Cervical Spine Pain

Central Zone

Central Zone

Zone where PLL is thickest

Disc usually herniates slightly lateral to this zone

Subarticular Zone

Aka Lateral Recess or Paracentral

Zone where disc extrudes between the spinal cord and the foramen

Next to spinous process

Foraminal Zone

Disc extrusion into the foramen

Extraforaminal Zone

Far lateral

Disc extrusion beyond the foramen

Suprapedicle

Superior portion of vertebra

Pedicle

Below suprapedicle, middle portion of vertebra

Disc level

Level of the disc

Cervical Radiculopathy

Cervical canal or foraminal stenosis at the level where the nerve roots exit the cervical spine

Typically due to disc herniation or facet joint hypertrophy

Radiculopathy Symptoms

Unilateral

Paresthesia - numbness

Weakness in arm, shoulder, or hand

Decreased motor skills

Loss of sensation in a dermatome fashion

Pain associated with neck movement or strain

Disc herniation

Displacement of intervertebral disc

Involves less than 25% of the circumference

Protrusions

Base wider than the dome

Confined to disc level

Outer annular fibers intact

Involves less than 90 degrees of the disc circumference

Extrusions

Base is narrower than the herniation dome

Conservative Disc Herniation Treaments

Managed with non-surgical treatments as the majority of patients will improve

Collar Immobilization

Short course (1 week) may be beneficial during the acute inflammatory period

Traction

Widens the neuroforamen and relieves the stress placed on affected nerve. Involves approximately 8 - 12 lbs of traction over a period of 15-20 minutes

Pharmacotherapy

No evidence the efficacy of NSAIDs in the treatment of cervical radiculopathies. Commonly used and can be beneficial for some patients. Opioids effective in relieving acute pain (risk of addiction)

Physical Therapy

No evidence demonstrates efficacy over placebo

Cervical Manipulation

Short-term benefits for neck pain and cervicogenic headaches

Interventional Treatments

Spinal steroid injections into the epidural space decreases the swelling of irritated nerve roots and are common alternative to surgery.

Surgical Treatments

Indications: severe or progressive neurological compromise; significant pain that is refractory to non-operative measures

Anterior Cervical Discectomy and Fusion

Gold standard treatment

Allows the removal of the pathology

Prevention of recurrent neural compression by performing a fusion

Posterior Laminoforaminotomy

Considered in patients with anterolateral herniations and/or osteophytes

Prognosis with conservative treatment

Symptoms subside on their own over six weeks in the majority of patients

Symptoms persist in ¼ of patients despite intervention

Prognosis with surgical intervention for disc disease

More rapid resolution of symptoms.

No significant difference from non-surgical treatment after 5 years.

Disc Bulge

Displacement of the outer fibers of the annulus beyond the margins of the endplate

Involves more than 25% of the circumference of the intervertebral disc

Cervical Degenerative Spondylosis or DDD

Osteophyte formation, disc height narrowing, and end-plate sclerosis

Normal: no degenerative change

Minimal: minimal anterior osteophyte formation, no reduction of disc height, no end-plate sclerosis

Mild to Moderate-increasing anterior osteophytes, decrease of disc height, increased endplate sclerosis and osteophyte sclerosis.

Advanced-Large and multiple osteophyte formation, severe narrowing of the disc space (>75%), end-plate sclerosis with irregularities.

Grade level for C3-C4

Minimal

Grade level for C6-C7?

Advanced

Aging Disc

Disc herniates, annulus fibers begin to weaken-bulging

Surrounding ALL, PLL, and facet joint capsules weaken

Osteophyte formation and eventual bridging of disc space

How the bone reacts in an attempt to stabilize the disc space and facet joints

Compressive Cervical Myelopathy

Upper motor neuron signs:

-hand weakness

-spasticity

-clumsiness

-altered tonus

-hyperreflexia

Causes of compressive cervical myelopathy

Spondylotic osteophyte/disc complex most common

Central disc herniation

Congenital cervical spinal stenosis

OPLL

Rheumatoid arthritis of the neck

Malalignment of cervical spine

Spondylolisthesis: one vertebral body slips forward (or backward) out of alignment with the column. Relative to the vertebral body above.

Results in an unstable spine that can eventually narrow the spinal canal, the neuroforamina or both.

Spondylosis

Degenerative changes in the spine with disc space narrowing and osteophytes

Spondylolisthesis

Off set of the vertebral bodies from the spinal column

Spondylolysis

Stress fracture of the pars interarticularis

Ossification of PLL (OPLL)

High cervical region (C2-C4)

Myelopathy pain, neurological deficits

Majority without significant symptoms

Posterior cervical decompression

Removing the lamina or reconstructing in order to release pressure on the cord. May or may not include a fusion and instrumentation depending on risk of instability.

Discitis and Osteomyelitis

Results from direct inoculation, extension or hematogenous spread (S. aureus most common).

Symptoms: neck pain, back pain, focal tenderness, fever and myelopathy. Pain with pounding.

Pyogenic: predisposing factors - IV drugs, immmunocompromised

Early: subtle disc space narrowing, mild endplate irregularity (best seen on sagittal views

Late: overt body collapse, paraspinal/epidural swelling and fluid collection

MRI is the most sensitive for osteomyelitis and epidural abscess/phlegmon

Bone metastatic disease

Sites: thoracic, lumbar, ribs, pelvis, skull, and proximal femur

Bone is the third most common location for metastasis after lung and liver

CT scans and nuclear medicine bone scans detect bone metastases before becoming symptomatic

Diffuse Idiopathic Skeletal Hyperostosis (DISH)

Aka Forestier disease

Common condition - bony proliferation site of tendinous and ligamentous insertion of the spine (at least four contiguous bodies) - affects elderly individuals

Characterized by flowing ossification of ALL - cervical and thoracic spine and enthesopathies.

DISH clinical presentation

Spine stiffness and decreased mobility. Monoarticular synovitis, dysphagia and airway obstruction are less common.

Focal and diffuse calcification and ossification of ALL.

Hypervascularity, chronic inflammatory cellular infiltration, ossification of entheses-bony attachments of tendons and ligaments.

Periosteal new bone formation on the anterior surface of the vertebral bodies.

DISH

“Melted candle wax” appearance of calcification and ossification. Note the preponderance on the patient’s right side.

Ankylosing spondylitis

Seronegative spondyloarthropathy (RF negative) results in fusion of the spine and SI joints

HLA B27 is the gene with the strongest association

Radiographic features: “bamboo spine” appearance. Axial skeleton is predominantly affected. 20% of cases the peripheral joints are also involved.

Syndesmophytes

Classically described as paravertebral ossification running parallel to the spine

Dagger spine

Linear ossification along the central spine representing the interspinous ligament ossification

CT

Excellent at evaluating bony changes and ossification

MRI

Soft tissue abnormalities and evaluation of the cord