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About um sever radiculopathy. Um And I'm actually gonna keep this very brief um and illustrate to the point because most of it's pretty obvious and um most of it's anatomical and most of it's very logical and really, actually the important thing is getting to grips with myelopathy and what happens in myelopathy and why that's so important because you're more likely to get a myopathic type case in your the exam. And to be honest, myelopathy is far more important that you, you can miss ac arco radiculopathy with rarely without problems. Um But you can't really miss uh if you miss a myelopathy, then you leave someone with all sorts of problems. Um But Nick's gonna talk about that. So, um so radiculopathy is this is your definition when you're doing your exam, spinal nerve root dysfunction, causing Dermatal pain and paresthesia, myothermal weakness, reduced tendon reflexes. So, um that's your sort of classic definition. Uh but you have to differentiate between a radiculopathy and radicular pain. So, radicular pain is the pain that you get from a nerve being pinched. Um And it's that pain that goes along that nerve. Um but a radiculopathy is actually a neurological state when the conduction is blocked and that leads to muscle weakness and sensory changes. So they're two very slightly different things. They can coexist. Um, you can have one or you can have the other. Um So, you know, it's not quite as simple as pain weakness and paresthesia. Um, you know, they are slightly different things and it is, it's quite useful to remember that. Um So what I'm going to talk about briefly is the anatomy, why it happens? What, what patients tend to present with, uh and their history, um, the differentials that you always have to have in the back of your mind, how you investigate it, which is pretty obvious and the treatment options. Um And so what we're really talking about here is the cervical nerve roots from C three down uh to T one that form your brachial plexus, which I'm sure you will know perfectly for your exam. Um And uh it's kind of, we're kind of talking about the cervical nerve roots. We're not talking about um brachial plexus or anything that, you know, in those scaling muscles or distal to the nerve roots that causes problems. We're talking about where it comes off the cord and where it goes out um through the Foramen and oops, sorry. Um And so in a bit of an old picture, but you've got your, you've got the body, you've got your unconvertible joints, you've got the little pedicle here, which it's very different, the cerar um vertebra to um the thoracic and the lumbar, you've got your super articular process and you've got your inferior articular process underneath. You've got the lamina and the spinus process at the back and you've got, so the cord is in the middle and then the nerve root is exiting going anteriorly, um antral laterally. Um And when you look at it from the side, you have got the disc, you've got ii prefer to call the onco ver broad joint, the joints of Lusa, that's how I remembered it, but you can call it whatever you want. And that's that saddle bit of the vertebra and then you've got your uh facet joint at the back. Um And then you've got the arch of bone above and below. And all of that combines to form the intervertebral foramen. And what we're really talking about for cervical radiculopathy is anything that causes compression of the nerve root as it's leaving. Um So that's either within the canal or narrowing the neural foramen. And that, that can be anything that you would expect. It can be a disc prolapse. It can be overgrowth of either the facet joint or the joint of Luschka with osteophytes poking into the nerve or narrowing the foramen um flaval thickening that comes through, uh the just degenerate, change anything that causes a slip. Um So that can be um a degenerate slip or it can be due to a fracture. So a uni facet fracture um will have, I got that picture. Not yet. I will come to that um can cause narrowing of the um of the foramen and thus cause a radiculopathy and tumors or infections obviously can press directly on the nerve root as well. Um So it's the same sort of list of things that you would expect in thoracic or lumbar spine as well. Um And so when you're looking at the cervical spine, you're thinking about this bit here, the foramen and you see, you're gonna have a disc prolapse coming out and pressing here, a central disc bulge or thickening of the anterior longitudinal ligament or the post, sorry, the rather the posterior longitudinal ligament is not going to cause a radiculopathy unless it's over to where the nerve root is. Because obviously, if you pinch the cord itself, you don't tend to get pain, you get a myelopathy, which uh Mr Steele's going to deal with. Whereas if you're just that little bit more lateral with your bulge, then you start to catch the nerve root and it's the difference between an upper motor problem and a lower motor problem. Um So, and as soon as you get into the, you know, you're no longer in the upper motor zone, then you start to get pain and it can be anywhere along where that nerve ridge is going out. So it can be right within the canal, which is typically where you tend to see the disc prolapses just at the edge or it can be within the foramen itself, which is typically tends to be more the overgrowth of uh the facet joints and the unconvertible joints with their osteophytes. Um, uh going to the facet joint fractures or dislocations. You can see it's not very, you know, you can see from what happens with a, you know, disrupted facet joint or a perched or indeed a locked facet. The foramen is getting narrowed down significantly in the nerve. It's been putting under tension. I'm not gonna talk about fractures in this torque because it, you just know that it's one of the causes. Um and the treatment for that is a sort of whole separate torque which either you've had or you're going to have. Um So going back to talking about the pathophysiology, going back to this picture, um which I showed you about that joint of Luschka, the articular process when it gets a bit manky and old, you get these disc osteophyte spurs sticking back into that lovely foramen, which is no longer nice and round and the nerve root gets pinched. So it's quite easy to understand why people can get pain, but it doesn't always just come from direct compression. You can also get a chemical radiculopathy um due to the site of the sort of proinflammatory cytokine releases. You don't have to know all of these, but just know that when you get an annular tear and that can happen anywhere in the spine, you get a release, a cytokine release. Um and that, that pro inflammatory release can cause neural irit. Um So you don't always necessarily have to have direct compression. So that needs to be at the back of your mind as well. And so the classical presentation of a CVA radiculopathy is that, is that pain um and pins and needles or a horrible cold feeling or that they describe sometimes with weakness, but a patient will rarely describe that. And that's your sort of textbook type um history the way that they present. But the reality as you guys will know from anyone that does our spine clinics is that patients can really present any way whatsoever. They can talk about the fact that they can no longer use their hand properly. They may be very, they cannot really describe the pain that they're getting and it doesn't always fit what we describe as a classic radicular pattern. Um The history will also give you lots of clues as to the sorry, the potential cause of your radiculopathy. Um So, you know, if it's a rapid onset, then it's more likely to be a disc prolapse. Whereas if it's gradually just an annoying nag a gnawing pain that is getting more and more interfering with their quality of life, then that's more likely to be more be more due to a progressive degenerate type phenomenon phenomenon such as you know that overgrowth of the facet joints, narrowing the foramen, it, you kind of want it to be unilateral bilateral radiculopathy in the neck is a, is problematic because if there's a central problem in the neck, it's more likely to cause myelopathy than it is to cause a radiculopathy. So really, it does want to be unilateral and so if it's bilateral, then you've got to start thinking a little bit more, why is this going on? What else might it be? Um, er, you're looking for any clues in your history about that might guide you towards the potential cause of it. And so that's the preceding symptoms, whether they've hurt their neck in any way at all, what they do for a job, lorry drivers, people that sit and stare at screens all day long, um, these are, again, will give you clues and then you're also watching out as you are with any spinal patient for the yellow flags because a lot of the patients that come in with pain, um, don't really actually have, um, a sort of a genuine problem. So the distribution of the pain is quite useful. Um, you have to really push a patient. So when I'm teaching the medical students that come to our clinic, I really do go on about, you know, you learn about Socrates, don't you, when you're at medical school and the site and the origin and the radiation? But in, in radiculopathies, be it cervical or lumbar, you, it really is important. You want to know where the pain goes. So when the patient says it goes down to their fingers, you want to know which fingers does it go down to? Is it the ulnar border? Is it the radial border? Is it in the middle? Is, is, is the, are the pins and needles on the back of the hand? Does the pain come down, you know, through the, the triceps or is it in the mobile w in the forearm? Because that all gives you a clue as to which nerve root might be, um, being pinched. And that's particularly important when you think about a 70 year old patient, because you can bet your bet your money on the fact that when you look at the MRI scan of the neck of somebody who's 70 you will see foraminal narrowing at multiple levels because wear and tear in the human spine is inevitable. We don't, we don't get away without it. And so the actual, the way the patient describes the pain can point you towards which of the nerve roots that's being pressed is the one that might be the source of their pain. Because the narrowing of the foramen that happens with the generic change is a very gradual thing and the nerves seem to sort of get used to it. So when you look at an MRI scan of someone who's 70 you'll see a very tight Foramen and um they may have no symptoms from it at all. But if I had a disc prolapse that over the space of a day, pressed my nerve that tightly, I'd be in absolute agony with lots of dysfunction. So nerve roots seem to be able to accommodate um gradual narrowing. So they're not just because you see it on the scan, it doesn't always mean it's the C cause. And so the history really is very important. Um You're also looking out for clues in the history of the differentials. Um I've lost track of the number of patients that have come in with, been referred for a CVA radiculopathy because they're 65 years old, they've got some frontal narrowing on their MRI scan, but then you actually examine them, you talk to them in history and they say they can't lift their shoulder up or they've got a, you know, symptoms far more consistent with a frozen shoulder or elbow arthritis or tennis, elbow or carpal tunnel syndrome. Um One thing to always, always have again at the back of your mind is parsonage turner, um that um brachial neuritis, the inflammation. Um and the history for that tends to be quite classic, a sort of severe sudden onset burning sensation, sometimes associated with weakness. Um And it's a sort of post viral inflamma, often a postviral inflammation of the brachial plexus and nothing to do with the cervical nerve roots. And then as Nick will talk about. You've always got myopathy at the back of your mind. Um examination. You, you've got to be good at your neurological examination. Um And it's really easy to be quick and slick at doing it and testing each nerve root. You've always got to remember that your biceps is C 56. And deltoid is C five, there isn't really a sort of just an isolated C six nerve root. I tend to test dorsal wrist extension. But you can find one textbook that tells you that that is um uh C six. Another one that will tell you that that's C seven. triceps is very important because um you want to know whether they've got that power cos triceps is probably more important than the biceps in terms of everyday function, pushing out of a chair. Um And obviously anything that affects the hand can be um er very debilitating. There are some specific tests. So there is the Spurling test where you extend the neck slightly. So you're just effectively, the maneuver is to tilt is to compress the foramen, extending the neck, rotate it towards the side where the pain is put a little bit of load on. I don't tend to push down too hard. I tend to sort of flex the neck over laterally and you want to know whether that recreates their pain or their paresthesia. And it's quite when you see one that's positive, you're like, OK, because they really do. You tilt their head over and you just push it down and their symptoms, they feel it, they can feel the parasthesia are coming. It's a bit like when you do a, a Phaen or a Durkin's for a carpal tunnel, you know, it's a similar type process. You're exaggerating the narrowing that's already there. Um, but you can also do the reverse, which is the shoulder abduction or the, the, I didn't even know this was called the Bacoti sign until I wrote it. So I wouldn't expect you to know it. And, and what you're doing is you are taking the tension off the nerve root. So, and if you imagine that, say you've got a disc prolapse sitting under the nerve root here and when your arms down, the nerve roots draped over that, and there's a degree of tension in the nerve root, it's going to cause the pain. So when you then abduct the shoulder and sort of put patients tend to sleep like this with their elbow up and their hand behind their head, cos it's the only comfortable position they can get in. Um What you've done is you've reduced that tension. So the nerve root is no longer raped and pulling over the thing that's causing it the pain. So it tends to work well for things like disc prolapses or disc osteophytes that are pinching the nerve, but it doesn't have an awful lot of impact on somebody who's got a more chronic foraminal narrowing um diagnosis as always correlation of history. Um And then the MRI and the CT findings, um nerve conduction studies are useful. They're very useful at excluding differentials. And a good neurophysiologist can sometimes say to you, look, you've got a, a preganglionic C six type problem here. Um In a pure radiculopathy, the the sensory part should be normal because most of the things that we're talking about that can, can, can cause a radiculopathy um happen proximal to the dorsal root ganglion. So in theory, the sensory part should be left intact, but often it's a mixed picture. And then if there's any doubt at all, you ask someone far clever than us orthopods, you ask a neurologist to take a look at it. Um management as always conservative injection surgery, um medication. If it's an acute episode, then just trying to get, you know, dealing with that cytokine rush, um nonsteroidals for a couple of weeks, often very good. Go up the pain ladder. The role of amitriptyline gabapentin, pregabalin is debatable. You will be. Well, if you've been in a spine clinic, you know that we do, they do get prescribed. But you've got to remember that neuropathic medication is actually only really licensed for pain from things like uh shingles, um where it's true, neuropathic pain radiculopathy is not neuropathic pain. And hence, um these medications aren't as effective and they're probably, we're almost using them off license Um, but if you asked me if I had right arm radicular pain and there is a sort of 60% chance that gabapentin may make a difference to it. Then I'd take the gabapentin. I've seen how, how painful an acute radiculopathy can be for patients. So it's worth trying physiotherapy. Um, oops, that's not flexing the lumbar spine wrong slide there. Sorry. Um uh physiotherapy does have a role in the acute setting and also in the more chronic pain type setting, anything that normalizes the neck motion is very important. And the other thing is that shoulder and neck pain often coincides and when a patient has a radiculopathy, they don't move their arm normally. And so they don't move their shoulder normally. And so it, it can be very, not very common, but it is not uncommon to find patients developing uh an adhesive capsulitis after a radiculopathy. So their, their radiculopathy starts to settle down, but because they haven't moved their shoulder normally, they develop an adhesive capsulitis. Um And so keeping the shoulder moving normally is absolutely crucial er to their recovery. So that's again, one of the roles of physiotherapy. It's not just about the neck motion, it's about the shoulder motion and injections. Uh There are a few people who will very bravely do an over injection with X ray guidance. I don't, I wouldn't even consider it because of the risk of paralysis and all the um plumbing in the neck So CT guided and average injections, uh, to me is the only option. Um, if you're going to do an injection and it's really indicated when the patient's got pain that isn't getting better and it hasn't responded to conservative management, uh, for a couple of months. The other thing it's good for is in somebody where you just can't get on top of the pain, um, where, you know, even four weeks of pain, they're in absolute agony, even though there's a very good chance that it's going to get better. Um You know, if you're having an injection to temporarily reduce the pain whilst the body does its repair job, I think it's very reasonable. Um It's important that they're not getting a progressive neurological deterioration. So one of the things that can be an indication for surgery is if somebody obviously prolonged pain, not responding to conservative measures hasn't well, has had a brief um response to an injection, but then the symptoms have come back, sorry, just going back to injections. The only other thing to say about the indications for an injection is that a, you can use it for pain relief. But b you can use it from a diagnostic point of view because if a patient's got a very mixed picture of shoulder arthritis, right, you know, arm pain paresthesia, and you want to know how much of a role the foraminal narrowing in the neck is playing in their symptoms. Then doing a CT guided injection can give you clues because if even for that, for the 1st 12 hours at the local anesthetics around the nerve root, their symptoms go disappear. Then even if their symptoms come back after 24 hours, you know that you can potentially replicate that with surgery. So the goal of surgery, whatever, you know, we're really talking about either degenerate changes here or disc prolapse is not fractures and tumors um is to create space. And so if you create space for that nerve, you've got a sort of 80 85% chance of getting rid of their symptoms. But there's a sort of 10 twen 15 to 20% chance. It doesn't matter how perfect the surgery is that the nerve root isn't going to respond that that chronic uh radiculopathy has developed. And it's, you know, we don't know an awful lot about it, but we know enough the, what we do know is that the nerve roots undergoing a AAA sort of profound change um down at a cellular level and in the way that they feedback the information to the brain and it's not dissimilar to a sort of chronic regional pain type picture. Um Options for surgery is essentially anterior, posterior, anterior. You're talking about um a er, anterocervical decompression and fusion where you're going in from the front through the disc, removing the osteophytes to open up the foramen. Um It's use, it's quite useful to say that if you're doing your anterior approach, which I'm not going to describe in detail today. But you should all know it. If you, if somebody's got a right arm radicular pain, you would typically approach, you would do a left sided approach. Even though it's a midline procedure, it's easier to get to the right foramen from the left and vice versa. So you can put in a cage, you can put in a standalone cage, you can put in a cage with screws, you can put it in a cage with a plate. However, one of the consequences of having a cage, which which Nick might talk about is that you're fusing the bone together. And so um the disc above and the disc below are then doing the work of the disc in the middle. And so there is that 10% chance of getting increasing adjacent segment problems that can replicate the symptoms. And so those patients go on to need things. So one of the other options at the moment out there, which is there's still a bit a degree of debate. And I think if you're mentioning in the exam, it's important to acknowledge this is a um disc replacement. So this is the mob C, which is the one that I use and I will tend to use it in young patients um where they've got a lifetime ahead of them and you want to try and preserve a little bit of motion. So you're offloading the segments above and load, offloading those adjacent segments. Um You wouldn't put it in an 80 year old who's got an arthritic spine because it's not going to work, it's not going to have any impact and you're not really saving them very much. So, it tends to be for younger patients where there isn't a lot of degenerate change, um where you're not having to remove lots of osteophytes. So it's great for disc prolapses. Um uh Because if you have to remove lots of osteophytes, it's going to fuse up anyway. Uh But the there is some debate about the fact that it's just an expensive fusion because three or four or five years down the line, a lot of them aren't moving anymore. Um Posteriorly, you're talking about a foraminotomy, which can be single level and multilevel where you're removing that bone. Um That overlies the nerve, the nerve root from the back and to open up space. Sometimes you, you know, some of the neurosurgeons will move those nerve roots out of the way to get it to a disc prolapse. There are pros and cons to this, obviously, you're not fusing it. Um but you are disrupting the facet joint, you're increasing the facet joint type, wear and tear and pain and it's a much more morbid operation um going posteriorly. So, before I hand over to Mister Steele, um who's going to talk to you about how he does spinal operations Um, I just wondered if there were any questions.