June 08, 2024
"For cervical radiculopathy, it's most important to select the right patient for the right treatment," says Brett A. Freedman, M.D., chair of spine care at Mayo Clinic in Minnesota. "This almost always leads to successful outcomes. Performing the wrong surgery — despite technical soundness — on the wrong patient typically leads to poor outcomes and dissatisfied patients."
During his time at Mayo Clinic, Dr. Freedman learned the adage: "It's the decision, not the incision" that determines spine surgery outcomes. He believes selecting a spine surgeon who emphasizes prior planning and counsel is critical.
Identifying the cause of a patient's cervical radiculopathy is essential to treatment selection, notes Dr. Freedman. While most cervical disk disease is treatable without surgery, if surgery is the best option, it is paramount that the surgeon identifies the specific anatomic problem and develops a surgical plan to fully address it, he says. It is equally important that the surgeon takes time to counsel the patient on the plan's rationale, risks and benefits, and most importantly, realistic perioperative experience and long-term outcome expectations.
Cervical radiculopathy symptom cascade
Cervical radiculopathy typically produces arm symptoms in the following order, reflecting the cervical nerve root's progressive and sustained compression:
- Pain.
- Tingling.
- Weakness.
Removing pressure on the nerve is the primary goal of cervical radiculopathy surgery. Dr. Freedman notes that sufficiently compressed nerves may incur internal injury that may not recover post-surgically. Thus, when cervical radiculopathy is determined to be surgically treatable, optimal outcomes occur with surgery performed in a timely manner.
Dr. Freedman notes a favorable natural history for over 80% of patients who develop acute cervical radiculopathy symptoms, making surgery unnecessary. With a herniated disk, a jellylike material emerges, pushing on the nerve root and producing pressure, inflammation and pain that can resolve without treatment in 6 to 8 weeks. Thus, waiting for an orthopedic surgery appointment provides a built-in healing period.
Cervical radiculopathy ideal surgical candidates
Dr. Freedman indicates that optimal surgical candidates are otherwise healthy and have the following traits:
- Failed nonoperative therapy (for 6 to 8 weeks or more) or developed worsening neurological problems. Profound or progressive neurological deficits warrant early surgery.
- Instituted lifestyle modifications, including quitting nicotine, stopping high-impact physical activity, setting screens at eye level to avoid "tech neck," engaging in regular low-impact exercise, and maintaining a healthy diet and body mass.
- Present with acute symptom onset.
- Have high neck disability index scores.
- Have significantly more arm than neck pain. When a surgeon relieves nerve pressure, it improves arm symptoms, and more than 60% of the time both arm and neck pain improve. Dr. Freedman says sometimes only arm pain improves, as neck pain may have multiple causes, most of which have no surgical cure.
- Have clear, focused neck anatomic problems that explain the patient's arm symptoms.
"For these patients, surgical risk and suffering or limitations during the healing phase are offset by symptom relief," he says. "These are my favorite patients to treat. Typically, we share a high-five moment post-surgery, as pain is relieved. The patient knows they made the right decision and received appropriate care."
For younger patients (<45-50 years old) with acute soft disk herniation at one or two levels, cervical disk arthroplasty is an excellent option that is selective and oftentimes underused, Dr. Freedman says. He encourages spine surgeons not to perform arthroplasty for patients with poor facet joint quality, as the surgery only replaces the disk and not facet joints. For patients with facet arthritis, disk replacement often worsens cervical pain. Dr. Freedman also urges considering other anatomic limitations and patient-specific factors before offering cervical disk arthroplasty. Yet, with appropriate cervical disk arthroplasty selection he says that results are immediate.
"These are home-run operations," he says. "By six weeks, patients typically live normal lives without restrictions."
Because familiarity with this surgery's technique is paramount for good outcomes, he encourages physicians to refer to surgeons with extensive arthroplasty experience.
Cervical radiculopathy treatment
Patients with suspected cervical radiculopathy receive nonsurgical treatments first. When these fail, surgery becomes the best option.
Surgical techniques include two anterior techniques and one posterior technique. Anterior approaches are more common and include anterior cervical diskectomy and fusion (ACDF) or arthroplasty. Laminoforaminotomy is the posterior technique. Surgeon preference and experience often dictate the approach selected. Dr. Freedman prefers an anterior approach and decides between artificial disk replacement and ACDF based on each patient's situation. He says while posterior approach outcomes are positive, addressing recurrence at the same level, if needed, is more difficult. While he does not prefer that approach, he acknowledges some surgeons believe in the posterior technique and have demonstrated success with it.
Laminoforaminotomy and arthroplasty are the motion-preserving options for cervical radiculopathy treatment. In ACDF, the surgeon fuses the bones into one so that level never moves again.
In the anterior approach, the two options are identical until the end. The surgeon starts with a small horizontal neck incision, moving the throat aside to view the spine's front, followed by diskectomy. Since both operations include this step, removing nerve pressure, both typically produce similar excellent arm symptom relief. However, diskectomy destabilizes the cervical spine, requiring an addition to restore stability. The surgeon places a spacer and plate or an arthroplasty device to fill the disk space and attach to the surrounding bone, producing immediate stability. The spacer and plate hold the spinal segment still, encouraging fusion. The arthroplasty device's ball and trough articulate together, allowing stable motion.
"I do every surgery twice — once in my head and once on the patient."
Key fusion-arthroplasty distinctions include:
- Motion preservation. Fusion stabilizes the cervical spine yet limits motion. Arthroplasty allows stable movement.
- Adjacent segment disease. When a surgeon fuses the spine, the disks above and below that level must compensate for the previous motion at the fusion level. Orthopedic spine surgeons theorize this stress increases breakdown and risk of reoperation for adjacent disks. Dr. Freedman indicates that motion-preserving techniques appear to reduce this risk. He considers adjacent segment disease complex and far from fully understood.
- Recovery. Arthroplasty recovery is shorter than fusion because it requires less bone healing. Surgical fusion starts the process, yet the bones must grow together over at least six months to form bridging fusion bone.
- Reoperation rates. Since ACDF requires bones to heal together — which does not always occur — reoperation rates after ACDF are higher than those post-arthroplasty, which Dr. Freedman indicates studies comparing disk replacement and fusion have consistently demonstrated.
Dr. Freedman's unique surgical planning and execution style involves preparing a presentation before all cervical spine surgeries, including a decompression plan and implant measurements. He projects these slides in the OR, promoting surgical team communication and a common goal.
"I do every surgery twice — once in my head and once on the patient," he says.
For more information
Refer a patient to Mayo Clinic.