Cervical Radiculopathy: Diagnosis and Nonoperative Management

Multi-Level Posterior Cervical Foraminotomy Associated With Increased Post-operative Infection Rates and Overall Re-Operation Relative to Anterior Cervical Discectomy With Fusion or Cervical Disc Arthroplasty

STUDY DESIGN

Retrospective Cohort Study.

OBJECTIVE

Cervical radiculopathy meeting operative criteria has traditionally been managed using anterior cervical discectomy and fusion (ACDF). However, cervical disc arthroplasty (CDA) and posterior cervical foraminotomy (PCF) are also reasonable options. This study aimed to assess differences in postoperative outcomes among patients undergoing multi-level ACDF, CDA, or PCF comparing medical/surgical complications and healthcare utilization parameters.

METHODS

Patients who underwent multi-level ACDF, CDA, or PCF between 2012 and 2019 were identified from the American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database. Patients were stratified based on procedure type and propensity score matched to resolve baseline differences. ANOVA was performed to identify differences in medical complications, surgical complications, and healthcare utilization metrics.

RESULTS

A total of 31 344 patients who underwent an eligible procedure were identified (ACDF: n = 28 089, CDA: n = 1748, PCF: n = 1507), and 684 patients remained in each group following propensity score matching. Patients undergoing multi-level PCF were found to experience longer lengths of hospital stay (PCF: 1.67 ± 1.61 days, ACDF: 1.50 ± 1.32 days, CDA: 1.27 ± 1.05 days, P < .001), higher rates of reoperation (PCF: 3.2%, ACDF: 1.0%, CDA: .4%, P = .020), superficial infection (PCF: 1.3%, ACDF: .3%, CDA: .1%, P = .008) and deep infection (PCF: 1.2%, ACDF: 0%, CDA: 0%, P < .001). There were no outcome differences between multi-level ACDF and CDA.

CONCLUSIONS

Patients undergoing multi-level PCF were at increased risk for longer hospital stay, re-operation, and infection relative to those undergoing ACDF and CDA. Future research should aim to uncover the precise mechanisms underlying these complications, as well as analyze long term outcomes.

LEVEL OF EVIDENCE

III.

Diagnostic Uncertainty in Cervical Radiculopathy

Cervical radiculopathy is defined as a pathological process affecting the cervical nerve root(s). While not an uncommon entity, this report describes a case of cervical radiculopathy in an active duty Marine with unique features to include the C5 nerve root as the primary point of injury with corresponding severe motor weakness that warranted expedited workup. This expedited workup included early referral to Neurology for nerve conduction and electromyography (EMG) studies that were ultimately diagnostic in the setting of equivocal Magnetic Resonance Imaging findings. This highlight of this case is the demonstration of the utility of EMG in cervical radiculopathy evaluation, which aided in an efficient and effective treatment course. We contend that in cases of cervical radiculopathy with a focal deficit of profound weakness with shoulder abduction and elbow flexion, obtaining nerve conduction studies and EMGs within the first 4 to 6 weeks of presentation should be viewed as essential for the long-term recovery and effective management of the injured service member, particularly when injury to the upper trunk of the brachial plexus can also account for these specific motor deficits. This report will cover a brief review of the pathophysiology, evaluation, and natural history of cervical radiculopathy with special attention paid to the timing and efficacy of EMG.

Spinal Injuries in the Overhead Athlete

PURPOSE OF REVIEW

Treatment of overhead athletes requires a systematic approach that will make an accurate diagnosis, deliver effective treatment, and make timely and safe return to sport.

RECENT FINDINGS

New data has shown success rates and return to play effectiveness after different types of cervical and lumbar surgery. Cervical foraminotomy has been shown to have the highest rate and fastest return to play, but with the highest incidence of need for revision surgery. Cervical artificial disc replacement has shown promising results in the general population and is being done more commonly in elite athletes, but has an unknown risk for failure. Cervical fusion is a well-established and effective treatment, but has the longest healing time and risk for adjacent level pathology. In the lumbar spine, discectomy has a long and proven track record, fusion is rarely performed but can be effective, and artificial disc replacement is extremely rare in an elite athlete. An effective and comprehensive approach can diagnose, treat, and return overhead athletes to competitive play.

Morphology of cervical periradicular fibrous sheath and nerve roots in relation to postoperative C5 palsy

BACKGROUND CONTEXT

C5 palsy is a major complication of cervical spine surgery, however, its exact pathogenesis remains unclear. Some studies have shown that the superficial layer of the posterior longitudinal ligament extends laterally and forms the periradicular fibrous sheath (PFS), and envelopes the nerve roots. However, the anatomical relationship between the PFS and nerve root at each cervical level has not been fully revealed.

PURPOSE

To examine the difference of the PFS that covers the nerve root at each cervical level, and to consider its potential in the onset of postoperative C5 palsy.

STUDY DESIGN

Anatomical study of cervical dissection of 13 embalmed cadavers.

METHODS

Thirteen human formalin-fixed cadavers were dissected from posterior approach, and were observed their cervical nerves bilaterally from C3 to C8 (the total number of nerves was 156). The bare area length (BAL), which is the distance between the medial posterior edge of the PFS and the bifurcation of the nerve and dura mater, was measured by using electronic calipers. Thus, BAL is the uncovered area of the nerve root by the PFS. We examined whether BAL significantly varied at each cervical level.

RESULTS

We confirmed the PFS macro- and/or microanatomically in all cadavers. The average BAL gradually increased craniocaudally, and there was a significant step between that of C5 and C6 level.

CONCLUSION

The average BAL of the C5 root was significantly shorter than that of C6, C7, and C8, suggesting that C5 root was more tightly anchored. This could be one reason for C5 palsy, making C5 nerve root vulnerable to the traction caused by the postoperative spinal cord shift.

CLINICAL SIGNIFICANCE

This study provides clinicians an additional understanding of the anatomical factor of C5 palsy. Consideration of the anchoring effect of the PFS for nerve roots, release of the PFS could be a preventive procedure for C5 palsy.

Clinical and Radiological Comparisons of Percutaneous Low-Power Laser Discectomy and Low-Temperature Plasma Radiofrequency Ablation for Cervical Radiculopathy: A Prospective, Multicenter, Cohort Study

Background

Minimally invasive techniques, such as percutaneous low-power laser discectomy (PLLD) and low-temperature plasma radiofrequency ablation (coblation) can be applied to treat degenerative cervical radiculopathy. However, less evidence supports the superiority of distinct minimally-invasive therapy. Our study aimed to evaluate the clinical and radiological characteristics of the PLLD and coblation for cervical radiculopathy.

Methods

This was a prospective, multicenter, cohort study (ChiCTR-ONC-17010356). The modified Macnab criteria was performed to assess the clinical improvement pre- and post-surgery. To evaluate the radiological effect, the Pfirrmann grading system and disk herniation index were applied with MRI.

Results

In this study, 28 patients were enrolled in the coblation group and 30 patients in the PLLD group. The mean good-excellent rate at 3-month follow-up was 82.1% for PLLD group, and 66.7% for coblation group, respectively (p = 0.179). The PLLD group achieved higher good-excellent rate 6 and 12 months after discharge (92.9 vs. 70.0%, p = 0.026). Radiological data revealed that PLLD but not coblation treatment achieved significant reduction of disk herniation index (p < 0.0001). Coblation treatment did not change the Pfirrmann grades of cervical radiculopathy patients (n = 18), and 7 out of 17 (41.2%) patients achieved improvement after PLLD therapy. None obvious adverse event was observed in this study.

Conclusion

Both PLLD and coblation are effective and safe option for patients with cervical radiculopathy. Better long-term clinical outcomes may be potentially associated with the improvement of disk degeneration after PLLD treatment.

Cervical Disc Herniations, Radiculopathy, and Myelopathy

The key to successful treatment of elite athletes is optimizing the medical care at every step: injury prevention and sport-specific training; comprehensive history and physical examination; high-quality and complete diagnostic studies; accurate diagnosis; control and completion of rehabilitation program; minimally invasive, safe, and effective surgeries; risk assessment for return to sport; guided and gradual return to sport; and continued rehabilitation and exercise program after return to sport.

Herniated discs: when is surgery necessary?

In all levels of disc herniations the absolute surgical indications include deteriorating neurological deficits with myelopathy or cauda equina syndrome. However, this review summarized the relative indications for surgery in each level.

In cervical disc herniation (CDH), the indications for surgery consist of six months of persisting symptoms, not responding to conservative treatment. However, high-quality studies are lacking, and a randomized controlled trial is now underway to clarify the indications.

In thoracic disc herniation (TDH), the indications for surgery comprise failure of conservative measures and/or worsening neurological symptoms. Moreover, giant calcified thoracic disc herniations or myelopathy signs on magnetic resonance imaging, even in the absence of neurological symptoms, may benefit from surgical treatment as a preventive measure.

In lumbar disc herniation (LDH), the indications for surgery include imaging confirmation of LDH, consistent with clinical findings, and failure to improve after six weeks of conservative care.

Cite this article: EFORT Open Rev 2021;6:526-530. DOI: 10.1302/2058-5241.6.210020

Effects of oscillatory mobilization as compared to sustained stretch mobilization in the management of cervical radiculopathy: A randomized controlled trial

BACKGROUND

Cervical radiculopathy is a relatively common musculoskeletal disorder resulting in a significant social and occupational impact. Manual therapy is thought to provide relief in cervical radiculopathy; however, evidence is lacking regarding the comparison of different manual therapy concepts.

OBJECTIVE

To determine the effects of Maitland's oscillatory mobilization as compared to Kaltenborn's sustained stretch mobilization in the management of cervical radiculopathy.

METHODS

A randomized controlled trial was conducted at Fauji Foundation Hospital comprising of 46 patients randomized into oscillatory and sustained stretch mobilization groups. Numeric Pain Rating Scale (NPRS), Neck Disability Index (NDI) and cervical range of motion (ROM) were used as outcome variables.

RESULTS

No significant differences were observed at base line between the two groups (P> 0.05) except for ROM in extension and left side bending (P< 0.05). In terms of pre and post treatment comparison, P value of less than 0.05 was observed for both groups, indicating both treatments to be effective in isolation. However, post treatment comparison between both groups showed oscillatory mobilization to be superior to sustained stretch mobilization (P< 0.05) in the management of cervical radiculopathy except for the outcomes of pain and side bending.

CONCLUSION

Both oscillatory and sustained stretch mobilization techniques are found to be effective in the management of cervical radiculopathy in terms of pain, range and disability. However, oscillatory mobilization is found to be superior in terms of functional ability and range of motion.

Longer Preoperative Duration of Symptoms Negatively Affects Health-related Quality of Life After Surgery for Cervical Radiculopathy

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

Determine the effect of duration of symptoms (DOS) on health-related quality of life (HRQOL) outcomes for patients with cervical radiculopathy.

SUMMARY OF BACKGROUND DATA

The effect of DOS has not been extensively evaluated for cervical radiculopathy.

METHODS

A retrospective analysis of patients who underwent an anterior cervical decompression and fusion for radiculopathy was performed. Patients were grouped based on DOS of less than 6 months, 6 months to 2 years, and more than 2 years and HRQOL outcomes were evaluated.

RESULTS

A total of 216 patients were included with a mean follow-up of 16.0 months. There were 86, 61, and 69 patients with symptoms for less than 6 months, 6 months to 2 years, and more than 2 years, respectively. No difference in the absolute postoperative score of the patient reported outcomes was identified between the cohorts. However, in the multivariate analysis, radiculopathy for more than 2 years predicted lower postoperative Short Form-12 Physical Component Score (P = 0.037) and Short Form-12 Mental Component Score (P = 0.029), and higher postoperative Neck Disability Index (P = 0.003), neck pain (P = 0.001), and arm pain (P = 0.004) than radiculopathy for less than 6 months. Furthermore, the recovery ratios for patients with symptoms for less than 6 months demonstrated a greater improvement in NDI, neck pain, and arm pain than for 6 months to 2 years (P = 0.041; 0.005; 0.044) and more than 2 years (P = 0.016; 0.014; 0.002), respectively.

CONCLUSION

Patients benefit from spine surgery for cervical radiculopathy at all time points, and the absolute postoperative score for the patient reported outcomes did not vary based on the duration of symptoms; however, the regression analysis clearly identified symptoms for more than 2 years as a predictor of worse outcomes, and the recovery ratio was statistically significantly improved in patients who underwent surgery within 6 months of the onset of symptoms.

LEVEL OF EVIDENCE

3.

Motor Evoked Potentials after Supraspinal Stimulation in Pre- and Postoperative Evaluations of Patients with Cervical Radiculopathy

Objective

Pre- and postoperative comparative evaluation of neurophysiological tests and clinical trials. Analysis of the diagnostic value of motor evoked potentials (MEP) induced by a magnetic field after supraspinal stimulation. Evaluation of the sensitivity and specificity of electromyography (EMG) and MEP is achieved.

Methods

EMG, ENG, M-wave, F-wave, and MEP tests were performed on 35 patients with confirmed cervical radiculopathy in pre- and postoperative evaluations. The clinical trial consisted of evaluation of muscle strength, a sensory perception test and evaluation of tendon reflexes and pain severity.

Results

The sensitivity of the resting EMG and MEP tests is 24%-67% and 6%-27%, while their specificity is 43%-80% and 86%-100%, respectively. The postoperative evaluation revealed a statistically significant reduction in pain severity (p=0001), an increase in muscle strength in DP (p=0.0431), BB (p=0,0431), and TB (p=0.0272), and improvement of touch sensation in terms of dermatomal innervation in C5 (p=0.0001) and C6 (p=0.0044).

Conclusions

Tests comparing MRI sensitivity to neurophysiological tests show that neuroimaging is more sensitive in diagnostics of patients with cervical radiculopathy; however, clinical neurophysiology tests are more specific in reference to clinical trials.

Effects of active versus passive upper extremity neural mobilization combined with mechanical traction and joint mobilization in females with cervical radiculopathy: A randomized controlled trial

BACKGROUND

Neural mobilization is an effective technique in the management of cervical radiculopathy (CR). However, the difference between active versus passive upper extremity (UE) neural mobilization techniques in the management of cervical radiculopathy is not well established.

OBJECTIVE

To determine the role of active versus passive UE neural mobilization in females with cervical radiculopathy.

METHODS

A double blind randomized controlled trial was conducted at Shifa International Hospital from Sep 2016 to Feb 2017, and 44 females were included and randomized into 2 groups, receiving 12 treatment sessions in total. Group A received active whereas Group B received passive UE neural mobilization, along with cervical traction and Unilateral Posterior Anterior (UPA) glide regardless of the group. Numeric pain rating scale (NPRS), Neck Disability Index (NDI) and cervical range of motion (ROM) were used as outcome measurement tools. Non-parametric tests of significance were used for inter group and intra group comparison (Mann-Whitney U test and Wilcoxon test).

RESULTS

A statistically significant difference was observed between pre and post NPRS, NDI and ROM scores after 4 weeks of treatment for both groups (p< 0.05). However, no significant differences were observed in post treatment scores of active and passive neural mobilization groups (p> 0.05).

CONCLUSION

Both active and passive neural mobilization is effective in the management of cervical radiculopathy. One of the interventions is not superior to the other.

Comparative effectiveness of transverse oscillatory pressure and cervical traction in the management of cervical radiculopathy: A randomized controlled study

BACKGROUND

Radiating neck pain is one of the major symptoms of cervical radiculopathy (CR).

OBJECTIVE

This study compared the effects of cervical traction (CT) and transverse oscillatory pressure (TOP) in management of CR.

METHODS

Seventy-five participants with unilateral radiating neck pain were randomly allocated into three groups, 25 (14 males, 11 females) for CT, 25 (15 males and 10 females) for TOP and 25 (11 males and 14 females) control (Cnt) group. All participants received massage, cryotherapy and active exercises three times in a week for six weeks. CT was administered to CT group, TOP to TOP group while the third group served as control. Pain intensity (PI) and neck functional disability (NFD) were assessed pretreatment, 3rd and 6th week of intervention. Data were analyzed using descriptive and inferential statistics.

RESULTS

There was a significant reduction in PI and NFD between pretreatment and 6th week in all the groups ( p < 0 . 05 ). The effect size of PI ( F = 7 . 533 , p < 0 . 001 ) and disability index ( F = 37 . 888 , p < 0 . 001 ) in CT group were significantly lower than that of TOP group at 3rd week. PI of TOP was significantly ( p < 0 . 05 ) lower than that of CT and Cnt groups at the 6th week.

CONCLUSION

TOP reduces the PI and disability of patients with CR faster compared to CT.

UPPER CERVICAL RADICULOPATHY: THE HIDDEN PATHOLOGY OF THE SPINE

Axial neck pain can frequently be a vexing clinical problem for practitioners. Cervical spine surgery is generally regarded as less successful for axial neck pain than arm complaints. Although only few case series exist in the literature, there is evidence to suggest that upper cervical radiculopathy could be an important, treatable source of axial neck pain. Unlike patients with axial neck pain, patients with radiculopathy usually present with unilateral pain, particularly in the trapezial, parascapular, mid clavicular, or even in the form of suboccipital headaches. Similar to other regions of the cervical spine, initial imaging often consists of plain radiographs of the cervical spine, with the use of magnetic resonance imaging (MRI) or computed tomography (CT) if further evaluation of the pathology is warranted. Selective injections and electromyography can be used in conjunction with the imaging studies to aid with proper diagnosis. The surgical management of upper cervical radiculopathy is reserved for patients who fail to improve with non-operative modalities. Anterior cervical discectomy and fusion (ACDF) remain the most commonly performed and most reliable procedure for the treatment of cervical radiculopathy. Wide decompression of disc material from uncinate to uncinate is performed with or without a foraminotomy on the symptomatic side to address anterior compressive pathology. Artificial disc replacement (ADR) has been recently introduced in hopes of maintaining motion at the pathologic levels. Young patients (<40 years old) with minimal facet joint arthrosis are best indicated for this surgery. Posterior cervical foraminotomy avoids many approach related complications associated with anterior surgery and is the preferred approach when anterior surgery is contraindicated. Very few studies with small sample sizes (likely due to underdiagnosis) make it difficult to perform a comparative analysis of the different types of procedures. Ultimately, an accurate diagnosis is likely the most important predictor of a positive surgical outcome.

A randomized controlled trial of intermittent Cervical Traction in sitting Vs. Supine position for the management of Cervical Radiculopathy

Objective:

To compare the effectiveness of intermittent cervical Traction in sitting vs. supine position for the management of cervical radiculopathy

Methods:

A randomized clinical trial was done to compare pain and disability modification of cervical radiculopathy patients by using cervical traction in sitting and supine positions. Forty patients (males and females aged between 18-60 years with chronic cervical radiculopathy) were recruited for the trial. Participants were randomized into two homogeneous groups by dice method. The Group-A (n=20) received 3-weeks of intermittent cervical traction in sitting position along with Transcutaneous Electric Nerve Stimulation (TENS) and hot pack. The Group-B (n=20) received the same treatment except the intermittent cervical traction that was applied in supine position. Participants were assessed two times: at baseline (week 0) and at the termination of rehabilitation (week 3). Neck disability index was used to collect the data before and after the treatment.

Results:

The mean age of the patients was 43.15±8.99 vs. 48.80±6.89 years in Group-A vs. Group-B respectively. Mean (±S.D.) weight of the patients was 74.75±12.11 vs. 74.60±11.24 kg in Group-A vs. Group-B respectively. Mean Neck Disability Index score at start of treatment was 30.30±7.46 vs. 30.75±7.85 in Group-A and Group-B respectively. There was a significant difference in Group-A and Group-B regarding aggregate NDI score at the end of treatment (19.45±7.12 vs. 11.05±4.40; p<0.0001).

Conclusion:

Supine position is better choice for applying cervical traction as compared to sitting position for the management of cervical radiculopathy comparing post interventional NDI score.

Prolonged Preoperative Opioid Therapy Associated With Poor Return to Work Rates After Single-Level Cervical Fusion for Radiculopathy for Patients Receiving Workers' Compensation Benefits

STUDY DESIGN

Retrospective comparative cohort study.

OBJECTIVE

Examine the effect of prolonged preoperative opioid use on return to work (RTW) status after single-level cervical fusion for radiculopathy.

SUMMARY OF BACKGROUND DATA

The use of opioids has a dramatic effect in a workers' compensation population. The costs of claims that involved opioids in the management plan are catastrophic particularly for those undergoing spinal surgical procedure.

MATERIALS

Data of patients who underwent single-level cervical fusion for radiculopathy and had received opioid prescriptions before surgery were retrospectively collected from Ohio Bureau of Workers' Compensation between 1993 and 2011 after work-related injury. Then, based on opioid use duration, short-term use (STO) group (<3 mo), intermediate-term use (ITO) group (3-6 mo), and long-term use (LTO) group (>6 mo) were constructed. A multivariate logistic regression analysis was used to determine whether successful RTW status was achieved. Chi-square and analysis of variance tests were used to compare other secondary outcomes after surgery.

RESULTS

Prolonged preoperative opioid use was a negative predictor of successful RTW status (odds ratio = 0.73; 95% confidence interval: 0.55-0.98; P value: 0.04). Prolonged preoperative opioid use was associated with increasingly lower rates of achieving stable RTW status (P < 0.05) and RTW within 1 year after surgery (P < 0.05). The odds of achieving successful RTW status were 0.49 (0.25-0.94) for ITO, and 0.40 (0.24-0.68) for LTO compared with STO group. The odds of RTW less than 1 year after surgery were 0.43 (0.21-0.88) for ITO and 0.36 (0.21-0.62) for LTO compared with STO group. Prolonged preoperative opioid use was also associated with increasingly higher net medical costs (P < 0.01), and disability benefits awarded after surgery (P < 0.01).

CONCLUSION

Prolonged preoperative opioid use was associated with poor functional outcomes after cervical fusion. STO and earlier inclusion of the surgical approach in the management plan may offer better surgical and functional outcomes after cervical fusion.

LEVEL OF EVIDENCE

3.

Does pain relief by CT-guided indirect cervical nerve root injection with local anesthetics and steroids predict pain relief after decompression surgery for cervical nerve root compression?

BACKGROUND

The relationship of pain relief from a recently presented CT-guided indirect cervical nerve root injection with local anesthetics and steroids to surgical decompression as a treatment for single-level cervical radiculopathy is not clear. This retrospective study aimed to compare the immediate and 6-week post-injection effects to the short- and long-term outcomes after surgical decompression, specifically in regard to pain relief.

METHODS

Patients (n = 39, age 47 ± 10 years) who had undergone CT-guided indirect injection with local anesthetics and steroids as an initial treatment for single cervical nerve root radiculopathy and who subsequently needed surgical decompression were included retrospectively. Pain levels (VAS scores) were monitored before, immediately after, and 6 weeks after injection (n = 34), as well as 6 weeks (n = 38) and a mean of 25 months (SD ± 12) after surgical decompression (n = 36). Correlation analysis was performed to find potential associations of pain relief after injection and after surgery to investigate the predictive value of post-injection pain relief.

RESULTS

There was no correlation between immediate pain relief after injection (-32 ± 27 %) and 6 weeks later (-7 ± 19 %), (r = -0.023, p = 0.900). There was an association by tendency between immediate pain relief after injection and post-surgical pain relief at 6 weeks (-82 ± 27 %), (r = 0.28, p = 0.08). Pain relief at follow-up remained high at -70 ± 21 % and was correlated with the immediate pain amelioration effect of the injection (r = 0.37, p = 0.032). Five out of seven patients who reported no pain relief from injection had a pain relief from surgery in excess of 50 %.

CONCLUSIONS

The amount of immediate radiculopathic pain relief after indirect cervical nerve root injection is associated with the amount of pain relief achieved at long-term follow-up after surgical decompression of single-level cervical radiculopathy. Patients can still expect sufficient pain relief from surgery even if they did not respond to the cervical infiltration.

An Evidence-Based Approach to Differentiating the Cause of Shoulder and Cervical Spine Pain

Differentiating the cause of pain and dysfunction due to cervical spine and shoulder pathology presents a difficult clinical challenge in many patients. Furthermore, the anatomic region reported to be painful may mislead the practitioner. Successfully treating these patients requires a careful and complete history and physical examination with appropriate provocative maneuvers. An evidence-based selection of clinical testing also is essential and should be tailored to the most likely underlying cause. When advanced imaging does not reveal a conclusive source of pathology, electromyography and selective injections have been shown to be useful adjuncts, although the sensitivity, specificity, and risk-reward ratio of each test must be considered. This review provides an evidence-based review of common causes of shoulder and neck pain and guidelines for assistance in determining the pain generator in ambiguous cases.

Cervical radiculopathy

Cervical radiculopathy is a common clinical scenario. Patients with radiculopathy typically present with neck pain, arm pain, or both. We review the epidemiology of cervical radiculopathy and discuss the diagnosis of this condition. This includes an overview of the pertinent findings on the patient history and physical examination. We also discuss relevant clinical syndromes that must be considered in the differential diagnosis including peripheral nerve entrapment syndromes and shoulder pathology. The natural history of cervical radiculopathy is reviewed and options for management are discussed. These options include conservative management, non-operative modalities such as physical therapy, steroid injections, and operative intervention. While the exact indications for surgical intervention have not yet been elucidated, we provide an overview of the available literature regarding indications and discuss the timing of intervention. The surgical outcomes of anterior cervical decompression and fusion (ACDF), cervical disc arthroplasty (CDA), and posterior cervical foraminotomy (PCF) are discussed.

Transverse oscillatory pressure in management of cervical radiculopathy: A randomised controlled study

Background:

Cervical radiculopathy is an important subgroup of neck disorders causing severe pain and disability.

Objectives:

The study assessed the effect of transverse oscillatory pressure (TOP) on pain intensity and functional disability of patients with cervical radiculopathy.

Methods:

Twenty-six individuals with unilateral radiating neck pain were randomly allocated into Group A (8 males and 5 females) and Group B (6 males and 7 females). Participants in the two groups received kneading massage, cryotherapy, and active isometric exercises to the posterior paraspinal muscles, trapezuis, and sternomastoid muscles. TOP was administered to Group A, whereas Group B served as control. Treatment was applied three times per week for 4 weeks, making 12 treatment sessions for each participant. Visual analogue scale and Neck Disability Index were used to assess pain intensity and neck disability, respectively, at baseline, 2 weeks, and 4 weeks. Data were analysed using repeated-measures analysis of variance.

Results:

There was a significant improvement in pain intensity and neck functional disability of patients between baseline, 2^nd week, and 4^th week of treatment sessions in Groups A and B (p < 0.05). There was a significant reduction in pain intensity in Group A (f = 7.08, p < 0.05) at the 2^nd week and 4^th week compared with Group B.

Conclusion:

It can be concluded that TOP reduces pain faster in patients with cervical radiculopathy.

Jingtong Granule: A Chinese Patent Medicine for Cervical Radiculopathy

Objective. This paper systematically assessed the efficacy and safety of Jingtong granule (JG) for cervical radiculopathy (CR). Methods. Randomized controlled trials comparing JG with no intervention, placebo, or conventional therapies were retrieved. The trials testing JG combined with conventional therapies versus conventional therapies were also enrolled. Study selection, methodological assessment, data extraction, and analysis were conducted in accordance with the Cochrane standards. The strength of evidence was evaluated according to GRADE approach. Results. Three trials with 400 participants were included. Methodological quality was evaluated as generally low. One study found that JG showed significant difference on decreasing pain scores compared with placebo. Meta-analysis indicated that JG plus conventional analgesic exhibited a significant immediate effect on the pain scores (WMD = 1.63; 95% CI: 1.29 to 1.98; P < 0.00001). Additionally, JG combined with analgesic presented beneficial immediate effect on neck disability index. However, the treatment effects of JG demonstrated in the trials were not large, and the safety of JG was unproven. Finally the evidence level was evaluated to be low. Conclusions. Our results indicated that JG showed some potential benefits for CR. Nevertheless, treatment effects are uncertain due to both the methodological concerns and the very modest reported improvements.

Using the modified Delphi method to establish a new Chinese clinical consensus of the treatments for cervical radiculopathy

PURPOSE

Although cervical radiculopathy is very common, there is no standard treatment for this condition, with little high-level evidence available to guide the treatment choice. Thus, this study aimed to review the current data on the management of cervical radiculopathy; and, further, to establish a new Chinese clinical consensus of the treatments for cervical radiculopathy using the Delphi method.

METHODS

First, a systematic review of the previously established treatment guidelines and of articles related to cervical radiculopathy was conducted to establish a protocol for the clinical consensus of the treatment for cervical radiculopathy. Second, from February 2012 to June 2014, we performed a modified Delphi survey in which the current professional opinions from 30 experienced experts, representing almost all of the Chinese provinces, were gathered. Three rounds were performed, and consensus was defined as ≥70% agreement.

RESULTS

Consensus of the treatments for cervical radiculopathy was reached on seven aspects, including the proportion of patients requiring only non-surgical therapies; the effectiveness of neck immobilization, physiotherapy, pharmacologic treatment; surgical indications; contraindications; surgery.

CONCLUSIONS

The modified Delphi study conducted herein reached a consensus concerning several treatment issues for cervical radiculopathy. In the absence of high-level evidence, at present, these expert opinion findings will help guide health care providers to define the appropriate treatment in their regions. Items with no consensus provide excellent areas for future research.

Cervical radiculopathy

Cervical radiculopathy is the result of irritation and/or compression of nerve root as it exits the cervical spine. Pain is a common presenting symptom and may be accompanied by motor or sensory deficits in areas innervated by the affected nerve root. Diagnosis is suggested by history and corresponding physical examination findings. Confirmation is achieved with MRI. A multimodal approach to treatment helps patients improve. Medications may be used to alleviate symptoms and manage pain. Physical therapy and manipulation may improve neck discomfort. Guided corticosteroid injections and selected nerve blocks may help control nerve root pain. Most patients improve with a conservative, nonoperative treatment course.

Feasibility of Early and Repeated Low-dose Interscalene Brachial Plexus Block for Residual Pain in Acute Cervical Radiculopathy Treated with NSAIDS

Background

To improve residual pain management in acute cervical radiculopathy treated with NSAIDs, the feasibility of early and repeated low-dose interscalene brachial plexus block (IS-BPB) needs to be assessed.

Methods

This was a prospective study on patients receiving NSAIDs (loxoprofen) for cervical radiculopathy of ≤ 2-week onset. Pain was assessed using the visual analogue scale (VAS). A low-dose ultrasonography (USG)-guided IS-BPB (dexamethasone [1.65 mg; 0.5 ml] and mepivacaine [1%; 3.0 ml]) was performed at baseline and weekly thereafter for 4 weeks in an outpatient setting for the intervention group. All patients were evaluated using a visual satisfaction score (VSS) at week 4. Patients with baseline VAS scores < 70 (mild to moderate pain; MM group) and ≥ 70 (severe pain; SE group) were compared to the controls receiving NSAIDs.

Results

A total of 316 IS-BPBs were performed in the intervention group. There was a significant difference in the decline in the VAS from week 0 to week 3 in the MM and SE groups (P < 0.05); however, from week 3 to week 4, the therapeutic effect exhibited no significant difference. Thirteen patients at week 2 (15.5%; MM: 27.7%; SE: 0%), 43 at week 3 (51.2%; MM: 83.0%; SE: 10.8%), and 47 at week 4 (56.0%; MM: 85.1%; SE: 18.9%) achieved a VAS score of ≤ 20. Patient satisfaction was high, and the decrease in VAS scores in both groups was significant (P < 0.05) compared to the controls.

Conclusions

Weekly, low-dose, USG-guided IS-BPB can be implemented for early pain relief in acute cervical radiculopathy, with high patient satisfaction.

The study of diagnostic efficacy of nerve conduction study parameters in cervical radiculopathy

BACKGROUND

Cervical Radiculopathy (CR) is a neurologic condition characterised by dysfunction of a cervical spinal nerve, the roots of the nerve, or both. Diagnostic criteria for CR are not well defined, and no universally accepted criteria for its diagnosis have been established. Clinical examination, radiological imaging and electrophysiologic evaluation are the different modalities to diagnose CR. The incidence of Cervical Spondylosis and related conditions is increasing in the present scenario and the use of radiologic examination is time consuming and uneconomical for the common Indian setup. Thus, there is a definite need to establish a cost effective, reliable, and accurate means for establishing the diagnosis of cervical radiculopathy. Electrodiagnostic tests are the closest to fulfill these criteria.

AIM

To evaluate diagnostic utility of various motor and sensory nerve conduction study parameters in cervical radiculopathy.

SETTING AND DESIGN

It was a cross-sectional study conducted on 100 subjects of age > 40 years.

MATERIAL AND METHODS

The consecutive patients clinically diagnosed to have cervical radiculopathy, referred from department of Orthopaedics were prospectively recruited for the motor and sensory nerve conduction study using RMS EMG EP Mark-II. Parameters studied were Compound Muscle Action Potential (CMAP), Distal Motor Latency (DML) and Conduction Velocity (CV) for motor nerves and Sensory Nerve Action Potential (SNAP) and CV for sensory nerves.

STATISTICAL ANALYSIS

Study observations and results were analysed to find the Specificity, Sensitivity, Positive Predictive Value and Negative Predictive Value using SPSS 16.0.

RESULTS

Among various motor nerve conduction parameters CMAP was found to be more sensitive with high positive predicative value. CV was found to have greater specificity and DML had least negative predictive value. Sensory nerve conduction parameters were found to have less sensitivity but higher specificity as compared to motor parameters.

CONCLUSION

Nerve conduction studies are useful supportive diagnostic tool for suspected cervical radiculopathy as they are found to have reliable sensitivity and specificity.

What is the best way to apply the Spurling test for cervical radiculopathy?

BACKGROUND

A diagnosis of cervical radiculopathy is based largely on clinical examination, including provocative testing. The most common maneuver was described in 1944 by Spurling and Scoville. Since then, several modifications of the original maneuver have been proposed to improve its value in the diagnosis of cervical radiculopathy.

QUESTIONS/PURPOSES

We assessed the ability of six known variations of the Spurling test to reproduce the complaints of patients diagnosed with cervical radiculopathy.

METHODS

We prospectively enrolled 67 patients presenting with cervical radicular-like symptoms and concordant radiographic findings. Each patient underwent six distinct provocative cervical spine maneuvers by two examiners, during which three parameters were recorded: (1) pain intensity (VAS score), (2) paresthesia intensity (0 - no paresthesia, 1 - mild to moderate, and 2 - severe), and (3) characteristic pain distribution (0 - no pain, 1 - neck pain only, 2 - arm pain only, 3 - pain elicited distal to the elbow). The interobserver reliability of the reported VAS score (measured by the intraclass coefficient correlation) ranged from 0.78 to 0.96 and the calculated kappa values of the categorical parameters ranged from 0.58 to 1.0 for paresthesia intensity and from 0.63 to 1.0 for pain distribution. Differences in scores elicited between the two examiners for the 67 patients were resolved by consensus.

RESULTS

A maneuver consisting of extension, lateral bending, and axial compression resulted in the highest VAS score (mean, 7) and was associated with the most distally elicited pain on average (mean, 2.5). The highest paresthesia levels were reported after applying extension, rotation, and axial compression (mean, 1). These maneuvers, however, were the least tolerable, causing discontinuation of the examination on three occasions.

CONCLUSIONS

Whenever cervical radiculopathy is suspected our observations suggest the staged provocative maneuvers that should be included in the physical evaluation are extension and lateral bending first, followed by the addition of axial compression in cases with an inconclusive effect.

Chiropractic management using Cox cervical flexion-distraction technique for a disk herniation with left foraminal narrowing in a 64-year-old man

OBJECTIVE

The purpose of this case report is to describe chiropractic management of a patient with a C6/C7 left posteromedial disk herniation with foraminal narrowing and concomitant neurological compromise in the form of left upper extremity radiating pain and hypoesthesia/anesthesia using Cox flexion-distraction technique.

CLINICAL FEATURES

A 64-year-old man presented to a chiropractic clinic with complaints of neck/left shoulder pain and hypoesthesia/anesthesia into the palmar side of his left hand. Magnetic resonance images of the cervical spine revealed a left posteromedial C6/C7 disk herniation along with foraminal narrowing. In addition, there were other levels of degeneration, most noted at the C3/C4 spinal level, which also had significant left-sided foraminal narrowing.

INTERVENTION AND OUTCOME

Treatment included Cox flexion-distraction protocols aimed to reduce nerve root compression along with supportive physiological therapeutic interventions to aid with pain reduction and functional improvement. The patient was treated a total of 10 times over a course of 4 weeks. The patient reported being pain-free and fully functional 8 months following the conclusion of care.

CONCLUSION

This case study demonstrated the use of Cox flexion-distraction for treatment of a patient with a cervical disk herniation, foraminal narrowing, and associated radiating pain and radiculopathy in the left upper extremity.

Clinical outcomes of cervical radiculopathy following epidural steroid injection: a prospective study with follow-up for more than 2 years

STUDY DESIGN

A prospective clinical outcome study.

OBJECTIVE

To analyze clinical outcome and prognostic factors of the epidural steroid injection (ESI) for cervical radiculopathy (CR) patients who were considered surgical candidates.

SUMMARY OF BACKGROUND DATA

The clinical outcomes and prognostic factors of ESI for CR have not been consistently reported, and there has been no prospective study with long-term follow-up.

METHODS

ESI was administered in 98 patients (mean age = 50.1 yr, follow-up = 40.4 mo) with CR without major neurological deficit. A total of 3 or fewer ESIs were administered, using either the interlaminar or transforaminal technique. The patients were divided into 2 groups: those who did not have surgery and those who underwent surgery at the last follow-up. We analyzed statistical difference of relevant clinical (sex, age, duration of symptom, previous episode of CR, visual analogue scale [VAS] of arm pain, etc.), radiological factors (soft disc vs. hard disc, central disc vs. foraminal disc, single segment involvement vs. multiple segment involvement, degree of neural compression and degeneration, etc.) and clinical outcomes (VAS of arm pain, Odom's criteria, and neck disability index) between the 2 groups.

RESULTS

The patients received mean 1.8 ESI treatments. At the final follow-up, 79 of the patients (80.6%) did not undergo surgery, whereas the other 19 patients (19.4%) underwent surgery. Of the clinical factors, recurred CR (15.2% vs. 42.1%, P = 0.022) and mean VAS score of arm pain before (6.1 vs. 8.2, P = 0.000) and after ESI (2.8 vs. 6.9, P = 0.000) were significantly different between both groups. Radiological factors and outcome parameters showed no significant difference.

CONCLUSION

In more than 80% of patients with CR who were surgical candidates, surgery was avoided using ESI. The significant factors predisposing failure of ESI were intensity of symptom and a previous episode of CR. ESI is therefore considered a safe and effective treatment to choose before undergoing surgery.

Lack of uniform diagnostic criteria for cervical radiculopathy in conservative intervention studies: a systematic review

PURPOSE

Cervical radiculopathy (CR) is a common diagnosis. It is unclear if intervention studies use uniform definitions and criteria for patient selection. Our objective was to assess the uniformity of diagnostic criteria and definitions used in intervention studies to select patients with CR.

METHODS

We electronically searched the Cochrane Controlled Trials Register, MEDLINE, EMBASE and CINAHL. Studies were included when evaluating conservative interventions in randomised clinical trials (RCTs) in patients with CR. Selection criteria and definitions for patients with CR were extracted and evaluated on their uniformity.

RESULTS

Thirteen RCTs were included. Pain was used as an inclusion criterion in 11 studies. Inclusion based on the duration and location of pain varied between studies. Five studies used sensory symptoms in the arm as inclusion criterion. Four studies used cervical range of motion and motor disturbances as inclusion criteria, while reflex changes were used in two studies. Three studies included patients with a positive Spurling's test and two studies used it within a cluster of provocation tests.

CONCLUSIONS

Criteria used to select patients with CR vary widely between different intervention studies. Selection criteria and test methods used are poorly described. There is consensus on the presence of pain, but not on the exact location of pain.

Use of a multimodal conservative management protocol for the treatment of a patient with cervical radiculopathy

OBJECTIVE

The purpose of this study is to describe and discuss the treatment of a cervical disk herniation using a sequential multimodal conservative management approach.

CLINICAL FEATURES

A 40-year-old man had complaints of headache and severe sharp neck pain radiating to his left shoulder down to his arm, forearm, and hand. Results of electromyography/nerve conduction studies were abnormal. Magnetic resonance imaging revealed a large disk protrusion at C5-C6 with indentation of the thecal sac and a spur at the posterior margin. Moderate left neural foraminal narrowing was present at C5-C6 with narrowed intervertebral disk space at C5-C6 and C6-C7.

INTERVENTION AND OUTCOME

High-velocity, low-amplitude chiropractic manipulation; electrotherapy; ice; and exercise were used for treatment. The Neck Disability Index was used as a primary and electromyography/nerve conduction studies as a secondary outcome measurement. Based on the Neck Disability Index, there was an overall 89.65% symptoms improvement from the baseline.

CONCLUSIONS

This case study demonstrated possible beneficial effects of the multimodal treatment approach in a patient with cervical radiculopathy.

Pain patterns and descriptions in patients with radicular pain: does the pain necessarily follow a specific dermatome?

Background

It is commonly stated that nerve root pain should be expected to follow a specific dermatome and that this information is useful to make the diagnosis of radiculopathy. There is little evidence in the literature that confirms or denies this statement. The purpose of this study is to describe and discuss the diagnostic utility of the distribution of pain in patients with cervical and lumbar radicular pain.

Methods

Pain drawings and descriptions were assessed in consecutive patients diagnosed with cervical or lumbar nerve root pain. These findings were compared with accepted dermatome maps to determine whether they tended to follow along the involved nerve root's dermatome.

Results

Two hundred twenty-six nerve roots in 169 patients were assessed. Overall, pain related to cervical nerve roots was non-dermatomal in over two-thirds (69.7%) of cases. In the lumbar spine, the pain was non-dermatomal in just under two-thirds (64.1%) of cases. The majority of nerve root levels involved non-dermatomal pain patterns except C4 (60.0% dermatomal) and S1 (64.9% dermatomal). The sensitivity (SE) and specificity (SP) for dermatomal pattern of pain are low for all nerve root levels with the exception of the C4 level (Se 0.60, Sp 0.72) and S1 level (Se 0.65, Sp 0.80), although in the case of the C4 level, the number of subjects was small (n = 5).

Conclusion

In most cases nerve root pain should not be expected to follow along a specific dermatome, and a dermatomal distribution of pain is not a useful historical factor in the diagnosis of radicular pain. The possible exception to this is the S1 nerve root, in which the pain does commonly follow the S1 dermatome.

Quantitative changes in the cervical neural foramen resulting from axial traction: in vivo imaging study

BACKGROUND CONTEXT

Cervical traction has a long history as a method of conservative treatment for cervical spine diseases. However, information on quantitative changes in the cervical neural foramen resulting from axial traction in vivo is lacking.

PURPOSE

To quantitatively evaluate the changes in the neural foramen of the cervical spine during axial traction in vivo.

STUDY DESIGN

A prospective radiographic analysis of the cervical neural foramen of adult volunteers.

PATIENT SAMPLE

Fifteen healthy volunteers (10 men, 5 women) without any history of cervical spine disease.

OUTCOME MEASURES

The changes in cervical cross-sectional foraminal areas and heights were measured.

METHODS

Cervical magnetic resonance (MR) images of the volunteers were taken at the neutral position and were reconstructed in the oblique plane perpendicular to the long axis of each neural foramen from the C2-3 to the C6-7 level. The changes in the neural foraminal dimensions at incremental axial traction forces (0, 5, 10, and 15 kg) were analyzed.

RESULTS

After each 5-kg incremental increase in traction weight, there was a significant (p value less than .05) increase in area and height of the intervertebral foramen compared with the position in which no weight was applied. There was an average increase of 5.81%, 16.56%, and 18.9% in the foraminal area and an average increase of 3.75%, 8.67%, and 10.43% in foraminal height compared with the position with no weight at traction of 5, 10, and 15 kg, respectively. There was no statistically significant difference for the increase in foraminal area and height from 10 to 15 kg of traction (p value greater than .05).

CONCLUSIONS

There was a significant increase in intervertebral foraminal area and height after each 5-kg increment in traction weight compared with the position in which no weight was applied. From 10 to 15 kg of traction, there was no significant change in the foraminal area and height.

Cervical radiculopathy

Cervical radiculopathy is a disorder involving dysfunction of cervical nerve roots that commonly manifests as pain radiating from the neck into the distribution of the affected root. Acute cervical radiculopathy generally has a self-limited clinical course, with up to a 75% rate of spontaneous improvement. Thus, nonsurgical treatment is the appropriate initial approach for most patients. When nonsurgical treatment fails to relieve symptoms or if a significant neurologic deficit exists, surgical decompression may be necessary. Surgical outcomes for relief of arm pain range from 80% to 90% with either anterior or posterior approaches.

Impact of neck and arm pain on overall health status

STUDY DESIGN

A prospective, multicenter, cross-sectional analysis of data from the National Spine Network database.

OBJECTIVES

To compare the relative impact of radicular and axial symptoms associated with disease of the cervical spine on general health as measured by the SF-36 Health Survey, and to compare the impact of these symptoms among patients of varying age and symptom duration.

BACKGROUND

Degenerative disorders of the cervical spine can cause debilitating symptoms of neck and arm pain. Physicians generally treat radiculopathy more aggressively than axial neck pain alone, although it has never been shown that the presence of radiculopathy leads to a greater impairment of physical and mental function.

MATERIALS AND METHODS

SF-36 Health Survey data were collected from all consenting patients seen within the National Spine Network. Patients with symptoms referable to the cervical spine (as per their physician) were included (n = 1,809). SF-36 scores for all eight scales (bodily pain (BP), vitality (VT), general health (GH), mental health (MH), physical function (PF), role physical (RP), role emotional (RE), and social function (SF), and two summary scales (Physical Component Summary [PCS] and Mental Component Summary [MCS]) were calculated. Age/gender normative scores were subtracted from the scale scores to produce a negative "impact" score, which reflected how far below normal health status these patients were. Patients were grouped according to location of symptoms (axial only, radicular only, or axial and radicular), age (younger than 40, 40 to 60, and older than 60 years), and symptom duration (acute: <6 wk; subacute: 6 wk-6 mo; and chronic: >6 mo). SF-36 scores were compared between all groups using analysis of variance and multiple comparisons with Bonferroni adjustment.

RESULTS

Patients who presented with both axial and radicular symptoms had the lowest SF-36 scores relative to age and gender norms. These scores were significantly lower than those for patients with only axial or only radicular symptoms across all eight subscales (P < 0.05- P < 0.0001). Scores for patients with only axial pain were significantly lower than for patients with only radicular pain for VT (P < 0.04) and GH (P < 0.004). Patients younger than 40 and those between ages 40 to 60 years were significantly more impacted by their symptoms than patients older than 60 years for all eight scales (P < 0.01). PCS scores were similar for acute, subacute, and chronic groups, whereas MCS scores were significantly worse for patients with chronic pain.

CONCLUSIONS

Combined neck and arm pain were much more disabling than either symptom alone. Younger patients (younger than 40 or 40-60) were more affected by these symptoms than patients older than 60 years. In addition, as symptom duration increased, a negative impact on mental health was observed, although chronic symptoms did not affect physical health. This study suggests that patients with a significant component of axial pain in conjunction with cervical radiculopathy should be considered the most affected of all patients with cervical spondylosis. Given the evidence that the treatment methods at the disposal of physicians are effective, this study suggests that prompt treatment of these patients may help avoid the harmful effects of chronic symptoms on mental functioning, especially among younger patients who were found to be more impacted by the symptoms.

Cervical radiculopathies: conservative approaches to management

It is now well recognized that the natural course of cervical radiculopathy is generally favorable. Comprehensive, aggressive, nonsurgical management often is successful with respect to functional outcomes, pain reduction, and patient satisfaction. Surgery is avoidable for most patients. The focus of this article is a review of the most recent and classic literature related to the nonsurgical management of cervical radiculopathies.

Neural space integrity of the lower cervical spine: effect of normal range of motion

STUDY DESIGN

An experimental investigation of intervertebral foramen and spinal canal neural space integrity was performed throughout physiologic range of motion of the lower cervical spine in intact human cadaver specimens.

OBJECTIVE

To investigate cervical positions that might place the neural tissues of the spine in heightened risk of injury. To meet this objective the following hypotheses were tested: 1) spinal canal integrity varies with specific normal range of motion positions of the lower cervical spine, and 2) intervertebral foramen integrity is dependent on and unique for different physiologic positions of the lower cervical spine.

SUMMARY OF BACKGROUND DATA

Cervical spine injuries are frequently associated with compressive damage to neurologic tissues and consequently poor clinical outcomes. Neurologic injury typically occurs from disc, ligamentous, or bony occlusion of the spinal canal and intervertebral foraminal spaces dynamically during an injury event or with abnormal alignment and position after the injury event. Prior studies have shown pressure and geometric changes in cervical spine neural spaces in certain cervical spine positions. However, to the authors' knowledge, this is the first research effort aimed at elucidating the integrity of the cervical spine neural spaces throughout the normal physiologic range of motion.

METHODS

The authors instrumented 17 fresh-frozen unembalmed cadaveric human cervical spines (C3-C7) with specially designed intervertebral foramen occlusion transducers and a spinal canal occlusion transducer. The specimens were loaded with pure bending moments to produce simulated physiologic motions of the lower cervical spine. The resulting occlusion profiles for the intervertebral foramen and spinal canal were recorded along with the 6-degree of freedom position of the cervical spine. Because these occlusion measurements describe the ability of the spine to preserve the space for the neural structures, the authors define this neuroprotective role of the vertebral column as neural space integrity.

RESULTS

The range of motion developed experimentally in this study compared well with published reports of normal cervical motion. Thus, subsequent changes in neural space integrity may be regarded as resulting from normal human cervical spine motion. No significant change in the spinal canal space was detected for any physiologic motion; however, intervertebral foramen integrity was significantly altered in extension, ipsilateral bending, combined ipsilateral bending and extension, and combined contralateral bending with extension when compared with intact upright neutral position.

CONCLUSIONS

This study defines the range of neural space integrity associated with simulated physiologic motion of the lower cervical spine in an experimental setting. This information may be useful in comparing neural space changes in pathologic conditions and may enhance refinement of neurologic injury prevention strategies.

Surgical management of cervical radiculopathy

Cervical radiculopathy presents as pain in a dermatomal distribution. Despite conservative nonoperative therapy, a large subset of patients will require surgical intervention. Indications for surgery include recalcitrant radiculopathy despite nonoperative treatment for more than 6 weeks and progressive motor deficit or disabling motor deficit (deltoid palsy, wrist drop) prior to 6 weeks. Anterior and posterior approaches have both yielded successful results in appropriately selected patients. Anterior cervical diskectomy and fusion is the generally preferred treatment for radiculopathy when there is a significant component of axial neck pain, when the disease is centrally located, or when there is any degree of segmental kyphosis. Posterior laminoforaminotomy is an acceptable choice for lateral soft disk herniations with predominant arm pain and for caudal lesions in large, short-necked individuals.