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The nerves to the cervical and thoracic vertebrae were traced in 10 serially sectioned human embryos. It was found that the vertebral bodies receive nerve fibres from the trunks of the spinal nerves, anterior branches and meningeal branches of the spinal nerves, and from the sympathetic trunks. Slender twigs from the trunk of the spinal nerve arise close to the spinal ganglion and terminate in the posterior and lateral surfaces of the vertebrae. Fibres from the anterior branches of the spinal nerves terminate in the lateral and anterior surfaces of the vertebrae. Thin rami from the sympathetic trunk reach the anterior surface of the vertebrae.

Object: Approaching the C2-3 disc level is challenging because of its location behind the mandible and the vital neurovascular structures overlying the area. The purpose of this study was to illustrate in a stepwise fashion the microsurgical anatomy of the submandibular approach to the C2-3 disc., Methods: Ten adult formalin-fixed cadaveric specimens (20 sides) were studied. Particular attention was paid to the structures limiting the exposure. The authors measured the distance between the inferior border of the mandible and the marginal mandibular branch of the facial nerve running inferior to the mandible, the distance between the horizontal segment of the hypoglossal nerve and the hyoid bone, and the distance between the horizontal segment of the hypoglossal nerve and the mandible. They compared the location of the superior laryngeal nerve with regard to the submandibular and the standard Smith-Robinson approaches. A clinical case illustrating the usefulness of the surgical technique in this region is presented., Results: The mean distance between the inferior border of the mandible and the lowest point of the marginal mandibular branch of the facial nerve was 6.7 +/- 1.69 mm. The hypoglossal nerve's mean distance above the hyoid bone was 8.4 +/- 1.78 mm and below the mandible was 19.6 +/- 6.39 mm. The internal branch of the superior laryngeal nerve, with respect to the cervical spine, always entered the thyrohyoid membrane just inferior to the C-3 vertebral body. The superior laryngeal nerve was found to be an impediment to approaching the C2-3 disc through the standard Smith-Robinson approach., Conclusions: The submandibular approach provides excellent exposure, with a perpendicular view of the C2-3 disc level. This approach is one of the options to be considered when dealing with high cervical pathologies.

Twenty-four cadavers (48 sides) were used to clarify the terminal insertional segment and communications of the vertebral nerve in the cervical region under a surgical microscope. After displacing the prevertebral muscles (longus colli and longus capitis) laterally, the ventral parts of the transverse foramen of vertebrae (from C2 to C6) were removed, and the insertional segment and communicates of the vertebral nerve surrounding the vertebral artery were observed. The results showed: (1) the vertebral nerve ascended along the ventral or mediodorsal vertebral artery and terminated mainly at C3 (22/36 sides) but not terminated at C4 or C5 only; (2) the superficial communicates from the cervical sympathetic trunk ran in a proximal and distal direction when the fibers entered the anterior branches of the cervical nerves. The fibers running to the proximal direction communicated with the vertebral nerve in the part of transverse foramen; (3) motor and/or sensory rami supplying the prevertebral muscles, corpus vertebrae and intervertebral discs could pass through an "arched-shaped" fiber bundle on the ventral surface of the vertebral artery. In conclusion, the vertebral nerve and the fibers surrounding the vertebral artery could be considered as a stable deep pathway of cervical sympathetic nerves. The deep pathway (vertebral nerve and its branches) with the superficial pathways (cervical sympathetic trunk and its branches) formed a sympathetic nervous "plexus" in the cervical region. This sympathetic nervous "plexus" may be involved in the effects of cervical ganglionic blockade.

Objective: The aim of the study was to investigate if changes in head repositioning accuracy (HRA), and standing balance could be evoked by unilateral facet nerve blockade (FNB) or spinal manipulative therapy (SMT)., Methods: This time series research study (n = 6) was chosen because of the viability of the experiment, sample characteristics, and small sample size. Cervical proprioceptive functions were assessed by exploring HRA and static posture by computerized posturography. All participants were subjected to 2 interventions, unilateral FNB using local anesthetic and SMT., Results: No significant trends were seen in the subjects over the period of the study. All measurements were taken approximately 3 weeks apart. Visually, it was detected that most of subjects appeared to be greatly affected by the FNB, thus, increasing their deviation from the center point of measurement in extension and flexion movements. When comparing the changes with respect to the baseline after SMT, all subjects showed some differences, though there was a great deal of variation between the subjects. These trends were also seen when comparing the changes from baseline measurements to those after FNB., Conclusions: Data from this time series research design suggest there was no uniform response to unilateral FNB or to SMT. However, differences indicate that there may be important effects of unilateral FNBs for some of the HRA aspects measured. Balance testing using computerized posturography did not show clear differences between baseline assessments and interventions. A future larger clinical study to detect changes in HRA evoked by unilateral FNB or SMT appears feasible.

Pain in patients who have cancer can be caused by direct effects of the tumor or by complications of treatment, or it can be unrelated to the disease or its treatment. This article discusses interventional pain procedures in the treatment of head and neck pain as they relate to malignancies and cervicogenic headache and neck pain.

Preganglionic nerve root avulsion precludes sensory return, but motor regeneration is possible with sparing of motoneurons. The effect of GM-1 ganglioside treatment was studied with parallel evaluation of the autoimmune response. Rats (N=64) received injections of either GM-1 ganglioside or saline for 30 days following either C5 root avulsion or a hemilaminectomy control. The Bertelli grooming test assessed functional return. Before sacrifice at 5 months, serum was collected for enzyme-linked immunoabsorbent assay testing. Only 44% of the rats treated with ganglioside had a good functional outcome compared with 50% for controls. Although 17% of the rats developed anti GM-1 antibodies, there was no functional or histological evidence of neuropathy in any of the rats. We conclude that ganglioside treatment did not enhance recovery from peripheral nerve injury. Although an immune response was present in some rats, no overt signs of neuropathy were observed.

The neck torsion test (NTT) can be used to evaluate the cervico-ocular reflex (COR). We think there are two main reasons why NRT has failed to gain general acceptance in clinical practice: the test does not fully exploit the somatosensory examination potential, and electronystagmography has been most commonly used but is inferior to videonystagmography for a very low-amplitude nystagmus. These considerations have led us to develop a modified neck torsion test (mNTT) with three-dimensional video-oculographic (3D-VOG) recording. Sensors on the video glasses enable three-dimensional and continuous registration of the head position. Horizontal, vertical and rotatory eye movements are determined in six different head-body positions (right/left head tilt, ante/retroflexion of the head, and right/left body rotation). The basis for assessing the mNTT is described in detail. We used the mNTT to examine prospectively compensated, vestibularly deficient (n = 52), and cervically deficient (n = 93) patients with vertigo against a control group (n = 22). Our results show that upbeat-nystagmus (UBN) significantly differentiated the groups. This occurs most frequently in the tonic analysis phase of head inclination and reclination. UBN is differential-diagnostically discussed on the basis of these examination findings, and its cervical origin is elucidated with the aid of model conceptions. We conclude that our modified NRT is an improved instrument for COR determination. A suspected cervical somatosensory reduction warrants testing particularly for UBN.

Background: Radiofrequency neurolysis is a common technique used in the treatment of chronic pain, particularly facet (zygapophyseal joint) arthralgia. A needle-like cannula is insulated except for the exposed active tip, which is positioned as parallel and adjacent as possible to the targeted nerve branch. Via an inserted probe connected to a radiofrequency generator, energy flowing from the tip of the cannula creates a heat lesion in the 80 - 85 degree Celsius range mostly about the length of the exposed active tip and in proportion to the diameter of the probe. The common active tip lengths used for neurolysis are 5mm or 10mm. The cannulae are FDA approved. The manufacturer advises physicians not to bend or otherwise modify a cannula prior to use. The cannulae are available straight or bent, sharp and blunt. The technique is guided under C-arm fluoroscopy. X-rays passing through the patient demonstrate in 2 dimensions the projected relative radio-opaque bony landmarks and the metallic cannula. Most currently available cannulae are uniform in their radio-opacity from tip to hub. The physician must make an educated guess as to the portion of the cannula that will be making the lesion in relationship to the bony landmark., Objective: A new radiofrequency cannula with a radio-opaque marker (ROC) delineates the proximal end of the active tip. The cannula was used in a phantom model. Images were reproduced with explanation of the potential advantage of the new device., Result: The marker on the new cannula was visible and did help delineate the active tip as well as its orientation. It was also helpful in making sequential lesions at the same nerve using a "tip to tail" repositioning technique., Conclusion: The ROC did represent an improvement over standard cannulae to optimize visualization of cannula and thus lesion placement using a phantom model. The applications described were only for conventional or "hot" RF.

Horner syndrome due to injury to the cervical sympathetic trunk (CST) is a very rare complication of anterior cervical decompression and fusion (ACDF). We have not mentioned the possibility of Horner syndrome as a postoperative complication in patients before surgery. We present a patient with Horner syndrome after ACDF and discuss the anatomical background of the CST and the causes and preventative measures against postoperative Homer syndrome. A 48-year-old man presented with disturbance of fine movement and reduction of grasping power in the right hand. MRI revealed osteophytes and a prolapsed disc compressing the spinal cord at C5-6 and C6-7. Two-level ACDF with inclusion of titan cages was performed via a right-sided exposure. Anisocoria (right > left) and right blepharoptosis were observed immediately after surgery. Postoperatively, disturbance of fine movement was resolved. Japanese Orthopaedic Association (JOA) score improved from 12 to 16. Horner syndrome disappeared at 6 months after surgery. The CST runs 10-15 mm lateral to the medial edge of the longus colli muscle (LCM) and exists in the loose fascia and approaches most medially at C6. During the decompressive procedure under microscopic viewing, the right blade of a retractor was found to come out of the medial edge of the LCM on the level of C6. It is postulated that the blade injured the right CST. Knowledge of the anatomical relation between the CST and the LCM is very important to avoid Horner syndrome in ACDF. The tip of a retractor blade must be placed between the medial edge of the LCM and the vertebral body.

This study was undertaken to investigate any relationship between sensory features and neck pain in female office workers using quantitative sensory measures to better understand neck pain in this group. Office workers who used a visual display monitor for more than four hours per day with varying levels of neck pain and disability were eligible for inclusion. There were 85 participants categorized according to their scores on the neck disability index (NDI): 33 with no pain (NDI<8); 38 with mild levels of pain and disability (NDI 9-29); 14 with moderate levels of pain (NDI30). A fourth group of women without neck pain (n=22) who did not work formed the control group. Measures included: thermal pain thresholds over the posterior cervical spine; pressure pain thresholds over the posterior neck, trapezius, levator scapulae and tibialis anterior muscles, and the median nerve trunk; sensitivity to vibrotactile stimulus over areas of the hand innervated by the median, ulnar and radial nerves; sympathetic vasoconstrictor response. All tests were conducted bilaterally. ANCOVA models were used to determine group differences between the means for each sensory measure. Office workers with greater self-reported neck pain demonstrated hyperalgesia to thermal stimuli over the neck, hyperalgesia to pressure stimulation over several sites tested; hypoaesthesia to vibration stimulation but no changes in the sympathetic vasoconstrictor response. There is evidence of multiple peripheral nerve dysfunction with widespread sensitivity most likely due to altered central nociceptive processing initiated and sustained by nociceptive input from the periphery.

Several techniques have been described for selective nerve root blocks. We describe a novel 'two-needle technique', performed through the postero-lateral route with the patient in lateral position under C-arm guidance. The aim of the current study is to highlight the effectiveness and safety of cervical selective nerve root block for radiculopathy using this technique. We present results of a retrospective 2-year follow-up study of 33 injections carried out on 33 patients with radiculopathy due to cervical disc disease and or foraminal stenosis using this procedure. Patients with myelopathy, gross motor weakness and any other pathology were excluded. The outcome was measured comparing 'Visual Analogue Score' (VAS) and 'Neck Disability Index' (NDI) before the procedure with those at 6 weeks and 12 months after the procedure. Thirty patients were included in the final analysis. Average pre-operative VAS score was 7.4 (range 5-10), which improved to 2.2 (range 0-7) at 6 weeks and 2.0 (range 0-4) at 1 year and the mean NDI score prior to intervention was 66.9 (range 44-84), which improved to 31.7 (range 18-66) at 6 weeks and 31.1 (range 16-48) at 1 year. The improvements were statistically significant. Patients with involvement of C6 or C7 nerve roots responded slightly better at 6 weeks with regards to VAS improvement. Mean duration of radiation exposure during the procedure was 27.8 s (range 10-90 s). Only minor complications were noted-transient dizziness in two and transient nystagmus in one patient. Our 'two-needle technique' is a new, safe and effective non-surgical treatment for cervical radiculopathy.

Object: The purpose of this cadaveric study was to explore a modification to the Bertrand procedure for the treatment of spasmodic torticollis, namely the denervation of the levator scapulae (LS) muscle for laterocollis., Methods: The authors performed a series of 9 cadaveric dissections. Five were done to identify the anterior innervation of the LS, and the remaining 4 were to identify the tendinous insertions of the LS onto the lateral masses of the cervical spine via a posterior approach. The nerve supply to the LS from the anterior divisions of the C-3 and C-4 nerve roots and the contribution from the dorsal scapular nerve were identified over the anterior surface of the muscle., Results: The C-3 and C-4 nerve root branches were situated within 2 cm of each other and inferior to the punctum nervosum. The dorsal scapular contribution was clearly identified in 2 cadavers. Selective denervation of this muscle is possible through the same posterior triangle incision used for denervating the sternocleidomastoid muscle of its accessory nerve branches. This approach will be helpful in patients with laterocollis contralateral to the direction of chin turning. The authors compare this approach to the posterior approach for sectioning the insertions of the LS muscle onto the C1-4 posterior tubercles. The latter approach is appropriate for ipsilateral laterocollis., Conclusions: The posterior triangle approach for denervating the LS muscle is a safe and easy addition to the Bertrand procedure and can be helpful in selected cases of torticollis with a laterocollis component.

Morphological features of ansa cervicalis and phrenic nerve were studied in 106 cadavers. Ansa cervicalis was located medial to the internal jugular vein in 63% (medial type) and lateral to the vein in 33.7% (lateral type). Ansa cervicalis was derived from a combination of C1-C4 spinal segments, with C1-C3 being the most frequent pattern (87.5%). In >60% the ansa was bilaterally symmetrical. The distribution of medial and lateral types was equal on left and right sides of the body. The segmental composition of the inferior root was higher in the medial type and also on the left side of the body. In the lateral type the branches that formed the inferior root frequently (75%) formed a common trunk before joining the superior root, but in 74.8% of the medial type they joined the superior root independently. The phrenic nerve was derived from C4 and C5 in 52%. The C4 segment was present in the phrenic nerve in all cases except one. Additional phrenic components that pass anterior to the subclavian vein were defined as accessory phrenic nerves and found in 28.7%, while those passing posterior to the same vein were defined as secondary phrenic nerves (19.8%). Most of the accessory phrenic nerves contained a C5 segment and the nerve to subclavius was the commonest source. Various relationships between the ansa cervicalis and the phrenic nerve are investigated and, based on these findings, two separate classifications for the two nerves are suggested.

We report a case of Horner's syndrome (HS) occurring as a complication after total thyroidectomy. Horner's syndrome is characterized by myosis, eyelid ptosis, enophthalmos, and lack of sweating, with vascular dilatation of the lateral part of the face, caused by damage of the cervical sympathetic chain. We found only 28 other reports of HS developing after thyroidectomy, and only seven of these patients recovered completely. Of the 495 thyroidectomies performed at our hospital between 1997 and 2007, only one (0.2%) was complicated by the development of HS. The patient was a 35-year-old woman who underwent total thyroidectomy for Basedow-Graves' disease. Horner's syndrome manifested on postoperative day 2, but without anhydrosis or vascular dilatation of the face, and the symptoms resolved spontaneously 3 days later. The possible causes of HS after thyroidectomy include postoperative hematoma, ischemia-induced neural damage, and stretching of the cervical sympathetic chain by the retractor. The prompt and complete recovery of this patient suggests that the cervical sympathetic chain was damaged by retractor stretching.

Occipital neuralgia (ON) presents a diagnostic challenge because of the wide variety of symptoms, surgical findings, and postsurgical outcomes. Surgical removal of the second (C2) or third (C3) cervical sensory dorsal root ganglion is an option to treat ON. The goal of this study was to evaluate the short-term and the long-term efficacy of these procedures for management of cervical and occipital neuropathic pain. Twenty patients (mean age 48.7 years) were identified who had undergone C2 and/or C3 ganglionectomies for intractable occipital pain and a retrospective chart review undertaken. Patients were interviewed regarding pain relief, pain relief duration, functional status, medication usage and procedure satisfaction, preoperatively, immediately postoperative, and at follow-up (mean 42.5 months). C2, C3 and consecutive ganglionectomies at both levels were performed on 4, 5, and 11 patients, respectively. All patients reported preoperative pain relief following cervical nerve blocks. Average visual analog scale scores were 9.4 preoperatively and 2.6 immediately after procedure. Ninety-five percent of patients reported short-term pain relief (<3 months). In 13 patients (65%), pain returned after an average of 12 months (C2 ganglionectomy) and 8.4 months (C3 ganglionectomy). Long-term results were excellent, moderate and poor in 20, 40 and 40% of patients, respectively. Cervical ganglionectomy offers relief to a majority of patients, immediately after procedure, but the effect is short lived. Nerve blocks are helpful in predicting short-term success, but a positive block result does not necessarily predict long-term benefit and therefore cannot justify surgery by itself. However, since 60% of patients report excellent-moderate results, cervical ganglionectomy continues to have a role in the treatment of intractable ON., ((c) 2008 S. Karger AG, Basel)

A total of 73 patients with obstetric brachial plexus palsy and extremity shortness were evaluated clinically, electrophysiologically, and with cervical magnetic resonance imaging. Patients were separated into groups according to age and the level of lesion. The differences of the length of the humerus, ulna, radius, and the second and fifth metacarpal bones were significant between the involved and uninvolved extremities. The difference in shortness increased in relation to the age of the groups and stabilized to approximately 10% in the groups aged 4 to 8 years and 8+ years. A significant relationship was observed between bone length differences and lesion levels. Differences in bone lengths were statistically significant in patients with avulsion in the group aged 8+ years. Extremity shortness appears to be related to avulsion and the level of lesion. The effect of avulsion on extremity shortness gradually increases with age. Finally, root avulsion can be an important factor in extremity shortness of obstetric brachial plexus palsy patients.

Study Design: A test-retest design evaluated stability as well as within and between day reliability., Objective: The study aimed to define optimum protocols for the cervical joint position error (JPE) and cervicocephalic kinesthesia tests and to investigate association between performances in the tests., Summary of Background Data: The cervical JPE and cervicocephalic kinesthesia tests are proposed as measures of cervical proprioception. However, there has been little investigation of the number of trials needed to obtain stable and reliable estimates of performance. Both tests have potential limitations in reflecting the underlying construct of cervical proprioception and association between performances in both has not been investigated previously., Methods: Head repositioning and head-tracking errors were measured using an electromagnetic-tracking system in 16 normal subjects, tested on 3 occasions over 2 days. The effect of different numbers of trial repeats was analyzed descriptively in terms of stability of measures obtained and by using intraclass correlation coefficients to assess reliability. Association between the tests was analyzed with the Pearson correlation coefficient., Results: Stable estimates of performance were obtained when data from 6 or more trials was included. The greatest test-retest reliability was obtained with 5 or more trials in both the cervical JPE (intraclass correlation coefficients = 0.73-0.84) and cervicocephalic kinesthesia (intraclass correlation coefficients = 0.90-0.97) tests. Correlation analyses indicated no significant association between performances in the 2 tests (r = -0.476-0.228, P > 0.05)., Conclusion: Our finding that at least 6 trials were needed to optimize stability, and reliability of outcome measures has important implications for application of these tests. The lack of correlation between performances in the tests supports the suggestion that they are not comparable measures of cervical proprioception. Further planned studies will include a range of tests challenging different aspects of cervical proprioceptive contribution to sensorimotor control in different subcategories of neck pain patients.

Objective: To investigate the effect of neurolysis on intractable greater occipital nerve neuralgia., Methods: From March 1998 to August 2005, twenty-six patients suffering from intractable greater occipital nerve neuralgia were treated. There were 12 males and 14 females with an average age of 52 years (ranged 38-63 years). The disease course was 3-7 years. Sixteen cases had a long duration of work with bowing head, 5 cases symptoms appeared after trauma, and others had no identified causes. The visual analogue scales (VAS) scoring was 6.0 to 9.5, averaged 8. 6. Seven cases were treated by apocope of obliquus capitis inferior under general anaesthesia and 19 cases were treated by neurolysis of greater occipital nerve under local anaesthesia. The compression mass were examined., Results: Symptoms ameliorated or disappeared in 26 cases immediately after operation. The wounds healed by first intention. The pathological results of the removal mass included lymph node (3 cases), neurilemmoma (2 cases) and scar (5 cases). The VAS scoring of 26 cases was 0 to 5 (average, 2) 3 days after operation. Twenty-three cases were followed up for 1 to 3 years. The VAS scoring of 23 cases was 0 to 4.5 ( average, 1.9) 1 months after operation. Only two cases recurred and the symptoms were ameliorated. Pain aggavated after tiredness and reliveed after oral anti-inflammatory analgesics in 6 cases. No relapse occurred in the others., Conclusion: The complete neurolysis of greater occipital nerve (including apocope of obliquus capitis inferior, release between the cucullaris and semispinalis) which make the greater occipital nerve goes without any compression is the key point to treat intractable greater occipital nerve neuralgia.

Discrepancies abound in the literature regarding the anatomy and incidence of the C1 dorsal roots, ganglia, and rami. The present study was performed to elucidate further the detailed anatomy of these structures and to review their clinical relevance. Thirty-adult cadavers were used for this study. The mean age for this group was 72 years. C1 and C2 spinal nerves were identified in 100% of the specimens examined. In 46.6% of specimens, C1 dorsal rootlets were identified and of these, 28.5% had an associated dorsal root ganglion. In 50% of specimens, the spinal accessory nerve joined with dorsal rootlets of C1. C1 in these cases did not possess a dorsal root ganglion. There were no significant differences between left sides, gender, and age (P > 0.05). Additional knowledge regarding the C1 dorsal roots, ganglia, and rami may be of use to the clinician who treats various pain syndromes including medically and surgically intractable occipital neuralgia.

There is significant paucity in the literature regarding the vertebral nerve. Moreover, descriptions of this structure are conflicting. To evaluate further the anatomy and potential clinical significance of this structure, 10 fresh adult cadavers (20 sides) underwent dissection and macroscopic observation of this structure. All specimens were found to have a vertebral nerve that originated from the stellate ganglion with the exception of two left sides (10%) in which this nerve arose from the inferior cervical ganglion. This nerve ascended posteromedial to the vertebral artery. The vertebral nerve was found to be, in essence, a long and deep gray ramus communicans that connected most commonly the stellate ganglia to C6 or C7 spinal nerves by passing through the C6 and C7 transverse foramina. Fifteen percent of sides were found to have a vertebral nerve that was plexiform in its configuration. Fifty percent were found to have very small branches that entered the fibrous capsule of adjacent zygapophyseal and intervertebral joints. Some specimens were noted to have meningeal branches of the vertebral nerve. Based on our observations, the vertebral nerve is simply a deep ramus communicans, which often provides articular and meningeal branches to the adjacent spine. As neck pain is a significant reason for physician office visits, additional knowledge of the nerves innervating the joints and adjacent meninges of the neck could be important for both surgical and medical blockade of nerve fibers.

Cervical radiculopathy is a condition encountered commonly in the evaluation of neck pain that may result in significant discomfort and functional deficits. Although the long-term prognosis of this condition is favorable, a standardized approach to therapy is important to minimize unnecessary tests and identify patients who require more urgent intervention. Patient education, pain control, and physical therapy are the first line of therapy. Patients who have protracted pain or significant functional deficits may require a more thorough evaluation, including imaging, electrodiagnostic testing, and, possibly, surgical referral. This article outlines the basic clinical, diagnostic, and therapy considerations in the evaluation of cervical radiculopathy.

The control of the scapulothoracic muscles trapezius (Tr) and serratus anterior (SA) has been examined in normal human subjects. Electromyographic recordings were made from the SA and Tr muscles (upper trapezius UTr, lower trapezius LTr) using surface electrodes placed bilaterally. Magnetic stimulation of the motor cortex and electrical stimulation of peripheral nerves were used to examine their descending and reflex control. The average optimal site of cortical stimulation was found to be the same for SA, UTr and LTr (an approximate centre of gravity of -0.6 cm, 3.7 cm where the centre of gravity is expressed as the mean anterio-posterior position, the mean medio-lateral position). Some asymmetry in the cortical representation of UTr was found in each individual tested. Magnetic stimulation evoked bilateral MEPs in Tr (latency contralateral (c) UTr 8.5 +/- 1.6 ms, ipsilateral (i) UTr 19.0 +/- 2.7 ms) but only contralateral responses were evoked in SA (11.2 +/- 2.6 ms). Electrical stimulation of the long thoracic nerve at two sites was used to examine homonymous and heteronymous reflexes of SA, while electrical stimulation of cervical nerve of C3/4 was used to examine the heteronymous reflexes of Tr. Ipsilateral SA H reflexes were evoked at a latency of 9.9 +/- 0.8 ms (proximal site) and 10.8 +/- 1.2 ms (distal site). No group I reflexes were evoked from SA to its contralateral homologue. No group I reflexes were evoked between Tr and SA. Finally, cross-correlation of activity from the Tr muscle pairs and the SA muscle pair revealed that the motoneurones of the Tr muscles share some common presynaptic input whereas there was no detectable common presynaptic input to the SA muscle pair. This study extends and consolidates knowledge regarding the neural control of trapezius and for the first time explores the neural control of SA. The study demonstrates a contrasting bilateral control of Tr and SA. These patterns of connections are discussed in relation to the contrasting bilateral functional roles of these muscles.

Today, diagnosis and treatment of chest pain related to pathologic changes in the visceral pleura are often difficult. Data in the literature on the sensory innervation of the visceral pleura are sparse. The present study aimed at identifying sensory end-organs in the visceral pleura, and at obtaining more information about neurochemical coding. The immunocytochemcial data are mainly based on whole mounts of the visceral pleura of control and vagally denervated rats. It was shown that innervation of the rat visceral pleura is characterized by nerve bundles that enter in the hilus region and gradually split into slender bundles with a few nerve fibers. Separate nerve fibers regularly give rise to characteristic laminar terminals. Because of their unique association with the elastic fibers of the visceral pleura, we decided to refer to them as "visceral pleura receptors" (VPRs). Cryostat sections of rat lungs confirmed a predominant location on mediastinal and interlobar lung surfaces. VPRs can specifically be visualized by protein gene product 9.5 immunostaining, and were shown to express vesicular glutamate transporters, calbindin D28K, Na+/K+-ATPase, and P2X3 ATP-receptors. The sensory nerve fibers giving rise to VPRs appeared to be myelinated and to have a spinal origin. Because several of the investigated proteins have been reported as markers for sensory terminals in other organs, the present study revealed that VPRs display the neurochemical characteristics of mechanosensory and/or nociceptive terminals. The development of a live staining method, using AM1-43, showed that VPRs can be visualized in living tissue, offering an interesting model for future physiologic studies.

Objective: To study the immediate sensorimotor neurophysiological effects of cervical spine manipulation using somatosensory evoked potentials (SEPs)., Methods: Twelve subjects with a history of reoccurring neck stiffness and/or neck pain, but no acute symptoms at the time of the study were invited to participate in the study. An additional twelve subjects participated in a passive head movement control experiment. Spinal (N11, N13) brainstem (P14) and cortical (N20, N30) SEPs to median nerve stimulation were recorded before and for 30min after a single session of cervical spine manipulation, or passive head movement., Results: There was a significant decrease in the amplitude of parietal N20 and frontal N30 SEP components following the single session of cervical spine manipulation compared to pre-manipulation baseline values. These changes lasted on average 20min following the manipulation intervention. No changes were observed in the passive head movement control condition., Conclusions: Spinal manipulation of dysfunctional cervical joints can lead to transient cortical plastic changes, as demonstrated by attenuation of cortical somatosensory evoked responses., Significance: This study suggests that cervical spine manipulation may alter cortical somatosensory processing and sensorimotor integration. These findings may help to elucidate the mechanisms responsible for the effective relief of pain and restoration of functional ability documented following spinal manipulation treatment.

A variety of techniques exist for fixation of the upper cervical spine. The development of universal posterior cervical screw-rod instrumentation systems has resulted in recent interest in new and stable segmental fixation into C1 and C2. The C1 lateral mass is a safe and robust anchor point; however, the anatomic corridor to access the screw entry portal is unfamiliar. Understanding the C1 bony landmarks and the course and relationship of the soft-tissue structures (such as the vertebral artery and the C2 nerve root) is critically important. Alternative techniques for achieving segmental screw fixation into C2 are being developed. With polyaxial screw heads and lateral offset connectors, screw anchors can be driven into the most sturdy and safest aspects of C2 without concern for the position of the longitudinal rod.

Objective: To explore the patterns of innervation of cervical facet joints and determine the pathways from facet joints to dorsal root ganglions (DRGs) in order to clarify the causes of diffuse neck pain, headache, and shoulder pain., Methods: Forty-two male-Sprague-Dawley rats, weighing 250-300 g, were randomly divided into three groups: Group A (n=18), Group B (n=18), and Group C (n=6). Under anesthesia with intraperitoneal pentobarbital sodium (45 mg/kg body weight), a midline dorsal longitudinal incision was made over the cervical spine to expose the left cervical facet joint capsule of all the rats under a microscope. The rats in Group A underwent sympathectomy, but the rats in Group B and Group C did not undergo sympathectomy. Then 0.6 microlitre 5% bisbenzimide (Bb) were injected into the C1-2, C3-4 and C5-6 facet joints of 6 rats respectively in Group A and Group B. The holes were immediately sealed with mineral wax to prevent leakage of Bb and the fascia and skin were closed. But in Group C, 0.9% normal saline was injected into the corresponding joint capsules. Then under deep re-anesthesia with intraperitoneal pentobarbital sodium (45 mg/kg body weight), C1-C8 left DRGs in all rats and the sympathetic ganglions in Group B were obtained and the number of the labeled neurons was determined., Results: Neurons labeled with Bb were present in C1-C8 DRGs in both Group A and Group B, and sympathetic ganglions in Group B. In the C1-2 and C3-4 subgroups, labeled neurons were present from C1 to C8 DRGs, while in C5-6 subgroups they were from C3 to C8. The number of Bb(+) neurons after sympathectomy was not significantly different in the injected level from that without sympathectomy. But in the other levels, the number of Bb(+) neurons after sympathectomy was significantly less than that without sympathectomy., Conclusions: The innervation of the cervical facet joints is derived from both sensory and sympathetic nervous system, and DRGs are associated with sympathetic ganglions through nerve fibers outside the central nerve system.

Object: Cervical radiofrequency neurotomy (CRFN) is used in the treatment of patients with chronic pain and disability due to whiplash injury. Confirmation of its efficiency has, however, been based solely on pain and psychological distress factors. The aim of the present study was to extend the assessment of CRFN efficacy by adding other outcome measures to shed light on neuromotor-functional-psychological interactions by undertaking comparison of pre- and 1-year postintervention data., Methods: Forty patients with chronic whiplash injury-associated disorders were evaluated prior to and at two separate sessions after CRFN. The evaluation included Neck Disability Index, cervical range of motion, isometric cervical muscle strength, cervical pressure pain threshold, Symptom Check List-90-Revised, and subjective Self-Report of Improvement (SRI). The authors found that the CRFN had a significantly positive effect on all measured parameters. A case-by-case analysis revealed improvement in 70% of the patients at the final follow-up examination. Using stringent cutoff values, between 30 and 60% of the patients experienced measurable improvement. Evaluation of SRI results indicated that more than 80% of the patients were satisfied with the procedure., Conclusions: Approximately 1 year after intervention, CRFN was associated with an acceptable rate of success, as reflected by objective and subjective outcome measures.

Aim: The frequency of cardiovascular adverse effects of cervical nerve root infiltration was investigated by means of a prospective study., Method: The hemodynamic and respiratory parameters systolic and diastolic blood pressure, heart rate, respiratory rate and oxygen saturation were monitored continuously in 56 patients undergoing cervical spine nerve root infiltration (injection of 10 ml Lidocain 0.5 %, mean depth of injection 5 cm). The monitored time frame ranged from 5 minutes before to 10 minutes after its administration, an additional holter-monitoring began 1 day prior to the injection., Results: Severe complications such as syncopes were not observed in any of the 56 patients, 4 patients developed presyncopes. None of the registered parameters showed a significant change. In a group of patients with known, pre-existing cardiovascular morbidity, no significant changes occurred either. No relevant cardiac arrhythmias were observed., Conclusion: The observed cardiovascular complications were not severe. Most probably, the observed reactions were vasavagal presyncopes. Supine positioning led to immediate recovery in all of these patients. A complete hemodynamic monitoring and the placement of an intravenous line do not seem to be absolute necessities in the routine cervical nerve root infiltration.

Objectives: It has been known that cervical dystonia develops secondarily to spinal cord injuries as secondary dystonia. However, little is known about the pathophysiological mechanism., Patients and Methods: We examined motor and sensory conduction in six patients with symptomatic cervical dystonia by transcranial magnetic stimulation (TMS). All of the patients exhibited unilateral head rotation. They had symptoms corresponding to cervical myelopathy and felt discomfort in the neck, shoulders or arms before involuntary movement occurred., Results: Although the overall central motor conduction time (CMCT) was not different from that of normal controls, contralateral CMCT was significantly delayed compared to ipsilateral CMCT (p<0.05). The results of somatosensory evoked potential study demonstrated that contralateral central conduction time (CCT) was not significantly different from ipsilateral CCT., Conclusion: These findings indicate that there is a selective interference with the contralateral corticospinal tract in patients with symptomatic cervical dystonia.

Background: Randomized controlled trials in research settings have demonstrated the efficacy of percutaneous radiofrequency neurotomy of the medial branches of the cervical dorsal rami in the palliation of chronic zygapophysial joint pain, a common cause of chronic neck pain, but one that is under-recognized in some quarters., Aims: This study aimed to determine the outcomes of radiofrequency neurotomy in usual clinical practice for patients with established cervical zygapophysial joint pain., Methods: The study was conducted in a public hospital, incorporating the private practice and public clinic elements of a single physician. All patients who underwent radiofrequency neurotomy had a diagnosis of cervical zygapophysial joint pain established by controlled cervical medial branch blocks. The primary outcome of duration of pain relief was determined for all consecutive procedures performed during a two-year period. Data were collected by chart review and telephone contact by an independent assessor., Results: Forty-seven procedures were performed on 35 patients. Two patients were lost to follow-up. Twelve patients had two procedures. Thirty-six of 45 assessable procedures (80%) achieved significant pain relief. These 36 procedures achieved a mean duration of pain relief of 36 weeks, with a median of 35 weeks. Repeat procedures usually achieved reproducible pain relief. Most patients had significant postprocedural pain for about one week. Only one serious adverse event (local superficial infection) was reported., Conclusion: Radiofrequency neurotomy is an effective palliative treatment for chronic cervical zygapophysial joint pain when performed in routine clinical practice.

Cervical facet joints have been implicated as a major source of pain after whiplash injury. We sought to identify facet joint capsule receptors in the cervical spine and quantify their responses to capsular deformation. The response of mechanosensitive afferents in C5-C6 facet joint capsules to craniocaudal stretch (0.5 mm/s) was examined in anaesthetized adult goats. Capsular afferents were characterized into Group III and IV based on their conduction velocity. Two-dimensional strains across the capsules during stretch were obtained by a stereoimaging technique and finite element modeling. 17 (53%) Group III and 14 (56%) Group IV afferents were identified with low strain thresholds of 0.107+/-0.033 and 0.100+/-0.046. A subpopulation of low-strain-threshold afferents had discharge rate saturation at the strains of 0.388+/-0.121 (n=9, Group III) and 0.341+/-0.159 (n=9, Group IV). Two (8%) Group IV units responded only to high strains (0.460+/-0.170). 15 (47%) Group III and 9 (36%) Group IV units could not be excited even by noxious capsular stretch. Simple linear regressions were conducted with capsular load and principal strain as independent variables and neural response of low-strain-threshold afferents as the dependent variable. Correlation coefficients (R2) were 0.73+/-0.11 with load, and 0.82+/-0.12 with principal strain. The stiffness of the C5-C6 capsules was 16.8+/-11.4 N/mm. Our results indicate that sensory receptors in cervical facet joint capsules are not only capable of signaling a graded physiological mechanical stimulus, but may also elicit pain sensation under excessive deformation.

Study Design: To establish a methodology for the neurophysiologic study of mechanoreceptors in the cervical facet joint capsule., Objectives: To test a custom designed miniature dual bipolar electrode for recording the neural activity in cervical dorsal roots. To determine if the neural activity from different receptors in the capsule can be differentiated using this methodology., Summary of Background Data: Injury to cervical facet joint capsules has been regarded as an important source of whiplash pain, but no neurophysiologic study has been performed to demonstrate or characterize sensory nerve function in the capsule., Methods: Nineteen goats weighing 34 to 55 kg were used under general anesthesia. A C4-C6 laminectomy was performed to expose the C6 nerve root. Custom designed miniature dual bipolar electrodes were used to record neural activity in the left C6 branches. Electrical and mechanical stimuli were used to evoke receptor activity in the dorsal aspect of the C5/6 capsule. Conduction velocities (CVs) of evoked units were determined by electrical stimulation and dual-bipolar-electrode recording methods. The units were classified based on their CVs. The waveform of each classified unit was saved as a template for later single unit discharge search among multiunit discharges during the stretch of the capsule. The C5/6 facet joint with capsule was pulled by a computer-controlled actuator instrumented with a load cell at a rate of 0.5 mm per second. The evoked neural activity and load were recorded, digitized, and analyzed to determine CV, discharge rate, and response to the stretch., Results: Miniature bipolar electrodes recorded the neural activity in both channels, with single unit CVs being measured. There was no discernible motion between the electrode and dorsal root when the capsule was pulled. Both local compression and stretch on capsule evoked multiunit discharges. A-beta, A-delta, and C-fiber units were found among these multiunit discharges. The rate of single unit and multiunit discharges increased during capsule stretch in the physiologic range and afterdischarges occurred beyond the physiologic range., Conclusions: The novel miniature electrodes not requiring a micromanipulator made it feasible and reliable to record neural activity from short cervical spinal roots. Waveforms of different units could be identified, making it possible to study sensory functions of the facet joint capsule. A-beta, A-delta, and C-fiber units were found responding to mechanical stimuli, indicating that facet joint capsule has functional proprioceptors and nociceptors.

Objective: Neurosurgical procedures such as proximal brachial plexus repair, scalenotomy, and direct isolation of the proximal vertebral artery require a good working knowledge of the triangle of the vertebral artery. This deep triangle of the neck is bound by the subclavian artery and the anterior scalene and longus cervicis muscles. In addition to the vertebral artery, many important structures are found in this area, such as the ganglionated sympathetic chain and certain cervical spinal nerves., Methods: Twenty formalin-fixed cadavers were used for this study. Dissection of this triangle was performed, and measurements were made not only of parts of its borders, but also distances from these borders to neurologically important structures within its confines, such as the C8 spinal nerve., Results: In all specimens, the middle scalene muscle was noted to form part of the posterior wall of the triangle. The mean height of the triangle was found to be 3.2 cm, and the mean width of its base was 1.3 cm. We observed that the C8 spinal nerve had a mean distance of 1.2 cm inferior to the apex of the triangle and that the C7 spinal nerve was found inside the triangle in 5% of sides. If the phrenic nerve entered the triangle, it was never found more than 6 mm medial to the anterior scalene muscle. The vertebral artery always traveled intimately along the lateral border of the longus cervicis muscle, and its lateral edge ranged 5 to 8 mm medial to the medial edge of the anterior scalene muscle., Conclusion: The C7 spinal nerve was observed in the triangle of the vertebral artery. In addition, the posterior border of the triangle of the vertebral artery was clearly defined in this study, and the middle scalene muscle could be used as a landmark. These data, coupled with our quantitation of parts and structures within the triangle, may assist neurosurgeons who operate on this area of the neck.

This study analyzed the effect of head position and visual condition on the control of balance in handstand, a gymnastics posture that necessitates adaptation of sensory information processing. Five expert gymnasts participated. Centre of pressure trajectories and kinematics of different body segments were recorded. The gymnasts were instructed to maintain three handstands as long as possible in four head positions, with and without vision. Performances and postural stability was much better in the standard and dorsiflexion positions than in the aligned and ventroflexion positions under the two conditions of vision. Performances were lower without vision in the standard and dorsiflexion position. If vision clearly plays an important role, yet the tonic neck reflexes also seem to contribute greatly to control body sways during inverted posture.

The central nervous system is involved in 10-20% of cases in Lyme disease. The neurological symptoms, time course of the disease and imaging findings are multifaceted. We report two patients with cervical radiculitis. Magnetic resonance imaging revealed strong enhancement of the cervical nerve roots on contrast-enhanced T1-weighted images. These imaging patterns of borrelia-associated radiculitis have not been reported before. Knowledge of these imaging features may help to diagnose neuroborreliosis, which presents with non-specific symptoms.

The authors present selective C7 nerve root transfer in a rat model. The musculocutaneous nerve was neurotized by various portions of ipsilateral C7. The latent period and maximum amplitude of evoked motor action potential of the biceps, number of regenerating myelinated nerve fibers, cross-sectional area and wet weight of the biceps, and twitch and tetanic tensions of the biceps were measured at four postoperative intervals. In the early postoperative period (1 and 2 months), nerve regeneration in neurotization with the posterior division or the anterior division of C7 was significantly better than that with the anterolateral fascicles of the anterior division or the phrenic nerve. As the postoperative interval prolonged, the parameters of nerve regeneration in the latter two groups approximated those in the former two groups. This indicated that there were enough regenerating nerve fibers in the anterolateral fascicles of the anterior division and a promising potential for nerve regeneration. The clinical significance of the results lies in the design of selective C7 transfer which, using the anterolateral fascicles of the anterior division, could preserve the function of the muscles innervated by the posterior division to the greatest extent, and provide sufficient donor outflow as well. It is therefore a new option for C7 transfer.

The objective of this study was to compare onset of deep and superficial cervical flexor muscle activity during rapid, unilateral arm movements between ten patients with chronic neck pain and 12 control subjects. Deep cervical flexor (DCF) electromyographic activity (EMG) was recorded with custom electrodes inserted via the nose and fixed by suction to the posterior mucosa of the oropharynx. Surface electrodes were placed over the sternocleidomastoid (SCM) and anterior scalene (AS) muscles. While standing, subjects flexed and extended the right arm in response to a visual stimulus. For the control group, activation of DCF, SCM and AS muscles occurred less than 50 ms after the onset of deltoid activity, which is consistent with feedforward control of the neck during arm flexion and extension. When subjects with a history of neck pain flexed the arm, the onsets of DCF and contralateral SCM and AS muscles were significantly delayed ( p<0.05). It is concluded that the delay in neck muscle activity associated with movement of the arm in patients with neck pain indicates a significant deficit in the automatic feedforward control of the cervical spine. As the deep cervical muscles are fundamentally important for support of the cervical lordosis and the cervical joints, change in the feedforward response may leave the cervical spine vulnerable to reactive forces from arm movement.

Study Design: Human cervical facet joint capsules were evaluated by immunohistochemistry., Objectives: To study the neuropeptide innervation of the cadaveric cervical facet joint capsules., Summary of Background Data: Various clinical and biomechanical studies indicate a role for cervical facet joint capsules in the etiology of neck pain. However, studies on innervation of these capsules are very limited. There is also a dearth of studies on the neuropeptide nature of this innervation., Methods: Facet joint capsules harvested from unembalmed cadavers were studied by the avidin biotin peroxidase method for the presence of nerve fibers. Neuropeptide innervation was investigated by using antisera to substance P and calcitonin gene-related peptide. Antisera to protein gene product 9.5 (PGP 9.5), a general neuronal marker, were also used., Results: In a study of 12 human cervical facet joint capsules, short segments of substance P were observed in 6 capsules, while fibers reactive to calcitonin gene-related peptide were demonstrated in 7 capsules. Nerve fibers immunoreactive to protein gene product 9.5 were also observed in 9 of the 14 capsules studied. Protein gene product 9.5 reactive fibers were the most extensively distributed fibers, observed as bundles and also as single fibers., Conclusions: An abundance of protein gene product 9.5 reactive nerve fibers indicates an extensive innervation of the cervical facet joint capsules. The presence of substance P and calcitonin gene-related peptide reactive nerve fibers in a population of these lends credence to cervical facet joint capsules as a key source of neck pain.

Stellate ganglion blockade (SGB) has long been considered pivotal in the diagnosis, determination of prognosis and management of chronic regional pain syndrome (CRPS) by sympathectomy. To date a variety of SGB techniques have been described. An inaccurate SGB may mislead clinicians and deny patients a potentially beneficial procedure. In order to obtain a predictable and readily reproducible blockade of the upper limb, a modified anterior technique was evaluated. This modified sympathetic block was performed in 10 adult cadavers (n=19 sides). Toluidine blue solution (10 ml) was injected and, following median sternotomy, the extent of spread of dye was evaluated. In one cadaver a dual block using both the modified and the standard techniques was performed. Proximal spread to the seventh cervical vertebra was noted in all blocks; distal spread extended to the neck of the third rib (n=3), neck of the fourth rib 7 (n=15) and neck of the seventh rib (n=1). Medial spread was greater than lateral spread and extended to the vertebral bodies (vagus nerve was also stained) while lateral spread in all cases "blocked" lower roots of the brachial plexus and was consistently noted beyond the usual location of the nerve of Kuntz. This modified technique demonstrated that the lower cervical ganglia and proximal thoracic sympathetic trunk were consistently stained. It should be noted that the spread was sufficiently lateral to block the nerve of Kuntz. The pitfalls of this technique aside, we suggest that this technique be reserved for therapeutic purposes, particularly when sympathectomy is not possible.

The purpose of this review is to identify recently observed features of the sympathetic and sensory systems and their pathways which characterize cervical spine innervation and their potential relevance to the clinical pain syndromes. The results of studies examining the innervation patterns of the zygoapophysial joints serve to demonstrate that structures in the cervical spine, as in other spinal regions, are partly innervated by sensory nerves traveling along sympathetic pathways. These studies also demonstrate that the neuropeptide levels in the cell bodies located within the dorsal root ganglion of these sensory nerves fluctuate according to the physiological state of the zygoapophysial joint. Additional to the sympathetic nerves accompanying the vertebral artery, the innervation patterns of dura and posterior longitudinal ligament in the upper cervical spine are distinctive features of cervical spine innervation. The possible clinical implications of cervical innervation patterns are considered with reference to referred pain, the pain patterns associated with a dissecting vertebral artery and cervicogenic headaches.

Propriospinal neurones located in the cervical enlargement and projecting bilaterally to sacral segments of the spinal cord were investigated electrophysiologically in eleven deeply anaesthetized cats. Excitatory or inhibitory postsynaptic potentials from forelimb afferents were recorded following stimulation of deep radial (DR), superficial radial (SR), median (Med) and ulnar (Uln) nerves. 26 cells were recorded from C7, 22 from C8 and 3 from Th1 segments. The majority of the cells were located in the Rexed's laminae VIII and the medial part of the lamina VII. In 10 cases no afferent input from the forelimb afferents was found. In the remaining neurones effects were evoked mostly from DR (88%) and Med (63%), less often from SR (46%) and Uln (46%). Inhibitory actions were more frequent than excitatory. The highest number of IPSPs was evoked from high threshold flexor reflex afferents (FRA)--all connections were polysynaptic. However, inhibitory actions were often evoked from group I or II muscle afferents (polysynaptic or disynaptic) and, less frequently, from cutaneous afferents (mostly polysynaptic). Di- or polysynaptic IPSPs often accompanied monosynaptic EPSPs from group I or II muscle afferents. Disynaptic or polysynaptic EPSPs from muscle and cutaneous afferents were also recorded in many neurones, while polysynaptic EPSPs from FRA were observed only exceptionally. Various patterns of convergence in individual neuronal subpopulations indicate that they integrate different types of the afferent input from various muscle and cutaneous receptors of the distal forelimb. They transmit this information to motor centers controlling hind limb muscles, forming a part of the system contributing to the process of coordination of movements of fore--and hind--limbs.

Study Design: A literature review was conducted to integrate and compile available reports on postoperative C5 palsy., Objectives: To review the clinical features, possible pathogenesis, and procedures for treatment and prevention of postoperative C5 palsy as a complication of surgery for cervical compression myelopathy., Summary of Background Data: Although postoperative C5 palsy develops in approximately 5% of patients after decompression surgery of the cervical spine, its pathogenesis and the options for prevention and treatment remain unidentified and many controversies exist., Method: We reviewed and analyzed papers published from 1986 to 2002 regarding C5 palsy as a postoperative complication. Statistical comparisons were made when appropriate., Results: Postoperative C5 palsy is reported to occur in an average of 4.6% of patients after surgery for cervical compression myelopathy. No significant differences were noted between patients undergoing anterior decompression and fusion and laminoplasty, nor were distinctions apparent between unilateral hinge laminoplasty and French-door laminoplasty, or between cervical spondylotic myelopathy and ossification of the posterior longitudinal ligament. Two theories were put forth to account for the pathogenesis of C5 palsy: nerve root injury and segmental spinal cord disorder. Neither of these hypotheses has been consistently supported and evidence to refute each hypothesis can be found in the literature. Recently, surgeons have advocated foraminotomy combined with laminoplasty to prevent or treat C5 palsy, but further studies into the efficacy of this procedure are needed. Although patients with C5 palsy generally have a good prognosis for neurologic and functional recovery, those with severe paralysis require significantly longer recovery times when compared to more mild cases., Conclusion: The incidence of postoperative C5 palsy has been reported at 4.6% after surgery for cervical compression myelopathy and this value has not varied with different surgical procedures or disease etiologies. The pathogenesis of postoperative C5 palsy remains unclear at the present time. Patients with postoperative C5 palsy generally have a good prognosis for functional recovery, but the severely paralyzed cases required significantly longer recovery times than the mild cases.

Study Design: An anatomic study investigated the cervical dorsal rami and major cervical paravertebral muscles., Objective: To provide a detailed description of the cervical dorsal rami and important paravertebral muscles as a way of avoiding inadvertent injuries during the posterior approach., Summary of Background Data: No detailed anatomic studies of the nerves and the muscles in the posterior neck useful for the posterior approach have been reported previously., Methods: Running courses of the cervical dorsal rami of spinal nerves and the morphology of cervical major paravertebral muscles were studied using 14 cadavers. In four posterior approaches of cervical laminoplasty, subcutaneous facial exits of cutaneous nerves and the running course of the right C3 medial branches around facet joint were exposed for observation of living anatomy., Results: Every medial branch from the dorsal rami of the C3-C8 spinal nerves passed through an anatomic tunnel dorsolateral to the facet joint. The base of the tunnel was a bony gutter between neighboring facet joint capsules, and the roof was the tendon of the semispinalis capitis. In this tunnel, the medial branch had a little laxity in moving, and was assumed to be the most susceptible to iatrogenic injury during the operation. The semispinalis cervicis was composed with long muscle bundles. Each of these had only one or two innervating nerves from the dorsal rami of cervical spinal nerves. Cutaneous branches from the dorsal rami were found adjacent to every spinous process below the C2 spinous process in cadaveric studies. However, only two or three larger cutaneous nerves were discernible below the C5 or C6 spinous process in surgical approaches., Conclusions: With the posterior approach to the cervical spine, a precise knowledge of the cervical dorsal rami anatomy and the innervating patterns of the paravertebral muscles is necessary for avoidance of inadvertent injuries to the nerves.

This article reports the use of thermography to monitor 123 plexus decompressions for neurogenic thoracic outlet syndrome. The diagnosis and management of this disease continues to be controversial. Questions about pathologic mechanisms, the extent and frequency of muscular entrapment, scar, and interdigitations, as well as their relative contributions, remain. Thermographic visualization of the operated extremity allowed us to map and correlate thermal changes with specific surgical manipulations, as well as to analyze the tissues resected to better answer these questions. Initial thermal abnormalities indicating, usually, ulnar entrapments or irritation, normalized sequentially as discrete entrapments were resected. Thermographic monitoring continues to provide surgically useful information in one third of operations.