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Duke Orthopaedics
presents
Wheeless' Textbook of Orthopaedics

Cervical Spondylosis


- See:
      - Cervical Stenosis:
      - Central Cord Syndrome
      - Soft Disc Protrusion:
      - SCIWORA Syndrome
      - Uncovertebral joints

- Discussion:
    - refers to a combination of degenerative disc disease and osteophyte formation;
    - cervical spondylosis typcially begins to be seen at age 40-50, is seen in men > women, & most common occurs at C5-6 > C6-7 levels;
    - risk factors include frequent lifting, smoking, and driving;
    - chronic disc degeneration & associated facet arthropathy may lead to myelopathy, radiculopathy, or both;
    - radiculopathy:
           - radiculopathy is caused by spondylosis (w/ or w/o disk protrusion) in 70% of patients where asisolated soft disc protrussion 
                 causes radiculopathy in only 20-25% of patients;
           - a C7 radiculopathy is most common followed by C6 radiculopathy;
    - anatomy and pathoanatomy:
    - diff dx:
           - AS, Reiter's, DISH;
           - unlike AS or JRA, the uncommon occurance of bony ankylosis found in spodylosis will involve only 1 or 2 levels;
    - EMG:
           - EMG studies have a high false negataive rate, but may be helpful in select cases for differentiating
                  peripheral nerve lesions from more central compression and disease such as AML;


- Physical Exam:


- Radiographs:
    - loss of disk height, with subsequent loss of cervical lordosis;
    - soft disc protrusion:
    - vaccum phenomena:
           - indicates spondylosis, whereas errosive changes in the disk and end plates are more suggestive of inflammatory lesions;
    - anterior osteophytes are the largest and may alter the overall shape of the vertebral body;
           - large anterior osteophytes may be suggestive of DISH;
    - posterior osteophytes are smaller but are more important clinically because of hypertrophic changes here will project into spinal canal;
    - instability:
           - AP subluxation of more than 3.5 mm or more than 20 deg of saggital angulation on flexion-extension views;
    - stenosis:
           - in upright erect lateral view at distance of 6 feet, distance from posterior cortex of vertebral body at its midpoint to laminar line 
                 should be approximately 17 mm;
           - if this distance is narrowed by posterior osteophyte, diameter of 13 mm should begin to raise suspicion of impingement of spinal 
                 canal, & diameters of < 10 mm correlate highly w/ cord compression;


- Surgical Indications:
    - intractable pain;
    - progressive neurological deficit;
    - severe deltoid or wrist extensor weakness;
    - myelopathy or pending myelopathy;


- Surgical Treatment:
  - anterior approach: & fusion;
         - fusion of one or more levels is performed by countersinking iliac crest bone graft between vertebral bodies;
         - requires discectomy, removal of posterior osteophytes, and removal of the bony sclerotic bed of the vertebral body;
         - stability of bone graft is achieved by initial distraction of soft tissues as graft is inserted;
                - once, distractive force is removed the graft will be held firmly between vertebral bodies;
                - note: to maintain stability the posterior longitudinal ligament should be left intact, if possible;
         - in most cases of cervical spondylosis involving one or two levels, the pathology will be anterior and will be reflecting clinically as 
                myelopathy, anterior cord syndrome, or central cord syndrome;
         - when the primary pathology is mostly anterior, generally the anterior approach should be anterior;
                - the one exception to this may be the rheumatoid C-spine;
  - posterior approach:
         - full laminectomy is required;
         - removal of the spinous process & lamina on each side at multiple levels;
         - facet joints:
               - resection of > 25 % of facet can result in cervical instability;
               - if destabilizing facet resection is needed in order to decompress cord, posterior arthrodesis should be done;
         - laminaplasty:
               - may be indicated for multi-level disease



Cervical spondylotic myelopathy and myeloradiculopathy. Anterior decompression and stabilization with autogenous fibula strut graft.

Long-term follow-up study of anterior surgery for cervical spondylotic myelopathy with special reference to the magnetic resonance imaging findings in 52 cases.

Abnormal magnetic-resonance scans of the cervical spine in asymptomatic subjects. A prospective investigation.

Treatment of cervical spondylotic myelopathy by enlargement of the spinal canal anteriorly, followed by arthrodesis.

An epidemiological study of acute prolapsed cervical intervertebral disc.

The sagittal diameter of the bony cervical spinal canal and its significance in cervical spondylosis.



Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Wednesday, April 11, 2012 4:11 pm