AAOS Comprehensive Orthopaedic Review 4: Print + Ebook (AAOS - American Academy of Orthopaedic Surgeons)

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Section 2 | Spine

• Prolonged duration of symptoms (>6 weeks) • Presence of constitutional symptoms and known systemic disease (cancer or inflam matory arthritis) • Radiculopathy or myelopathy b. Radiographic findings • AP radiographs will reveal degenerative changes in the uncovertebral joints. • Lateral radiographs allow assessment of overall alignment (lordosis, kyphosis), disk-­ space narrowing, vertebral body osteo phytes, and listheses. • Oblique radiographs can be useful to evalu ate radiculopathy from neuroforaminal ste nosis or facet arthrosis. • Flexion-extension views are indicated when suspecting instability or trauma and investigate the presence of postoperative pseudarthrosis. • Open-mouth odontoid view is used to reveal C1 or C2 fractures or the presence of atlan toaxial arthritis. c. Advanced imaging • CT with appropriate sagittal and coronal reconstructions delineates the bony anat omy associated with fractures, foraminal stenosis, facet arthritis, and ossification of the posterior longitudinal ligament (OPLL). • MRI or CT myelography is used to rule out neural compression. • MRI is useful for the diagnosis of infections and neoplasms. 3. Differential diagnosis of isolated axial neck pain a. The differential diagnosis includes fractures, dislocations, inflammatory arthritides (rheu matoid arthritis, ankylosing spondylitis), infections (discitis, osteomyelitis, epidural abscess), tumors (intradural, extradural), and nonspinal sources. b. The causes of neck pain should be ruled out before embarking on the management of cer vical spondylosis. 1. Nonsurgical a. Nonsurgical treatment is favored for most patients with isolated axial neck pain due to cervical spondylosis.

b. NSAIDs are favored over narcotic-based medication. c. Isometric cervical muscle strengthening, heat/ ice/massage, and short-term immobilization in a soft collar can be considered. d. Oral steroids can be used for short durations. e. Steroid injections: Depending on the etiology, facet blocks and transforaminal and central epidural steroids may be of some benefit. 2. Surgical a. Fusion for isolated midline axial neck pain is controversial and rarely indicated. b. Favorable results have been reported with posterior arthrodesis in selected patients with atlantoaxial osteoarthrosis in whom nonsur gical treatment has failed, patients with sec ondary C1-C2 instability, and patients with neurologic compromise. c. Paraspinal, upper trapezial, medial scapular, and retroauricular pain are often radiculopa thies and their source can be identified with selective nerve blocks, which are predictive of surgical outcomes. C. Atlantoaxial osteoarthrosis 1. Atlantoaxial osteoarthrosis is a frequently missed cause of axial neck pain. 2. Patients are typically older (70 years or older). 3. Pain is localized to the occipitocervical junc tion; rotation (to one side if the arthrosis is uni lateral, or to both sides if bilateral) exacerbates the pain, but sagittal plane motion typically does not. 4. Atlantoaxial osteoarthrosis can best be assessed on open-mouth odontoid radiographs or coronal CT cuts. 5. Reconstructed CT views may falsely show an autofusion. Check flexion-extension radiographs for motion. III. CERVICAL RADICULOPATHY A. Pathoanatomy 1. Compression of the exiting nerve root as it enters the neuroforamen

2 | Spine

a. Soft disk herniations ( Figure 1 )—Nuclear material arising from an acute herniation can impinge on the exiting nerve root posterolat erally most commonly at its takeoff from the spinal cord or laterally where it traverses the neuroforamen. Copyright © Wolters Kluwer, Inc. Unauthorized reproduction of the content is prohibited. 2023

B. Treatment

AAOS Comprehensive Orthopaedic Review 4

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