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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
        • Provides long-term relief in 40-70% of cases 
        • 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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