C5 Nerve Root Research Articles

C1 root decompression as a therapeutic target in non-suboccipital non-Valsalva related headache associated with Chiari I malformation

Headache is the most common symptom impacting the quality of life of patients with Chiari I malformation. While headaches typically present in the occipital or suboccipital regions, and induced by Valsalva maneuver, complex migraine-like headaches referring to frontal or orbital regions also occur. Our study explores the therapeutic potential of C1 nerve root decompression in addition to increasing intracranial compliance in patients with Chiari I malformation. We retrospectively analyzed cases operated on for Chiari I malformation, focusing on patients with non-suboccipital, non-Valsalva induced headaches. Preoperative and postoperative visual analog scale (VAS) scores and headache frequency were recorded. Surgical technique involved suboccipital craniectomy, C1 laminectomy, cerebellar tonsil reduction, and C1 root decompression. Twelve patients (10 females, 2 males) aged 22-52 were included. Preoperative mean VAS score was 8, which improved to 2 or less in 11 patients postoperatively. The mean headache frequency decreased significantly. Our findings suggest that C1 root compression contributes to atypical headaches in Chiari I malformation and that C1 root decompression may improve surgical outcomes.

Satisfaction of patients with frozen shoulder following silent manipulation: a prospective observation study.

Silent manipulation is a procedure for frozen shoulders that involves manipulating the shoulder while the patient is awake by performing C5, C6, and C7 cervical nerve root block under ultrasound guidance. This retrospective study, conducted at Yokohama City University Hospital, aimed to evaluate the clinical outcomes of silent manipulation and assess whether the experience level of the practitioner influenced treatment efficacy. Between October 2020 and January 2022, 53 patients who met the inclusion criteria underwent silent manipulation for frozen shoulder. The procedure was performed by either an experienced or a less experienced practitioner, and the patients were followed-up for up to 1year post-treatment. Silent manipulation resulted in significant improvements in shoulder range of motion, as measured by forward flexion, abduction, external rotation, and hand-behind-back, as well as in patient-reported outcomes, including disabilities of the arm, shoulder, and hand and Shoulder 36 scores. These improvements were observed 1week, 3months, and 1year after silent manipulation, indicating the short-term efficacy of the procedure. Furthermore, this study revealed that the practitioners' level of experience played a significant role in the outcomes. The experienced doctor achieved better 1st external rotation and belt tying outcomes, as well as Shoulder 36 pain, muscle strength, and activities of daily living domain scores. This suggests that technical expertise in silent manipulation is crucial to achieve optimal outcomes. Silent manipulation offers an effective therapeutic approach for frozen shoulder, leading to significant improvements in range of motion and patient satisfaction. Practitioner expertise is a vital factor in treatment success, emphasizing the importance of skilled professionals in the performance of this procedure.

Individualized C1-2 intra-articular three-dimensional printed porous titanium alloy cage for craniovertebral deformity

BackgroundCongenital craniovertebral deformity, including basilar invagination (BI) and atlantoaxial instability (AAI), are often associated with three-dimensional (3D) deformity, such as C1-2 rotational deformity, craniocervical kyphosis, C1 lateral inclination, among other abnormalities. Effective management of these conditions requires the restoration of the 3D alignment to achieve optimal reduction. Recently, 3D printing technology has emerged as a valuable tool in spine surgery, offering the significant advantage of allowing surgeons to customize the prosthesis design. This innovation provides an ideal solution for precise 3D reduction in the treatment of craniovertebral deformities.ObjectiveThis study aims to describe our approach to individualized computer-simulated reduction and the design of C1-2 intra-articular 3D printed porous titanium alloy cages for the quantitative correction of craniovertebral junction deformities.MethodsA retrospective analysis was conducted on patients with craniovertebral deformities treated at our institution using individualized 3D-printed porous titanium alloy cages. Preoperative CT data were used to construct models for 3D realignment simulations. Cage designs were tailored to the simulated joint morphology following computer-assisted realignment. Preoperative and postoperative parameters were statistically analyzed.ResultsFourteen patients were included in the study, with a total of 28 3D-printed porous titanium alloy cages implanted. There were no cases of C2 nerve root resection or vertebral artery injury. All patients experienced symptom relief and stable implant fixation achieved in all cases. No implant-related complications were reported.ConclusionThe use of individualized computer-simulated reduction and the design of C1-2 intra-articular 3D printed porous titanium alloy cage facilitates precise 3D realignment in patients with craniovertebral deformities, demonstrating effectiveness in symptom relief and stability.

Shoulder Traction as a Possible Risk Factor for C5 Palsy in Anterior Cervical Surgery: A Cadaveric Study.

Background and Objectives: Many risk factors for postoperative C5 palsy (PC5P) have been reported regarding a "cord shift" after a posterior approach. However, there are few reports about shoulder traction as a possible risk factor of anterior cervical surgery. Therefore, we assessed the stretched nerve roots when shoulder traction was applied on cadavers. Materials and Methods: Eight cadavers were employed in this study, available based on age and the presence of foramen stenosis. After dissecting the sternocleidomastoid muscle of the cadaver, the shoulder joint was pulled with a force of 2, 5, 8, 10, 15, and 20 kg. Then, the stretched length of the fifth nerve root was measured in the extra-foraminal zone. In addition, the same measurement was performed after cutting the carotid artery to accurately identify the nerve root's origin. After an additional dissection was performed so that the superior trunk of the brachial plexus could be seen, the stretched length of the fifth and sixth nerve roots was measured again. Results: Throughout the entire experiment, the fifth nerve root stretched out for an average of 1.94 mm at 8 kg and an average of 5.03 mm at a maximum force of 20 kg. In three experiments, the elongated lengths of the C5 nerve root at 8 kg and 20 kg were 1.69/4.38 mm, 2.13/5.00 mm, and 0.75/5.31 mm, respectively, and in the third experiment, the elongated length of the C6 nerve root was 1.88/5.44 mm. Conclusions: Although this was a cadaveric experiment, it suggests that shoulder traction could be the risk factors for PC5P after anterior cervical surgery. In addition, for patients with foraminal stenosis and central stenosis, the risk would be higher. Therefore, the surgeon should be aware of this, and the patient would need sufficient explanation.

Posterior Release, Reduction, and Intra-Articular Fusion for Irreducible Type III Atlantoaxial Rotary Fixation.

For irreducible atlantoaxial rotary fixation (AARF), anterior or posterior release was often needed before posterior reduction and fusion. Anterior atlantoaxial joint release has potential complications such as retropharyngeal abscess, persistent hoarseness, and infection. This study aims to assess the efficacy of posterior release, reduction, and intra-articular fusion without resecting the C2 nerve root on irreducible type III AARF. The data of 9 pediatric patients diagnosed with AARF who underwent posterior atlantoaxial release, reduction, and intra-articular fusion without resecting the C2 nerve root were retrospectively reviewed. Japanese Orthopaedic Association scores and Visual Analog Scale for Neck Pain were used to assess outcomes. The preoperative and follow-up assessments of atlantodens interval (ADI) were documented to evaluate the reduction of atlantoaxial joint. The patient demographics, surgery time, blood loss, bone fusion time, follow-up period, and surgery-related complications were meticulously documented. The mean follow-up duration was 35.1 ± 11.5 months. Complete reduction was achieved in 8 patients, while one patient did not achieve complete reduction. The ADI decreased significantly from 8.7 ± 2.2 mm before surgery to 2.1 ± 1.3 mm at the final follow-up. All patients demonstrated successful bone fusion, with an average fusion period of 3.7 ± 1.3 months. The Visual Analog Scale for Neck Pain at the final follow-up exhibited a significant decrease compared with preoperative values (P < .05), while no significant difference was observed in Japanese Orthopaedic Association scores. There were no complications related to surgery. Posterior atlantoaxial release, reduction, and intra-articular fusion with a C2 nerve root preservation technique is effective in the treatment of irreducible type III AARF.

Meridian massage in the treatment of cervical spondylotic radiculopathy

To observe the clinical efficacy of meridian massage in the treatment of cervical spondylotic radiculopathy. Sixty-four patients with cervical radiculopathy treated from March 2020 to June 2023 were divided into the observation group and the treatment group, with 32 cases in each group. The observation group received conventional treatment, including 14 males and 18 females with an average age of (41.34±7.23) years old ranging from 32 to 55 years old;the disease duration ranged from 9 to 17 months with an average of (14.23±3.56) months;C5 and C6 nerve root compression occurred in 12 cases, C7 nerve root compression occurred in 17 cases, C8 nerve root compression occurred in 3 cases. The treatment group received massage therapy on the basis of conventional treatment, including 17 males and 15 females with an average age of (40.86±6.97) years old ranging from 30 to 54 years old;the disease duration ranged from 8 to 18 months with an average of (15.43±3.48) months;C5 and C6 nerve root compression occurred in 14 cases, C7 nerve root compression occurred in 16 cases, C8 nerve root compression occurred in 2 cases. The clinical efficacy was evaluated by visual analogue scale(VAS), neck disability index(NDI) and clinical assessment scale for cervical spondylosis(CASCS) before and after 2-week treatment, and the range of motion of cervical spine was compared before and after treatment. After 2-week treatment, the VAS and NDI scores of the treatment group and the observation group decreased, while the CASCS scores increased(P<0.001). After 2-week treatment, the VAS and NDI scores were lower and the CASCS scores were higher in the treatment group than those of the observation group(P<0.001). Comparing with those before treatment, the range of motion of flexion, extension, left flexion, right flexion, left rotation and right rotation after 2-week treatment increased in two groups(P<0.05). Comparing with the observation group, the range of motion of flexion, extension, left flexion, right flexion, left rotation and right rotation increased more significantly in the treatment group(P<0.05). Meridian massage is effective in the treatment of cervical Spondylotic radiculopathy, which can effectively relieve neck pain, improve clinical symptoms and improve patient satisfaction.

Cervicomedullary cavernous malformation of the C1 nerve root: illustrative case.

Cavernous malformations (CMs) originating from spinal nerve roots are rare but can present with rapidly progressing neurological deficits. Therefore, quick identification and treatment are essential. The authors present the case of a 52-year-old male presenting with headaches and gait disturbance, found to have a CM of the C1 nerve root. The patient underwent successful suboccipital craniectomy and C1 laminectomy, with complete resection of the lesion, preservation of the cervical spinal nerve roots, and symptomatic improvement postoperatively. This is the first presentation in the literature of a CM originating from the C1 nerve root. The authors show complete resection of the lesion with preservation of the C1 nerve root. Nerve root lesions usually show insidious symptomatic onset. Quick identification and resection are recommended to prevent permanent neurological disability. https://thejns.org/doi/10.3171/CASE2456.

Modified Atlantoaxial Arthrodesis Technique for Atlantoaxial Instability via Intraarticular Autografting Using Structural Iliac Bone: Technical Nuances and Case Series

ObjectiveThe present study described a modified technique of atlantoaxial arthrodesis in patients with atlantoaxial instability (AAI) along with the postoperative clinical and radiological results. MethodsFive patients underwent this method for their AAI concurrent with C1 arch hypoplasia and/or the development of odontoid pannus causing myelopathy. After thorough exposure of the posterior surface of the C1-2 complex, the bilateral C2 nerve roots were sectioned to allow for easier access to the C1/2 facet joints. To prepare a suitable grafting bed, the C1/2 facet capsule was opened, then the articular cartilaginous and synovial tissues were thoroughly removed. After being properly fashioned to match the gap between the C1/2 facet joint spaces, the structural bone grafts from the iliac crest were directly inserted into the facet joint spaces. To alleviate cord compression caused by concomitant odontoid pannus and/or hypoplastic C1 arch, C1 laminectomy was necessitated in all cases. Subsequently, posterior screw-rod instrumental fixation was conducted. ResultsAll five patients underwent this procedure successfully. Clinical and radiological follow-up data of all patients indicated favorable relief of clinical symptoms and early rigid C1-2 stability. The sequelae of C2 nerve resection were not remarkable. No other neural or vascular damage associated with this technique was observed. ConclusionModified atlantoaxial arthrodesis via intraarticular autografting using the structural iliac bone combined with posterior instrumentation appears to be an efficient alternative treatment method for AAI patients with concurrent pathologies, even when the C1-2 posterior arches are unavailable for the grafting bed.

The prerequisites and clinical outcomes of ipsilateral C7 nerve root transfer to the upper trunk for adult C5-C6 brachial plexus injuries.

Although ipsilateral C7 nerve transfer is used for the treatment of C5-C6 brachial plexus injuries, accurately evaluating the functional quality of the donor nerve (ipsilateral C7 nerve root) is difficult, especially when the C7 nerve root is slightly injured. The purpose of this study was to determine the indicators to evaluate the quality of the ipsilateral C7 nerve and assess the clinical outcomes of this procedure. This study employed the following three indicators to assess the quality of the ipsilateral C7 nerve: (1) the muscle strength and electrophysiological status of the latissimus dorsi, triceps brachii, and extensor digitorum communis; (2) the sensibility of the radial three digits, especially the index finger; and (3) the intraoperative appearance, feel and electrophysiological status of the ipsilateral C7 nerve root. Transfer of the ipsilateral C7 nerve root to the upper trunk was implemented only when the following three tests were conducted, the criteria were met, and the clinical outcomes were assessed in eight patients with C5-C6 brachial plexus injuries. Patients were followed-up for an average of 90 ± 42months. At the final follow-up, all eight patients achieved recovery of elbow flexion, with five and three patients scoring M4 and M3, respectively, according to the Medical Research Council scoring. The shoulder abduction range of motor recovery averaged 86 ± 47° (range, 30°-170°), whereas the shoulder external rotation averaged 51 ± 26° (range, 15°-90°). Ipsilateral C7 nerve transfer is a reliable and effective option for the functional reconstruction of the shoulder and elbow after C5-C6 brachial plexus injuries when the three prerequisites are met.

Posterior Transdural Approach for Treatment of Spontaneous Intradural Cervical Disc Herniation-Causing Brown-Séquard Syndrome: A 2-Dimensional Operative Video.

Intradural disc herniations (IDH) account for 0.27% of all disc herniations. Cervical IDH account for 3% of these, with only 47 cases reported in the literature, making it an extremely rare diagnosis. Brown-Séquard syndrome is the most common presentation of cervical IDH. Emergent decompression is usually necessary. We present the case of a 56-year-old woman who presented with Brown-Séquard syndrome secondary to a spontaneous intradural C5-6 disc herniation. A posterior transdural approach was recommended to arrest her neurological deficit and promote improvement. The patient consented to the procedure. Institutional Review Board approval was not necessary, given this treatment was necessary and indicated. A standard posterior cervical exposure and C5-6 laminectomies were performed. The dura was opened with a "peeling" technique. The compressive disc fragments were removed. A dural defect was identified along the C6 nerve root sleeve. Fluoroscopy was used to confirm the communication of the defect with the C5-6 disc space. A single 5-0 Prolene suture was used to repair the defect, approximating the anterior dura with a flap from the nerve root sleeve. The patient had an uneventful postoperative course. At 7-month follow-up, her neurological deficits had nearly resolved. Surgeons should consider IDH in the differential diagnosis for sudden neurologic decline in the setting of an intradural mass and should be familiar with the association between cervical IDH and Brown-Séquard syndrome. The posterior transdural approach provides excellent exposure, easier management of dural defects, and ability to handle a variety of intradural pathologies and may avoid the need for concomitant fusion.

Unveiling the role of dorsal root ganglia in spasticity reduction: Insights from contralateral seventh cervical nerve cross transfer surgery.

Central nervous system (CNS) disorders, such as stroke, often lead to spasticity, which result in limb deformities and significant reduction in quality of life. Spasticity arises from disruptions in the normal functioning of cortical and descending inhibitory pathways in the brainstem, leading to abnormal muscle contractions. Contralateral seventh cervical nerve cross transfer (CC7) surgery has been proven to effectively reduce spasticity, but the specific mechanism for its effectiveness is unclear. This study aimed to investigate the changes in the dorsal root ganglia (DRG) following CC7 surgery. A comprehensive anatomical analysis was conducted through cadaveric study and magnetic resonance imaging (MRI) study, to accurately measure the regional anatomy of the C7 DRG. DRG perfusion changes were quantitatively assessed by comparing pre- and postoperative dynamic contrast-enhanced (DCE) MRI. In CC7 surgery, the C7 nerve root on the affected side is cut close to the DRG (3.6±1.0mm), while the C7 nerve root on the healthy side is cut further away from the DRG (65.0±10.0mm). MRI studies revealed that after C7 proximal neurotomy on the affected side, there was an increase in DRG volume, vascular permeability, and perfusion; after C7 distal neurotomy on the healthy side, there was a decrease in DRG volume, with no significant changes in vascular permeability and perfusion. This study provides preliminary insights into the mechanisms of spasticity reduction following CC7 surgery, indicating that changes in the DRG, such as increased vascular permeability and perfusion, could disrupt abnormal spinal γ-circuits. The resulting high-perfusion state of DRG, possibly due to heightened neuronal activity and metabolic demands, necessitating further research to verify this hypothesis.

V2 Vertebral Artery Transposition for Microvascular Decompression of C5 Nerve Root: A 2-Dimensional Operative Video.

Vertebral artery tortuosity is a common phenomenon with an estimated incidence of 2.7%. However, it is symptomatic in very rare instances, with only 21 cases reported in the literature. When a neurovascular conflict can be clearly identified, microsurgical decompression should be the treatment of choice. This can be performed through a variety of different strategies which can achieve either direct or indirect decompression. We present the case of a 68-year-old female who suffered from progressive right-sided C5 radiculopathy and deltoid weakness for over a year secondary to a neurovascular conflict between a V2 vertebral artery loop and the C5 nerve root. Microvascular decompression with vertebral artery transposition using an anterolateral approach was recommended for pain management and arrest of her neurological deficit, and the patient consented to the procedure. Institutional Review Board approval was not necessary given that this treatment was necessary and indicated. The longus colli is mobilized, and the anterior wall of the foramen transversarium is exposed. The foramen transversarium is drilled to unroof the vertebral artery. The neuroforamen is identified. A tailored foraminotomy is performed to expose the neurovascular conflict. The vertebral artery loop is dissected away from the C5 nerve root and transposed outside the neuroforamen. The transposition is maintained with Teflon felts. The patient had immediate resolution of her pain and weakness. Surgeons should be aware of this rare cause of radiculopathy and should be familiar with the surgical technique for vertebral artery mobilization. Direct decompression should be the goal of treatment when possible.

Post-operative morbidity after C2 nerve root sacrifice during C1-2 fixation in pediatric atlantoaxial instability

Post-operative morbidity after C2 nerve root sacrifice during C1-2 fixation in pediatric atlantoaxial instability

Investigating the effect of anatomical variations in the response of the neonatal brachial plexus to applied force: Use of a two-dimensional finite element model.

The brachial plexus is a set of nerves that innervate the upper extremity and may become injured during the birthing process through an injury known as Neonatal Brachial Plexus Palsy. Studying the mechanisms of these injuries on infant cadavers is challenging due to the justifiable sensitivity surrounding testing. Thus, these specimens are generally unavailable to be used to investigate variations in brachial plexus injury mechanisms. Finite Element Models are an alternative way to investigate the response of the neonatal brachial plexus to loading. Finite Element Models allow a virtual representation of the neonatal brachial plexus to be developed and analyzed with dimensions and mechanical properties determined from experimental studies. Using ABAQUS software, a two-dimensional brachial plexus model was created to analyze how stresses and strains develop within the brachial plexus. The main objectives of this study were (1) to develop a model of the brachial plexus and validate it against previous literature, and (2) to analyze the effect of stress on the nerve roots based on variations in the angles between the nerve roots and the spinal cord. The predicted stress for C5 and C6 was calculated as 0.246 MPa and 0.250 MPa, respectively. C5 and C6 nerve roots experience the highest stress and the largest displacement in comparison to the lower nerve roots, which correlates with clinical patterns of injury. Even small (+/- 3 and 6 degrees) variations in nerve root angle significantly impacted the stress at the proximal nerve root. This model is the first step towards developing a complete three-dimensional model of the neonatal brachial plexus to provide the opportunity to more accurately assess the effect of the birth process on the stretch within the brachial plexus and the impact of biological variations in structure and properties on the risk of Neonatal Brachial Plexus Palsy.

C5 nerve root palsy (without prior cervical decompression) case series: 9 patients with critical delay to presentation.

Distinguishing between cervical nerve root and intrinsic shoulder pathology can be a difficult task given the overlapping and often coexisting symptoms. The objective of this study was to highlight the often-complicated presentation of these symptoms and the subsequent potential for delay in care regarding this subset of patients. A total of 9patients, managed by one of two different surgeons, were identified with a history of C5 nerve root palsy. A chart review was conducted, and the following information was recorded: presenting complaint, time from symptom onset to diagnosis, time from symptom onset to presentation to a spine surgeon, first specialist seen for symptoms, non-spinal advanced imaging and treatment conducted before diagnosis, preoperative and postoperative exam, time to recovery, and type of surgery. We observed an average time from onset of symptoms to presentation to a spine surgeon to be 31.6weeks. These patients' time to full recovery after cervical decompression was 15weeks. : We observed a critical delay to presentation in this series of patients with C5 nerve palsy. C5 nerve palsy should remain an elemental part of the differential diagnosis in the setting of any shoulder or neck pain presenting with weakness.

Midterm Outcomes of Surgical Reconstruction and Spontaneous Recovery of Upper-Extremity Paralysis Following Acute Flaccid Myelitis.

Acute flaccid myelitis (AFM) is a disabling, poliomyelitis-like illness that mainly affects children. Although various surgical interventions are performed for intractable paralysis due to AFM, the timing of surgery and its long-term outcomes have yet to be established, especially for shoulder reconstruction. This study aimed to analyze the midterm outcomes of nonsurgically and surgically treated upper-extremity AFM and the factors influencing shoulder functional outcomes after surgical reconstruction. We retrospectively examined 39 patients with AFM in 50 upper extremities between 2011 and 2019. The degree of spontaneous recovery of completely paralyzed muscles was evaluated at a median of 3, 6, and 37 months after the onset of paralysis. Twenty-seven patients with 29 extremities underwent surgery involving nerve transfer, muscle-tendon transfer, or free muscle transfer for shoulder, elbow, and hand reconstruction. Patients with complete paralysis of shoulder abduction at 6 months did not show later recovery. Twenty-two patients with 24 extremities underwent shoulder surgery, and all but 1 were followed for at least 24 months after surgery. Although postoperative shoulder abduction recovery was similar between transfer of the spinal accessory nerve and of the contralateral C7 nerve root to the suprascapular nerve, the outcomes obtained with spinal accessory nerve transfer had more variability, likely related to latent spinal accessory nerve paralysis, shoulder instability related to pectoralis major paralysis, and the type of paralysis. Shoulder abduction recovery was also greatly affected by scapulothoracic joint movement. In contrast, the outcomes of the elbow flexion and hand reconstructions were more consistent and acceptable. All patients had loss of shoulder abduction, and restoration of shoulder function was less predictable and depended on the quality of the donor nerves and recovery of the synergistic muscles. Strict donor nerve selection and additional nerve transfer for shoulder reconstruction are imperative for satisfactory outcomes. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Neurosarcoidosis involving cervical nerve root with unusual MRI findings: a case report and systematic literature review.

Neurosarcoidosis is rare, and among its manifestations, nerve root involvement has been reported in only a few cases. Therefore, magnetic resonance imaging (MRI) findings of neurosarcoidosis, particularly those involving nerve roots, are scarce in the literature. We presented the case of neurosarcoidosis involving cervical nerve roots and cranial nerves, alongside a systematic literature review. A 28-year-old female suddenly developed right facial numbness as well as left upper extremity and left hand pain. Initial brain and spine MRI showed a bulging mass of T2 iso-to-high signal intensity in the left Meckel's cave/trigeminal nerve, as well as diffuse enlargement of the right C6 and C7 nerve roots. Follow-up MRI at 2months revealed a reduction in the size of the initial lesion and the appearance of new similar lesions on the contralateral side (right Meckel's cave, left C3-C8 nerve roots). In particular, the lesions involving the nerve roots demonstrated central enlargement along the nerve roots, without involvement of the adjacent spinal cord. All these lesions exhibited enhancement, leading to the differentiation between sarcoidosis and lymphoma. Sarcoidosis was subsequently confirmed through biopsy of a hilar lymph node. This report presents a distinctive MRI feature of neurosarcoidosis involving spinal nerve roots, representing the first of its kind, and describes the evolution of MRI findings throughout the clinical course.

Long-Term Outcomes after Surgery of the Neurogenic Thoracic-Outlet Syndrome in Adolescents

Neurogenic Thoracic Outlet Syndrome (nTOS) describes a complex of symptoms caused by the compression of neural structures at the upper thoracic outlet. Typical symptoms include pain, numbness and motor weakness of the affected extremity. The incidence of nTOS is 2-3 per 100,000 and is highest between the ages of 25 and 40. There are only a few studies evaluating the surgical outcomes of nTOS in adolescent patients. In particular, there is a lack of long-term data. In a retrospective study of nTOS cases receiving surgical treatment in our clinic between 2002 and 2021, eight patients between 15 and 18 years of age were included. Demographic data, risk factors, clinical symptoms, clinical functional tests, neurophysiological, radiological and intraoperative findings were evaluated. Postoperative data were recorded using a standardised questionnaire. Decompression of the inferior truncus and the C8 and Th1 nerve roots was performed via a supraclavicular approach. The average duration of symptoms before surgery was two years. Of the eight patients who underwent surgery, six answered the written questionnaire and could be analysed for the study. The average follow-up was nine years (1-18 years). After surgery, all patients experienced pain reduction; three were pain-free in the long run and five no longer required pain medication. Strength improved in all patients, but two patients still had mild motor deficits. Sensory disturbances were reduced in all patients, but residual hypoesthesia persisted in five. With regard to overhead work, half of the patients had no impairment after surgery. All patients were able to work at the time of the survey. Half of the patients pursued their sports activities without impairment, while mild impairment was reported by the other half. nTOS in adolescents is a rare compression syndrome. Decompression of the lower parts of the brachial plexus using a supraclavicular approach without resection of the first rib is an adequate treatment. This retrospective study showed that a reduction in pain was achieved in all patients. In some patients, slight sensory and motor disturbances as well as a certain restriction in overhead work persisted. Patients were able to return to sports.

An Independent C1 Nerve Root Variant of the Ansa Cervicalis: A Case Report

The ansa cervicalis (AC) is a neural loop within the carotid triangle of the anterior neck. The loop is traditionally formed by nerve roots C1–C3 of the cervical plexus and extends multiple motor branches. The current case was discovered during a routine dissection as an anatomical variation of the right AC in an 86-year-old Caucasian male cadaver. In this variation, the C1 nerve root did not form the typical loop with the C2 and C3 nerve roots, but instead, remained independent, traveling deep to the superior belly of the omohyoid muscle to supply the sternothyroid muscle. Because no loop was formed, the anatomy of the current case was not an ansa according to the Latin origin of the word, meaning handle or loop. The AC is an important anatomical landmark within the neck and is implicated in laryngeal reinnervation and respiratory nerve stimulation for patients with sleep apnea. The current anatomical variant contributes to a relatively limited catalog of identified anomalies. Knowledge of new AC variations can guide future surgical interventions and further develop the current base of knowledge surrounding the neuromuscular structures of the head and neck.

Posterior Percutaneous Endoscopic Cervical Discectomy for Single-Level Soft, Huge Central Disc Herniation

BACKGROUND: Posterior percutaneous endoscopic cervical discectomy (PPECD) has been proven safe and effective for foraminal cervical disc herniation (CDH). However, central CDH has long been considered as the contraindication of PPECD, because the path is obstructed by the spinal cord and nerve root. OBJECTIVES: To preliminarily assess the feasibility, safety, and effectiveness of PPECD for single-level soft, huge central CDH. STUDY DESIGN: A retrospective cohort study. SETTING: Zhejiang Provincial People’s Hospital (Affiliated People’s Hospital, Hangzhou Medical College). METHODS: Between 2017 and 2020, 31 patients diagnosed with single-level soft, huge central CDH were treated by PPECD. Primary outcomes included the measures of neck and radicular pain based on the numeric rating scale (NRS) and cervical neurologic status based on the Japanese Orthopedic Association (JOA) score. The global outcome was assessed using the Odom’s criteria at one-year follow-up. RESULTS: Compared to the baseline, there was a constant and significant reduction of NRS-rated pain and improvement of JOA-rated cervical neurologic status postoperatively (P &lt; 0.01). According to the Odom’s criteria, 96.8% (30/31) of patients had satisfactory postoperative clinical improvement (excellent or good outcomes) at one-year follow-up. Complications included C5 nerve root palsy and spinal cord injury. The total complication rate was 16.5% (2/31), but these complications were temporary and not catastrophic. LIMITATIONS: The limitations of this study include the volume of the sample, a short follow-up period, and the lack of a control group. CONCLUSIONS: Our preliminary experience indicates that PPECD is a feasible and promising alternative for symptomatic single-level soft, huge central CDH. KEY WORDS: Intervertebral disc displacement, minimally invasive surgical procedures, diskectomy, endoscopy