Summary Cervical radiculopathy is characterized by unilateral arm pain, numbness and tingling in a dermatomal distribution in the upper extremity, 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. Surgical decompression is 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 peaks in 50-54 y/o Risk factors white race cigarette smoking prior lumbar radiculopathy Etiology Pathophysiology causes degenerative cervical spondylosis login to view 2 more bullets disc herniation ("soft disc") login to view 8 more bullets double-crush phenomenon login to view 2 more bullets rare causes login to view 6 more bullets neural compression nerve root irritation caused by login to view 10 more bullets affects the nerve root below login to view 1 more bullet Anatomy Articulations facet joints facet hypertrophy and osteophytes can impinge on the nerve root posteriorly disc space loss of disc height can decrease the 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) login to view 2 more bullets 90% water content in patients <30 y/o login to view 1 more bullet Nerve root anatomy key differences between cervical and lumbar spine pedicle/nerve root mismatch login to view 3 more bullets horizontal (cervical) vs. vertical (lumbar) anatomy of nerve root login to view 2 more bullets ventrolateral course from spinal cord login to view 1 more bullet Presentation Symptoms occipital headache (common) trapezial or interscapular pain neck pain may present with an 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 the 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) decreased grip strength (C8) Physical exam common and testable exam findings C4 radiculopathy login to view 2 more bullets C5 radiculopathy login to view 3 more bullets C6 radiculopathy login to view 3 more bullets C7 radiculopathy login to view 4 more bullets C8 radiculopathy login to view 3 more bullets T1 radiculopathy login to view 3 more bullets provocative tests Spurling's test login to view 3 more bullets shoulder abduction test login to view 4 more bullets 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, and oblique views of cervical spine obtain flexion and extension views if suspicion for instability findings general login to view 3 more bullets lateral radiograph login to view 1 more bullet oblique radiograph login to view 1 more bullet flexion and extension views login to view 2 more bullets sensitivity & specificity changes often do not correlate with symptoms login to view 1 more bullet MRI indications red flags: login to view 5 more bullets views T2 axial imaging gives needed information on the status of the soft tissues login to view 2 more bullets findings disc degeneration and herniation foraminal stenosis with nerve root compression (loss of perineural fat) central compression with CSF effacement sensitivity & specificity high rate of false positives (28% >40 y/o will have findings of HNP or foraminal stenosis) >50% >40 y/o will have a degenerated disc CT indications preoperative login to view 4 more bullets postoperative login to view 1 more bullet CT myelography indications largely replaced by MRI useful in patients who cannot have an MRI (e.g. pacemaker) useful in patients with prior surgery and hardware causing artifact on MRI technique intrathecal injection of water soluble contrast given via C1-2 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 40-70% not a good screening study may be useful to distinguish a peripheral from central process (e.g. ALS) fibrillations and positive sharp waves in the affected distribution may not manifest until 3 weeks after the 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 proportionally decreases to muscle atrophy Selective nerve root corticosteroid injections may help confirm level of radiculopathy in patients with multilevel 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 myelopathy Brachial plexus injury Treatment Nonoperative rest, medications, and rehabilitation indications login to view 2 more bullets return to play login to view 3 more bullets selective nerve root corticosteroid injections indications login to view 1 more bullet outcomes login to view 6 more bullets Operative anterior cervical discectomy and fusion indications login to view 3 more bullets outcomes login to view 6 more bullets anterior cervical foraminotomy indications login to view 5 more bullets outcomes login to view 3 more bullets posterior foraminotomy indications login to view 6 more bullets contraindications login to view 5 more bullets outcomes login to view 5 more bullets cervical disc arthroplasty (CDA) indications (controversial) login to view 1 more bullet outcomes login to view 9 more bullets Techniques Rest, medications, and rehabilitation techniques (very few substantiated by evidence) immobilization login to view 3 more bullets medications login to view 6 more bullets rehabilitation login to view 4 more bullets Selective nerve root corticosteroid injections approach fluoroscopic guidance injection consisting of steroid and local anesthetic login to view 1 more bullet Anterior cervical discectomy and fusion (ACDF) approach uses Smith-Robinson anterior approach login to view 2 more bullets C7-T1 exposure login to view 1 more bullet lower risk of recurrent laryngeal nerve injury with left-sided approach login to view 3 more bullets superficial landmarks for levels login to view 4 more bullets techniques decompression login to view 2 more bullets fixation login to view 14 more bullets graft login to view 15 more bullets postoperative care ambulatory the day of surgery soft collar immobilization for short period of time login to view 1 more bullet 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 adjacent-level ossification development login to view 1 more bullet Anterior cervical foraminotomy approach anterolateral approach to the cervical spine longus coli split longitudinally login to view 1 more bullet 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 positioning login to view 6 more bullets posterior approach login to view 10 more bullets technique if anterior disc herniation is to be removed, then superior portion of inferior pedicle should be removed minimal nerve root retraction login to view 1 more bullet pros & cons advantages login to view 2 more bullets disadvantages login to view 5 more bullets Cervical disc arthroplasty approach Smith-Robinson anterior approach pros & cons avoids nonunion Complications Pseudarthrosis incidence 5-10% for single level fusions, 30% for multilevel fusions risk factors login to view 4 more bullets treatment if asymptomatic, observe if symptomatic, treat with posterior cervical fusion or repeat anterior decompression and plating in patients with radiculopathy login to view 1 more bullet Recurrent laryngeal nerve injury (1%) most common nerve injury from this operation anatomic course of the nerve differs on the right and left side theoretically the nerve is at greater risk of injury with a right-sided approach, but 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, then ENT consult to scope patient and inject Teflon same side approach should be used for revision cervical spine surgery 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 a 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 the esophagus Esophageal injury rare but devastating injuries early perforation (at the time of the procedure) usually caused by sharp instruments login to view 1 more bullet should be repaired as soon as the injury is noticed late perforation usually from plate loosening or pullout technically difficult to repair requires a nasogastric tube and parenteral nutrition for a prolonged period Horner's syndrome characterized by ptosis, anhidrosis, miosis, enophthalmos, and loss of the 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 >4 levels involved in fusion construct