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Radiculopathy from foraminal stenosis


Introduction

Radiculopathy is one of the most common symptoms derived from degenerative changes in the cervical spine. Radiculopathy is a disorder of the nerve roots and usually manifests as axial pain (neck/low back) radiating to the distribution of the affected nerve root. The estimated prevalence of this condition is 3.5 cases per 1000 in the cervical spine. This condition seems to peak around the fourth and fifth decades of life. In the younger population, compromise of the neural foramen is often attributed to an acute injury. Narrowing of the neural foramina with nerve root compromise occurs more frequently at the C7 level. Patients may present with pain, paresthesia, sensory loss, progressive weakness, or a combination of these. The development of specific symptoms and their magnitude vary according to the severity of foraminal narrowing and its impact on the neurovascular contents. However, accurate correlations between the severity of stenosis and that of symptoms are not consistent among studies. Magnetic resonance image (MRI) is generally the preferred imaging modality for the evaluation of degenerative changes of the spine, including the degree of foraminal stenosis. In the absence of concerning signs or symptoms, conservative management with multimodal approaches is usually advocated for cervical radiculopathy as initial treatment. Despite this, there is no high-level evidence available to predict which patients will fail conservative management. In cases of severe or refractory pain, progressive neurological dysfunction, myelopathy, and failure of conservative treatment, surgical intervention is often required.

Example Case

  • Chief complaint: left arm pain

  • History of present illness: This is a 59-year-old man with a history of 5 months of left arm pain in a C6 and C7 distribution. He has minimal neck pain. He has tried physical therapy, steroid injections, and pain injections without relief. The patient underwent an MRI of the cervical spine demonstrating the presence of chronic degenerative changes, with significant bilateral (left greater than right) foraminal stenosis at C5-C6 and C6-C7 levels mainly due to disc space collapse ( Fig. 16.1 ).

    Fig. 16.1, Preoperative magnetic resonance image (MRI) of the cervical spine. (A) Sagittal T2 and (B) axial T2 images demonstrating multilevel cervical spondylosis, most marked at the C5-C6 and C6-C7 levels. Circumferential disc bulging with hypertrophic changes is noted at C5-C7 levels. Changes are more evident on the left side at both levels, including prominent left posterolateral disc osteophyte complex. Obliteration of the central canal and left anterior aspects of the cervical thecal sac at C5-C6 are also noted, including the lateral recess. Mild central spinal stenosis at C6-C7. There is also multilevel bilateral cervical facet arthropathy.

  • Medications: aspirin

  • Allergies: no known drug allergies

  • Past medical and surgical history: none

  • Family history: noncontributory

  • Social history: smoker

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

  • Reflexes: 2+ in bilateral biceps/triceps/brachioradialis with negative Hoffman; 2+ in bilateral patella/ankle; no clonus or Babinski; paresthesia in the distribution of left C6 and C7

Selby Chen, MD Neurosurgery Mayo Clinic Jacksonville, Florida, United States Jason Cheung, MD Orthopaedic Surgery The University of Hong Kong, Queen Mary Hospital, Pokfulam, Hong Kong SAR, China Brett A. Freedman, MD Sandra Hobson, MD Orthopaedic Surgery Mayo Clinic Rochester, Minnesota, United States Rodrigo Navarro-Ramirez, MD Neurosurgery McGill University Montreal, Quebec, Canada
Preoperative
Additional tests requested EMG of left upper extremity

  • If i stated previously then fine. Otherwise i would do x-rays C-spine AP, flexion and extension instead of CT

    CT C-spine

  • EMG/NCS

  • C-spine AP/lateral/flexion/extension x-rays

  • CT C-spine

  • BMD

  • Smoking cessation program

  • C-spine AP/flexion-extension x-rays

  • CT C-spine

Surgical approach selected C5-7 anterior cervical discectomy and fusion If no improvement with conservative treatment, C5-7 anterior cervical discectomy and fusion If stops smoking and no improvement with conservative treatment, C5-7 anterior cervical discectomy and fusion Left C5-7 MIS tubular foraminotomy
Goal of surgery Decompress left C6 and C7 nerve roots Decompress left C6 and C7 nerve roots Decompress left C6 and C7 nerve roots Decompress left C6 and C7 nerve roots
Perioperative
Positioning Supine on a pillow Supine Supine on Jackson table, with Gardner-Wells tongs Prone on Jackson table, with Mayfield pins
Surgical equipment

  • Fluoroscopy

  • Surgical microscope

  • IOM (MEP/SSEP)

  • Fluoroscopy

  • Surgical microscope

  • Fluoroscopy

  • IOM (MEP/SSEP/EMG)

  • Surgical microscope

  • Fluoroscopy

  • Tubular retractor system

  • Surgical microscope

Medications Steroids Steroids Tranexamic acid None
Anatomical considerations Carotid sheath, trachea, esophagus Recurrent laryngeal nerve, vertebral artery, esophagus, uncovertebral joint location, and osteophytes Anterior neck structures, vertebral artery Lamina-facet landmark, ligamentum flavum, dura, nerve root
Complications feared with approach chosen Nerve root palsy/injury, CSF leak Inadequate decompression, dysphagia Pseudoarthrosis, hematoma, dysphagia, esophageal injury, hoarseness Pain, muscle spasms
Intraoperative
Anesthesia General General General General
Exposure C5-7 C5-7 C5-7 C5-7
Levels decompressed C5-7 C5-7 C5-7 C5-7
Levels fused C5-7 C5-7 C5-7 None
Surgical narrative Position supine with pillow, right-sided paramedian incision is made after confirming level with x-ray, dissect down beyond platysma and identify carotid sheath, retract carotid sheath laterally and strap muscles/trachea/esophagus medially, prevertebral fascia is incised with Metzenbaum scissors, spinal needle is placed for localization, disc space is exenterated and PLL is resected, decompression extended out to bilateral neural foramina, palpate with nerve hook to confirm decompression, end plates prepared using high-speed bur, structural allograft placed under fluoroscopy, other disc prepared in similar fashion, cervical plate affixed anteriorly and secured in place with variable screws at C5-C6 and fixed screws at C7, AP and lateral fluoroscopic images are obtained, wound closed in anatomical layers with possible drain Position supine, bolster placed behind scapula, right iliac crest also exposed if tricortical iliac crest autograft required, x-ray to check C5-7 and mark skin incision level, right-sided Robinson-Southwick approach, mark expected level with needle and confirm with x-ray, release longus colli to have enough lateral exposure, surgical microscope brought in, annulotomy of C5-7 and discectomy with complete disc and cartilaginous endplate removal, removal of PLL and any posterior osteophytes to expose dura, continue discectomy laterally and remove osteophytes at uncovertebral joint, cage filled with demineralized bone matrix and inserted in space with screw fixation, care to make sure screws are flush without prominence, Gelfoam between cage and esophagus, one deep fenestrated drain is placed, close in layers Position supine, x-ray to plan incision centered over surgical level, place Gardner-Wells tongs with 15 lb of traction, incise skin down through subcutaneous fat, monopolar cautery to dissect through platysma, develop subplatysmal flaps, work through plane medial to sternocleidomastoid bluntly to create a plane lateral to strap muscles and medial to carotid sheath, confirm level with x-ray, dissect longus colli muscles off anterior surface of the spine in subperiosteal fashion, place appropriate sized self-retaining retractors, deflate and reinflate endotracheal cuff, bur anterior surface of disc space, large annulectomy at C5-6, remove annular pieces with pituitary, curettes to clean disc space, resect inferior lip of cephalad vertebral body with Kerrison, drill down bilateral uncus and posterior bars, release posterior annulus, remove PLL using nerve hooks to dissect and Kerrison to resect, resect posterolateral aspects of the uncus and entry zone of the foramen, confirm no residual compression in foramen with nerve hook, place lordotically tapered cage with demineralized bone matrix in the center of the cage, repeat at C6-7, place anterior C5-7 plate, final lateral x-ray, vancomycin in wound, layered closure Position prone, identify levels using fluoroscopy or intraoperative navigation with reference array, two 2-cm skin incision and one or two fascial incisions, dock tube onto cervical facet, confirm location with x-ray, remove remnant muscle over spinal process/lamina/joint interface, find horizontal Y formed by upper/lower/interlaminar space under microscope, drill lamina until flavum is identified, dissect with curette and remove with Kerrison rongeur, remove bone until nerve can be seen from the top without removing more than 50% of the joint laterally, explore the nerve using a nerve hook, look for disc fragments or material compressing the nerve above and below the nerve, tube is removed under microscopic visualization, standard closure
Complication avoidance Confirm foraminal opening with nerve hook, allograft placed under fluoroscopic guidance, intraoperative fluoroscopy to confirm position of hardware Complete PLL removal, remove osteophyte laterally until foramina decompressed, insert cage with screws that are flush, gelfoam between cage and esophagus Deflate and reinflate endotracheal cuff, open PLL, confirm no residual compression in foramen MIS, tubular retractor, avoid anterior because of current smoking, preserve 50% of joint
Postoperative
Admission Floor High dependency unit Floor Outpatient
Postoperative complications feared Recurrent laryngeal nerve palsy, dysphagia, esophageal injury, neurological injury Hematoma, acute tracheal compression Pseudoarthrosis, hematoma, dysphagia, esophageal injury, hoarseness Muscle spasms, neuropraxia
Anticipated length of stay Overnight 2–3 days 1 day Same day
Follow-up testing AP and lateral cervical spine x-rays 6 weeks, 3 months, 6 months, 12 months, 24 months after surgery Cervical x-rays at 6 weeks, 3 months, 6 months after surgery

  • C-spine AP and lateral x-rays

  • C-spine flexion-extension x-rays 3 months, 6 months, 12 months after surgery

  • CT C-spine 6 months after surgery

  • ESR and CRP as inpatient

AP/lateral C-spine x-ray 2 weeks after surgery
Bracing None Rigid collar for 6 weeks Miami J collar for 6 weeks None
Follow-up visits 6 weeks after surgery 2 weeks, 6 weeks, 3 months, 6 months after surgery 2 weeks, 3 months, 6 months, 12 months after surgery 2 weeks, 1 month, 3 months after surgery
AP , Anteroposterior; BMD , bone mineral density; CRP , C-reactive protein; CT , computed tomography; EMG , electromyography; ESR , erythrocyte sedimentation rate; IOM , intraoperative monitoring; MEP , motor evoked potentials; MIS , minimally invasive surgery; NCS , nerve conduction study; PLL , posterior longitudinal ligament; SSEP , somatosensory evoked potentials.

Differential diagnosis

  • ▪

    Acute disc herniation

  • ▪

    Neoplasms within the spinal canal

  • ▪

    Primary nerve root tumors

  • ▪

    Epidural or vertebral metastases

  • ▪

    Polyradiculopathy of AIDS

  • ▪

    Peripheral nerve entrapment

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