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Cervical Spine Pathology and Correlative Exam Alfred J. Melillo, PA-C PA/APN Coordinator Cleveland Clinic Center for Spine Health Cleveland Spine Review July 2014
Cervical Spine Pathology • • • • • •
Degenerative Deformity Tumor Infection Inflammatory Diseases Masqueraders
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Cervical Neurological Exam • • • • • •
History Inspection Palpation Motor Sensory Reflexes
History
Most important part of patient evaluation - Establishes differential diagnosis - Guides physical exam - Guides diagnostic testing
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Inspection • Cervical ROM • Previous incision sites • Atrophy • Café au Lait Spots • hairy patches
Palpation • Tenderness/pain - Bone prominences - Paraspinal muscles
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Motor • • • • • •
C4-shoulder shrug C5-deltoids, biceps C6-wrist extension C7-triceps, wrist flexion C8-finger flexion T1-instrinsics
• Check LE motor exam also (cervical myelopathy)
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Motor
• • • • • •
Grade 5 - normal Grade 4 - weak against resistance Grade 3 - motion against gravity Grade 2 - motion w gravity eliminated Grade 1 - evidence of contractility Grade 0 - no contractility
Sensory • Pin prick • Light touch • Joint Position Sense • Temperature
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Reflexes • Biceps: C5, C6 • Brachioradialis: C6 • Triceps: C7 • Pathologic Reflexes - Hoffmann’s - Babinski - Clonus
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Types of Neck Pain
• • • • •
mechanical referred chronic neuropathic myofascial
Neck Pain Distribution
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Cervical Radiculopathy • Pain in dermatomal distribution • Neurologic findings may include: - Numbness and paresthesias - weakness - Changes in correlative reflexes
Cervical Radiculopathy • Pain related to neck position • worsened by cervical ROM • Numbness or motor deficit w/wo pain • Onset may be insidious or acute
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Cervical Radiculopathy • Spurling’s Sign - + pain with neck extension and rotation toward the symptomatic side
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Root Syndromes Myotomes-Dermatomes-Reflexes •
C5 - Motor – Shoulder Abduction/Elbow Flexion - Sensation - Lateral Arm - Reflex - Biceps
•
C6 - Primary Motor - Wrist Extension - Sensation - Lateral Forearm, Thumb, and Index Fingers - Reflex - Brachioradialis
•
C7 - Primary Motor - Elbow Ext, Wrist Flexion, Finger Ext - Sensation - Middle Finger - Reflex - Triceps
Root Syndromes Myotomes-Dermatomes-Reflexes • C8 - Primary Motor - Finger Flexion - Sensation - Medial Forearm/Ring/Small Finger. - Reflex - None
• T1 - Primary Motor - Finger Abduction - Sensation - Medial Arm - Reflex - None
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Cervical Radiculopathy
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Cervical Radiculopathy
Cervical Radiculopathy Treatment Options •
Non-Operative - Continue conservative management - PT, NSAIDS, ESI/nerve block - Most will likely get better without surgery
•
Operative - ACDF - Posterior Cervical Foraminotomy • Minimally Invasive Approach (limited patients) • Far lateral disc herniations • No stripping of muscles • No neck pain • Lordotic alignment
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Cervical Radiculopathy Post-Op
Cervical Myelopathy Usually a constellation of signs/symptoms Majority of patients exhibit gradual decline
• • • • • • • • •
+ or - neck pain Radicular pain/numbness/paresthesias aching to sharp gait disturbance/imbalance loss of fine motor skills/dexterity clumsy hands Spasticity UE/LE motor weakness in the UE/LE bowel and bladder dysfunction
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Cervical Myelopathy Possible Physical Findings • • • • • • • • •
Hypereflexia Positive Hoffmann’s sign Positive Babinski test Clonus/Spasticity in legs Sensory Changes Motor Changes Poor tandem gait Thenar Atrophy Positive Lhermitte’s sign
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Cervical Myelopathy Thenar Atrophy
Cervical Myelopathy • Classic presentation • Numbness /clumsiness of the hands • Stiff spastic gait • Inability to tandem walk
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Cervical Myelopathy
Cervical Myelopathy
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Cervical Myelopathy
Cervical Myelopathy Post-Op
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Myeloradiculopathy • Compression of spinal cord/nerve root • Symptoms consistent with both myelopathy and radiculopathy • Signs/symptoms the same
Cervical Spine Degeneration • Disc Herniation • Spondylosis • Stenosis
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Cervical Spine Degeneration • Loss of disc space height • Irregularities in the disc endplate • Sclerosis of the disc margins • Osteophyte formation
-
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Pathological Process of Degenerative Disc Disease
• Physiological responses to stresses placed on the spine • Accelerated deterioration of the integrity of spinal elements
Cervical Disc Herniation Epidemiology - More common in males - Age 30-65
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Cervical Disc Herniation • Pathogenesis of HNP - Aging/decreased H2O content of disc - Posture & Mechanical effects • Occupation, diving, lifting, violent sports - Minor repeated trauma from ADLs - May result in cord and or nerve root impingement • Most common levels affected C5-6 C6-7
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Terminology for Disc Herniations Desiccation - loss of disk water Disk bulge - circumferential enlargement of the disk contour in a symmetric fashion Protrusion - a bulging disk that is eccentric to one side but < 3 mm beyond vertebral margin Herniation - disk protrusion that extends more than 3 mm beyond the vertebral margin Extruded disk - extension of nucleus pulposus through the anulus into the epidural space Free fragment - epidural fragment of disk no longer attached to the parent disk Milette PC, Proper terminology for reporting lumbar intervertebral disk disorders. AJNR 18:1859-66, 1997.
Cervical Disc Herniation
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Cervical Disc Herniation
Cervical Disc Herniation C5 HNP • Primary Motor: Shoulder Abduction, Elbow Flexion • Sensation: Lateral Arm • Reflex: Biceps
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Cervical Disk Herniation C6 HNP • Primary Motor: Wrist Extension
• Sensation: Lateral Forearm, Thumb, and Index Fingers
• Reflex: Brachioradialis
Cervical Spondylosis Epidemiology • Symptoms arise at age 50-70 • More frequently seen in men • Normal aging process of the spine • Degenerative changes in the elderly population are universal
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Clinical Correlation is VERY IMPORTANT
Cervical Spondylosis Pathogenesis •
Loss of intervertebral disc height
•
Osteophyte formation
•
Segmental instability - kyphotic deformity may result
•
Bulging discs and osteophytes may impinge on the root or the cord
•
Canal narrowing
•
Slow and progressive or step-wise pattern or acute myelopathy
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Normal Curves of the Spine
Cervical Kyphosis
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Cervical Spondylosis
Cervical Spondylosis
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Cervical Stenosis • OPLL • Congenital Stenosis • Spondylosis
Congenital Canal Stenosis Less than 13 mm AP canal 9 mm AP diameter cord 1 mm CSF on each side of the cord 1 mm of dura
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Cervical Stenosis
Cervical Stenosis Post-Op
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Ossification of the Posterior Longitudinal Ligament (OPLL) Ossification and hypertrophy of the PLL
OPLL •
Occurs in 5-20% of patients aged 50-60
•
Occurs anywhere C1-C7
•
most often affects levels between C3-C5
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Not gender related
•
Basis for the ossification is unknown
•
Asymptomatic to severe myelopathy
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OPLL
OPLL
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Cervical Deformity • Congenital Anomalies • Post Traumatic Deformity • Post Surgical Deformity
Congenital Cervical Deformity
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Congenital Cervical Deformity
Congenital Cervical Deformity
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Post Traumatic Cervical Deformity
Post Traumatic Cervical Deformity
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Post Traumatic Deformity
Post Traumatic Cervical Deformity
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Post Traumatic Cervical Deformity Post-Op
Post Surgical Deformity
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Post Surgical Deformity
Post Surgical Deformity Post-Op
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Cervical Spinal Tumors • Primary vs Metastatic • Benign vs Malignant • Occurrence - Bone - Spinal Cord - Meninges
Classification of Spinal Tumors Classification of Spinal Tumors Extradural
IntraduralExtramedullary
Intramedullary
Metastases Myeloma Lymphoma Hemangioma Aneurysmal Bone Cyst Giant Cell Tumor Osteoid Osteoma Osteoblastoma Osteochondroma Eosinophilic Granuloma Ewing’s Sarcoma Osteosarcoma Chhordoma Leukemia Chondrosarcoma
Nerve Sheath Tumors Meningioma Lipoma Epidermoid Dermoid Arachnoid Cysts Paraganglioma Intradural Metastases
Ependymoma Astrocytoma Hemangioblastoma Metastases Glioblastoma
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Cervical Spine Tumors Space occupying lesions Compromise stability of the spine - Resection - Bony compromise
Cervical Spine Tumors • persistent pain, not relieved by rest, worse in PM • common areas of pain: neck, occiput, shoulder • neurological symptoms - Weakness - Sensory changes - Bowel/bladder changes
• primary lesions that metastasize to spine - breast, lung, prostate, kidney and thyroid
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Extradural Spinal Tumors - ~ 30% of all spinal neoplasms - Occur outside the dura - Vertebral bodies or paraspinal tissues
Intadural-Extramedullary • ~ 55% of all spine tumors • Largest group of spinal cord neoplasms • between the dura and the spinal cord
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Intramedullary • 16 to 25% of spinal tumors • Located within the spinal cord
Cervical Spine Metastasis • Usually do not present with neurologic deficits • Average life span after diagnosis is 14.7 months • Metastatic Disease commonly occurs in the thoracic and lumbar spine • Less common in the cervical spine
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Cervical Spinal Metastasis • Cervical spine is site of least frequent spread - 70% Thoracic - 20% Lumbar - 10% Cervical
Cervical Spine Metastasis • ~ 70-90% of patients with Stage IV cancer have a spinal met • Ten percent of patients presenting w symptomatic spinal mets have an unknown primary • Breast, lung, prostate, kidney, thyroid, lymphoma and myeloma common metastasis to the spine
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Cervical Spinal Metastasis - Site for metastasis is usually the vertebral body via the venous system - Anterior cord is site of compression resulting in motor deficits rather than sensory problems - Bone destruction results in deformity and instability - Neurologic deficits occurs in ~ 5% cases, compared to deficits in the thoraco/lumbar spine which is ~ 45%
Cervical Spinal Metastasis Presentation • Asymptomatic to severe neurologic deficits - Location of tumor within the spinal column - Bone involvement
• • • • •
Vertebral body mass invades the paraspinal tissue Secondary pathological fracture Spinal instability as a result of destruction Cord compression Adjacent nerve involvement
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Cervical Spinal Metastasis •
Pain - Local, gradual onset worse at night
•
Fracture - VB most common site of mets • Loss of height • Canal encroachment
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Instability - Uncommon presenting feature - Development complicates the course of treatment
•
Neurological Involvement - Asymptomatic to severe neurologic deficit
Cervical Spinal Metastasis
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Cervical Spinal Metastasis
Cervical Spinal Metastasis
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Cervical Spinal Metastasis
Treatment Goals for Spinal Metastasis • • • • • •
Pain free Neurologic uncompromised life STABILIZE if needed Keep as functional as possible Take into account survival rate Look at entire picture not just pathology • Evaluate the need for post-op radiation - Effect on fusion and wound healing
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Cervical Spine Infection •
Osteomyelitis
•
Wound & Disc Space Infection
•
Epidural abcess - Skin/soft tissue, bone/joint, spinal surgery/procedures, abdomen, IV drug abuse
•
Fungal Infection
•
Parasitic Disease
Presentation • Presentation may be acute, sub acute or chronic • Neck pain that radiates to trap & shoulder in 90% • ~ 50% present with fever • Radiculopathy or myelopathy secondary to epidural abcess can progress to paralysis • Rare symptoms include: HA, meningeal irritation, respiratory, or dysphagia issues • Very rare septic presentations
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Physical Exam • Tenderness • Spasm • Limited ROM • Torticollis • ~ 17 - 50% of cervical vertebral osteomyelitis will have a neurological deficit
Cervical Spine Infection MRI
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Inflammatory Disease of the Cervical Spine • • • • • •
Rheumatoid Arthritis Inflammatory disease affecting synovial joints 3:1 female to male ratio Steroids Poor wound healing Risk of injury during intubation
Rheumatoid Arthritis • • • • •
Most commonly involved levels C1-2 Subluxation of C1 on C2 C1-2 instability present in ~ 36% of patients Pannus formation Upward migration of odontoid/basilar invagination
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Rheumatoid Arthritis XR
Rheumatoid Arthritis MRI
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Rheumatoid Arthritis CT
Surgical Indications of RA •
C1-C2 instability - Neurologic deficits - Intractable neck pain - Radiographic evidence of instability
•
Focus on posterior atlanto-dental interval (PADI) rather than anterior atlanto-dental interval (AADI)
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PADI is the same as the space available for the spinal cord
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Better predictor of paralysis than AADI
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Presence of basilar invagination likely results in OC fusion
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Masqueraders of the Spine • • • • • • • • • •
Carpal Tunnel Syndrome Cervical Band Syndrome MS, ALS, Transverse Myelitis Shoulder Pathology-Rotator Cuff Brachial Plexus Injury Hydrocephalus Ulnar Neuropathy Pancoast Tumor Parsonage-Turner Syndrome Fibromyalgia
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