CERVICAL

RADICULOPATHY
SPINAL NERVE ROOT DYSFUNCTION CAUSING -
DERMATOMAL PAIN & PARASTHESIAS, MYOTOMAL WEAKNESS, AND/ OR
IMPAIRED DTRS
Typical cervical
vertebra
Intervertebral C1
foramina
GATEWAY OF C1
THE SPINAL
NERVE TO THE C2 C2
BODY
C3 C3

C4 C4

C5 C5

C6 C6

C7 C7

C8
1. Dermatomal testing
2. Myotomal testing
3. Special tests
History
Obtaining a detailed history is important to establish a diagnosis of cervical
radiculopathy. The examiner should ask the following questions:
First, what is the patient's chief complaint (eg, pain, numbness, weakness,
location of symptoms)?
A visual analogue scale from 0-10 can be used to determine the patient's
perceived level of pain.
Anatomic pain drawings can also be helpful in giving the physician a quick review
of the patient's pain pattern.
What activities and head positions increase or decrease symptoms?
This information can be helpful for both diagnosis and treatment.
When did the injury occur, what was the mechanism of injury, and what was
done at that time?
Has the patient experienced previous episodes of similar symptoms or localized
Does the patient have symptoms suggestive of a cervical myelopathy, such as
changes in gait, bowel or bladder dysfunction, or lower-extremity sensory
changes or weakness?
What previous treatments (prescribed or self-selected) has the patient tried?
The use of ice and/or heat,Medications (eg, acetaminophen, aspirin,
nonsteroidal anti-inflammatory drugs [NSAIDs]),Physical therapy, traction, or
manipulation,injections,Surgical treatments.
A social history should include the patient's sport and position, occupation, and
the use of nicotine and/or alcohol.
The typical patient with cervical radiculopathy presents with neck and arm
discomfort of insidious onset. The discomfort can range from a dull ache to a
severe burning pain. Typically, pain is referred to the medial border of the
scapula, and the patient's chief complaint is shoulder pain. As the radiculopathy
progresses, the pain radiates to the upper or lower arm and into the hand, along
the sensory distribution of the nerve root that is involved
The older patient may have had previous episodes of neck pain or give a history
of having arthritis of the cervical spine.
Acute disc herniations and sudden narrowing of the neural foramen may also
occur in injuries involving cervical extension, lateral bending, or rotation and
axial loading. These patients complain of increased pain with neck positions that
cause foraminal narrowing (eg, extension, lateral bending, or rotation toward the
symptomatic side).
Many patients report that they can reduce their radicular symptoms by
abducting their shoulder and placing their hand behind their head. This
maneuver is thought to relieve symptoms by decreasing tension at the nerve
root.
Patients may complain of sensory changes along the involved nerve root
dermatome, which can include tingling, numbness, or loss of sensation.
Some patients may complain of motor weakness. A small percentage of patients
will present with weakness only, without significant pain or sensory complaints.
Physical
Observation
The physical examination begins with observation of the patient during the
history portion of the evaluation. This includes head and neck posture and
movement during normal conversation. Typically, patients tilt their head away
from the side of injury and hold their neck stiffly.
Active ROM is usually reduced, particularly in extension, rotation, and lateral
bending, either toward or away from the affected nerve root.
Increased pain with lateral bending away from the affected side can result from
increased displacement of a herniated disc onto a nerve root, whereas ipsilateral
pain suggests impingement of a nerve root at the site of the neural foramen.
Palpation
On palpation, tenderness is usually noted along the cervical paraspinal muscles,
and it is usually more pronounced along the ipsilateral side of the affected nerve
root.
Muscle tenderness may be present along the muscles where the symptoms are
referred (eg, medial scapula, proximal arm, lateral epicondyle).
Associated hypertonicity or spasm on palpation in these painful muscles may
occur.
Letchuman et al showed that cervical radiculopathy is associated with increased
tender spots (both trigger and tender points) on the side of the radiculopathy,
with a predilection toward the muscles innervated by the involved nerve
root. [13] This study revealed that not only pain, but also tenderness, may be
referred in radiculopathy
Classic Patterns
ABNORMALITIES
NERVE MOTOR SENSORY REFLEX
ROOT
C5 Deltoid, elbow Lateral Biceps
flexion arm
C6 Biceps, wrist Lateral forearm, Brachioradialis
extension thumb

C7 Triceps, wrist Dorsal forearm, Tricep

flexion long s
finger
C8 Finger Medial forearm, ulnar NA
flexors digits
C5 radiculopathy
- Weakness: shoulder abduction
- Test: Have patients hold their shoulders in abduction, against downward force
by the examiner.
C6 radiculopathy
- Weakness: elbow flexion, wrist extension
- Test: Have patients lift their arm against resistance by the examiner.
C7 radiculopathy
- Weakness: elbow extension, wrist flexion
- Test: Have patients push with their arm away from their chest against
resistance by the examiner.
C8 radiculopathy
- Weakness: thumb extension, wrist ulnar deviation
- Test: Have the patients hold their extended fingers together against the
examiner's attempts to open the fingers
 Distribution of Pain
C5 Neck, shoulder,
lateral arm
C6 Neck, dorsal lateral
(radial) arm, thumb

C7 Neck, dorsal lateral

forearm, middle finger

C8 Neck, medial forearm,

ulnar digits
Myotomes
Upper limb movements that are affected:
C1/C2- Neck flexion/extension
C3- Neck lateral flexion
C4- Shoulder elevation
C5- Shoulder abduction
C6- Elbow flexion/wrist extension
C7- Elbow extension/wrist flexion
C8- Thumb extension
T1- Finger abduction
SPECIAL TESTS
•Positive spurling test
•Positive distraction test
•Positive Bakody’s sign
•Positive ULTT
•Positive Lhermitte sign
•Positive Anterior Doorbell sign
•Positive Naffziger’s test
•Valsalva Maneuver
•Cervical rotation<60degrees
Spurling test/ Foraminal compression test/ Neck
compression test/ Quadrant test
◦ Neck extension + Rotation +
Downward pressure on
head
◦ Positive finding eliciting
reproduction of radicular pain
into ipsilateral arm of head
rotation
◦ 92% sensitive, 95% specific
Low sensitivity but high specificity-
not useful as a screening tool, but
it does help confirm the diagnosis
Shoulder abduction test/ Shoulder abduction relief
sign/Bakody’s sign
◦ Active/passive abduction
of ipsilateral shoulder
◦ Relief of radicular
symptoms
◦ takes stretch off of the affected
nerve root and may decrease
or relieve radicular symptoms
Cervical spine tests
Neck distraction test/ Manual
traction test
 Lhermitte sign/ Barber chair phenomenon
◦ Flexion of neck producing electric
shock like sensations that extend
down the spine and shoot into
the limbs
◦ Usefulness is limited
◦ Indicates spinal canal stenosis,
disc impingement, multiple
sclerosis, or tumor
Anterior doorbell sign

•Indicates nerve root

tension/radiculopathy
•Deep palpation over C5
segment produces pain in
superior scapulovertebral
border that radiates to upper
limb
Flexion Compression Test
Tests the discal integrity,
possible posterolateral disc
lesion. patient is seated with
head flexed as far as
comfortable without
reproduction of symptoms
or pain.The therapist is
standing behind the patient
with both hands placed on
top of the posterior head.
Reproduction of symptoms
Foraminal Compression Test

Disc integrity, nerve root

compression / irritation, or
posterior apophyseal joint.
Reproduction of symptoms
in the cervical spine locally
or with radicular symptoms
in the upper extremity
Jackson’s Compression Test

Intervertebral foramina and

nerve root
Upper extremity radicular
symptoms to the side of
lateral flexion
Upper limb tension tests
• ULTTA (Median Nerve, Anterior Introsseous Nerve, C5-7)
• ULTTB ( Median nerve, Axillary Nerve, Musculocutaneous Nerve)
• ULTTC(Radial nerve)
• ULTTD (Ulnar nerve, C8-T1)
Others
NAFFZIGER'S TEST
(for nerve root compression)
Manual compression of the jugular
veins bilaterally
An increase or aggravation of pain or
sensory disturbance over the
distribution of the involved nerve
root confirms the presence of an
extruded intervertebral disk or other
mass
VALSALVA MANEUVER
Deep breath and hold it
while attempting to exhale
for 2-3 seconds
Positive response - reproduction
of symptoms
The pushing increases intrathecal
or intraspinal pressure revealing
presence of a space occupying
mass such as and extruded
intervertebral disc, or narrowing
due to osteophytes
1. Plain Radiographs
2. MRI
3. Cervical myelogram
4. Cervical myelogram +
CT
Plain radiography
Role somewhat limited in
evaluation of nerve roots
Initial study to rule out instability
or pathologic changes in bone
Oblique views can show
narrowing of the neuroforamina
secondary to degenerative changes
MR
Idetect significant soft-tissue pathology, such as disc herniation.
MRI has become the method of choice for imaging the neck to

The American College of Radiology recommends routine MRI as the

most appropriate imaging study in patients with chronic neck pain who
have neurologic signs or symptoms but normal radiographs
Sagittal T1 - Hypointense signal is common for herniated degenerative
disks, calcified ligaments, and bone spurs, making differentiation of these
structures more difficult
Axial T1 - Insight into both intraspinal and extraspinal disorders, as well as
the intrathecal nerve root anatomy
T2-weighted sequence or variants - ͞myelo-graphic͟ view
Cervical myelogram
Outlines SC and exiting nerve
roots with radiopaque dye
Water-soluble agent may be
injected via the C1-2 interval,
allowing the dye pool to gravitate
caudally
Accuracy has been estimated 67%
to 92%. For this reason, cervical
myelography is often accompanied
by CT
Excellent visualization of nerves
in relation to surrounding osseous
structures
Electrodiagnosis plays a critical role
Referred to as an extension of neurologic examination, as it is able
to provide physiologic evidence of nerve dysfunction
1. EMG
2. Motor and sensory nerve conduction studies
3. Late responses
ELECTROMYOGRAPHY
EMG is the most useful test
Localize lesions to a particular root level
The goal -- find a pattern of spontaneous and/or chronic motor unit changes in
a clear myotomal pattern
Limitations –
◦ can only detect change in the motor nervous system
Diagnostic Criteria for Needle EMG

To diagnose radiculopathy electrodiagnostically, needle study of

2 muscles that receive innervation from the same nerve root,
preferably via different peripheral nerves, should be abnormal.
Adjacent nerve roots should be unaffected unless a multilevel
radiculopathy is present
NERVE CONDUCTION STUDIES
The primary role -- determine if other neurologic processes exist
as an explanation for a patient’s clinical picture, or if another
process coexists with a root level problem
In pure radiculopathy, the sensory nerve studies should be normal.
Pathologic lesion in radiculopathy typically occurs proximal to
the DRG. Since the DRG houses the cell bodies for the sensory
nerves, the sensory nerve studies should be normal.
common nerve entrapments such as median neuropathy at the
wrist or ulnar neuropathy at the elbow
LATE RESPONSES
The utility of late responses such as F-waves and H-reflexes
in diagnoses of cervical radiculopathy is debated.
While H-reflexes can be useful in diagnosing S1 radiculopathies,
there is less evidence to support use of late responses in the
upper extremity.
F-waves are not sensitive
tend to be abnormal in severe disease
only tests motor fibers
not well tolerated by patients(supramaximal stimulation)
1. Immobilization
2. Traction
3. Pharmacological management
4. Spinal manipulation
5. Epidural Steroid injection
6. Surgery
Immobilization
Some advocate short course (one week)
of neck immobilization may reduce
symptoms in the inflammatory phase
Cervical collar has not been proven to
alter the course or intensity of the
disease process
Adverse effects - especially when used for
longer periods of time. It is feared that a
long period of immobilization, can result
in atrophy-related secondary damage
Physiotherapy Management

•Traction
•Electrotherapy
•Exercise Therapy. AROM, stretching and strengthing
•Manual Therapy - PAIVMs (Passive Assessory Intervertebral Movements) /
PPIVMs (Passive Physiological Intervertebral Movements) / NAGs (Natural
Apophyseal Glides) / SNAGs (Sustained Natural Apophyseal Glides),
Neurodynamic techniques
•Postural re-education
Traction
Distracts neural foramen
and decompresses nerve
root
Typically, 8 to 12 lb of traction
at approximately 24 degrees of
flexion for 15- to 20-minute
intervals
Most beneficial when
acute muscular pain has
subsided
Not be used in patients
Electrotherapy
•Ultrasound (patients received therapeutic US applied for a period of 5 minutes
to the most painful region of the neck, then a second 5-minute dose at the most
painful region of the upper extremity. The US dose was 0·5 w/cm2, with sonation
time 50% and frequency 1 MHz. The patient lay supine with the hand of the
involved upper extremity placed on the abdomen and the elbow supported on a
pillow. The two US doses and interaction time with the patient lasted a total of
15 minutes.
•TENS
•EMS(IFT)
•PEMF(Pulsed Electromagnetic Field)
•Repetitive Magnetic stimulation(rMS)
•Static Magnetic Field
Exercise Therapy
Exercises targeted at opening the intervertebral foramen are the best choice for
reducing the impact of radiculopathy. Exercises such as contralateral rotation
and sideflexion are amongst the simplest forms of exercises which are effective
against signs and symptons, given in the form of active ROM.Due to the intricate
and close relationship of muscles on the intervertebral foramen and the likely
presentation of reduced ROM, stretching is also an effective form of treatment
to regain ROM.Once ROM increases strengthening exercises can be performed
to develop stability and reduce the risk of developing nerve root irritation in the
future, as long as it is not caused by a structure which cannot be influenced by
physical therapy. During the initial stages of treatment, strengthening should be
limited to isometric exercises in the involved upper limb. Once the radicular
symptoms have been resolved, progressive isotonic strengthening can begin.
This should initially involve low weight and high repetitions (15-20 repetitions).
Closed kinetic chain activities can be very helpful in rehabilitating weak shoulder
. We suggest a 2 components program, as suggested by Fritz JM et al. 2
components: scapula strengthening and cervical strengthening.
Cervical strengthening exercises should include supine craniocervical flexion to
elicit contraction of the deep neck flexor muscles without contraction of
superficial neck muscles . Feedback using an air-filled pressure sensor or tactile
cues can be useful. Patient should perform three sets of 10 contractions of 10
seconds with proper muscle activation. Craniocervical flexion contractions were
also performed with the patient seated, with the goal of 30 repetitions of 10-
second contractions.
Scapular retraction against resistance using elastic bands or pulleys can be
added. Scapular-strengthening exercises included prone horizontal abduction,
sidelying forward flexion, prone extension of each shoulder, as well as prone
push-ups with emphasis on shoulder protraction. The goal was 3 sets of 10
repetitions, with resistance added as tolerated
Rotate your head 45 degrees to the
left. Place your left hand behind your
head and gently pull it at an angle
toward your knee. Stretch the muscle
in this manner for 5 to 10 seconds.
Stop the movement when you feel a
slight sting in the right side of your
neck
Rhomboid Major Stretch
Rhomboid Minor Stretch

 Stretch your arms out in

front of your body. Clasp
one hand on top of your
other hand. Gently reach
out so that you feel your
shoulder blades
stretching away from each
other
Lower Trapezius Stretch
Splenius Capitis & Cervicis Stretch
Strengthening exercises
Scalenie
(Neck Harness)
Neck Glide

Start with neck straight.

Slowly slide your chin
forward. Hold for 5 seconds
and return to starting
position. Do 10 times
Shoulder Shrugs Tilted Forward Flexion
Towel Pull
Closed Chain Exercises
Manual Therapy
Upglides
Cervical manipulation
Cervical UPA’s
Thoracic UPA’s
Thoracic Manipulation
s
NAG’s
In the cervical spine, Mulligan describes an occilatory mid to end range manual
therapy technique performed in seated weight bearing. As the therapists gliding
force is always performed parallel to the surface of the relevant apophyseal
joints under treatment they have been termed "Natural Apophyseal Glides" or
"NAGS".
Their application is well described by Mulligan and therapists using these this
technique find excellent results in both the mid and lower cervical as well as
upper thoracic spine. (5)
NAGS provide the therapist with an opportunity to both assess and treat the
patient in the closed kinetic chain weight bearing position where most patients
experience their symptoms. They are often indicated in the elderly and highly
useful in the management of the acute post-injury patient when other manual
therapy techniques would be poorly tolerated.
SNAG
Mulligan's other spinal manual therapy treatment techniques involve the
concurrent application of both therapist applied accessory apophyseal joint
gliding and end range active physiological movement on the part of the
patient. As these techniques are sustained at the end of available pain-free range
and still follow the plane of the apophyseal joints under treatment, they have
gained the name "Sustained Natural Apophyseal Glides".
"SNAGS" was of course the acronym of choice.
Continue……
Mulligan claims these to be a new and unique approach as they:
1. Are performed exclusively in weight bearing.
2. Are mobilizations which are combined with active or passive physiological
movements.
3. Follow the Kaltenborn treatment plane rule that applies to both spinal and
extremity joints.
4. Are sustained at the end of range where pain-free overpressure may be
applied.
5. Are applicable to all spinal joints.
6. Allow the therapist to quickly decide if they are indicated and will become part
of a given therapy regime.
7. Are painless when performed correctly and clinically indicated.
8. Produce immediate and sustained gains in pain-free function
Cervical Rotation SNAG & Self-SNAG
Cervical Extension SNAG
The current range of cervical extension (the comparable sign) is checked for
range, rhythm, deviation and limiting factors such as; increasing pain during
range, pain at end of the available range or painless stiffness at he end of a
reduced range of motion.
The therapist uses the medial border of one thumb reinforced by the pad of the
other thumb to apply an anterosuperior accessory glide through the superior
spinous process of the involved motion segment. The direction of this
mobilization must follow the plane described by the surfaces of the apophyseal
joints under treatment.
The cervical apophyseal joint planes are directed antero-superiorly with the
inclination increasing at lower levels. A general rule of thumb is that the planes
of the cervical apophyseal joints converge at or near to the eyes
of the patient.
While sustaining this pain-free accessory glide, the patient is instructed to
actively perform the comparable sign of cervical extension. The expectation is
that the range displayed will significantly increase and any pain previously
experienced will be virtually abolished.
As the patient progresses through the increasing physiological range, the
therapist must "track" with the spinous process to maintain his/her glide parallel
to the changing treatment plane. As such, the therapists forearms circumscribe
an arc whose apex faces antero-superiorly (see figure one). The end range
physiological movement is sustained for several seconds. Overpressure may be
given at the end of range by the patient to enhance the effect and the procedure
is repeated in sets of five to ten
Cervical Extension SNAG
Continue..
Unilateral SNAGS over the articular pillars may also be attempted for symptoms
not responding to centrally applied techniques.
One of the most exciting aspects of SNAGS mobilizations is the ability to treat a
patient dynamically through a range of movement. Painful arcs or deviations of
movement may be addressed dynamically through the affected range as
opposed to statically in a series of positions. The possibilities for treatment of
combined movements with SNAGS are most range as opposed to statically in a
series of positions. The possibilities for treatment of combined movements
with SNAGS are most rewarding
Passive Accessory Intervertebral
Movement
Passive accessory intervertebral movements (PAIVM) refers to a spinal 
physical therapy assessment and treatment technique developed by Geoff
Maitland. The purpose of PAIVM is to assess the amount and quality of
movement at various intervertebral levels, and to treat pain and stiffness of the 
cervical and lumbar spine

Spinal assessments by passive accessory intervertebral movements (PAIVMs) are

intended to assess segmental intervertebral mobility and were originally
considered to produce localized accessory glides between two vertebrae..
Features typically considered include range of movement (ROM) and end-of-
range stiffness (endfeel )
Technique
During assessment, the aim of PAIVM is to reproduce patient symptoms, and
assess the endfeel of cervical movement, quality of resistance, behaviour of pain
throughout the range of movement, and observe any muscle spasm. A posterior
to anterior force of varying strength is applied by the therapist either centrally
onto the spinous process, or unilaterally on either the left or right articular pillar.
As a treatment technique, pain is treated by oscillations of small amplitude short
of resistance, whilst stiffness is treated by larger amplitudes 50% into resistance
Passive Accessory Movement
Joint movement, performed by the PT, patient cannot reproduce
Types of Passive Accessory Movements:
CPA - Central Posterior Anterior
- best used for pain evenly distributed on both sides
- indicated when pain/ protective spasm is present in same direction
UPA - Unilateral Posterior Anterior
- best used for unilateral pain
- in cervical region, when pain is reproduced in AP direction, referred pain to
ear/throat/ anterior shoulder/ scapula/ headache.
CAP - Central Anterior Posterior
- best used for spondylolisthesis or intradiscal disorder1
UAP - Unilateral Anterior Posterior
- used mostly in cervical region
Rotation (General or Localized)
- Maitland feels this is most useful for lumbar spine
- best used for unilateral pain whether referred to leg or not
Transverse
- best used for unilateral distribution
- push towards the painful side
Longitudinal
-in cervical region, it helps the patient to gain confidence in the therapist
- in the lumbar spine, double leg method for even distribution, gentle for acute
localized pain
- single leg method for unilateral below the 4th lumbar vertebra
Bouts of treatment should be performed for 30 seconds. The physical therapist
will reasses the patient's symptoms after each bout. Never attempt to
manipulate a muscle in spasm, gentle passive movements may relieve the spasm
Passive Physiological Intervertebral
Movement
Passive physiological intervertebral movements (PPIVM) refers to a spinal 
physical therapy assessment and treatment technique developed by Geoff
Maitland used to assess intervertebral movement at a single joint, and to
mobilise neck stiffness
Technique
PPIVM is used as an assessment technique to assist with identifying the location,
nature, severity and irritability of vertebral symptoms. They can be used to test
for cervical or lumbar joint hypermobility or instability, or whether a joint is
locked. PPIVM assessments test the movement available at a specific spinal level
through the application of a passive physiological movement.
Cervical PPIVMs can be performed in cervical lateral flexion or rotation, with
the therapist restricting movement beyond a certain cervical level by blocking
with the hand; this allows the identification of the exact spinal level where
patient symptoms occur
Contraindications of PAIVM & PPIVM
bone disease
malignancy
pregnancy
vertebral artery insufficiency
active ankylosing spondylitis
rheumatoid arthritis
spondylolisthesis
gross foraminal encroachment
acute nerve root irritation or compression
instability of the spine
recent whiplash
undiagnosed pain
psychological pain where signs do not match symptoms5
steroid use affects ligament laxity
Muscle Energy Technique
The muscle energy technique (MET) has been used to clinically restore range of
motion in vertebral segments of the spine . MET as defined by Greenman, is a
manual medicine treatment procedure which involves voluntary contraction by
the patient, against a directly executed counterforce applied by the operator). It
is an active technique in which patient contributes corrective muscular force and
can directly affect the dosage applied by varying their amount of effort. MET can
be used to lengthen muscles which are shortened, contractured or spastic. This
technique can also strengthen physiologically weakened muscles and reduce
localized edema through muscle pump action.
Greenman reports that mobilization of any articulation with decreased mobility
can be achieved with MET.
Greenma
Greenman outlines three types of muscle contractions utilized in MET as follows
Isometric contraction-the distance between origin and insertion of the muscle is
maintained at a constant length.
2. Concentric contraction-the origin and insertion approximate during
contraction.
3. Eccentric contraction-muscle tension allows a controlled separation of origin
and insertion with a lengthening of the muscle
Soft tissue mobilization of the cervical and upper thoracic musculature. Kneading, performed in
a seated position, was one technique used for the upper trapezius and cervical paraspinals. The
patients in this case series were uncomfortable in prone
Pharmacological management
NSAIDs - effects on pain and inflammation
In general, 10-14 days of regular dosing is all that is needed to
control pain and inflammation
Oral steroids - reduce the associated inflammation
from compression
No controlled study exists
Longer-term use is not recommended
Tricyclic antidepressants - adjunct in controlling
radicular pain
Opioid medications - generally not necessary for pain relief, but
 Epidural Steroid
injection
Principle- steroid decreases pain and
inflammation at the site, decreases
PG
Indication –
◦ Radicular pain unresponsive to
non- interventional care for 1-2
months
◦ Patients without progressive
neurological deficit or cervical
myelopathy can be considered before sx
Complications
◦ Dural puncture, vasovagal reaction,
facial flushing, fever, nerve root injury,
pneumocephalus, epidural hematoma,
 Surgery
RED FLAGS!!!
Persistent or recurrent unresponsive to
management for at least 6 nonoperative
weeks
Disabling of 6 weeks’ duration or less (i.e., deltoid palsy,
drop) wrist
Progressi
ve
or referred
Static
or deformity of functionalpain
spinal unit
+

Surgical Management of Cervical Radiculopathy, Todd J. Albert, MD, and Samuel E. Murrell, MD, J Am Acad Orthop Surg 1999;7:368-
376
Posterior lamino-foraminotomy (with or
without diskectomy)
◦ Burr thins lamina over nerve
root
◦ Nerve root exposed
◦ Angled curette can
remove additional bone &
expand foraminotomy
◦ Disk material can be exposed
& removed
Anterior cervical diskectomy and fusion
(ACDF)
◦ Most widely used
◦ Removes ventral compressive
lesion
WITHOUT need for retraction of SC
◦ Disc removed and iliac crest
bone autograft placed to
ENCOURAGE FUSION
◦ Nowadays, allografts (no donor
site
morbidity)
◦ In 1990s, cervical plates were
added to INCREASE stability and
decrease post op bracing
Anterior cervical diskectomy without
fusion
◦ Because of high incidence
of pseudarthrosis after
ACDF
◦ Reported outcomes
comparable
◦ Disk-space collapse and
osseous fusion
◦ There is stress on removal of PLL
(buckling of ligament as disk space
collapses produces compression of the
neural elements) but removes another
stabilizing structure
 Cervical Disc Arthroplasty

ProDisc-C (Synthes Flexicore Bryan cervical disk (Medtronic,

Spine Company, USA)
USA)