Cervical Spondylosis : Wheeless' Textbook of Orthopaedics

- 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