⁨⁨⁨⁨أسئلة السابعة جراحة رابعة دمياط (نيورو)

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Cervical Disc Diseases Overview

• Cervical radiculopathy arises from dysfunction of cervical nerve roots due to irritation, stretching, or compression
• This leads to sensory, motor, or reflex issues.

The Intervertebral Foramina

• The intervertebral foramina are funnel-shaped, narrowest at the entrance. Compressions happen:
  • Anteriorly: due to protruding discs and osteophytes
  • Posteriorly: by the superior articular process or ligamentum flavum.

Cervical Nerves

• There are 7 vertebrae but 8 cervical nerve roots.
• Each nerve pair exits superiorly to its corresponding vertebra, except C8, exiting inferiorly to C7.
• Cervical nerve roots are horizontally oriented.
• Postero-lateral or foraminal disc herniation can compress exiting nerve roots.

Nerve Roots vs. Peripheral Nerves

• Nerve roots lack a perineurium; therefore, they are more vulnerable to mechanical injury.
• Blood supply to nerve roots is less secure, increasing ischemic damage risks.
• This explains why even minor pressure changes on nerve roots cause significant symptoms.
• Axial pain occurs with nerve root issues.
• Peripheral nerves have autonomic distribution.

Comparing Nerve Damage

• Cervical Radiculopathy involves damage to the nerve root and affects sensory and motor functions
• Peripheral Neuropathy damages the peripheral nerve, affecting sensory, motor, autonomic functions, and causing deformities.
• Cervical Myelopathy damages the spinal cord, impacting sensory and motor functions, and causing autonomic issues in upper motor lesions.

Pathophysiology of Cervical Radiculopathy

• Pathophysiology is caused by changes around nerve roots narrowing the intervertebral foramen.
• This is affected by tendons and ligaments, intervertebral discs, and osteophytes.
• Spasms, disc herniation, spondylosis, tumors, infections, fractures, foraminal stenosis, and nerve root irritation contribute.

Red Flag Signs

These are signs of underlying serious conditions

• History includes inflammatory arthritis, malignancy, systemic infection, HIV, immunosuppression, or drug abuse and trauma.
• Other factors: unexplained weight loss, unrelenting pain, fever, night sweats, persistent symptoms despite treatment, progressive motor weakness, and cervical lymphadenopathy.

Signs of Nerve Root Dysfunction

• Sensory: pain, paresthesia, anesthesia.
• Motor: weakness of lower motor neurons (LMN).
• Deep Tendon Reflexes: changes in Biceps, Triceps, and Brachioradialis reflexes.
• Special tests: Shoulder abduction, Spurling, and Axial manual traction tests.

Cervical Root Syndromes

Differential Diagnosis

• Mimics signs and symptoms of radiculopathy.
  • Peripheral neuropathies
  • Cervical myelopathy
  • Chest pain
  • Shoulder pathology.

Cervical Disc Herniation

• Cervical Disc Herniation arises from displacement of nucleus pulposus causing nerve root or spinal cord compression.
• The intervertebral disc includes:
  • Inner nucleus pulposus (NP)
  • Outer annulus fibrosus (AF): which maintains NP in the disc center
  • Cartilaginous end plate

The Central Nucleus Pulposus (NP)

• Collagen secretion site
• Contains proteoglycans (PG): to retain water and resist spine compression
• Primarily type II collagen, which accounts for 20% of the disc's dry weight.

Pathophysiology of Disc Herniation

• Recurrent torsional strain causes outer annulus tears, herniating nucleus pulposis
• Combination of mechanical factors which compress nerve root
• Inflammatory factors that irritate nerve root with cytokines.
• Microvascular factors lead to venous congestion/edema, potentially arterial ischemia.
• Herniations are more likely to occur posterolaterally as the annulus fibrosus is thinner

Cervical Nerve Root Trajectory

• The transverse direction exiting the neural foramen makes it susceptible to stretch with a herniation
• The arrangement might explain pain relief from arm abduction
• Herniation proximity to the nerve root results in radiculopathy in the associated dermatome, ex: C4-C5 disc herniation correlates to C5 radiculopathy.

Cervical Spondylosis

• Cervical Spondylosis is when disc height increases loads leading to possible hypertrophy, foraminal stenosis, and radiculopathy.
• It is identified by:
  • Osteophyte
  • Foraminal stenosis
  • Narrow disc space

Acute and Chronic Herniations

Epidemiology

History-Taking

• Should include the chief complaint, symptom onset, alleviating/aggravating factors, radicular symptoms, myelopathic symptoms, and past treatments.

Symptoms of Cervical Disc Disease

• Most common subjective complaints are axial neck pain, ipsilateral arm pain or paresthesia in the associated dermatomal distribution.
• Increased by: Coughing, sneezing, and neck extension
• Relieved by: Shoulder elevation
• Associated with: limitation of neck movement
• Time: in the early morning.

Physical Exam

• Assess the patient's range of motion (ROM)
• General exam: Look for red flag signs, chronic illness, and fitness for surgery.
• Neurological exam: Check for sensory disturbances, motor weakness, and conduct special tests.
• Check for myelopathy which is the presence of upper/lower motor neuron lesions.

Provocative Tests

• Shoulder abduction test: look for reduction/disappearance of radicular pain
• Spurling test: extend neck and rotate head causing narrowed neuroforamen which reproduces symptoms.
• Axial manual traction test: apply 10-15 KG axial traction to a patient with radicular pain, which is a positive test

Pathological Tests (for Myelopathy)

• Hoffman Test: flicking the long finger downward.
• Lhermitte's sign: flexing the patient's neck may cause electrical sensation down spine
• Babinski sign: lateral plantar stimulation resulting the big toe extension.

Imaging

• Indications, after 4-6 weeks of symptoms if there is failure of medical treatment or there are red flags signs
• Options include Plain X-ray, CAT scan, and MRI.

Plain X-ray

• A-P provides assessment of degenerative changes, osteophyte formation, disc space narrowing, and endplate sclerosis.
• Lateral radiograph for sagittal alignment
• Oblique views: asses foramenal stenosis.
• Flexion and extension views: asses angular or translational instability.

CAT scan

• Provides information on bony anatomy including osteophyte causing compression.
• Tool for pre operative planning tool and detect ossification of the PL

MRI Cervical Spine

• Provides information on soft tissues
• Detects loss of CSF around the cord and nerve root, disc degeneration/herniation
• Detects foraminal stenosis/ central compression
• Useful in patients who cannot have an MRI

Conservative Treatment

• Around 80% of patients w/ neck pain improve from this via soft discs resorption and decreased inflammation.

Lines of Treatment Include

• Rest and immobilization, lifestyle changes, medications, physical therapy & cervical traction, and interventional treatments.

Collar Immobilization

• Short course during acute inflammation.
• Prolonged immobilization is avoided in order to prevent atrophy.

Medication

• NSAIDS: COX-2 inhibitors
• Steroidal anti-inflammatory drugs: Methylprednisolone.
• Opioid: Morphine, Tramadol.
• Muscle relaxant: Cyclobenzaprine.
• Antidepressants: Amitriptyline
• Anticonvulsants: Gabapentin & Pregabalin

Physical Therapy

• Following short rest
• Methods: include range of motion, strengthening, stretching, ice/heat, ultrasound, electrical stimulation, and traction/manipulation.
• Be avoided in myelopathic patient

Interventional Procedures

• Spinal steroid injections and Radiofrequency ablation

Spinal Steroid Injections

• A common alternative to surgery.
• Include perineural injections (epidurals, & transforaminal selective nerve root blocks)
• The procedures should take place under radiologic guidance & local anesthesia.

Radiofrequency Ablation

• Radiofrequency ablation uses current to heat the nerve tissue and stop the sending of pain signals.
• Lasting relief is provided for chronic pain, neck pain, sever radicular pain, or arthritic joints.

Operative Treatment

Indications

• Severe neurological manifestation (Myelopathy)
• Radicular symptoms unresponsive to 6 weeks non operative treatment.
• Signs/symptoms of myelopathy, instability or deformity of spine.

Options

• Anterior Cervical Discectomy (ACD)
• Anterior Cervical Discectomy with Fusion (ACDF)
• Anterior Cervical Total Disc Arthroplasty (TDA) is a dynamic cage
• Anterior Cervical Corpectomy
• Posterior laminectomy is used to treat degenerative cervical canal stenosis
• Posterior foraminotomy is used to treat foraminal stenosis

Posterior Cervical Laminectomy

• Removing the cervical lamina, can be one or more
• Can be done with fusion and posterior fixation
• Indication is for cervical canal stenosis, multiple cervical discs, or posterior compressing element when OPLL is present