Surgical and Post‐Operative Management of Cervical Spine Stenosis

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Original Editors

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Search Strategy

Databases: CINAHL Plus with Full Text, Medline with Full Text, Sports Discus with Full Text, Healthsource_Consumer Addition

Keywords: Cervical, Spinal Stenosis, Surgery, Myelopathy, Rehabilitation, Post-surgical, Radiculopathy, Lumbar

Timeline: 4/4/11- 4/28/11

Definition/Description

Cervical spinal stenosis: Narrowing of the spinal canal in the neck. This can lead to squeezing or compressing of the nerve roots where they leave the spinal cord or it can damage the spinal cord itself. These conditions are referred to as radiculopathy and cervical spinal myelopathy respectively.

Epidemiology/Etiology

Spinal stenosis occurs most commonly in either the lumbar or cervical regions of the spine. Abnormalities that can lead to stenosis are twice as likely to be seen on an MRI in patients over the age of 40; however, even when such abnormalities exist stenosis may present without any signs or symptoms. In fact research has shown that degenerative changes that manifest in images or scans of the cervical region do not correlate to neck pain.

There are two main types of spinal stenosis:

• Primary: congenitally smaller than normal canal. Not very common, but usually leads to spinal stenosis in the middle of life.
• Acquired: result of disease or injury to the spine such as the causes listed below.

Common causes are:

• Age related changes, which include: chronic degeneration, excessive growth of the bones such as osteophytes, destruction of the cartilage, and bulging of the disc.
• Osteoarthritis
• Thickening of ligaments that connect the bones.
• Congenital factors such as Craniodisphyseal Dysplasia, Achondroplasia, and Paget’s disease of the bone.
• Spinal Tumors
• Spinal injuries causing dislocations or fractures.
  

Examination/Diagnosis

A complete exam including medical history and a neurological screen is essential to determine whether neurological findings exist (either myelopathy or radiculopathy) and whether surgery or other conservative intervention is indicated.  Spinal stenosis can only be diagnosed with imaging, and MRI is the preferred imaging technique.

Primary Complication

Cervical myelopathy is the most common problem that occurs as a result of spinal stenosis. The neurological symptoms associated with this pathology are usually the primary impetus for patients to seek care.

Treatment Options

Cervical lesions narrowing the spinal canal and affecting the spinal cord do not necessarily call for surgical treatment. In fact, 26% of asymptomatic older patients have cervical lesions affecting the spinal cord detectable by MRI. If cervical spinal myelopathy (CSM) or radiculopathy do exist, treatment options are either a conservative approach or surgery.

Conservative Approach

Conservative treatment options for CSM include: immobilization with a cervical collar, NSAIDS and/or muscle relaxants, traction, cervicothoracic stabilization (strengthening of nuchal, upper quadrant, and scapula musculature), and avoidance of activities that cause stress to the cervical spine. There are many surgery options to consider based on patient presentation and severity.

Surgical Approach

Surgery may prevent the progression of myelopathy and improve the neurological deficits. However, not enough prospective randomized trials have been done to demonstrate an absolute advantage or disadvantage of surgery. To date, only poor quality evidence has been produced supporting the effectiveness of a surgical approach to relieve specific nerve impingement.  The goal of surgery is to decompress the spinal cord by removing any space occupying lesions, such as osteophytes or disk protrusions, and neutralize any instability.

Anterior Approach

By clearing out the disk via an anterolateral access, surgeons reach the spinal canal or lateral to the neuroforamina through the intervertebral disk space. Once this is done, surgeons can resect vertebral disk protrusions and remove spondylophytes. The procedure decompresses the previously compressed spinal cord. This approach can also include fusion of vertebrae.

• Indications: generally recommended for anterior space-occupying osteophyte or disk tissue lesions, or if the pathology is mono- or bi-segmental. 
• Types:

1. Intercorporal spondylodesis procedure: surgeons fuse successive vertebral segments of the c-spine with short bone grafts.
2. Corporectomy: the middle section of the vertebral body is removed in addition to adjoining vertebral disks and then replaced by implantation of either a bone graft or a cage.
3. Monosegmental pathology: surgeons may insert an intervertebral disk prosthesis in order to maintain patients’ mobility and avoid future problems with adjacent segment instability. Advantages of this procedure have yet to be proven. 

• Advantages/Disadvantages: The advantage of the anterior approach is that it can be effective for correcting kyphosis. The disadvantages are that long stretches of ventral osteophytes may have to be removed, risking damage to the spinal cord, and that the risk of fusion failure increases with number of segments treated.

NeckandBack.com Text, Video and Graphic Content to Donald Corenman, MD - Spine Surgeon Colorado (http://www.youtube.com/watch?v=yfSkOF_DAfA&feature=player_embedded)

Posterior Approach

• Indications: The goal is to indirectly decompress the spinal cord. Hypertrophic facets, thickened ligamentum flava, or even anterior space occupying lesions can be removed. Additionally, any instability can be stabilized with hardware or osteosynthesis.
• Types:

1. Laminectomy: originally the gold standard treatment of multilevel cervical myelopathy, laminectomy alone has fallen out of favor due to documented post-surgery complications.
2. Laminectomy with fusion: With the addition of posterior fusion, this procedure reduces kyphosis and segmental instability caused by removing posterior elements during laminectomy; however, it also leads to altered cervical biomechanics that cause degeneration of adjacent segments.
3. Laminoplasty: This technique aims to preserve motion but with less alteration to the natural biomechanics of the c-spine. The spinal canal is widened by creating “gutters” in the laminae, and then pushing the spinous processes and more involved laminae toward the opposite side. Titanium miniplates are screwed in place to keep this widening open.

• Advantages/Disadvantages: Originally, laminectomy was highly regarded because of its extensive decompression of the spinal cord, but without fusion, it can result in postoperative kyphotic malposition due to lack of stability in the area. Laminoplasty has the advantages of decreased blood loss, bone loss, less operative time and decreased risk of dura and spinal cord injury, but it is contraindicated for patients with kyphosis and is associated with post-op mechanical neck pain.

Posterior Approach Video

Combined Procedures

Combination of anterior fusion with posterior approach -- the fusion rates are high for this procedure, but the surgery has a high rate of morbidity since it is a more extensive surgery.

Possible Surgical Complications

• Muscle weakness
• Neck pain and stiffness
• Deep infection
• Psuedomeningocele
• Closure of opened laminae
• Neurological deterioration
• Death

Physical Therapy Management (current best evidence)

The type of physical therapy intervention for post-operative patient of the cervical spine depends on the type of surgical approach. Therapists should take into consideration:

• Anterior vs. Posterior approach
• Wound healing
• Signs of infection
• Physical and Psychological condition of the patient
• Patient motivation
• Specific goals

Post-surgical lumbar and thoracic spine interventions may be applicable to the cervical spine, but more research is needed to validate the effectiveness of these interventions.

Lumbar and Thoracic Interventions

There is insufficient research on specific structured exercise programs that are effective treatments after surgery of the cervical spine. Research that showed the effectiveness for post-surgical intervention of the lumbar and thoracic spine involved the following interventions:

• Obtaining normal range of motion (ROM) in the movements affected by each type of surgery
• Spine mobilization
• Flexibility in posterior paraspinals, upper traps, levator scapula, and scalenes
• Strength of upper quarter muscles and mid back
• Stabilization of deep neck flexors
• Posture and body mechanics
• Abdominal strengthening
• Aerobic/Cardiovascular conditioning
• Patient education
• Neural mobilization and stretches

Proposed Cervical Interventions

• ROM (as per specific protocols in regards to limitations) progressive to tolerance
• Stabilization with neuromuscular re-education for deep neck flexors
• Flexibility: posterior paraspinals, upper traps, levator scapula, scalenes
• Strengthening of upper quarter muscles
• Mobility–manual therapy to cervico-thoracic joints (where appropriate)
• Aerobic conditioning program
• Cognitive behavioral therapy
• Patient education
• Activity modification
• Postural awareness
• Body mechanics for work or ADLs
• HEP
  

Recommended Intervention Timeline

4 weeks:

• Posture education
• Cervical stabilization in supine
• UE AROM as tolerated
• Cervical AROM as tolerated in pain-free ROM
• Gentle 2-finger isometrics
• Scapular retraction, shrugs, chin tucks

4-12 weeks:

• UE theraband strengthening
• Scapular retraction strengthening
• Light weight UE strengthening
• CV exercise
• Ergonomics education
• TENS and ice for pain

12-24 weeks:

• UE and LE weight training
• Theraband PNF
• Push-up progression
• Sit-up progression
• Work hardening

24+ weeks:

• Functional training
• Progressive weight training
• High impact aerobic activity
• May begin contact sports

Clinical Bottom Line

Although research exists regarding the different surgical approaches for cervical spinal stenosis, there is a lack of agreement about the optimal approach; even more lacking is high quality evidence supporting specific post-surgical physical therapy interventions.

Recent Related Research (from Pubmed)

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