Spinal Injections Transforaminal injections can results in serious complications Anecdotally, transforaminal injections with epidural steroid application can result in instant pain relie
Trang 1Manipulative Therapy
There is moderate evidence for the effectiveness of manipulative treatment
Manipulative therapy remains a mainstay of conservative treatment for
degenera-tive disorders of the cervical spine Particularly, traction has been reported to
result in short-term relief of radiculopathy [60, 61, 197] Debate continues on the
safety of manipulative therapy of the cervical spine Based on a national survey of
19 122 patients, minor side effects (headache, fainting/dizziness,
numbness/tin-gling) were not uncommon up to 7 days after the intervention, with an incidence
rate ranging from 4 to 15/1 000 Serious adverse events (leading to in-hospital
treatment or permanent disability) were very rare (1/10 000) However, this does
not rule out a deleterious course in individual patients (Case Introduction)
Rubin-stein et al [230] concluded that the benefits of chiropractic care for neck pain seem
to outweigh the potential risks There is moderate evidence that spinal
manipula-tive therapy (SMT) and mobilization is superior to general practitioner
manage-ment for short-term pain reduction of chronic neck pain However, SMT offers at
most similar pain relief to high-technology rehabilitative exercise in the short and
long term In a mix of acute and chronic neck pain, there is moderate evidence that
mobilization is superior to physical therapy and family physician care [41] There
are only a few studies on acute neck pain and the evidence is currently inconclusive
[41]
Physical Exercises
Moderate evidence supports physiotherapy for chronic neck pain
There is moderate evidence supporting the effectiveness of both long-term
dynamic as well as isometric resistance exercises of the neck and shoulder
mus-culature for chronic or frequent neck disorders No evidence supports the
long-term effectiveness of postural and proprioceptive exercises or other very low
intensity exercises [106, 296]
Multidisciplinary Rehabilitation Programs
In contrast to the lumbar spine, there appears to be little scientific evidence so far
for the effectiveness on neck and shoulder pain of multidisciplinary
rehabilita-tion programs compared with other rehabilitarehabilita-tion methods [145] However, this
conclusion is due to the low quality of available clinical trials [145]
Massage
No clinical practice recommendations can be made for the effectiveness of
mas-sage for neck pain [115]
Spinal Injections
Transforaminal injections can results in serious complications
Anecdotally, transforaminal injections with epidural steroid application can
result in instant pain relief in patients suffering from cervical radiculopathy [70,
163, 262], although injection of local anesthetic appears to have similar effects
[8] However, recent articles have prompted major concerns over the safety of
transforminal steroid injections because of cases with subsequent deleterious
spinal cord injuries [120, 181, 245] For chronic neck pain, intramuscular
injec-tion of lidocaine was superior to placebo or dry needling at short-term follow-up,
but similar to ultrasound There is limited evidence of effectiveness of epidural
injection of methylprednisolone and lidocaine for chronic neck pain with
radicu-lar symptoms [208]
Trang 2Radiofrequency Denervation
The treatment effect of
radiofrequency denervation
is unproven
Although some studies reported satisfactory results [170, 253], there is limited evidence that radiofrequency denervation offers short-term relief for chronic
neck pain of zygapophysial joint origin and for chronic cervicobrachial pain
[188]
Acupuncture
The evidence for acupuncture is considered inconclusive and difficult to
inter-pret [27]
Electrotherapy
The systematic review by Kroeling et al [158] could not make any definitive con-clusions about electrotherapy for neck pain The present evidence on galvanic current (direct or pulsed), iontophoresis, electromuscle stimulation (EMS), transcutaneous electrical nerve stimulation (TENS), pulsed electromagnetic field (PEMF) and permanent magnets is either lacking, limited, or conflicting
Infrared Laser Therapy
The review by Chow et al [55] provided limited evidence from one randomized controlled trial (RCT) for the use of infrared laser for the treatment of acute neck pain and chronic neck pain from four RCTs
Operative Treatment General Principles
Degenerative disorders of the cervical spine are a heterogeneous group of pathol-ogies with a wide spectrum of treatment modalities For the vast majority of clin-ical entities, surgery is only indicated after an adequate trial of non-operative treatment has failed As outlined in the preceding paragraph, the scientific evi-dence for the effectiveness of many conservative measures is very limited
Simi-larly, the evidence is limited for the surgical treatment options While surgery for
chronic neck pain is not broadly supported, it appears that patients with CSR and CSM benefit from surgery after non-operative care has failed [86, 297] Indica-tions for surgery for CSR and CSM include (Table 6):
Table 6 Indications for surgery
Cervical spondylotic radiculopathy Cervical spondylotic myelopathy
) progressive, functionally important motor deficit
) definitive evidence for nerve root compression
) concordant symptoms and signs of radiculopathy
) persistent pain despite non-surgical treatment for
at least 6 – 12 weeks
) progressive myelopathy despite non-operative care ) acute onset, deterioration or progression of neurological deficits ) definitive evidence of spinal cord compression with moderate-to-severe myelopathic symptoms
) progressive kyphosis with neurological deficits
The goal of CSM treatment
primarily is to arrest
progression
Surgery for cervical radiculopathy is generally recommended when all of the aforementioned criteria are present [45] The primary goal of surgery in CSM is
the prevention of further progression of the neurological symptoms because
improvement of established myelopathic changes is rare [164, 166] One of the most important aspects in dealing with CSM is to inform the patients
Trang 3preopera-tively that the goal of surgery is primarily to arrest progression of the disease.
Patients are frequently disappointed by the results of surgery when neurological
recovery is lacking although the vast majority of patients do show improvements
[76, 127, 225, 294] It is therefore reasonable to extensively inform patients about
the goals and realistic expectations of surgery
Surgical Techniques
There is an ongoing debate on the approach to deal with disc herniation related
radiculopathy, CSR or CSM, i.e.:
) anterior approach
) posterior approach
The pathology should be treated where it is
Each technique has its advantages and drawbacks The controversy which of the
two approaches is better cannot be generalized but must always be related to the
target pathology It is important to recognize whether the compressing structure
is anterior or posterior to the neural structures The pathology should be treated
where it is Thus, an anterior neural compression is better removed from anterior
and a multisegmental posterior compression from a posterior approach In cases
with three or more level stenosis, a posterior approach is preferred unless there
is no coexisting substantial anterior compression
Anterior Cervical Discectomy and Fusion
Anterior cervical discectomy and fusion remains the gold standard for CSR
In 1955, Robinson and Smith [229] reported on a technique for removal of
cervi-cal disc and fusion with a horseshoe-shaped graft which later became the gold
standard for the treatment of disc herniations and cervical spondylotic
radiculo-pathy [260] Cloward [62] developed a similar anterior approach, i.e drilling a
hole in the intervertebral disc space and adjacent vertebrae to insert a bone
dowel In contrast to the Robinson-Smith technique, Cloward removed the
com-pressing structures at the level of the posterior longitudinal ligament Robinson
and Smith [229] did not decompress the neural structures, but believed that by
immobilizing the segment osteophytes and herniated disc would be reabsorbed
In the following years many variations of this technique were developed [12, 35,
37, 77, 99, 258] Anterior cervical discectomy and fusion (ACDF) with a
tricorti-cal bone graft harvested from the iliac crest is the most widely used technique
and has become the gold standard for the treatment of cervical radiculopathy
(Case Introduction)
Fusion rates are dependent
on the number of levels treated
The radiological fusion rate is dependent on the amount of levels to be fused.
Bohlmann et al [33] reported a solid fusion for one, two and multilevel fusions
of 89 %, 73 % and 67 %, respectively Cauthen et al [49] analyzed the outcome of
anterior cervical discectomy and interbody fusion (Cloward technique) in 348
patients with an average follow-up of 5 years The fusion rate was 88 % for one
level and 75 % for multilevel fusions Emery et al [78] reported a fusion rate of
only 56 % for three-level fusions
The surgical outcome
is mainly dependent on the decompression effect
Clinical outcome of ACDF for cervical radiculopathy is good to excellent in
70 – 90 % of patients [223] and mainly dependent on the decompression of the
compromised nerve root [45] However, Bohlmann et al have reported a
signifi-cant association between the presence of non-union and postoperative neck or
arm pain [33]
Trang 4Autograft Versus Allograft
Autograft is superior
to allograft for ACDF
The use of allograft for spinal fusion in conjunction with anterior decompression for degenerative cervical disorders has a long tradition Cloward [62, 63] used allografts from the 1950s However, there are only a few studies [7, 28, 42, 303] comparing allografts versus autografts which were analyzed in a meta-analysis [83] Floyd and Ohnmeiss [83] concluded from their meta-analysis that for both one- and two-level anterior cervical discectomy and fusion, autograft demon-strated a higher rate of radiographic union and a lower incidence of graft col-lapse However, it was not possible to ascertain whether autograft is clinically superior to allograft The authors advised that the decision of the bone graft should not be solely based on the radiographic results but that additionally donor site morbidity, transmission of infectious disease, quality of the autograft (osteoporosis) and patient preference must be taken into consideration [83]
Plate Fixation
The conventional fusion techniques were not universally successful Complica-tions causing persistent pain included [10, 33, 69, 78, 102, 228, 287, 288, 292, 304]:
) non-union (particularly for multilevel fusions)
) graft displacement
) graft collapse
) sagittal malalignment (kyphosis)
For traumatic cervical lesions, anterior plate fixation gained widespread
accep-tance because it provides immediate stability and high fusion rates [4, 31, 46] Similarly, instrumented fusion was introduced for degenerative cervical disor-ders [156, 247, 279] Additional plating theoretically increases the fusion rate, preserves cervical lordosis, and prevents graft subsidence and migration partic-ularly when two or more levels are involved [247]
Plate fixation increases
the fusion rate for multilevel
fusions
However, three RCTs failed to demonstrate the superiority of additional plate fixation for one-level fusions in terms of clinical or radiological outcome [105,
244, 309] For multilevel fusion, there is some evidence that plating appears to
result in higher fusion rates [47, 94, 146, 280, 281]
Anterior plate fixation
does not suffice for three-level fusions
Wang et al [281] indicated that a three-level fusion is still associated with a
high non-union rate (18 %), although the use of cervical plates decreased the pseudarthrosis rate Bolesta reported that three- and four-level modified Robin-son cervical discectomy and fusion results in an unacceptably high rate of pseud-arthrosis which is not improved by a cervical spine plate alone [34] Additional posterior fixation is advocated in three and more level fusion to decrease the non-union rate [180] (Case Study 1)
Fusion with Cages
One drawback of the conventional fusion (Smith-Robinson or Cloward) tech-niques could not be overcome by plating, i.e bone graft donor side pain
Persis-Bone graft donor site pain
remains a drawback of ACDF
tent pain from the anterior iliac crest is reported in up to 31 % of patients [110] During the last decade, cages have become increasingly popular in stabilizing and fusing the cervical spine subsequent to anterior discectomy Compared to
conventional fusion techniques, the theoretical advantages of cages are to:
) restore disc height
) restore cervical lordosis
) prevent graft collapse
Trang 5a b c
Case Study 1
A 47-year-old male had experienced some numbness, clumsiness and tingling in his hands for over 1 year before he
sud-denly developed gait disturbance and weakness in both legs The patient was admitted to the Neurology Department
for further diagnostic work-up Clinically, the patient presented with an incomplete tetraparesis sub C4 A lateral
radio-graph (a) demonstrates a congenitally narrow spinal canal with cervical spondylosis particularly at the levels C5/6 and
C6/7 and decrease of cervical lordosis Sagittal T2W image (b) demonstrating a large disc herniation at C4/5 with
com-pression of the spinal cord, advanced disc degeneration with endplate changes (Modic Type II), signal intensity changes
within the spinal cord at C5/6, and a disc protrusion with spinal cord compression at C6/7 Axial T2W images confirm the
severe myelon compression at the levels of C4/5 (c) and C6/7 (d) The patient underwent multilevel anterior cervical
dis-cectomy and fusion with a tricortical iliac bone graft and anterior plating In a second operation, the patient underwent
posterior laminectomy and instrumented fusion to completely decompress the narrow spinal canal and spinal cord
(e,f) Postoperatively, the patient substantially improved with regard to his neurological function but a residual
tetrapa-resis remained at latest follow-up.
) avoid donor site pain
) reduce operative time
Many different cage designs (e.g cylindrical, mesh, ring or box shaped) and
materials (e.g titanium, carbon, polyetheretherketone, hydroxyapatite coated)
Trang 6have been introduced [54, 110, 144, 216, 221, 271] Debate continues on the fact of
the cage filling with bone (autograft or allograft), bone graft substitutes or void
and favorable clinical results have been reported with each technique [53, 132,
157, 168, 203, 233, 248]
Cage fusions are not better
than conventional
ACDF
Randomized studies have so far not been able to reveal a significantly better clinical outcome of patients undergoing cage fusion compared to conventional techniques [111, 210, 233, 273] although the rate of non-union appears to be higher and bone graft donor site pain lower [273]
Anterior Corpectomy
In patients suffering from CSM, anterior discectomy and osteophyectomy may not suffice to sufficiently decompress the spinal cord The spinal cord may not only be compromised by disc protrusions and spondylophytes but also by a spi-nal malalignment (kyphosis) or a narrow spispi-nal caspi-nal In these cases, a subtotal
corpectomy is required [236] Partial vertebral body resection and
decompres-sion was first used to treat traumatic cervical disorders [91] and later adopted for degenerative disorders [114, 236]
Compared to ACDF, a median corpectomy offers the advantage of:
) enlarging the spinal canal
) allowing for a more radical decompression
) increasing the fusion rate Corpectomy allows
for better decompression
and a high fusion rate
A variety of techniques were developed to stabilize the cervical spine after decompression through vertebrectomy [21, 35, 113, 116, 298] The extent to which decompression should be performed depends on the pathology and the size of the spinal canal [125, 295] Most authors [143] advocate the complete removal of the posterior osteophytes and PLL to achieve maximum decompres-sion (Fig 5) Compared to multilevel ACDF, corpectomy offers the advantage of
reducing the host-graft interfaces Swank et al [263] have shown that the
non-union rate of two-level ACDF was 36 % while one-level corpectomy resulted in a non-union rate of 10 % (Case Study 2) Similar results were obtained by Hilibrand
et al [125], who reported a non-union rate of 34 % for ACDF (one to four levels) and 7 % for corpectomy
One-level corpectomies are best reconstructed using iliac crest autograft The
angulation of the iliac crest limits its applicability for longer anterior
reconstruc-tions Therefore, fibula strut allografts have been used with satisfactory results
[263] However, the fusion rate of allograft fibula is somewhat lower than with autograft [100, 263] This limitation can be overcome with additional posterior
instrumented fusion [180] Recently, cages constructs have been used for long
anterior column reconstructions [56, 187, 261, 268, 293] The drawbacks of cage buttressing for anterior cervical reconstructions include subsidence, limited assessment of fusion status, and difficult revision surgery because of frequent partial incorporation [180]
Three-level corpectomies
necessitate
anterior-posterior fixation
Anterior plating currently is recommended to increase fusion rate and
decrease the incidence of graft dislocation [153] However, the ability of plate fix-ation to stabilize a three-level corpectomy is limited [136, 242, 270] and addi-tional posterior stabilization is recommended to circumvent implant failure and non-union [73, 93, 162, 226]
Anterior Discectomy Without Fusion
A drawback of the classic Robinson-Smith technique is that the intervertebral disc is removed to reach the location of the neural compromise Attempts have
Trang 7a b c
Figure 5 Technique of corpectomy and instrumented fusion
The cervical spine is exposed by an anteromedial approach.aThe intervertebral discs are excised adjacent to the target
level.bThe medial three-thirds of the vertebral body are resected The lateral wall is preserved to protect the vertebral
arteries.cA high-speed diamond burr is used to remove the median part of the vertebral body.dThe remaining part of
the posterior vertebral wall is elevated away from the spinal cord and resected with a Kerrison rongeur.eKerrison
ron-geur and curettes are used to remove posterior osteophytes and decompress spinal cord and exiting nerve roots.fThe
spine is reconstructed by insertion of a tricortical iliac bone block and anterior plating.
therefore been made to remove the disc herniation without completely resecting
the intervertebral disc Indications of this technique are:
) soft disc herniation
) disc sequestration
) young individual
) no spondylosis
) no segmental instability
Retrospective case series did not report a clinical outcome inferior to discectomy
and fusion [24, 25, 183, 192, 219, 220] The disadvantages of this method,
how-ever, were:
) recurrent herniation
) motion segment degeneration
) segmental instability
) chronic neck pain
) spontaneous fusion
Trang 8a b
c
d
Case Study 2
A 56-year-old male had recurrent episodes of neck pain with occasional radiating pain to his right forearm for 18 months before he developed acute onset excruciating arm pain followed by a progressive sensorimotor deficit of C6 on the right side Lateral radiograph (a) showing cervical spondylosis at the level of C5/6 and C6/7 Sagittal T2W image (b) reveals cer-vical spondylosis and disc protrusions at C5/6 and C6/7 Axial T2W image shows a sequestrated disc herniation at C5/6
(arrow) with compression of the exiting nerve root C6 (c) and a disc protrusion at C6/7 with compromise of the C7 nerve
root (d) The indication for surgery was prompted by the progression of the paresis The patient underwent a corporec-tomy of C6, decompression of the C6 and C7 nerve root, reconstruction with a tricortical iliac bone block and anterior plating (e,f) At 1 year follow-up, the sensorimotor deficit had completely recovered The patient was fully functional but occasionally had some episodes of benign neck pain.
Outcome of discectomy
without fusion is not inferior
to that of ACDF
In a prospective randomized study on 91 patients with single-level cervical root compression, Savolainen et al [244] analyzed three different treatment groups: discectomy without fusion, fusion with autologous bone graft, and fusion with autologous bone graft plus plating Clinical outcomes were good for 76 %, 82 %, and 73 % of the patients, respectively A slight kyphosis developed in 62.5 % of the patients who had undergone discectomy, 40 % of the patients who had undergone fusion, and 44 % of the patients who had undergone fusion plus
Trang 9plating [244] This study indicates that discectomy without fusion is not inferior
to ACDF
Techniques were developed to preserve the intervertebral disc, which often is
not substantially degenerated and can therefore be preserved Verbiest [274]
sug-gested a lateral approach while Hakuba [112] described a trans-unco-discal
Disc preserving anterior nerve root decompression
is feasible
approach The latter approach is a combined anterior and lateral approach to the
cervical discs Interbody fusion was not performed except for special cases with
significant kyphosis or instability [112] Minimally invasive techniques were
sug-gested by Jho [140] and Saringer et al [240], who reported on a microsurgical
anterior foraminotomy which provides direct anatomical decompression of the
compressed nerve root by removing the compressive spondylotic spur or disc
fragment Saringer et al [241] modified this technique by using an endoscopic
approach Other authors removed the herniated disc under endoscopic view
using a transdiscal route [13, 84]
Total Disc Arthroplasty
Adjacent segment degeneration is the main argument for TDA
Adjacent segment degeneration ( Fig 6) has been mentioned as the main
argu-ment against spinal fusion and therefore favoring total disc arthroplasty (TDA)
However, the data on adjacent segment degeneration is sparse [14, 52, 124, 160]
Hilibrand et al [124] followed 374 patients who had a total of 409 anterior
cervi-cal fusions for a maximum of 20 years Symptomatic adjacent-segment disease
occurred at an incidence of 2.9 % per year during the 10 years after operation
About one-fourth of the patients who had an anterior cervical fusion were at risk
of developing symptomatic adjacent segment disease within 10 years A
single-level arthrodesis involving C5/6 or C6/7 and preexisting radiographic evidence
of degeneration at adjacent levels appeared to be the greatest risk factors for new
Figure 6 Adjacent segment degeneration
aSymptomatic cervical spondylosis at C5/6 with anterior and posterior osteophytes.bPostoperative lateral radiograph
after anterior cervical discectomy and fusion with a tricortical iliac bone graft (Robinson-Smith technique).cLateral
radiographs at 6 years follow-up demonstrate a perfect fusion at C5/6 with remodeling of the osseus structures
(arrow-heads) Note the adjacent segment degeneration at C4/5 (arrow).
Trang 10disease [124] Importantly, no study so far was able to differentiate the effect of natural history versus the effect of the arthrodesis on the development of adja-cent segment degeneration [52, 101]
More than 15 different designs are now under pre-clinical and clinical
evalua-tion (e.g Prestige II, Bryan, PCM, ProDisc-C, Cervicore, Discover) [199] Current TDA designs include one-piece implants and implants with single or double glid-ing articulations with either metal-on-metal or metal-on-polymer bearglid-ing
c
Case Study 3
A 53-year-old female patient complained of persistent (4 months) right-sided shoulder/arm pain and was referred to our shoulder specialists with suspected impingement syndrome A thorough physical examination revealed a normal shoul-der function but a decreased sensation at the lateral aspect of the radial forearm and thumb as well as weakness in dor-siflexion of the hand The biceps tendon reflex was diminished on the right A lateral radiograph (a) showed segmental kyphosis at C4/5 and minimal cervical spondylosis at C5/6 and C6/7 Parasagittal T2W image (b) revealed a lateral disc protrusion at C5/6 Axial T2W image (c) confirms the foraminal disc protrusion with compression of the exiting C6 nerve root Non-operative therapy (medication, physiotherapy) failed to provide persistent substantial pain relief A nerve root block (C6) completely alleviated the symptoms for 1 week Discectomy, nerve root decompression and total disc arthro-plasty at C5/6 was carried out (d,e) Immediately after surgery, the patient had complete pain relief and was fully
func-tional 2 weeks after surgery At the 2-year follow-up, the patient was still completely symptom-free.