Rotator cuff tears with cervical radiculopathy

Untwining the intertwined: a comprehensive review on differentiating pathologies of the shoulder and spine

Background

The anatomic interplay and overlap between the cervical spine and the shoulder constitutes a challenge for shoulder and spine surgeons, as symptoms of spine and shoulder pathologies are often similar and may lead to entity misdiagnosis.

Methods

PubMed, Cochrane, and Google Scholar (page 1-20) searches were updated to October 2023 in search of the qualified papers. Boolean Operators were used with a combination of the keywords "spine" OR "neck" And "Shoulder". Furthermore, reference lists from papers were also searched to find literature.

Results

It is of pivotal importance to conduct comprehensive preoperative clinical investigation to appropriately evaluate and assess the source of the pathology and the leading causes behind it. Certain markers can help guide surgeons towards etiologies, and these include areas of pain and physical exam findings with the arm squeeze test having the highest sensitivity and specificity for diagnosing cervical radiculopathy. As for the shoulder, despite its low sensitivity, the Yergason test had the highest specificity for diagnosing subacromial impingement. Local anesthetic injection can help as well in the diagnostic approach. Moreover, the interplay between these anatomic locations is not solely related to preoperative diagnosis. Studies have shown that previous surgery for cervical spine pathology may negatively affect the outcomes of shoulder procedures like arthroplasties.

Conclusion

Shoulder and spine surgeons should be wary and vigilant of accurately diagnosing the etiology of the presenting symptoms to ensure proper management and optimize prognosis.

The effect of concurrent cervical spine degenerative disease on the outcome of rotator cuff repair: a national database study

BACKGROUND

Cervical spine degenerative disease (CSD) can cause shoulder pain, potentially confounding the management of patients with rotator cuff tears. This study aimed to investigate the relationships between CSD and rotator cuff repair (RCR).

METHODS

A national administrative database (PearlDiver) was used to study 4 patient cohorts: (1) RCR only (RCRo), (2) RCR with concurrent CSD (RCRC), (3) RCR after a cervical spine procedure (RCRA), and (4) RCR before a cervical spine procedure (RCRB). The outcomes of RCR were compared using multivariable logistic regression, controlling for age, sex, and Elixhauser Comorbidity Index, as well as preoperative opioid utilization in the analysis of opioid use.

RESULTS

Between 2010 and 2021, a total of 889,977 patients underwent RCR. Of these patients, 784,230 (88%) underwent RCRo whereas 105,747 (12%) underwent RCRC, of whom 21,585 (2.4%) underwent cervical spine procedures (RCRA in 9670 [1.1%] and RCRB in 11,915 [1.3%]). At 2 years after RCR, compared with RCRo patients, RCRC patients had an increased risk of surgical-site infection (adjusted odds ratio [aOR] = 1.25, P = .0004), deep vein thrombosis (aOR = 1.17, P = .0002), respiratory complications (aOR = 1.19, P = .0164), and ipsilateral shoulder reoperations (débridement [aOR = 1.66, P < .0001], manipulation under anesthesia or arthroscopic lysis of adhesions [aOR = 1.23, P < .0001], distal clavicle excision [aOR = 1.78, P < .0001], subacromial decompression [aOR = 1.72, P < .0001], biceps tenodesis [aOR = 1.76, P < .0001], incision and drainage [aOR = 1.34, P = .0020], synovectomy [aOR = 1.48, P = .0136], conversion to shoulder arthroplasty [aOR = 1.62, P < .0001], revision RCR [aOR = 1.77, P < .0001], and subsequent contralateral RCR [aOR = 1.71, P < .0001]). At 2 years, compared with RCRC patients who did not undergo cervical spine procedures, RCRC patients who underwent cervical spine procedures had an increased risk of incision and drainage (aOR = 1.50, P = .0255), conversion to arthroplasty (aOR = 1.40, P < .0001), and revision RCR (aOR = 1.11, P = .0374), as well as a lower risk of contralateral RCR (aOR = 0.89, P = .0469). The sequence of cervical spine procedures did not affect the risk of shoulder reoperations. At 1 year, the risk of opioid use after RCR was less for RCRA patients compared with RCRB patients (aOR = 1.71 [95% confidence interval, 1.61-1.80; P < .0001] vs. aOR = 2.01 [95% confidence interval, 1.92-2.12; P < .0001]).

CONCLUSION

Concurrent CSD has significant detrimental effects on RCR outcomes. Patients with concurrent CSD undergoing cervical spine procedures have a greater risk of ipsilateral shoulder reoperations but a decreased risk of contralateral RCR. The risk of prolonged opioid use was lower if RCR followed a cervical spine procedure. Concurrent CSD must be considered and possibly treated to optimize the outcomes of RCR.

Short-term outcomes after primary reverse total shoulder arthroplasty in patients with cervical spine pathology or previous cervical spine surgery compared to those without

BACKGROUND

Cervical spine (c-spine) and shoulder pathology have been known to cause similar symptoms and often co-exist, making an accurate diagnosis difficult, especially in an elderly population. Reverse total shoulder arthroplasty (rTSA) has been shown to decrease pain and improve quality of life when shoulder pathology is the source of pain and disability. The purpose of this study was to identify the prevalence of c-spine pathology in a cohort of patients who underwent rTSA and to compare postoperative outcome scores to a cohort without c-spine pathology.

METHODS

A retrospective review was performed utilizing a single institution's operative records of primary rTSAs. Radiology reports, imaging, and operative reports were reviewed, and presence of any c-spine pathology or previous surgery were recorded. Additionally, postoperative outcome scores (American Shoulder and Elbow Surgeons [ASES], Constant Score, University of California, Los Angeles [UCLA], and Simple Shoulder Test [SST]) were evaluated at >2 years post-rTSA.

RESULTS

A total of 438 primary rTSA cases were evaluated. Of these, 143 (32.6%) had documentation of prior c-spine pathology and/or history of previous c-spine surgery. After applying further exclusion criteria, a total of 50 patients with c-spine pathology and 108 patients without c-spine pathology were found to have complete medical records and postoperative outcome scores to allow comparison between groups. Patients without c-spine pathology were found to have statistically higher postoperative UCLA, ASES, and SST scores when compared to patients with c-spine pathology. Patients without c-spine pathology also demonstrated a significant improvement in the difference between their postoperative and preoperative UCLA and ASES scores.

CONCLUSION

This study demonstrated a high prevalence of c-spine pathology (32.6%) in a cohort of patients who underwent primary rTSA. Additionally, short-term outcome scores of patients undergoing rTSA with concomitant c-spine pathology are significantly lower than those of patients without a history of c-spine pathology.

The Association Between the Rotator Cuff Status and the Severity and Recovery of Weakness in the Shoulder Abductor Strength in a Case of Proximal Type Cervical Spondylotic Amyotrophy

STUDY DESIGN

Case series study.

OBJECTIVE

We aimed to clarify the prevalence of rotator cuff tear (RCT), and the association between RCT and the severity and prognosis in patients with proximal type cervical spondylotic amyotrophy (CSA).

METHODS

We retrospectively analyzed 35 proximal type CSA patients who were treated conservatively. The following data was collected: age, rotator cuff status on MRI, manual muscle test (MMT) score of shoulder abductor and biceps brachii muscles both at the first visit and final follow-up. We investigated the prevalence of RCT and the association between the rotator cuff status, and the severity and recovery of upper extremity weakness in patients with proximal type CSA.

RESULTS

Of the 35 patients, 21 had an RCT on MRI, indicating that the prevalence of RCT in patients with proximal type CSA was 60%. An age-adjusted analysis showed that the presence of RCT was significantly associated with the MMT score of the shoulder abductor muscles both at the first visit and at the final follow-up. The presence of RCT was significantly associated with the recovery of the shoulder abductor muscles. The size of the RCT was negatively correlated with the MMT score of the shoulder abductor muscles at the final follow-up. The size of the RCT was independently correlated with the change of the MMT score of the shoulder abductor muscles.

CONCLUSION

RCT was detected in >50% in patients with proximal type CSA, and the presence and severity of RCT can be used as prognostic factors for proximal type CSA patients who are treated conservatively.

Patients with Dual Shoulder-Spine Disease: Does Operative Order Affect Clinical Outcomes?

OBJECTIVE

1) To analyze the effect of operative sequence (anterior cervical discectomy and fusion [ACDF] first or rotator cuff repair [RCR] first) on surgical outcomes after both procedures for patients with dual shoulder-spine injuries and 2) to determine how operative sequence affects patient-reported outcome measures (PROMs) after surgery.

METHODS

Patients >18 years of age who underwent primary ACDF and primary RCR at our institution were retrospectively identified. Only patients with overlapping symptoms before the first procedure were included. Patients were divided into 2 cohorts (ACDF first or RCR first). Patient demographics, surgical characteristics, surgical outcomes, and PROMs were compared between groups. Multivariate linear regression models were developed to determine if operative order was predictive of improvements in PROM scores at the 1-year postoperative point after the second procedure. Alpha was set at P < 0.05.

RESULTS

Of the 85 patients included, 44 patients (51.8%) underwent ACDF first, whereas 41 patients (48.2%) underwent RCR first. There were no significant differences in the rate of 90-day readmission, spine reoperations, and rotator cuff reoperations between groups (all, P > 0.05). Multivariate linear regression showed that undergoing an ACDF first was not a significant predictor of Δ Mental Component Score of the Short-Form 12 (β = -2.78; P = 0.626) and Δ Physical Component Score of the Short-Form 12 (β = 7.74; P = 0.077) at the 1-year postoperative point after the second procedure.

CONCLUSIONS

For patients with dual shoulder-spine injuries who are appropriate surgical candidates, undergoing ACDF first compared with RCR first does not result in significant differences in clinical surgical or patient-reported outcomes.

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.

Persistent Shoulder Pain After Anterior Cervical Discectomy and Fusion (ACDF): Another Dual Pathology

Purpose

It is often difficult for the clinician to isolate the etiology of pain occurring either in the neck or shoulder because of the reason that neck pain can refer to the shoulder and vice versa. Concordance research has found that around one in 10 patients who were referred for cervical radiculopathy had comorbid shoulder pathology. The goal of this research is to analyze and correlate risk factors for persistent shoulder pain (non-dermatomal) following cervical spine surgery.

Methods

This was a single-center, retrospective study. The medical records of patients admitted for anterior cervical discectomy and fusion (ACDF) were reviewed from August 2018 to Feb 2021. Patients of both sexes and age more than 18 years who underwent ACDF (single/multiple levels) were included and the medical record was checked for whether they had persistent shoulder pain following ACDF. The proportion of patients undergoing shoulder surgery for associated rotator cuff tears and subacromial impingement were recorded.

Results

Seventy patients presenting with cervical prolapsed intervertebral disc (PID) were studied. A majority of our patients were females (n=48, 68.6%) and males (n=22, 31.4%) with an M:F ratio of 1:2 and the majority of patients were between the ages of 40 to 60 years (n=34, 48.6%). After surgical intervention (ACDF), 48 patients (68.6%) noted the cessation of shoulder symptoms (pain, weakness, and numbness) during their last visit. Rotator cuff tear (supraspinatus mainly) was the predominant finding in MRI in those who didn’t improve after ACDF (n=18, 25.7%, p-value: 0.001). Twenty patients (28.6%) underwent acromioplasty and rotator cuff tendon repair and four patients responded well to subacromial injection. The C6-7 level was most commonly affected (n=48, 68.6%) followed by C5-6 level (n=19, 27.1%). No significant association was found between cervical levels with shoulder pathologies (p-0.171), though a significant association between a visual analog scale (VAS) score >7 after surgery with shoulder pathologies (p-0.001) was found. The C6-7 level was commonly affected in females (p=0.038) but no significant association between gender and shoulder pathologies was found (p=0.332).

Conclusion

Dual pathologies in patients with cervical PID are very common. It needs careful attention by doing thorough clinical examination and correlating patient symptoms with radiological investigations. A patient who presents with persistent shoulder pain after cervical spine surgery had a higher chance of having concurrent shoulder pathology, and they should be properly investigated and managed to alleviate the suffering of the patient.

Risk Factors for Persistent Shoulder Pain After Cervical Spine Surgery

OBJECTIVE

To define risk factors of having persistent shoulder pain following cervical spine surgery.

METHODS

From April 1995 to May 2012, 862 patients underwent cervical spine surgery in a tertiary referral university hospital. Ninety-six patients were referred to a shoulder surgeon for persistent shoulder pain over 3 months after cervical spine surgery. Thirty-five were excluded from the study due to failure to follow-up or lack of radiographic data. We analyzed a total of 61 patients as patient group (PG) compared to age, sex, and surgeon matched control group (CG) with no shoulder pain after surgery. Medical records were reviewed for age, sex, level of cervical surgery, approach of cervical surgery, underlying medical problems, final diagnosis of the shoulder pathology, and shoulder visual analog scale (VAS) score. The pre- and post-operative variables for level of cervical surgery, approach of cervical surgery, underlying medical history, and shoulder VAS were compared and analyzed in this study.

RESULTS

The number of patients with lower cervical level surgery was significantly higher (91 patients, 74.6%) compared to upper cervical level surgery (31 patients, 25.4%) (P = 0.005). Anterior approach was more frequently used (70 patients, 57.3%) compared to posterior approach (52 patients, 42.7%) (P < 0.001). The final diagnosis of shoulder pathology in PG were rotator cuff disease in 31 patients, adhesive capsulitis in 18 patients, and calcific tendinitis in 10 patients respectively. No significant difference for preoperative shoulder VAS score was found in both groups. A lower level of cervical spine pathology in patients (C₄ -T₁ level) and posterior approach surgery were factors that significantly presented with more shoulder pain. Subgroup analysis revealed no statistical difference for level of cervical surgery and approach of cervical surgery among groups with different shoulder pathology.

CONCLUSIONS

The current study includes patients with persistent shoulder pain following cervical surgery without having evidence of concurrent preexisting shoulder pathology documented previously. We suggest that posterior approach and lower level of cervical surgery patients could be clinically relevant risk factors for persistent shoulder pain following cervical spine surgery.

Increased Risk of Chronic Opioid Use and Revision After Anterior Cervical Diskectomy and Fusion in Patients with Prior Shoulder Arthroscopy

OBJECTIVE

The purpose of this study was to compare differences in the outcomes of patients who undergo anterior cervical diskectomy and fusion (ACDF) with and without a history of shoulder arthroscopy.

METHODS

The PearlDiver Patient Records Database (www.peardiverinc.com) from 2007 to 2017 was used to query patients by Current Procedural Terminology, isolating those who underwent ACDF with and without prior shoulder arthroscopy. Postoperative complications within 30 days of the index procedure, opioid use, and revision procedures were assessed for each cohort using ICD-9/10 and Current Procedural Terminology coding.

RESULTS

A total of 39,969 ACDF patients were queried, of which 38,859 (97.2%) underwent ACDF alone and 1110 (2.8%) underwent ACDF with prior shoulder arthroscopy. ACDF revision rates were significantly greater in patients with prior shoulder arthroscopy compared with ACDF alone (5.8% vs. 3.6%, aOR = 1.64, P = 0.0002). Patients with prior shoulder arthroscopy were also significantly more likely to fill opioid prescriptions at 3 months (aOR 1.19, P = 0.02), 6 months (aOR 1.22, P = 0.01), and 12 months (aOR 1.18, P = 0.04).

CONCLUSIONS

Patients who undergo ACDF with a prior shoulder arthroscopy have significantly greater revision rates, respiratory complications, and prolonged opioid use compared with patients without prior shoulder arthroscopy. With efforts to limit narcotic use and the importance of maximizing patient satisfaction, this analysis improves on the surgeon's ability to set expectations and postoperative plans for patients undergoing ACDF who have a history of shoulder arthroscopy.

Cross-talk between shoulder and neck pain: an imaging study of association between rotator cuff tendon tears and cervical foraminal stenosis

Rotator cuff tendon tears are prevalent in patients with shoulder pain, the third most common musculoskeletal complaint. As shoulders are largely innervated by cervical nerves, it seems possible that rotator cuff pathology could have an association with cervical spine disorders, although few studies have investigated this possibility. This study aimed to explore the association between rotator cuff tendon tears and cervical radiculopathy (at C5 and C6 levels) in the shoulder pain population.We conducted a retrospective review of a clinical registry of shoulder ultrasound (US) examinations and cervical spine radiographs, recruiting a total of 126 patients with cervical spine radiographs taken within 1 year of US examinations. Foraminal stenosis was grouped into 4 categories: C4/5 intervertebral foramen only, C5/6 intervertebral foramen only, both C4/5 and C5/6 intervertebral foramina, and neither C4/5 nor C5/6 intervertebral foramen. The groups with and without rotator cuff tendon tears were compared for various factors, using the Mann-Whitney U test for continuous variables and the χ test for categorical variables. A multivariate analysis was conducted using a logistic regression model to investigate the association between rotator cuff tendon tears and cervical foraminal stenosis.Patients with rotator cuff tendon tears tended to be older and had more night-time pain. No significant association was identified between rotator cuff tendon tears and cervical foraminal stenosis at C5 and C6 levels. The only factor significantly predicting rotator cuff tendon tears was old age (odds ratio, 1.04; 95% confidence interval: 1.00-1.09).In patients with shoulder or neck pain, no significant association existed between rotator cuff tendon tears and cervical foraminal stenosis (at the C5 and C6 levels). When patients present with undifferentiated shoulder and neck pain, physicians should take a detailed history, perform physical examinations and imaging studies of both the neck and shoulder regions.

The association between cervical spine pathology and rotator cuff dysfunction

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To investigate the relationship between cervical spine (C-spine) and rotator cuff (RTC) pathology.

SUMMARY OF BACKGROUND DATA

Cervical spine and RTC pathology cause significant shoulder pain in isolation and in tandem, but there is limited information about the relationship between these 2 entities.

METHODS

Patients with a diagnosis of C-spine and/or RTC pathology between 2005 and 2011 were identified using a large national database composed of private payer as well as Medicare patient records. Patients with concomitant C-spine and RTC diagnoses were then stratified by age group and sex. Patients with lumbar spine (L-spine) and RTC pathology were used as a comparative group, and multivariate logistic regression was used for statistical analysis.

RESULTS

Concomitant C-spine and RTC diagnoses were identified in 86,928 patients representing 13% of 679,112 patients with a RTC diagnosis and 16% of 531,177 patients with a C-spine diagnosis. The association between C-spine and RTC pathology increased significantly with age as RTC diagnoses were present in 13% of patients with C-spine pathology younger than 60 years old but increased to 25% in C-spine patients older than 60 years (P<0.0001). For patients over 60 years old who developed a new C-spine diagnosis, 11% would develop a new RTC diagnosis or undergo an operation for a RTC disorder within 5 years. Lumbar diagnosis codes (2,297,480 patients) were over 4 times more common than C-spine codes but RTC pathology had a significantly higher correlation with C-spine pathology than L-spine pathology (odds ratio, 2.32) and patients with C-spine pathology were more likely to develop new rotator cuff pathology (odds ratio, 1.53).

CONCLUSIONS

The association between cervical spine and RTC pathology is significantly greater than that between L-spine and RTC pathology and increases substantially with patient age. Further studies are needed to elucidate the cause of this relationship.

The role of the peripheral and central nervous systems in rotator cuff disease

Rotator cuff (RC) disease is an extremely common condition associated with shoulder pain, reduced functional capacities, and impaired quality of life. It primarily involves alterations in tendon health and mechanical properties that can ultimately lead to tendon failure. RC tendon tears induce progressive muscle changes that have a negative impact on surgical reparability of the RC tendons and clinical outcomes. At the same time, a significant base of clinical data suggests a relatively weak relationship between RC integrity and clinical presentation, emphasizing the multifactorial aspects of RC disease. This review aims to summarize the potential contribution of peripheral, spinal, and supraspinal neural factors that may (1) exacerbate structural and functional muscle changes induced by tendon tear, (2) compromise the reversal of these changes during surgery and rehabilitation, (3) contribute to pain generation and persistence of pain, (4) impair shoulder function through reduced proprioception, kinematics, and muscle recruitment, and (5) help explain interindividual differences and response to treatment. Given the current clinical and scientific interest in peripheral nerve injury in the context of RC disease and surgery, we carefully reviewed this body of literature with a particular emphasis on suprascapular neuropathy that has generated a large number of studies in the past decade. Within this process, we highlight the gaps in current knowledge and suggest research avenues for scientists and clinicians.