C5 Nerve Root Research Articles

Morphology of cervical periradicular fibrous sheath and nerve roots in relation to postoperative C5 palsy

Background ContextC5 palsy is a major complication of cervical spine surgery, however, its exact pathogenesis remains unclear. Some studies have shown that the superficial layer of the posterior longitudinal ligament extends laterally and forms the periradicular fibrous sheath (PFS), and envelopes the nerve roots. However, the anatomical relationship between the PFS and nerve root at each cervical level has not been fully revealed. PurposeTo examine the difference of the PFS that covers the nerve root at each cervical level, and to consider its potential in the onset of postoperative C5 palsy. Study DesignAnatomical study of cervical dissection of 13 embalmed cadavers. MethodsThirteen human formalin-fixed cadavers were dissected from posterior approach, and were observed their cervical nerves bilaterally from C3 to C8 (the total number of nerves was 156). The bare area length (BAL), which is the distance between the medial posterior edge of the PFS and the bifurcation of the nerve and dura mater, was measured by using electronic calipers. Thus, BAL is the uncovered area of the nerve root by the PFS. We examined whether BAL significantly varied at each cervical level. ResultsWe confirmed the PFS macro- and/or microanatomically in all cadavers. The average BAL gradually increased craniocaudally, and there was a significant step between that of C5 and C6 level. ConclusionThe average BAL of the C5 root was significantly shorter than that of C6, C7, and C8, suggesting that C5 root was more tightly anchored. This could be one reason for C5 palsy, making C5 nerve root vulnerable to the traction caused by the postoperative spinal cord shift. Clinical SignificanceThis study provides clinicians an additional understanding of the anatomical factor of C5 palsy. Consideration of the anchoring effect of the PFS for nerve roots, release of the PFS could be a preventive procedure for C5 palsy.

Impact of morphological restoration of the spinal cord from the preoperative to early postoperative periods on C5 palsy development.

C5 palsy (C5P) is a known complication of cervical decompression surgery. The tethering effect of the C5 nerve root following the posterior shift of the spinal cord is the most accepted pathologic mechanism for C5P development; however, this mechanism cannot fully explain C5P by itself in clinical practice. Separately, some studies have suggested that preoperative severe spinal cord compression and postoperative morphological changes in the spinal cord affect C5P development; however, no previous study has quantitatively addressed these possibilities. The aim of this study was to examine whether spinal cord morphology and morphological restoration after surgery affect C5P development. The authors reviewed consecutive patients with degenerative cervical myelopathy who underwent laminoplasty including the C3-4 and C4-5 intervertebral disc levels. All participants underwent MRI both preoperatively and within 4 weeks postoperatively. To assess the severity of spinal cord compression, the compression ratio (CR; spinal cord sagittal diameter/transverse diameter) was calculated. As an index of morphological changes in the spinal cord during the early postoperative period, the change rate of CR (CrCR, %) was calculated as CRwithin 4 weeks postoperatively/CRpreoperatively × 100. These measurements were performed at both the C3-4 and C4-5 intervertebral disc levels. The study cohort was divided into C5P and non-C5P (NC5P) groups; then, CR and CrCR, in addition to other radiographic variables associated with C5P development, were compared between the groups. A total of 114 patients (mean age 67.6 years, 58.8% men) were included in the study, with 5 and 109 patients in the C5P and NC5P groups, respectively. Preoperative CR at both the C3-4 and C4-5 levels was significantly lower in the C5P group than in the NC5P group (0.35 vs 0.44, p = 0.042 and 0.27 vs 0.39, p = 0.021, respectively). Patients with C5P exhibited significantly higher CrCR at the C3-4 level than those without (139.3% vs 119.0%, p = 0.046), but the same finding was not noted for CrCR at the C4-5 level. There were no significant differences in other variables between the groups. This study reveals that severe compression of the spinal cord and its greater morphological restoration during the early postoperative period affect C5P development. These findings could support the involvement of segmental cord disorder theory, characterized as the reperfusion phenomenon, in the pathomechanism of C5P, in addition to the tethering effect.

Giant cell arteritis with cervical radiculopathy mimicking polymyalgia rheumatica and elderly-onset rheumatoid arthritis: a case report

BackgroundGiant cell arteritis has a wide variety of clinical symptoms, one of them being cervical radiculopathy, which mainly involves the C5 nerve root. If the patient does not develop typical clinical symptoms of giant cell arteritis but has C5 radiculopathy, it may be misdiagnosed as polymyalgia rheumatica or elderly-onset rheumatoid arthritis due to old age, high serum inflammatory markers, and difficulty in raising both upper limbs.Case presentationA 72-year-old Japanese man with a month-long history of dyspnea on exertion and with difficulty in raising both upper limbs was referred to our hospital because of elevated serum C-reactive protein (12.62 mg/dL). He had no typical symptoms of giant cell arteritis such as headache, jaw claudication, visual loss, and fever. The patient tested negative for rheumatoid factor and anti-cyclic citrullinated peptide antibody, and matrix metalloproteinase-3 was within the normal range (54.3 ng/mL). Musculoskeletal ultrasound examination showed absence of tenosynovitis, bursitis, and synovitis, and the patient did not meet the classification criteria of polymyalgia rheumatica or rheumatoid arthritis; hence, those two diseases were unlikely. A precise neurological examination suggested bilateral C5 and C6 anterior radiculopathy and left C4 radiculopathy. Since cervical magnetic resonance imaging showed no mechanical causality, cervical radiculopathy of unknown origin was suggested. Fluorodeoxyglucose positron emission tomography/computed tomography revealed increased fluorodeoxyglucose lineal uptake along the vessel walls, including temporal arteries, vertebral arteries, and axillary arteries. Results of the biopsy of the left superficial temporal artery were compatible with giant cell arteritis. He was successfully treated with 30 mg of prednisolone, and both upper limbs could be elevated.ConclusionsIf the patient was misdiagnosed with polymyalgia rheumatica or elderly-onset rheumatoid arthritis based on only clinical symptoms and laboratory data, his symptoms might not improve due to insufficient steroid dose and vascular complications may occur later. Although rare, peripheral neuropathy in giant cell arteritis may include cervical radiculopathy. The musculoskeletal ultrasound and precise neurological examination were the turning points for the diagnosis of this case, and making a careful diagnosis using these methods was important.

Application of Triggered EMG in the Intraoperative Neurophysiological Monitoring of Posterior Percutaneous Endoscopic Cervical Discectomy.

ObjectiveTo describe the rationale and application of triggered EMG (T‐EMG) in intraoperative neurophysiological monitoring, and to explore the efficacy and safety of posterior percutaneous endoscopic cervical discectomy (PPECD) in the treatment of cervical spondylotic radiculopathy (CSR) under multimodal intraoperative neurophysiological monitoring (IOM).MethodsThis study was a retrospective cohort control study. The clinical data of 74 patients with single‐segment CSR from June 2015 to August 2018 were analyzed retrospectively, of whom 35 underwent IOM‐assisted PPECD with triggered EMG (T‐EMG group), while 39 were subjected to IOM‐assisted PPECD alone (IOM group). Operation time, hospital stay, and complications were recorded for both groups. The curative effect was evaluated according to the Visual Analog Scale (VAS) of neck and arm pain, Japanese Orthopaedic Association (JOA) score, and modified MacNab scale.ResultsOperations were successful and all patients were followed up for at least 24 (average 31.77 ± 9.51) months with no patient lost to follow‐up. No significant difference was found in preoperative baseline data between the T‐EMG and the IOM group (P > 0.05). Also, no significant difference was found in the operation time between the T‐EMG (108.29 ± 11.44 min) and the IOM (110.13 ± 12.70 min) (P > 0.05) group, but the difference in hospital stay (T‐EMG: 5.66 ± 0.99 days; IOM: 7.10 ± 1.43 days) was statistically significant (P < 0.05). The VAS for the neck and upper limbs in the two groups at 1 month post‐operation (T‐EMG: 2.09 ± 1.07, 2.26 ± 0.92; IOM:2.18 ± 1.05, 2.31 ± 0.77) and the last follow‐up (T‐EMG: 0.83 ± 0.62, 0.86 ± 0.55; IOM: 0.90 ± 0.50, 0.87 ± 0.61) were significantly different from the preoperative scores (T‐EMG: 6.14 ± 1.09, 7.17 ± 1.04; IOM: 6.18 ± 1.28, 7.15 ± 1.23) (P < 0.05). However, no significant difference was found between the two groups (P > 0.05). The 1‐month postoperative JOA scores for the two groups (12.69 ± 0.76; 12.59 ± 0.82) and those at the last follow‐up (14.60 ± 0.77; 14.36 ± 0.78) were significantly different from the preoperative scores (11.09 ± 0.98; 11.05 ± 0.89) (P < 0.05), but the difference between the two groups was not significant (P > 0.05). One patient in the T‐EMG group developed a transient aggravation of symptoms on the first day after surgery. In the IOM group, three patients had intraoperative cerebrospinal fluid leakage, and symptoms of C5 nerve root paralysis were presented in four patients following surgery. Compared with the IOM group, the T‐EMG group had fewer complications (1/35; 7/39, P < 0.05). At the last follow‐up, the modified MacNab criteria were 91.43% (32/35) and 89.7% (35/39) for the T‐EMG group and IOM group, respectively.ConclusionsTriggered EMG prevents the occurrence of neurological complications, which not only aids PPECD for CSR treatment in achieving satisfactory results, but also reduces average hospital stay and complication rates.

C6 nerve root palsy after double-door cervical laminoplasty.

Background: This study correlated the relationship between postoperative C6 nerve root palsies and various patient-related clinical, radiographic, and surgical parameters.Methods: The medical records of 318 patients undergoing double-door cervical laminoplasty for myelopathy were reviewed. Twelve (3.8%) had postoperative C6 nerve root palsies. Their clinical, radiographic, and surgical procedures were analyzed looking for a correlation/explanation for these new C6 root deficits.Results: The following factors correlated with patients’ developing new postoperative C6 nerve root deficit following double-door cervical laminoplasty; a high correlation with additional C5 palsies, narrower C6 intervertebral foraminal widths, greater anterior protrusions of the C6 articular process, and larger posterior shifts of the spinal cord on magnetic resonance (MR) between the C4/C5-C6/C7 levels.Conclusion: Factors correlating with the new onset of C6 nerve root palsies following double-door cervical laminoplasty included; a high correlation with new C5 palsies, more severe foraminal stenosis, greater anterior protrusions of the C6 articular process, and more extensive dorsal spinal cord migration.

C2 Nerve Root Preservation During Posterior Fixation for Instability Secondary to Congenital Craniovertebral Junction Anomalies: Feasibility Factors and Related Outcomes

Patients with instability because of congenital craniovertebral anomalies often have complex C1-C2 osseovascular anomalies. C2 nerve root sacrifice has been described to address such difficult anatomy during posterior C1-C2 fixation and has its own downsides. Its preservation as a recent alternative poses greater surgical challenge, and the considerations differ from other causes of craniovertebral junctional instability; the pertaining outcomes have been scarcely studied. The objective of this study was to prospectively determine the feasibility and outcomes related to C2 nerve root preservation in patients with congenital atlantoaxial dislocation (CAAD) after posterior C1-C2 fixation. In this observational study, 63 patients (126 nerve roots) with CAAD after posterior fixation were prospectively assessed. Underlying osseovascular anomalies affecting the feasibility of C2 nerve root preservation, and C2 nerve-related dysfunction at 12 months follow-up were analyzed. The overall C2 nerve root preservation rate was 89.7%. Even in the presence of extreme joint obliquity/spondyloptosis and anomalous vertebral artery, it was feasible in about three fourths. After preservation, 28.3% patients developed new-onset C2 nerve root dysfunction: neuralgia in 2, dysesthesia in 6, and hypoesthesia/paresthesia in 9. The symptoms were not disabling in most patients. In most patients with CAAD, C2 nerve root preservation is feasible despite an aberrant bony and vascular anatomy. A few patients after nerve root preservation develop related symptoms that are conservatively manageable, with no significant adverse consequences. Given the controversy in the literature on C2 nerve sacrifice-related outcomes, we favor an attempt at C2 nerve root preservation.

Nerve root morphological and functional changes after degenerative cervical myelopathy surgery: preliminary study using ultrasound and electrophysiology

A prospective observational study. To depict morphological and functional changes in the cervical nerve roots before and after spinal cord decompression surgery for degenerative cervical myelopathy (DCM). A general hospital in Japan. Thirteen DCM patients who underwent posterior spinal cord decompression surgery, laminoplasty or laminectomy, were included in this study. The neural foramen shown on MRI and the cross-sectional area (CSA) of the nerve roots on ultrasound were used to evaluate the C5 and C6 nerve roots. The compound muscle action potentials (CMAPs) of deltoid and biceps muscle were also recorded. All patients showed sensorimotor functional improvement without the postoperative C5 palsy after surgery. Foraminal stenosis and preoperative CSA of the nerve root: C4/5 foramen and C5 nerve root, C5/6 foramen and C6 nerve root, had no significant correlation (P = 0.53 and 0.08). CSA of the C5 nerve root displayed no significant change before and after surgery (P = 0.2), however, that of the C6 nerve root reduced significantly after surgery (P = 0.038). The amplitude of the deltoid and biceps CMAPs displayed no significant change before and after surgery (P = 0.05 and 0.05). The C6 nerve root CSA change was observed after spinal cord decompression surgery with functional recovery. However, deltoid and biceps CMAPs amplitude showed no significant change. Independent CSA changes on ultrasound might be useful when conducting a functional evaluation of the postoperative nerve root. The Grant of Japan Orthopaedics and Traumatology Research Foundation No. 395.

Retracted: Overexpression of Neuregulin-1 (NRG-1) Gene Contributes to Surgical Repair of Brachial Plexus Injury After Contralateral C7 Nerve Root Transfer in Rats

Retracted on the author's request: "We would like to withdraw our manuscript. We restarted the project for further study last year, we found that the results in this study are not solid enough and need to be further explored." Reference: Zong-Qiang Wang, Dian-Hui Xiu, Gui-Feng Liu, Jin-Lan Jiang. Overexpression of Neuregulin-1 (NRG-1) Gene Contributes to Surgical Repair of Brachial Plexus Injury After Contralateral C7 Nerve Root Transfer in Rats.Med Sci Monit 2018; 24: 5779-5787; DOI: 10.12659/MSM.908144.

Postural physiotherapy for cervicogenic headache after occipital nerve block: a retrospective study

Cervicogenic headache has a complex and poorly understood pathophysiology. Symptoms are typical and involve the C2 and C3 nerve roots. There are no specific recommendations for physical therapy, although occipital nerve block is a known pharmacological treatment. Some evidence suggests that hip rotation correction could aid in reducing cervical pain symptoms. The objective of this work is to evaluated the role of postural physiotherapy for hip rotation correction using the Maitland technique in patients with cervicogenic headache who underwent an occipital nerve block. In this retrospective, observational and uncontrolled study, patients were evaluated from January 2017 to February 2018. After diagnosis of cervicogenic headache they underwent anesthetic block, hip radiography with lower limb scanometry and cervical tomography, after which they were referred to physical therapy. The analog pain scale was used for evaluation at the time of diagnosis and after the proposed physiotherapy. Patients submitted to an occipital nerve block were divided into three groups: Group I (n = 15, physical therapy with Maitland technique) had an analog pain score of 1.6 after the physical therapy, Group II (n = 11, conventional physiotherapy) had an analog pain score of 3.7 after the physical therapy and Group III (n = 13, occipital nerve block only) had an analog pain score of 5.2 after the occipital nerve block. The results suggest that an occipital nerve block in combination with the Maitland technique is superior in patients with cervicogenic headache compared to nerve block only or blockade combined with non-specific physical therapy (p=0,013).

Detailed features and prognostic factors of twenty-three patients with drop finger caused by cervical radiculopathy: a retrospective multicentre study.

It has been reported that C7 and C8 nerve root impairment can cause drop finger; however, the clinical characteristics of each injured nerve root and post-operative outcomes remain unclear. This study aimed to investigate the detailed features and surgery-related prognostic factors of drop finger caused by cervical radiculopathy. We retrospectively investigated the clinical characteristics, paralysis patterns and surgery-related prognostic factors of 23 patients with drop finger caused by cervical radiculopathy who underwent posterior cervical foraminotomy. We classified paralysis into three patterns based on the fingers predominantly exhibiting extensor digitorum communis (EDC) muscle weakness: index finger side-dominant, middle and ring fingers-dominant and little finger side-dominant. The aetiologies were cervical disc hernia (CDH) in ten patients, cervical spondylotic radiculopathy (CSR) in eight and both CDH and CSR in five. The levels of the decompressed root were C7 in one patient, C8 in 11 and both C7 and C8 in 11. Scapular pain was frequently observed as the initial symptom (78%), especially in patients with only C8 nerve root disorder (91%). Drop finger recovered to a score of ≥ 3 on manual muscle testing in 17 patients; patients with the little finger side-dominant pattern tended to have poor recoveries. Patients with CDH improved significantly than those with CSR or both CDH and CSR (p < 0.05). Good surgical recovery of drop finger can be expected in patients with CDH and in those with index fingers-dominant and middle and ring fingers-dominant patterns.

When to Refer Patients With Cervicogenic Headache for an Occipital Nerve Corticosteroid Injection: A Multiple-Case Series

Objectives To evaluate the impact of physical therapist assessment in patients with cervicogenic headache (CGH) to identify who may benefit from occipital nerve corticosteroid injections (ONCIs). Design Retrospective multiple-case series. Methods Based on the physical therapist assessment, patients with C2 nerve root involvement were referred to a neurologist for ONCI. Median pain intensity per episode of CGH was measured with a numeric pain-rating scale at baseline, after ONCI, and at 3 weeks. Results Ten of the 22 patients were referred to the neurologist to receive ONCIs (mean ± SD, 2.1 ± 1.0 injections). Median headache intensity per episode was reported to be 8/10 (interquartile range [IQR], 8-10) at baseline, 6/10 (IQR, 3-6.25) immediately postintervention, and 5/10 (IQR, 2.25-6) at the 3-week follow-up. Conclusion Identification of patients who had CGH from the C2 nerve root and were referred for 1 or more ONCIs by the physical therapist may be associated with a significant pain reduction. JOSPT Cases 2021;1(3):135–142. doi:10.2519/josptcases.2021.10303

Contralateral C7 Nerve Transfer for Stroke Recovery: New Frontier for Peripheral Nerve Surgery.

Ischemic stroke remains a major cause of disability in the United States and worldwide. Following the large-scale implementation of stroke thrombectomy and the optimization of treatment protocols for acute stroke, the reduction in stroke-associated mortality has resulted in an increased proportion of stroke survivors, many of whom have moderate to severe disability. To date, the treatment of subacute and chronic stroke has remained a challenge. Several approaches, involving pharmacological interventions to promote neuroplasticity, brain stimulation strategies and rehabilitative interventions, are currently being explored at different stages of the translational spectrum, yet level 1 evidence is still limited. In a recent landmark study, surgical intervention using contralateral C7 nerve transfer, an approach used to treat brachial plexus injury, was implemented in patients with chronic stroke, demonstrating an added benefit to standard rehabilitation strategies, leading to improved motor performance and reduced spasticity. The procedure involved the transfer of the C7 nerve root and middle trunk from the uninjured extremity to the injured extremity using a short conduit that allows for faster regeneration and innervation of the injured upper extremity via the ipsilateral (contralesional) hemisphere. In this work, we review the rationale for using contralateral C7 nerve transfer in stroke, describe the surgical intervention with associated variations and limitations, and discuss the current evidence for the efficacy of this technique in ischemic stroke research.

Analysis of risk factors for C5 nerve root paralysis after posterior cervical decompression

BackgroundC5 nerve root paralysis is a nonnegligible complication after posterior cervical spine surgery (PCSS). The cause of its occurrence remains controversial. The purpose of this study was to analyse the incidence of and risk factors for C5 nerve root paralysis after posterior cervical decompression.MethodsWe retrospectively analysed the clinical data of 640 patients who underwent PCSS in the Department of Orthopaedics, Affiliated Hospital of Qingdao University from September 2013 to September 2019. According to the status of C5 nerve root paralysis after surgery, all patients were divided into paralysis and normal groups. Univariate and multivariate analyses were used to determine the independent risk factors for C5 nerve root paralysis. A receiver operating characteristic (ROC) curve was used to demonstrate the discrimination of all independent risk factors.ResultsMultivariate logistic regression analysis revealed that male sex, preoperative cervical spine curvature, posterior longitudinal ligament ossification, and preoperative C4/5 spinal cord hyperintensity were independent risk factors for paralysis, whereas the width of the intervertebral foramina was an independent protective factor for paralysis. The area under the curve (AUC) values of the T2 signal change at C4-C5, sex, cervical foramina width, curvature and posterior longitudinal ligament ossification were 0.706, 0.633, 0.617, 0.637, and 0.569, respectively.ConclusionsMale patients with C4-C5 intervertebral foramina stenosis, preoperative C4-C5 spinal cord T2 high signal, combined with OPLL, and higher preoperative cervical spine curvature are more likely to develop C5 nerve root paralysis after surgery. Among the above five risk factors, T2 hyperintensity change in C4-C5 exhibits the highest correlation with C5 paralysis and strong diagnostic power. It seems necessary to inform patients who have had cervical spine T2 hyperintensity before surgery of C5 nerve root paralysis after surgery, especially those with altered spinal cord T2 signals in the C4-C5 segment.

Comparable study of alternative-level and all-level Arch mini-plate fixation for unilateral open-door laminoplasty

Objectives: To compare the clinical effect of alternative-level and all-level Arch mini-plate fixation in patients undergoing unilateral open-door laminoplasty. Methods: Clinical data of 134 patients administrated in the Peking University International Hospital for multistage cervical spondylotic myelopathy from March 2015 to March 2019 were reviewed retrospectively. There were 63 males and 71 females with an average age of (62±8) years and a mean disease course of (18±7) months (3-37 months). All the patients underwent posterior cervical unilateral open-door laminoplasty with Arch titanium plate fixation. All the patients were divided into two groups according to the different amount of titanium plates used during operation as follow: group A, Arch plates were fixed at the door sides of C3, C5 and C7 (n=68) and group B, Arch plates were fixed at the door sides of C3, C4, C5, C6 and C7 (n=66). Operation time, intraoperative blood loss, postoperative hospitalization days and the cost of consumables, the Japanese orthopaedic association (JOA) score, cervical dysfunction index (NDI), the rates of improved JOA score, cervical curvature index, C2-7 Cobb angle, cervical range of motion, sagittal diameter of vertebral canal, opening angle of laminar, hinges bone healing and surgery related complications (axial symptoms, C5 nerve root palsy, screw loosening, laminar re-closing, cervical kyphosis, etc.) were recorded and compared between the two groups. Results: There was no complications during the operation, and the mean follow-up was (20±8) months (14-48 months). There was no statistically significant difference between the two groups in terms of gender, age, course of disease and compression segments (all P>0.05). There was no statistically significant differences between the two groups in operation time, intraoperative blood loss and postoperative hospital stay too (all P>0.05). The cost of consumables in group A was (34 970±1 325) yuan, and it was (57 450±2 161) yuan in group B, the difference between the two groups was statistically significant (P<0.01). The JOA and NDI score were significantly improved 3 months and 1 year after operation in both groups (both P<0.05). The sagittal diameter of each segment of the spinal canal at C3, C4, C5, C6 and C7 were all significantly increased in both groups 3 months and 1 year after surgery (all P<0.05). The C2-7 Cobb angle and cervical curvature index were all significantly reduced in both groups 3 months and 1 year after surgery (all P<0.05). The cervical range of motion in both groups was significantly reduced 3 months and 1 year after surgery compared with that before surgery (both P<0.05). The range of motion of the cervical spine in group A was significantly higher than that in group B (P<0.05). The opening angles of C4 and C6 segment lamina in group A 3 months and 1 year after operation were significantly lower than those in group B (all P<0.05). At 3 months after the operation, the hinges healing rate of C4 and C6 in group B was significantly better than that of group A (both P<0.05). At 1 year after the operation, there was no difference in the hinges healing rate of C4 and C6 in the two groups (both P>0.05). There was no statistically significant difference in postoperative complications between the two groups (P>0.05). Conclusions: The safety and early clinical efficacy of alternative-level and all-level Arch titanium plate fixation in posterior cervical unilateral open-door laminoplasty are comparable, alternative-level fixation can effectively reduce the cost of hospitalization. The open Angle loss and lower early hinges healing rate of the non-fixed segment in the alternative-level fixed group does not lead to laminar re-closing in early period of post operation.

Clinical Anatomy of Human Donor C7 Nerve Roots for Surgical Transfer in Patients with Spastic Arm Paralysis

Contralateral C7 (CC7) nerve transfer has successfully restored hand function in patients with spastic hemiplegia from chronic central nervous system injuries. However, little is known about the morphology and anatomy of the donor C7 nerve root in patients undergoing this procedure. This study quantified intraoperative measurements of donor C7 nerve roots during CC7 transfer surgery for spastic hemiplegia in patients treated at a high-volume center to describe observed anatomical variations for successful direct anastomosis. A database of images from 21 patients (2 females, 19 males) undergoing CC7 surgery was searched for photographic data that contained a standard ruler measuring donor C7 nerve root length after surgical sectioning and before transfer. Two independent observers analyzed these images and recorded C7 nerve root diameter, length, and branch lengths. Mean (SD) values of donor C7 nerve measurements were length, 53.5 (8.0) mm; diameter, 5.1 (0.9) mm; branch length following surgical sectioning, 18.3 (6.3) mm. Right-sided donor C7 nerve roots yielded significantly longer branches compared with left-sided donor C7 nerve roots (P= 0.01). Other patient factors such as age, sex, or laterality of brain injury did not influence intraoperative anatomy. We report detailed intraoperative measurements of the donor C7 root during CC7 nerve transfer for spastic hemiplegia. These findings describe existing variation in surgical C7 nerve root anatomy in patients undergoing this procedure and may serve as a general reference for the expected donor C7 length in successful direct anastomosis.

Risk Analysis of Needle Injury to the Long Thoracic Nerve during Ultrasound-Guided C7 Selective Nerve Root Block.

Background and Objectives: Ultrasound (US)-guided cervical selective nerve root block (SNRB) is a widely used treatment for upper limb radicular pain. The long thoracic nerve (LTN) passes through the middle scalene muscle (MSM) at the C7 level. The needle trajectory of US-guided C7 SNRB pierces the MSM, therefore indicating a high probability of injury to the LTN. We aimed to identify the LTN and to investigate the risk of needle injury to the nerve during US-guided C7 SNRB. Materials and Methods: This retrospective observational study included 30 patients who underwent US-guided SNRB at the C7 level in a university hospital. We measured the maximal cross-sectional diameter (MCSD) of the LTN and cross-sectional area (CSA) of the C7 nerve root and assessed the injury risk of LTN during US-guided C7 SNRB by simulating the trajectory of the needle in the ultrasound image. Results: The LTN was detectable in all the cases, located inside and outside the MSM in 19 (63.3%) and 11 (36.7%) of cases, respectively. The LTN’s mean MCSD was 2.10 mm (SD 0.13), and the C7 root’s CSA was 10.78 mm2 (SD 1.05). The LTN location was within the simulated risk zone in 86.7% (26/30) of cases. Conclusion: Our findings suggest a high potential for LTN injury during US-guided C7 SNRB. The clear visualization of LTNs in the US images implies that US guidance may help avoid nerve damage and make the procedure safer. When performing US-guided C7 SNRB, physicians should take into consideration the location of the LTN.

Extracranial non-vestibular head and neck schwannomas: a case series with the review of literature

IntroductionSchwannomas are tumous that arise from Schwann cells. Schwannoma is one of the differential diagnosis for lateral neck swelling. ObjectiveIn this study, we aim to describe the incidence, presenting clinical features and management of extracranial, non-vestibular schwannomas of head and neck region, along with the review of the literature. MethodsPatients treated at our tertiary care hospital for head and neck schwannomas for the past 15 years were included in the study. A review of literature on the extracranial head and neck schwannoma was also done. ResultsTwenty-five cases were assessed in this study. Nineteen cases presented as a neck swelling during the initial evaluation. Vagus nerve was the most common nerve of origin, followed by the cervical sympathetic plexus. A rare presentation arising from brachial plexus C5 nerve root was also encountered. A few rare cases of schwannomas arose from the nasal cavity, paranasal sinuses, and oral cavity. Surgical excision was done in all the cases with histopathology suggestive of schwannoma. The nerve of origin of the tumor was identified in nineteen patients. Among them, 11 (58%) were from the vagus nerve, 7 (37%) from the cervical sympathetic chain, and 1 (4%) from the brachial plexus C5 nerve root. ConclusionA long-standing unilateral neck mass is the most common presenting complaint in head and neck schwannoma. The diagnosis is mainly based on clinical features and investigations such as imaging. The mainstay of treatment is complete surgical excision. The diagnosis is confirmed on the histopathological study after excision of the lesion. Due to the proximity of the tumor with the involved nerve, palsy may occur. Hence, an accurate preoperative diagnosis of schwannoma is essential.

Prognostic value of nerve ultrasonography: A prospective multicenter study on the natural history of chronic inflammatory neuropathies.

Nerve ultrasound is a promising new tool in chronic inflammatory neuropathies. The aim of this study was to determine its prognostic value in a prospective multicenter cohort study including incident and prevalent patients with CIDP and MMN. We enrolled 126 patients with CIDP, and 72 with MMN; 71 were treatment-naive. Patients with chronic idiopathic axonal polyneuropathy (CIAP; n=35) were considered as disease controls. Standardized neurological examination, questionnaires, and nerve ultrasonography were obtained at time of inclusion and 1-year follow-up. Nerve size development over time and correlation between nerve size and clinical outcome measures were determined using linear mixed effects models. Nerve size development over time was heterogeneous. Only in MMN was there a correlation between C5 nerve root size and deterioration of grip strength (-1.3kPa/mm2 (95% confidence interval [CI] -2.3 to -0.2). No other significant correlations between nerve size and clinical outcome measures were found. In MMN, presence of nerve enlargement at inclusion predicted deterioration of grip strength, and MMN patients with enlargement confined to the brachial plexus seemed to have more favorable outcomes. No other predictive effects of sonographic nerve size were found. The present study indicates that the natural course of nerve size development in CIDP and MMN is heterogeneous, and that the prognostic value of sonographic nerve enlargement is limited. It had some predictive effect in patients with MMN. Further research in specific subgroups of chronic inflammatory neuropathy is necessary to determine the usefulness of nerve ultrasonography after the diagnostic phase.

A Computed Tomographic Study to Document Anatomical Variations of First Cervical Vertebra: Prevalence, Classification and Possible Clinical Implications

Background - First cervical vertebra has different anatomical features as compared to other cervical vertebrae. It holds globe of skull and lacks body and spine. It is composed of 2 lateral masses linked by anterior and posterior arches. Posterior atlanto-occipital membrane is attached to posterior arch. Lateral edge of this membrane sometimes ossifies thus converting groove into canal. Consequently, neurovascular groove gets converted into a bony ring “ponticulus posticus”. It is considered as potential cause of neck pain and headache. Knowledge of this variation is important during procedures like instrumentation of atlas including C1 lateral mass screw placement which requires mobilization of C2 nerve root and screw insertion inferior to bony arch of atlas directly into lateral mass. In patients with ponticulus posticus, if not identified pre-operatively may give impression of wide bony arch for screw placement, which may result in vertebral artery injury due to a breach of this variation. Congenital defects of atlantal arch a developmental failure of chondrogenesis is a rare anomaly. These defects are a benign variation discovered incidentally. Detection of these anomalies is clinically important as they can cause acute neurologic deficits, which is associated with neck extension. Currarino et al proposed classification of posterior arch anomalies Type A Failure of posterior midline fusion of the 2 hemi arches. Type B Unilateral cleft. Type C Bilateral cleft with persistent dorsal part of arch. Type D Absence of posterior arch with persistent posterior tubercle. Type E Absence of entire posterior arch Objective Objectives this study is to find the prevalence of Ponticulus posticus Congenital anomalies of atlantal arch and classify them Material and Method- 250 computerized tomography (CT) head and neck in axial and sagittal sections from Picture Archiving and Communication System (PACS) of Dr RMLIMS, Lucknow was studied as CT is the best method to study the bony landmarks and any anomaly. Prevalence of variations was calculated. Data was analyzed statistically using SPSS version 21 by Chi-square test. Result- Prevalence of ponticulus posticus was 32.4%. Males had higher prevalence (20.4%) than females (12%). Incomplete ponticulus posticus (24.4%) was more than complete variant (8%). There was predominance of left sided ponticulus posticus(12% vs 8.4%) Deficient posterior arch was found in 9(3.6%) cases. 6 were of type A 3 were of type B. Conclusion- This study will help in determining cause of neurological deficit in patients due to presence of above variations. Significance Accurate evaluation of anatomic landmarks in patient with migraine or neck ache is important because changes in anatomy of atlas may be index pointing towards underlying disease process like vertebrobasilar insufficiency. Asymmetrical deviations of atlas in form, size, shape, and contour are often multiple and confusing. Therefore, they must not only be studied with care and precision and meticulously recorded. In our future project we plan to carry out computed tomographic study to find association of these variations in patients with migraine and cervical pain.

Postoperative complications of Goel-Harms C1-C2 screw-rod fixation technique for C1-C2 instability after C2 nerve sacrifice, a prospective study over two years follow up

BackgroundAtlantoaxial instability is mainly caused by trauma. C2 nerve is usually needed to be sacrificed for adequate exposure of the lateral mass and screw insertion. ObjectivesThis study aimed to investigate the clinical outcome of postoperative complications of C1 and C2 screw-rod fixation using the Goel-Harms technique for C1-C2 instability after sacrificing the C2 nerve root. MethodsAmongst forty patients with C1-C2 pathology, twenty-seven cases were enrolled into the study, then variables, including age, sex, primary pathology, operation duration, postoperative pain, paresthesia, anesthesia, and other specific conditions, were documented. Data analyzed by an expert biostatistician. p-value < 0.05 was considered significant. ResultsRegardless of gender, the most postoperative adverse effect was occipital anesthesia (81.5%). Most of the patients (63%) had both occipital pain and anesthesia one-month post-surgery. At 3- and 6-months post-surgery, occipital pain and anesthesia were seen in 40.7% and 14.8%, respectively. ConclusionThe most common postoperative adverse effect of C2 nerve root scarification after C1-C2 fixation is occipital anesthesia followed by occipital paresthesia and pain, which are reduced in severity over time.