Cervical Radiculopathy Cervical Radiculopathy and Myelopathy and Myelopathy Wayne Cheng, MD Wayne Cheng, MD Instructor Instructor Loma Linda University Medical Loma Linda University Medical Center Center Department of Orthopaedic Department of Orthopaedic Surgery Surgery
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Cervical Radiculopathy and Myelopathy Wayne Cheng, MD Instructor Loma Linda University Medical Center Department of Orthopaedic Surgery.
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Cervical Radiculopathy and Cervical Radiculopathy and MyelopathyMyelopathy
Wayne Cheng, MDWayne Cheng, MDInstructorInstructor
Loma Linda University Medical CenterLoma Linda University Medical CenterDepartment of Orthopaedic SurgeryDepartment of Orthopaedic Surgery
Physical ExamPhysical ExamSpurling TestSpurling Test
• Extending the neckExtending the neck• Rotating headRotating head• Downward pressure on headDownward pressure on head• Positive if pain radiates to Positive if pain radiates to
side patient’s head is pointedside patient’s head is pointed– Positive Spurling in 71% football Positive Spurling in 71% football
players c recent burner players c recent burner (Levitz et al (Levitz et al AM J Sp MedAM J Sp Med 1997) 1997)
• Response in days to weeksResponse in days to weeks• Protracted non-op care Protracted non-op care notnot
recommended in presence ofrecommended in presence of– Persistent, severe painPersistent, severe pain– WeaknessWeakness– Major sensibility lossMajor sensibility loss– Myelopathy with obvious cord findingsMyelopathy with obvious cord findings
• Technique described by Robinson & Technique described by Robinson & Smith 1955Smith 1955– Use tricortical iliac crest graftUse tricortical iliac crest graft
– 14-18 degrees ideal14-18 degrees ideal– Bevel up for superior vertebral bodyBevel up for superior vertebral body– Bevel down for inferior vertebral bodyBevel down for inferior vertebral body
ACDFACDF
• 42 yo with both C6 42 yo with both C6 and C7 and C7 radiculopathyradiculopathy
• 81 year old with 81 year old with quadriparesis, loss quadriparesis, loss of function of all 4, of function of all 4, worse with BUE worse with BUE than BLE.than BLE.
CombinedCombined
• 42 year old with 42 year old with progressive progressive quadriplegia in the quadriplegia in the ERER
CombinedCombined
CombinedCombined
• 64 year old male, 64 year old male, loss function of loss function of right arm, unsteady right arm, unsteady gait.gait.
CombinedCombined
OITEOITE
OITE 2000-#73OITE 2000-#73• A 45yo man has had spontaneous neck and right arm pain for the A 45yo man has had spontaneous neck and right arm pain for the
past 2 days, and he states that the pain is relieved when he places his past 2 days, and he states that the pain is relieved when he places his hand on the top of his head. Examination reveals decreased hand on the top of his head. Examination reveals decreased sensation on the dorsum of the first web space, weakness in the sensation on the dorsum of the first web space, weakness in the wrist extensors, and an absent brachioradialis reflex. The remainder wrist extensors, and an absent brachioradialis reflex. The remainder of the exam is unremarkable. What is the most likely diagnosis?of the exam is unremarkable. What is the most likely diagnosis?1—Double-crush phenomenon with carpal tunnel syndrome & cervical disk 1—Double-crush phenomenon with carpal tunnel syndrome & cervical disk herniation at C5-6herniation at C5-62—Cervical disk herniation at C6-72—Cervical disk herniation at C6-73—Cervical disk herniation at C5-6 with myelopathy3—Cervical disk herniation at C5-6 with myelopathy4—Acute cervical disk herniation at C5-64—Acute cervical disk herniation at C5-65—A shoulder impingement lesion & cervical disk herniation at C6-75—A shoulder impingement lesion & cervical disk herniation at C6-7
OITE 2000-#73OITE 2000-#73• A 45yo man has had spontaneous neck and right arm pain for the A 45yo man has had spontaneous neck and right arm pain for the
past 2 days, and he states that the pain is relieved when he places his past 2 days, and he states that the pain is relieved when he places his hand on the top of his head. Examination reveals decreased hand on the top of his head. Examination reveals decreased sensation on the dorsum of the first web space, weakness in the sensation on the dorsum of the first web space, weakness in the wrist extensors, and an absent brachioradialis reflex. The remainder wrist extensors, and an absent brachioradialis reflex. The remainder of the exam is unremarkable. What is the most likely diagnosis?of the exam is unremarkable. What is the most likely diagnosis?1—Double-crush phenomenon with carpal tunnel syndrome & cervical disk 1—Double-crush phenomenon with carpal tunnel syndrome & cervical disk herniation at C5-6herniation at C5-62—Cervical disk herniation at C6-72—Cervical disk herniation at C6-73—Cervical disk herniation at C5-6 with myelopathy3—Cervical disk herniation at C5-6 with myelopathy4—Acute cervical disk herniation at C5-64—Acute cervical disk herniation at C5-65—A shoulder impingement lesion & cervical disk herniation at C6-75—A shoulder impingement lesion & cervical disk herniation at C6-7
SAE Spine 2000 #2SAE Spine 2000 #2• A 60yo man underwent an anterior diskectomy and fusion for C4-A 60yo man underwent an anterior diskectomy and fusion for C4-
5 disk disease using a left-sided approach 1 week ago. He now 5 disk disease using a left-sided approach 1 week ago. He now reports a persistent dry cough and mild horseness. Pulmonary reports a persistent dry cough and mild horseness. Pulmonary evaluation shows evidence of a mild aspiration, and ear, nose, evaluation shows evidence of a mild aspiration, and ear, nose, and throat visualization shows laxity of the vocal cord on the left and throat visualization shows laxity of the vocal cord on the left side. What is the most likely explanation for these findings?side. What is the most likely explanation for these findings?1—Traction on the recurrent laryngeal nerve1—Traction on the recurrent laryngeal nerve2—Traction on the superior laryngeal nerve2—Traction on the superior laryngeal nerve3—Injury to the pharyngeal nerve branches when ligating the superior 3—Injury to the pharyngeal nerve branches when ligating the superior thyroid arterythyroid artery4—Direct trauma to the larynx from retractor blades4—Direct trauma to the larynx from retractor blades5—Direct injury to the vocal cords from endotracheal intubation5—Direct injury to the vocal cords from endotracheal intubation
SAE Spine 2000 #2SAE Spine 2000 #2• A 60yo man underwent an anterior diskectomy and fusion for C4-A 60yo man underwent an anterior diskectomy and fusion for C4-
5 disk disease using a left-sided approach 1 week ago. He now 5 disk disease using a left-sided approach 1 week ago. He now reports a persistent dry cough and mild horseness. Pulmonary reports a persistent dry cough and mild horseness. Pulmonary evaluation shows evidence of a mild aspiration, and ear, nose, evaluation shows evidence of a mild aspiration, and ear, nose, and throat visualization shows laxity of the vocal cord on the left and throat visualization shows laxity of the vocal cord on the left side. What is the most likely explanation for these findings?side. What is the most likely explanation for these findings?1—Traction on the recurrent laryngeal nerve1—Traction on the recurrent laryngeal nerve2—Traction on the superior laryngeal nerve2—Traction on the superior laryngeal nerve3—Injury to the pharyngeal nerve branches when ligating the superior 3—Injury to the pharyngeal nerve branches when ligating the superior thyroid arterythyroid artery4—Direct trauma to the larynx from retractor blades4—Direct trauma to the larynx from retractor blades5—Direct injury to the vocal cords from endotracheal intubation5—Direct injury to the vocal cords from endotracheal intubation
OITE 1999-#24OITE 1999-#24• An otherwise healthy 79yo woman has had An otherwise healthy 79yo woman has had
deteriorating function in her hands for the past 6 deteriorating function in her hands for the past 6 months when she is knitting or buttoning. She also months when she is knitting or buttoning. She also reports neck pain and stiffness and diminished reports neck pain and stiffness and diminished sensation in the left hand. Examination reveals a sensation in the left hand. Examination reveals a broad-based gait, weakness in the interossei in the left broad-based gait, weakness in the interossei in the left hand, a positive left Hoffman sign, and bilateral hand, a positive left Hoffman sign, and bilateral upgoing toes. What is the most likely diagnosis?upgoing toes. What is the most likely diagnosis?1—Syringomyelia1—Syringomyelia2—Pathologic fracture of C4 with incomplete spinal cord injury2—Pathologic fracture of C4 with incomplete spinal cord injury3—Amytrophic lateral sclerosis3—Amytrophic lateral sclerosis4—Multiple sclerosis4—Multiple sclerosis5—Cervical spondylotic myelopathy5—Cervical spondylotic myelopathy
OITE 1999-#24OITE 1999-#24• An otherwise healthy 79yo woman has had deteriorating An otherwise healthy 79yo woman has had deteriorating
function in her hands for the past 6 months when she is function in her hands for the past 6 months when she is knitting or buttoning. She also reports neck pain and knitting or buttoning. She also reports neck pain and stiffness and diminished sensation in the left hand. stiffness and diminished sensation in the left hand. Examination reveals a broad-based gait, weakness in the Examination reveals a broad-based gait, weakness in the interossei in the left hand, a positive left Hoffman sign, and interossei in the left hand, a positive left Hoffman sign, and bilateral upgoing toes. What is the most likely diagnosis?bilateral upgoing toes. What is the most likely diagnosis?1—Syringomyelia1—Syringomyelia2—Pathologic fracture of C4 with incomplete spinal cord injury2—Pathologic fracture of C4 with incomplete spinal cord injury3—Amytrophic lateral sclerosis3—Amytrophic lateral sclerosis4—Multiple sclerosis4—Multiple sclerosis5—Cervical spondylotic myelopathy5—Cervical spondylotic myelopathy