Surgical and Post‐Operative Management of Cervical Spine Stenosis

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Search Strategy[edit | edit source]

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Definition/Description[edit | edit source]

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.[1] These conditions are referred to as radiculopathy and cervical spinal myelopathy respectively.

Epidemiology/Etiology[edit | edit source]

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[2]; however, stenosis may present without any signs or symptoms. In fact, degenerative changes that manifest in images or scans of the cervical region have been found to not correlate to neck pain.[3]

There are two main types of spinal stenosis[4]:

  • Primary: born with a canal that is narrower than most people. Not very common, but usually leads to spinal stenosis in the middle of life.
  • Acquired: usually result of disease or injury to the spine such as the causes listed.

Common causes are[1][2]:

  • 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 Dysplasia3, Achondroplasia, and Paget’s disease of the bone.
  • Spinal Tumors
  • Spinal injuries causing dislocations or fractures.

Examination/Diagnosis[edit | edit source]

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.[2] Diagnosis of spinal stenosis can only be done with imaging and MRI is the method of choice for diagnosis of spinal stenosis and any possible spinal cord damage.[2]

Primary Complication[edit | edit source]

Cervical myelopathy is the most common problem that occurs as a result of spinal stenosis.[5] The highest frequency of cervical myelopathy occurs in patients between ages 50 and 60.[5] Signs and symptoms vary but it is usually a slow deterioration process of symptoms and there may be years between onset and first treatment.[2] Neurological symptoms are usually the primary problem that cause patients to seek care. Typical early symptoms are abnormal sensation or motor function of the hand or abnormal gait, especially in the dark.[2] These symptoms are often ignored or unnoticed since they are common comorbidities of aging. Progression leads to complete loss of hand grasp.[2] Additional symptoms can be numbness and weakness in other parts of the body including arm, leg, or foot.[1] Neck and shoulder pain can occur, but is not common.[1] Also, bowel or bladder problems can occur in severe cases.

Treatment Options[edit | edit source]

Cervical lesions narrowing the spinal canal and affecting the spinal cord do not necessarily call for surgical treatment. 26% of asymptomatic older patients have cervical lesions affecting the spinal cord detectable by MRI.[6] If cervical spinal myelopathy (CSM) or radiculopathy do exist, treatment options are either a conservative approach or surgery.

Conservative Approach[edit | edit source]

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.[2] There are many surgery options to consider based on patient presentation and severity.

Surgical Approach[edit | edit source]

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.[2] To date, only poor quality evidence has been produced supporting the effectiveness of a surgical approach to relieve specific nerve impingement.[7]
The goal of surgery is to decompress the spinal cord and neutralize any instability. Any space occupying lesions, such as osteophytes or disk protrusions are removed.

Anterior Approach[edit | edit source]

  • Indications: generally recommended for anterior space-occupying osteophyte or disk tissue lesions, or if the pathology is mono- or bi-segmental.
  • Surgeons can resection vertebral disk protrusions and remove spondylophytes. By clearing out the disk via an anterolateral access, surgeons reach the spinal canal or lateral to the neuroforamina through the intervertebral disk space.
  • 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.[2] The disadvantages are that long streteches 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.

Posterior Approach[edit | edit source]

  • 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 osteosynthesis2.
  • Types:
  1. Laminectomy: originally the gold standard treatment of multilevel cervical myelopathy, laminectomy alone has fallen out of favor due to documented post-surgery complications7

Physical Therapy Management (current best evidence)[edit | edit source]

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References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 Mayo Clinic Staff. Spinal Stenosis. http://www.mayoclinic.com/health/spinal-stenosis/DS00515/DSECTION=causes. Updated July 8, 2010. Accessed April 12, 2011.
  2. ↑ 2.0 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 Meyer F, Borm W, Thome C. Degenerative cervical spinal stenosis: current strategies in diagnosis and treatment. Deutsches Ärzteblatt International [serial online]. May 16, 2008;105(20):366-372. Available from: CINAHL Plus with Full Text, Ipswich, MA. Accessed April 11, 2011.
  3. ↑ Guzman J, Haldeman S, Carroll L, Carragee E, Hurwitz E, Peloso P, Nordin M, Cassidy JD, Holm L, Cote P, van der Velde G, Hogg-Johnson S. Clinical practice implications of the bone and joint decade 2000-1=2010 task force on neck pain and its associated disorders. J of Manip and Physio Therap. 32:2S 227-243
  4. ↑ Ullrich PF. Cervical Stenosis with myelopathy. http://www.spine-health.com/conditions/spinal-stenosis/cervical-stenosis-myelopathy. Accessed April 12, 2011.
  5. ↑ 5.0 5.1 Naique S, Laheri V. Stenosis of the cervical canal in craniodiaphyseal dysplasia. The Journal Of Bone And Joint Surgery. British Volume [serial online]. April 2001;83(3):328-331. Available from: MEDLINE with Full Text, Ipswich, MA. Accessed April 5, 2011.
  6. ↑ Kadanka Z, Mares M, Bednarik J, Smrcka V, Krbec M, Chaloupka, Dusek L. Predictive factors for mild forms of spondylotic cervical myelopathy treated conservatively or surgically. European Journal of Neurology. 2005;12:16-24.
  7. ↑ Carragee EJ, Hurwitz EL, Cheng I, Carroll LJ, Nordin M, Guzman J, Pelos P, Holm L, COte P, Hogg-Johnson S, van der Velde G., Cassidy JD, Haldeman S. Injections and surgical interventions: results of the bone and joint decade 2000-2010 task force on neck pain and its associated disorders. J of Manip and Phys Therap 32: 2S

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