14.1 Introduction

Degenerative disk disease (DDD) in the elderly is an increasingly important problem for health systems worldwide. The osteoarticular system, of which the spine is an essential part, together with the cardiovascular system, grant functional autonomy. In fact, the aging of the population results in two phenomena: the first is the increase in the number of people over 60, with their pathologies and desire to remain healthy (growing old staying autonomous and healthy); the second is the increase in the costs of maintaining quality of life despite the decrease in funding contributions. This problem is far beyond the scope of this chapter as it involves societal choices.

DDD combines two problems: on the one hand, disk degeneration causing loss of cervical and lumbar lordosis and increasing thoracic kyphosis, ¹ and on the other hand, consequences on the neurologic system as a result of narrowing of the vertebral canal and foramina. The first problem seems inevitable and probably depends largely on individual genetics, as suggested by Battié et al. ² The second problem is responsible for pain and neurological deficits, the extent of which determines the loss of autonomy, which is associated with osteoporosis, fostering cuneiform collapse of the vertebrae by both thoracic and lumbar compression fractures. All these developments or events aggravate the overall kyphosis by a progressive anterior imbalance of the torso. ³ The aging of Junghans’ functional unit of the spine, whether cervical or lumbar, is essentially manifested by a narrowing of the spinal canal. Narrowing takes place either in the center of the canal or in the foramina, or in both. It is responsible for various symptoms: single-, multiradicular, or medullary. Moreover, the combination of cervical and lumbar damage affects 30% of patients. ⁴

All in all, the characteristic pathologies of the elderly can be grouped under different headings:

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  The narrowed central canal, whether cervical or lumbar, with its neurological consequences on the upper and lower limbs, is often accompanied by deformities: less in cervical deformities that resemble vertebral ankyloses and much more in lumbar deformities with narrowing as result of arthrosis.

  
  
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  Kyphotic deformation caused by disk degeneration aggravated by osteoporotic compression fractures causes loss of sagittal balance. In this chapter, only nonscoliotic arthrogenic kyphoses will be analyzed.

We shall describe these two themes, and for each, clinical and paraclinical evaluations as well as the most appropriate therapeutic options.

14.2 Spinal Narrowing of Degenerative Origin with Loss of Normal Spine Shape at the Cervical Level

The most common pathology is cervicobrachial neuralgia characterized by typical pain most commonly found in elderly patients with disk osteophytes compressing the nerve root in the foramen. This must be distinguished from soft hernia neuralgia, more common in young patients.

The diagnosis is based on a clinical examination, without particular tests, to determine whether radicular pain is typical or incomplete. The paraclinical examinations are based on magnetic resonance imaging (MRI) that may reveal a narrowing, but it is mainly on axial and sagittal computed tomography (CT) sections that the disk-osteophytic nature of the stenosis can be confirmed (Fig. 14‑1). Electromyography is often useful when there are neurologic impairment symptoms indicating an acute phase.

In diagnosing, it is necessary to inspect for soft hernias as well as carpal tunnel and Guyon symptoms, which are quite common in older patients, while keeping in mind potential shoulder pathologies. The treatment is based on prescription of analgesics (level I, II, or III) and nonsteroidal anti-inflammatory drugs, in accordance with the precautions and contraindications applicable to the elderly and patients with multicomorbidity, but also through rest by wearing a surgical collar and by physiotherapy (self-stretching exercises and stress-relieving massages). A CT-guided infiltration can help overcome an acute phase, but has little or no effect in cases with calcified hernias and posterior osteophytes.

Surgery is only required when there are neurological radicular disorders or when pain increases over more than 6 to 8 weeks despite suitable medical treatment. Treatment is usually a standard diskectomy-arthrodesis via the anterior sternocleidomastoid approach. ⁵ In rare cases, the posterior approach is indicated, but the calcified nature of the hernias and the median prolongation of the osteophytes makes this surgery increasingly risky. The restoration of lordosis during the arthrodesis is still a matter of debate. Based on the work of Le Huec, ⁶ lordosis is physiological in only 50% of cases. It therefore seems advisable to measure the C7 slope before any cervical arthrodesis. If the C7 slope is less than 20°, a neutral fixation is preferable. If greater than 20°, the cervical spine is naturally in lordosis and it therefore makes sense to maintain the native curvature by arthrodesis. Surgery involving several levels is problematic because the risk of developing an adjacent syndrome is not negligible. Whereas there are presently no guidelines available, maintaining good posterior cervical muscle strength is undoubtedly the best prevention.

Myelopathy as a result of osteoarthrosis of the cervical spine is a common phenomenon. It is all the more important when there is a C2-C7 cervical kyphosis, which presses the spinal cord against the corporal osteophytes, even in the absence of ossification of the posterior longitudinal ligament.

The standard clinical picture associates certain signs

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  To the upper limbs with parasthesia of the hands, more or less systemic with clumsiness (difficulty buttoning clothes, sewing, tinkering, etc.).

  
  
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  To the lower limbs that with gait fatigue. This fatigue is often wrongly labeled because of the lack of any characteristic radicular signs, patients describing a general weakness, often with a reduced walking perimeter, but also sometimes with an erratic or spastic gait.

  
  
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  To the urinary sphincter, often present but wrongly diagnosed as dysuria.

However, this standard clinical picture is not the most commonly observed, and the clinical presentations may combine several elements (posterior cord compression, amyotrophic, sphincteral, etc.). The presence of pyramidal signs can be noted, with a positive Hoffmann sign and a unilateral or bilateral Babinski sign.

Possible complications are mostly the Schneider syndrome or suspended spinal cord syndrome, which can ensue from a benign trauma or a low-impact fall, rather than the classic whiplash mechanism following a road accident. The clinical diagnosis is based on frontal and lateral radiography, but above all on MRI, which will reveal a narrowing of the cervical central canal caused by osteophytes at several levels, accompanied by myelopathy, well-illustrated by a T2 hypersignal on the MRI (Fig. 14‑2). The treatment of these changes has not yet been clearly coded.

Management of osteoarthritic cervical myelopathies is based on surgical decompression, which has proved more efficient than conservative treatment. ⁷ Surgery does not always reduce clinical signs, but permits stabilization of lesions. The choice of technique depends on the patient’s age and general state, the number of segments affected by stenosis, and, last, the sagittal profile of the spine. Therefore, the treatment must be adapted according to the following criteria ⁸ :

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  If the spine is lordotic, with a central stenosis at more than three levels, “open-door” laminoplasty and reconstruction is the technique of choice. However, caution should be taken at the C5-C6 level, where a risk of paresis or paralysis of both roots exists through elongation when the spinal cord is released backward.

  
  
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  If the spine is lordotic with stenosis at one to three levels, then the anterior approach with corporectomy, grafting, and fusion is satisfactory (Fig. 14‑3).

  
  
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  If the spine is kyphotic with a central stenosis, an anterior approach is also preferable, with a corporectomy at one or two levels; if more than two levels of corporectomy are required, an intermediate vertebra must be retained to ensure a stable assembly. In fact, corpectomies at more than two levels have a much higher incidence of failure. Lordosis may be restored by the anterior approach using a sufficiently long graft or expandable cages. Occasionally, this anterior approach is insufficient and can be supplemented by posterior facet screws.

  

These criteria are no more than a decision-making framework. The advantages and disadvantages of each of these methods are not clearly agreed on and remain the subject of numerous studies.

14.2.1 At the Lumbar Level

The most common pathology is intermittent radicular claudication. The diagnosis is based on the general clinical experience of radiculalgia. It must be differentiated from vascular pathology. The palpation of the distal pulse must be systematic because in elderly patients the two pathologies may be interlinked. However, a posture in lumbar kyphosis to relieve pain, as well as its metameric topography, both help determine the diagnosis. The use of a cane to attend consultation often indicates the patient’s need to compensate for the kyphosis necessary to increase the width of the central canal and the foramina. This analgesic kyphotic posture must be differentiated from a fixed kyphosis, irreducible in the supine position, and from a kyphosis caused by muscular insufficiency as with camptocormia. Radiography, MRI, and CT are standard examinations to confirm this central canal and/or foraminal stenosis, sometimes associated with disk inflammation and especially with vacuum disks caused by degenerative collapse (Fig. 14‑4).

Treatment is mostly surgical. In fact, conservative treatment is not without merit, but is less effective than surgery for reducing pain and improving quality of life. ⁹ Decompression is the technique ¹⁰ mostly associated with stabilization, depending on the extent of the facet resection needed to free the roots. An analysis of their sagittal balance is therefore an important factor in determining whether or not to operate on these patients. The use of minimally invasive techniques is highly desirable as they are not very destabilizing. The tube technique, with or without an endoscope or microscope, is the method of choice for operating on a single level. Differentiation of a voluntary kyphosis for dynamic widening of the canal is essential because a simple decompression, best assessed by the patient’s odontoid-hip axis angle (OD-HA), and the absence of pelvic retroversion will suffice. Postoperatively, the patient will regain a satisfactory overall balance. ¹¹ If the kyphotic posture is related to pathology such as multilevel kyphogenic DDD, ankylosing spondylitis, or major muscular insufficiency, then stabilization and correction of the deformity will be needed as described hereafter. In the second situation, the patient has pelvic retroversion and other compensatory mechanisms visible on the full standing X-rays. ¹²

Related posts:

17 Advantages and Limitations of the SRS-Schwab Classification for Adult Spinal Deformity 15 Scheuermann’s Kyphosis 16 Cervical Sagittal Alignment and Cervicarthrosis 13 Degenerative Spondylolisthesis: Does the Sagittal Balance Matter? 12 Isthmic Lytic Spondylolisthesis—The Physiopathology, Classification, and Treatment Better Explained by the Sagittal Balance 24 Surgical Failures Mechanisms and Their Treatment

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