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EDITORIAL
Year : 2018  |  Volume : 9  |  Issue : 2  |  Page : 81-82  

Is the symptom of cervical or lumbar radiculopathy an evidence of spinal instability?


Department of Neurosurgery, Seth G.S. Medical College and K.E.M. Hospital, Mumbai, Maharashtra, India

Date of Web Publication19-Jun-2018

Correspondence Address:
Prof. Atul Goel
Department of Neurosurgery, King Edward VII Memorial Hospital and Seth G.S. Medical College, Parel, Mumbai - 400 012, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcvjs.JCVJS_52_18

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How to cite this article:
Goel A. Is the symptom of cervical or lumbar radiculopathy an evidence of spinal instability?. J Craniovert Jun Spine 2018;9:81-2

How to cite this URL:
Goel A. Is the symptom of cervical or lumbar radiculopathy an evidence of spinal instability?. J Craniovert Jun Spine [serial online] 2018 [cited 2018 Nov 17];9:81-2. Available from: http://www.jcvjs.com/text.asp?2018/9/2/81/234742

Cervical or lumbar radiculopathy associated with pain in the nape of neck or pain in the low back is a common symptom and is related to degenerative spinal changes. Radiating pain is frequently associated with the symptom of tingling paresthesia and numbness and weakness related to affected dermatome. The question is if the radicular symptom is related to nerve root compression or is it related to segmental instability.

Association with disc protrusion or osteophyte formation in relationship to the traversing root and compromise of the dimensions of spinal or root canal is commonly incriminated to be the cause of radiculopathy. Radiological correlation with clinical symptoms guides the conduct of surgery. Claudication pain in the low back or legs on walking for a distance is a rather common symptom of lumbar canal stenosis. Exaggeration of pain in the nape of the neck or radiating pain in the hand on activity is also a frequent presenting complaint.

Decisions regarding the need for surgery and the levels of proposed surgical intervention are correlated with the extent and location of radiological deformation of the dural tube or neural structures. Spinal or root canal stenosis is treated by decompressive surgical treatment that involves laminectomy and/or foraminotomy. Decompressive lumbar or cervical laminectomy and/or foraminotomy have enjoyed the premier surgical place for decades and are still considered as gold standards of treatment. Multilevel spinal decompression has been associated with the possibility of development of delayed spinal instability. Laminoplasty has been identified to be effective and addresses both spinal decompression and stabilization. Single or multiple level anterior cervical or lumbar discectomy or corpectomy and stabilizing instrumentation are currently the more preferred surgical options aiming for both decompression and stabilization.

In the year 2010, we proposed that “vertical” spinal instability that is manifested at the facets is the nodal or primary point of pathogenesis of the process of spinal degeneration.[1],[2],[3] The superior facet telescopes on the inferior facet resulting in their “retrolisthesis.”[1],[2],[3] Lateral location of the facets and their oblique profile makes identification of instability difficult or impossible on static or dynamic imaging. We proposed that ligamentum flavum buckling, posterior longitudinal ligament buckling, and osteophyte formation and disc space reduction are all secondary processes to primary spinal instability. It was identified that distraction of facets by impaction of “Goel facet spacer” results in or has the potential for reversal of all the known and described features of spinal degeneration.[4],[5],[6] Posterior longitudinal ligament and ligamentum flavum can unbuckle, disc space height can be reversed toward normalcy, and there can be restoration of spinal and root canal dimensions. We identified that, in the long run, the osteophytes can regress.

As we matured in our understanding of the subject and our experience in the field increased, we realized that more than neural deformation or compression it is subtle spinal instability and repeated microtrauma related to instability that is the cause of symptoms.[7] Accordingly, we resorted to only spinal fixation as the mode of surgical treatment.[8],[9],[10] We used transarticular technique of spinal fixation and identified it to be safe, quick, and remarkably effective. We used only fixation in the treatment of both lumbar and cervical spondylotic disease. We adopted only fixation as a treatment for radiculopathy related to osteophytes and disc bulges encroaching on the spinal or root canal. In addition, we used only fixation of the spinal segments for prolapsed and herniated disc.[11]

Apart from radiological interpretation and clinical correlation, we identified that real-time physical assessment of status of the facets and the joint and manual manipulations of bones can identify unstable spinal segments.[12] It was observed that the radiological evidences might not demonstrate the instability of the spinal segments. It may be possible that the major instability of the spinal segment is not at the radiological spinal level demonstrated by osteophyte formation or disc bulge. Fixation generally included one or more levels above or below the site of radiological guide.

With our further experience in the field, it was realized that significant symptom of radiculopathy can by itself be an evidence of spinal instability even when there is no radiological abnormality in the form of osteophyte formation or disc bulge. Radiculopathy of significant intensity and for significant duration can by itself suggest the need for stabilization surgery even in the absence of radiological abnormality. Although radiological guides or evidences are usually present, it may be that there is no radiological evidence or demonstration of spinal instability. Wide exposure of the posterior elements of the spine that includes spinous process, laminae, and facets and the facetal articulation is necessary to identify the unstable spinal segments. Manual handling of the spinous process and other bones of the region can assist in determining the unstable spinal segments and guide the levels of spinal fixation.

Essentially, it means that radiculopathy is a manifestation of spinal instability. In the presence of symptoms, instability can be presumed to be present even in the absence of any radiological abnormality of the root or cord compression and appropriate surgical treatment of spinal stabilization can be instituted. Identification and stabilization of the affected spinal segments form the basis of treatment. In the absence of any radiological guide, the clinical guidance is obtained from the affected dermatome. Any kind of decompressive bone removal is not warranted or can be a negative surgical technique.

 
   References Top

1.
Goel A. Facet distraction spacers for treatment of degenerative disease of the spine: Rationale and an alternative hypothesis of spinal degeneration. J Craniovertebr Junction Spine 2010;1:65-6.  Back to cited text no. 1
[PUBMED]    
2.
Goel A. Facet distraction-arthrodesis technique: Can it revolutionize spinal stabilization methods? J Craniovertebr Junction Spine 2011;2:1-2.  Back to cited text no. 2
[PUBMED]    
3.
Goel A. Vertical facetal instability: Is it the point of genesis of spinal spondylotic disease? J Craniovertebr Junction Spine 2015;6:47-8.  Back to cited text no. 3
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4.
Goel A, Shah A. Facetal distraction as treatment for single- and multilevel cervical spondylotic radiculopathy and myelopathy: A preliminary report. J Neurosurg Spine 2011;14:689-96.  Back to cited text no. 4
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5.
Goel A, Shah A, Jadhav M, Nama S. Distraction of facets with intraarticular spacers as treatment for lumbar canal stenosis: Report on a preliminary experience with 21 cases. J Neurosurg Spine 2013;19:672-7.  Back to cited text no. 5
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6.
Goel A, Shah A, Patni N, Ramdasi R. Immediate postoperative reversal of disc herniation following facetal distraction-fixation surgery: Report of 4 cases. World Neurosurg 2016;94:339-44.  Back to cited text no. 6
[PUBMED]    
7.
Goel A. Not neural deformation or compression but instability is the cause of symptoms in degenerative spinal disease. J Craniovertebr Junction Spine 2014;5:141-2.  Back to cited text no. 7
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8.
Goel A. 'Only fixation' as rationale treatment for spinal canal stenosis. J Craniovertebr Junction Spine 2011;2:55-6.  Back to cited text no. 8
[PUBMED]    
9.
Goel A. Only fixation for lumbar canal stenosis: Report of an experience with seven cases. J Craniovertebr Junction Spine 2014;5:15-9.  Back to cited text no. 9
[PUBMED]    
10.
Goel A. Only fixation for cervical spondylosis: Report of early results with a preliminary experience with 6 cases. J Craniovertebr Junction Spine 2013;4:64-8.  Back to cited text no. 10
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11.
Goel A, Dharurkar P, Shah A, Gore S, More S, Ranjan S, et al. Only spinal fixation as treatment of prolapsed cervical intervertebral disc in patients presenting with myelopathy. J Craniovertebr Junction Spine 2017;8:305-10.  Back to cited text no. 11
    
12.
Goel A. Beyond radiological imaging: Direct observation and manual physical evaluation of spinal instability. J Craniovertebr Junction Spine 2017;8:88-90.  Back to cited text no. 12
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