Article

Clinical practice. Cervical radiculopathy.

Division of Rheumatology, Toronto Western Hospital, University Health Network, Toronto, ON, Canada.
New England Journal of Medicine (Impact Factor: 54.42). 08/2005; 353(4):392-9. DOI: 10.1056/NEJMcp043887
Source: PubMed
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    ABSTRACT: Though both clinical evaluation and MRI are complimentary in detection and precise localization of the level of lesion in patients with cervical myelopathy, there is paucity of data comparing segment specific clinical features with the MRI abnormalities in cervical myelopathy. Thirty one patients with cervical myelopathy and abnormal MRI of the cervical spine (signal changes in the cord) admitted to the neurology and neurosurgery wards during the study period were included in the study. The patients were prospectively evaluated by a detailed neurological examination. Clinically, the site of lesion was determined by highest of the pyramidal, sensory or segmental features of involvement. The MRI lesions were categorized based on the vertebral level at which the abnormalities were seen. The patients were divided into three groups according to the site of lesion on MRI: (1) cervico-medullary (foramen magnum to C1) lesions (2) upper cervical (C2-C4) lesions and (3) lower cervical (C5-T1) lesions. Comparisons of clinical symptoms, signs and level of lesion with MRI abnormalities were done and the level of significance was set at p < 0.05. Clinical evaluation showed limb weakness in all, sensory loss in 90%, sphincter disturbances in 67.7%, scissoring gait in 32.2%, diaphragmatic weakness in 12.9% of patients. Based on clinical examination the site of lesion was cervico-medullary in 9, upper cervical region in 4 and lower cervical region of involvement in five patients. The maximal antero-posterior extent of the lesion and neurological deficits were concordant (p-0.05). As compared to pyramidal signs or sensory abnormalities, segmental features - segmental sensory loss, weakness, wasting or 'reflex' loss - were most concordant with the MRI level of lesion (p - 0.03). Among 'motor', 'sensory' and 'reflex' levels, the 'reflex (DTR)' levels were most concordant with the MRI level of lesion (p - 0.04). Segmental features form the foundation for clinical localization of the level of lesion. Though the clinical level of lesion and MRI level of lesion were discordant in 14 patients, clinical evaluation may still provide useful information.
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    ABSTRACT: There have been several imaging studies of cervical radiculopathy, but no three-dimensional (3D) images have shown the path, position, and pathological changes of the cervical nerve roots and spinal root ganglion relative to the cervical bony structure. The objective of this study was to introduce a technique that enables the virtual pathology of the nerve root to be assessed using 3D magnetic resonance (MR)/computed tomography (CT) fusion images that show the compression of the proximal portion of the cervical nerve root by both the herniated disc and the preforaminal or foraminal bony spur in patients with cervical radiculopathy. MR and CT images were obtained from three patients with cervical radiculopathy. 3D MR images were placed onto 3D CT images using a computer workstation. The entire nerve root could be visualized in 3D with or without the vertebrae. The most important characteristic evident on the images was flattening of the nerve root by a bony spur. The affected root was constricted at a pre-ganglion site. In cases of severe deformity, the flattened portion of the root seemed to change the angle of its path, resulting in twisted condition. The 3D MR/CT fusion imaging technique enhances visualization of pathoanatomy in cervical hidden area that is composed of the root and intervertebral foramen. This technique provides two distinct advantages for diagnosis of cervical radiculopathy. First, the isolation of individual vertebra clarifies the deformities of the whole root groove, including both the uncinate process and superior articular process in the cervical spine. Second, the tortuous or twisted condition of a compressed root can be visualized. The surgeon can identify the narrowest face of the root if they view the MR/CT fusion image from the posterolateral-inferior direction. Surgeons use MR/CT fusion images as a pre-operative map and for intraoperative navigation. The MR/CT fusion images can also be used as educational materials for all hospital staff and for patients and patients' families who provide informed consent for treatments.
    SpringerPlus 01/2015; 4:123. DOI:10.1186/s40064-015-0898-6
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    ABSTRACT: Study Design Systematic literature review and meta-analysis. Objective This study is a meta-analysis assessing the fusion rate and the clinical outcomes of cervical pseudarthrosis treated with either a posterior or a revision anterior approach. Methods A literature search of PubMed, Cochrane, and Embase was performed. Variables of interest included fusion rate and clinical success. The effect size based on logit event rate was calculated from the pooled results. The studies were weighted by the inverse of the variance, which included both within- and between-study error. The confidence intervals were reported at 95%. Heterogeneity was assessed using the Q statistic and I (2), where I (2) is the estimate of the percentage of error due to between-study variation. Results Sixteen studies reported fusion outcomes; 10 studies reported anterior and/or posterior results. The pooled fusion success was 86.4% in the anterior group and 97.1% in the posterior group (p = 0.028). The anterior group demonstrated significant heterogeneity with Q value of 34.2 and I (2) value of 73.7%; no heterogeneity was seen in the posterior group. The clinical outcomes were reported in 10 studies, with eight reporting results of anterior and posterior approaches. The pooled clinical success rate was 77.0% for anterior and 71.7% for posterior (p = 0.55) approaches. There was significant heterogeneity in both groups (I (2) 16.1; 19.2). Conclusions Symptomatic cervical pseudarthrosis can be effectively managed with either an anterior or a posterior approach. The posterior approach demonstrates a significantly greater fusion rate compared with the anterior approach, though the clinical outcome does not differ between the two groups.
    04/2015; 5(2):148-55. DOI:10.1055/s-0035-1544176