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Cervical spondylotic radiculopathy and myelopathy from facet and uncovertebral hypertrophy


Introduction

Cervical spondylotic myelopathy (CSM) is the most common type of spinal cord dysfunction in adults. This chronic spinal degeneration is characterized by intervertebral disc herniations, abnormal ligament and joint hypertrophy, and ossification. It almost invariably results in progressive neurological decline. Surgery is the only proven treatment to halt disease progression and restore neurological functioning. The surgical treatment of CSM can be challenging, especially in the setting of ossification of the posterior longitudinal ligament (OPLL) and multilevel disease involving both anterior and posterior spinal cord compressions. In this chapter, we utilize a case example to illustrate the clinical presentation and surgical management of a case with multilevel CSM with anterior and posterior spinal cord compression from OPLL, intervertebral disc herniation, and interlaminar ligament, uncinate, and facet hypertrophy and ossification.

Case Example

  • Chief complaint: pain in neck and right arm

  • History of present illness: The patient is a 69-year-old male with a 1-year history of worsening neck pain and right arm pain in a C7 root distribution. He also reports progressive difficulty ambulating. Cervical spine imaging ( Figs. 9.1 and 9.2 ) shows severe cervical spondylosis with left-sided posterolateral spinal cord compression by facet (zygapophyseal) and interlaminar ligament hypertrophy and ossification at C4–5 and right-sided ventrolateral spinal cord and neuroforaminal compression by uncovertebral and disc-osteophyte hypertrophy and ossification at C6–7.

    Fig. 9.1, Preoperative T2-weighted magnetic resonance imaging (MRI). (A) Midline sagittal MRI demonstrating loss of cervical lordosis, diffuse cervical spondylosis, intervertebral disc desiccation, and reduced and bulging at C4–5, C5–6, and C6–7 levels. (B) Axial MRI at C4–5 level demonstrating severe posterolateral spinal cord compression from ligamentum flavum and facet hypertrophy and ossification. (C) Axial MRI at the C6–7 level demonstrating severe ventrolateral and neuroforaminal compression from uncovertebral joint hypertrophy and intervertebral disc herniation.

    Fig. 9.2, Preoperative computed tomography bone windows. (A) Left paramedian sagittal and (B) axial sections demonstrating hypertrophied facets and calcified interlaminar ligament at the C4–5 level. (C) Midline and (D) axial sections demonstrating ossified posterior longitudinal ligament and prominent osteophytes and uncovertebral joints at the left C6–7 level.

  • Medications: aspirin 81 mg

  • Allergies: no known drug allergies

  • Past medical history: none

  • Past surgical history: cholecystectomy

  • Family history: noncontributory

  • Social history: no smoking and occasional alcohol

  • Physical examination: awake, alert, and oriented to person, place, and time; cranial nerves II–XII intact; bilateral deltoids/triceps/biceps 5/5; interossei 5/5; iliopsoas/knee flexion/knee extension/dorsi, and plantar flexion 5/5.

  • Reflexes: bilateral upper extremity hyperreflexia with 3+ response in bilateral biceps/triceps/brachioradialis and Hoffman’s present bilaterally; ataxic gait

  • Laboratories: all within normal limits

  • Pedro Luis Bazán, MD

  • Spine Surgeon

  • HIGA San Martín La Plata (Chief Orthopaedic)

  • Hospital Italiano La Plata

  • Instituto de Diagnóstico La Plata

  • La Plata, Buenos Aires, Argentina

  • Esteban F. Espinoza-García, MD, MSc

  • University of Valparaíso

  • San Felipe, Chile

  • Brett A. Freedman, MD

  • Sandra Hobson, MD

  • Orthopaedic Surgery

  • Mayo Clinic

  • Rochester, Minnesota, United States

  • Meic H. Schmidt, MD, MBA

  • Neurosurgery

  • University of New Mexico

  • Albuquerque, New Mexico, United States

Preoperative
Additional tests requested

  • C-spine flexion-extension x-ray

  • Neurology evaluation

  • EMG

  • EMG/NCS

  • MRI brain

  • C-spine upright AP, lateral, flexion/extension x-rays

  • BMD scans

  • Additional physical exam

  • Swallow evaluation

  • Vocal cord function assessment

  • Anesthesia clearance

Surgical approach selected MIS C6–7 foraminotomy C4–5 laminectomy, C6–7 foraminotomy C2-T2 posterior instrumented fusion, C4–7 decompression, right C6–7 foraminotomy C4–5, C5–6, C6–7 ACDF
Goal of surgery Nerve root decompression Spinal cord and nerve root decompression Spinal cord decompression, right C7 nerve root decompression, stabilization Spinal cord decompression
Perioperative
Positioning Prone Prone without pins Prone on Jackson table with Mayfield pins Supine with cervical traction
Surgical equipment

  • Fluoroscopy

  • Endoscope

Fluoroscopy

  • IOM (MEP/SSEP/EMG)

  • Surgical navigation

  • O-arm

  • Surgical microscope

  • IOM

  • Surgical microscope

  • Fluoroscopy

  • Allograft spacer

  • Dynamic plate

Medications Maintain MAP Steroids, maintain MAP Tranexamic acid Steroids
Anatomical considerations Surgical level, facet Dura Vertebral artery, anterior ossification at right C6–7 Esophagus, carotid artery, spinal cord
Complications feared with approach chosen Spinal instability Durotomy, CSF leak Inadequate decompression Spinal cord injury from hypotension, dysphagia, vocal cord paralysis, CSF leak
Intraoperative
Anesthesia General General General General
Exposure Right C6–7 C4–7 C2-T2 C4-C7
Levels decompressed Right C6–7 C4–5, right C6–7 C4–7 C4–5, C5–6, C6–7
Levels fused None None C2-T2 C4–5, C5–6, C6–7
Surgical narrative Position prone, x-ray to confirm level, posterior midline incision, dissect down onto right C6–7 lamina under exoscopic visualization, foraminotomy, confirm decompression of nerve root, layered closure Position prone on foam headrest, localizing x-ray, midline incision, bilateral subperiosteal dissection from C4–7, x-ray confirmation of levels, C4–5 laminectomy, yellow ligament removal until dura visualized, localize C6–7 segment, right C6–7 hemilaminectomy and foraminotomy Preflip signals, apply pin and position prone, postflip IOM after positioning, midline prone incision, dissect down through subcutaneous fat to level of nuchal ligament and deep dorsal fascia, subperiosteal dissection down over and preserving facet joints, x-ray to confirm level, complete exposure from C2–3 facet down to T1–2 facet, decorticate dorsal bone and facets, C3–6 lateral mass screws (start hole in inferior-medial quadrant and aimed up and out) and T1/2 pedicle screws based on anatomical landmarks and stereotactic navigation, skip C7, pack facets and posterolateral bone with bone graft prior to final insertion of screws, C3–6 laminectomy as well inferior C2 and superior C7 with microscope, elevate and resect ligamentum flavum, general right C6–7 foraminotomy by resecting portions of the inferior and superior articulating processes with a bur and curettes and Kerrison rongeurs, repeat on left, confirm head and heck are in preferred posture/alignment, place appropriate rods and final tighten set screws except for bottom screws, gently compress and final tighten bottom screws, place residual graft, final x-rays, wound filled with dilute povidone solution, removed and vancomycin powder placed, layered closure with drain, incisional VAC placed Position supine with roll behind shoulder and neck, mild Holter traction with baseline MEP and SSEP, horizontal incision with fluoroscopy aid, dissection, cervical traction, ET tube balloon deflated and reinflated, confirm levels based on fluoroscopy, Caspar pins at all levels, microscopic discectomies and placement of grafts starting at top, dynamic plate placement, subplatysmal drain
Complication avoidance No fusion, endoscopic MIS No fusion Preflip IOM, decorticate bone and facet prior to screw placement, exclude C7 lateral mass screw, surgical navigation for pedicle screws, compress on lower screws before final tightening, VAC placement Traction to aid exposure, IOM, cuff deflation/inflation
Postoperative
Admission Floor Floor Floor ICU
Postoperative complications feared Nerve root injury, spinal instability CSF leak, spinal instability C5 palsy, wound healing issues, continued neck pain Dysphagia, vocal cord paralysis, CSF leak, esophageal injury, spinal cord injury
Anticipated length of stay 1–2 days 2 days 2–3 days 2–3 days
Follow-up testing

  • C-spine CT within 24 hours after surgery

  • C-spine flexion-extension x-rays 1 month after surgery

C-spine CT 1 day and 3 months after surgery

  • C-spine upright AP and lateral x-rays prior to discharge, 3 months, 6 months after surgery

  • CT C-spine 6 months after surgery

  • ESR/CRP while inpatient

  • L-spine upright AP/lateral x-rays

  • Outpatient physical therapy

Bracing None Philadelphia collar for 3 months Aspen collar for 3 months None
Follow-up visits 2 weeks after surgery 3 weeks after surgery 2 weeks, 3 months, 6 months after surgery 3, 6, 12, and 24 months with x-raysCT at 12 months
AP , Anteroposterior; BMD , bone mineral density; CRP , C-reactive protein; CSF , cerebrospinal fluid; CT , computed tomography; EMG , electromyography; ESR , erythrocyte sedimentation rate; ICU , intensive care unit; IOM , intraoperative monitoring; MAP , mean arterial pressure; MEP , motor evoked potentials; MIS , minimally invasive surgery; MRI , magnetic resonance imaging; NCS , nerve conduction study; SSEP , somatosensory evoked potentials; VAC , vacuum-assisted closure.

Differential diagnosis

  • ▪

    Cervical disc herniation

  • ▪

    Amyotrophic lateral sclerosis

  • ▪

    Diffuse idiopathy skeletal hyperostosis (DISH)

  • ▪

    Tuberculosis

  • ▪

    Fungal infection

  • ▪

    Metastasis

  • ▪

    Primary bone tumor

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