Published by: Boulder Neurosurgical & Spine Associates CONNECTIONS Justin Parker Neurological Institute IN SPINE & BRAIN TREATMENT Volume 1 www.bnasurg.com • www.jpni.org Edition 4 Summer 2015

Treatment and Warning Signs for Cervical Radiculopathy

Cervical radicular pain (cervical radiculopathy) Musculoskeletal pain associated with ulnar Other warning signs that warrant referral to a is a pathological process originating from the or median nerve peripheral neuropathy or, as spine specialist and more specific work-up are: spinal nerve roots and is a commonly seen con- noted above, shoulder joint pathology may • Progressive weakness and numbness dition across many patient populations. It typi- sometimes be confused with cervical radiculop- • Intractable arm pain cally presents with neck pain and radicular pain athy. Careful history and physical examination • Persistent symptoms radiating to the shoulder and arms, and is often are usually sufficient to distinguish between > 6 weeks unilateral. The most common causes of cervical these pathologies. The Lhermitte sign (an radiculopathy is cervical disc herniation and fo- Diagnostic imaging studies should be typically electric shock-like sen- raminal impingement as a result of decreased be reserved to the patients who don’t improve sation radiating down disc height or degenerative changes of the cervi- after at least 4 - 6 weeks of conservative man- the spine elicited by cal joints. It is seen most commonly at the C5/ agement in absence of red flag symptoms and flexion of the neck) is C6 and C6/C7 levels. Intervertebral discs often A B low index of suspicion. MRI is a primary imaging one of the provocative protrude posterior laterally, because the poste- Brain CT before (A) and examination for most cases of cervical radicu- tests, which indicates rior longitudinal ligament does not extent very after shunting (B) lopathy and has a greater sensitivity than other spinal cord compres- far beyond the midline. Besides mechanical imaging modalities for diagnosing tumors and sion and needs to be recognized and treated compression, chemical irritation caused by in- infections. Plain films are very useful if spinal promptly. It is helpful in distinguishing cervical flammatory changes also plays an important instability is suspected or there is a history of radiculopathy associated with degenerative disc role as it may lead to irreversible changes in the trauma. Degenerative changes in the cervical disease from a myeloradiculopathy syndrome. affected nerve. spine are an inevitable part of normal aging pro- Classic cervical radicular pain may be accom- cesses, therefore cervical radiculopathy is pri- Treatment panied by paresthesias or sensory loss and may marily a clinical diagnosis with imaging testing There are 3 major groups of treatment options follow a dermatomal sensory nerve root distribu- providing only supportive evidence. for cervical radiculopathy: tion, but that is not necessarily the case in all • Conservative treatment Warning Signs/Red Flags patients. Non-dermatomal pain referred from • Interventional pain management other anatomical structures such as the shoul- The goal of diagnosis is to identify the anatomic • Surgical management der, or direct neural impingement with an over- pain generator(s); a patient history and exami- lap between dermatomes, can result in radicular nation are important in identifying red flags and There is no high quality evidence comparing pain perceived in a wider area. distinguishing potential causes. A referral to a conservative treatment and surgical interven- specialist is warranted and the etiology of ra- tions, but conservative measures are initially Infectious processes (e.g. Lyme disease, herpes dicular pain should be further investigated in indicated for patients without progressive neu- zoster), demyelination, root avulsion, infiltration patients with a history of malignancy or uninten- rologic and profound motor deficits. Up to 90% by tumor or granulomatous tissue may cause tional weight loss, unremitting pain, particularly of patients will improve and most neurologic noncompressive radiculopathy symptoms. They at night, patients that are immunocompromised, deficits will resolve with non-operative care usually affect the ventral and dorsal roots more or have fever, chills or a history of intravenous (Saal et al, Spine 1996). Conservative measures diffusely leading to deficits that are more com- drug use. initially may include activity counseling, physical plete and dense. therapy, traction, chiropractic manipulations, analgesic and non-steroidal anti-inflammatory In selected patients, a less invasive procedure Alan T. Villavicencio, MD medications. A cervical collar can be used to called posterior cervical foraminotomy may be Board-Certified: American Board of Neurological Surgery MD: Harvard Medical School, Boston MA provide support and limit motion in the early sufficient to relieve radicular symptoms. Residency: Neurosurgery, Duke University Medical phase of cervical radiculopathy. Oral steroid Artificial Disc Replacement is the newest surgi- Center, Durham, NC Fellowship: Orthopedic Spine Surgery, Institute for medication is often the last conservative treat- cal treatment option alternative to arthrodesis Spinal Disorders at Cedars-Sinai, University of ment option prior to the consideration of surgery, for patients with single- or two-level radiculopa- California at Los Angeles, CA as long-term use may impose risks for immuno- thy symptoms caused by either herniated disc(s) E. Lee Nelson, MD suppression, osteoporosis, hyperglycemia, and or spondylotic osteophytes from C3/C4 to C6/C7. Board-Certified: American Board of Neurological Surgery MD: Baylor College of Medicine & Texas Medical adrenal insufficiency. Clinical outcomes compare favorably with ACDF Center, Houston, TX according to the currently published literature, Residency: Neurosurgery (Chief Resident), Baylor Interventional pain management is usually con- College of Medicine & Texas Medical Center, Houston, TX but arthroplasty may be associated with a lower sidered for patients who have not responded to Sharad Rajpal, MD rate of adjacent segment disease. Arthroplasty conservative treatment measures and may in- Board-Certified: American Board of Neurological Surgery also allows for effective decompression without MD: University of Wisconsin, Madison, WI clude cervical facet injections, translaminar and Residency: Neurosurgery, University of Wisconsin, sacrificing segmental motion, therefore main- transforaminal epidural steroid injections, or Madison, WI taining preoperative biomechanical properties. radiofrequency and intradiscal therapies. Fellowship: Neurosurgery and Orthopedic Spine Surgery, Center for Spine Health, Cleveland Clinic, Although reflex, sensory and motor deficits itself References: Cleveland, OH Kara Beasley, DO, MBe are not indications for surgery and may even Saal JS, Saal JA, Yurth EF. Nonoperative Manage- DO and Masters of Arts, Biomedical Ethics, persist despite surgery, surgical treatment is ment of Herniated Cervical Intervertebral Disc Midwestern University, Glendale, AZ considered for patients with intractable pain, with Radiculopathy. Spine. 1996 Aug 15; Residency: General Neurosurgery, Phildelphia College of Osteopathic Medicine, Philadelphia, PA progressive motor weakness and reflex loss 21(16):1877-83. Fellowships: Stereotactic Radiosurgery, Cooper which corresponds with clear nerve impinge- University Hospital, Camden, NJ and Functional Burneikiene S, Nelson EL, Mason A, Rajpal S, ment at the appropriate level on imaging stud- and Restorative Neurosurgery, Cleveland Clinic, Villavicencio AT. The duration of Symptoms and Cleveland, OH ies. Patients with rapid neurologic deterioration Clinical Outcomes in Patients Undergoing David Shafer, MD should undergo earlier operative intervention, Anterior Cervical Discectomy and Fusion for MD: Drexel University College of Medicine, but an optimal timing for surgical treatment is Philadelphia, PA Degenerative Disc Disease and Radiculopathy. Residency: Neurosurgery (Chief Resident), University of still controversial. The physicians at Boulder Spine J. 2015 Mar 1;15(3):427-32. Colorado Department of Neurosurgery, Aurora, C Neurosurgical and Spine Associates performed a prospective clinical study (Burneikiene et al, This brief summary is not intended to be Spine J 2015), which analyzed if duration of comprehensive, nor should this take the place symptoms had any effect on resolution of radic- of specialized evaluation and management of ular symptoms in patients undergoing anterior spinal conditions .For more information and to cervical discectomy and fusion (ACDF) for cervi- discuss a potential patient in further detail cal radiculopathy. All patients failed at least 6 please call us at 303.938.5700, or email us at weeks of conservative therapy, unless they re- [email protected]. Information is also avail- quired immediate surgical intervention. The pa- able on our website at. www.bnasurg.com. tients who had surgery within 6 months after becoming symptomatic reported significantly P. 303.938.5700 higher reduction in arm pain scores compared F. 303.998.0007 with patients who had waited longer. These find- 4743 Arapahoe Ave., Ste. 202, Boulder, CO 80303 ings should help to define an optimal timing for (In the Anderson Medical Center adjacent to Boulder surgical interventions if surgery is indicated, Community Foothills Hospital) especially in cases of definite cervical nerve root 2030 Mountain View Ave., Ste. 500, Longmont, CO 80501 (In the United Medical Building adjacent to Longmont compressions before irreversible nerve damage United Hospital) occurs. 300 Exempla Circle, Ste. 270, Lafayette, CO 80026 (In the Community Physicians Pavilion adjacent to Good The main goals of surgery are to decompress the Samaritan Hospital nerves by removing the parts of bone and soft 1606 Prairie Center Pkwy., Ste. 250, Brighton, CO 80601 (In the Medical Office Building adjacent to the Platte tissue, to maintain stability and restore correct Valley Medical Center) alignment of the spine. ACDF is the most common 90 Health Park Drive, Ste. 300, Louisville, CO 80027 procedure performed for cervical radiculopathy. (In Medical Office Building 1 adjacent to Avista Adventist Hospital)