CSM and CSR

Cervical Spndylosis

• A common age-related condition that affects the spinal disks and joints in the cervical spine.

• It is caused by normal wear-tear of aging.

• More than 85 percent of people older than age 60 are affected by cervical spondylosis.

When the process of cervical spondylosis progresses, it often leads to the following conditions.

• Cervical Spondylotic Myelopathy (CSM)

• Cervical Spondylotic Radiculopathy (CSR)

Thesis

This presentation will differentiate CSM and CSR by discussing the similarities and differences to gain a thorough knowledge of the pathologies.

General Causes

• Disk Degeneration

With aging, the disks begin to dry out, shrink and bulge out.

• Osteophytes formation

Osteophytes (bone spurs) are formed around the joints to support the vertebrae.

Causes for CSM

• The degenerative changes compress the the spinal cord.

• When the spinal canal gets narrower than 12mm, spinal cord dysfunction occurs. ( normal -> 17mm-18mm)

https://www.shibire2.com/english/spinal-diseases-and-treatments/cervical-spondylosis/

Causes for CSR

• The degenerative changes compress the nerve root at unconvertebral joint.

http://xn--thoihakhp-21a4rr746a.com/thoat-vi-dia-dem/thoat-vi-dia-dem-co/

• When the nerve roots are pinched and become swollen, they will not fit into narrowed exit holes, and radiculopathy symptoms occur.

Symptoms for CSM

• CSM develops slowly over years

• The symptoms do not occur until the spinal cord is compressed by at least 30 %

Most common symptoms symptoms

• Weakness or numbness of arms or legs
• Loss of fine motor skills
• Imbalance with walking
• Neck pain
• Nerve pain

Severe symptoms

• Incontinence (severe case)
• Paralysis (severe case)

Symptoms for CSR

• The symptoms differ depending on the location of the nerve being affected

• unilateral pain

https://www.netterimages.com/dermatomes-and-myotomes-of-upper-limb-labeled-jones-2e-neurology-neurosciences-frank-h-netter-63560.html

The most common symptoms

• Occipital headache
• Neck pain
• Shoulder/arm pain
• Numbness or weakness in hands and fingers

X ray

• The first step in imaging examination for CSM & CSR since it is relatively inexpensive and widely available.

Lateral

Normal

Kyphosis

Retrived from https://lifechiropracticcentre.ca/chiropractic-care/cervical-spine-images

Retrived from https://www.slideshare.net/NeurologyKota/cervical-spondylosis-58045562

X ray

Oblique

AP

Flexion and Extension

Retrived from https://reference.medscape.com/features/slideshow/c-spine

Retrived from https://clinicalgate.com/cervical-radiculopathy-anterior-surgical-approach/

Retrived from https://neckandback.com/ap__c5-6_ddd_1/

Narrowing of foramen

Instability

Narrowing of Joint and disk space

MRI

The gold standard for CSM and CSR to demonstrate

• Disk degeneration and herniation
• Foraminal stenosis with nerve root compression
• Central compression with CSF signal loss

CSM

CSR

Retrived from https://neckandback.com/ap__c5-6_ddd_1/

Retrived from https://www.aafp.org/afp/2016/0501/p746.html

Axial image

Sagittal image

CT

Performed for patients who cannot have MRI due to contraindications such as pacemakers, metal devices etc...

General findings are

• Osteophytes that are compressing neural elements
• The spinal cord is seen when given with contrast (CT myelography)

Retrived from http://www.drwolgin.com/laminoplasty/

CSM

Non-surgical treatment options for CSM

• Cervical immobilization (most common)
• Cervical traction
• Skull traction
• Physical therapy

• Mild CSM cases may be treated non-surgically.
• Surgical intervention is advisable once myelopathy occurs.

CSR

• The majority of patients (75%-90%) will improve with non-operative management.

Non-surgical treatment for CSR

• Cervical immobilization
• Physical therapy
• Medications
• Steroid injection

When patients have not responded to these treatments, a surgical treatment is considered.

CSM

Anterior approach

• Anterior Cervical Discectomy and Fusion (ACDF)

> A removal of a disk

• Anterior Cervical Corpectomy and Fusion (ACCF)

> A removal of both disks and vertebrae

ACCF

ACDF

Retrived from https://www.researchgate.net/figure/Postoperative-lateral-radiographs-of-four-surgical-techniques-a-Anterior-cervical-hybrid_fig1_260716801

Posterior approach

• Laminectomy

> A removal of a lamina

• Laminoplasty

> Cutting a part of lamina to give more space for the spinal cord

Laminectomy

Laminoplasty

Retrived from http://52.62.202.235/spine/cervical/cx-degeneration/cervical-myelopathy

Retrived from https://radiopaedia.org/cases/cervical-laminoplasty

CSR

Anterior approach

ACDF

Retrived from http://play2748.time-to-live19.loan/?utm_medium=NQ3aDvyuBCtafRQJPeFC66tm%2bMNW8T%2baflxP0d0AJGo%3d&t=main4

• Anterior Cervical Discectomy and Fusion (ACDF)

> A removal of a problematic disk

• Artificial Disk Replacement (ADR)

> Artificial disk is placed to preserve motion

ADR

Posterior approach

Retrived from https://www.spineuniverse.com/treatments/surgery/cervical/cervical-disc-replacement-considerations-surgery

• Posterior Cervical Laminoforaminotomy

> A removal of a part of a lamina to enlarge the space of foramen.

Laminoforaminotomy

Retrived from https://www.spine-health.com/video/cervical-posterior-foraminotomy-video

Summary

Similarities

• MRI is the gold standard to diagnose CSM and CSR
• ACDF is the common surgical procedure to treat CSM and CSR

Differences

• CSM affects the spinal cord.

-difficulty walking, clumsiness in hands, and incontinence.

• CSR affects the nerve root.

- unilateral pain in upper limbs

• Most CSM cases need a surgery
• Most CSR cases are manageable with non-operative treatments.

References

1. Cervical spondylosis. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/cervical-spondylosis/symptoms-causes/syc-20370787. Published November 18, 2015. Accessed January 27, 2018.

2. Our knowledge of orthopaedics. Your best health. Cervical Spondylotic Myelopathy (CSM) - Spinal Cord Compression - OrthoInfo - AAOS. https://orthoinfo.aaos.org/en/diseases--conditions/cervical-spondylotic-myelopathy-spinal-cord-compression/. Accessed January 31, 2018.

3. de C, Orsini M, Leite MA, et al. Cervical Spondylotic Myelopathy: What the Neurologist Should Know. Neurology international. https://www.ncbi.nlm.nih.gov/pubmed/27994827. Published November 23, 2016. Accessed January 31, 2018.

4. Cervical Radiculopathy Spine Specialist Vail, Aspen, Denver CO. Donald Corenman MD DC Spine Surgeon Colorado Vail, Denver, Aspen. https://neckandback.com/conditions/radiculopathy-pinched-nerve-in-neck/. Published July 27, 2017. Accessed January 31, 2018.

5. Tidy DC. Cervical Spondylosis. What is cervical spondylosis and symptoms Health. Cervical Spondylosis . https://patient.info/health/neck-pain/cervical-spondylosis. Published June 2016. Accessed February 22, 2018.

6. Young WF. Cervical Spondylotic Myelopathy: A Common Cause of Spinal Cord Dysfunction in Older Persons. American Family Physician. https://www.aafp.org/afp/2000/0901/p1064.html. Published September 1, 2000. Accessed February 3, 2018.

7. MS BBMD. Symptoms of Cervical Stenosis with Myelopathy. Spine-health. https://www.spine-health.com/conditions/spinal-stenosis/symptoms-cervical-stenosis-myelopathy. Accessed January 31, 2018.

8. Moore D. Cervical Radiculopathy. Cervical Radiculopathy - Spine - Orthobullets. https://www.orthobullets.com/spine/2030/cervical-radiculopathy. Accessed February 22, 2018.

9. Cervical Radiculopathy Spine Specialist Vail, Aspen, Denver CO. Donald Corenman MD DC Spine Surgeon Colorado Vail, Denver, Aspen. https://neckandback.com/conditions/radiculopathy-pinched-nerve-in-neck/. Published July 27, 2017. Accessed January 31, 2018

10. Caridi JM, Pumberger M, Hughes AP. Cervical Radiculopathy: A Review. HSS Journal. 2011;7(3):265-272. doi:10.1007/s11420-011-9218-z.

11. MRI of the Adult Spine . ACR Practice Parameter for Communication of Diagnostic Imaging Findings. https://www.acr.org/-/media/ACR/Files/Practice-Parameters/mr-adult-spine.pdf. Published 2012.

12. Bartleson JD, Toledano M. Cervical Spondylotic Myelopathy. Neurologic Clinics. 2013;31(1):287-305.

13. Hwang MWW. Our knowledge of orthopaedics. Your best health. Cervical Radiculopathy: Surgical Treatment Options - OrthoInfo - AAOS. https://orthoinfo.aaos.org/en/treatment/cervical-radiculopathy-surgical-treatment-options/. Published June 2015. Accessed February 22, 2018.