Review Question - QID 4231

The patient presents with symptoms of a left C7 cervical radiculopathy. Both a paracentral and far lateral (foraminal) disc herniation can compress the C7 nerve root due to the horizontal anatomy of the cervical nerve roots (Illustration A).

Cervical radiculopathy is defined as pain and/or sensorimotor deficit as a result of injury or compression of one or more of the cervical nerve roots. Despite the significant interweaving of the cervical nerve roots in the brachial plexus, there are physical exam findings that are typical of individual nerve distributions. Wrist flexion, elbow extension, sensation to the middle finger, and the triceps reflex are all relatively specific for a C7 radiculopathy (see illustration B). It is postulated that disc herniation and neural compression causes an inflammatory response and production of cytokines such as IL-6, IL-1, TNF-alpha, bradykinin, substance P, and various prostaglandins. Approximately 75% of patients with cervical radiculopathy will improve with non-operative management, which consists of activity modification, short-term immobilization, NSAIDs, PT, and possibly steroid injections.

Kahraman et al. performed a retrospective chart review of 235 patients who underwent anterior cervical surgery over a 10 year period. 3/235 patients developed dysphonia (likely related to a recurrent laryngeal nerve injury) during this period, and all recovered within a 3 month period. The authors conclude that most cases of dysphonia after anterior cervical surgery are likely temporary.

Davidson et al. report on a case series of 22 patients with severe cervical radiculopathy. They found that 15 of these patients had symptom relief with abduction of their arm above their head (shoulder abduction relief test). Of the 15 that had a positive shoulder abduction test, 13 later required surgery, while the other 9 patients were eventually managed conservatively, indicating the value of this maneuver as diagnostic of significant cervical extradural compressive radiculopathy.

Illustration A demonstrates that in the cervical spine, paracentral and far lateral disc herniations affect the exiting nerve root. Illustration B shows the sensory, motor, and reflex distributions of the C7 nerve root.

Incorrect Answers:
Answer 1+2: This would compress the C6 nerve root and cause elbow flexion and wrist extension weakness and paresthesias in the thumb.
Answer 4: This would compress the C8 nerve root and cause finger flexion weakness and paresthesias in the small finger.
Answer 5: The arcade of Struthers is a compression site for the ulnar nerve which would cause intrinsic muscle weakness and decreased sensation at the ulnar aspect of the hand.