Cervical Radiculopathy

Cervical disc

Definition

 

Pain / sensory disturbance / motor weakness in distribution of a cervical nerve root

 

Impingement of exiting nerve roots

- herniated nucleus pulposis (HNP)

- facet joint hypertrophy

 

Epidemiology

 

Kelsey et al JBJS 1984

- 4th decade of life

- men

- cigarette smoking

- occupations with driving / vibrating equipment

 

Natural History

 

Wong et al Spine J 2014

- systematic review of natural history of cervical radiculopathy

- substantial improvement in 4 - 6 months

- complete recovery in 83% of patients in 2 - 3 years

 

Anatomy

Subaxial spine anatomy 1Subaxial spine anatomy 2

 

Each subaxial C-spine motion segment has 5 articulations

 

A. Intervertebral disc

 

B.  Two uncovertebral joints

- joint of Luschka

- along posterolateral vertebral body

- lie between disc & nerve root

 

C.  Two facet joints - angulated 30-50° to transverse plane

 

Intervertebral foramina boundaries

 

A. Anterior - vertebral bodies, vertebral disc, uncinate process & disc

B.  Posterior - facet joints

C.  Above & below - pedicles

 

Cervical Nerve Roots

 

Each cervical root exits above the pedicle for which it is named except C8

- C5/6 – C6

- C6/7 – C7

- C7/T1 – C8

 

Cervical nerve roots

 

Causes of nerve root compression

 

1.  Herniated nucleus pulposis (HNP)

- in contrast to lumbar spine both posterolateral and central HNP compress exiting nerve root

 

A. Central - myelopathy

B. Posterolateral - mainly motor weakness

C. Intraforaminal - most common / often dermatomal distribution

 

2.  Bony impingement on nerve root foramen

 

A.  Uncovertebral osteophytes / hard discs

B.  Superior articular facet osteophytes

 

2.  Spondylosis / Disc degeneration

- loss of height causes foraminal compression

 

History

 

Pain / parasthesia in distribution of nerve root

 

Examination

 

Spurling's test

 

Hyperextension with tilt toward affected side 

- stimulates radiculopathy symptoms

 

Thoomes et al Spine J 2018

- systematic review of examination for cervical radiculopathy

- Spurling's test high specificity (0.9 - 1.0) but variable sensitivity

 

Nerve root signs

 

Nerve root Sensory Motor weakness Affected Reflex
C2 Occipital headaches    
C3 Occipital headaches    
C4 Neck pain Scapular winging  
C5 Shoulder and upper arm pain and numbness

Deltoid

Biceps

Biceps
C6 Radial forearm and thumb

Wrist extension

Brachioradialis
C7 Middle finger

Triceps

Wrist flexion

Triceps

C8 Ring and little finger Finger flexors  
T1 Axillary numbness Intrinsics Horner's syndrome

 

DDx

 

Nerve entrapment syndromes

Thoracic outlet syndrome

 

MRI

 

Cervical disc MRI

Paracentral disc

 

Paracentral disc 1

 

C disc MRI sagittalMRI cervical disc

Foraminal disc

 

CT

 

May add complementary information to MRI

- posterolateral impingement from uncovertebral spur

- ossification of the PLL

 

EMG / NCS

 

Exclude peripheral nerve entrapment

 

Management

 

Operative versus nonoperative management

 

Luyao et al Global Spine J 2022

- systematic review of operative v nonoperative at one year for cervical radiculopathy

- improved neck pain, arm pain and NDI scores at all time periods for operative care

- faster pain resolution with surgery versus nonoperative care

 

Nonoperative Management

 

Options

 

Rest

NSAIDS

Physiotherapy +/- traction

Injections

 

Physiotherapy +/- traction

 

Cervical Traction

 

Liang et al Medicine 2019

- meta-analysis of 10 RCTs looking at exercises for cervical radiculopathy

- improved VAS scores and reduced disability with exercises

 

Romeo et al Phys Ther 2018

- meta-analysis of 5 RCTs with regards use of traction

- mechanical traction improved pain at short and intermediate term

- manual traction improved pain at short term

 

Cortisone injections

 

Options

- transforaminal injections with CT

- interlaminar injections with CT

- ultrasound guided nerve blocks

 

Nerve root injection 1Nerve root injection 3

 

Operative

 

Indications

 

Severe pain

Severe neurological impairment

Failure non operative treatment

 

Options

 

Anterior Cervical Discectomy (ACD)

Anterior Cervical Disc and Fusion (ACDF)

Anterior Cervical Disc Arthroplasty (ACDA) / Disc Replacement

Posterior Cervical Laminoforaminotomy (PCF)

 

Results

 

ACD versus ACDF

 

Broekema et al JBJS Am 2020

- systematic review of 21 RCTs and 1500 patients with cervical radiculopathy

- worse outcomes for anterior cervical discectomy without addition of intervertebral spacer / fusion

 

Fusion (ACDF) versus disc replacement (ACDA)

 

Goedmakers et al Eur Spine J 2020

- meta-analysis of ACDF versus ACDA for cervical radiculopathy secondary to herniated disc

- 8 studies

- no difference in clinical outcomes

 

Hu et al PLoS One 2016

- meta-analysis of 8 studies of ACDF versus ACDA

- improved outcomes with disc replacement with regards neck and arm pain

- lower complications and secondary surveys with disc replacement

 

Goedmakers et al Spine J 2023

- 5 year follow up of RCT of 109 patients

- ACDF versus ACDA for cervical radiculopathy secondary to herniated disc

- no difference in outcomes between fusion and arthroplasty

- no difference in adjacent level degeneration

 

Fusion (ACDF) versus posterior laminoforaminotomy (PCF)

 

Sahai et al Spine 2019

- systematic review of minimally invasive PCF versus ACDF

- 14 studies with 1216 patients

- similar outcomes with regards neck pain

- improved arm pain with MIS - PCF

- no difference complications / reoperation rate

 

ACDF / Fusion

 

ACDF 2ACDF C34Cervical Disc Degeneration Above Fusion

 

Technique

 

ACDFInterbody spacer

 

Depuy Synthes surgical technique article

 

Vumedi anterior discectomy technique

 

Anterior approach / Smith Robinson

- discectomy

- decorticate end plates

- interbody fusion with bone graft +/- interbody spacer

- anterior plate / integrated cage

 

Complications

 

Risks of Smith Robinson / Anterior Cervical Approach

 

Specific

- pseudarthrosis 0 - 4.3%

- hardware failure

- insufficient decompression

- degeneration at second level

 

ACDA / Disc replacement

 

Cx disc replacement 1Cervical disc replacement 2

 

Advantage

 

Theoretically maintain some motion and preserve other disc segments

 

Contra-indications

 

Instability / Severe deformity / kyphosis - risk prosthesis displacement

Osteoporosis - risk of subsidence

Facet joint arthropathy - continued pain with disc motion

 

Technique

 

Discover discMedtronic PrestigeMedtronic Prestige

Depuy Discover                                Medtronic Prestige

 

Vumedi disc replacement technique

 

You tube prodisc C surgical technique animation

 

Complications

 

Risks of Smith Robinson / Anterior Cervical Approach

 

Specific

- anterior displacement

- posterior displacement and spinal cord injury

- subsidence 3% - higher risk if remove or disrupt end plates

- osteolysis

- implant failure

- heterotopic ossification

 

Kong et al Medicine 2017

- meta-analysis of HO after disc replacement

- 38% at 1-2 years, 54% at 5-10 years

- severe HO 11% at 1-2 years, 48% at 5 - 10 years

 

Posterior Cervical Laminoforaminotomy (PCF)

 

ForaminotomyForamen

 

Indication

 

Foraminal stenosis

Laterally located disc

 

Rarely used

 

Options

 

Open

Minimally invasive (MIS) - tube retractor and microscope

Endoscopic

 

Technique

 

Youtube animation of cervical laminoforaminotomy

 

Vumedi MIS Cervical Foraminotomy

 

Endoscopic Cervical Foraminotomy Technique article

 

Posterior approach

- laminotomy

- decompress foramin

- discectomy

 

Results

 

McAnany et al Spine J 2015

- meta-analysis of open versus MIS PCF

- no difference in clinical success rate (95% MIS, 93% open)

 

Wu et al Pain Physician 2019

- systematic review of MIS versus endoscopic PCF

- no difference in clinical success rate (90% MIS, 94% endoscopic)

- increased dural tears with MIS

- increased transient nerve root palsy with PCF