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One level cervical radiculopathy from a herniated disc


Introduction

The cervical spine is composed of seven vertebrae. With the exception of the first cervical vertebrae, each vertebra has an associated nerve that exits the foramen above the named vertebrae. Additionally, the vertebral artery enters the foramen transversarium typically at the sixth cervical vertebrae and exits at C1 prior to entering the foramen magnum. Cervical radiculopathy is pain or sensorimotor deficit resulting from compression of the cervical nerve root. Cervical radiculopathy can be caused by degenerative changes or more acute causes such as a disc herniation. While degenerative changes can lead to disc-osteophyte complex formations that cause nerve compression in older adult patients, disc herniation is more commonly found in younger patient populations. The compression of the nerve leads to inflammatory process, which is cytokine-mediated, resulting in demyelination of large-diameter axons. This results in radicular pain, numbness/tingling, or motor deficits typically in a characteristic distribution of the compressed nerve root. The usual first step in the treatment of cervical radiculopathy is conservative management with physical therapy, steroid injection, and nonsteroidal pain medications, as up to 90% will improve without surgical intervention; however, some may warrant surgical intervention.

Example case

  • Chief complaint : right arm pain

  • History of present illness : A 61-year-old male presents a history of radiculopathy in the C7 distribution for approximately 3 months. He rates the pain as approximately 8/10 but is now improved to about 5/10. The pain is constant and worse at certain times. He also has weakness in his right upper extremity. He has tried physical therapy and gabapentin without improvement. This led to imaging of his cervical spine ( Figs. 10.1 and 10.2 ).

    Fig. 10.1, Preoperative magnetic resonance images

    Fig. 10.2, Preoperative x-ray

  • Medications : Eliquis, amlodipine, lisinopril, tramadol

  • Allergies : no known drug allergies

  • Past medical and surgical history : atrial fibrillation status post ablation and cardioversion, hypertension, knee arthroscopy

  • Family history : noncontributory

  • Social history : construction worker, no smoking history, occasional alcohol

  • Physical examination : awake, alert, and oriented to person, place, and time; cranial nerves II–XII intact; bilateral deltoids/biceps 5/5; interossei, 5/5 left triceps, 4/5 right triceps; iliopsoas/knee flexion/knee extension/dorsi, and plantar flexion 5/5

  • Reflexes : 2+ in bilateral biceps/triceps/brachioradialis; 2+ in bilateral patella/ankle; no clonus or Babinski; negative Hoffman; sensation intact to light touch

  • Lorin M. Benneker, MD

  • Orthopaedic Surgery

  • Spine Unit, Sonnenhofspital, Bern Switzerland

  • Bern, Switzerland

  • Paul M. Huddleston, III, MD

  • Orthopaedic Surgery

  • Mayo Clinic

  • Rochester, Minnesota, United States

  • Justin S. Smith, MD, PhD

  • Neurosurgery

  • University of Virginia

  • Charlottesville, Virginia, United States

  • Clemens Weber, MD, PhD

  • Neurosurgery

  • Stavanager University Hospital

  • Stavanager, Norway

Preoperative
Additional tests requested

  • MRI C-spine for better assessment of foramen

  • Periradicular right C6–7 steroid injection

  • CT C-spine

  • DEXA

  • EMG

  • Right C7 nerve root steroid/local anesthetic block

  • MRI C-spine for better assessment of foramen

  • EMG/NCS of upper extremities

  • Selective nerve block

Cardiology evaluation
Surgical approach selected If temporary improvement with steroid injection, C6–7 ACDA and right C6–7 foraminotomy If not responsive to steroid injection and EMG confirms level, right C6–7 posterior keyhole lamino-foraminotomy

  • Conservative approach first

  • Right C6–7 foraminotomy

C6–7 ACDF
Goal of surgery Decompress C7 nerve root, preserve segmental mobility Decompress C7 nerve root, preserve segmental mobility Decompress C7 nerve root Decompress C7 nerve roots
Perioperative
Positioning Supine, with Gardner-Wells tongs Prone in Jackson table, with pins Prone, with pins Supine, no pins
Surgical equipment

  • Surgical microscope

  • Fluoroscopy

  • IOM (MEP/SSEP/EMG)

  • Fluoroscopy

  • Surgical microscope

Fluoroscopy

  • Fluoroscopy

  • Surgical microscope

Medications None Tranexamic acid, steroids, Toradol, liposomal bupivacaine None None
Anatomical considerations ICA, recurrent laryngeal nerve Dura, exiting nerve root, vertebral artery Spinal cord, nerve root, vertebral artery ICA, esophagus
Complications feared with approach chosen Recurrent laryngeal palsy Instability, CSF leak, neuropraxia, C5 palsy Bleeding, instability Bleeding, nerve root injury
Intraoperative
Anesthesia General General General General
Exposure C6–7 C6–7 C6–7 C6–7
Levels decompressed C6–7 C6–7 C6–7 C6–7
Levels fused C6–7 None None C6–7
Surgical narrative Position supine, left-sided oblique incision, blunt dissection to expose C6–7 disc, confirm correct level with x-ray, place Caspar pin in C6 and C7, discectomy, slight distraction, right foraminotomy, placement of trials, placement of final prosthesis, x-ray control, layered closure Position prone with Mayfield pins after IOM, postflip IOM, x-ray to localize level, subperiosteal dissection, confirm level with x-ray, right C6–7 laminoforaminotomy under microscopic visualization, identify thecal sac and exiting C7 nerve root, decompress nerve root removing bony spurs and ligamentum while preserved facet capsule, irrigate with dilute betadine and saline, layered closure with liposomal bupivacaine, apply cervical collar Position prone with Mayfield pins, fluoroscopy to mark midline posterior incision at C6–7 level, expose right C6–7, confirm level with fluoroscopy, right C6–7 foraminotomy with drill and Kerrison punch, close wound in layers Position supine, right-sided neck dissection to C6–7 level, blunt dissection between vessels and trachea/esophagus, confirm level with fluoroscopy, black belt retractor, microscopic visualization, incision and removal of disc, identify uncus bilaterally, open PLL, decompression of nerve roots, insertion of titanium cage with no plate, no drain
Complication avoidance Left-sided approach to access right foramen, slight distraction, arthroplasty to preserve segment motion Pre- and postflip IOM, preserve facet capsule Right foraminotomy, only expose right side Blunt dissection between vessels and trachea/esophagus
Postoperative
Admission Floor Outpatient Floor Outpatient
Postoperative complications feared Recurrent laryngeal nerve injury Instability, CSF leak, neuropraxia, C5 palsy Bleeding, instability Nerve root injury, hoarseness, dysphagia
Anticipated length of stay 1–2 days Same day Overnight 6 hours
Follow-up testing C-spine x-ray within 48 hours, 6–8 weeks after surgery C-spine flexion/extension x-rays 3 months after surgery MRI in 12 months if symptoms do not improve

  • Physical therapy 6 weeks after surgery

  • No follow-up imaging unless needed

Bracing Soft collar for sleep for 2 weeks Soft collar for 2 weeks None None
Follow-up visits 6–8 weeks after surgery 2 weeks, 3 months, 12 months after surgery 10–14 days, 6 weeks, 6 months, and 1 year after surgery 3 months after surgery
BMP , Bone morphogenic protein; DEXA , dual-energy x-ray absorptiometry; EMG , electromyogram; ICA , internal carotid artery; ICU; intensive care unit; IOM , intraoperative monitoring; MEP , motor evoked potentials; MIS , minimally invasive surgery; MRI , magnetic resonance imaging; NCS , nerve conduction study; PLL , posterior longitudinal ligament; SSEP , somatosensory evoked potentials.

Differential diagnosis

  • ▪

    Cervical radiculopathy

  • ▪

    Radial nerve neuropathy

  • ▪

    Brachial plexus injury

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