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Cervical Disc Herniations Ma#hew McDonnell, M.D. October 27, 2015
Cervical Disc Herniations
Ma#hewMcDonnell,M.D.October27,2015
Disclosures
• NoRelevantFinancialDisclosures
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Clinical Question
• WhataretheappropriatetreatmentopBonsforcervicaldischerniaBonsinadults?
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Background
• AsignificantnumberofsportsrelatedinjuriesinvolvedthespineandprevalentamongthesearecervicalandlumbardischerniaBons.
• DegeneraBvechangesofthecervicalspineareubiquitousintheadultpopulaBon– Naturalconsequenceofaging– OKenasymptomaBcunBlinjury– Verycommonoverageof40
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3 Clinical Syndromes
• AxialNeckPain• CervicalRadiculopathy• CervicalMyelopathy
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3 Clinical Syndromes
• AxialNeckPain
• CervicalRadiculopathy*
• CervicalMyelopathy
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AcuteCervicalDiscHernia8on
Axial neck pain • EBology:– Sprainsandstrains– muscular/ligamentousimbalancerelatedtopoorposture,faultyergonomics,musclefaBgueorstress
– DegeneraBvediscorfacetjoints,spondylosis(subaxial)
– C1-C2degeneraBve/inflammatorycondiBons(suboccipital)
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Axial neck pain • ClinicalpresentaBon:– Painalongposteriorneck/trapeziusmuscleswithoutradiaBontotheextremity
– Painmayreferalongparaspinalmusclesofnecktoocciputortoshoulderandperiscapularregion(alsoseenwithlowercervicalradiculopathy)
– sBffness
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Axial neck pain • Typicallyrespondstononsurgicaltreatment
• OKenresolvesspontaneously• Axialneckpainfromcervicalspondylosis– 3monthsnonoperaBvetreatment– 78%totalsymptomsrelieforimproved
– 22%notimproved– (Depalma,ClinOrthopRelRes,1965)
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Axial neck pain • Surgery– Chronicneckpainfailing6-12monthsnonoperaBvetreatment
– Mixedresults– PaBentselecBonchallenging
• Paingenerators?• Numberofinvolvedlevels?• Advancedstudies/discogram?• PsychosocialconsideraBons?
– ACDF(standard),discreplacement
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Cervical Myelopathy • MorecommonlyseensecondarytoadvancedcervicalspondylosiswithresulBngstenosisandspinalcordcompression(CervicalspondyloBcmyelopathy
• CanoccurinsecngofcervicaldischerniaBonduetospinalcordcompressionandsignificantcervicalstenosis.
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Cervical Myelopathy • ResultsinspinalcorddysfuncBonleadingto:– Upperextremitysensoryimpairment,weakness,lossofFMSfuncBon,clumsinessofhands,difficultygraspingobjects
– Clumsy,unsteadygait,difficulBeswithbalance,lossofpropriocepBon,lowerextremityweakness
– SeverelyaffectedindividualscanbequadripareBcorquadriplegic
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Cervical Myelopathy • Naturalhistory– 5%rapidonsetfollowedbylongperiodsofremission
– 20%gradualdeclineinfuncBonwithoutperiodsofremission
– 75%stepwisedeterioraBoninfuncBonfollowedbyepisodicperiodsofremission.
– (ClarkandRobinson,1956)
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Cervical Myelopathy • Physicalexam– hyperreflexia– pathologicreflexes(Hoffmanreflex,invertedradialreflex,Babinskisign)
– clonus– difficultywithgait– Variouspa#ernsofsensorydisturbancesandpa#ernsofweakness
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Cervical Myelopathy • Treatmentissurgical• Goals– Decompressspinalcord,preventfurtherfuncBonaldecline
– Stabilizespinalcolumn– Restablishnormalsagi#alalignment
• discherniaBonàACDF• Anteriordiscectomyorcorpectomyandfusion,posteriorlaminectomyandfusion,posteriorlaminoplastyforCSM
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Cervical Radiculopathy • Resultofcervicalnerverootcompression/impingementfrom:1. SoKdischerniaBonposterolateralorintraforaminal2. Discbulgingwithosteophytespurring
(uncovertebral)insecngofdegeneraBvediscdisease(alsoassociatedwithfacetovergrowthandforaminalnarrowing)
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Cervical Radiculopathy
• PaBentpresentaBon:• Neckpainandreferred/radiaBngsymptomsinaspecificdermatomaldistribuBonintheupperextremity(frequentlyunilateral)– Sharppain,burning,BnglingsensaBons
• DifficultBmefindingcomfortableposiBon• SomeBmespresentwithheadcockedtooppositesideorarmelevatedoverhead(shoulderabducBonsign)
• SubjecBvenumbnessorweaknesscommon
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Cervical Radiculopathy
• PaBentpresentaBon:• Maybeassociatedmotororsensorylosscorrespondingtothenerverootinvolved
• ReflexacBvitymaybediminished
• +Spurlingmaneuver
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Cervical Radiculopathy
• PaBentpresentaBon:• Reviewof736paBentswithcervicalradiculopathy
– 95%armpain– 85%sensorydeficits– 79%neckpain– 71%reflexdeficit– 68%motordeficit– 52%scapularpain– 17%anteriorchestpain– 9%headaches– 6%anteriorchest+armpain– 1%leKsidedchest+armpain– (Henderson,Neurosurgery,1983)
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CervicalAngina
Common pain and neurologic patterns of radiculopathy
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DifficulttodifferenBatefromaxialneckpaininsecngofDDD
Cervical Radiculopathy • RadiographicevaluaBon
– PlainxraysmayrevealdecreaseddischeightorosteophyteformaBon
– AdvancedimagingobtainedinpaBentnotrespondingtononoperaBvetreatmentorwithseveresymptoms
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Cervical Radiculopathy • AdvancedRadiographicevaluaBon– MRI• Currentstandard,noninvasive,noradiaBon,goodatidenBfyingdischerniaBons(centralandforaminal),qualityofintervertebraldisc,spinalcordsignalabnormaliBesorlesions
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Cervical Radiculopathy • AdvancedRadiographicevaluaBon– CTMyelogram• IfMRIcontraindicated,invasive,radiaBon,maybebe#eratdetecBngforaminalstenosisandwhethernerverootcompressionisfromhard(osteophyte/spurring)vssoK(HNP)eBology
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SpurcompressingNerveroot
Nonoperative Management • CervicalCollar– DiminishinflammaBonaroundirritatednerveroot– Diminishmusclespasm– NighcmecollarmaymaintainproperalignmenttodiminishnighBmeposturalsymptoms
• NosignificantbenefitinreducingtheduraBonorseverityofsymptoms(radiculopathy)(Naylor,BrJRheum,1991)
• Longtermuseassociatedwithmuscleatrophy(limittolessthan2weeks)
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Nonoperative Management • MedicaBon– NSAIDS– MuscleRelaxants– NarcoBcs– OralSteroids• OKenadministeredasmedroltaper• Excellentanecdotalresultsforacutelydiminishingintensityofsevereradicularpain
• Nolongtermbenefitinalteringthenaturalhistoryhasbeenshown
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Nonoperative Management • PhysicalTherapy– CommonlyprescribedaKeriniBalperiodofrestandacutepainhasresolved
– Hasnotbeenshowntoalterthenaturalhistoryofcervicalradiculopathy(Levine,JAAOS,1996andTanOrthopClinNorthAm,1992)
• CervicalManipulaBon– Shorttermbenefitsforaxialneckpain– ShouldnotbeperformedinpaBentwithcordcompressionormyelopathyduetoriskofcatastophicinjury(complicaBonrate5-10per10million)
– NosolidevidencesupporBngclinicaleffecBveness
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Nonoperative Management • CervicaltracBon– Anecdotallyfoundtotemporarilyrelievesymptomsofaxialneckpainorradiculopathy
– Failedtoshowlongtermbenefits– Avoidinmyelopathyorcordcompressiontoavoidstretchingalreadycompromisedspinalcord
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Nonoperative Management • CervicalsteroidinjecBons– Cervicalepidurals– SelecBvenerverootblocks
• SpecifictargeBngofproblemaBcroots,diagnosBcinformaBonobtainedforsurgicalplanning
• NumberofretrospecBveandprospecBvestudiesdemonstraBng50-80%goodtoexcellentresultsforshorttermreliefincervicalradiculopathy– Lackcontrolgroups– NaturalhistoryfavorsresoluBonofsymptomswithBme– Rowlingson1986,Ferrante1993,Slipman2001,Vallee2001,Sasso2005
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Surgical Management • IndicaBons:– Significantpainthatfailstorespondtononsurgicaltreatment
– SevereorprogressiveneurologicdeficitOpBons:– Anteriorcervicaldecompressionandfusion(ACDF)– Posteriorlaminoforaminotomy– Cervicaldiscreplacement
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Surgical Management • ACDF• Advantages– Allowsdirectvisualizatonandremovaloflesionscausingradiculopathy(discherniaBon,uncovertebralspur)withoutneuralretracBon
– AnteriorbonegraKallowsopeningofneuroforamenandindirectdecompressionofnerveroot
– FusionmayprovidereliefofneckpainassociatedwithdiscdegeneraBon/spondylosis
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Surgical Management • ACDF• Advantages– LowinfecBonandwoundcomplicaBonrates– CosmeBcscar– MinimalperioperaBvepain–li#lemuscledissecBon– NumerousstudiesdocumenBnggoodoutcomesandeffecBvenessforreliefofradicularandneckpain
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Surgical Management • ACDF• Disadvantages– SwallowingandspeechcomplicaBonsduetoretracBonofesophagusandlaryngealnerves
– Riskofpseudarthrosis– AdjacentSegmentDisease
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Surgical Management • ACDFFusionRates– Historically,literaturereportsratesrangingfrom0-20%for1-or2-levelACDFsandashighas50-60%for3-and4-levelACDFs
– Morerecentstudiesdemonstrateveryfavorableresults
– 2015systemaBcreviewandmeta-analysis:– 2.6%overalrateofpseudarthrosisfor1-,2-,and3-levelACDFsaKerACDFwithplatefixaBon
– Shriver,SpineJ,2015
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Surgical Management • Adjacentsegmentdisease– CervicalfusionmayleadtoaccelerateddegeneraBonofasegmentadjacenttoafusiondueincreasedstressandalteredbiomechanicalforces
– AdjacentsegmentdegeneraBoncanbecomesymptomaBcresulBnginneckpain,stenosis,radiculopathyormyelopathy
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Surgical Management • Adjacentsegmentdisease– Annualincidenceapprox3%– Prevalenceapproximately25%at10yrfollowup
– (Hilibrand,1999)– Approximately17%reoperaBonrateforASD
– (Yue2005,Ishihara2004)
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Surgical Management • CervicalDiscReplacement– SimilardecompressionofneuralelementsasACDF
– PreservemoBon,minimizingriskofadjacentsegmentdisease
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Surgical Management • CervicalDiscReplacement– Disadvantages• Recurrentstenosis(re-developmentofosteophytessecondarytoconBnuedmoBon
• Segmentalkyphosis• MechanicalfailureofdevicesoverBme
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Surgical Management • CervicalDiscReplacement
Mostcurrentstudiesdemonstrateequivalentoutcomesat1and2yearfollowuptoACDF.Nolongtermdatayetforlongtermfollowup,actualimpactonadjacentsegmentdisease,andratesoflongtermmechanicalfailure.BeingperformedselecBvely
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Surgical Management • PosteriorLaminoforaminotomy– IdealforfarlateralorforaminaldischerniaBon
– Posteriorapproach,nodestabilizaBonofspine,nofusionrequired
– Disadvantages:• Possibilityforincompletedecompression• Doesnotaddressdiscissues,noforaminalheightrestoraBon
• RecurrenceordeterioraBonorresultswithBmeifprogressivedegeneraBonoccurs
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What about athletes?
• SmallretrospecBveseriesof16NFLplayerswithMRIconfirmedcervicaldischerniaBons
• MostcommonpresentaBonwasradiculopathyaKersingletraumaBcevent(9/16)
• 3/16presentedwithtransientquadraparesis
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What about athletes?
• 8/16treatednonoperaBvelyandreturnedtosport– Normalexam– ResoluBonofsymptoms
• 3/16failednonsurgicaltreatmentorhadspinalcordcompressionwithsignalchangeonMRIandhad1-levelACDF– Only1/3returnedtosport
• 5/16treatednon-opdidnotreturntosport– 2hadcordcompressionbutreBredratherthanhavesurgery– 3wereclearedtoreturnbasedonimprovementbutwerereleasedbytheteam
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What about athletes?
• RetrospecBvecohortstudyof99NFLathleteswithcervicaldischerniaBonsand2yearfollowup.
• opera8vegroup:38of53(72%)playerssuccessfullyreturnedtoplayfor29gamesovera2.8-yearperiod,whichwassignificantlygreaterthannonopera8vegroup:only21of46(46%)playerssuccessfullyreturnedtothefieldtoplayaKertreatmentfor15gamesovera1.5-yearperiod(P<0.04).
• Defensivebackshavepoorerprognosis
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What about athletes?
• 40MLBpitchersfrom1984to2009withacervicaldiskherniaBonorlumbardiskherniaBonwereidenBfied
• CervicaldiskherniaBonwasidenBfiedin11pitchers,8ofwhichweretreatedoperaBvely.
• ThemajorityofpitcherswithcervicaldiskherniaBon(8/11)returnedtoplayatanaverageof11.6months
• LumbardiskherniaBonwasidenBfiedin29pitchers,20ofwhichweretreatedoperaBvely
• AllpitcherswithlumbardiskherniaBon(29/29)returnedtoplayatanaverageof7.3monthsaKerdiagnosis.
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Conclusion
• TOUGHNESS!!
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Athletes return to play after cervical disc herniation
• OKtoreturntoplay:– KnowncervicaldischerniaBon,nowasymptomaBc– Previous1levelACDF– Posteriorlaminoforaminotomy
• RelaBvecontraindicaBon:– Previous2levelACDF
• AbsolutecontraindicaBon– SymptomaBcdischerniaBon– Spinalcordcompression– Cervicalmyelopathy– Previous3ormorelevelACDF
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Clinical Question • Basedoncurrentliterature..• WhataretheappropriatetreatmentopBonsforcervicaldischerniaBonsinadultswithradiculopathy?
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Clinical Question • 1.IniBaltreatmentwithconservaBvetreatmentmodaliBes.– NaturalhistoryshowsgoodprognosisforresoluBonofsymptomsandgoodclinicalresults
– OpBonsincludemedicaBons• NSAIDS,musclerelaxants,opiates,oralsteroids
– therapy(cervicaltracBon)– injecBons
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Clinical Question • 2.SurgeryisanexcellenttreatmentopBonforpaBentswithseveredebilitaBngpain,progressiveweakness,orpersistentsymptomsdespitenonsurgicaltreatment– ACDF(mostcommon)
• ExcellentclinicaloutcomeswithlowcomplicaBonrates• Adjacentsegmentdisease
– Cervicaldiscreplacement• FavorableshortandintermediatetermresultsequivalenttoACDF
• Longtermresultsandrisksoflongtermmechanicalfailuretobedetermined
– Posteriorlaminoforaminotomy
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