Clinical analysis of cervical radiculopathy causing deltoid paralysis

Alteration of muscle activity during voluntary rehabilitation training with single-joint Hybrid Assistive Limb (HAL) in patients with shoulder elevation dysfunction from cervical origin

Shoulder elevation, defined here as arm raising, being essential for activities of daily living, dysfunctions represent a substantial burden in patients' lives. Owing to the complexity of the shoulder joint, the tightly coordinated muscular activity is a fundamental component, and neuromuscular impairments have devastating effects. A single-joint shoulder type version of the Hybrid Assistive Limb (HAL) allowing motion assistance based on the intention of the user via myoelectric activation has recently been developed, and its safety was demonstrated for shoulder rehabilitation. Yet, little is known about the physiological effects of the device. This study aims to monitor the changes in muscle activity and motion during shoulder HAL rehabilitation in several patients suffering from shoulder elevation dysfunction from cervical radicular origin. 8 patients (6 males, 2 females, mean age 62.4 ± 9.3 years old) with weakness of the deltoid muscle resulting from a damage to the C5 nerve root underwent HAL-assisted rehabilitation. We combined surface electromyography and three-dimensional motion capture to record muscular activity and kinematics. All participants showed functional recovery, with improvements in their Manual Muscle Testing (MMT) scores and range of motion (ROM). During training, HAL decreased the activity of deltoid and trapezius, significantly more for the latter, as well as the coactivation of both muscles. We also report a reduction of the characteristic shrugging compensatory motion which is an obstacle to functional recovery. This reduction was notably demonstrated by a stronger reliance on the deltoid rather than the trapezius, indicating a muscle coordination tending toward a pattern similar to healthy individuals. Altogether, the results of the evaluation of motion and muscular changes hint toward a functional recovery in acute, and chronic shoulder impairments from cervical radicular origin following shoulder HAL rehabilitation training and provide information on the physiological effect of the device.

When Clinical Diagnosis Differs From Advanced Imaging: A Case Series of Disc Herniations Causing Radiculopathy and Review of Aberrant Nerve Root Innervation

ABSTRACT

Radiculopathy is diagnosed using a combination of history, physical examination, and imaging. Unfortunately, well-established dermatomal and myotomal maps are an oversimplification of the convoluted nature of spinal sensory and motor innervation. When clinical presentation and imaging seemingly contradict one another, it is important to consider variant innervation patterns. This article presents three patients with objective dermatomal and/or myotomal deficits due to disc herniations whose clinical presentations are "textbook" for nerve root pathology that is adjacent to the nerve root that is actually compromised. In addition, the literature is reviewed to discuss the history of dermatomal and myotomal maps, the effectiveness of a clinician's ability to determine the precise pathologic disc and nerve root level in patients presenting with radiculopathy, and anatomical explanations as to why inconsistencies such as those seen in the patients in these cases exist.

Arthroscopic rotator cuff repair results in similar postoperative functional outcomes in patients with only rotator cuff tears and those with concomitant cervical radiculopathy

PURPOSE

The aim of this study was to compare postoperative functional outcomes after arthroscopic rotator cuff repair in patients with only rotator cuff tears versus those with concomitant cervical radiculopathy.

METHODS

A retrospective study of patients who underwent unilateral rotator cuff repair at a tertiary hospital between 2012 and 2016 was conducted. Patients included in the study were divided into two groups: (1) those with rotator cuff tears only (RC only) and (2) those with concomitant cervical radiculopathy (RC + radiculopathy). Cervical radiculopathy was treated non-surgically in these patients. Oxford Shoulder Score (OSS), Constant Shoulder Score (CSS), University of California at Los Angeles Shoulder Score (UCLASS) and Visual Analog Scale (VAS) pain score were measured for each patient preoperatively and at 3, 6, 12, and 24 months postoperatively.

RESULTS

As compared to the RC-only group (n = 324), the RC + radiculopathy group (n = 33) had significantly poorer OSS (p = 0.001), CSS (p = 0.017) and UCLASS (p = 0.009) functional scores preoperatively. On follow-up, there were no significant differences in functional outcomes between the groups at 3, 6, 12 and 24 months postoperatively for OSS, CSS, UCLASS and VAS pain scores, with the exception of CSS which was higher in the RC-only group at 6 months (p = 0.007). The absolute change and number of patients that attained minimum clinically important difference (MCID) for OSS, CSS and UCLASS at 12- and 24-month follow-ups were also comparable between the groups.

CONCLUSION

Patients with rotator cuff tears and concomitant cervical radiculopathy achieve similar postoperative functional outcomes to those with only rotator cuff tears, after arthroscopic rotator cuff repair.

LEVEL OF EVIDENCE

III.

Evaluation of Anterior Decompression Surgical Outcomes of Proximal-Type Cervical Spondylotic Amyotrophy: A Retrospective Study

OBJECTIVE

To investigate the efficiency of anterior decompression on the proximal-type cervical spondylotic amyotrophy patients.

METHODS

This was a retrospective analysis. From January 2014 to November 2017, 21 patients with proximal-type cervical spondylotic amyotrophy (CSA) underwent anterior decompression. There were 15 males and 6 females, aged 35-73 years with an average of 51.62 years. All the patients underwent surgery of anterior decompression (ACDF or ACCF). Among them, 12 patients underwent C_4/5 single level ACDF, eight patients underwent C_4/5 and C_5/6 double level ACDF, and one patient underwent C5 anterior cervical corpectomy decompression and fusion surgery. Preoperative and postoperative clinical and radiologic parameters were assessed. The clinical examinations were reviewed, including muscle strength, neck disability index (NDI) score, cervical Japanese Orthopaedic Association (JOA) score, and improvement rate of manual muscle test (MMT) at the last follow-up. Preoperative spinal cord or nerve impingement was assessed by magnetic resonance imaging (MRI) or computed tomography (CT) myelography. Postoperative lateral X-ray radiographs were performed every 3 months after the surgery.

RESULTS

Severe preoperative muscle atrophy of the deltoid or biceps muscles occurred in 21 patients included in the study. All of them involve impingements of the ventral nerve root and/or the anterior horn according to MRI and CT myelography. The preoperative duration of symptoms averaged 8.4 months. The average follow-up for all patients was 13.2 months. At the final follow-up, all patients showed statistically significant improvements in muscle strength and NDI scores (P < 0.05, P < 0.05). For the deltoid muscles force and C-JOA scores, the average improvement rates were 66.49% ± 10.04% and 62.23% ± 9.23%, respectively. With respect to MMT, 12 proximal-type patients were graded excellent, six were good, and three were fair, and the overall improvement rate was 85.7%.

CONCLUSIONS

For proximal-type CSA patients with cervical radiculopathy, earlier anterior decompression surgery can achieve satisfactory results by significantly improving a patient's muscle strength and relieving compression symptoms.

Why Does C5 Palsy Occur After Prophylactic Bilateral C4-5 Foraminotomy in Open-Door Cervical Laminoplasty? A Risk Factor Analysis

STUDY DESIGN

Retrospective study.

OBJECTIVES

To evaluate the efficacy of bilateral C4-5 foraminotomy in preventing occurrence of postoperative C5 palsy and to identify possible risk factors for its development.

METHODS

A total of 70 consecutive patients who underwent open-door laminoplasty with bilateral C4-5 foraminotomy were included. Clinical, radiographic, and operative data was reviewed. Development of postoperative C5 palsy was analyzed.

RESULTS

A total of 54 males and 16 females were reviewed. Mean age was 56 years (range, 30-86 years). The primary pathology was spondylosis in 76% of cases and ossified posterior longitudinal ligament in 21%. Radiographic evidence of C4-5 foraminal stenosis was seen in 81% of the patients. The mean duration of preoperative symptoms was 7 ± 19 months. Four (5.7%) out of 70 patients developed C5 palsy after open-door laminoplasty with bilateral C4-5 foraminotomy. Multivariate analysis showed that a long duration of preoperative symptoms (>12 months) and the presence of preoperative C4-5 T2-MRI cord signal change were statistically significant risk factors for the development of C5 palsy even after bilateral C4-5 foraminotomy in open-door laminoplasty (P < .0001 and P = .036, respectively).

CONCLUSIONS

Prophylactic bilateral C4-5 foraminotomies do not completely eliminate the occurrence of C5 palsy. Prolonged duration of symptoms and presence of preoperative T2-MRI cord signal change increase the risk for developing postoperative C5 palsy despite foraminotomy.

Can intraoperative neurophysiologic monitoring during cervical spine decompression predict post-operative segmental C5 palsy?

BACKGROUND

C5 nerve root palsy is a known complication after cervical laminectomy or laminoplasty, characterized by weakness of the deltoid and bicep brachii muscles. The efficacy of intraoperative monitoring of these muscles is currently unclear. In the current prospective study, intraoperative monitoring through somatosensory (SSEPs), motor (TcMEPs) evoked potentials and real-time electromyography activity (EMG) were analyzed for their ability to detect or prevent deltoid muscle weakness after surgery.

METHODS

One hundred consecutive patients undergoing laminectomy/laminoplasty with or without fusion were enrolled. Intraoperative SSEPs, TcMEPs and EMGs from each patient were studied and analyzed.

RESULTS

Intraoperative EMG activity of the C5 nerve root was detected in 34 cases, 10 of which demonstrated a sustained and repetitive EMG activity lasting 5 or more minutes. Paresis of the unilateral deltoid muscle developed in 5 patients, all from the group with sustained C5 EMG activity. None of the patients with weakness of deltoid muscle after surgery demonstrated any abnormal change in TcMEP or SSEP.

CONCLUSIONS

Real-time EMG recordings were sensitive to C5 nerve root irritation, whilst SSEPs and TcMEPs were not. Sustained EMG activity of the C5 nerve root during surgery is a possible warning sign of irritation or injury to the nerve.

Prognostic Factors for Postsurgical Recovery of Deltoid Palsy due to Cervical Disc Herniations

Study Design

Retrospective multicenter study.

Purpose

We aimed to investigate prognostic factors affecting postsurgical recovery of deltoid palsy due to cervical disc herniation (CDH).

Overview of Literature

Little information is available about prognostic factors affecting postsurgical recovery of deltoid palsy due to CDH.

Methods

Sixty-one patients with CDH causing deltoid palsy (less than grade 3) were included in this study: 35 soft discs and 26 hard discs. Average duration of preoperative deltoid palsy was 11.9 weeks. Thirty-two patients underwent single-level surgery, 22 two-level, four three-level, and three four-level. Patients with accompanying myelopathy, shoulder diseases, or peripheral neuropathy were excluded from the study.

Results

Deltoid palsy (2.4 grades vs. 4.5 grades, p<0.001) and radiculopathy (6.4 points vs. 2.1 points, p<0.001) significantly improved after surgery. Thirty-six of 61 patients (59%) achieved full recovery (grade 5) of deltoid palsy, with an average time of 8.4 weeks. Longer duration of preoperative deltoid palsy and more severe radiculopathy negatively affected the degree of improvement in deltoid palsy. Age, gender, number of surgery level, and disc type did not affect the degree of improvement of deltoid palsy. Contrary to our expectations, severity of preoperative deltoid palsy did not affect the degree of improvement. Due to the shorter duration of preoperative deltoid palsy, in the context of rapid referral, early surgical decompression resulted in significant recovery of more severe grades (grade 0 or 1) of deltoid palsy compared to grade 2 or 3 deltoid palsy.

Conclusions

Early surgical decompression significantly improved deltoid palsy caused by CDH, irrespective of age, gender, number of surgery level, and disc type. However, longer duration of deltoid palsy and more severe intensity of preoperative radiating pain were associated with less improvement of deltoid palsy postoperatively.

Visualization of the foramen intervertebral nerve root of cervical spine with 3.0 tesla magnetic resonance imaging: a comparison of three-dimensional acquisition techniques

Identification of the compression factor in cervical disc herniation and cervical spondylotic radioculopathy is often problematic when using two-dimensional magnetic resonance imaging (MRI). This prompted us to compare and examined three-dimensional sequences, coherent oscillatory state acquisition for the manipulation of image contrast (COSMIC), fast imaging employing steady state acquisition (FIESTA) and T2 star weighted MR angiography (SWAN) with 3.0-Tesla (T) MRI to visualize the foramen intervertebral nerve root for the cervical spine. Fat-suppressed COSMIC (FS-COSMIC) sequence gave the highest signal intensity ratio (1.85 ± 0.06) of the nerve root and vertebral arch. A significant difference in signal intensity ratio of the nerve root was found between FS-COSMIC and FIESTA sequences. No significant difference was found between the FS-COSMIC and FIESTA sequences in the cerebrospinal fluid and the spinal cord. The FS-COSMIC sequence proved to be the most suitable sequence for intra and extra dura matter.

Radiculopathy at the C5/6 intervertebral foramen resulting in isolated atrophy of the deltoid: an aberrant innervation complicating diagnosis. Report of two cases

We present two cases in which the diagnosis was complicated by the presence of a weak muscle innervated by a compressed motor root in the intervertebral foramen (IVF) at an atypical level. The patients were 59- and 53-year-old men; they presented with marked atrophy and weakness predominantly in a unilateral deltoid. Neuroimaging revealed narrowing of the nerve root sleeve at the C5/6 IVF due to a herniated disk or osteophyte. Predominant atrophy and weakness of the deltoid were not consistent with radiculopathy at the C5/6 IVF, i.e. C6 radiculopathy. During an extended observation period to rule out motor neuron disease, their weakness did not spread and the patients underwent posterior medial facetectomy and anterior foraminotomy. This produced marked improvement of the deltoid weakness soon after the operation. We considered unexpectedly wide motor innervation of the C6 nerve root predominantly in the deltoid, anatomic variations in the C5 root such as the trunk of the C5 root entering into the C5/6 IVF, and descending anastomoses connecting the C5 and C6 rootlets as possible explanations. Awareness of this rare presentation may aid in the diagnosis and surgical management of these patients.

Cervical Spondylotic Amyotrophy Treated by Anterior Decompression-Three Case Reports-

Cervical spondylotic amyotrophy (CSA) is a rare type of cervical spondylotic disorder. The surgical treatment of CSA is controversial. We treated three patients with the proximal type of CSA by anterior decompression. Three men (65, 61, and 58 years old) presented with CSA manifesting as unilateral muscle weakness and atrophy in the deltoid and biceps muscles without significant sensory deficit. Preoperative neuroradiological examinations revealed anterolateral spinal cord compression in one patient and ventral root compression in two patients at the C4-5 and C5-6 spaces. Magnetic resonance (MR) imaging showed no abnormal intramedullary signal intensity in any patient. Vertebrotomy deviated to the lesion side was performed to provide a better view of the laterally situated osteophytes. Anterior decompression was focused on the paramedial to lateral area, and further foraminotomy was performed according to the radiological findings. After decompression, intervertebral instrumentation was performed using titanium cervical cages. Two of the patients had good recovery of motor strength and one had moderate recovery despite persistent motor atrophy. Surgical intervention is effective in patients with CSA despite severe muscle atrophy unless MR imaging shows the presence of severe degenerative intramedullary lesion.