Management of Bulging Disc Osteophytes with Congenitally Narrow Spinal Canal and Position-Dependent Vertigo
Surgical decompression is recommended for patients with cervical disc osteophytes at C5-6 and C6-7 with congenitally narrow spinal canal, particularly when neurological symptoms like vertigo with head turning are present, as this indicates potential vertebrobasilar insufficiency or central cord compression. 1
Diagnostic Approach
Cervical Spine Evaluation
- MRI is the preferred imaging modality for evaluating the cervical spine as it provides superior visualization of soft tissues, vertebral marrow, and spinal canal 1
- Assess for:
- Degree of spinal canal stenosis (critical if diameter <13 mm) 2
- Extent of cord compression from disc osteophytes
- Signal changes within the spinal cord indicating myelopathy
- Presence of instability with flexion/extension views
Vertigo Assessment
- Perform the Dix-Hallpike maneuver to rule out BPPV as a cause of positional vertigo 1
- Perform the supine roll test to evaluate for lateral canal BPPV 3
- Note that vertigo with leftward head turning in this case is more likely related to cervical pathology rather than BPPV, as:
- BPPV typically produces brief (<60 seconds) episodes of vertigo
- Cervical spondylosis with narrow canal can cause vertebrobasilar insufficiency with head rotation
Treatment Algorithm
Step 1: Determine if Vertigo is Related to BPPV or Cervical Pathology
- If positive Dix-Hallpike or supine roll test:
Step 2: If Vertigo Persists or BPPV Tests Negative
- The vertigo is likely related to cervical pathology with the following mechanisms:
- Vertebrobasilar insufficiency from mechanical compression during head rotation
- Central cord syndrome from cervical stenosis 1
- Direct irritation of proprioceptive afferents in the upper cervical spine
Step 3: Surgical Management
- Surgical decompression is indicated due to:
Surgical Options:
Posterior approach: Laminoplasty or laminectomy with fusion
- Preferred for multi-level compression with congenitally narrow canal 4
- Lower complication rate than anterior approaches for multi-level disease
- Addresses the entire narrowed canal
Anterior approach: Anterior cervical discectomy and fusion (ACDF)
- Consider for 1-2 level disease without significant congenital narrowing
- Better for addressing focal disc osteophytes but less effective for diffuse stenosis
Important Considerations and Pitfalls
Risks of Delayed Treatment
- Patients with congenitally narrow canals (<13 mm) are at significantly higher risk for developing progressive myelopathy 2
- Acute neurological deterioration can occur even with minor trauma or neck movements in patients with pre-existing stenosis 5
Surgical Risks
- Potential for temporary neurological worsening after decompression due to cord reperfusion injury 1
- Risk of C5 palsy after posterior decompression
- Careful surgical planning is essential to avoid complications like those described in case reports of cervical decompression 6
Non-Surgical Management
- While some cases of disc calcification may resolve spontaneously (particularly in pediatric patients) 7, this is unlikely in an adult with osteophytes and congenital stenosis
- Non-surgical management carries the risk of progressive myelopathy and should be avoided when neurological symptoms are present
Follow-up Care
- Post-surgical rehabilitation focusing on neck strengthening and proprioception
- Regular neurological assessment to monitor for improvement in vertigo symptoms
- Avoidance of extreme neck positions that may trigger symptoms
The combination of bulging disc osteophytes and congenitally narrow spinal canal represents a significant risk factor for developing myelopathy, and the presence of vertigo with head turning suggests neurological compromise is already occurring, making surgical intervention the most appropriate management strategy.