Ryba L., Chaloupka R. Department of Orthopaedic Surgery University Hospital Brno Faculty of Medicine, MU Brno Head: prof. MUDr. Martin Repko Ph.D. Degeneration ̶ physiological ̶ Begins mostly from 30 yrs ̶ Could be without difficulties ̶ Most frequently C5-6 + adjacent segments X-ray degenerative changes in 90% of males older than 50 yrs + 90% of females older than 60 yrs (Schmorl + Junghann) – only minority of them with compression of neural structures Degeneration of motion segment ̶ Osteochondrosis – involvement of intervertebral disc protrusion, hernia ̶ Spondylosis – involvement of vertebral end plates – anterior, posterior, lateral osteophytes ̶ Spondylartrosis – involvement of intervertebral joints – lateral stenosis ̶ Uncoartrosa – involvement of proc. uncinatus – foraminal stenosis Examination ̶ Anamnesis ̶ Clinical ̶ Radiological ̶ Neurological - EMG, mJOA score, Nurick scale Clinical manifestation ̶ Pain syndrome without neural deficit ̶ radiculopathy – nerve compression ̶ myelopathy – spinal cord compression (clumsy hands, gait and sensory, sfincter disorders) Radiological examination ̶ X-ray, including flexion / extension (functional) ̶ MRI ̶ (CT, myelo CT, KPMG, ….) X-ray diagnostics 14 yrs 30 yrs 58 yrs X-ray - FUNCTIONAL Cobb angle -29° +14,7° SVA C2-7 29,6mm -7,4mm Sagittal vertical axis Plumb line from C2, C7 Therapy ̶ Conservative – remedies, orthoses, physiotherapy, régime measures ̶ Surgical Surgery indications ̶ Spinal instability ̶ Compression of neural structures ̶ pain? (relative) ̶ Other Principles of tx ̶ Non fusion systems ̶ Anterior fusion systems ̶ Posterior decompression + fusion techniques Surgical approaches 1.Anterior -transoral -transmandibular -anterolateral -pre SCM -retro SCM (sternocleidomastoid m.) 2.Posterior Anterior surgeries Removal of spondylophytes Swallowing act Anterior surgery – non fusion ̶ Non fusion technologies – artificial disc – total disc endoprosthesis ̶ Indication: soft hernia without skeletal degenerative changes Anterior surgeries – fusion techniques ̶ Disectomy – replacement by cage or graft ̶ Somatectomy 1- several vertebral bodies – replacement by graft, bone cement, cage ̶ Fit / recommend to add anterior plate pelvic autograft Polyetheretherketon (PEEK)- polymer Titanium implants - cages Trabecular metal Cervical plates Cervical plates - dynamic cages Posterior approaches - principles ̶ Foraminotomy ̶ Laminoplasty ̶ Laminectomy ̶ Stabilisation Posterior approaches ̶ Enlargement of spinal canal - decompression ̶ Laminectomy + stabilisation ̶ Laminoplasty in most cases without stabilisation Laminoplasty ̶ Indication – multilevel, posterior event. combined stenosis, preserved cervical lordosis Laminoplasty indication ̶ CSM – cervical spondylogenic myelopathy ̶ OPPL – ossification of posterior longitudinal ligament Laminoplasty Types – open door x french door Hirabayshi x Kurokawa Hirabayshi Kurokawa Laminoplasties with plates Open door laminoplasty Principles of stabilisation ̶ Occpitocervical fusion ̶ Sublaminar fixation by loop + graft + event. plate ̶ Transarticular fixation C1/2 ̶ Fixation by screws and plate / rod Occipitocervical fusion Combined surgeries Huspeninová – k operaci C páteře Complications ̶ Early - late ̶ Worsening of neural finding - hematoma, oedema with myelopathy, prominence of soft and bone structures, prominence of implants ̶ MRI - CT Complication – worsening of neural deficit Late complication - adjacent segment disease Conclusion ̶ Anamnesis, Clinical, Neurological examination ̶ X-ray of the whole C spine ̶ Functional X-ray ̶ MRI ̶ CT ̶ Recommendation