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Cervical Radiculopathy

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Topic updated on 03/29/14 3:12pm
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 is 
      • 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 for 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 identitfy 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 compression 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 can not 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 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 resorbption 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 inflamation 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
    • selective nerve root corticosteroid injections
      • indicaitons
        • 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 itrogenic 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 swallowng 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 logus colli muscle at C6
  • Adjacent segment disease

 

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Qbank (12 Questions)

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

1. Shoulder abduction test
2. Lateral forearm pain with resisted extension of the long fingers
3. Intrinsic wasting
4. Hoffman Sign
5. Inverted brachioradialis reflex

PREFERRED RESPONSE ▶
TAG
(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. A preoperative laryngoscopy shows abnormal function of the left vocal cord. What approach would be contraindicated during revision surgery and why? Topic Review Topic
FIGURES: A          

1. Revision ACDF with a right-sided approach due to hypoglossal nerve palsy
2. Revision ACDF with a left-sided approach due to hypoglossal nerve palsy
3. Revision ACDF with a right-sided approach due to recurrent laryngeal nerve palsy
4. Revision ACDF with a left-sided approach due to recurrent laryngeal nerve palsy
5. Posterior cervical fusion due to inferior thryroid nerve palsy

PREFERRED RESPONSE ▶
TAG
(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? Topic Review Topic
FIGURES: A          

1. A C5 radiculopathy leading to deltoid and biceps weakness.
2. A C5 radiculopathy leading to brachioradialis and wrist extension weakness.
3. A C5 radiculopathy leading to triceps and wrist flexion weakness.
4. A C6 radiculopathy leading to brachioradialis and wrist extension weakness.
5. A C6 radiculopathy leading to finger flexion weakness.

PREFERRED RESPONSE ▶
TAG
(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? Topic Review Topic
FIGURES: A          

1. Biceps weakness, posterolateral C5-6 disc herniation
2. Hand intrinsic weakness, C8-T1 foraminal stenosis from an uncovertebral osteophyte
3. Shoulder abduction weakness, posterolateral C4-5 disc herniation
4. Wrist flexion weakness, C6-7 foraminal stenosis from an uncovertebral osteophyte
5. Wrist extension weakness, posterolateral C6-7 disc herniation

PREFERRED RESPONSE ▶
TAG
(OBQ12.192) Which of the following patients would be considered the best candidate for treatment with a posterior cervical foraminotomy? Topic Review Topic
FIGURES: A   B   C   D   E  

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)
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)
3. A 56-year-old male that presents left arm pain, and weakness to elbow flexion and wrist extension (MRI shown in Figure C)
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)
5. A 45-year-old female that presents with progressive intermittent weakness and paresthesia is all 4 extremities (MRI shown in Figure E)

PREFERRED RESPONSE ▶
TAG
(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. Topic Review Topic

1. Tendinosis and inflammation at origin of ECRB
2. Compression of the posterior interosseous nerve by the proximal edge of supinator
3. Compression of the ulnar nerve in Guyon's canal
4. A paracentral cervical disc herniation at C5/6
5. A foraminal disc herniation at C6/7

PREFERRED RESPONSE ▶
TAG
(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: Topic Review Topic

1. Increased intraoperative blood loss
2. Longer postoperative hospitalization
3. Decreased revision surgery rate
4. Decreased fusion rate
5. Increased complication rate

PREFERRED RESPONSE ▶
TAG
(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? Topic Review Topic

1. C3-4
2. C4-5
3. C5-6
4. C6-7
5. C7-T1

PREFERRED RESPONSE ▶
TAG
(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? Topic Review Topic

1. tongue deviation to left when extruded
2. tongue deviation to right when extruded
3. ptosis on left side of face
4. ptosis on right side of face
5. change in voice

PREFERRED RESPONSE ▶
TAG
(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? Topic Review Topic
FIGURES: A          

1. Weakness to shoulder shrug
2. Weakness to shoulder abduction and elbow flexion
3. Weakness to elbow flexion and wrist extension
4. Weakness to elbow extension and wrist flexion
5. Weakness to finger abduction

PREFERRED RESPONSE ▶
TAG
(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. Topic Review Topic

1. Numbness of the lateral shoulder and deltoid weakness
2. Numbness of 2nd and 3rd fingers and triceps weakness
3. Numbness of the thumb with weakness to wrist extension
4. Numbness of 5th finger with weakness to long flexor function in all digits and thumb
5. Numbness of the medial elbow and weakness to long finger flexion of the 4th and 5th digits only

PREFERRED RESPONSE ▶
TAG
(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. Topic Review Topic

1. Relief of pain when holding the arm above the head
2. Reproduction of pain with tilting head to affected side and rotating head to contralateral side
3. Compensatory inter-phalangeal joint flexion of the thumb when attempting to pinch
4. Patient is unable to make "AOK" sign with index finger and thumb
5. Forearm pain with resisted wrist extension

PREFERRED RESPONSE ▶
TAG
(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? Topic Review Topic
FIGURES: A          

1. Physical therapy and NSAIDS
2. High dose methylprednisone
3. C5/6 hardware removal and C4/5 ACDF using a left sided anterior approach
4. C5/6 hardware removal and C4/5 ACDF using a right sided anterior approach
5. C5 to C7 posterior laminectomy and fusion

PREFERRED RESPONSE ▶
TAG
(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? Topic Review Topic

1. Guyon’s canal syndrome
2. Cubital tunnel syndrome
3. Diabetic neuropathy
4. Cervical radiculopathy
5. Cervical myelopathy

PREFERRED RESPONSE ▶



Cases

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