SPINAL DISORDERS

Disc Disease and Degenerative Disease of the Spine

Epidemiology of low back and log pain: Low back pain with or without radicular
leg pain affects up to 85% of individuals at some point in their lives. In a given year it has
been estimated that between 10%-15% of the population have back and/or leg pain.
Sciatica is thought to affect about 2% of the population and about 12% of people with back
pain. Age is an important factor in determining the likelihood of back symptoms with peak
incidence in the 35- 55 age range. There is no difference in the incidence of back
symptoms between men and women. However there are significant differences in the
incidence of back symptoms according to race (white> black > other), education
(elementary or none > high school > college) and region of the country (West >South and
Midwest > Northeast).
In the United States, back pain is the leading cause of activity limitation for people
younger than 45 years. It is the second most common cause of physician visits, the fifth
most common reason for hospitalization and the third ranked reason for a surgical
procedure. One percent of the U.S. population is permanently disabled with back pain
and at any given time another 1% is temporarily disabled. Each year there are an estimated
400,000+ compensable back "injuries" in the U.S.
A number of occupational risk factors have been studied. The relationship between
occupation and back symptoms is complex and affected by a variety of confounding
factors, e.g. reporting bias influenced by the insurance and Worker's Compensation
systems. Several studies have shown an increased risk of low back pain and disc
prolapse (HNP) for occupations associated with heavy physical work. Exposure to
vibration may increase the frequency of low back pain as seen in truck drivers, machinery
operators and individuals who drive automobiles extensively. Psychological work factors
are also known to affect the frequency of back symptoms. Monotony, work dissatisfaction, and
poor relationships with coworkers are all associated with higher rates of back pain and work
incapacity.
Individual risk factors have also been carefully studied. The effect of age has
already been mentioned. Although gender. differences are not observed in the frequency
of low back symptoms, males undergo surgery for disc herniation about 1.5-3 times as
often as females. Spinal deformity, such as scoliosis and kyphosis, and leg length
differences do not have a predictable predisposition to low back pain. There is also no
strong association between body habitus and low back pain or sciatica. Some studies
have demonstrated an association between tallness and low back symptoms. Surprisingly
a similar finding for obesity has not been uniformly observed. An association between
smoking and HNP and low back pain has been noted by several investigators. Numerous
other individual risk factors have been examined although clear-cut relationships have not
been forthcoming.

Spinal Disorders

Cervical and Thoracic Disorders: Most large epidemiological surveys lump

cervical and thoracic pain with lumbosacraI symptoms, making it difficult to ascertain the
relative incidence of these complaints. In one study, neck problems accounted for 7% of
work absences related to "back" pain; thoracic problems accounted for only 0.2%.
There may be a slightly greater frequency of cervical disc herniation observed in men as
compared to women. The C5-6 and C6-7 discs are the most commonly affected.
Increased risk for neck pain has been found to be associated with frequent lifting, cigarette
smoking and frequent diving from a board, Driving, operating vibrating machinery,
frequent head turning and several other plausible risk factors have not proven to be
statistically significant.
Thoracic spine pain is less common than pain localized to the cervical or lumbar
regions. Symptomatic thoracic disc herniation is every more infrequent. Because
complaints referable to Lite thoracic region are relatively uncommon especially in the
context of 'back strain' or 'lumbago', and because certain disorders, such as metastatic
tumors, may have a predilection for this region, the clinician should he suspicious of nondegenerative causes in looking for the etiology of thoracic pain (see section on spinal
tumors).
Historical background: Although the treatment of spinal disorders was discussed in the Edwin
Smith papyrus and the writings of Hippocrates, surgery for these ailments was not generally
undertaken until the latter part of the nineteenth century. The first successful laminectomy was
probably performed by Paul of Aegina in the 7th century A.D., but this feat was not repeated
until 1829 by Alban Smith of Danville, Kentucky. Elective spinal surgery required the
development of anesthesia, aseptic techniques, improved instruments and, with the discovery of
X-rays in 1895, improved diagnostic methods.
Walter Dandy developed air myelography in 1918 at the Johns Hopkins Hospital.
The difficulties in properly performing this procedure limited its widespread use in the
spine, although pneumoencephalography became an important procedure for intracranial
imaging. Sicard introduced iodinated contrast myelography in 1920, allowing the relatively
accurate diagnosis of intraspinal pathology. Subsequent evolution in contrast agents from
lipid soluble to water soluble to non-ionic water soluble agents has greatly enhanced the
accuracy and safety of this diagnostic procedure, which remains as the "gold standard" in
intraspinal imaging. Computed tomography (CT) was first used to image the brain in1972.
Several years elapsed before high-quality spinal images were routine.
The development of magnetic resonance imaging (MRI) soon followed with the first head scan
being produced on May 18,1979 in Nottingham, England. Spinal imaging became
available within two years and is rapidly becoming the imaging modality of choice for most
spinal disorders.

The syndrome of sciatica has been recognized since ancient times but the
association of sciatic pain with lumbar disc herniation was not made until the twentieth
century. Several descriptions of traumatic disc herniations existed in the pathological
literature of the late 1800's and in the surgical literature of the early 1900's, but disc
herniation was not linked with the genesis of sciatic pain. In 1929, Walter Dandy
published two cases of sciatic pain associated with herniated disc fragments which
responded to surgical discectomy. Unfortunately, the importance of this paper went
largely unrecognized. During those years pathological specimens from what would now
be called discectomy procedures were frequently interpreted as "chondromas". In 1934.
Mixter and Barr published a paper describing their observations regarding the role of
lumbar disc herniation as a common etiology of sciatic pain This revolutionized medical
thinking at the time, ushering in a greater interest in the lumbar disc as a source of back and leg
pain and in the surgical treatment of such disorders. Surgery for back and leg pain in association
with nerve root compression has become one of the most commonly
performed operative procedures.
This enthusiastic and generally successful treatment of sciatica secondary to
lumbar disc herniation resulted in a preoccupation with the. disc as a source of back pain
by physician and the public alike. It is worth remembering, however, that disc herniation
accounts for a small percentage of radiating leg pains and an even smaller proportion of
back pain. Incidental herniations are not rare and may be observed in up to 25%-30% of
myelograms or MRIs. Bulging discs, in which there is a diffuse bulging of the annulus into the
spinal canal, are oven more common and are less likely to produce sciatica.
The current management of patients with degenerative spine disease and low back
pain involves physicians and allied health personnel from numerous disciplines including
family practice, internal medicine, neurosurgery, physical medicine arid rehabilitation,
orthopedics, neurology; psychiatry, anesthesiology, physical therapy, social work, orthotics
and chiropractic. The number of proposed interventions for this group of patients is mindboggling. Many widely prescribed treatments have no evidence for efficacy. Other
efficacious treatments, which may benefit subsets of patients, are indiscriminately applied.
Clearly, the optimal management of these conditions requires a broad-based
understanding of the pathophysiology of these disorders, astute clinical skills, and an
unbiased appreciation of effective therapeutic interventions.
Disc pathophysiology: The intervertebral disc consists of three parts: the annulus
fibrous, the nucleus pulposus, and the cartilaginous endplates. The annulus, which forms
the peripheral aspect of the disc, consists of collagenous fibers arranged in concentric
layers. The fibers are oriented at a 30 degree angle to the horizontal and are embedded
in an amorphous ground substance of proteoglycans and water. The nucleus also
consists of these same components, although the amount of collagen is considerably less
and the amount of proteoglycans is greater than the annulus. The annular fibers attach to
the end plates and have dense attachment via Sharpeys fibers
to the periphery of the
vertebrae above and below. The cartilaginous end plates consist of hyaline cartilage and
provide an avenue for diffusion of nutrients from the bone of the vertebral bodies into the
disc.

Pathological evidence of degenerative changes within the disc is apparent

beginning in the third decade. Fissures develop in the annulus and progress
and enlarge
throughout life. These fissures may extend in a radial direction completely through the
annulus. Concurrent changes within the nucleus include a loss of water content,
and necrosis of nuclear fibers and fibrosis. These pathological
events significantly alter
the biomechanical properties of the disc and therefore the spinal motion segment as a
whole (the motion segment consists of two adjacent vertebral bodies and the associated
ligaments and disc). These changes may then predispose to disc herniation or bulging,
facet arthropathy and osteophyte formation as well as ligamentous laxity and segmental
instability".
The mechanisms producing a disc herniation are not well understood. Attempts to
produce
herniated discs in cadaver spines by application of various loads have not
been generally successful. Most acute loading conditions produce endplate fractures
rather than posterolateral disc herniations. These finding suggest that most disc herniations are
not the result of a single, acute traumatic event.
Numerous structures in the region of the disc are innervated by nociceptive afferent nerves.
These include the anterior and posterior longitudinal ligaments, the periosteum, vascular
adventitia, the dura, and the posterior aspects of the annulus. The development of
back pain in association with disc herniation may be the result of stimulation of these
nerve endings. The nerve root is invested with its own nociceptor system, the nervi
nervorum. It is presumed that the radicular pain associated with HNP is the result of
stimulating these fibers. The neurological manifestations of nerve root compression
(reflex inhibition, paresthesias, sensory loss and motor weakness) likely result from either
direct compression by the disc fragment or from stretching the root between the herniation
and the fibrous attachments of the root at the foramen. It is unclear whether disc
herniation per se is a painful condition. The finding of incidental HNP on up to 30% of
myelograms or MRIs would tend to support the view that the disc herniation itself is not the
source of pain. On the other hand, some patients with radicular pain and HNP do give a
prior history of low back pain which then evolved into a typical sciatic distribution. This
may present pain arising from the disruption of the disc without root impingement.
The degenerative processes occurring in the disc also impacts on the osseous
elements. There is good evidence that disc degeneration leads to facet degeneration with
the occasional subsequent development of facet hypertrophy, acquired spinal stenosis, ligament
hypertrophy, synovial changes, segmental instability and the clinical syndromes associated
with these changes.

CLINICAL EVALUATION
Low Back Disorders:
T
he clinical assessment of patients with degenerative spine
disease must be heavily weighted toward the history. Pain is frequently the chief
complaint and must be well-characterized. A complete description of the pain is critical
including its location, quality, severity, onset and duration., Factors which aggravate or
relieve the pain must be elicited as well as any associated symptoms. Some impressions
regarding the impact that the pain is having on the patient in terms of work and leisure
activities, sleep, mood and interpersonal interactions should are obtained. If the patient
perceives the symptoms as the result of injury, the circumstances surrounding this event
roust be documented. It is well known that extraneous factors, such as Workmen's
Compensation, litigation and disability issues have a major impact on the response to
treatment; therefore, they must be accounted for. The patient must be questioned
regarding neurological symptoms, such as weakness or gait difficulties, clumsiness or
bowel or bladder complaints. The patient should be questioned about numbness, tingling
or other sensory changes. The distribution and character of these changes should be
understood.
The temporal course of the patient's symptoms is important as is a description of
previous diagnostic and therapeutic attempts and the results. The past medical history
should be elicited, both to evaluate for predisposing or associated conditions, as well as to
determine the patient's fitness for various therapies (e.g. surgery). Because psychosocial
factors are so influential in this patient population, a social history should also be obtained.
The physical assessment emphasizes the musculoskeletal, neurological and
peripheral vascular examinations.
Lumbar radiculopathy: Pain which radiates from the hip or low lumbar region into
the leg is commonly presumed to be the result of lumbar nerve root irritation and/or
compression. The most common cause of lumbar nerve root compression is disc herniation.
Other observed causes include compression by a hypertrophic facet joint,
ligamentum flavum hypertrophy in association with stenosis of the lateral spinal canal, and
intraspinal synovial cysts. Less frequently, spinal roots may be compressed by tumors or other
masses.
When the pain radiates down the posterior thigh and posterolateral calf
approximating the distribution of the. sciatic nerve, it may be properly referred to as
"sciatica", although this term predates the modern understanding that most sciatic pain is
of radicular origin. Posterior thigh pain which does not extend below the knee may
frequently be seen in patients without nerve root compression. This sort of referred pain

can occur with sacroiliac joint inflammation, myofascial pain syndromes, facet syndromes and
a number of other conditions. Pain which radiates into the anterior thigh may result
from upper lumbar (L1, 2 ,3 and occasionally L4) root involvement. Other diagnoses such as
meralgia paresthetica, femoral mononeuropathy (especially in diabetics), muscular strains and
hip disease should be considered.
Patients with true radiculopathy will often note an exacerbation of pain with cough, sneeze
or Valsalva's. Also pain of radicular origin is frequently relieved by flexion of the
knee (e. g. lying supine with the knee resting over a pillow).
Physical findings in patients with lumbar radiculopathy may include motor loss,
dermatomal sensory findings or reflex changes alone with nerve root tension signs i.e.,
positive straight leg raising (SLR) test. The femoral stretch test may be positive in patients with
upper lumbar radiculopathy (see Table 1).
Lumbar spinal stenosis: Lumbar spinal stenosis frequently presents as
neurogenic spinal claudication. In this syndrome, patients describe pain involving the
buttocks, thighs and legs which is brought on by ambulation and decreased by rest. These
symptoms must be differentiated from true vascular claudication caused by occlusive arterial
disease of the distal aorta or more peripheral arteries. Neurogenic claudication arises from
ischemia of the cauda equina brought on by increased metabolic demand in the setting of tight
stenosis of the spinal canal. Differential points between these two syndromes include the
presence of normal peripheral pulses, and normal skin color and temperature in neurogenic
patients. Patients with neurogenic symptoms also often describe relief of symptoms with the
adoption of a flexed posture (e.g. will have greater exercise tolerance on a bicycle or when
walking behind a shopping cart). Patients with lumbar stenosis may also describe low back
pain and radicular symptoms in combination with or instead of, classic claudication.
The neurological examination in patients with spinal stenosis is frequently normal.
Occasionally, walking the patient to bring out the symptoms of claudication will yield
positive findings on sensory or reflex testing. Straight leg raise is typically negative. Pain is
occasionally elicited with lumbar extension.
TABLE 1
Root

Pain Pattern

L2

Anterior thigh

L3

Anterior thigh

L4

Lateral thigh

L5

Posterior lateral
thigh; lateral calf

Motor
Symptoms
Iliopsoas

Sensory
Symptoms
Inguinal

Reflex Change

Iliopsoas;
Quadriceps
Quadriceps

Anterior-lateral
Thigh
Anterior-lateral
Calf
Lateral calf;
dorsum foot;
great toe

Knee Jerk

Dorsiflexors;
extensor hallucis
longus

None

Knee jerk
None

S1

Posterior thigh;
lateral calf;
lateral foot

Gastroc

Lateral foot

Ankle jerk

Cervical and thoracic disorders: Degenerative conditions of the cervical spine

are less frequent than those of the lumbar spine. Cervical disc herniation and cervical spinal
stenosis are the most commonly seen conditions. Thoracic disc herniations
account for less than 1% of disc herniations in the spine.
Thoracic disc disease: Thoracic disc hernintion.is commonly an incidental finding on MR
scans. Symptomatic thoracic disc herniation produces pain, sensory loss or weakness
(myelopathy). Pain may be radicular -- following the course of an intercostal
nerve -- or it may be spinal. Sensory findings in this context are usually consistent with an
incomplete ventral or lateral cord lesion (e:g. a Brown Sequard pattern ). A sensory level is
usually not present except with severe myelopathy. Motor findings are those of a spastic
paraparesis (weakness, hyperreflexia, clonus, hypertonus, Babinskis).
Cervical radiculopathy: Root compression in the cervical spine produces
characteristic symptoms analogous to those in the lumbar region (Table 2). The
numbering of cervical roots is such that a given root exits above its like-numbered
vertebral body. Thus a C6 root will exit the C5-6 foramen and will be compressed by a
herniation of the C5-6 disc. Although disc herniation is the most common cause of cervical
radicular symptoms, foraminal stenosis as a result of osteophytes may produce an
identical syndrome. Cervical radiculopathy is frequently first noted upon awakening without an
identifiable precipitation event. The question of a cardiac source of pain is often raised when
the radiculopathy is left-sided. Neck pain and pain with neck movements are important
differentiating factors.
The pain of cervical radiculopathy is often brought on with axial neck compression
associated with lateral flexion to the symptomatic side (Spurlings sign) or by downward
traction of the involved arm with lateral neck flexion to the opposite side. Conversely, many
patients report relief of symptoms by abducting their shoulder and placing their hand on their
head.
Cervical myelopathy: Symptoms resulting from compression of the cervical spinal cord are
most commonly caused by disc herniations or spinal stenosis. The latter may occur as a result of
a congenitally narrow cervical spinal canal but is usually associated with spondylotic changes
(osteophytes, disc bulged, facet and ligament hypertrophy). Infrequently spinal canal narrowing
is produced by ossification of the posterior longitudinal ligament (OPLL). The radiographic
changes consistent with spondylosis are common after age 40 and demonstrate increasing
incidence with increasing age.
The measurement of spinal canal diameter on lateral radiographs taken at 3 feet tube-to-plate
distance can be used to predict probable spinal cord impingement. The average A-P diameter in
the mid and lower cervical spine in 17mm-18mm. Measurement less than 11mm are consistent

with significant spinal cord impingement. The spinal cord may be compressed even when
larger spinal cord diameters are noted because soft tissue, such as disc or ligamentum, may
encroach on the spinal canal.
Varying patterns of clinical signs and symptoms may be noted. Their relative frequencies are
seen in Table 3.
TABLE 2

Findings in Cervical Radiculopathy

Disc Level
Percent Cervical
Discs
Root

C4-5

C5-6
20%

C6-7
70%

C7-T1

C5

C6

C7

C8

Reflex

Pectoral

Triceps

Finger Jerk

Motor Symptoms

Deltoid
(Biceps)
Shoulder

Biceps;
Brachioradialis
Biceps;
Brachioradialis
Radial Forearm;
Thumb, Index

Triceps;
Wrist Extensors
Dorsal
Forearms;
Middle Finger

Hand Intrinsics

Sensory Symptoms

Ulnar Hand,
Forearm

Cervical myelopathy is frequently of insidious onset and is usually progressive. Acute

worsening is occasionally seen as are periods of static symptoms lasting months or even years.
Patients commonly describe symptoms of numbness or weakness of the hands, citing difficulty
manipulating small objects. Proximal lower extremity weakness is often noted as is stiffness
(spasticity). Patients may be aware of clumsiness of their gait and a tendency to fall. Overt
sphincter disturbance is uncommon but urinary urgency is often reported. Amyotrophic lateral
sclerosis (ALS) is an important differential consideration in some cases.
Table 3: Findings in Cervical Myelopathy
FINDINGS
Pure Myelopathy
Myelopathy + Radiculopathy
Hyperreflexia
Babinski
Sensory Level
Posterior Column
Dermatomal Arm
Arm Weakness
Paraparesis
Hemiparesis
Quadriparesis
Brown-Sequard

PERCENT
59%
41%
87%
54%
41%
39%
33%
31%
18%
18%
10%
10%

Muscle Atrophy
Fasciculations

10%
10%

Radiological Evaluation: The radiologic evaluation of degenerative disease of the

spine must be individualized. Extensive and expensive study is generally not indicated in
patients who are not surgical candidates. The types of evaluation that may be performed include
plain radiographs, dynamic radiograms (e.g. flexion-extension films), CT scanning (with or
without intrathecal contrast), myelography, an MR scanning. Radio nuclide bone scanning is
occasionally helpful. Other ancillary tests such as discography are rarely performed and their
value may be questioned.
Plain radiographs: The role of plain films in the evaluation of degenerative spine
disease is somewhat limited. Nonetheless they are a useful screening tool to rule out
bony destruction as seen with neoplasm or infection, and to visualize deformities, fractures
or subluxation. Hyper mobility on flexion-extension films may be associated with pain or
neurological symptoms. Vertebral movement of more than 4mm to 5mm in the lumbar region or
more than 3mm in the cervical region should be considered abnormal.
CT scan: CT is often useful in the evaluation of a variety of disorders. It provides
excellent visualization of bony detail. Disc material can often be differentiated from the
thecal sac on plain CT of the lumbar spine. This test is less expensive than MR scanning
or myelography, but is less likely to be diagnostic in most cases. In cases of far lateral
disc herniation, CT is superior to myelography. A major disadvantage of CT scanning is
visualization in only the axial plane. In spinal degenerative disease, CT has the
advantages of excellent bony detail. It is noninvasive, and can be done as an outpatient
procedure. It has a faster scanning time as compared to MR scanning. It is less
expensive than MR scanning. It visualizes paraspinal soft tissue. It is often adequate for
making a diagnosis.
Table 4
Advantages to CT in-Spinal Degenerative Disease
Excellent bony detail
Noninvasive, outpatient procedure
Faster scanning time .vs MR
Inexpensive
Visualizes paraspinal soft tissue
Often adequate for diagnosis

Myelography: Myelography is currently performed in conjunction with CT

scanning. This study remains as the gold standard for evaluation of most degenerative
conditions of the spine. It is, however, are invasive test but it can be done on an outpatient
basis. Some morbidity is to be expected (most commonly "post myelogram headache"
seen in roughly 10%). Myelography may provide a more "dynamic" sense of the pathology in
that films can be obtained after changes in position (e.g. a myelographi (block in
cervical stenosis may allow passage of contrast with changes in neck position). Root
impingement, especially in the cervical spine, is probably more clearly demonstrated on
myelography than on MR scanning.
MR scan: Magnetic resonance imaging will be the first imaging study obtained for
the evaluation of most patients presenting with hack or neck pain or radiculopathy. MR
scanning will be diagnostic in most instances as it provides excellent anatomic resolution
and allows visualization in multiple planes. Contrast enhancement with gadolinium is very
helpful in distinguishing scar from recurrent disc in the previously-operated patient.
Disadvantages to MR scanning are the relatively long scanning times which may not he
tolerated by patients in severe pain or who are claustrophobic, the expense, the high level of
operator skill required to produce consistently excellent image and the inability to scan patients
with certain implants (cardiac pacemakers, ferromagnetic aneurysm clips etc.) Bony detail is
also not as well demonstrated on MR as with CT.
TREATMENT
Lumbar Disc Herniation: Most (80%+) patients with acute lumbar radiculopathy
will improve without surgery, therefore a trial of nonoperative therapy is appropriate with
the primary goal of palliating painful symptoms until resolution occurs.
Generally if symptoms are severe, a few (2-3) days of bed rest are appropriate.
Longer regimens are not clearly more beneficial. Analgesics are usually required. Nonsteroidal anti-inflammatory drugs (NSAIDS) may be prescribed for this purpose.
Occasionally narcotic (codeine, oxycodone) or propoxyphene are necessary for adequate pain
control. So-called muscle relaxants are probably of limited value, although their
sedating effect may help patients comply with bed rest.
A number of therapeutic modalities have been proposed for the treatment of back pain and
radiculopathy, most with tenuous evidence of efficacy. These include physical therapy, spinal
manipulation, acupuncture, TENS and traction.
The duration of non-operative treatment must be individualized, but generally, a
period of 4-6 weeks is considered appropriate before surgery is contemplated. Clearly the
presence of a neurological deficit alters these considerations. The development of a
cauda equine syndrome (urinary retention, perineal numbness, bilateral motor deficits, sphincter
paresis) is an indication for emergent surgery.

Table 5

Indications for surgery in lumbar herniated nucleus pulposus (HNP)

Failure of nonsurgical management
Cauda equina syndrome
Acute or progressive motor deficit
Severe pain not responding to analgesics (rare):

Lumbar spinal stenosis: Patients with neurogenic claudication secondary to spinal

stenosis should be given a trial of nonoperative management because symptom severity
may wax and wane, and patients may achieve a tolerable level of symptoms without
surgery. NSAIDS, rest and physiotherapy are all appropriate early in the management of
these patients. Surgical decompression is reserved for those individuals with refractory
symptoms. Serious neurological deficits are very unusual in this disorder.
Operative treatment consists of relieving spinal canal and individual nerve root
compression by means of bony removal. Hypertrophic facets and ligamentum flavum are
removed along with any impinging disc material. This is most. frequently accomplished via a
laminectomy although various modifications have been described, consisting of removal of
lesser amounts of bone (laminotomies) Spinal segment instability is both a
preoperative and a postoperative consideration and may be an indication for concomitant spinal
fusion in a subset of these cases.
Thoracic disc herniation: Operation in thoracic disc herniation is most often
indicated for neurological deficits (myelopathy). The approach is either through a
thoracotomy which allows a very ventral trajectory to the disc approaching the problem
.away from the neural elements; or through a paramedian approach which does not enter
.the chest cavity. This latter approach is more useful when the disc fragment is laterally
situated in the canal. Both of these approaches are considerably more difficult than the
surgery for lumbar disc herniation and are associated with greater risks of morbidity.
Cervical disc herniation: As in lumbar radiculopathy, most patients with arm pain
from a cervical disc will recover spontaneously. Initial treatment should consist of rest
(avoidance of activities which exacerbate symptoms), NSAIDS, cervical traction (home
cervical traction 7-10 pounds for 15-20 min TID), and when pain has improved, physical
therapy. Narcotic analgesics and muscle relaxants, may be necessary when symptoms
are severe. Upper extremity motor weakness, if moderate or severe, is an indication to
abandon nonoperative therapy and consider surgery. Patients who present with signs and
symptoms of spinal cord compression should be considered for early surgery.

There are two main surgical approaches to deal with cervical disc herniation; either an
anterior operation or a posterior approach. Each technique has its advantages and indications.
The posterior approach is well suited to lateral disc herniations, especially if there are
concurrent lesions at more than one level. The anterior interbody approach is best for central
disc herniations with spinal cord compression, but it is also a very effective means for treating
radiculopathy secondary to a disc herniation.
Cervical stenosis: Surgery is generally indicated for treatment of progressive
myelopathy resulting from spinal canal stenosis. Several different operative approaches

are available for different circumstances. The nature of the compression must be carefully
evaluated preoperatively. When the cord is compressed ventrally, consideration should be
given to an anterior approach. Stenosis is usually most marked adjacent to the disc spaces
because of ventral oseophytes (bars) so that decompression at the disc space may be
sufficient. In some cases, greater bone removal is required usually in the form of a trough
corpectomy where a slot of bone is removed spanning the necessary number of spinal
segments. In this situation, the spine is fused usually with a strut graft and sometimes with
internal fixation such as a cervical plate. In some cases, especially with a congenitallynarrow spinal canal, a posterior decompression is the appropriate operation, and is achieved
by multilevel laminectomy or by laminoplasty in which the laminar arches are cut but then
reattached in a way to provide a roomier spinal canal while maintaining the posterior
elements.
The result from cervical decompression for myelopathy are sometimes disappointing.
Patients occasionally progress in spite of an apparently adequate decompressive operation.
The cause for this is unclear although contributing factors might be some degree of minor
instability or selection of the wrong surgical approach. It is estimated that 70%-80% of
patients are improved by surgery, although there may be a falloff in good results as patients
are followed over time. Spasticity, if pronounced preoperatively, may continue to be a
problem postoperatively. Baclofen may be indicated in these cases to try to reduce the
increased muscle tone.