Surgery for cervical spine disease Patrick Statham, Consultant Neurosurgeon, Western General Hospital, Edinburgh

Format Anatomy and load bearing Spectrum of Pathology Clinical examination and assessment Differential diagnosis Special tests Approaches Instrumentation and prosthesies Specific pathology The future

Functional units: anatomy and pathology Occiput C1 and C2 C3 to C7 Cervicothoracic junction

Longus colli

Spinal cord anatomy

Gross cervical cord anatomy

Human cervical spine

Occipital-Atlanto Complex C0 C1 C0-C1 Flex/Ext 10-15° 13° Lat Flex 8° Axial Rot 0°

Atlanto-Axial Complex C1 C2 C1-C2 Flex/Ext 10° Lat Flex 0° Axial Rot 47° 40% to 50% of axial Rotation The first 45° of axial rotation

Atlanto-Axial Complex C1 C2 – Coupling C1 C2 Biconvex cartilagenous articulation Double threaded screw

Cervical Spine Kinematics & Anatomy Flexion/Extension 145° Axial rotation 180° Lateral flexion 90° Atypical C1 C2 C7 Typical C3-C6

Lower cervical Spine C3-C7 – Coupling On lateral bending the spinous processes go to the covexity of the curve C2-2° of coupled axial rot for every 3° of lateral bending C7-2° of coupled axial rot for every 7.5° of lateral bending Angle of incline of the facet joints in the sagittal plane increases cephalocaudally

Cervical Spine instability Misjudgement – Death or major neurological deficit – Un-necessary surgery with risk of surgical complications Definition “Clinical stability is defined as the ability of the spine to limit its patterns of displacement under physiologic loads so as not to damage the spinal cord or nerve roots.” White and Panjabi Clin Orthopaedics 1975

Cervical Spine instability C0 C1 C2 Transverse ligament 7-8 mm Tectorial membrane Posterior A-O A-A membranes Nuchal Ligament Wolf et al. J Mt Sinai Hosp. NY. 23:283,1956

Cervical Spine instability C2-C7 Flex-Ext All ant structures + 1 post All post structures + ant Laminectomy In children - Kyphosis

Cervical Spine instability C2-C7 Radiology

Cervical Spine instability C2-C7 A Check List Ant elements destroyed 2 Post elements destroyed 2 Sagittal translation >3.5 mm 2 Sagittal angulation > 11° 2 Spinal cord damage 1 Nerve root damage 1 Abnormal disc narrowing 1 Dangerous Loading anticipated 1 Total of 5 or more = unstable White et al Spine 1:15, 1976.

Spectrum of pathology Prolapsed discs, osteophytic compression: ‘wear and repair’ Inflammatory: rheumatoid, ankylosing spondylitis Trauma: odontoid, rotatory subluxation Neoplastic: meningiomas, schwannomas, metastatic cord compression,intrinsic cord Congenital Klippel Feil, fused, Down’s, enterogenous cysts Infection: discitis, osteomyelitis, epidural abscess

Clinical examination Posture Tone Clothing zips, velcro Power Sensation Deep tendon reflexes Co ordination Gait Clothing zips, velcro Aids: stick, wheelchair Deformity OA,RhA, AS, klippel feil, Downs Other disease; cancer

dermatomes

Diagnosis MRI CT or CT myelogram Nerve conduction studies Blood CSF Multiple sclerosis Mononeuritis multiplex Peripheral n entrapment (median, ulnar) SACDC Brachial amyotrophy

Clinical assessment Natural history of condition Risks and benefits of the intervention Alternatives; collar halo physiotherapy Appropriateness for this particular patient

Surgical approaches C1/2 anterior: trans oral C1/2 posterior: midline sub-occipital Sub-axial anterior: anterior cervical decompression Sub-axial posterior: cervical laminectomy, laminoplasty, foramenotomy

Results: NASCIS 2 6 weeks: ‘no statistical difference between groups’ 6 months: MPSS improved PP (p=0.012), Touch (p=0.042) 1 year:(95%) ‘no significant differences in neurological function by treatment group’

Bracken 1993: segmental and longtract recovery in NASCIS 2

Disc prolapse C6/7

Anterior cervical approach

PATIENT POSITIONING Hdvhjfdvfd

Plate removal, disc decompression, solis cage and graft

Total discectomy, iliac graft, Anterior locking plate