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Introduction
  • A clinical symptom caused by nerve root compression in the cervical spine
    • characterized by sensory or motor symptoms in the upper extremity
  • Pathophysiology
    • causes
      • degenerative cervical spondylosis topic
        • discosteophyte complex and loss of disc height
        • chondrosseous spurs of facet and uncovertebral joints
      • disc herniation ("soft disc")
        • usually posterolateral
          • between posterior edge of uncinate and lateral edge of PLL
    • neural compression
      • nerve root irritation caused by
        • direct compression
        • irritation by chemical pain mediators, including
          • IL-1
          • IL-6
          • substance P
          • bradykinin
          • TNF alpha
          • prostaglandins
      • affects the nerve root below
        • C6/7 disease will affect the C7 nerve root
Anatomy
  • Nerve root anatomy
    • key differences between cervical and lumbar spine are 
      • pedicle/nerve root mismatch
        • cervical spine C6 nerve root travels above C6 pedicle (mismatch)
        • lumbar spine L5 nerve root travels under L5 pedicle (match)
        • extra C8 nerve root (no C8 pedicle) allows transition
      • horizontal (cervical) vs. vertical (lumbar) anatomy of nerve root
        • because of vertical anatomy of lumbar nerve root, a paracentral and foraminal disc will affect different nerve roots
        • because of horizontal anatomy of cervical nerve root, a central and foraminal disc will affect the same nerve root
Symptoms
  • Symptoms 
    • occipital headache (common)
    • trapezial or interscapular pain
    • neck pain
      • may present with insidious onset of neck pain that is worse with vertebral motion
      • origin may be discogenic, or mechanical due to facet arthrosis
      • pain may radiate to shoulders
    • unilateral arm pain
      • aching pain radiating down arm
      • often global and nondermatomal
    • unilateral dermatomal numbness & tingling
      • numbness/tingling in thumb (C6)
      • numbness/tingling in middle finger (C7)
    • unilateral weakness
      • difficulty with overhead activities (C7)
      • difficulty with grip strength (C7)
  • Physical exam
    • common and testable exam findings
      • C5 radiculopathy
        • deltoid and biceps weakness 
        • diminished biceps reflex 
      • C6 radiculopathy   
        • brachioradialis and wrist extension weakness
        • diminished brachioradialis reflex
        • paresthesias in thumb 
      • C7 radiculopathy
        • triceps and wrist flexion weakness 
        • diminished triceps reflex
        • paresthesia in the index,middle, ring 
      • C8 radiculopathy
        • weakness to distal phalanx flexion of middle and index finger (difficulty with fine motor function)
        • paresthesias in little finger 
    • provocative tests
      • Spurling Test positive 
        • simultaneous extension, rotation to affected side, lateral bend, and vertical compression reproduces symptoms in ipsilateral arm
      • shoulder abduction test   
        • shoulder abduction relieves symptoms 
          • shoulder abduction (lifting arm above head) often relieves symptoms
          • valuable physical exam test to differentiate cervical pathology from other causes of shoulder/arm pain
    • myelopathy 
      • check for findings of myelopathy in large central disc herniations
Imaging
  • Radiographs
    • recommended views
      • AP, lateral, oblique views of cervical spine
      • obtain flexion and extension views if suspicion for instability
    • findings
      • general
        • degenerative changes of uncovertebral and facet joints
        • osteophyte formation
        • disc space narrowing & endplate sclerosis
      • lateral radiograph
        • important to look for sagittal alignment and spinal canal diameter
      • oblique radiograph
        • best view to identify foraminal stenosis caused by osteophytes
      • flexion and extension views
        • important to look for angular or translational instability
        • look for compensatory subluxation above or below the spondylotic/stiff segment
    • sensitivity & specificity
      • changes often do not correlate with symptoms
        • 70% of patients by 70 yrs of age will have degenerative changes seen on plain xrays
  • MRI  post
    • views
      • T2 axial imaging is the modality of choice and gives needed information on the status of the soft tissues. 
    • findings
      • disc degeneration and herniation
      • foraminal stenosis with nerve root compression (loss of perineural fat)
      • central compression with CSF effacement
    • sensitivity & specificity
      • has high rate of false positive (28% greater than 40 will have findings of HNP or foraminal stenosis)
  • CT 
    • indications
      • gives useful information on bony anatomy including osteophyte formation that is compressing the neural elements
      • useful as a preoperative planning tool to plan instrumentation
      • study of choice to evaluate for postoperative pseudoarthosis
  • CT myelography
    • indications
      • largely replaced by MRI
      • useful in patients who cannot have an MRI due to pacemaker, etc
      • useful in patients with prior surgery and hardware causing artifact on MRI
    • technique
      • intrathecal injection of contrast given via C1-C2 puncture and allowed to diffuse caudally
      • lumbar puncture and allowed to diffuse proximally by putting patient in Trendelenburg position.
  • Discography
    • indications
      • controversial and rarely indicated in cervical spondylosis
    • techniques
      • approach is similar to that used with ACDF
    • risks include esophageal puncture and disc infection
Studies
  • Nerve conduction studies
    • high false negative rate
    • may be useful to distinguish peripheral from central process (ALS)
  • Selective nerve root corticosteroid injections
    • may help confirm level of radiculopathy in patients with multiple level disease, and when  physical exam findings and EMG fail to localize level
Differential
  • Carpal tunnel syndrome
  • Cubital tunnel syndrome
  • Parsonage-Turner Syndrome
Treatment
  • Nonoperative 
    • rest, medications, and rehabilitation
      • indications
        • 75% of patients with radiculopathy improve with nonoperative management 
        • improvement via resorption of soft discs and decreased inflammation around irritated nerve roots
      • techniques (very few substantiated by evidence)
        • immobilization
          • immobilization for short period of time (< 1-2 weeks) may help by decreasing inflammation and muscles spasm
        • medications
          • NSAIDS / COX-2 inhibitors
          • oral corticosteroids
          • GABA inhibitors (neurontin)
          • narcotics
          • muscle relaxants
        • rehabilitation
          • moist heat
          • cervical isometric exercises
          • traction/manipulation
            • avoid in myelopathic patients
      • return to play 
        • indicated after resolution of symptoms and repeat MRI demonstrating no cord compression
        • studies have shown return to play expedited with brief course of oral methylprednisolone (medrol dose pack) 
        • no increased risk of subsequent spinal cord injury
    • selective nerve root corticosteroid injections
      • indications
        • may be considered as therapeutic or diagnostic option
      • outcomes
        • increased risk when compared to lumbar selective nerve root injections with the following rare but possible complications, including
          • dural puncture
          • meningitis
          • epidural abscess
          • nerve root injury
  • Operative
    • anterior cervical discectomy and fusion
      • indications
        • persistent and disabling pain that has failed nonoperative modalities
        • progressive and significant neurologic deficits
      • outcomes
        • remains gold standard in surgical treatment of cervical radiculopathy
        • single level ACDF is not a contraindication for return to play for athletes
    • posterior foraminotomy 
      • indications 
        • foraminal soft disc herniation causing single level radiculopathy ideal
        • may be used in osteophytic foraminal narrowing
      • outcomes
        • 91% success rate
        • reduces the risk of iatrogenic injury with anterior approaches
    • cervical total disc replacement
      • indications (controversial)
        • single level disease with minimal arthrosis of the facets 
      • outcomes
        • studies show equivalence to ACDF
        • effect on adjacent level disease remains unclear
          • some studies show 3% per year for all approaches
Techniques
  • Anterior Cervical Discectomy and Fusion (ACDF) 
    • approach
      • uses Smith-Robinson anterior approach 
    • techniques
      • decompression
        • placement of bone graft increases disk height and decompresses the neural foramen through indirect decompression
        • corpectomy and strut graft may be required for multilevel spondylosis
      • fixation
        • anterior plating functions to increase fusion rates and preserve position of interbody cage or strut graft
    • pros and cons
      • complications of anterior surgery including persistent swallowing problems
  • Posterior foraminotomy
    • approach
      • posterior approach
    • technique
      • if anterior disc herniation is to be removed, then superior portion of inferior pedicle should be removed
    • pros & cons
      • advantages
        • avoids need for fusion
        • avoids problems associated with anterior procedure
      • disadvantages
        • more difficult to remove discosteophyte complex
        • disc height can not be restored
  • Total disc replacement
    • approach
      • uses Smith-Robinson anterior approach 
    • pros & cons
      • avoids nonunions
Complications
  • Pseudoarthrosis 
    • incidence
      • 5 to 10% for single level fusions, 30% for multilevel fusions
      • risk factors
        • smoking
        • diabetes
        • multi-level fusions
    • treatment
      • if asymptomatic observe
      • if symptomatic, treat with either posterior cervical fusion or repeat anterior decompression and plating if patient has symptoms of radiculopathy
        • improved fusion rates seen with posterior fusion 
  • Recurrent laryngeal nerve injury (1%)  
    • laryngeal nerve follows aberrant pathway on the right
      • although theoretically the nerve is at greater risk of injury with a right sided approach, there is no evidence to support a greater incidence of nerve injury with a right sided approach.
    • treatment
      • initial treatment is observation
      • if not improved over 6 weeks, than ENT consult to scope patient and inject teflon
  • Hypoglossal nerve injury  
    • a recognized complication after surgery in the upper cervical spine with an anterior approach
    • tongue will deviate to side of injury 
  • Vascular injury
    • vertebral artery injury (can be fatal)
  • Dysphagia 
    • higher risk at higher levels (C3-4)
  • Horner's syndrome
    • characterized by ptosis, anhydrosis, miosis, enophthalmos and loss of ciliospinal reflex on the affected side of the face
    • caused by injury to sympathetic chain, which sits on the lateral border of the longus coli muscle at C6
  • Adjacent segment disease
 

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Questions (14)

(OBQ13.45) A 28-year-old man presents with pain in the distribution shown in Figure A, and numbness in the middle finger. After performing a complete neurological exam, his surgeon orders an MRI of his cervical spine. Which of the following motor exam findings and MRI findings are consistent with the symptoms present? Review Topic

QID:4680
FIGURES:
1

Biceps weakness, posterolateral C5-6 disc herniation

3%

(82/2607)

2

Hand intrinsic weakness, C8-T1 foraminal stenosis from an uncovertebral osteophyte

3%

(68/2607)

3

Shoulder abduction weakness, posterolateral C4-5 disc herniation

1%

(25/2607)

4

Wrist flexion weakness, C6-7 foraminal stenosis from an uncovertebral osteophyte

62%

(1612/2607)

5

Wrist extension weakness, posterolateral C6-7 disc herniation

31%

(811/2607)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

The distribution of pain and numbness is consistent with C7 radiculopathy.

Characteristic motor findings in C7 radiculopathy include middle finger pain, weak triceps (elbow extension) and wrist flexion, and diminished triceps reflex. In the cervical spine, nerve roots exit ABOVE their correspondingly numbered pedicles. Thus C7 root exits between C6-7. In comparison, in the lumbar spine, nerve roots exit BELOW their correspondingly numbered pedicles. And posterolateral pathologies impinge on TRAVERSING roots, while foraminal pathologies impinge on EXITING roots.

Rhee et al. reviewed cervical radiculopathy. They state that acute cervical radiculopathy has 75% rate of spontaneous improvement with nonsurgical treatment. If surgery is necessary, either anterior cervical discectomy and fusion (ACDF) or posterior laminoforaminotomy is warranted.

Caridi et al. also reviewed cervical radiculopathy. Advantages of ACDF include increased fusion rates (with graft insertion in the disc space) and decompression of the neural foramina by increasing its cephalocaudal dimension. On the other hand, the posterior approach maintains spinal alignment and does not require fusion, but increases risk of neck pain (from posterior muscle dissection).

Figure A shows the distribution of pain in C7 radiculopathy. Illustration A shows the distribution of pain in C5-C8 radiculopathies (A, C5; B, C6; C, C7; D, C8). Illustration B shows the spectrum of signs with different cervical radiculopathy patterns. Illustration C shows root positions with respect to the intervertebral disc at cervical and lumbar levels.

Incorrect Answers:
Answer 1: Biceps weakness indicates C5 or C6 radiculopathy. The bicep is served by nerve roots C5 and C6. C5-6 disc herniation leads to C6 radiculopathy.
Answer 2: Hand intrinsic weakness indicates T1 radiculopathy. C7-T1 foraminal stenosis from an uncovertebral osteophyte leads to C8 radiculopathy (same as posterolateral C7-T1 disc herniation). There is no C8 vertebra.
Answer 3: Shoulder abduction (deltoid) weakness indicates C5 radiculopathy. Posterolateral C4-5 disc herniation leads to C5 radiculopathy.
Answer 5: Wrist extension weakness indicates C6 radiculopathy. Posterolateral C6-7 disc herniation leads to compression on the exiting root (C7), same as foraminal compression (also C7 root).

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(SBQ12.17) Which of the following physical exam findings supports the diagnosis of cervical radiculopathy? Review Topic

QID:3715
1

Shoulder abduction test

58%

(1543/2668)

2

Lateral forearm pain with resisted extension of the long fingers

3%

(71/2668)

3

Intrinsic wasting

16%

(415/2668)

4

Hoffman Sign

16%

(432/2668)

5

Inverted brachioradialis reflex

7%

(193/2668)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1

The shoulder abduction test is a maneuver that has been found to be specific for the diagnosis of cervical radiculopathy.

Two helpful tests for diagnosing cervical radiculopathy include the Spurling test and the shoulder abduction test. Patients with a positive shoulder abduction sign will have improvement of their symptoms with elevation of the arm above the head. This is an important test to distinguish cervical pathology from other sources of shoulder/arm pain.

Rhee et al. note that cervical nerve roots course at 45-degree angles when entering the neural foramina. This occurs in a ventro-lateral direction across compressive lesions. They postulate that abduction of the shoulder may cause relief as a result of decreased tensile stresses in the nerve root adjacent to the compressive lesion.

Viikari-Juntura et al. investigated validity of the shoulder abduction test in the diagnosis of cervical radiculopathy. They found this test was highly specific but had low sensitivity. Thus, they recommend this test as a valuable aid in the clinical examination of a patient with neck and arm pain.

Illustration A shows an example of a patient demonstrating the shoulder abduction sign.

Incorrect Answers:
Answer 2: Lateral forearm pain with resisted extension of the long fingers is consistent with a diagnosis of lateral epicondylitis
Answer 3: Intrinsic wasting is most consistent with ulnar neuropathy, not cervical radiculopathy.
Answer 4: A Hoffman sign is indicative of an upper motor neurologic disorder. It is noted to be positive when the there is flexion of the other digits after flicking the distal phalanx of the long digit. This may be seen in cervical myelopathy.
Answer 5: An inverted brachioradialis reflex is seen when tapping of the distal brachioradialis leads to a reflexive contraction of the finger flexors, despite a diminished brachioradialis reflex. This is consistent with cervical myelopathy.

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(SBQ12.84) A 50-year-old woman presents for followup two years after having cervical spine surgery through a left-sided approach with severe neck pain. A recent radiograph is seen in Figure A. Her surgeon advises her that she will need revision surgery. Preoperative laryngoscopy shows abnormal left vocal cord function because of paralysis of the left posterior cricoarytenoid muscle. What approach would be CONTRAINDICATED during revision surgery? Review Topic

QID:3782
FIGURES:
1

Revision ACDF with a right-sided approach due to superior laryngeal nerve palsy

3%

(84/2606)

2

Revision ACDF with a left-sided approach due to superior laryngeal nerve palsy

1%

(23/2606)

3

Revision ACDF with a right-sided approach due to recurrent laryngeal nerve palsy

83%

(2156/2606)

4

Revision ACDF with a left-sided approach due to recurrent laryngeal nerve palsy

13%

(326/2606)

5

Posterior cervical fusion due internal laryngeal nerve palsy

0%

(6/2606)

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PREFERRED RESPONSE 3

A recurrent laryngeal nerve palsy on the left contraindicates revision ACDF with a right-sided approach.

Patients with RLN injury from the initial surgery may eventually become asymptomatic. If revision surgery is planned from the opposite side, the vocal cords need to be evaluated with laryngoscopy preoperatively. If there was asymptomatic (left) RLN injury from the initial surgery, then the opposite side approach is inadvisable for fear of developing bilateral vocal cord paralysis and its catastrophic complications. The recurrent laryngeal nerve innervates the posterior cricoarytenoid, the only muscle to open the vocal cords.

Edwards et al. discussed treatment strategies for cervical myelopathy. They state that temporary hoarseness occurs in 3-11% and permanent hoarseness in 0.33%. The risk of injury is also related to the length of the procedure and force of retraction, increased levels of decompression and revision surgery. They also draw attention to the superior laryngeal nerve (SLN), which innervates a portion of the larynx and vocal cords and is located between C2-3. The SLN may be damaged during higher anterior cervical approaches.

Kahraman et al. examined dysphonia after anterior cervical approach. The incidence of temporary unilateral vocal cord paralysis is 1-8% and permanent paralysis is 0.15-3.5%. They state that the RLN is usually injured from indirect stretch or focal pressure.

Figure A shows ACDF of C5-6 with nonunion and hardware failure.

Incorrect Answers:
Answers 1, 2: The vocal cords are innervated by the recurrent laryngeal nerve. The superior laryngeal nerve supplies the cricothyroid muscle and modulates voice pitch and explosive sounds.
Answer 4: A vocal cord palsy on 1 side is a contraindication to a CONTRALATERAL approach.
Answer 5: The internal laryngeal nerve branch of the superior laryngeal nerve is purely sensory.


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(OBQ12.192) Which of the following patients would be considered the best candidate for treatment with a posterior cervical foraminotomy? Review Topic

QID:4552
FIGURES:
1

A 72-year-old female with progressive numbness and tingling in her bilateral upper extremities, and complaints of frequently dropping objects (MRI shown in Figure A)

6%

(75/1357)

2

A 36-year-old male that presents following a motor vehicle accident and exam and is an ASIA B on presentation (CT shown in Figure B)

2%

(23/1357)

3

A 56-year-old male that presents left arm pain, and weakness to elbow flexion and wrist extension (MRI shown in Figure C)

20%

(267/1357)

4

A 45-year-old male that presents with right arm pain and weakness to elbow extension and wrist flexion (MRI shown in Figure D)

69%

(933/1357)

5

A 45-year-old female that presents with progressive intermittent weakness and paresthesia is all 4 extremities (MRI shown in Figure E)

4%

(51/1357)

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PREFERRED RESPONSE 4

Answer 4 gives the clinical presentation of cervical radiculopathy caused by a soft disc herniation in a young patient. Figure D shows an axial MRI that reveals a right foraminal disc herniation at C6/7. A posterior cervical foraminotomy would be an appropriate treatment option in this patient.

Posterior cervical foraminotomy is highly effective in treating patients with cervical radiculopathy. The approach is effective in decompressing lateral spinal roots that are compromised by soft disk herniations or osteophytic spurs. It also reduces the risk of iatrogenic injury with anterior approaches. Long-term radiographic follow-up shows no significant trend toward kyphosis and improved long-term pain scores compared to non-operative treatment.

Kumar et al. reviewed 89 patients treated with laminoforaminotomy for cervical spondylotic radiculopathy caused by osteophytes. Using Odom's outcomes criteria, approx. 95% of patients had good to excellent results, with a mean followup of 8.6 months. Revision surgery for recurrence was required in 6.7% of cases.

Jagannathan et al. retrospectively reviewed of 162 cases of cervical radiculopathy treated with posterior cervical foraminotomy. Neck Disability Index (NDI) was used for clinical follow-up, which showed that 93% improved with this procedure. Resolution of radiculopathy was relieved in 95% of patients.

Illustrations A and B show schematic images of cervical foraminal nerve compression and posterior cervical foraminotomy, respectively.

Incorrect Answers and Figure descriptions:
Answer 1: This clinical presentation is consistent with cervical myelopathy. Posterior cervical foraminotomy would not be an approriate treatment. Figure A shows multilevel disease with increased signalling within the cervical spinal cord.
Answer 2: This clinical presentation in consistent with incomplete spinal cord injury. Posterior cervical foraminotomy would not be an approriate treatment. Figure B shows a C6-7 facet disloation with impingement on the spinal cord.
Answer 3: This clinical presentation in consistent with a C6 cervical radiculpathy due to a midline/paracentral disc osteophyte complex. Posterior cervical foraminotomy would not be an approriate treatment. Figure C shows a MRI axial cut of a midline disc osteophyte causing cord compression.
Answer 5: This clinical presentation in consistent with a multiple sclerosis. MS is not treated with surgical decompression. Figure E shows multiple lesions within the cervical spine, which is consistent with a diagnosis of MS.

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(OBQ12.197) A 57-year old male presents with right arm pain of 4 weeks duration. He reports the pain began following a tennis match and has not improved with time. He describes the pain as an aching sensation that affects his lateral forearm that improves when he abducts the shoulder. He also describe a sensation of numbness in this right thumb. Reflex exam shows he has 1+ right biceps reflexes and 2+ right triceps reflexes which are both symmetric with the left side. Sensory exam shows paresthesias in the distribution of the right thumb. Motor exam shows no evidence of radial deviation with active wrist extension. Motor exam on the right shows 5/5 deltoid, 5/5 elbow flexion with the palms facing upward, 4/5 wrist extension, and 5/5 elbow extension, and 5/5 wrist flexion. What is the most likely etiology of his symptoms. Review Topic

QID:4557
1

Tendinosis and inflammation at origin of ECRB

7%

(231/3093)

2

Compression of the posterior interosseous nerve by the proximal edge of supinator

10%

(299/3093)

3

Compression of the ulnar nerve in Guyon's canal

1%

(20/3093)

4

A paracentral cervical disc herniation at C5/6

63%

(1958/3093)

5

A foraminal disc herniation at C6/7

18%

(566/3093)

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PREFERRED RESPONSE 4

The clinical presentation is most consistent with a C6 radiculopathy. This would be cause by a a paracentral cervical disc herniation at C5/6.

The differential diagnosis for neuropathic pain in the upper extremity includes peripheral neuropathies, cervical radiculopathy, and peripheral musculoskeletal conditions. Cervical radiculopathy is characterized by unilateral dermatomal distribution of pain which often improves with abduction of the shoulder. A C6 radiculopathy is characterized by weakness to brachioradialis (elbow flexion weakness at a midpoint between supination and pronation), ECRL weakness (wrist extension weakness), sensory changes in the thumb, and a diminished brachioradialis reflex.

Rhee et al. report the differential diagnosis of cervical radiculopathy includes peripheral nerve entrapment syndromes; brachial plexus injury; Parsonage-Turner’s syndrome; and tendinopathies of the shoulder, elbow, and wrist. They report that selective cervical nerve root injections can be useful in confirming the source of symptoms if they improve for a time after the injection, and that electromyography and nerve conduction tests may help differentiate radiculopathy from peripheral entrapment disorders.

Viikari-Juntura et al. investigated validity of the shoulder abduction test in the diagnosis of cervical radiculopathy. They found this test was highly specific but had low sensitivity. Thus, the recommend this test as a valuable aid in the clinical examination of a patient with neck and arm pain.

Illustration A shows the dermatomal distribution of C6. Illustration B shows some key differences between the cervical spine and lumbar spine nerve root anatomy. It shows that in the cervical spine the nerve root travels above the corresponding pedicle whereas in the lumbar spine it travels below the corresponding pedicle. In addition, due to the direct lateral trajectory of the cervical nerve root, both a central and foraminal disc affect the same nerve root. This differs in the lumbar spine where due to the descending path of the nerve root, a paracentral and foraminal (far lateral) disc often affect different nerve roots.

Incorrect Answers:
Answer 1: Lateral epicondylitis, caused by tendinosis and inflammation at origin of ECRB, present with lateral forearm pain and weakness to wrist extension. However, pain relieved by shoulder abduction and paresthesias of the thumb are not characteristic of tennis elbow.
Answer 2: Compression of the posterior interosseous nerve by the proximal edge of supinator is a common cause of PIN compression syndrome. This condition is characterized by painless weakness to wrist extension with noticeable radial deviation.
Answer 3: Compression of the ulnar nerve in Guyon's canal is cause of ulnar tunnel syndrome. This condition is characterized by paresthesias in ulnar 1-1/2 digits and clawing of the ring and little fingers.
Answer 5: A foraminal disc herniation at C6/7 would lead to a C7 radiculopathy. This would be characterized by decreased triceps reflexes, weakness of elbow extension and wrist flexion, and paresthesias of the index and middle finger.

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(OBQ10.88) Treatment options for a symptomatic cervical pseudoarthrosis following anterior cervical diskectomy and fusion include revision anterior surgery versus a posterior instrumented cervical fusion. When comparing these treatment options, all of the following are true of posterior cervical fusion EXCEPT: Review Topic

QID:3176
1

Increased intraoperative blood loss

4%

(75/1773)

2

Longer postoperative hospitalization

5%

(89/1773)

3

Decreased revision surgery rate

21%

(373/1773)

4

Decreased fusion rate

54%

(952/1773)

5

Increased complication rate

16%

(279/1773)

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PREFERRED RESPONSE 4

Despite increased complications, posterior cervical fusion is the treatment of choice for symptomatic cervical pseudoarthrosis following anterior cervical diskectomy and fusion due to its increased fusion rate and lower revision surgery rate.

The study by Carreon et al is a retrospective case series that compared posterior cervical fusion versus revision anterior surgery for the treatment of a symptomatic pseudoarthrosis. They found a second revision surgery for persistent nonunion was required in 44% of patients in the anterior revision group, and only 2% of the patients in the posterior revision group. Therefore, they argue that despite increased blood loss, longer postoperative hospitalization, and an increased complication rate, posterior cervical fusion is a better treatment option due to higher fusion rates and a decrease in revision surgery rates.

The study by Kuhns et al looked at the results of treating a cervical pseudoarthrosis with posterior cervical fusion. They found that 33 of 33 patients went on to fusion with posterior surgery and all 33 patients noted significant improvement in their preoperative symptoms. They did find a significant rate of persistent postoperatively neck pain despite fusion. They found no difference in fusion rates between those treated with iliac crest versus patients treated with local bone graft.


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(SBQ09.6) A 49-year-old male presents with left arm pain of four weeks duration. A T2-weighted axial MRI is shown in Figure A. Which of the following statements would most accurately describe his diagnosis and physical exam findings? Review Topic

QID:3369
FIGURES:
1

A C5 radiculopathy leading to deltoid and biceps weakness.

19%

(358/1859)

2

A C5 radiculopathy leading to brachioradialis and wrist extension weakness.

2%

(31/1859)

3

A C5 radiculopathy leading to triceps and wrist flexion weakness.

1%

(15/1859)

4

A C6 radiculopathy leading to brachioradialis and wrist extension weakness.

75%

(1398/1859)

5

A C6 radiculopathy leading to finger flexion weakness.

2%

(44/1859)

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PREFERRED RESPONSE 4

The MRI is consistent with a posterolateral disc herniation at C5/6. This would lead to a C6 radiculopathy, which is most likely presents with dermatomal arm pain, paresthesias in the thumb, weakness to brachioradialis and wrist extension, and a diminished brachioradialis reflex.

Eubanks reviews the pathophysiology of cervical radiculopathy. They describe that unlike the lumbar spine, the cervical spine has cervical nerve roots that exit above the level of the corresponding pedicle. For instance, the C6 nerve root exits at the C5-C6 disk space, and a C5-C6 disk herniation typically leads to C6 radiculopathy.

Heller emphasizes separating patterns of symptomatic degenerative cervical disease from other causes of neck, shoulder, and arm symptoms rests on an awareness of the broad spectrum of subjective complaints, a thorough physical examination, and confirmatory diagnostic studies. Clear delineation of the etiology will increase the likelihood of successful treatment.

Incorrect Answers:
Answer 1 & 2: A C5 radiculopathy leads to deltoid and biceps weakness, and would be caused by a posterolateral disc herniation at C4/5.
Answer 3: A C7 radiculopathy leads to triceps and wrist flexion weakness, and would be caused by a posterolateral disc herniation at C6/7.
Answer 5: A C8 radiculopathy leads to finger flexion weakness, and would be caused by a posterolateral disc herniation at C7/T1.


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(OBQ09.199) A 59 year-old man complains of acute pain radiating from the neck down the right upper extremity. Physical exam demonstrates right arm triceps weakness, decreased triceps reflex, and diminished sensation of the middle finger. A cervical disk herniation will likely be found at which level? Review Topic

QID:3012
1

C3-4

0%

(6/2460)

2

C4-5

1%

(13/2460)

3

C5-6

3%

(76/2460)

4

C6-7

90%

(2218/2460)

5

C7-T1

6%

(142/2460)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

The exam findings are consistent with a C7 radiculopathy which is commonly caused by a C6-7 cervical disk herniation.

A cervical spine herniated disk causes impingement on the exiting nerve root at the herniation level. In the cervical spine the nerve roots exit ABOVE the pedicle of the numbered level. For example, the C7 nerve root exits above the C7 pedicle at the C6-7 level.

Heller et al. describes the characteristic findings of cervical radiculopathies and myelopathy. A C7 radiculopathy affects the motor strength of the triceps and wrist flexion, has a diminished triceps reflex, and diminished sensation in the middle finger distribution.

Illustration A shows the two key difference between cervical and lumbar spine with respect to pathology and level affected.

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(OBQ07.35) During an anterior diskectomy and fusion at C2-3 there is concern for an injury to the left hypoglossal nerve. What physical findings would be expected if this were the case? Review Topic

QID:696
1

tongue deviation to left when extruded

84%

(995/1190)

2

tongue deviation to right when extruded

14%

(169/1190)

3

ptosis on left side of face

1%

(6/1190)

4

ptosis on right side of face

0%

(3/1190)

5

change in voice

1%

(15/1190)

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PREFERRED RESPONSE 1

The hypoglossal nerve is the twelfth cranial nerve and innervates the tongue muscles. If there is a unilateral injury to the hypoglossal nerve, the tongue will deviate towards the side of injury. In this question there is concern for an injury to the left hypoglossal nerve so you would expect tongue deviation to the left.

Horner's syndrome is characterized by ptosis, anhidrosis, miosis, enophthalmos and loss of ciliospinal reflex on the affected side of the face. It is caused by injury to the sympathetic chain, which can occur during an anterior approach to the neck.

The recurrent (inferior) laryngeal nerve is a branch of the vagus nerve (tenth cranial nerve) that supplies motor function and sensation to the larynx. A unilateral injury to the recurrent laryngeal nerve may lead to voice changes including hoarseness. Bilateral nerve damage can result in breathing difficulties and aphonia, the inability to speak.


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(OBQ07.148) A 33-year-old male presents with neck and left arm pain. He denies symptoms in his right arm. Based on the MRI image shown in Fig A, what findings would be expected on physical exam? Review Topic

QID:809
FIGURES:
1

Weakness to shoulder shrug

8%

(162/2086)

2

Weakness to shoulder abduction and elbow flexion

88%

(1829/2086)

3

Weakness to elbow flexion and wrist extension

4%

(83/2086)

4

Weakness to elbow extension and wrist flexion

0%

(7/2086)

5

Weakness to finger abduction

0%

(2/2086)

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PREFERRED RESPONSE 2

The MRI shows an axial T2-weighted image with a left sided disc herniation causing foraminal stenosis at the C4/5 level. This would affect the C5 nerve root, and lead to deltoid (shoulder abduction) and biceps (elbow flexion) weakness.

In the cervical spine, the nerve root runs above the corresponding pedicle in a horizontal manner. Therefore, the inferior nerve root is affected (C4/5 would affect C5) with both a central and foraminal disc herniation. This is in contrast to the lumbar spine where the nerve root runs below the corresponding pedicle. In addition, in the lumbar spine the nerve root runs in a vertical descending direction before exiting. For this reason, at each level in the lumbar spine you can find both a descending and exiting nerve root. This explains why in the lumbar spine a foraminal disc affects the exiting nerve root (L4 with a L4/5 foraminal disc) and a paracentral disc affects the descending nerve root (L5 with a L4/5 paracentral disc).

Figure A shows a left side disc-osteophyte complex affecting the C5 nerve root. Illustration A shows the primary differences between the cervical and lumbar spine with regard to nerve root anatomy.

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(OBQ06.82) A 38-year-old male presents with a cervical disc herniation at the C7/T1 level with associated foraminal stenosis, but no significant central stenosis. What would be the expected symptoms and physical exam findings. Review Topic

QID:193
1

Numbness of the lateral shoulder and deltoid weakness

0%

(8/1795)

2

Numbness of 2nd and 3rd fingers and triceps weakness

12%

(214/1795)

3

Numbness of the thumb with weakness to wrist extension

2%

(31/1795)

4

Numbness of 5th finger with weakness to long flexor function in all digits and thumb

56%

(1004/1795)

5

Numbness of the medial elbow and weakness to long finger flexion of the 4th and 5th digits only

30%

(532/1795)

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PREFERRED RESPONSE 4

A disc hernation at the C7/T1 level will most likely affect the C8 nerve root. A C8 radiculopathy usually presents with sensory symptoms in the medial border of the forearm and hand, and weakness in long flexor function in all digits and thumb. It is important to differentiate a C8 radiculopathy from a peripheral ulnar neuropathy which also presents with sensory symptoms in the ulnar hand and finger. One way to do so is to test DIP flexion of the middle and index finger. The function of the flexor digitorum profundus in the index and middle fingers can be affected by 8th cervical radiculopathy, but they are not affected by ulnar nerve entrapment. The reference by Rao is a review of the pathoanatomy of cervical spondylosis and the different clinical manifestations. They recommend a simplified clinical approach of dividing the presenting findings into the categories of axial neck pain, radiculopathy, myelopathy, or some combination of these three.


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(OBQ06.175) In a patient with arm pain and paresthesias, which of the following symptoms or physical exam findings supports a cervical radiculopathy as opposed to a peripheral neuropathy. Review Topic

QID:361
1

Relief of pain when holding the arm above the head

47%

(291/617)

2

Reproduction of pain with tilting head to affected side and rotating head to contralateral side

48%

(295/617)

3

Compensatory inter-phalangeal joint flexion of the thumb when attempting to pinch

4%

(24/617)

4

Patient is unable to make "AOK" sign with index finger and thumb

1%

(5/617)

5

Forearm pain with resisted wrist extension

0%

(2/617)

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PREFERRED RESPONSE 1

Relief of pain when holding the arm above the head is indicative of a cervical radiculopathy instead of a peripheral neuropathy.

Davidson et al found that in 22 patients requiring myelography for unremitting radicular pain, 15 experienced relief of pain with shoulder abduction. Of the 15 with this physical exam finding, 13 patients achieved a good result with cervical surgery. In conclusion, they argue this exam finding has value as an indicator for cervical radicular compressive disease and postulate that the maneuver seems to occur by decreasing tension on the nerve root.

Incorrect Answers:
Answer 2: Reproduction of pain with tilting head to the affected side and rotating head to the ipsilateral (not contralateral) side is called the Spurling's sign and also indicates cervical pathology.
Answer 3: Compensatory inter-phalangeal joint flexion of the thumb when attempting to pinch (Froment's sign) is seen with a peripheral ulnar neuropathy.
Answer 4: Inability to make an "A-OK" sign with index finger and thumb is seen with a peripheral AIN compressive neuropathy.
Answer 5: Forearm pain with resisted wrist extension is seen with lateral epicondylitis (tennis elbow).


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(OBQ05.119) A 52-year-old woman underwent a C5/6 ACDF for cervical radiculopathy through a left-sided approach two years ago. Radiographs are shown in Figure A. She has had an altered voice since this operation. Recently, the patient has developed myelopathic symptoms including gait instability and dexterity problems with her hands. An MRI shows a fusion at C5/6, and an adjacent-level midline disc herniation at C4/5 with cord compression and myelomalacia. Laryngoscopy of the vocal cords demonstrates abnormal function of the vocal cords on the left hand side. Which of the following is the most appropriate treatment for this patient? Review Topic

QID:1005
FIGURES:
1

Physical therapy and NSAIDS

1%

(19/1716)

2

High dose methylprednisone

0%

(5/1716)

3

C5/6 hardware removal and C4/5 ACDF using a left sided anterior approach

85%

(1459/1716)

4

C5/6 hardware removal and C4/5 ACDF using a right sided anterior approach

4%

(73/1716)

5

C5 to C7 posterior laminectomy and fusion

9%

(154/1716)

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PREFERRED RESPONSE 3

The clinical scenario describes a patient with cervical myelopathy due to an anterior midline disc herniation at the adjacent C4/5 level. In addition, she has voice changes and abnormal vocal cord function likely due to an injury to the left recurrent laryngeal nerve (RLN) during her prior left sided approach. The most appropriate treatment at this time is hardware removal at C5/6 (she is fused) and anterior cervical discectomy and fusion at C4/5 utilizing a left sided approach through her old incision. One should avoid using a right-sided approach, as a right recurrent larygngeal nerve (RLN) injury would cause denervation of both vocal cords leading to breathing difficulties and aphonia.

Netterville et al showed that multiple branches of the vagus nerve are are risk during surgery. They also concluded that right-sided approaches carry a greater risk to the recurrent laryngeal nerve as its course is more variable.

Kilburg et al reviewed 418 cases and showed no significant difference in RLN injury based on laterality of approach.

Steurer et al found that hoarseness following neck surgery may be present with or without the presence of a RLN palsy. They also found patients may have a normal voice despite an RLN palsy. Therefore, they recommend evaluation with laryngoscopy or videostroboscopy in "at risk" patients to identify a RLN palsy.

Incorrect Answers:
Answer 1 & 2: Because the patient is myelopathic, physical therapy and high dose steroid are not appropriate.
Answer 4: See description above.
Answer 5: The patient has anterior compression from a midline disc herniation, and therefore a posterior decompression would not adequately address her focal anterior compression.


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(OBQ05.257) A 50-year-old diabetic woman describes left arm pain and tingling in the ulnar side of her hand and wrist. She denies weakness or trouble with fine motor tasks. Her symptoms are worse when she is sleeping without a pillow on her left side, and with her left elbow in an extended position. Sleeping with her left hand above her head seems to improve her symptoms. What is the most likely diagnosis? Review Topic

QID:1143
1

Guyon’s canal syndrome

2%

(37/1761)

2

Cubital tunnel syndrome

8%

(146/1761)

3

Diabetic neuropathy

1%

(12/1761)

4

Cervical radiculopathy

88%

(1551/1761)

5

Cervical myelopathy

1%

(14/1761)

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PREFERRED RESPONSE 4

The patient is describing cervical radiculopathy symptoms that are alleviated with shoulder abduction, which removes tension on the cervical roots, and are worsened with sleeping with her neck bent laterally in a position similar to the Spurling compression test.

The reference by Vikari-Juntura et al describes the high specificity of cervical exam maneuvers like the Spurling compression test, shoulder abduction test, and axial traction test but found low sensitivity (25-50%) of these tests in diagnosing cervical radiculopathy.

Incorrect Answers:
Answer 1: Guyon’s canal syndrome would not affect sensation in the dorsal wrist area.
Answer 2: Cubital tunnel syndrome is typically worse with elbow flexion and improved with extension.
Answer 3: Diabetic neuropathy is typically in a glove and stocking distribution and is rarely painful.
Answer 5: Myelopathy typically has upper motor findings and difficulty with fine motor tasks.


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