Cervical Stenosis: Radiculopathy –
24
Review of Concepts, Surgical
Techniques, and Outcomes
Zachary A. Smith, Sean Armin, and Larry T. Khoo
k e y p o i n t s REGIONAL ANATOMY OF THE CERVICAL SPINE
ll The clinical presentation of spondylosis can range from no symptoms to
radiculopathy or severe myelopathy.
ll Diagnostic imaging modalities include plain radiography and magnetic
resonance imaging (MRI). Computed tomography with intrathecal contrast
may play a role in evaluating certain disease processes poorly imaged by MRI.
ll The role of neurophysiologic testing with motor and somatosensory evoked
potentials is not clearly defined, but may prove beneficial in measuring
subclinical disease and predicting outcome following surgery.
ll Conservative medical management is indicated for patients with minimal
symptoms, with surgical intervention reserved for patients with significant
disability and/or a progressive clinical course.
ll Surgical techniques include anterior and posterior decompression, which
have demonstrated greater than 85% efficacy in the treatment of neurological
symptoms. The addition of arthrodesis and instrumentation may yield better
neck pain scores and radiographic lordosis at while increasing cost, morbidity,
and adjacent segment degeneration (ASD).
ll Preliminary data on cervical artificial disc replacement demonstrate equal
efficacy to classic anterior cervical discectomy and fusion in relieving
symptoms with trends toward improved recovery and decreased soft-tissue
complications. As yet, the long-term ability of these prosthetic devices to
decrease the incidence of ASD remains undefined.
INTRODUCTION
Cervical spondylosis is a progressive degenerative process resulting in patho-
logic changes in the intervertebral discs and surrounding structures1. Such
changes include intervertebral disc protrusion, osteophyte formation, and
hypertrophy of the lamina, ligaments, and hypophyseal joints.2,3 Clinical
onset can begin as early as the third decade, with progression continuing
into the eighth decade.1 Radiographic signs of spondylosis are evident in
50% of the population by the fifth decade, while prevalence is estimated at
98% for people over 70.4 Secondary myelopathy is considered to be the most
common cause of spinal cord dysfunction in patients over 55.5
The effects of spondylosis can range from subclinical symptoms to pri-
mary root impingement (radiculopathy) and myelopathy. Proper diagnosis
depends on meticulous history-taking, thorough physical examination, and
the use of appropriate imaging, neurophysiologic, and laboratory tests. The
natural history of cervical spondylosis is not well understood6, and treatment
of spondylosis includes both conservative medical management and surgi-
cal intervention. A variety of surgical procedures have been well described
including anterior and posterior approaches with or without fusion. This
chapter reviews the relevant anatomy, pathophysiology, symptomatology,
diagnosis, natural history, and management of cervical spondylosis.
Normal anatomy of the cervical spine consists of vertebrae, intervertebral
discs, ligaments and joints, neural elements, and surrounding soft tissue and
vascular structures.
Osseous Components
The bony cervical spine is composed of seven vertebrae (Figure 24-1A-
C). The lower five segments (C3-C7) are similar in morphology, while the
first two segments (C1 and C2) are anatomically distinct. The first cervical
segment, the atlas (C1), is ring-shaped and articulates primarily with the
occipital condyles above and the superior facets of the second cervical seg-
ment below. The second cervical segment, the axis (C2), has a cone-shaped
projection (the odontoid process) that articulates with the anterior arch of
C1. The remaining cervical vertebrae (C3-C7) share similar architecture;
the vertebral bodies are roughly cylindrical in shape and increase in size
from rostral to caudal. From each body projects an uncinate process superi-
orly, which indents the posterolateral margins of its respective intervertebral
disc. The transverse processes project anterolaterally and house the foramen
through which the vertebral arteries pass. The spinal cord runs through the
spinal canal, which is formed by the posterior elements including the pedi-
cles, the facet joints, the lamina, and the spinous process. At each level, nerve
roots exit the canal between vertically adjacent pedicles (Figure 24-1C,D)
The unique morphology of C1 and C2, as well as the increasing verte-
bral body size of the lower segments, may contribute to the pathogenesis of
spondylosis. The anteroposterior diameter of the canal is generally larger at
C1 and C2 when compared to the lower vertebrae; thus the spinal cord is
estimated to occupy only one third of the atlantal ring at C1, while it occu-
pies up to three fourths of the canal in the lower segments. This variability
may account for the predisposition for spinal stenosis with symptomatology
at the C4-C7 levels.7
Intervertebral Discs
The vertebrae are linked together by intervertebral discs, which provide a
stable yet flexible architecture. The discs normally account for 22% of the
height of the spinal column and function to spread axial loading forces. Each
disc is composed of four elements: the nucleus pulposus, the anulus fibrosus,
and the two cartilaginous endplates. The nucleus pulposus accounts for 40%
of the cross-sectional area of the intervertebral disc and is located toward
the posterior aspect of the disc. It consists of primarily of Type II collagen
fibers and mucopolysaccharide ground substance. The anulus fibrosus is
made of fibrocartilage that surrounds the nucleus pulposus in a concentric
lamellar fashion. It is attached directly to the vertebral bodies via Sharpey
fibers, which project from the outer lamella to the epiphyses. The anulus
also attaches to the anterior and posterior longitudinal ligaments, but the
posterior attachment weakens with age, which may lead to a predisposition
133