MRI showing cervical spondylosis
A 34-year-old man presents with right-sided arm pain for 6 months. The pain radiates down his arm and is associated with occasional numbness and tingling into his right hand. MRI (shown in Figure 1) shows cervical spondylosis and a right paracentral disc herniation at C5-C6 resulting in severe right-sided foraminal stenosis. He has failed conservative treatment and is considering a C5-C6 cervical total disc replacement.
Submit your diagnosis to see full explanation.
The patient has cervical radiculopathy from a right-sided C5-C6 disc herniation. When conservative treatment with NSAIDS, physical therapy, and epidural injections fail, surgery is indicated. The goal of surgical treatment is to decompress the nerve root being impinged, which relieves radicular pain. The most common surgical procedure performed for cervical radiculopathy is an anterior cervical discectomy and fusion (ACDF). A drawback of an ACDF is the risk of developing symptomatic arthritis at the cervical levels adjacent to the fused level. Cervical fusion immobilizes the disc space, which creates more stress on the disc spaces above and below the fused level. This additional stress causes an increase in progressive arthritis at these levels. This condition, called adjacent segment degeneration, can require future surgery if symptomatic. This risk is especially important in young patients who undergo ACDF, as the lifetime risk of additional surgery is much higher than patients treated nonoperatively. Cervical total disc replacements were developed to help solve this problem. Cervical total disc replacements allow for normal motion of the disc space and have a lower risk of repeat surgery. Cervical disc replacements also have the benefit of a faster recovery after ACDF. A contra-indication to cervical disc replacement includes axial neck pain caused by facet arthropathy. Facet arthropathy, associated with radiculopathy, will continue or get worse with neck motion and therefore is better treated with an ACDF. Other contra-indications to cervical total disc replacement include disk space collapse, segmental instability, kyphotic deformity, and osteoporosis.1,2
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor-in-chief of the Journal of Orthopedics for Physician Assistants (JOPA).
1. Sinkov VA. Cervical total disc replacement. JBJS JOPA. 2013;1:7-10.
2. Orthobullets team. Cervical total disc replacement. Available at: https://www.orthobullets.com/spine/12279/cervical-disc-replacement. Accessed on April 17, 2018.