Updated: 6/1/2021

Cervical Radiculopathy

0%
Topic
Review Topic
0
0
0%
0%
Flashcards
52
N/A
N/A
Questions
41
0
0
0%
0%
Evidence
67
0
0
0%
0%
Videos / Pods
6
0%
0%
Cases
3
0%
Techniques
1
Topic
Images
https://upload.orthobullets.com/topic/2030/images/mri-cervical-t2 axial-c6-7hnp-derekpersonal.jpg
https://upload.orthobullets.com/topic/2030/images/axial.jpg
https://upload.orthobullets.com/topic/2030/images/sagittal.jpg
https://upload.orthobullets.com/topic/2030/images/foraminal_disc.jpg
  • Summary
    • Cervical Radiculopathy is a clinical condition characterized by unilateral arm pain, numbness and tingling in a dermatomal distribution in the hand, and weakness in specific muscle groups.
    • Evaluation consists of a thorough neurologic examination, cervical spine radiographs including flexion-extension views, and MRI of the cervical spine.
    • Nonoperative treatment is successful in 75% - 90% of patients, with surgical decompression reserved for refractory cases or patients with progressive neurologic deficits.
  • Epidemiology
    • Incidence
      • 107.3 per 100,000 men annually
      • 63.5 per 100,000 women annually
      • 50 to 54 years age peak range
    • Risk factors
      • white race
      • cigarette smoking
      • prior lumbar radiculopathy
  • Etiology
    • Pathophysiology
      • causes
        • degenerative cervical spondylosis
          • discosteophyte complex and loss of disc height
          • chondrosseous spurs of facet and uncovertebral joints
        • disc herniation ("soft disc")
          • intraforaminal
            • radicular pain predominantly
          • posterolateral
            • most common
            • between posterior edge of uncinate and lateral edge of PLL
            • mostly motor symptoms
          • midline herniation
            • usually presents with myelopathic symptoms
        • double-crush phenomenon
          • combined cervical root compression and distal nerve compression
          • decreased axoplasmic flow from root compression predisposes downstream nerves to peripheral entrapment syndromes
        • rare causes
          • intraspinal/extraspinal tumors
          • trauma with nerve root avulsion
          • synovial cysts
          • meningeal cysts
          • dural arteriovenous fistulae
          • tortuous vertebral arteries
      • neural compression
        • nerve root irritation caused by
          • direct compression
          • irritation by chemical pain mediators, including
            • IL-1
            • IL-6
            • substance P
            • neuropeptide Y
            • calcitonin gene-relate peptide
            • bradykinin
            • TNF alpha
            • prostaglandins
        • affects the nerve root below
          • C6/7 disease will affect the C7 nerve root
  • Anatomy
    • Articulations
      • facet joints
        • facet hypertrophy and osteophytes can impinge on nerve root posteriorly
      • disc space
        • loss of disc height can decrease volume of neuroforamen
      • uncovertebral joints
        • osteophytes from posterior joint can impinge on exiting nerve anteriorly
    • Intervertebral disc
      • annulus fibrosus
        • thick fibrous outer layer of the intervertebral disc
        • contains type I collagen
        • thicker ventrally than dorsally
      • nucleus pulposus
        • "cushioning" between the vertebral bodies
        • contains type II collagen and glycosaminoglycans (GAGs)
          • GAGs contains a high negative charge and attacts large amounts of water molecules
            • GAGs breakdown with increasing age
        • 90% water content in patients under 30 years of age
          • decreases to 70% by eighth decade of life
    • 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
        • ventrolateral course from spinal cord
          • predisposes to ventral compression
  • Presentation
    • 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
        • C4 radiculopathy
          • scapular winging
          • numbness and pain at the base of the neck
        • C5 radiculopathy
          • deltoid and biceps weakness
          • diminished biceps reflex
          • pain and numbness in the superior shoulder and lateral upper arm
          • brachioradialis and wrist extension weakness
          • diminished brachioradialis reflex
          • paresthesias in the thumb and radial arm
        • C7 radiculopathy
          • triceps and wrist flexion weakness
          • diminished triceps reflex
          • paresthesia in the middle finger
          • most commonly affected nerve root in cervical radiculopathy in several studies
        • C8 radiculopathy
          • weakness to distal phalanx flexion of middle and index finger (difficulty with fine motor function)
          • paresthesias in ring and little finger
          • C8 radiculopathy is extremely rare and often manifests similarly as ulnar neuropathy
        • T1 radiculopathy
          • intrinsic hand muscle weakness
          • axillary numbness
          • ipsilateral Horner's syndrome
      • provocative tests
        • Spurling's test
          • simultaneous extension, rotation to affected side, lateral bend, and vertical compression reproduces symptoms in ipsilateral arm
          • narrowing of the intervertebral foramina causes exacerbation of symptoms
          • specific, but not sensitive for radiculopathy
        • shoulder abduction test
          • shoulder abduction relieves symptoms
            • shoulder abduction (lifting arm above head) often relieves symptoms
              • decreases tension on affected nerves
            • valuable physical exam test to differentiate cervical pathology from other causes of shoulder/arm pain
        • upper limb tension tests
        • valsalva maneuver
        • neck distraction test
      • 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
      • indications
        • red flags signs
          • fever
          • weight loss
          • pain that wakes patient at night
          • persisent symptoms despite 6 weeks of conservative treatment
          • motor weakness
      • views
        • T2 axial imaging is the modality of choice and gives needed information on the status of the soft tissues
          • CSF appears hyperintense
            • loss of CSF signal around the cord and nerve root
      • 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)
        • >50% over the age of 40 years will have a degenerated disc
    • 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
          • detect ossification of the posterior longitudinal ligament
            • may not be as evident on MRI or radiography
        • 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 water soluble 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
        • sensitivity 40% to 70%
        • not a good screening study
      • may be useful to distinguish peripheral from central process (ALS)
      • fibrillations and positive sharp waves in the affected distribution
        • may not manifest until 3 weeks after onset of symptoms
        • paraspinal muscles are affected before appendicular muscles
      • sensory nerve action potentials are typically normal
        • compression is usually proximal to the dorsal root ganglion
      • compound muscle action potential proportional decrease to muscle atrophy
    • 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
    • Thoracic outlet syndrome
  • Diagnosis
    • Clinical and MRI studies
      • diagnosis is be made by history, physical examination and MRI studies
  • 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
        • 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 three months of conservative management
          • progressive and significant neurologic deficits
          • static neurologic deficit associated with significant radicular pain
        • outcomes
          • remains gold standard in surgical treatment of cervical radiculopathy
          • single level ACDF is not a contraindication for return to play for athletes
          • very high success rate with single level disease
          • higher rate of pseudoarthrosis with multilevel procedures
            • 20% for single level ACDF vs >50% for multilevel ACDF
            • pseudoarthrosis rate does not appear to correlate with clinical outcomes
      • anterior cervical foraminotomy
        • indications
          • isolated unilateral nerve root compresssion
          • avoidance of fusion
            • high risk patients for pseudoarthrosis
              • smokers
              • diabetics
        • outcomes
          • limited studies
          • not widely accepted
          • 98% excellent outcomes reported in literature
      • posterior foraminotomy
        • indications
          • foraminal soft disc herniation causing single level radiculopathy ideal
          • may be used in osteophytic foraminal narrowing
          • failed nonoperative treatment
          • high risk patients with anterior approach
            • previous anterior surgery
            • abnormal anatomy
        • contraindications
          • large central disc herniation
          • cervical myelopathy
          • instability
          • OPLL
          • kyphotic deformity
        • outcomes
          • >91% success rate
          • reduces the risk of iatrogenic injury with anterior approaches
          • low complication rate
            • ~3%
          • no difference in outcomes compared to ACDF
          • faster return to work and lower treatment cost than ACDF
      • cervical disc arthroplasty
        • indications (controversial)
          • single level disease with minimal arthrosis of the facets
        • outcomes
          • studies show equivalence to ACDF
            • no difference in arm pain, NDI, SF-36 scores, and neurologic improvement
          • effect on adjacent level disease remains unclear
            • some studies show 3% per year for all approaches
            • systmeatic reviews have demonstrated no difference in ASD rate between CDA and ACDF
          • lower reoperation rates seen with CDA
          • lower neck pain intensity and freauency with CDA
          • high incidence of heterotopic bone formation
            • 60% of cases
            • no effect on motion profile
  • Techniques
    • Rest, medications, and rehabilitation
      • techniques (very few substantiated by evidence)
        • immobilization
          • immobilization for short period of time (< 1-2 weeks) may help by decreasing inflammation and muscles spasm
          • prolonged immobilization should be avoided
            • cervical muscle atrophy
        • medications
          • NSAIDS / COX-2 inhibitors
          • oral corticosteroids
          • GABA inhibitors (neurontin)
          • narcotics
            • short term use in the acute phase
          • muscle relaxants
        • rehabilitation
          • moist heat
          • cervical isometric exercises
          • traction/manipulation
            • avoid in myelopathic patients
    • Selective nerve root corticosteroid injections
      • approach
        • fluoroscopic guidance
        • injection consisting of steroid and local anesthetic
          • studies have shown no difference in long-term pain relief with local anesthetic alone and combined steroid
    • Anterior Cervical Discectomy and Fusion (ACDF)
      • approach
        • uses Smith-Robinson anterior approach
          • transverse incision for 1- and 2-level disease
          • longitudinal incision for multilevel disease and corpectomies or patients with short and thick necks
            • C7-T1 exposure
              • increased risk of thoracic duct injury with left-sided approach
        • C7-T1 exposure
          • increased risk of thoracic duct injury with left-sided approach
        • lower risk of recurrent laryngeal nerve injury with left-sided approach
          • recurrent laryngeal nerve passes between trachea and esophagus
          • retractor displacement compresses nerve against inflated endotracheal tube
            • cuff deflation can theoretically decrease recurrent laryngeal nerve injury
        • superficial landmarks for levels
          • C1-2: inferior margin of the mandible
          • C3-4: hyoid
          • C4-6: thyroid cartilage
          • C5-6: cricoid cartilage
      • 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
            • increased cost and complication risk for increased exposure
            • decreases implant extrusion and graft collapse
          • historically, plating required bicortical fixation (Caspar plates)
            • high risk for neurologic injury
              • intraoperative fluoroscopy used to prevent over penetration of screws
          • modern plating contains constraining mechanism to allow sufficient fixation with unicortical screws
            • dynamic plates:
              • allow controlled settling of the interbody construct and physiologic loading of the graft
              • theoretical benefit of increased fusion rates and decreased screw pull out
            • static plates:
              • maintains screws at fixed angles through plate (similar to locking plate)
          • no difference in fusion rates with single-level disease with plating compared to no plating
            • increased fusion rate, decreased graft complications, lower reoperation rate, and earlier return to work with plating in multilevel disease
        • graft
          • autograft
            • locally harvested
            • iliac crest bone graft
              • gold standard
              • donor site pain
                • minimized with limited surgical exposure
                • careful dissection of the inner and outer tables of the ilium
          • allograft
            • higher potential for disease transmission
            • higher pseudoarthrosis rates (41% vs 27%)
            • higher graft subsidence rates (28% vs 16%)
            • structural graft
              • iliac crest
              • fibular strut
              • patella
      • post-op care
        • ambulatory the day of surgery
        • soft collar immobilization for short period of time
          • prolonged immobilization in hard collar if anterior plating not used
        • range of motion and strengthening beginning at 6 weeks
        • return to full activity by 3 months
      • pros and cons
        • complications of anterior surgery including persistent swallowing problems
        • adjacent segment disease
    • Anterior cervical foraminotomy
      • approach
        • anterolateral approach to the cervical spine
        • longus colli split longitudinally
          • medial to the anterior tubercle of the transverse process
      • technique
        • removal of uncovertebral joint
        • decompression of the exiting nerve root
      • pros and cons
        • avoids fusing the involved level
        • potential risk of sympathetic chain and vertebral artery injury
    • Posterior foraminotomy
      • approach
        • postitioning
          • sitting
            • comfortable position
            • limits epidural bleeding (less engorgement of veins compared to prone positioning)
            • risk of venous air embolism
          • prone
            • familiar approach for most surgeons
        • posterior approach
          • open
            • muscle stripping from lamina and spinous process
            • lateral exposure to the lateral border of the lateral mass
          • microendoscopic
            • minimally invasive approach
              • reduced intraoperative blood loss
              • faster OR time
              • shorter hospital stays
              • less postoperative narcotic consumption
            • no difference in effectiveness of decompression compared to open foraminotomy
      • technique
        • if anterior disc herniation is to be removed, then superior portion of inferior pedicle should be removed
        • minimal nerve root retraction
          • nerve root decompressed posteriorly, superiorly, and inferiorly
      • 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
          • significant muscle pain and spasm (muscle splitting approach)
          • significant bleeding (epidural vessels)
          • inability to correct sagittal alignment
    • Cervical disc arthroplasty
      • 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
          • diabetes
          • multi-level fusions
          • revision surgery
      • 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%)
      • most common nerve injury from this operation
      • anatomic course of the nerve differs on the right and left side
        • 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)
        • very rate injury
        • aberrant vertebral artery path poses greater risk for injury
    • Dysphagia
      • higher risk at higher levels (C3-4)
      • risk can be minimized with the use of zero-profile anchored cages
        • less prominence of anterior hardware reduces irritation and impingement of prevertebral structures, such as espohagus
    • Esophageal injury
      • rare but devastating injuries
      • early perforation (at the time of the procedure)
        • usually caused by sharp instruments
          • can be minimized by using dull retractors and avoiding excessive retraction
        • should be repaired as soon as the injury is noticed
      • late perforation
        • usually from plate loosening or pullout
        • technically difficult to repair
        • require nasogastric tube and parenteral hyperalimentation for a prolonged period of time
    • 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
    • Airway complications
      • risk factors
        • prolonged surgical duration (>5 hours)
        • exposure above C4
        • greater than 4 levels involved in fusion construct
Technique Guides (1)
Flashcards (52)
Cards
1 of 52
Questions (41)
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK

(OBQ17.198) A 36-year-old man presents with acute onset of pain in his left shoulder and arm. The pain began after a pick-up football game 10 days ago. He localizes the pain to the lateral and posterior aspect of his arm and describes it as an aching sensation. He also reports numbness over the dorsal forearm and long finger. On physical exam, his pain is alleviated when abducting and elevating his arm. He also has weakness with long finger extension. Radiographs are shown in Figures A-D. Which of the following is the most likely diagnosis and finding that would be seen on a magnetic resonance imaging study?

QID: 210285
FIGURES:
1

C6 radiculopathy, left paracentral disc at the C5/C6 level

7%

(134/1892)

2

C6 radiculopathy, left paracentral disc at the C6/C7 level

4%

(68/1892)

3

C7 radiculopathy, left paracentral disc at the C6/C7 level

64%

(1203/1892)

4

C7 radiculopathy, left paracentral disc at the C7/T1 level

7%

(131/1892)

5

C8 radiculopathy, left paracentral disc at the C7/T1 level

18%

(343/1892)

L 3 A

Select Answer to see Preferred Response

Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK

(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?

QID: 4680
FIGURES:
1

Biceps weakness, posterolateral C5-6 disc herniation

4%

(182/4993)

2

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

2%

(124/4993)

3

Shoulder abduction weakness, posterolateral C4-5 disc herniation

1%

(54/4993)

4

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

62%

(3080/4993)

5

Wrist extension weakness, posterolateral C6-7 disc herniation

30%

(1518/4993)

L 3 A

Select Answer to see Preferred Response

Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK

(SBQ12SP.102) A 63-year-old male has a long-standing history of neck pain. Recently he developed pain radiating into his right shoulder and arm as well as numbness and tingling in his right small finger. He also reports decreased grip strength. On physical exam he has a positive shoulder abduction provocative test, weakness with distal phalanx flexion of the right middle and index fingers, and weakness to thumb extension. At which vertebral level is there likely pathology compressing the nerve root?

QID: 3800
1

C4/5

2%

(38/2316)

2

C5/6

10%

(227/2316)

3

C6/7

22%

(498/2316)

4

C7/T1

65%

(1514/2316)

5

T1/T2

1%

(14/2316)

L 3 B

Select Answer to see Preferred Response

Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK

(SBQ12SP.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?

QID: 3782
FIGURES:
1

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

4%

(188/4861)

2

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

1%

(65/4861)

3

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

83%

(4012/4861)

4

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

11%

(541/4861)

5

Posterior cervical fusion due internal laryngeal nerve palsy

0%

(22/4861)

L 2 B

Select Answer to see Preferred Response

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

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)

5%

(138/2773)

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%

(59/2773)

3

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

14%

(395/2773)

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)

75%

(2067/2773)

5

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

4%

(98/2773)

L 3 B

Select Answer to see Preferred Response

(SBQ12SP.17) Which of the following physical exam findings supports the diagnosis of cervical radiculopathy?

QID: 3715
1

Shoulder abduction test

61%

(3004/4950)

2

Lateral forearm pain with resisted extension of the long fingers

3%

(142/4950)

3

Intrinsic wasting

14%

(675/4950)

4

Hoffman Sign

15%

(767/4950)

5

Inverted brachioradialis reflex

7%

(338/4950)

L 4 A

Select Answer to see Preferred Response

(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.

QID: 4557
1

Tendinosis and inflammation at origin of ECRB

6%

(292/4760)

2

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

9%

(419/4760)

3

Compression of the ulnar nerve in Guyon's canal

1%

(28/4760)

4

A paracentral cervical disc herniation at C5/6

66%

(3148/4760)

5

A foraminal disc herniation at C6/7

18%

(834/4760)

L 3 A

Select Answer to see Preferred Response

Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK

(SBQ11AN.18) Which of the following statements is true regarding the recurrent laryngeal nerve and anterior cervical discectomy and fusion (ACDF)?

QID: 4153
1

It is the most common nerve injury with anterior cervical discectomy and fusion.

80%

(1322/1654)

2

Injuring the nerve leads to anhydrosis, pupil dilation, and facial drooping on the ipsilateral side of the injury.

1%

(12/1654)

3

The anatomic course of the nerve is symmetric on the left and the right sides.

1%

(15/1654)

4

It originates from the nerve roots C3, C4, and C5.

2%

(37/1654)

5

It runs along with the superior thyroid artery in the upper cervical spine.

16%

(257/1654)

L 2 B

Select Answer to see Preferred Response

Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK

(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:

QID: 3176
1

Increased intraoperative blood loss

5%

(137/3000)

2

Longer postoperative hospitalization

5%

(154/3000)

3

Decreased revision surgery rate

22%

(670/3000)

4

Decreased fusion rate

53%

(1578/3000)

5

Increased complication rate

15%

(450/3000)

L 4 C

Select Answer to see Preferred Response

Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK
Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK

(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?

QID: 3012
1

C3-4

0%

(13/3832)

2

C4-5

1%

(20/3832)

3

C5-6

3%

(115/3832)

4

C6-7

91%

(3480/3832)

5

C7-T1

5%

(189/3832)

L 1 B

Select Answer to see Preferred Response

(SBQ09SP.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?

QID: 3369
FIGURES:
1

A C5 radiculopathy leading to deltoid and biceps weakness.

17%

(505/2916)

2

A C5 radiculopathy leading to brachioradialis and wrist extension weakness.

2%

(52/2916)

3

A C5 radiculopathy leading to triceps and wrist flexion weakness.

1%

(21/2916)

4

A C6 radiculopathy leading to brachioradialis and wrist extension weakness.

77%

(2253/2916)

5

A C6 radiculopathy leading to finger flexion weakness.

2%

(66/2916)

L 2 B

Select Answer to see Preferred Response

Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK

(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?

QID: 809
FIGURES:
1

Weakness to shoulder shrug

7%

(238/3197)

2

Weakness to shoulder abduction and elbow flexion

87%

(2772/3197)

3

Weakness to elbow flexion and wrist extension

5%

(154/3197)

4

Weakness to elbow extension and wrist flexion

0%

(15/3197)

5

Weakness to finger abduction

0%

(6/3197)

L 1 C

Select Answer to see Preferred Response

(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?

QID: 696
1

tongue deviation to left when extruded

82%

(2300/2802)

2

tongue deviation to right when extruded

16%

(448/2802)

3

ptosis on left side of face

0%

(10/2802)

4

ptosis on right side of face

0%

(3/2802)

5

change in voice

1%

(32/2802)

L 2 C

Select Answer to see Preferred Response

(SBQ06SN.3) A 65-year-old female presents for evaluation of a 1-year history of neck pain. She has a history of C6-C7 anterior cervical discectomy and fusion (ACDF) performed 12 years ago and was doing well until last year. She describes her pain as a dull ache which is made worse by flexion and rotation of her cervical spine without radiation to the arms. Her current imaging is shown in Figure A. Her flexion and extension imaging does not show any listhesis and her MRI studies reveal mild cervical stenosis at C4-C5 and C5-C6 without evidence of cord compression. Her neurologic examination is normal and she has a normal gait with no difficulties with fine motor activities. Which of the following is the next best step in management?

QID: 1688
FIGURES:
1

Removal of hardware

2%

(26/1406)

2

Revision C6-C7 ACDF

9%

(122/1406)

3

Posterior instrumentation and fusion C4-C7

5%

(65/1406)

4

Epidural steroid injection

4%

(51/1406)

5

Patient education and physical therapy

80%

(1129/1406)

L 2 D

Select Answer to see Preferred Response

Question locked
Sorry, this question is for
PEAK Premium Subscribers only
Upgrade to PEAK

(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.

QID: 361
1

Relief of pain when holding the arm above the head

57%

(976/1711)

2

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

38%

(655/1711)

3

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

3%

(47/1711)

4

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

1%

(12/1711)

5

Forearm pain with resisted wrist extension

1%

(9/1711)

L 4 B

Select Answer to see Preferred Response

(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?

QID: 1143
1

Guyon’s canal syndrome

2%

(75/3446)

2

Cubital tunnel syndrome

9%

(316/3446)

3

Diabetic neuropathy

1%

(24/3446)

4

Cervical radiculopathy

87%

(2983/3446)

5

Cervical myelopathy

1%

(40/3446)

L 1 B

Select Answer to see Preferred Response

(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?

QID: 1005
FIGURES:
1

Physical therapy and NSAIDS

1%

(29/2713)

2

High dose methylprednisone

0%

(11/2713)

3

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

85%

(2309/2713)

4

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

4%

(112/2713)

5

C5 to C7 posterior laminectomy and fusion

9%

(234/2713)

L 2 B

Select Answer to see Preferred Response

Evidence (67)
VIDEOS & PODCASTS (8)
CASES (3)
EXPERT COMMENTS (25)
Private Note