Cervical Laminoplasty by Pablo Pazmino MD

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Information about Cervical Laminoplasty by Pablo Pazmino MD

Published on July 8, 2008

Author: Beverlyspine

Source: slideshare.net

Description

This video explains Cervical Stenosis and Cervical Spondylosis/Arthritis. When stenosis begins to affect the spinal cord this is called Cervical Spondylotic Myelopathy. This video highlights the history, epidemiology, and treatment options both conservative and surgical. If you or someone you know needs to be seen in regards to Cervical Stenosis/Arthritis for a Laminoplasty feel free to look us up online www.beverlyspine.com or www.santamonicaspine.com OR call toll free 1-8SPINECAL-1

Pablo Pazmi ño, MD

Orthopaedic Surgery American Academy of Orthopaedic Surgeons Clinical Faculty Olympia Medical Center Cedars Sinai Medical Center Century City Doctors Hospital Education The University of California, Los Angeles The University of Michigan, Ann Arbor

Education

The University of California, Los Angeles

The University of Michigan, Ann Arbor

The beauty of the laminoplasty is that it increases the space available for the spinal cord It does this without fusing the spine whatsoever

The beauty of the laminoplasty is that it increases the space available for the spinal cord

It does this without fusing the spine whatsoever

Cervical Spondylotic Myelopathy: Natural History Pathophysiology Diagnosis Symptoms Exam Findings Studies Surgical Laminoplasty Cases

Cervical Spondylotic Myelopathy: Natural History

Pathophysiology

Diagnosis

Symptoms

Exam Findings

Studies

Surgical Laminoplasty

Cases

 

Cervical Spondylosis This is a Progressive degenerative changes that develop slowly over time , this alters the spinal biomechanics from the loss of shock absorption properties of intervertebral discs. This leads to other changes in surrounding structures.

Cervical Spondylosis

This is a Progressive degenerative changes that develop slowly over time , this alters the spinal biomechanics from the loss of shock absorption properties of intervertebral discs.

This leads to other changes in surrounding structures.

Dysfunction  Instability  Stabilization (Marginal Osteophytes) Initially you develop a dysfuntion in your neck The neck then becomes unstable as a result Arthritis is your bodies attempt to stabilize this naturally by growing bone spurs and stiffening an unstable area. This is why you may develop stiffness.

Dysfunction  Instability  Stabilization (Marginal Osteophytes)

Initially you develop a dysfuntion in your neck

The neck then becomes unstable as a result

Arthritis is your bodies attempt to stabilize this naturally by growing bone spurs and stiffening an unstable area. This is why you may develop stiffness.

Patients develop Stepwise degeneration with periods of stability between exacerbations. 45% of patients with non myelopathic symptoms have good resolution after onset, the remaining 55% continue to have moderate long term morbidity Lees Turner BMJ 63:2:1607 (44pts/ CSM 3-40yrs) Do well for awhile Then Get Worse

Patients develop Stepwise degeneration with periods of stability between exacerbations.

45% of patients with non myelopathic symptoms have good resolution after onset, the remaining 55% continue to have moderate long term morbidity

Lees Turner BMJ 63:2:1607 (44pts/ CSM 3-40yrs)

Do well for awhile

Then Get Worse

In the Front  disc degeneration and osteophytes ,PLL Anterolaterally  Uncovertebral joint, and facet hypertrophy In the Back  Ligamentum flavum thickens and buckles Parke WW. Spine 1988 Bernhardt et al JBJS 1993 Progressive cervical spondylotic changes result in circumferential narrowing of the cervical canal

In the Front  disc degeneration and osteophytes ,PLL

Anterolaterally  Uncovertebral joint, and facet hypertrophy

In the Back  Ligamentum flavum thickens and buckles

Parke WW. Spine 1988

Bernhardt et al JBJS 1993

Anteriorly  disc degeneration and osteophytes ,PLL Anterolaterally  uncovertebral joint, and facet hypertrophy Posteriorly  Ligamentum flavum buckling Parke WW. Spine 1988 Bernhardt et al JBJS 1993 Circumferential Process= It occurs from all sides

Anteriorly  disc degeneration and osteophytes ,PLL

Anterolaterally  uncovertebral joint, and facet hypertrophy

Posteriorly  Ligamentum flavum buckling

Parke WW. Spine 1988

Bernhardt et al JBJS 1993

Three distinct clinical syndromes can result: Type I: Cervical Radiculopathy: Cmprsn +Inflammation of Spinal Nerve with symptoms that correspond to the level involved Type II: Cervical Myelopathy: Cord involvement Type III: Axial Joint Pain (Mechanical neck pain, “discogenic pain”, facet syndrome, painful instability

Radiculopathy is not a specific condition, but rather a description of a problem in which one or more nerves are affected and do not work properly The emphasis is on the nerve root (“Radix" = "root“ ). This can result in radicular pain, weakness, numbness, or difficulty controlling specific muscles.

Radiculopathy is not a specific condition, but rather a description of a problem in which one or more nerves are affected and do not work properly

The emphasis is on the nerve root (“Radix" = "root“ ).

This can result in radicular pain, weakness, numbness, or difficulty controlling specific muscles.

Sex: Radiographic changes are more severe in men than in women. Cervical Spondylosis present in 50% of population at 50 years of age. Kellgren Ann Rheum Dz 1958 Irvine et al defined the prevalence of Spondylosis using radiographic evidence. Lancet 1965 ♂ prevalence was 13% in the third decade  100% by age 70 years. ♀ prevalence ranged from 5% in the fourth  96% > 70 years. In 1992, Rahim and Stambough noted that spondylotic changes are most common in those older than 40 years. Eventually, more than 70% of men and women are affected Orthop Clin North Am 1992 By age 60-65 95% of nonsymptomatic men and 70% of asymptomatic women develop at least one degenerative change on Xray Gore Spine 1986 Moore and Blumhardt series, 23.6% of patients presenting with nontraumatic myelopathic symptoms had CSM. Spinal Cord 1997 CSM is the most common cause of nontraumatic spastic paraparesis and quadriparesis.

Sex: Radiographic changes are more severe in men than in women.

Cervical Spondylosis present in 50% of population at 50 years of age. Kellgren Ann Rheum Dz 1958

Irvine et al defined the prevalence of Spondylosis using radiographic evidence. Lancet 1965

♂ prevalence was 13% in the third decade  100% by age 70 years.

♀ prevalence ranged from 5% in the fourth  96% > 70 years.

In 1992, Rahim and Stambough noted that spondylotic changes are most common in those older than 40 years. Eventually, more than 70% of men and women are affected Orthop Clin North Am 1992

By age 60-65 95% of nonsymptomatic men and 70% of asymptomatic women develop at least one degenerative change on Xray Gore Spine 1986

Moore and Blumhardt series, 23.6% of patients presenting with nontraumatic myelopathic symptoms had CSM. Spinal Cord 1997

CSM is the most common cause of nontraumatic spastic paraparesis and quadriparesis.

No patient ever returned to normal state 75% Had episodic worsening/progression 20% Slow steady progression 5% Rapid onset followed by lengthy disability Motor changes tended to persist and progress with time Sensory/bladder changes were transient Soft collar improved gait and Nroot syx for 50% pts Clark E, Robinson PK Cervical Myelopathy: a complication of cervical spondylosis Brain 56:79:483-70 (120 patients) Stepwise degeneration with periods of stability between exacerbations. 45% of patients with nonmyelopathic symptoms have good resolution after onset, the remaining 55% continue to have moderate long term morbidity Lees Turner BMJ 63:2:1607 (44pts/ CSM 3-40yrs)

No patient ever returned to normal state

75% Had episodic worsening/progression

20% Slow steady progression

5% Rapid onset followed by lengthy disability

Motor changes tended to persist and progress with time

Sensory/bladder changes were transient

Soft collar improved gait and Nroot syx for 50% pts

Clark E, Robinson PK Cervical Myelopathy: a complication of cervical spondylosis Brain 56:79:483-70 (120 patients)

Stepwise degeneration with periods of stability between exacerbations.

45% of patients with nonmyelopathic symptoms have good resolution after onset, the remaining 55% continue to have moderate long term morbidity

Lees Turner BMJ 63:2:1607 (44pts/ CSM 3-40yrs)

Cervical Spine Research Society Multicenter, Nonrandomized study Poor outcome of Nonsurgical Mgmt of CSM 43pts 23 Medical treatment: Decrease in ability to perform ADLs, worsening of Neurologic symptoms 20 Surgical treatment: Decreased neurologic symptoms,overall pain, and improved functional status Sampath P et al Spine 2000: 25:670

Cervical Spine Research Society

Multicenter, Nonrandomized study

Poor outcome of Nonsurgical Mgmt of CSM

43pts

23 Medical treatment: Decrease in ability to perform ADLs, worsening of Neurologic symptoms

20 Surgical treatment: Decreased neurologic symptoms,overall pain, and improved functional status

Sampath P et al Spine 2000: 25:670

T he Cervical discs themselves have been shown to account for consistent patterns of neck pain Grubb Spine 25: 1382-1389, 2000

T he Cervical discs themselves have been shown to account for consistent patterns of neck pain

Grubb Spine 25: 1382-1389, 2000

The facet joints themselves can account for significant neck pain. The facet joint capsules have free nerve endings which send referred pain into these specific distributions. This is why many of the patients we see every day have neck/ shoulder/scapular pains. Dwyer Spine 15: 453-7, 1990.

The facet joints themselves can account for significant neck pain.

The facet joint capsules have free nerve endings which send referred pain into these specific distributions.

This is why many of the patients we see every day have neck/ shoulder/scapular pains.

With my background as a Third grade teacher I always make it a point to build a foundation concept before moving on to complex ideas. As a Spine surgeon I want the most vantage points on an object, this gives me a frame of reference and helps to construct the anatomy in my mind.

With my background as a Third grade teacher I always make it a point to build a foundation concept before moving on to complex ideas.

As a Spine surgeon I want the most vantage points on an object, this gives me a frame of reference and helps to construct the anatomy in my mind.

Here is what I mean by a foundation concept. You will see side view images and top down images throughout this presentation and on your MRIs. This can be hard to grasp unless we stop and point a few things out initially The Sagittal view is also called the lateral view and this is pictured here it displays the spine as viewed from the SIDE. The Axial view is a top down view of the spine. This image repsents a slice obtained as if an Axe were to chop you, therefore the name Axial view.

Next we will review some basic anatomy Some images will be in the Sagittal plane

Next we will review some basic anatomy

Some images will be in the Sagittal plane

Others will be in the Axial Plane

Others will be in the Axial Plane

There are seven bones which make up the cervical spine. Each vertebral body ( these look like blocks) are separated by intervertebral discs which function as shock absorbers. 1 2 3 4 5 6 7

There are seven bones which make up the cervical spine. Each vertebral body ( these look like blocks) are separated by intervertebral discs which function as shock absorbers.

 

A Herniated disc A herniated disc (sometimes called a slipped disc) is the most common cause of sciatica. Discs are the cushions between the bones in the back. They act like "shock absorbers" when we move, bend, and lift.

A Herniated disc A herniated disc (sometimes called a slipped disc) is the most common cause of sciatica. Discs are the cushions between the bones in the back. They act like "shock absorbers" when we move, bend, and lift.

There is a tough ring around the outside called the Annulus Fibrosus , and a thick almost crabmeat like center inside called the Nucleus pulposus.

There is a tough ring around the outside called the Annulus Fibrosus , and a thick almost crabmeat like center inside called the Nucleus pulposus.

If the outer edge of the disc ruptures, the center can push through and put pressure on the exiting nerve, leading to the pain of sciatica (referred to as a Herniated nucleus pulposus or disc herniation).

If the outer edge of the disc ruptures, the center can push through and put pressure on the exiting nerve, leading to the pain of sciatica (referred to as a Herniated nucleus pulposus or disc herniation).

Are located posteriorly, these are the joints of the spine and are essential for control of normal motion and based on their orientation Compromised facets will alter the distribution of mechanical forces throughout the spine

Are located posteriorly, these are the joints of the spine and are essential for control of normal motion and based on their orientation

Compromised facets will alter the distribution of mechanical forces throughout the spine

Joint Facet Nucleus Pulposus Right Nerve Root Left Nerve Root As you can see here on MRI and CT scans the Facet joints end up looking like the buns of a hamburger. Its just the way the happen to look when they are sliced in this plane. We will show you this on some examples later Annulus Fibrosus Axial View of the Disc and Neural elements Spinal Cord

Joint Facet Disc Right Nerve Root Left Nerve Root Axial View

Radiographs CT: Computed Tomography MRI: Magnetic Resonance Imgaing

Radiographs

CT: Computed Tomography

MRI: Magnetic Resonance Imgaing

Joint Facet Disc Right Nerve Root Left Nerve Root Next I will show you some MRIs You will see this is a patient with a left sided herniation pinching off her exiting left nerve root Spinal Cord

Joint Facet Disc Right Nerve Root Left Nerve Root Axial Scans: Spinal Cord

Cervical 7 Spinous Process Nerves 2-3 Disc 3-4 Disc 4-5 Disc 5-6 Disc 6-7 Disc

Early stages intermittent symptoms (neural inflammation) Activity modification Staying in shape physically/aerobically Bedrest 2-3 days: Avoid longterm bedrest Avoid certain activities : bending,twisting, lifting, unnecessary walking…..Usually eases pain PTherapy: stretching and isometrically strengthening atrophied muscles Modalities: heat, U/S, Whirlpool, massage

Early stages intermittent symptoms (neural inflammation)

Activity modification

Staying in shape physically/aerobically

Bedrest 2-3 days: Avoid longterm bedrest

Avoid certain activities : bending,twisting, lifting, unnecessary walking…..Usually eases pain

PTherapy: stretching and isometrically strengthening atrophied muscles

Modalities: heat, U/S, Whirlpool, massage

Avoid Narcotic medications and muscle relaxants (depression/sedation) Anti-inflammatory meds Bracing Epidural steroids and oral steroid ‘dose packs’ relieve pain and inflammation and allow aerobic conditioning and incr fcn All temporary not a cure for stenosis, and gives indication of severity

Avoid Narcotic medications and muscle relaxants (depression/sedation)

Anti-inflammatory meds

Bracing

Epidural steroids and oral steroid ‘dose packs’ relieve pain and inflammation and allow aerobic conditioning and incr fcn

All temporary not a cure for stenosis, and gives indication of severity

Surgery should be a last resort, when conservatives measures fail. In some cases surgery needs to be done sooner than later, or even urgently, depending on the physical exam, history, neural deficits, and size of the herniation.

Surgery should be a last resort, when conservatives measures fail.

In some cases surgery needs to be done sooner than later, or even urgently, depending on the physical exam, history, neural deficits, and size of the herniation.

All the procedure does is increase the space available for the spinal cord Again it does this without fusing the spine whatsoever

All the procedure does is increase the space available for the spinal cord

Again it does this without fusing the spine whatsoever

Joint Facet Disc Right Nerve Root Left Nerve Root This is an Axial view of a normal space around the spinal cord. Notice how much room the Cord has Spinal Cord

Joint Facet Disc Right Nerve Root Left Nerve Root This is an Axial view of a normal space around the spinal cord. Notice how much room the Cord has

Joint Facet Disc Right Nerve Root Left Nerve Root This is an Axial view of the decreased space around the spinal cord with CSM. Notice how it is now triangular in shape

Joint Facet Disc Right Nerve Root Left Nerve Root This is an Axial view of the decreased space around the spinal cord with CSM. Notice how it is now triangular in shape and the Spinal cord looks like a bean

Joint Facet Disc Right Nerve Root Left Nerve Root The Laminoplasty seeks to increase the area around the spinal cord here and give the nerves an environment to heal

Joint Facet Disc Right Nerve Root Left Nerve Root The way Dr Pazmino performs this is by literally “hinging open “ the bone in the back of the neck called the Lamina Hinge open Here

Joint Facet Disc Right Nerve Root Left Nerve Root The way Dr Pazmino performs this is by literally “hinging open “ the bone in the back of the neck called the Lamina Hinge open Here

Joint Facet Disc Right Nerve Root Left Nerve Root To keep this hinge open a plate and a piece of bone is placed inside the Hinge to keep this open. This is a Laminoplasty Keep the Hinge open Bone

Joint Facet Disc Right Nerve Root Left Nerve Root Small screws are placed into the Lamina and the Lateral masses to keep the Hinge open. This is a Laminoplasty Keep the Hinge open Bone

Joint Facet Disc Right Nerve Root Left Nerve Root Now the SPINAL CORD has an environment where it can heal Bone

Joint Facet Disc Right Nerve Root Left Nerve Root Now the SPINAL CORD has an environment where it can heal Bone

Team approach All procedures are done by two Spinal Surgeons

Team approach

All procedures are done by two Spinal Surgeons

All our procedures are peformed in a minimally invasive manner. All discectomies are performed as a microdiscectomy as opposed to the traditional open discectomy. All patients receive a plastics closure and are followed closely afterwards

All our procedures are peformed

in a minimally invasive manner.

All discectomies are performed as a microdiscectomy as opposed to the traditional open discectomy.

All patients receive a plastics closure and are followed closely afterwards

Thank you for your time. If you know someone who could benefit from a consultation for Laminoplasty please refer them to our online website or call toll free to schedule an appointment 1-8SPINECAL-1 www.beverlyspine.com www.santamonicaspine.com

Thank you for your time.

If you know someone who could benefit from a consultation for Laminoplasty please refer them to our online website or call toll free to schedule an appointment

1-8SPINECAL-1

www.beverlyspine.com

www.santamonicaspine.com

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