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1. Cervical Spondylosis;
Etiology, Evaluation and
Management
Steven D. Wray M.D.
Atlanta Brain and Spine Care P.C.
Piedmont Spine Center

2. Conclusion:
Cervical nerve root or cord
compression from bone spur
formation (spondylosis) is a
degenerative and progressive
process which should be referred to
a neurosurgeon early as outcome is
directly related to the duration of
symptoms.

3. Cervical Spondylosis; Definition
Age related degeneration of the
cervical spine
“Osteoarthritis”
Most common in persons over 40
Most common cause for myelopathy
in persons over 55
Male>Female

4. Cervical Spondylosis;
Pathology
Age Related Degeneration and
Dehydration of intervertebal Disks
Decreased cartilage between
adjacent vertebral bodies
Developmental laxity in the spinal
supportive ligaments
Hyper-mobility of spinal segment
Bone-on bone apposition
propagates bone spur formation
which narrow the cervical spinal
canal and may compress the
cervical nerve roots and spinal cord

5. Cervical Spondylosis;
Clinical Presentation
Mechanical
• Pain
• Stiffness
• Muscle Spasm
• “Pop and Crack”
Neurologic
• Nerve Root Compression
• Spinal Cord Compression

6. Cervical Spondylosis;
Spondylitic change with bone
spur/disk complex formation
Developmental narrowing of
spinal canal with
compression of spinal cord
and nerve roots

7. Cervical Spondylosis;
Cord Compression
64 Year old patient
with severe
symptomatic
spondylitic
myelopathy.
Multilevel Cord
compression seen on
MRI.

8. Cervical Spondylosis;
Natural History
Predisposition
• Some individuals have a congenitally narrow spinal
canal
• Increased incidence of symptom development with mild
to moderate spondylosis
• Pre-participation screening of athletes to asses
vulnerability to spinal cord injury
Evolution
• Unlike soft cervical disk herniation which usually
resolves, Cervical Spondylosis is progressive
• May be insidious and then more rapidly progressive as
Spinal Fluid “reserve” becomes depleted by enlarging
bone spurs

9. Cervical Spondylosis
Symptom Pathogenesis
Hyper-mobility / instability of spinal
segments
Irritation/inflammation of heavily
innervated vertebral body endplates
Direct compression of cervical nerve
root or spinal cord
Repetitive trauma to cord or roots
Ischemic change to the cord

10. Cervical Spondylosis;
Presentation with “Headache”
Kyphotic Angular deformity
creates added stress on the
paraspinal muscles and causes
severe myofascial pain and
spasm and often produces
suboccipital headaches where
the paraspinal muscles insert on
the base of the skull.
For this reason, some
degenerative cervical spine
disease can present with
“headache”.

11. Cervical Spondylosis;
Developmental Scoliosis; Facet Arthropaty
Coronal Plane angulation
causes myofascial pain as
well as changes of the facet
joints. The added stress on
joints leads to joint
hypertrophy and inflammatory
change which is painful.

12. Cervical Spine Dynamic Instability;
Flexion/Extension Radiographs!

13. Nonsurgical Treatment
NSAIDS
Traction
PT
• Ultrasound for trigger points
• Neuromuscular massage
• TENS
• Traction
Interventional
• Selective nerve root block
• ESI
• Facet block/ RFA

14. Definitions
Radiculopathy
• Nerve Root Compression
• Pain, weakness, numbness in the distribution
of a nerve root (neck or back)
Myelopathy
• Spinal Cord Compression in the cervical or
thoracic area
• Symptoms
Numbness, tingling of the arms/ hands
Dexterity difficulty with fine motor movements
Gait instability
Balance and coordination difficulty
Bowel/Bladder disturbances (incontinence)

15. Cervical Nerve Root Symtoms
C4-5 C5-6 C6-7 C7-T1
Incidence 2% 19% 69% 10%
Root C5 C6 C7 C8
Affected
Motor Deltoid Biceps/ Triceps Intrinsics
BR
Sensory Shoulder Upper 2nd 3rd 4th and 5th
arm/ finger/ all finger
Thumb fingertips

16. Incidence of Myelopathy is Related
to Canal Diameter
xxxx
Canal Diameter <13mm increases
risk for myelopathy
Canal Diameter <10mm almost
always results in symptomatic
cord compression
xxxxxx

17. Differential Diagnoses
ALS
• Exclusively Motor
• Tongue Fasciculations
Multiple Sclerosis
• Relapsing/remitting symptoms
• Demyelinating plaques on Brain MRI
Subacute Combined Degeneration
• Macrocytic Anemia
• B12 deficiency

18. Who Needs Surgery?
Neurologic Compromise
• Symptomatic Nerve root compression
refractory to non-surgical management
• Spinal Cord Compression with
myelopathy
Biomechanical Instability
• Instability on Flexion/Extension Films
• Angular deformity
• Subluxation/ Listhesis

19. Surgical Options; Considerations
Type of Pathology
• Soft Disk
• Bone Spur; Spondylosis
Location of Compression
• anterior vs. posterior
Angulation of Spine
• Preserved Lordosis vs. Kyphosis
Patient age and co-morbidities
Health of adjacent levels
Bone Density
Number of spinal segments involved

20. Surgical Options
Anterior vs. Posterior Decompression
Simple Decompression vs. Fusion
and Stabilization

21. Anterior Cervical Decompression
and Fusion
Performed through a transverse cervical
incision
Microscopic Decompression of spinal cord
by removal of compressive bone spur
Restore and maintain intervertebral height
using an intervertebral bone graft or
plastic spacer
Stabilize spinal segment with low profile
titanium plate (promotes fusion)

22. Anterior Cervical Decompression
and Fusion

23. Anterior Cervical Diskectomy and
Fusion
Minimal pain as no muscle disruption
Subcuticular closure
Overnight observation
Addresses ventral pathology without
any neural element retraction or
manipulation

24. Anterior Cervical Decompression
and Fusion
High fusion rate.
Fusion promoted by good blood supply
at the ventral moment arm of the spine.

25. Fusion Substrate
Historical Gold Standard; Freshly
harvested iliac crest bone autograft
• Donor site morbidity
• Pain/ Infection Risk
Banked Allograft
• Small but present risk for disease transmission
PEEK Spacers
• Plastic cement restrictors which are non-
compressible and restore inter-vertebral height

26. Bone Morphogenic Protein
Recombinant protein with no risk of
disease transmission and High fusion
rate

27. Biologics to Promote Fusion
Osteocondustion
Osteoinduction
Transverse Process

28. BMP and Fusion

29. Goals of Surgery
Decompress neural elements
Restore Intervertebral height which also
restores neural foraminal patency
Restore anatomic alignment in the case of
kyphosis or scoliosis
Stabilize spinal segment(s) to prevent
bone spur propagation and repetitive
nerve root irritation
Promote solid arthrodesis over time

30. ACDF to correct Developmental
Scoliosis from Spondylosis
XXXXX

31. ACDF to Correct Developmental
Kyphosis due to spondylosis
xxxxxxx

32. Posterior Cervical Fusion
Decompress neural elements by
removal of the bony lamina and
underlying ligament (Laminectomy)
Stabilization by posterior lateral
mass screws and rods
Fusion performed by on-lay
technique and inter-facet graft
material (laminar bone or iliac crest
autograft)

33. Posterior Cervical Fusion

34. Posterior Cervical Decompression
Decompression alone is
contraindicated with preexisting
kyphotic deformity
High risk of developing late swan-
neck deformity
Post operative Pain
In case of hyperlordosis, posterior
cord migration may cause cord
compression

35. Surgical Outcomes
Anterior or Posterior approaches that
effectively decompress spinal cord
promote improvements in outcome
Higher Risk of late kyphosis in patients
who undergo laminectomy or anterior
cervical decompression alone compared to
patients in whom decompression is
combined with fusion
Fehlings MG, Arvin B. J Neurosurg Spine. 2009 Aug:11 (2): 97-100

36. Outcomes
Duration of Symptoms and advanced age
negatively affect outcome in patients with CSM
• 50% improve if operated within a year
compared with only 16% is operated after
Abnormal Pre-operative SSEP/EMG Findings
adversely affect outcome
Cord Signal Change or the presence of spinal
cord atrophy negatively affect outcome
Fehlings MG, Arvin B. J Neurosurg Spine 2009 Aug;11(2):97-100

37. REFER EARLY!!
Patients with spinal cord or nerve
root compression should be referred
for neurosurgical evaluation
promptly.

38. Thank You