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Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC.
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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?
Biceps weakness, posterolateral C5-6 disc herniation
Hand intrinsic weakness, C8-T1 foraminal stenosis from an uncovertebral osteophyte
Shoulder abduction weakness, posterolateral C4-5 disc herniation
Wrist flexion weakness, C6-7 foraminal stenosis from an uncovertebral osteophyte
Wrist extension weakness, posterolateral C6-7 disc herniation
Select Answer to see Preferred Response
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.
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).
Rhee JM, Yoon T, Riew KD
J Am Acad Orthop Surg. 2007 Aug;15(8):486-94. PMID: 17664368 (Link to Abstract)
Caridi JM, Pumberger M, Hughes AP.
HSS J. 2011 Oct;7(3):265-72. Epub 2011 Sep 9. PMID: 23024624 (Link to Abstract)
Please rate question.
Average 3.0 of 22 Ratings
Which of the following physical exam findings supports the diagnosis of cervical radiculopathy?
Shoulder abduction test
Lateral forearm pain with resisted extension of the long fingers
Inverted brachioradialis reflex
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.
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.
Viikari-Juntura E, Porras M, Laasonen EM
Spine. 1989 Mar;14(3):253-7. PMID: 2711240 (Link to Abstract)
Average 4.0 of 13 Ratings
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?
Revision ACDF with a right-sided approach due to superior laryngeal nerve palsy
Revision ACDF with a left-sided approach due to superior laryngeal nerve palsy
Revision ACDF with a right-sided approach due to recurrent laryngeal nerve palsy
Revision ACDF with a left-sided approach due to recurrent laryngeal nerve palsy
Posterior cervical fusion due internal laryngeal nerve palsy
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.
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.
Edwards CC 2nd, Riew KD, Anderson PA, Hilibrand AS, Vaccaro AF.
Spine J. 2003 Jan-Feb;3(1):68-81. PMID: 14589250 (Link to Abstract)
Kahraman S, Sirin S, Erdogan E, Atabey C, Daneyemez M, Gonul E.
Eur Spine J. 2007 Dec;16(12):2092-5. Epub 2007 Sep 8. PMID: 17828422 (Link to Abstract)
Average 4.0 of 11 Ratings
Which of the following patients would be considered the best candidate for treatment with a posterior cervical foraminotomy?
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)
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)
A 56-year-old male that presents left arm pain, and weakness to elbow flexion and wrist extension (MRI shown in Figure C)
A 45-year-old male that presents with right arm pain and weakness to elbow extension and wrist flexion (MRI shown in Figure D)
A 45-year-old female that presents with progressive intermittent weakness and paresthesia is all 4 extremities (MRI shown in Figure E)
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.
Am Fam Physician. 2010 Jan 1;81(1):33-40. PMID: 20052961 (Link to Abstract)
Jagannathan J, Sherman JH, Szabo T, Shaffrey CI, Jane JA
J Neurosurg Spine. 2009 Apr;10(4):347-56. PMID: 19441994 (Link to Abstract)
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.
Tendinosis and inflammation at origin of ECRB
Compression of the posterior interosseous nerve by the proximal edge of supinator
Compression of the ulnar nerve in Guyon's canal
A paracentral cervical disc herniation at C5/6
A foraminal disc herniation at C6/7
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.
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.
Average 4.0 of 25 Ratings
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:
Increased intraoperative blood loss
Longer postoperative hospitalization
Decreased revision surgery rate
Decreased fusion rate
Increased complication rate
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.
Carreon L, Glassman SD, Campbell MJ.
Spine J. 2006 Mar-Apr;6(2):154-6. Epub 2006 Jan 25. PMID: 16517386 (Link to Abstract)
Kuhns CA, Geck MJ, Wang JC, Delamarter RB
Spine. 2005 Nov;30(21):2424-9. PMID: 16261120 (Link to Abstract)
Average 2.0 of 40 Ratings
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?
A C5 radiculopathy leading to deltoid and biceps weakness.
A C5 radiculopathy leading to brachioradialis and wrist extension weakness.
A C5 radiculopathy leading to triceps and wrist flexion weakness.
A C6 radiculopathy leading to brachioradialis and wrist extension weakness.
A C6 radiculopathy leading to finger flexion weakness.
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.
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.
Orthop Clin North Am. 1992 Jul;23(3):381-94. PMID: 1620533 (Link to Abstract)
Average 4.0 of 21 Ratings
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?
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.
Average 4.0 of 29 Ratings
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?
tongue deviation to left when extruded
tongue deviation to right when extruded
ptosis on left side of face
ptosis on right side of face
change in voice
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.
Sengupta DK, Grevitt MP, Mehdian SM.
Eur Spine J. 1999;8(1):78-80. PMID: 10190859 (Link to Abstract)
Beutler WJ, Sweeney CA, Connolly PJ.
Spine (Phila Pa 1976). 2001 Jun 15;26(12):1337-42. PMID: 11426148 (Link to Abstract)
Average 3.0 of 29 Ratings
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?
Weakness to shoulder shrug
Weakness to shoulder abduction and elbow flexion
Weakness to elbow flexion and wrist extension
Weakness to elbow extension and wrist flexion
Weakness to finger abduction
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.
Average 4.0 of 32 Ratings
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.
Numbness of the lateral shoulder and deltoid weakness
Numbness of 2nd and 3rd fingers and triceps weakness
Numbness of the thumb with weakness to wrist extension
Numbness of 5th finger with weakness to long flexor function in all digits and thumb
Numbness of the medial elbow and weakness to long finger flexion of the 4th and 5th digits only
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.
J Bone Joint Surg Am. 2002 Oct;84-A(10):1872-81. PMID: 12377921 (Link to Abstract)
Average 4.0 of 42 Ratings
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.
Relief of pain when holding the arm above the head
Reproduction of pain with tilting head to affected side and rotating head to contralateral side
Compensatory inter-phalangeal joint flexion of the thumb when attempting to pinch
Patient is unable to make "AOK" sign with index finger and thumb
Forearm pain with resisted wrist extension
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.
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).
Davidson RI, Dunn EJ, Metzmaker JN
Spine (Phila Pa 1976). 1981 Sep-Oct;6(5):441-6. PMID: 7302677 (Link to Abstract)
Average 3.0 of 53 Ratings
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?
Physical therapy and NSAIDS
High dose methylprednisone
C5/6 hardware removal and C4/5 ACDF using a left sided anterior approach
C5/6 hardware removal and C4/5 ACDF using a right sided anterior approach
C5 to C7 posterior laminectomy and fusion
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.
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.
Netterville JL, Koriwchak MJ, Winkle M, Courey MS, Ossoff RH.
Ann Otol Rhinol Laryngol. 1996 Feb;105(2):85-91. PMID: 8659941 (Link to Abstract)
Steurer M, Passler C, Denk DM, Schneider B, Niederle B, Bigenzahn W.
Laryngoscope. 2002 Jan;112(1):124-33. PMID: 11802050 (Link to Abstract)
Kilburg C, Sullivan HG, Mathiason MA
J Neurosurg Spine. 2006 Apr;4(4):273-7. PMID: 16619672 (Link to Abstract)
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?
Guyon’s canal syndrome
Cubital tunnel syndrome
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.
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.
Average 4.0 of 31 Ratings
HPI - History of recent numbness of the 2nd and 3rd finger of the left hand of 14 days duration, associated with mild neck pain.
What is the diagnosis?
HPI - # Pain in the neck and right arm since 8 weeks. Pain significant in the first 2 weeks and gradually getting better and is under control on Pregabalin (75 mg BD). Initially treated with Diclofenac and oral steroid course. Pain still present but intermittent and mild discomfort. Noted especially while repeatedly abducting the shoulder.No interruption in daily routines.
# Weakness: Initial weakness using the right hand in the first 2 weeks. Gradually improving. Currently some subjective weakness.
No history of trauma
What should be the next step of management for pain (still requiring oral medications) and subjective weakness
HPI - The patient, a retired professional tennis player, developed pain in his right arm approximately 12 weeks ago following a tennis match. Initially the pain was severe, but with a trial of physical therapy, and selective corticosteroid injections the pain resolved. However, now we continues to have significant weakness in the right arm that is severe enough that he can no longer play tennis anywhere near the level he use to. He reports some mild numbness and tingling in his right thumb. He denies any weakness or paresthesias in the left arm.
He reports ~ 30 years ago he had a diving accident where he hit his head and had immediate and severe neck pain. He denies having any neurologic symptoms at that time.
An EMG was done which showed a C5 and C6 radiculopathy.
How would you treat this patient with weakness (C5 and C6) and paresthesias (C6) but no significant pain.
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