Cervical Stenosis: Myelopathy and Radiculopathy O R, WHAT G O O D I S A S P I NE S U R G E ON F O R MY MESSED -UP

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1 Cervical Stenosis: Myelopathy and Radiculopathy O R, WHAT G O O D I S A S P I NE S U R G E ON F O R MY MESSED -UP NECK

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3 Common Presenting Symptoms for Cervical Stenosis Why this patient keeps calling you Arm numbness Pain radiating down the arms Arm weakness Gait imbalance Neck pain

4 Which of these gets my attention as a surgeon? Arm numbness Pain radiating down the arms Arm weakness Gait imbalance Neck pain (Unless there s a tumor, trauma, or severe congenital abnormality)

5 Why Axial Neck Pain is Not Usually On My Radar And why it gets stuck on yours Surgery has been generally ineffective at fixing neck pain. Surgery needs a target with 22 joints in the neck, not to mention other sources for pain, this becomes extremely difficult. No one has yet perfected the whole-neck replacement surgery. Fusing the entire neck will probably not come without its own neck pain. However, neck pain does have value as a reference point for radicular symptoms.

6 But my neck hurts and I have a bulging disk!!! You need to fix it.

7 The Problem with MRI Our overly useful imaging technology Overly sensitive. Almost everyone has degeneration on imaging. Cervical spine radiology reports will list many findings that are not at all clinically relevant. Patients will pin any and all symptoms on the MRI results I m so glad I finally found out why my stomach has hurt so much since I was a teenager. *The disclaimer at the end of the report does nothing to reassure the patients.

8 Not the same but sounds like it on some reports

9 How We Use MRI Identify any areas of possible neural compression Correlate with clinical presentation and exam findings Not typically useful for neck pain (with exceptions mentioned earlier) MRI cannot diagnose myelopathy or radiculopathy but it can alert us to the possibility

10 Primary Concern When Assessing a New Cervical Spine Patient: Myelopathy (My Spinal Cord Hurts) This is a clinical diagnosis, not a radiographic one

11 Secondary Concern When Assessing a Cervical Spine Patient: Radiculopathy (My Nerve Root Hurts) This too is a clinical, not radiographic, diagnosis

12 What is the difference between myelopathy and radiculopathy? Myelopathy refers to spinal cord dysfunction Radiculopathy refers to nerve root dysfunction

13 Why does it matter? Different natural histories The treatment algorithm is different

14 Cervical Myelopathy Refers to dysfunction of the spinal cord Many possible causes the most common being spondylosis Other causes include acute disk herniations, trauma, tumors, congenital instability, vascular malformations, hemorrhage, infection Should get your attention

15 Cervical Spondylotic Myelopathy

16 Diagnosis of Cervical Myelopathy How to make the call Signs and symptoms of myelopathy with appropriate imaging findings Imaging should be expedited if there are significant clinical concerns Should be seen by a surgeon more urgently than other spine patients when diagnosed

17 Signs and Symptoms of Myelopathy Paresthesias in upper extremities, especially the hands, often not in a specific dermatomal distribution Functional hand weakness trouble buttoning buttons, opening jars, writing, dropping things Gait imbalance Arm weakness and leg paresthesias or weakness typically develop later Bowel and bladder changes are uncommon

18 Key Imaging Findings in Cervical Myelopathy Central canal stenosis Spinal cord compression Spinal cord signal

19 Natural History of Cervical Spondylotic Myelopathy Majority of patients will have progressive decline in spinal cord function over time Some patients may stabilize or improve over time

20 Treatment Recommendations for Cervical Myelopathy Since it typically progresses over time, surgical treatment of myelopathy is recommended to decompress the spinal cord Physical therapy may be a helpful adjunct Medical management with gabapentin may be helpful for paresthesias or dysesthesias Epidural steroid injections are generally not employed Call the spine surgeon sooner than later

21 Surgical Approaches for Cervical Myelopathy Anterior approaches ACDF, arthroplasty, or corpectomy Posterior approaches Laminectomy with or without instrumentation and fusion, laminoplasty

22 ACDF

23 Cervical Arthroplasty

24 Anterior Cervical Corpectomy

25 Cervical Laminectomy

26 Posterior Cervical Instrumentation and Fusion

27 Cervical Laminoplasty

28 Cervical Radiculopathy Refers to dysfunction of a cervical nerve root Many possible causes the most common being spondylosis Other causes include acute disk herniations, trauma, tumors, congenital instability, vascular malformations, hemorrhage, infection

29 Cervical Radiculopathy

30 Diagnosis of Cervical Radiculopathy How to make the call Signs and symptoms of radiculopathy with appropriately correlated imaging findings Imaging should be expedited for significant neurologic deficit typically weakness in the arm or hand Presence of weakness or severe pain should prompt earlier assessment by surgeon Unclear distribution of symptoms may necessitate EMG/NCS to more clearly identify the involved nerve root(s) or distinguish from peripheral causes such as carpal tunnel syndrome or cubital tunnel syndrome

31 Signs and Symptoms of Cervical Radiculopathy Radicular pain in a specific dermatomal distribution Paresthesias and numbness in upper extremities, especially the hands, often in a specific dermatomal distribution. However, many patients have more than one nerve with possible compression on imaging, and the dermatomal pattern can become more difficult to clearly ascertain. Weakness of muscle groups specific to a nerve root (i.e., deltoid weakness with a C5 compression) Arm weakness tends to develop later in the course

32 Key Imaging Findings in Cervical Radiculopathy Foraminal stenosis Nerve root compression Lateral disk/osteophyte complexes

33 Natural History of Cervical Radiculopathy Much more variable than myelopathy Some patients will improve with time and nonsurgical management Others will have persistent or progressive symptoms

34 Treatment Recommendations for Cervical Radiculopathy Multiple treatment options, including nonsurgical options Without focal weakness or severe pain, nonsurgical options should be tried first With focal weakness or unmanageable pain, surgery may be pursued early With failure of nonsurgical therapies, surgery may be pursued over time

35 Nonsurgical Management of Cervical Radiculopathy Medications NSAIDs, steroids, gabapentin, narcotics Physical therapy Epidural steroid injections

36 Surgical Approaches for Cervical Radiculopathy Anterior approaches ACDF, arthroplasty Posterior approaches Foraminotomy

37 ACDF

38 Cervical Arthroplasty

39 Cervical Foraminotomy

40 Key Points to Remember Differences between myelopathy and radiculopathy Myelopathy and radiculopathy with weakness should prompt quick evaluation by surgeon Radiculopathy without weakness can be managed with multiple nonsurgical therapies prior to surgery Surgery is generally not useful for neck pain