Dr. Ng Wing Kit Specialist in Neurosurgery

Dr. Ng Wing Kit 

Specialist in Neurosurgery

How common is it?

Neck pain 

• Incidence 14‐17% 

• 23 cases per 1000 

• More common in females 

• Resolution less common with advancing age.

Cervical radiculopathy 

• Much less common than neck pain 

• Incidence 3.3 cases per 1000 

• Commoner in females 

• 4 th and 5 th decades

Cervical myelopathy 

• Less well defined 

• Common cause of spinal cord dysfunction in elderly 

• Ossification of posterior longitudinal ligament (OPLL) 

high prevalence in Japanese

Anatomy 

Biomehanics

Cervical spine anatomy 

• 7 Segments 

• Superior 2 segments being 

specialised structures: 

atlas (C1) and axis(C2) 

• Spondylosis more 

common in subaxial 

cervical spine (C3‐C7)

C1/2 complex

Cervical spine anatomy

Intervertebral disc

Pathophysiology

Disc change with age 

•Chondrocyte proliferation 

•Mucous degeneration 

•Cell death 

•Tear and cleft formation 

•Granular changes

Disc degeneration 

• Nutritional factors 

• Genetic factors 

• Mechanical factors

Disc degeneration results in microinstability 

•Disc bulging and hyperostosis 

reaction leading to osteophyte 

formaiton 

•Ligamentous hypertrophy

Micro‐instability causes facet 

hypertrophy



Cervical myelopathy

Neck pain‐possible pain generators 

• Muscular and ligamentous origin 

• Intervertebral disc 

• Facet joint degeneration 

• Non‐specific

Spondylotic syndrome 

• Recurrent neck pain 

• Aggravate with motion 

• Position dependent 

• Arm and shoulder pain (non‐radicular)

Spondylotic syndrome 

• Night and early morning pain 

• Vertigo and dizziness 

• Vegetative symptoms 

• headaches

Ergonomics


• Disc herniations 

• Spondylolytic change

Disc herniations

Spondylotic radiculopathy


• Radicular pain 

• Sensory disturbances 

• Motor weakness 

• Reflex deficits

Examination findings 

• Sensory deficit 

• Motor deficit 

• Reflex deficit

Special tests 

• Spurling test 

• Shoulder abduction or depression test 

• Axial traction test

Spurling test

How good are these tests?

Myelopathic syndrome 

• Numb, painful, clumsy hands 

• Fine movement 

• Balance and gait 

• Very often together with spondylotic syndrome

Examination findings 

• Atrophy of small muscles 

• Gait disturbances and ataxia 

• Spasticity, hyperreflexia, and clonus 

• Sensory and vibratory deficits 

• Muscle weakness 

• Lhermitte sign


Radiculopathy 

Myelopathy


• Most cases of acute neck pain resolve within a few days 

• For patients with neck pain at baseline: 

• Persistent and recurrent neck is however not 

uncommon 

• 10% will have aggravation 

• Lack of radiological correlation


• Disc herniation decrease in size with time in 1/3 of 

patients, particularly in disc migration 

• 90% of patients become asymptomatic or mildly 

incapaciated


• Once diagnosed almost never recovered to normal 

(Clark and Robinson) 

• 75% episodic worsening with stability in between 

• 25% slow steady progression 

• 5% rapid progression


• Patient with symptoms of more than 2 years showed 

no improvement 

• In OPLL, minor trauma can cause acute deterioration 

• For individual patient, clinical course is variable


Radiculopathy 

myelopathy


• Non operative treatment is the mainstay of therapy 

• Pathomorphological correlate is unreliable


• Physical therapy 

• Oral medications: NSAIDs, muscle relaxant, analgesics 

• Spinal injections 

• RF ablations for facet joint pain


• In absence of motor deficit, non‐surgical management 

should be tried first 

• Traction 

• Transforaminal epidural injection 

• Safety concern


• Unlikely to cause improvement


Radiculopathy 

Myelopathy


• Surgery for neck pain alone is rarely indicated 

• Need throughout investigation to identify source of 

pain 

• C1/2 lesions

Cervical radiculopathy‐indications 

for surgery 

• Progressive, and functional motor deficit 

• Definitive evidence of nerve root compression 

• Concordant symptoms and signs 

• Persistent symptoms despite non‐surgical treatment

Cervical myelopathy‐indications for 

surgery 

• Progressive myelopathy 

• Acute deterioration with progression of deficit 

• Definitive cord compression with myelopathic 

symptoms 

• Progressive deformity with deficits

Anterior spinal fusion (ASF) 

Laminectomy 

Laminectomy with instrumentaiton and fusion 

Laminoplasty 

Posterior foraminotomy 

Cervical total disc arthroplasty

Surgical considerations 

• Anterior or posterior? 

• Fusion or non fusion? 

• Instrumentation ?

Anterior spinal fusion 

• Robinson‐Smith 

• Cloward procedure 

• Gold standard in treatment of Cervical disc disease 

• High fusion rate for 1 level, decreases as no. of level 

goes up

Anterior diskectomy

Fusion choices 

• Tricortical bone graft 

• Cage: Titanium, PEEK 

• +/‐ plating

Laminectomy and fusion 

Rigid fixtion to prevent 

deformity

Laminoplasty 

•Motion preserving 

•Less kyphotic deformity

Posterior Foraminotomy

Posterior foraminotomy

Cervical artificial disc replacement 

• ASF gold standard for Cervical disc pathology 

• Concerns about adjacent segment degeneration 

• Radiologically segments adjacent to fused level are 

more likely to degenerate

Cervical artifical disc replacement 

• Try to address the problem of motion preservation 

• Prevent adjacent segment degeneration 

• Sofar outcome of TDR are not inferior to ASF

Case illustration 

• YWT 

• 40/F 

• Dizziness and left C6 radiculopathy 

• Clinically no muscle wasting 

• Spurling +ve

MRI

Cervical total disc arthroplasty

Postoperative 

• Improved left sided numbness 

• Dizzness persists! 

• Repeated Xray FU motion preserved

Conclusions 

• Cervical spondylosis is common 

• Mainstay of treatment for neck pain alone is nonsurgical 

• Surgery has significant role in treatment of cervical 

radiculopathy and in particular myelopathy

Dr. Ng Wing Kit Specialist in Neurosurgery

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