The aging cervical spine presents complex issues for the patient and surgeon. Factors associated with degenerative cervical radiculopathy and myelopathy, odontoid fractures, facet fractures , and central cord syndrome are discussed. Cervical spine surgery should not be withheld based on patient age alone.
As a nation, we are an aging population, and the surgical needs of the aging with regard to cervical disease will become an increasing problem. By 2030, the U.S. is estimated to be home to over 70 million people over the age of 65. The number of spinal fusions for degenerative disease, especially involving the cervical spine, have increased dramatically over the past few decades.
Physiologic changes associated with the aging process require special considerations to effectively manage cervical spine disease. As degenerative arthritis of the cervical spine is an inevitable disease as we all age, special consideration must be made to treat the conditions most commonly encountered in the elderly. These would include chronic neck pain due to facet, ligament, and disk disease; cervical radiculopathy and myelopathy secondary to nerve root and spinal cord compression; fractures of the cervical spine most commonly seen in the elderly such as odontoid fractures and facet fractures; and central cord syndrome. Treatment of these conditions is complicated by poor wound healing, osteoporosis, impaired bone formation, impaired mobility, pre-existing disc and ligament degeneration, and co-existing medical problems associated with advanced age.
As discs and ligaments age, they lose their elasticity, resulting in progressive laxity and abnormal motion. Our bodies counteract these changes by depositing calcium, leading to the formation of osteophytes (commonly referred to as “bone spurs”). When these osteophytes compress a cervical nerve root, the result is a cervical radiculopathy, marked by pain, numbness, and weakness in the distribution of the neck or upper extremity that the nerve supplies. If the osteophytes cause spinal cord compression, dysfunction of the spinal cord occurs, marked by spasticity of gait, impaired coordination, numbness, burning pain in the hands, abnormally increased reflexes (hyperreflexia), and possible bowel/bladder impairment. (See the related articles located elsewhere on Wascherspineinstitute.com for more complete descriptions of both cervical radiculopathy and myelopathy). Bone formation within the ligaments along the posterior aspect of the vertebral bodies anterior to the spinal cord can be particularly problematic; this is referred to as ossification of the posterior longitudinal ligament. Regardless of the location of the bone spurs, conservative treatment is initially preferred unless overt spinal cord dysfunction is diagnosed. This would consist of physical therapy, anti-inflammatory agents and oral steroidal agents; judicious chiropractic care; analgesic agents; neuromodulating agents like gabapentin; use of cervical immobilization or gentle cervical traction; and steroid injections and nerve blocks for both therapeutic and diagnostic reasons. Careful physical examination and appropriate testing is necessary to rule out chronic neck pain due to nonoperative causes. Patients who do not improve after 4-6 weeks of conservative care or show definite signs of a severe or progressive myelopathy are candidates for surgical decompression via anterior (either anterior cervical diskectomy with osteophytectomy or anterior cervical corpectomy, both including fusion and instrumentation) or posterior (cervical laminectomies with fusion and instrumentation) approaches. In fact, in especially severe cases, both an anterior and a posterior decompression with fusion and instrumentation may be advised. Laminectomy alone (without fusion and instrumentation) is generally not recommended due to risks of development of post-op kyphosis (abnormal posterior curvature associated with toggling of the spinal vertebrae). Studies on patients undergoing surgery over age 65 have shown that surgery definitely improves symptomatic patients with degenerative cervical osteoarthritis, but their recovery may be prolonged compared to younger patients. In short, cervical spine surgery should not be withheld for senior citizens.
The C2 vertebra demonstrates unique anatomy; the second vertebral body fuses in utero to the body of C1 resulting in a thumb-like process of bone extending upward from the C2 body into the ring of C1 anterior to the spinal canal. This bony feature is referred to as the odontoid process. Elderly patients that fall can experience hyperextension of the neck, causing a fracture along the base of the odontoid (technically called a type II odontoid fracture). This fracture can be difficult to heal as it disrupts the blood supply to the odontoid itself. This fracture is best diagnosed on a reconstructed CT scan; an MRI scan of the cervical spine is also indicted to make certain the associated ligaments have not been disrupted as well. If severe ligamentous injury has occurred, the potential for slipping/translation of the fracture fragment (subluxation) exists, resulting in spinal cord compression, neurologic injury, and death. Most type II odontoid fractures can be safely treated with a hard cervical collar; even if incomplete bony healing occurs, the fibrous union that results is adequate to allow a normal lifestyle without worry of cord compression. Use of an external electrical bone stimulator may be useful to create an environment optimal to bony healing. In the past, halo jacket immobilization was utilized for treatment of odontoid fractures. However, the morbidity and mortaility due to aspiration and respiratory complications associated with their use in the elderly is not insignificant. Surgery in those individuals who are medically fit is indicated for intractable pain or instability that threatens spinal cord compression. This can be performed via anterior or posterior approaches. A lag screw can be placed anteriorly via a retropharyngeal approach to approximate the C2 body with the odonotid fragment; in the elderly, this procedure has a relatively high nonunion rate due to osteoporosis and poor bone. A posterior approach with fusion and instrumentation at C1-C2 limits cervical rotation but appears to have a better long-term outcome.
The facet joints are synovial joints on either side of the spinal canal that are connected via ligaments to the adjacent levels above and below; they function to maintain alignment while preserving motion and limit excessive motion. Once again, the most common cause of a facet fracture in the elderly is a fall. Flexion-extension x-rays should be performed to rule out instability; an MRI/MRA scan may also be indicated to rule out nerve root or spinal cord compression or damage to the adjacent vertebral artery. Most facet injuries heal in a cervical collar. Intractable pain with neural compression, instability, and progressive deformity are indication for surgical intervention.
Also associated with a hyperextension injury, central cord syndrome occurs because of transient spinal cord compression due to anterior osteophytes and posteriorly due to infolding of hypertrophic ligaments. This results in preferentially damaging the motor nerve cells of the cervical cord, causing weakness of the upper extremities greater than the legs (the “man in the barrel” syndrome). In most cases, symptoms improve over time. Timing of surgery to prevent recurrence is controversial; most recent studies suggest early surgery may lead to earlier recovery, fewer complications associated with immobility, and better overall quality of life. Delayed surgery, however, carries a lower overall mortality. Once again older age portends a worse prognosis. As is the case with all geriatric patients, surgical risks and benefits must be carefully weighed on a case-by-case basis.
If you or a loved one are over age 65 and have been recommended for cervical surgery, a second opinion is always a good idea. Call us today if we can be of assistance at +1-(855)-854-9274