

28 votes
With allogenic bone

6 votes
With bone substitute (e.g. hydroxyapatite)

2 votes
Bone morphogenetic proteins

0 votes
Total: 36 Specialists answered


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AGING CERVICAL SPINE

Degeneration may lead to painful alterations of the anatomy. Osteoarthritis of the facet joints and degenerative disc disease are the most common conditions. Encroachment of the nerve root or the spinal canal may result from the formation of osteophytes or the thickening and calcification of the ligaments. In advanced stages, kyphotic deformity of the cervical spine with consecutive static problems can occur.

Painful facet syndrome
This condition is characterised by predominantly axial pain. It originates from osteoarthritis of the intervertebral joints (facets). The existence of “facet syndrome” as a pathological entity is controversial. Diagnosis: This condition may be diagnosed by clinical examination, imaging (degenerative changes of the facets) and local infiltration of the facets.

Invasive diagnostics
Fig 4
Treatment: Replacements for the facet joints, such as those known for hips and other articulations of the body, are not yet available. The aim of the treatment is thus to eliminate pain by immobilizing the painful segment.

Permanent stability after fusion
Fig 5
Fixation of C1/C2 (atlantoaxial): Screws
Fig 6

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DISCOGENIC PAIN
Pain originating from one or several discs in the cervical spine may cause excruciating axial neck pain. The pain mechanism originating from a cervical disc is not yet fully understood. It is assumed that trauma, degeneration or other adverse factors influencing the integrity of the disc may lead to a painful neck syndrome.
Diagnosis: Diagnosis is made by clinical investigation, imaging (predominantly MRI) and discography.
Treatment: The classic way to deal with discogenic pain is immobilization of the painful segment. Fusion is generally performed using an anterior approach, removing and replacing the painful disc using some kind of biocompatible spacer with or without plate fixation.

Cervical spine: Decompression of the spinal canal
Fig 7
Newer techniques avoid immobilization of the segment by using disc prosthesis. This allows the source of pain (disc) to be eliminated without having to sacrifice segmental (physiological) mobility. Clinical experience with disc prosthesis is still limited (2005). Preliminary studies conclude that disc prosthesis provides similar results to those observed in fusions in the medium to short term.

Artificial disc in the cervical spine
Fig 8
Specialist's opinion:
5) Preferred treatment for axial neck pain identified as facet pain (symptoms, positive response to diagnostic facet infiltration, imaging)
Only non-operative

14 votes
Surgical, if non-operative tx is unsuccessful

11 votes
Facet blocks

10 votes
Other

1 votes
Total: 36 Specialists answered
6) Preferred intervention for axial neck pain identified as facet pain
Anterior interbody fusion

12 votes
Motion-preserving techniques (disc prosthesis)

1 votes
Posterior fusion

9 votes
Other

14 votes
Total: 36 Specialists answered
7) Preferred treatment for axial neck pain identified as discogenic pain (symptoms, positive response to diagnostic discography, imaging)
Only non-operative

10 votes
Surgical, if non-operative tx is unsuccessful

26 votes
Other

0 votes
Total: 36 Specialists answered
8) Preferred intervention for axial neck pain identified as discogenic pain
Anterior interbody fusion

18 votes
Disc prosthesis

10 votes
Percutaneous, intradiscal procedures

0 votes
Posterior fusion

1 votes
Other

6 votes
Total: 36 Specialists answered
9) Preferred technique for anterior interbody disc replacement of the CS
Autologous bone (e.g. iliac crest)

9 votes
Bone cement

0 votes
Customized cages (e.g. titanium, PEEK, hydroxyapatite), no autologous bone

13 votes
Cages in combination with autologous bone

10 votes
Cages with bone morphogenetic proteins, etc.

1 votes
Other

3 votes
Total: 36 Specialists answered
10) Preferred technique of internal fixation in interbody fusion of the CS
No internal fixation

3 votes
Regular use of plates

18 votes
Plates only in multisegmental interventions

14 votes
Other

1 votes
Total: 36 Specialists answered


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NEUROCOMPRESSION OF THE CERVICAL SPINE
Cervical discs can herniate or protrude like lumbar discs. Furthermore, due to degenerative changes to parts of the cervical spine, osteophytes (bony appositions) can form in time. Both conditions can increase pressure on the spinal nerve or the spinal cord. Depending on the location of the compression, the clinical symptoms show up as radicular (spinal nerve) or myelopathic signs and symptoms (spinal cord). Compression by extruded disc material only (usually acute) is called soft hernia, while compression by osteophytes (or in combination with disc material) is usually chronic and is referred to as a hard herniation.


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DISC HERNIATIONS IN THE CERVICAL SPINE
Fig 9
Magnetic resonance of a median disc herniation in the cervical spine
Fig 10

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RADICULAR SYMPTOMS
Radicular symptoms by disc material/osteophytes
Depending on the nerve root involved, pain, sensory disturbances or muscular weakness appear in the corresponding segment.
Fig 11
Diagnosis: Radicular symptoms may be diagnosed by evaluation of the clinical history, clinical examination, imaging (CT and MRI) and neurological investigations.

Treatment: The aim of the surgical treatment is to eliminate pressure on the nerve root by removing the protruded disc/bone material. Conservative management with anti-inflammatory medication and muscle exercises may be successful.

Specialist's opinion:
11) Preferred treatment for cervical radicular symptoms (disc/osteophyte)
Non-operative

0 votes
Surgical only if herniated disc is involved

1 votes
Non-operative as long as there is no muscular deficit

0 votes
Surgical, if neurological deficit(s) (sensory or motor) exist(s)

4 votes
Surgical, if symptoms (pain) are resistant to non-operative treatment

23 votes
Surgery, if imaging and symptoms (pain or neurology or both) correlate

7 votes
Other

1 votes
Total: 36 Specialists answered
12) Preferred interventional treatment for compression by disc material (soft hernia)
Percutaneous procedure (e.g. mechanical disc removal, laser)

0 votes
Disc removal – no fusion

4 votes
Disc removal with anterior interbody fusion

23 votes
Disc replacement by disc prosthesis

9 votes
Other

0 votes
Total: 36 Specialists answered
13) Preferred interventional treatment for compression by osteophytes (and disc material) in hard or mixed herniation
Percutaneous procedure (e.g. mechanical disc removal, laser)

0 votes
Disc removal – no fusion

3 votes
Disc removal with anterior interbody fusion

31 votes
Disc replacement by disc prosthesis

2 votes
Other

0 votes
Total: 36 Specialists answered


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COMPRESSION OF THE SPINAL CORD WITH MYELOPATHY (CERVICAL SPINAL STENOSIS)
The spinal canal can be narrowed by surrounding tissue, creating compression on the myelon. Apart from injuries, this process is chronic and symptoms develop slowly. Sometimes the onset of symptoms goes unnoticed by the patient, and only neck pain or imaging for other purposes reveals stenosis and compression. This makes the choice of treatment difficult. Surgical treatment including the widening of the spinal canal takes on a prophylactic nature in such situations. In advanced stages, the myelon is severely damaged and the symptoms of myelopathy are obvious to both patient and doctor.

Stenosis of the cervical spinal canal (transverse section)
Fig12

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DECOMPRESSION IN THE CERVICAL SPINAL
Fig 13
Compare fig 7

Cervical spine: Decompression of the spinal canal
Fig 7
Diagnosis: Narrow spinal canal or spinal stenosis is diagnosed and confirmed by imaging (CT and MRI), but this is not conclusive for the diagnosis of myelopathy, which is primarily a clinical or neurophysiological diagnosis. The choice of optimal treatment has to take both factors into account: clinical symptoms and imaging findings. The decision to operate is also influenced by the number of stenotic segments.

Treatment: An important factor for decompressive procedures is timing.

Specialist's opinion:
14) For cervical spinal stenosis with neck pain and subjective symptoms without neurological signs of myelopathy, I recommend
No surgery

1 votes
Decompressive surgery

9 votes
No surgery now, but when neurological symptoms appear

25 votes
Total: 36 Specialists answered
15) The principle of surgical treatment is to decompress the spinal cord. My preferred surgical technique is
Posterior laminoplasty/laminectomy as a standard procedure

2 votes
Anterior decompression (discectomy, corpectomy) as a standard procedure

6 votes
Combined anterior/posterior

0 votes
Anterior or posterior depending on the individual's anatomy

28 votes
Total: 36 Specialists answered
© The above text, figures and data are property of EuroSpine®, the Spine Society of Europe and may not be reproduced or used in any other way.

EuroSpine, April 2007

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