Minimally Invasive Solutions for Neck Related Arm Pain in an Athletic Physician
Dr. Nitin Bhatia
This is a very pleasant 44-year-old right hand dominant male physician whose problems started approximately one to two years ago. They began with acute onset of right shoulder pain, followed by increased pain in the right side of the neck radiating down the arm into his fingers. This arm pain was associated with paresthesias and fluctuating weakness. At that time, he received two-three months of physical therapy with traction, which helped improve arm strength. However, he had recurrent episodes and flare-ups of severe right-sided neck pain accompanied by debilitating symptoms of pain radiating to the upper neck, right scapula, shoulder blade, forearm, then to his hand where he had numbness, tingling sensation, and weakness in the biceps and hand grip. He gradually lost motor strength in the right arm, which affects his ability to perform long radiology procedures. After working for two hours, he feels that the right arm is fatigued and weaker. He denies any balance problems and does not have similar symptoms on the left side. He reports a constant coldness in the right hand and rates his pain as being 8 on a scale of 1 to 10. The pain is directly related to activities. He continues to do cervical traction at home as he has his own cervical traction device. He has tried cervical epidural steroid injections that provide temporary and limited relief.
Physical exam showed a positive Spurling sign to the right with decreased right biceps reflex and 4/5 strength in the right biceps. Otherwise, his exam was normal.
Imaging studies showed degenerative disc disease at C5-6 with loss of disc height [Figure 1], and right sided C5-6 foraminal stenosis [Figure 2].
The numerous options were discussed with this knowledgeable patient. He chose to undergo surgical intervention due to his increasing symptoms and failure to respond to non-surgical treatment. The different options included anterior cervical discectomy and fusion of C5-6 versus cervical total disc arthroplasty versus posterior right C5-6 foraminotomy. The patient chose to undergo a minimally invasive foraminotomy.
The patient was positioned in the prone position using Mayfield head tongs. His head was elevated to decrease intraoperative bleeding. A minimally invasive approach to the posterior cervical spine was performed using gradually larger tubular dilators. An appropriately sized working tube was placed and locked in position using a positioning arm attached to the OR table. The position of the tube was confirmed on multiple views of fluoroscopy [Figure 3A and 3B].
The operating microscope was used for the remainder of the case. A right sided laminoforaminotomy was performed. Excellent improvement of the foraminal stenosis was achieved.
For pain management, oral Celebrex was used preoperatively. Liposomal bupivacaine was used to provide long acting local anesthetic relief.
The patient reported immediate relief of his preoperative painful radiculopathy. He was discharged home within 24 hours of surgery. A cervical collar was provided for comfort, but the patient chose not to use it after 72 hours. For six weeks, pushing, pulling, and lifting were limited to 10 pounds. After the six week period, all restrictions were eliminated. Two weeks after surgery, the patient returned to work, including interventional radiology.
Figure 1 - Preop lateral xray
Figure 2 - MRI axial C5-6
Figure 3a - Intraop AP
Figure 3b - Intraop lateral