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Cervical disc disease and cervical spondylosis

Cervical spine disorders predominantly cause neck pain and/or arm symptoms. Cervical disc prolapse and cervical spondylosis are the two common cervical spine disorders. Degenerative changes in the vertebral column are the basic underlying pathological processes in both these conditions. Although the two conditions may be distinct clinical entities, the shared common pathogenetic mechanism results in a spectrum of clinical presentation depending upon whether the degenerative disease has resulted primarily in disc rupture or cervical spondylosis. As in the lumbar region the critical clinical feature depends on whether there is nerve root entrapment causing arm pain and/or focal signs of neural compression in the upper limb. Cervical cord compression due to disc prolapse or cervical spondylosis is discussed in Chapter 15.

Anatomy and pathology

The structure of the cervical disc is essentially the same as in the lumbar region and consists of an internal nucleus pulposus surrounded by the external brous lamina, the annulus brosus. The role of trauma in the degenerative process and disc herniation is not clear. It is probable that repetitive excessive stresses do exacerbate the normal ageing process and cause disc degeneration. Although it is frequently possible to identify some minor episode of trauma prior to the onset of an acute disc prolapse, a readily identiable episode of more major trauma as the precipitating event is much less frequent. The cervical disc prolapse is usually in the posterolateral direction, because the strong posterior longitudinal ligament prevents direct posterior herniation. The posterolateral disc herniation will cause compression of the adjacent nerve root as it enters and passes through the intervertebral neural foramen. Unlike the lumbar region, the nerves pass directly laterally from the cervical cord to their neural foramen, so that the herniation compresses the nerve at that level (Fig. 14.1). The arrangement of the cervical nerve roots and the relationship to the vertebral bodies differ from the lumbar region the C1 nerve root leaves the spinal canal between the skull (the foramen magnum) and the atlas, and the C8 root, for which there is no corresponding numbered vertebra, passes through the C7/T1 foramen. Consequently, a C5/6 disc prolapse will cause compression of the C6 nerve root, a C6/7 prolapse causes compression of the C7 nerve root and the C7/T1 disc 197

Cervical disc prolapse

In the 1934 report of their experiences with ruptured intervertebral discs, Mixter and Barr described four cases with cervical disc disease. Prolapse of an intervertebral disc is less common in the cervical region than in the lumbar area. The disc herniation occurs most frequently at the C6/7 level and slightly less commonly at the C5/6 level. Disc herniation above these levels and at the C7/T1 level is much less common. The predominant frequency of disc prolapse at C6/7 and C5/6 is due to the force exerted at these levels which act as a fulcrum for the mobile spine and head.

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lesions, middle nger (and sometimes index nger) in C7 lesions, and little and ring ngers in C8 lesions. The patient may notice weakness of the arm, particularly if the C7 root is affected, as this causes weakness of elbow extension and the movement has only very little supply by other nerve roots (C8). A severe C5 root lesion may cause weakness of shoulder abduction and the patient may complain of difculty in elevating the arm.

Examination features
Fig. 14.1 Posterolateral cervical disc prolapse causing compression of the adjacent nerve root.

prolapse causes compression of the C8 nerve root. Occasionally a cervical disc may herniate directly posteriorly, causing compression of the adjacent cervical spinal cord (Chapter 15) which is a neurosurgical emergency.

Clinical presentation
The characteristic presenting features of a patient with an acute cervical disc herniation consist of neck and arm pain and the neurological manifestations of cervical nerve root compression. Although the pain usually begins in the cervical region it characteristically radiates into the periscapular area and shoulder and down the arm (brachial neuralgia). The neck pain commonly regresses while the radiating arm pain becomes more severe. It is usually described as a deep, boring or aching pain and the patient is usually severely distressed and debilitated by the discomfort. The distribution of the pain is widespread and conforms to sclerotomes (segmental distribution to muscle and bone) rather than to dermatomes. The patient frequently complains of sensory disturbance, particularly numbness or tingling in the distribution of the dermatome affected. The location of the sensory disturbance is more useful than the pain as an indication of root level: thumb (and sometimes index nger) in C6

Cervical spine movements will be restricted and the head is often held rigidly to one side, usually moderately exed, and tilted towards the side of the pain in some patients but occasionally away from it in others. Lateral tilt relaxes the roots on the side of the concavity but diminishes the intervertebral foraminae, and exion slightly separates the posterior part of the intervertebral space and lessens the tension in the prolapse. If the disc herniation is long standing there may be wasting in the appropriate muscle group, particularly the triceps in a C7 root lesion. The patient is then examined for weakness in each of the muscle groups (Tables 14.1 and 14.2). Weakness of elbow extension and nger extension is most commonly caused by a C6/7 prolapse with compression of the C7 nerve root. Less commonly, disc herniation with compression of the C5 root will cause weakness of shoulder abduction, compression of the C6 root will cause mild weakness of elbow exion, and compression of C8 may cause weakness of the long exor muscles, triceps, nger extensors and intrinsic muscles. The deep tendon reexes provide objective evidence of nerve root compression in the following distribution. Biceps reex C5 Brachioradialis (supinator) reex C6 Triceps reex C7 Sensation should be tested in the arm and hand and the sensory loss will be characteristic for the nerve root involved (Fig. 14.2) although there may be some overlap. A full neurological examination must be performed and particular care taken to assess the

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Table 14.1 Segmental innervation of upper limb musculature. C3, 4 C5 C6 C7 Trapezius; levator scapulae Rhomboids; deltoids; supraspinatus; infraspinatus; teres minor; biceps Serratus anterior; latissimus dorsi; subscapularis; teres major; pectoralis major (clavicular head); biceps; coracobrachialis; brachialis; brachioradialis; supinator; extensor carpi radialis longus Serratus anterior; latissimus dorsi; pectoralis major (sternal head); pectoralis minor; triceps; pronator teres; exor carpi radialis; exor digitorum supercialis; extensor carpi radialis longus; extensor carpi radialis brevis; extensor digitorum; extensor digiti minimi Pectoralis major (sternal head); pectoralis minor; triceps; exor digitorum supercialis; exor digitorum profundus; exor pollicis longus; pronator quadratus; exor carpi ulnaris; extensor carpi ulnaris; abductor pollicis longus; extensor pollicis longus; extensor pollicis brevis; extensor indicis; abductor pollicis brevis; exor pollicis brevis; opponens pollicis Flexor digitorum profundus; intrinsic muscles of the hand (except abductor pollicis brevis; exor pollicis brevis; opponens pollicis); hypothenar muscles

C8

T1

Table 14.2 Segmental innervation of upper limb joint movements. Shoulder Abductors and lateral rotators Adductors and medial rotators Flexors Extensors Supinators Pronators Flexors and extensors Long exors and extensors Intrinsic muscles C5 C6, 7, 8 C5, 6 C7, 8 C6 C7, 8 C6, 7 C7, 8 C8, T1
C6 C6

C3 C4 T2 C5 T2 C5 C4

Elbow Forearm Wrist Digits Hand

T1

T1

C8

C8 C7

C6

presence in the lower limbs of long tract signs, such as increased tone, a pyramidal pattern of weakness, hyperreexia or an upgoing plantar response. If there is a cervical disc herniation these features will indicate that it is compressing the spinal cord.

C7

Fig. 14.2 Upper limb dermatome distribution.

Summary of clinical features

Clinical localization of disc prolapse is possible in

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most patients with brachial neuralgia due to cervical disc prolapse. The following features are typical (but not invariable) for disc herniation: C6/C7 prolapsed intervertebral disc (C7 nerve root) Weakness of elbow extension Absent triceps jerk Numbness or tingling in the middle or index nger. C5/6 prolapsed intervertebral disc (C6 nerve root) Depressed supinator reex Numbness or tingling in the thumb or index nger Occasionally mild weakness of elbow exion. C7/T1 prolapsed intervertebral disc (C8 nerve root) Weakness may involve long exor muscles, triceps, nger extensors and intrinsic muscles Diminished sensation in ring and little nger and on the medial border of the hand and forearm Triceps jerk may be depressed.

Management
Most patients with arm pain due to an acute soft cervical disc herniation achieve good pain relief with conservative treatment. This should include bed rest, a cervical collar, simple analgesic medication, non-steroidal anti-inammatory medication and muscle relaxants. Manipulation of the neck is potentially hazardous and is contraindicated. The following are indications for further investigation and surgery. 1 Pain: (a) continuing severe arm pain for more than 10 days without benet from conservative therapy (b) chronic or relapsing arm pain. 2 Signicant weakness in the upper limb that does not resolve with conservative therapy. 3 Evidence of a central disc prolapse causing cord compression this should be investigated urgently.

Differential diagnosis
The clinical features of an acute cervical disc prolapse, with severe neck and arm pain and commonly diminished sensation in the dermatome of the affected cervical root, are so characteristic that in the vast majority of cases the diagnosis is self-evident. The most common cause of radiating arm pain, other than acute prolapse, is spondylosis but, as has been indicated, disc prolapse and spondylosis are aspects of one continuing degenerative process and, in the cervical region, the distinction between them becomes blurred. Other unlikely but possible differential diagnoses include: cervical nerve root compression by a spinal tumour (e.g. meningioma, neurobroma) (Chapter 15) thoracic outlet syndrome (Chapter 17) Pancoasts tumour inltrating the roots of the brachial plexus peripheral nerve entrapments, such as carpal tunnel syndrome, median nerve entrapment in the cubital fossa and tardy ulnar palsy (Chapter 17).

Radiological investigations
High-quality MRI is now the investigation of choice and has almost completely replaced both myelography and CT (Fig. 14.3). The cervical myelogram using water-based non-ionic iodine contrast material was a most useful investigation for determining the presence and site of the disc herniation (Fig. 14.4). CT scanning by itself is frequently not helpful, but if performed following intrathecal iodine contrast it will demonstrate a disc herniation, and smaller volumes of intrathecal contrast are necessary than with myelography (Fig. 14.5).

Operative procedure
The two most commonly performed operations for cervical disc prolapse are: 1 Cervical foraminotomy with excision of the disc prolapse. 2 Anterior cervical discectomy, with subsequent fusion. Cervical foraminotomy. This involves fenestration

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(a)

(b)

(c)

Fig. 14.3 MRI of cervical disc prolapse. (a) Cervical axial T1-weighted image (arrow shows disc prolapse). (b,c) Sagittal MRI showing disc prolapse compressing the spinal theca and distorting the cervical cord.

of the bone posteriorly, to provide direct access to the cervical nerve root and disc prolapse. A small amount of bone from the lateral margins of the adjacent lamina and articular facets is removed to identify the nerve root in the foramen. Further bone can then be removed from around the nerve root to enlarge the neural canal. The nerve root is gently retracted and the disc herniation excised. The major advantages of the technique are that the nerve is directly decompressed both by removal of the disc herniation and by enlargement of the foramen, and cervical fusion is not necessary. The major disadvantage is the possibility of

recurrent disc herniation, but this is very uncommon. In general, the results of the procedure are very satisfactory, with excellent relief of arm pain and, provided the nerve has not been irreparably damaged by long-standing disc herniation, return of full strength to the arm. Anterior cervical discectomy. This involves an anterior approach to remove the cervical disc and the prolapse. Some surgeons perform formal fusion at the level using bone taken from the iliac crest, bovine bone, articial bone, or an intervertebral cage, usually lled with bone chips. The fusion

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Fig. 14.5 CT myelogram showing a posterolateral cervical disc protrusion.

Cervical spondylosis
Fig. 14.4 Cervical myelogram showing a posterolateral cervical disc protrusion with compression of the cervical nerve root.

may be supplemented by a metal (usually titanium) plate screwed onto the anterior vertebral surface, bridging the disc space. Some surgeons do not perform a formal fusion, as spontaneous brous or bony fusion will occur across the disc space provided all the disc has been excised. The major disadvantage is that the fusion will result in additional stress at the adjacent cervical levels, thereby rendering them more prone to degenerative disease. An anterior approach with disc excision is mandatory for a central disc protrusion.

Cervical spondylosis is a degenerative arthritic process involving the cervical spine and affecting the intervertebral disc and zygapophyseal joints. Radiological ndings of cervical spondylosis are present in 75% of people over 50 years of age who have no signicant symptoms referable to the cervical spine.

Pathological changes
The degenerative process resulting in cervical spondylosis and its progression occur in most cases largely as a result of the inevitable stresses and traumas that occur to the cervical spine as a result of the normal activities of daily living. It is probable that the process is aggravated by repetitive or chronic trauma, as may occur in some occupations, and as a result of an episode of severe trauma. The process principally involves the intervertebral discs and zygapophyseal joints. Reduced water content and fragmentation of the nuclear portion of the cervical discs are natural ageing processes. As the disc degenerates there is greater stress on the articular cartilages of the vertebral end-plates and osteophytic spurs develop around the margins of the disintegrating end-plates, projecting posteriorly into the spinal canal and anteriorly into the prevertebral space.

Postoperative care Whatever approach is used, the patient is encouraged to mobilize the day after surgery. A soft cervical collar may be useful in the rst week after a foraminotomy to minimize the neck pain. A rm collar is usually worn for the rst 46 weeks after anterior discectomy, or until there is evidence of fusion. The prognosis for pain relief following the operation is excellent provided the diagnosis has been accurate and the nerve decompressed.