Etiology
Protrusion or prolapse of the nucleus pulposus, osteophytes or traumatic arthritis of the posterior tuberosity, bone spur formation in the hook joint, and loosening and displacement of the three adjacent joints (intervertebral joint, hook joint, and posterior tuberosity) can cause irritation and compression of the spinal nerve roots. In addition, narrowing of the root canal, adhesive arachnoiditis in the root cuff, and inflammation and tumors in the surrounding area can also cause symptoms similar to this disease. Wu Yongchao, Department of Orthopedics, Wuhan Union Medical College Hospital
Clinical manifestations
1. Neck symptoms
The severity of symptoms varies depending on the cause of radicular compression. If it is mainly caused by the herniated nucleus pulposus, it is accompanied by obvious neck pain, paravertebral muscle pressure and formal cervical posture due to the direct stimulation of local sinus nerve. If the symptoms are caused by simple degeneration and osteophytes of the hook vertebral joint, the cervical symptoms are mild, and there may not be any special findings.
2. Radicular pain
It is most common and its extent corresponds to the area of distribution of the spinal nerve roots in the affected vertebral segment. The radicular pain is accompanied by other sensory disorders in the distribution area of the nerve root, among which numbness of the fingers, sensory hypersensitivity of the fingertips and hypoesthesia of the skin are most common.
3. Radicular muscle disorder
It is more obvious when the nerve root is first compressed, the muscle tone is increased in the early stage, but it will be weakened soon and the muscle atrophy will appear. The involvement is limited to the muscle group innervated by the spinal nerve root. In the hand, the greater and lesser interosseous muscles and interosseous muscles are the most obvious.
4. Tendon reflex changes
The reflexes involved in the affected spinal nerve roots are abnormal. The reflexes are active in the early stages, but diminish or disappear in the middle and late stages. There should be no pathological reflexes in purely radicular involvement, but if there are pathological reflexes, it means that the spinal cord is involved at the same time.
5. Physical signs
All pull tests that increase the tension of spinal nerve roots are mostly positive, especially in the acute phase and in those with posterior root compression. Positive cervical spine compression test is mostly seen in cases with nucleus pulposus herniation, nucleus pulposus prolapse and vertebral segment instability, while most of them are weakly positive due to hooked vertebral hyperplasia and mostly negative due to intraspinal occupying lesions.
Examination
MRI can show disc degeneration and nucleus pulposus protrusion, and the nucleus pulposus may even protrude into the root canal and spinal canal, mostly to the affected side.
Diagnosis
It is mainly based on the following five points.
1. with more typical radicular symptoms
1. The symptoms are typical of the root, including numbness and pain, and the extent is consistent with the area innervated by the cervical spinal nerve.
2. Neck pressure test and upper limb pull test
Mostly positive, painful point closure is not effective, but the test is not needed for clear diagnosis.
3. Imaging examination
MRI examination can clearly show the local pathological anatomy, including the protrusion and prolapse of the nucleus pulposus, the site and degree of spinal nerve root involvement, etc.
Differential diagnosis
There are eight pairs of cervical spinal nerves, which are innervated at different sites, so when they are involved, the distribution of symptoms varies widely depending on the site of involvement. Clinically, the cervical 5-8 spinal nerve roots are more frequently involved, so this is the focus for differentiation of easily confused diseases.
The disease should be differentiated from substantial cervical skeletal lesions (tuberculosis, tumors, etc.), thoracic outlet syndrome, carpal tunnel syndrome, ulnar, radial and median nerve injuries, periarthritis of the shoulder, tennis elbow and biceps tendinitis, and other disorders that are mainly painful in the upper extremities.
The radicular pain of this disease must be distinguished from the dry pain (mainly radial nerve trunk, ulnar nerve trunk and median nerve trunk) and plexus pain (mainly cervical plexus, brachial plexus and axillary plexus).
It is also necessary to differentiate the radicular muscle weakness from the dry and plexiform muscle atrophy, and from the muscle strength changes caused by spinal cord lesions. If necessary, electromyography or cortical evoked potentials should be performed to differentiate.
Treatment
1. Non-surgical treatment
Various targeted non-surgical therapies have obvious efficacy, especially continuous (or intermittent) head and neck traction, cervical braking and correction of poor posture are effective. Manual massage also has certain efficacy, but should be gentle, do not cause accidents due to rough operation, should not use massage.
2. Surgical treatment
Surgery can be considered for those who have the following conditions.
(1) After regular non-surgical treatment for more than 3 months is ineffective, clinical manifestations, imaging and neurological localization are consistent.
(2) There is progressive muscle atrophy and severe pain.
(3) Although the non-surgical treatment is effective, the recurrent symptoms affect work, study and life.
The operation style is anterior cervical lateral anterior decompression, which is not only effective, but also has little effect on the stability of the cervical spine. For those with vertebral segment instability or root canal stenosis, internal fixation of the intervertebral interface can also be used at the same time to open up the vertebral segments and fix the fusion. The posterior cervical approach of decompression through incision of small joints is effective, but has been gradually abandoned because of the postoperative tendency to cause angular deformity of the cervical spine. Bony compressive material can also be removed posteriorly through the laminae or scraped from the lateral posterior aspect of the vertebral body, but this procedure is more difficult and prone to accidental injury and should not be used by the inexperienced.
Prognosis
1. The prognosis is good in most cases due to simple cervical nucleus pulposus herniation, and there are few recurrences after cure.
2. Those whose nucleus pulposus has formed adhesions are prone to residual symptoms.
3. If it is caused by hyperplasia of the hook vertebral joint, the prognosis is more satisfactory with early and timely treatment. If the disease is longer and subarachnoid space adhesions have formed at the root canal, the treatment effect is less satisfactory due to the prolonged symptoms.
4. Root pain due to extensive bone proliferation is not only complicated to treat, but also has a poor prognosis.
(Reproduced from Baidu Encyclopedia)