Cervical Disc Disorders, Dr. Steven Tresser

So I do have one relevant disclosure which is I help new vasive of design a cervical cage implant for which I receive royalties. So let’s talk a little bit of this review the anatomy of the cervical spine. So I’m sure you’ll know there are seven cervical vertebrae and they’re connected to each other. Through several joints. There are two facet joints one on either side and in the poster aspect of the spine. And then we have the desk which is also a joint and then the supporting structures which are the ligaments and then inside of this spinal column we have the neural structures the spinal cord and the nerve roots. So the deaths have basically an annulus which is this outer Part of the disk.
which you see there on the right side. It looks like a radial tire has all these different lamellar rings and they’re oriented and horizontally across orientation to each other. It’s very strong part of the structural part of the desk and then inside sort of like where. The jelly would be inside of a jelly doughnut you have the nucleus and a lot of people.
Patients think it’s actually like a gel. It’s not it’s really the consistency would be more like tough crab meat really and they annulus and the nucleus both are can contain all this all the compounds that you see on the left side. And the real difference is the cause the composition the proportions. So the nucleus has a much higher water content than the annulus and that gives it its that’s a sponge genius. Its shock absorbing ability and and so let me go back for one second.
So the disks are probably 25 percent of the height of our entire spinal column it’s our major shock absorbing ability for our body. The disk also have poor blood supply. Really things get into and out of the desk through osmosis more than real blood supply. So injuries to the disks are hard for the body to repair. Infections very difficult to eradicate inside a desk just because of this poor blood supply.
So what are the things that can happen to the disk. One is over time as we age the disks lose water. And this is very easy to see on MRI on a T2 signal MRI. You can see that the loss of water is very apparent and by the time we’re in our 40s sometimes in our 30s begin to see desiccation or loss of water content in the deaths. And this results ultimately in loss of height of the disks so the disk now ow they lose height and we begin to develop a bone spring and that’s sort of a normal part of aging and that’s why we are all gradually and suddenly shrinking over time. The other thing is that can happen you can see in the bottom right. So you can get a weakness in the annulus and this is due to again loss of water content or trauma which results in loss of integrity of the annulus loss of elasticity.And resistance to trauma. You can get areas where looks like a tire that’s bulging out or where you actually have through and through tears in the disk.
Here you can see an annual tear this white spot which just called a high intensity zone is called an annular tear and it’s a sign that the back of the annulus is torn or damaged. And then through that the nucleus can protrude or herniated and get out and either in this picture as you see in the bottom right laterally towards where the nerve it is or more centrally towards where the spinal cord is and then and that and then the top right. We talked about the degenerative process where we have loss of loss of height of the desk and the body’s response to that as the form osteo fights to form bone literally to try and bridge across the joint and stabilize it and ultimately fuse and sometimes we do see in older patients where deaths have become auto fused together.
I won’t cover the trauma and the really that or the infection aspects much here. I mean those would I think necessarily dictate referral to a surgeon. That’s not something that’s going to be dealt with in a primary care environment. So what are the symptoms and signs of radiculopathy which is where. Where you have a nerve root that’s compressed whether you have something off to the side laterally that’s compressing the nerve it after it’s or right as it’s exiting the spinal cord. And typically, this would be the symptoms of pain numbness tingling and weakness and some combination of those frequent we see people who just have pain. And they don’t have it in the others and I think that’s important to remember. There are obviously other reasons that someone could have pain in there in their neck and in their shoulder in their arm. There’s a lot of overlap.
We frequently see patients referred to us by the shoulder service because they were patients were sent to the shoulder service thinking that was their shoulder and it’s actually their neck and vice versa. So we see people who come in thinking it’s their neck and we end up sending him to the shoulder. Her shoulder surgeons to have them look at him. But you can see that there is a referral pattern for each specific nerve root and there’s and this is not. It’s not as well demarcated in real life as it is in these drawing sometimes. People complaining of the symptoms are somewhat vague it’s hard to pin them down where the exact pattern is. I mean sometimes they’ll literally say it’s rating right down my radial forearm right into my thumb and index finger. Well you know that C6 but many times it’s frequently vague description of where their pain is. We do see a lot of pain referred into the into the shoulder scapula area and that’s very common.
We see some patients who just have that actually they don’t have arm symptoms. We see a lot of people with pain in the trapezius and scapular area as well as neck pain and that’s frequently a sign of a ridiculous thing.
And then you can have something that’s compressing the spinal cord itself which is called myelopathy. And that’s usually not actually painful. Most people have my lot but they don’t have pain and they don’t realize they have it. That’s usually more, I mean it can be acute but usually it’s something that’s very chronic and insidious and it’s onset and people develop over time with date problems, loss of fluidity of their movements, loss of dexterity, weakness, spasticity, a lot of times something that we pick up on exam and the patient is even aware that they have something really wrong. So one of the first signs of that would be hyperreflexia and we picked that up on exam. The patient really does have any symptoms. So, we send people for scans sometimes just based on examining them and identifying this even though the patient has no complaints.
But as it gets further along people do begin to notice. You know they’re having problems walking they’re having problems getting up from a chair their legs are not powerful they can’t climb stairs. They’re losing their balance they’re falling frequently. And they’re losing their hands are getting numb. They’re having difficulty holding onto objects. Essentially, they’re just getting clumsy. And so this is a sign of a spinal cord compression which can be due to a discrimination or due to bone spurs that have form there.
So what is the ladder, the non-operative treatment ladder. That we use when we see these patients. Well first of all we obviously do the work up and identify what the problem is and rule out these other possible ideologies. One of the things is just time. I mean with someone with an acute disk. Frequently more than half the time and in two to three months those will get better on its own. So a lot of this is just palliating the patient as they go through time and heal themselves. And usually that includes medications which would be you know the traditional and time limit non-steroidal, anti-inflammatory medications muscle relaxers steroids frequently if it’s an acute problem if it’s a more chronic problem that’s usually not going to be that effective. Although we can try it.
And then you have the neurotransmitter type medications like GABA Penton, Lyrica, Cymbalta, and these are all that this will be sort of our first line of defense and encourage patients to do an exercise and stretching program. And then physical therapy and chiropractic treatment are very important. Particularly I think traction helps a lot in someone who has got a narrow frame and or something compressing their nerve. Some traction to alleviate that’s usually very effective and some people would get a good response Go on then to get a home traction device of some sort and use that intermittently because many patients do have recurrent flare ups. Other modalities that are effective and therapy would be the electrical stimulation and ultrasound and an isometric exercise is very effective.
And I think also variable resistance exercise just like the medics machine I think are very effective and failing all of these things and will frequently send someone for steroid injections’. I think covered that quite completely, I won’t go into that.
And there are times where we just reach the end of the ladder. We don’t really have anything else. And that’s when we start to think about surgery and so usually it depends upon when the patients referred us but usually, they’ve undergone some non-operative treatment for several months. It’s rare for us to really operate acutely unless the person is just you know very impaired to say know disabled by pain or have some significant neurologic problems that need to be remedied immediately. Usually we’ll go through two to three to four months of non-operative treatment.
So what are the indications for surgery. One would be I think they call to two compelling categories one is pain that’s really not responded to these other treatments and that’s most of the people. And then the other thing would be some type of neurologic deficit that’s not improving or towards worsening. And that depends again on the timing of when we see the patient.
So someone who’s got a pretty profound neurologic deficit early on we might operate on them earlier than someone who’s maybe got something more minor and then instability. So if we identify that there’s some type of actual structural instability there that obviously something that would be indicated for surgery and then there’s sometimes we see people that don’t actually have any symptoms and their exam might be fairly normal. Or maybe they have some mild hyperreflexia or something that we could probably watch but at times the risk of a neurologic impairment left untreated is too significant for us to just avoid doing anything. And so then we when then we recommend surgery so to be someone who comes in with very severe spinal stenosis cord compression and or if we see someone who’s got a lot of atrophy for instance in their in their limb from a ridiculous thing.
So the approach is for surgery would be essentially you know to categories a.. We’re going through the front, going through the back, into your up options. And this is probably in this day and age the vast majority, probably night more than ninety five percent of the surgeries are being done through the front of the neck. Historically for the advent of this entire approach, maybe 50, 60 years ago, the surgeries were done almost all through the back of the neck but that’s more rare now. And so you have fusions on the left you have a fusion where you basically go in there and you clean out the desk. You clean out the whatever is compressing the neural structures. You clean out the bone spurs and then you fix it in some way either with some type of an implant in the disk space some type of a cage or bone graph with a plate on the front or. Or a device like device like this which has the screws actually go right through the implant we call that a self-integrated implant and they both work very efficiently.
They both have very high fusion rates and they’re very good outcomes. And then on the right you see something that’s been developed more in the last decade 10 to 15 years. Which is just replacements and we’ll get into that a little bit more in just a moment.
So for the fusions we have you know there’s a very old operation has been done for decades. There are still some evolution going on in terms of the implants. But for by large it’s a mature operation. It does address the pathology directly which is why we would like to go through the front because usually whatever is compressing the nerve roots as it is impinging it from some interior entirely. It’s a highly successful operation. Outcomes are great at Fusion rates. The downsides are that we do develop adjacent level issues which as you fuse segments together most people ask well how much is my belt mobility going to be reduced. It’s actually very little. Most people won’t notice. But the other disk notice because now they’re actually becoming hyper mobile and they’re taking on more of the stress so they tend to wear out faster and regenerate faster and we have adjacent level problems and then people become repeat offenders come back for more surgery and then this loss emotion that we discussed.
So the benefits of total disk replacement. Which I think in most practices is not, there a lot of people that come to us asking for that, when in reality it’s a small percentage of people that it would be appropriate for. Maybe 10 or 15 percent of the people are actually candidates for total disk replacement. But when it’s when it is applicable it’s a very good option because it allows them to have the retain normal range of motion and reduces the adjacent level effect that we talked about.
They tend to recover in about half the time and get back to work quicker. I’m gonna skip through this a little bit the poster on the poster approaches and we talked about a really more for something that’s kind of far off laterally to the side where you where it’s not in from the spinal cord itself or someone who’s got a multi-level problem that’s really not really logistically feasible to do through the front because at so many levels. And then we’ll do like a multi-level operation through the back. So what are some of the acute post op issues that we see though that our rehab colleagues will sometimes be asked to help us address and that’s post-operative neck pain which many people have is more common through the posterior approach. A lot of people do have paraspinous tightness and trapezious spasm a lot of that’s due to the facet of opening of the facets that’s as we spread apart the vertebrae to work on them dysplasia, hoarseness is a weakness. Sometimes people are post-operative weakness which is temporary needs to be rehabbed and then some.
This is standard in my rehab protocol and this is somewhat variable. People do this different ways. But my you know I think I tell people it’s just normal neck movements there’s nothing you have to really do like people ask How can I sleep. Well whatever is comfortable just normal neck movements nothing extreme like you’re not going on roller coasters but you’re just kind of dealing with life sort of normally. I don’t brace people typically I don’t think there’s any need for that with the current implants that we have where they’re quite secure and they’re that’s internally very stable. I usually recommend some type of limited lifting particularly overhead and limited like light activity initially so what contact sports but they can do low impact low impact aerobics like a treadmill, Stairmaster, elliptical, swimming, things like that and then afterwards at some point in time that gets advance.
So for a total disk placement of two weeks I start advancing their activity. By six weeks they’re back to normal activity for us fusion we really have to have that period of time where we wanted to fuse so that could be two to three months depending on the patient where we have them restricted from you know more than those other activities that we talked about earlier or the lifting. And they usually start therapy at about two to four weeks depending on the patient. And this is really to address some of the post-operative neck pain range of motion and also strengthening. The only thing that would be different from the preoperative physical therapy would be that I don’t I don’t like them to distraction at least until we’re sure that they’re beyond that you know that period of time where the whatever implants we’ve put in there have healed.
And I think that’s it. Thank you for your attention.