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  • 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 age of 40 will have findings of HNP or foraminal stenosis)
        • >50% over the age of 40 years will have a degenerated disc
    • CT
      • indications
        • pre-operative
          • 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
        • post-operative
          • 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
    • Cervical myleopathy 
    • Brachial plexus injury
  • 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
            • systematic reviews have demonstrated no difference in ASD rate between CDA and ACDF
          • lower reoperation rates seen with CDA
          • lower neck pain intensity and frequency 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 rare 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
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