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Cervical Radiculopathy

Author: Derek Moore
Topic updated on 03/29/14 3:12pm

Introduction
 A clinical symptom caused by nerve root compression in the cervical
spine
o characterized by sensory or motor symptoms in the upper
extremity
 Pathophysiology
o causes
 degenerative cervical spondylosis
 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
o 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
o key differences between cervical and lumbar spine is
 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

ring  C8 radiculopathy  weakness to distal phalanx flexion of middle and index finger (difficulty with fine motor function)  paresthesias in little finger o provocative tests  Spurling Test positive . 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 o occipital headache (common) o trapezial or interscapular pain o 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 o unilateral arm pain  aching pain radiating down arm  often global and nondermatomal o unilateral dermatomal numbness & tingling  numbness/tingling in thumb (C6)  numbness/tingling in middle finger (C7) o unilateral weakness  difficulty with overhead activities (C7)  difficulty with grip strength (C7)  Physical exam o 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.

 simultaneous extension. lateral. oblique views of cervical spine  obtain flexion and extension views if suspicion for instability o 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 identitfy 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 o 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 o views  T2 axial imaging is the modality of choice and gives . 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 for other causes of shoulder/arm pain myelopathy  check for findings of myelopathy in large central disc herniations  o Imaging  Radiographs o recommended views  AP. lateral bend. rotation to affected side.

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 compression the neural elements  useful as a preoperative planning tool to plan instrumentation  study of choice to evaluate for postoperative pseudoarthosis CT myelography o indications  largely replaced by MRI  useful in patients who can not have an MRI due to pacemaker etc  useful in patients with prior surgery and hardware causing artifact on MRI o 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.o o  needed information on the status of the soft tissues. Discography o indications  controversial and rarely indicated in cervical spondylosis o techniques  approach is similar to that used with ACDF o risks include esophageal puncture and disc infection o   Studies   Nerve conduction studies o high false negative rate o may be useful to distinguish peripheral from central process (ALS) Selective nerve root corticosteroid injections o may help confirm level of radiculopathy in patients with multiple level disease and physical exam findings and EMG fail to localize .

and rehabilitation  indications  75% of patients with radiculopathy improve with nonoperative management  improvement via resorbption 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 inflamation 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 o selective nerve root corticosteroid injections  indicaitons  may be considered as therapeutic or diagnostic option  outcomes  increased risk when compared to lumbar selective nerve root injections with the following rare but possible complications including  dural puncture  meningitis  epidural abscess . medications.level Differential  Carpal tunnel syndrome  Cubital tunnel syndrome  Parsonage-Turner Syndrome Treatment  Nonoperative o rest.

  nerve root injury Operative o 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 o 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 itrogenic injury with anterior approaches o 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) o approach  uses Smith-Robinson anterior approach o 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 .

30% for multilevel fusions  risk factors  smoking  diabetes  multi-level fusions o 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%) o laryngeal nerve follows aberrant pathway on the right  although theoretically the nerve is at greater risk of injury with .anterior plating functions to increase fusion rates and preserve position of interbody cage or strut graft o pros and cons  complications of anterior surgery including persistent swallowng problems Posterior foraminotomy o approach  posterior approach o technique  if anterior disc herniation is to be removed then superior portion of inferior pedicle should be removed o 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 o approach  uses Smith-Robinson anterior approach o pros & cons  avoids nonunions    Complications   Pseudoarthrosis o incidence  5 to 10% for single level fusions.

there is no evidence to support a greater incidence of nerve injury with a right sided approach. anhydrosis. miosis. which sits on the lateral border of the logus colli muscle at C6 Adjacent segment disease . enophthalmos and loss of ciliospinal reflex on the affected side of the face o caused by injury to sympathetic chain. treatment  initial treatment is observation  if not improved over 6 weeks than ENT consult to scope patient and inject teflon Hypoglossal nerve injury o a recognized complication after surgery in the upper cervical spine with an anterior approach o tongue will deviate to side of injury Vascular injury o vertebral artery injury (can be fatal) Dysphagia o higher risk at higher levels (C3-4) Horner's syndrome o characterized by ptosis.o      a right sided approach.