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OBJECTIVE:To evaluate whether anterior cervical spine surgery offers sustained (7 years) relief in patients with cervicogenic headaches (CGHs), and evaluate the difference between cervical disc arthroplasty (CDA) and anterior cervical discectomy and fusion (ACDF) for 1 and 2-level surgeries from a multicenter randomized clinical trial. METHODS:A post hoc analysis was performed of 575 patients who underwent one or 2-level CDA or ACDF for symptomatic cervical spondylosis as part of a prospective randomized clinical trial. Assessment of pain and functional outcome was done with the Neck Disability Index (NDI) in the trial. We used the NDI headache component to assess headache outcome. RESULTS:For both 1- and 2-level CDA and ACDF groups, there was significant headache improvement from preoperative baseline out to 7 years (p < 0.0001). For 1-level surgeries, headache improvement was similar for both groups at the 7-year point. For 2-level treatment, CDA patients had significantly improved headache scores versus ACDF patients at the 7-year point (p = 0.016). CONCLUSION:The headache improvement noted at early follow-up was sustained over the long-term period with ACDF and CDA populations. In the case of 2-level operations, CDA patients demonstrated significantly greater benefit compared to ACDF patients over the long-term. Sinuvertebral nerve irritation at the unco-vasculo-radicular junction and anterior dura may be the cause of CGH. Therefore, it is possible that improved cervical kinematics and preservation of range of motion at adjacent uncovertebral joints in CDA may contribute to the observed difference between the groups.

Blockage of the dorsal rami of the spinal nerves (DRSN) provides analgesia to the epaxial musculature area in dogs. However, techniques to block the DRSN at the cervical level in dogs haven't yet been investigated. This study aimed to study the anatomy of the cervical area, and to describe a new ultrasound (US)-guided inter-transversospinalis plane (ITP) block technique at the 5th cervical vertebrae (C5). Fourteen adult canine's cadavers were used in this blinded, cadaveric, experimental study. One cadaver for cryo-section, one for anatomical research and twelve to do an ITP injection using 0.3 mL/kg (HV) or 0.15 mL/kg (LV) of dye/contrast solution in each lateral at C5, followed by a computed tomography and anatomical dissection. The HV and LV groups stained a median (range) of 4.67 (3-6) and 3.67 (2-5) DRSN into the ITP, respectively (P<0.017). Stained DRSN in the splenius plane were found in nine (75%) HV and five (41.66%) LV injections, respectively. Spread in the epidural space was found in two dogs using LV. One of them was injected into the ITP (4.33 %) while the other one was done accidentally outside of this plane. The paravertebral spread was found in one injection of each group. There was no dye of the ventral rami of the spinal nerves. The US-guided ITP injection is feasible in dog cadavers. The LV injected just after the medial surface of the semispinalis capitis muscle is recommended to avoid a possible extensive epidural spread., Competing Interests: Declaration of competing interest None of the authors has any financial or personal relationships that could inappropriately influence or bias the content of the paper., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objective To evaluate whether anterior cervical spine surgery offers sustained (7 years) relief in patients with cervicogenic headaches (CGHs), and evaluate the difference between cervical disc arthroplasty (CDA) and anterior cervical discectomy and fusion (ACDF) for 1 and 2-level surgeries from a multicenter randomized clinical trial. Methods A post hoc analysis was performed of 575 patients who underwent one or 2-level CDA or ACDF for symptomatic cervical spondylosis as part of a prospective randomized clinical trial. Assessment of pain and functional outcome was done with the Neck Disability Index (NDI) in the trial. We used the NDI headache component to assess headache outcome. Results For both 1- and 2-level CDA and ACDF groups, there was significant headache improvement from preoperative baseline out to 7 years (p < 0.0001). For 1-level surgeries, headache improvement was similar for both groups at the 7-year point. For 2-level treatment, CDA patients had significantly improved headache scores versus ACDF patients at the 7-year point (p = 0.016). Conclusion The headache improvement noted at early follow-up was sustained over the long-term period with ACDF and CDA populations. In the case of 2-level operations, CDA patients demonstrated significantly greater benefit compared to ACDF patients over the long-term. Sinuvertebral nerve irritation at the unco-vasculo-radicular junction and anterior dura may be the cause of CGH. Therefore, it is possible that improved cervical kinematics and preservation of range of motion at adjacent uncovertebral joints in CDA may contribute to the observed difference between the groups.

Background: In pan-brachial plexus injury, distinguishing between preganglionic and postganglionic injuries is crucial to reconstructive planning. This study aimed to identify preoperative factors that would accurately predict a reconstructible C5 spinal nerve., Methods: Patients with pan-brachial plexus injury from a single institution between 2001 and 2018 were reviewed. Patient demographics, clinical examination, diagnostic imaging, and electrodiagnostic results were recorded. C5 viability was determined based on supraclavicular exploration and intraoperative electrophysiologic testing. Univariate analysis identified significant factors for regression analysis. A multivariable parsimonious model was created using stepwise high-performance logistic regression., Results: A total of 311 patients (mean age, 29.9 years; 46 women and 265 men; mean Injury Severity Score, 17.2) were included. A total of 134 patients (43%) had a viable C5 nerve, and 50 patients (12%) had a viable C6 nerve. Intact C5 spinal nerve on computed tomographic (CT) myelogram (OR, 5.4), positive Tinel test (OR, 2.6), muscle strength greater than or equal to 4 (according to the modified British Medical Research Council scale) for the rhomboid (OR, 1.3) or greater than or equal to 4 for the serratus anterior (OR, 1.4), and rhomboid needle electromyography (OR, 1.8) were predictive of having a viable C5 spinal nerve. The multivariable parsimonious stepwise model (area under the curve, 0.77) included four factors: positive Tinel test, intact C5 spinal nerve on CT myelogram, hemidiaphragmatic elevation, and midcervical paraspinal fibrillations., Conclusions: In this cohort of pan-brachial plexus patients with major polytrauma, there was a 43% incidence of viable C5 spinal nerve. A positive Tinel test (OR, 2.1) and intact C5 spinal nerve on CT myelogram (OR, 4.9) predicted a viable C5 nerve. In contrast, hemidiaphragmatic elevation (OR, 3.1) and midcervical paraspinal fibrillations (OR, 2.92) predicted root avulsion., Clinical Question/level of Evidence: Risk, III., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Elite athletes are often faced with difficult decisions when faced with a cervical spinal disorder. There are many aspects to consider such as the risk of further injury, short- and long-term effects on an athlete's life both during and after his/her career, and the options for treatment. Although there have been some recent contributions to this topic, the evidence-based literature is generally devoid of high-level clinical studies to help guide the decision-making process. This article reviews the pertinent available data/criteria and offer an algorithm for return-to-play considerations., Competing Interests: Disclosure The author has nothing to disclose., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Purpose: The vertebral triangle (VT) located in the root of the neck most commonly contains the vertebral artery (VA), cervical sympathetic chain and certain roots of the brachial plexus. Although other structures have been reported, few studies have reported on the overall content of this space. Based on the current literature, there is a general paucity of anatomical information pertaining to the dimensional anatomy of the VT and specifically the structures related to it. Therefore, this study aimed to quantitatively analyze the size, position, content, and anatomical structures in relation to the vertebral triangle in a South African sample., Methods: Forty-three VTs were dissected on bodies donated to science. Measurements taken include the dimensions of the triangle, as well as distances between prominent structures and landmarks of the VT. Observations were made on the presence/absence of the varying neurovascular structures within the VT., Results: Mean height was 30.1 ± 1.51 mm (R) and 32.9 ± 1.78 mm (L). Mean width was 18.3 ± 0.74 mm (R) and 19.3 ± 0.98 mm (L). The C8 spinal nerve was found on average approximately halfway [16.4 ± 0.74 mm (R) and 15.9 ± 0.95 mm (L)] in the VT. The VA was present in the VT in 100% of the sample and the C7 spinal nerve and inferior sympathetic ganglia were present in more than 80% of the sample., Conclusion: Understanding the VT and the content is of the utmost importance and of great interest to neurosurgeons, to avoid these important neurovascular structures and prevent iatrogenic complications during surgery.

Rationale: The incidence of Martin-Gruber anastomosis ranges from 5% to 34%, which is characterized by crossing over from the median to the ulnar nerve and innervating the first dorsal interosseous, thenar or hypothenar muscles. However, the reverse Martin-Gruber anastomosis, or Marinacci anastomosis, is far less discussed and appears in recent literature., Patient Concerns: A 56-year-old man presented to the clinic of a university hospital because of left neck soreness with numbness radiating to the left lateral shoulder. The neck discomfort was aggravated while the neck rotated or tilted to the right., Diagnosis: Higher compound muscle action potential over the abductor pollicis brevis on elbow stimulation than on the wrist was found during upper limb nerve conduction velocity study. Ulnar to median anastomosis was identified., Intervention: We performed cervical spine X-ray and electrophysiological examinations and monitored the patient., Outcomes: We identified that this patient had left C5 and C6 subacute radiculopathy with active denervation and left subclinical ulnar sensory neuropathy, and verified the existence of ulnar-to-median anastomosis., Lessons: We demonstrated a pure motor ulnar-to-median anastomosis without sensory correspondence and higher CMAP over the abductor pollicis brevis on elbow stimulation of the ulnar nerve than on the wrist. The prevalence might be underestimated in a Chinese population-based published study., Competing Interests: The authors have no conflicts of interest to disclose. Patient consent: The patient provided written informed consent for the publication and use of the report., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Abstract: Currently, minute structures, such as cervical nerve roots, can be viewed using magnetic resonance imaging (MRI) sequences; however, studies comparing multiple sequences in the same set of patients are rare. The aim of the study is to compare the diagnostic values of three 3.0-T MRI sequences used in the imaging of cervical nerve roots.This study included 2 phases. In the first phase (n = 45 patients), the most optimal MRI sequence was determined. In the second phase, this MRI sequence was compared with surgical results (n = 31 patients). The three-dimensional double-echo steady-state (3D-DESS), multi-echo data image combination (MEDIC), and 3D sampling perfection with application-optimized contrasts using different flip angle evolutions (3D-SPACE) sequences were performed to analyze the image quality. Furthermore, the most optimal MRI sequence was compared with surgical results to determine the agreement rate.The image quality scores of the 3 sequences were significantly different (P < .05). The score for 3D-DESS sequence was superior to that of MEDIC sequence, while the score for 3D-SPACE sequence was the worst. For visualization of compressed nerve roots, 3D-DESS sequence was superior to the other 2 sequences in terms of the total quality score and compressed nerve root score. Therefore, 3D-DESS sequence was used for MRI in 31 patients with cervical spondylosis in the second phase of this study. The diagnostic agreement rate was 93.5%.This study concluded that in patients with cervical radiculopathy, the 3D-DESS sequence is superior to the MEDIC and 3D-SPACE sequences and shows a high agreement rate with the surgical diagnosis., Competing Interests: The authors have no funding and conflicts of interest to disclose., (Copyright © 2021 the Author(s). Published by Wolters Kluwer Health, Inc.)

Objective: To study the distribution of sympathetic nerves of the ligamentum flavum (LF), confirm its existence by histological observation and nuclear magnetic resonance spectroscopy, and analyze the relationship between sympathetic nerve fibers and the biomechanical structure of the LF., Methods: Randomly controlled scientific research selected 15 cases of posterior surgery in the affiliated hospital of Qingdao University from January 2013 to December 2019. The average age was 67.5 ± 14.5 years old, eight males and seven females. The LF specimens (completely separated fresh tissue) of different segments (C 3-7 ) were taken during the operation. Two pages of LF specimens on the left and right sides of the same segment are randomly allocated by the pairing method for formalin fixation and cryopreservation in liquid nitrogen. LF specimens extracted from seven other adult cadaver specimens (average age at death of about 56.8 ± 4.0 years, three males and four females) were used as a control group; together with formalin- fixed specimens obtained during surgery, 3D slices were given layer by layer. The distribution of sympathetic nerves in different parts of the LF was analyzed by glyoxylic acid-induced biological monoamine fluorescent technique (SPG) and hematoxylin-eosin (HE) staining. Fifteen liquid nitrogen storage specimens were divided into the back of the LF and the spinal canal through frozen sections, and were analyzed by nuclear magnetic resonance spectroscopy-hydrogen spectrum ( 1 H -NMR) for neurotransmitters and neurometabolites., Results: There were type C sympathetic nerve fibers in the LF, which were divided into linear shape (α) and wave shape (β). Experimental group (χ 2 = 1.705, P > 0.05) and control group (χ 2 = 0.879, P > 0.05) can detect no difference in fluorescence units. Nerve fiber transmitter metabolites choline (Cho), creator (Cr), γ-aminobutyric acid (GABA) also indicate that the sympathetic nerve is present in the LF. LF sympathetic nerve fibers were mainly distributed in the proximal spinal canal surface, nerve fibers on the medial belt (area II) were fewer than the lateral belt (area I) (W = 210, P < 0.05). The 1 HNMR spectrum of LF spinal canal PG / Cho (t = 8.721, P < 0.05), GABA (t = 16.01, P < 0.05) value increased, lactic acid (Lac) / Cr (t = 4.213, P < 0.05), Cho / Cr (t = 2.402, P < 0.05) value decreased, indicating that nerve fibers are actively metabolized on the surface of the spinal canal, mainly distributed in tube surface. βtype fibers were more often distributed around microvessels. A small amount of α type fibers went next to the vascular structures, while α type fibers and β type fibers go cross within LF. Two patients with vertebral artery dissection had no recurrence of sympathetic symptoms within a total of 12 follow-ups 2 years after discharge., Conclusions: There are many sympathetic nerve fibers distributed on LF, and their distribution may be correlated with histological and mechanical characteristics of LF. It may also be the anatomical basis of cervical vertigo., (© 2020 The Authors. Orthopaedic Surgery published by Chinese Orthopaedic Association and John Wiley & Sons Australia, Ltd..)

Objective:  The aim of this study was to describe the anatomy of the nerves supplying the cervical articular process joint and to identify relevant anatomical landmarks that could aid in the ultrasound-guided location and injection of these nerves for diagnostic and therapeutic purposes., Study Design:  Twelve cadaveric equine necks were used. Five necks were dissected to study the anatomy of the medial branch of the dorsal ramus of the cervical spinal nerves 3 to 7. Relevant anatomical findings detected during dissections were combined with ultrasonographic images obtained in one other neck. Six additional necks were used to assess the accuracy of ultrasound-guided injections of the medial branch with blue dye., Results:  Each examined cervical articular process joint, except for C2 to C3, presented a dual nerve supply. The articular process joints were found to be in close anatomical relationship with the medial branch of the dorsal ramus of the cervical spinal nerve exiting from the intervertebral foramen at the same level, and with the medial branch of the dorsal ramus of the cervical spinal nerve exiting from the intervertebral foramen one level cranial to the articular process joint of interest. A total of 55 nerves were injected under ultrasonographic guidance, 51 of which were successfully stained., Conclusion:  The current study provided new detailed information regarding the innervation of the cervical articular process joint. The medial branches of the dorsal rami of the cervical spinal nerves were injected with an accuracy that would be of clinical value. Our study offers the foundations to develop new diagnostic and therapeutic techniques for pain management in cervical articular process joint arthropathy in horses., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: Standard posterior percutaneous endoscopic cervical discectomy (PECD) is considered an effective minimally invasive surgery. Although standard PECD can be used to treat radiculopathy with relatively minimal trauma, it is still a challenge to use this approach for treating myelopathy., Objective: This report is aimed at first describing a posterior transpedicular approach under endoscopy for myelopathy and evaluating the feasibility and short-term clinical effects of this approach., Methods: In our retrospective analysis between Feb. 2016 to Mar. 2017, 16 patients managed with PECD using the posterior transpedicular approach for symptomatic single-segment myelopathy. Surgery involved drilling 1/2 to 2/3 of the medial portion of the pedicle under endoscopy to provide sufficient space and an appropriate angle for inserting the endoscope into the spinal canal, followed by ventral decompression of the spinal cord. Computed tomography and magnetic resonance imaging were used to evaluate pedicle healing and spinal cord decompression. The primary outcomes included a visual analog scale (VAS) scores of axial neck pain and Japanese Orthopaedic Association (JOA) scores of neurological conditions., Results: All patients completed a 1-year follow-up examination. The mean duration of surgery was 95.44 ± 19.44 min (52-130 min). The fluoroscopy duration was 5.88 ± 1.05 (4-7). The VAS scores of axial pain significantly improved from 6.94 ± 0.75 preoperatively to 2.88 ± 1.22 postoperatively ( P < 0.05). The mean JOA scores improved from 8.50 ± 1.12 preoperatively to 14.50 ± 1.46 at the final follow-up ( P < 0.05). The effects were excellent in 8 cases, good in 6 cases, and fair in 2 cases. After partial pedicle excision, the width of the remaining pedicle was 1.70 ± 0.22 mm postoperatively and significantly recovered to 3.38 ± 0.49 mm at the 1-year follow-up. There were no surgery-related complications, such as dural tearing, spinal cord injury, nerve root injury, pedicle fracture, and cervical hematocele or infection., Conclusions: The posterior transpedicular approach is an effective method for the treatment of myelopathy in select patients and is a supplement to the described surgical approach for PECD., Competing Interests: Ke-Xiao Yu, Wei-Zhong Lu, Chang-Ming Xiao, Lei Chu, Rui Deng, Liang-Chen, and Zhong-Liang Deng declare no conflict of interest., (Copyright © 2020 Ke-Xiao Yu et al.)

Background: The anatomical distribution of the extraforaminal ligaments in the cervical intervertebral foramina has been well studied. However, detailed descriptions of the biomechanical characteristics of these ligaments are lacking., Methods: The paravertebral muscles were dissected, and the extraforaminal ligaments and nerve roots were identified. The C5 and C7 or C6 and C8 cervical nerve roots on both sides were randomly selected, and a window was opened on the vertebral lamina to expose the posterior spinal nerve root segments. Five needles were placed on the nerve root and the bone structure around the intervertebral foramen; the distal end of the nerve root was then tied with silk thread, and the weights were connected across the pulley. A weight load was gradually applied to the nerve root (50 g/time, 60 times in total). At the end of the experiment, segments of the extraforaminal ligaments were selectively cut off to compare the changes in nerve root displacement., Results: The displacement of the C5, C6, C7, and C8 nerve roots increases with an increasing traction load, and the rate of change of nerve root displacement in the intervertebral foramen is smaller than that in the nerve root on the outside area (p < 0.05). Extraforaminal ligaments can absorb part of the pulling load of the nerve root; the C5 nerve root has the largest load range., Conclusions: Cervical extraforaminal ligaments can disperse the tension load on the nerve root and play a role in protecting the nerve root. The protective effect of the C5 nerve root was the strongest, and this may anatomically explain why the C5 nerve roots are less prone to simple avulsion.

Background: Fluoroscopy-guided blockade of the greater occipital nerve (GON) is an accepted method for treating the symptoms of cervicogenic headaches (CGHs). However, the spread patterns among different injectate volumes of fluoroscopy-guided GON blocks are not well defined., Objective: A cadaveric study was established to determine the spread patterns of different volumes of dye injectate within a fluoroscopic GON block. Study Design . Cadaveric study. Setting . Xingtai Institute of Orthopaedics; Orthopaedic Hospital of Xingtai., Methods: 15 formalin-fixed cadavers with intact cervical spines were randomized in a 1 : 1 : 1 ratio to receive a fluoroscopy-guided GON injection of a 2, 3.5, or 5 ml volume of methylene blue. The suboccipital regions were dissected to investigate nerve involvement., Results: The suboccipital triangle regions, including the suboccipital nerves and GONs, were deeply stained in all cadavers. The third occipital nerve (TON) was stained in 7 of 10 administered 2 ml injections and in all the 3.5 ml and 5 ml injections. Compared to the 3 ml injectate group, the 5 mL cohort consistently saw injectate spreading to both superficial and distant muscles. Limitations . Given that cadavers were used in this study, cadaveric soft tissue composition and architecture can potentially become distorted and consequently affect injectate diffusion., Conclusions: A 3.5 or 5 mL fluoroscopy-guided GON injection of methylene blue successfully stains the GON, TON, and suboccipital nerves. This suggests that such an injection would generate blockade of all three nerve groups, which may contribute to the efficacy of the block for CGH. A volume of 3.5 ml may be enough for the performance of a fluoroscopy-guided GON block for therapeutic purposes., Competing Interests: All the authors declare that they have no conflicts of interest., (Copyright © 2020 Zhanfeng Song et al.)

Background: Cervical vertigo commonly concurs in patients with neck pain, but the concurrent mechanism of these 2 symptoms still remains unclear. We previously reported a bidirectional segmental nerve fiber connection between cervical spinal and sympathetic ganglia, which provided a hypothesis that this connection between the 2 ganglia may be the anatomic basis for the concurrence of neck pain and cervical vertigo. However, this concurrent mechanism needs biochemical and functional evidence., Objectives: This study aimed to investigate a possible noradrenergic pathway between cervical spinal and sympathetic ganglia., Study Design: We performed both clinical and laboratory research. Clinical observation was a prospective case-control study., Setting: Clinical study took place in our hospital; laboratory study was in an orthopedic laboratory., Methods: Cervical lamina block therapy used in patients with cervical vertigo was clinically evaluated; norepinephrine (NE) expressions in cervical sympathetic ganglia were analyzed using immunohistochemical staining after electrical stimulation to the cervical spinal ganglia; the influence of phentolamine local injection to the vertebrobasilar artery flow was experimentally measured., Results: Cervical lamina block therapy could significantly shorten the clinical hospital stays of patients with cervical vertigo (P = 0.000) and improve vertebral artery flow (P < 0.05). NE expressions in superior cervical sympathetic ganglia (SCG) or inferior cervical sympathetic ganglia (ICG) increased significantly when ipsilateral C2 to C3 or C6 to C8 spinal ganglia were electrically stimulated, respectively. Adrenergic receptor block with phentolamine significantly inhibited the decrease of basilar artery (BA) flow induced by electrical stimulation of the cervical spinal ganglia. The change range of BA flow caused by stimulations of C2 to C3 and C6 to C8 spinal ganglia was more than that of C4 and C5., Limitations: The inpatients observed in this clinical study might be influenced by some factors including emotion, diet, sleep, and others. The limitations of the laboratory study included animal species and small sample size., Conclusions: Adrenergic system could play a part in cervical spinal ganglia altering the vertebrobasilar artery system. It could provide a neurochemical foundation between neck pain and vertigo, and that segmental functional connections exist between cervical spinal and sympathetic ganglia., Key Words: Cervical vertigo, neck pain, cervical sympathetic ganglia, cervical spinal ganglia, noradrenaline.

Background: Cervical proprioception is critical in the maintenance of posture and movements, so its assessment in different cervical conditions has gained importance in recent clinical practice. Studies reporting this assessment in subjects with cervical spondylosis (CS) have not previously been investigated. The goals of the study are (1) comparison of joint position error (JPE) in subjects with CS to healthy control group. (2) Correlation of neck pain intensity to cervical proprioception in patients with CS., Methods: In a Cross-sectional study, 132 subjects with CS and 132 healthy age-matched control subjects were evaluated for cervical JPE with the cervical range of motion device. The subjects were blindfolded and repositioned their heads to a target position, which was determined by the examiner previously and their repositioning accuracy (absolute error in degrees) was measured in the frontal (flexion and extension) and transverse planes (left rotation and right rotation). The CS subjects resting neck pain intensity was assessed using visual analog scale (VAS)., Results: CS subjects showed statistically significantly larger JPEs compared to healthy control subjects in all the directions tested (flexion - 95% CI = 2.38-3.55, p < 0.001, extension - 95% CI =3.26-4.33, p < 0.001, left rotation - 95% CI = 2.64 - 3.83, p < 0.001, right rotation - 95% CI = 3.77-4.76, p < 0.001). The mean JPE errors in the CS group ranged from 6.27° to 8.28° and in the control group ranged from 2.36° to 4.48°. Pearson's correlation coefficient showed a significant and positive relationship between neck pain intensity and cervical proprioception (p ≤ 0.001)., Conclusions: Proprioception is impaired in subjects with CS when compared to healthy control group. Higher pain intensity was associated with greater cervical JPE in patients with CS.

Background: Benign osseous lesions of the spine are common but precise population prevalence estimates are lacking. Our study aimed to provide the first population-based prevalence estimates and examine association with back and neck pain., Materials and Methods: We used data from the population-based Study of Health in Pomerania (SHIP). Whole-body MRI examinations (1.5 Tesla: T1, T2, and TIRM weightings) were available from 3,259 participants. Readings of the spinal MRI images were conducted according to a standardized protocol by a single reader (JS). The intra-rater reliability was greater than Kappa values of 0.98. Pain measures included the seven-day prevalence of spine pain and neck pain, and average spine pain intensity due to spine pain during the past three months., Results: We found 1,200 (36.8%) participants with at least one osseous lesion (2,080 lesions in total). Osseous lesions were less common in men than in women (35.5% vs 38.9%; P = .06). The prevalence of osseous lesions was highest at L2 in both sexes. The prevalence of osseous lesions increased with age. Up to eight osseous lesions were observed in a single subject. Hemangioma (28%), and lipoma (13%) occurred most often. Sclerosis (1.7%), aneurysmal bone cysts (0.7%), and blastoma (0.3%) were rare. Different osseous lesions occurred more often in combination with each other. The association with back or neck pain was mostly negligible., Conclusion: Osseous lesions are common in the general population but of no clinical relevance for spinal pain. The prevalence of osseous lesions varied strongly across different regions of the spine and was also associated with age and gender. Our population-based data offer new insights and assist in judging the relevance of osseous lesions observed on MRIs of patients., Competing Interests: The authors have declared that no competing interests exist.

We investigated a technique to reconstruct the suprascapular nerve in patients with C5/C6 brachial plexus palsies, using pectoral fascicles from the ipsilateral C7 root. Using a supraclavicular approach in eight cadavers, the suprascapular nerve was placed side by side with an anterior quadrant fascicle from the C7 root. Several criteria were assessed, including the fascicle length, the overlap between the two nerves and their respective diameters. The mean length of the C7 fascicles was 19.3 mm, with a mean overlap of 4.7 mm. The suprascapular nerve and the C7 fascicles had mean diameters of 2.2 mm and 2.1 mm, respectively. Pectoral fascicles from C7 seem to be an option for reconstruction of the suprascapular nerve in C5/C6 palsies. Clinical studies will be required to establish the potential limitations of this transfer, especially in cases with complex lesions of the suprascapular nerve.

Background: Atlantoaxial fusion often requires C2 nerve transection for complete C1 lateral mass exposure. Nerve transection is made ideally at the preganglionic segment proximal to the dorsal root ganglion to minimize the risk of postoperative dysesthesias. If the nerve is transected too proximally, cerebrospinal fluid leak may be encountered by violation of the dura and arachnoid where the sensory and motor nerve rootlets exit the subarachnoid space. In this study we aimed to quantify the length of the C2 nerve preganglionic segment using cadaveric specimens and develop a method for reliable intraoperative localization for sectioning during C1-2 arthrodesis., Methods: Using microsurgical techniques, 16 C2 nerves from 8 frozen and injected cadaveric cervical spine specimens were dissected. Two key measurements were taken to establish a reliable method of preganglionic segment identification. The "sweet spot" for nerve transection was based on the approximate location of the midpoint of the preganglionic segment., Results: The final determination of the ideal spot for C2 nerve transection using these calculations was 3 mm lateral to the medial border of the lateral mass., Conclusions: This anatomic study found remarkable consistency in the preganglionic segment length. The medial border of the lateral mass appeared to be a consistently reliable landmark for identification of the preganglionic segment of the C2 nerve root. By using relationships between known anatomic structures intraoperatively, safety of atlantoaxial fixation can be optimized to maximize complication avoidance and satisfactory patient outcomes., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Cervicogenic headache (CEH) is characterized by unilateral posterior head and neck pain originating from cervical structures and may be improved or resolved by successful treatment of the causative cervical disorder or lesion. Cervical medial branch radiofrequency (RF) lesion therapy is effective in some CEH patients with no significant pathologic abnormalities that can be surgically corrected. However, patients with refractory CEH are often encountered clinically., Case Description: Here we describe the case of a 68-year-old female with an 18-year history of CEH who did not respond to a series of treatments including nonsteroidal antiinflammatory drugs, anticonvulsants, medial branch diagnostic block, medial branch RF lesion, and spinal cord stimulation. After careful examination, we performed percutaneous endoscopic right C2-C3 medial branch neurotomy under local anesthesia and neuroleptanalgesia. The patient's constant pain was ultimately relieved., Conclusions: For patients with refractory CEH who failed medial branch RF lesion, which could be relieved briefly by diagnostic medial branch injection, percutaneous endoscopic C2-C3 medial branches neurotomy may alleviate their pain under the premise of full informed consent, accurate localization, careful intraoperative exploration, and stimulation testing., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Background: Rising evidence indicate that oxytocin and IL-1β impact trigemino-nociceptive signaling. Current perspectives on migraine physiopathology emphasize a cytokine bias towards a pro-inflammatory status. The anti-nociceptive impact of oxytocin has been reported in preclinical and human trials. Cervical non-invasive vagus nerve stimulation (nVNS) emerges as an add-on treatment for the preventive and abortive use in migraine. Less is known about its potential to modulate saliva inflammatory signaling in migraine patients. The rationale was to perform inter-ictal saliva measures of oxytocin and IL-1ß along with headache assessment in migraine patients with 10 weeks adjunctive nVNS compared to healthy controls., Methods: 12 migraineurs and 12 suitably matched healthy control were studied with inter-ictal saliva assay of pro- and anti-neuroinflammatory cytokines using enzyme-linked immuno assay techniques along with assessment of headache severity/frequency and associated functional capacity at baseline and after 10 weeks adjunctive cervical nVNS., Results: nVNS significantly reduced headache severity (VAS), frequency (headache days and total number of attacks) and significantly improved sleep quality compared to baseline (p < 0.01). Inter-ictal saliva oxytocin and IL-1β were significantly elevated pre- as well as post-nVNS compared to healthy controls (p < 0.01) and similarly showed changes that may reflect the observed clinical effects., Conclusions: Our results add to accumulating evidence for a therapeutic efficacy of adjunct cervical non-invasive vagus nerve stimulation in migraine patients. This study failed to provide an evidence-derived conclusion addressed to the predictive value and usefulness of saliva assays due to its uncontrolled study design. However, saliva screening of mediators associated with trigemino-nociceptive traffic represents a novel approach, thus deserve future targeted headache research. Trial registration This study was indexed at the German Register for Clinical Trials (DRKS No. 00011089) registered on 21.09.2016.

Introduction: Contralateral cervical seventh nerve root (CC7) transfer has been widely applied for treatment of traumatic brachial plexus injury. The purpose of the study was to evaluate outcomes of patients with global brachial plexus avulsion (GBPA) after CC7 transfer and compare the recoveries of median nerve as the only recipient nerve and one of the multiple recipient nerves., Methods: A retrospective review of 51 patients treated with CC7 transfers after GBPA was carried out. The British Medical Research Council (MRC) grading system and range of joint motion (ROM) were used for motor and sensory assessment., Results: The effective rates of FCR were 57.7%, 45.5%, and 36.4% in CC7 transfer to median nerve (CC7-Md), CC7 transfer to median nerve and biceps branch (CC7-Md+Bic) and CC7 transfer to median nerve and triceps branch (CC7-Md+Tric) groups, respectively. There were no statistical differences no matter in FCR or FDS among groups. The effective rate in biceps had no significant difference with that in triceps. The effective sensory recovery rate was 65.4%, 54.5%, and 36.4% in CC7-Md, CC7-Md+Bic, and CC7-Md+Tric groups. There were no statistical differences in the sensory effective recovery rate among groups. All the ROMs were improved significantly after surgery. The improvement of ROM of elbow flexion after surgery in CC7-Md+Bic group was significantly larger than that of elbow extension after surgery in CC7-Md+Tric group (p = 0.047)., Conclusions: The CC7 transfer contributed to the functional improvement of the hand and wrist for the patients with global brachial plexus avulsion. The whole CC7 could be used to repair more than one recipient nerve (including median nerve) without affecting the recovery of median nerve. When CC7 was used to repair two nerves, biceps branch might be preferred to choose as one recipient nerve rather than triceps branch., (© 2018 The Authors. Brain and Behavior published by Wiley Periodicals, Inc.)

The mammalian imprinted Dlk1-Dio3 locus produces multiple long non-coding RNAs (lncRNAs) from the maternally inherited allele, including Meg3 (i.e., Gtl2 ) in the mammalian genome. Although this locus has well-characterized functions in stem cell and tumor contexts, its role during neural development is unknown. By profiling cell types at each stage of embryonic stem cell-derived motor neurons (ESC~MNs) that recapitulate spinal cord development, we uncovered that lncRNAs expressed from the Dlk1-Dio3 locus are predominantly and gradually enriched in rostral motor neurons (MNs). Mechanistically, Meg3 and other Dlk1-Dio3 locus-derived lncRNAs facilitate Ezh2/Jarid2 interactions. Loss of these lncRNAs compromises the H3K27me3 landscape, leading to aberrant expression of progenitor and caudal Hox genes in postmitotic MNs. Our data thus illustrate that these lncRNAs in the Dlk1-Dio3 locus, particularly Meg3 , play a critical role in maintaining postmitotic MN cell fate by repressing progenitor genes and they shape MN subtype identity by regulating Hox genes., Competing Interests: YY, WH, YT, YL, EL, HH, YC, TL, MC, JL, SL, JH, JC No competing interests declared, (© 2018, Yen et al.)

Background: When surgical treatment of cervical vertebral malformation is considered, precise localization of compression sites is essential, but remains challenging. Magnetic motor evoked potentials (mMEP) from paravertebral muscles are useful in localizing spinal cord lesions, but no information about cervical muscle mMEP in horses is available yet. Therefore, the aim of this study was to determine the possibility, normal values, inter- and intra-observer agreement and factors that have an effect on cervical mMEP in healthy horses., Methods: Transcranial magnetic stimulation was performed on 50 normal horses and 4 (2 left, 2 right) muscle responses were recorded at the middle of each cervical vertebra (C1-C7) and additionally just caudal to C7 to evaluate cervical nerves (Cn) Cn1 to Cn8. Latency time and amplitude of the recorded mMEP were defined by both an experienced and an unexperienced operator., Results: Latency increased gradually from 14.2 ± 1.38 ms for Cn3 to 17.7 ± 1.36 ms for Cn8, was significantly influenced by cervical nerve (P < 0.01), gender (P = 0.02) and height (P = 0.03) and had a good intra-observer agreement. The smallest mean amplitude (4.35 ± 2.37 mV) was found at Cn2, the largest (5.99 ± 2.53 mV) at Cn3. Amplitude was only significantly influenced by cervical nerve (P < 0.01) and had a low intra-observer agreement. No significant effect of observer on latency (P = 0.88) or amplitude (P = 0.99) measurements was found., Conclusion: mMEP of cervical muscles in normal horses are easy to collect and to evaluate with limited intra- and inter-observer variation concerning amplitude and should be investigated in future studies in ataxic horses to evaluate its clinical value.

BACKGROUND Surgeons usually transfer the contralateral C7 to the median nerve on the injured side via a nerve graft to recover sensation and movement in a paralyzed hand. The purpose of our study was to determine whether NRG-1 affects the recovery of nerve function in brachial plexus injury after contralateral C7 nerve root transfer in a rat model. MATERIAL AND METHODS An injury model of left brachial plexus and contralateral C7 nerve root transfer was established. Four weeks after the operation, NRG-1 expression was examined by reverse transcription quantitative polymerase chain reaction and Western blot analysis. The diameter rate differences of the healthy limb and affected limb were estimated. The postoperative mass of the left latissimus dorsi, triceps, extensor carpi radialis brevis, and musculus extensor digitorum were examined. The number of nerve fibers and typical area of the affected side were assessed. Postoperative left motor nerve conduction velocity (MNCV) and motor nerve action potential (MNAP) were tested by use of a biological information recording and collecting system. RESULTS Eukaryotic expression plasmid of pcDNA4/myc/A-NRG-1 was successfully constructed, and NRG-1 was overexpressed. Compared with the model group, the NRG-1 group had a lower rate of differences of the limbs; higher mass of left latissimus dorsi, triceps, extensor carpi radialis brevis, and musculus extensor digitorum; more nerve fibers and larger typical area in the affected side, left MNCV, and MNAP; and wider CSA of the left triceps. CONCLUSIONS These results demonstrated that NRG-1 can promote recovery of nerve function in brachial plexus injury after contralateral C7 nerve root transfer in rats.

Objective: Transoral odontoidectomy and ventral C1-2 stabilization are important surgical procedures, performed to decompress ventral spinal cord, and to stabilize craniovertebral junction. These procedures require knowledge regarding surgical anatomy of neurovascular structures ventral to the C1-2 complex. The aim of this study is to evaluate the relationships between neurovascular structures and bony landmarks in ventral atlantoaxial complex., Materials and Methods: This study was performed on six formaldehyde fixed cadaveric head and neck specimens. Relevant anatomical parameters, including distances from the midsagittal line to internal carotid arteries (ICA), vertebral arteries (VA), and hypoglossal nerves (HN), were measured using electronic calipers., Results: The mean distance between ICA and midsagittal line was observed as 26.13 mm at the level of axis and 24.67 mm at the level of the atlas. The mean distance between VA and midsagittal line was observed as 15.38 mm at the level of axis and 26.54 mm at the level of the atlas. The mean distance between HN and midsagittal line was observed as 33.27 and 33.58 mm at the level of the atlas and axis, respectively., Conclusion: This study confirmed that ICA and HN proceeded ventrally or laterally along the lateral aspect of the C1 lateral mass; therefore, the area located ventrally along the medial components of the C1 lateral mass was the safe zone for anterior surgical approach.

Objective: The aim of the study was to evaluate the prevalence of vulnerable vessels around the target of cervical transforaminal epidural steroid injection at the C3-C7 cervical nerve root levels in a clinical setting., Design: Retrospective, cross-sectional study was conducted., Participants: Patients complaining of neck or arm pain with no previous surgical history and who had undergone both precontrast and contrast-enhanced neck computed tomography were included retrospectively., Results: In 26 (21.0%) of 124 patients, none of the vulnerable vessels around the target of cervical transforaminal epidural steroid injection around both sides of the C3-C7 nerve roots were observed. Of 248 cervical root levels, the C3 level had 103 vessels (41.5%), the C4 level had 110 vessels (44.4%), the C5 level had 98 vessels (39.5%), the C6 level had 59 vessels (23.8%), and the C7 level had 34 vessels (13.7%) close to each target nerve root. In addition, variations of the vertebral artery at the C4-C7 level were observed in 11 (8.9%) of 124 patients., Conclusions: To prevent unexpected critical complications involving injury to vulnerable vessels during cervical transforaminal epidural steroid injection, it is recommended to routinely evaluate the vulnerable vessels around the cervical nerve root with computed tomography or Doppler ultrasound before cervical transforaminal epidural steroid injection, especially for the upper cervical nerve root level.

Well-adapted motor actions require intact and well-integrated information from all of the sensory systems, specifically the visual, vestibular, and somatosensory systems, including proprioception. Proprioception is involved in the sensorimotor control by providing the central nervous system with an updated body schema of the biomechanical and spatial properties of the body parts. With regard to the cervical spine, proprioceptive information from joint and muscle mechanoreceptors is integrated with vestibular and visual feedback to control head position, head orientation, and whole body posture. Postural control is highly complex and proprioception from joints is an important contributor to the system. Altitude has been used as a paradigm to study the mechanisms of postural control. Determining the mechanisms of postural control that are affected by moderate altitude is important as unpressurized aircrafts routinely operate at altitudes where hypoxia may be a concern. Deficits in motor performance arise when the reliance on proprioceptive feedback is abolished either experimentally or because of a disorder. As pilots require good neck motor control to counteract the weight of their head gear and proprioceptive information plays an important role in this process, the aim of this study was to determine if hypoxia at moderate altitudes would impair proprioception measured by joint position sense of the cervical spine in healthy subjects., Methods: Thirty-six healthy subjects (Neck Disability Index < 5) volunteered to participate. Neck position sense was evaluated using a three-dimensional motion analyzer. To create the environment, a hypobaric chamber was used to simulate artificial moderate altitude. Head repositioning error was measured by asking the subject to perform a head-to-neutral task after submaximal flexion-extension and right/left rotation movements, and a head-to-target task, in which the subjects had to return to a 30° right and left rotation position., Findings: Exposure to artificial acute moderate altitude of 7,000 feet had no significant effects on cervical joint position sense measured by head repositioning accuracy in healthy subjects. Discussion/impact/recommendations: Postural control mechanisms are very sensitive to acute mild hypoxia and have been recently investigated. Acute hypobaric hypoxia at moderate and high altitudes has a negative effect on postural control. However, which part of the postural system is affected has not yet been determined and proprioception has been little investigated. The results from this study highlighted that in healthy subjects with good cervical spine proprioception at baseline, artificial hypoxia induced by the simulation of moderate altitude does not increase head repositioning error. Further studies should investigate cervical joint position sense in real aircraft, at different altitudes and in a group of experienced helicopter pilots, to evaluate the impact of moderate altitude on cervical joint position sense in a different population. Conducting the same experiments in a population of pilots and in real flight conditions should be considered, since various factors such as the level of proprioception, head posture, type of movement, head load, muscle fatigue, flight altitude, and the length of flight time might influence the kinesthetic sensitivity., (Reprint & Copyright © 2017 Association of Military Surgeons of the U.S.)

Study Design: Immunohistochemistry labeled pre- and postsynaptic structural markers to quantify excitatory and inhibitory synapses in the spinal superficial dorsal horn at 14 days after painful facet joint injury in the rat., Objective: The objective of this study was to investigate the relationship between pain and synapse density in the spinal cord after facet injury., Summary of Background Data: Neck pain is a major contributor to disability and often becomes chronic. The cervical facet joints are susceptible to loading-induced painful injury, initiating spinal central sensitization responses. Although excitatory synapse plasticity has been reported in the superficial dorsal horn early after painful facet injury, whether excitatory and/or inhibitory synapse density is altered at a time when pain is maintained is unknown., Methods: Rats underwent either a painful C6/C7 facet joint distraction or sham surgery. Mechanical hyperalgesia was measured and immunohistochemistry techniques for synapse quantification were used to quantify excitatory and inhibitory synapse densities in the superficial dorsal horn at day 14. Logarithmic correlation analyses evaluated whether the severity of facet injury correlated with either behavioral or synaptic outcomes., Results: Facet joint injury induces pain that is sustained until day 14 (P <0.001) and both significantly greater excitatory synapse density (P = 0.042) and lower inhibitory synapse density (P = 0.0029) in the superficial dorsal horn at day 14. Injury severity is significantly correlated with pain at days 1 (P = 0.0011) and 14 (P = 0.0002), but only with inhibitory, not excitatory, synapse density (P = 0.0025) at day 14., Conclusion: This study demonstrates a role for structural plasticity in both excitatory and inhibitory synapses in the maintenance of facet-mediated joint pain, and that altered inhibitory, but not excitatory, synapse density correlates to the severity of painful joint injury. Understanding the functional consequences of this spinal structural plasticity is critical to elucidate mechanisms of chronic joint pain., Level of Evidence: N /A.

Ultrasound-guided cervical medial branch block (CMBB) is commonly performed to diagnose and treat head, neck, and shoulder pain. However, its use at the C7 level has been shown to be less accurate than at other levels, which may increase the chance of injury owing to the imprecision of needle site provided by the ultrasound guide. We report the first case of iatrogenic spinal cord injury from an ultrasound-guided C7 CMBB. The patient, upon receiving this procedure, had fainted shortly after experiencing an electrical sensation that ran from the neck to the toe. The patient complained of weakness and tingling sensation in the left upper extremity. Cervical magnetic resonance imaging revealed a hematoma in the cervical spinal cord, and an electrophysiological study, which was performed at 3 weeks after the incident, revealed an injury at the left C3-T2 anterior horn. After 2 months of rehabilitation, the patient showed moderate improvement in the strength of the left proximal upper extremity; however, there was no improvement in the strength of the left distal upper extremity. Therefore, we recommend caution when performing ultrasound-guided CMBB at the C7 level, as the guide particularly at this level is relatively inaccurate, posing a risk of spinal cord injury.

Purpose of Review: The ability of ultrasound to provide detailed anatomic visualization while avoiding radiation exposure continues to make it an appealing tool for many practitioners of chronic pain management. This review will present the most recent evidence regarding the use of ultrasound-guidance for the performance of interventional procedures in the treatment of chronic pain., Recent Findings: For a variety of different procedures, studies continue to compare ultrasound-guided techniques to commonly used fluoroscopic or landmark-based techniques. Small, randomized controlled trials are beginning to demonstrate that ultrasound-guided approaches to interventional pain procedures can be as well tolerated and effective as the traditionally used techniques, while providing some potential advantages in terms of decreased radiation exposure, avoidance of vascular structures, and in some cases, improved efficiency and decreased rates of adverse effects., Summary: Despite continued interest in ultrasound-guided techniques for chronic pain management procedures, the evidence is still limited mainly to small, randomized trials and case series. For some procedures, such as stellate ganglion block and peripheral joint injections, recent evidence appears to be tilting in favor of ultrasound-guidance as the preferred technique, though fluoroscopy continues to be a much more reliable method for detection of intravascular uptake of injectate.

Background Context: Innervation of anatomical structures is fundamental to their capacity to generate nociceptive impulses. Cervical spine meniscoids are hypothesized to be contributors to neck pain; however, their innervation is not comprehensively understood., Purpose: This study aimed to examine the presence and morphology of nerve fibers within cervical spine meniscoids and adjacent joint capsules., Study Design: This is a cross-sectional study., Patient Sample: The sample consists of cervical hemispines of 12 embalmed cadavers (mean [standard deviation] age 82.9 [6.5] years, six female, six left). Either the right or the left half of the cervical spine (hemispine) of each cadaver was included in the sample. So six left sides and six right sides of the cadaver cervical spines made up the 12 hemispines that formed the sample., Methods: Cervical spine meniscoids and adjacent joint capsules were excised from lateral atlantoaxial and cervical zygapophyseal (C2-C3 to C6-C7) joints (n=67), then paraffin embedded. Meniscoids were sectioned sagittally (5 µm), slide mounted, and immunohistochemistry was performed using primary antibodies to neurofilament heavy (NF-H) and pan-neurofilament (Pan-NF) to identify nerve tissue. The study was supported by institutional graduate student funding. The authors have no conflicts of interest to declare., Results: Seventy-seven meniscoids (23 lateral atlantoaxial, 54 cervical zygapophyseal) were extracted and processed (154 sections in total). Sixty-four individual nerve fiber bundles were identified (26 NF-H positive, 38 Pan-NF positive) from 14 meniscoids. Nerves immunoreactive to both NF-H and Pan-NF were identified in 13 of 77 meniscoids (10 of 14 lateral atlantoaxial joint) from 11 joints (eight cadavers). Nerves were always located in joint capsules except three exclusively Pan-NF immunoreactive nerve fiber bundles from two adipose meniscoids., Conclusions: The low nerve prevalence in elderly cervical spine meniscoids, with nerves only found in two adipose type meniscoids, suggests these structures may play a minimal role in cervical nociception generation in this demographic. The joint capsules, which were more frequently innervated, appear to be more likely generators of nociception in the elderly. Joint capsule nerves were mostly NF-H positive, indicating potential Aδ-fiber presence., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Introduction: The significance of cervical proprioception for human balance has thus far not been sufficiently elucidated. The aim of this study was to provoke selective cervico-vestibular stimulation using the trunk excursion test (TET) we ourselves constructed. This chair is designed to enable evaluation of cervico-ocular reactions during isolated trunk excursion and possible effects of aging., Methods: The previously used head excursion test (HET) was statistically compared to the TET. In both methods, 100 healthy subjects of two age groups (group(26): median age = 26 years, n = 50; group(50): median age = 50 years, n = 50) were randomized for comparison of similar neck-to-trunk-positions., Results: HET enabled detection of significant nystagmus modulation in horizontal and vertical dimensions; whereas in pure cervical stimulation using the new TET, this was only evident in the horizontal dimension and only during trunk torsion. Comparison of the two methods confirmed significantly stronger nystagmus modulation through head excursion. In terms of the HET, group(50) showed significantly more vertical nystagmus activity than group(26). However, no significant difference was found between the groups in terms of their reactions to trunk excursion in the TET. In a group-specific comparison of the methods, group(26) showed a significant increase in horizontal nystagmus in head compared to trunk excursion, whereas group(50) generally displayed a significantly greater response to provocation by head excursion in HET. Analysis of the significant vertical nystagmus modulation produced with the TET method showed predominance of upbeat- (UBN) over downbeat-nystagmus (DBN). Through head excursion with the HET, DBN was more frequently evoked in group(50) than in group(26). No significant age-dependent difference could be derived in UBN., Conclusion: The results of the pilot study indicate that head-to-trunk provocation is a suitable means of evaluating cervicotonic provocation nystagmus. Only by evaluation of adequate excursion limits and consistent analysis of patients with cervical deficiency can the effects of the method be further assessed.

Background: Recently, various examination and intervention techniques using cervical nerve ultrasonography have been developed. The specific shapes of the C7 transverse process and vertebral artery in front of the C7 transverse process have become landmarks., Purpose: To determine the prevalence of anomalies and anomalous vertebral artery entrances at the C7 transverse process., Material and Methods: The records of patients who underwent plain or contrast-enhanced neck or cervical spine computed tomography (CT) were reviewed. The examinations were scored for the anomalous presence of anterior tubercles or cervical ribs as well as vertebral artery entrances in the C7 transverse process. The prevalence of anomalies was compared based on patient sex and age., Results: Evaluating the examinations from 2067 patients (1046 men; 1021 women), 1% of patients exhibited an anomalous presence of anterior tubercles, and 0.3% of patients displayed cervical ribs at the C7 transverse process. The prevalence of anomalies process was significantly higher in men aged less than 40 years than in older men (P < 0.001), whereas the prevalence was not higher in women aged less than 40 years than in older women. The prevalence of vertebral artery entry into the C7 transverse foramen was 0.6%., Conclusion: Although an anomalous vertebral artery entry into the C7 transverse foramen was rare, the prevalence of an anomaly at the C7 transverse process was higher in men aged less than 40 years. Therefore, we recommend performing CT in younger men before cervical nerve ultrasonographic intervention to avoid misinterpretations at the cervical level., (© The Foundation Acta Radiologica 2015.)

Objective: The objective of this study was to provide anatomical data on modified contralateral C7 (cC7) nerve root transfers by dissecting and measuring the separable lengths of the C7 root, trunk, and divisions., Materials and Methods: Fifteen adult cervicothoracic specimens were dissected and measured using Vernier calipers after exposing the brachial plexus. Measurements included the length of the C7 from the root to the trunk, the lengths of the C7 root-trunk-anterior division (and posterior division). The epineuria at the C7 root-division-cord junctions were opened until the internal nerve bundles fused together and could not be separated by microdissection. The lengths of the C7 root-trunk-anterior (and posterior) division were measured again after microdissection. The lengths of cC7 nerve of 20 patients with bracial plexus avulsion were measured using the former technique., Results: The length of the C7 root-trunk was 45.87 SD 10.43 mm. Before separation, the lengths of the C7 root-trunk-anterior division and the root-trunk-posterior division were 61.14 SD 13.44 and 54.63 SD 11.35 mm, respectively; after separation, the lengths were 74.67 SD 12.86 and 68.73 SD 11.86 mm, respectively. The prolonged lengths were 13.15 SD 4.26 and 14.21 SD 6.98 mm, respectively. The prolonged lengths were significantly greater (p < 0.05). The prolonged length of C7 nerve clinically was anterior division, 15.30 SD 3.76 mm and posterior division, 11.10 SD 3.01 mm., Conclusion: The C7 division lengths can be prolonged by dissecting the epineuria at the division-cord junction of the C7 nerve root., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

In the current cadaveric study an unusual sizeable accessory phrenic nerve (APN) was encountered emerging from the trunk of the supraclavicular nerves and forming a triangular loop that was anastomosing with the phrenic nerve. That neural loop surrounded the superficial cervical artery which displayed a spiral course. The form of a triangular loop of APN involving the aforementioned artery and originating from the supraclavicular nerve to the best of our knowledge has not been documented previously in the literature. The variable morphological features of the APN along with its clinical applications are briefly discussed.

To explore suggestive evidence of focal proximal demyelination in multifocal motor neuropathy (MMN) without overt evidence of conduction block, we conducted sonographical assessment of cervical nerve roots in 9 MMN patients, 22 ALS patients, and 17 control subjects. The mean diameters of the C5 and C6 roots in MMN patients were significantly larger than those in ALS and controls, especially on the clinically dominant side. Although non-specific, sonography can be a potentially useful diagnostic procedure to support the diagnosis of MMN, even when overt conduction block is lacking.

Background: Age-related changes occur in both the peripheral and central nervous system, yet little is known about the influence of chronic pain on pain sensitivity in older persons. The aim of this study was to investigate pain sensitivity in elders with chronic neck pain compared to healthy elders., Methods: Thirty elderly women with chronic neck pain and 30 controls were recruited. Measures of pain sensitivity included pressure pain thresholds, heat/cold pain thresholds and suprathreshold heat pain responses. The pain measures were assessed over the cervical spine and at a remote site, the tibialis anterior muscle., Results: Elders with chronic neck pain had lower pressure pain threshold over the articular pillar of C5-C6 and decreased cold pain thresholds over the cervical spine and tibialis anterior muscle when compared with controls (p < 0.05). There were no between group differences in heat pain thresholds and suprathreshold heat pain responses (p > 0.05)., Conclusion: The presence of pain hypersensitivity in elderly women with chronic neck pain appears to be dependent on types of painful stimuli. This may reflect changes in the peripheral and central nervous system with age.

Objective: To investigate the incidence of C5 nerve root palsy after multi-segmental cervical decompression through different approaches., Methods: This study was conducted among 375 patients undergoing multi-segmental cervical decompression in anterior corpectomy and fusion fixation, anterior cervical corpectomy and fusion fixation + posterior decompression and fusion fixation, posterior cervical laminectomy decompression, fusion and internal fixation, and posterior laminoplasty and fusion groups. The exclusion criteria included lack of follow-up data, spinal cord injury preventing preoperative or postoperative motor testing, or surgery not involving the C5 level. The incidence of C5 palsy was determined and the potential risk factors C5 palsy were analyzed including age, sex, revision surgery, preoperative weakness, diabetes, smoking, number of levels decompressed, and a history of previous upper extremity surgery., Results: Of the 375 patients, 60 patients were excluded and the data of 315 patients were analyzed, including 146 women and 169 men with a mean age of 57.7 years (range 39-72 years). The overall incidence of C5 nerve palsy was 6.03% (19/315) in these patients; in the subgroups receiving different surgeries, the incidence was 8.62% in the cervical road laminectomy and fusion fixation group, 7.79% in the anterior cervical corpectomy and fusion fixation + posterior decompression and fusion and internal fixation, 4.68% in the anterior corpectomy and fusion fixation group, and 3.85% in the posterior laminoplasty and fusion group. No significant difference was found in the incidences among the subgroups, but men were more likely than women to develop cervical nerve root palsy (8.28% vs 3.42%, P<0.05)., Conclusion: The overall incidence of C5 nerve palsy following postoperative cervical spinal decompression was 6.03% in our cohort. The incidence of C5 nerve palsy did not differ significantly following different cervical decompression surgeries, but the incidence was the highest in the posterior cervical laminectomy and fusion and internal fixation group.

An analysis has shown association between a vertebral dysfunction and dysfunction in the autonomic nervous system in children. Medical follow-up and electroencephalography, myographic and rheoencephalography findings has allowed concluding over clinical importance of the complaints on the back pain and changes in the cervical part of a backbone for diagnostics, prevention and treatment of autonomous dysfunction.

Background and Objectives: Cervical medial branch blocks are used to treat patients with chronic neck pain. The aim of this study was to clarify the anatomical aspects of the cervical medial branches to improve the accuracy and safety of radiofrequency denervation., Methods: Twenty cervical specimens were harvested from 20 adult cadavers. The anatomical parameters of the C4-C7 cervical medial branches were measured. The 3-dimensional computed tomography reconstruction images of the bone were also analyzed., Results: Based on cadaveric analysis, most of the cervical dorsal rami gave off 1 medial branch; however, the cervical dorsal rami gave off 2 medial branches in 27%, 15%, 2%, and 0% at the vertebral level C4, C5, C6, and C7, respectively. The diameters of the medial branches varied from 1.0 to 1.2 mm, and the average distance from the notch of inferior articular process to the medial branches was about 2 mm. Most of the bifurcation sites were located at the medial side of the posterior tubercle of the transverse process. On the analysis of 3-dimensional computed tomography reconstruction images, cervical medial branches (C4 to C6) passed through the upper 49% to 53% of a line between the tips of 2 consecutive superior articular processes (anterior line). Also, cervical medial branches passed through the upper 28% to 35% of a line between the midpoints of 2 consecutive facet joints (midline)., Conclusions: The present anatomical study may help improve accuracy and safety during radiofrequency denervation of the cervical medial branches.

Ten forelimbs of five Myrmecophaga tridactyla were examined to study the anatomy of the brachial plexus. The brachial plexuses of the M. tridactyla observed in the present study were formed by the ventral rami of the last four cervical spinal nerves, C5 through C8, and the first thoracic spinal nerve, T1. These primary roots joined to form two trunks: a cranial trunk comprising ventral rami from C5-C7 and a caudal trunk receiving ventral rami from C8-T1. The nerves originated from these trunks and their most constant arrangement were as follows: suprascapular (C5-C7), subscapular (C5-C7), cranial pectoral (C5-C8), caudal pectoral (C8-T1), axillary (C5-C7), musculocutaneous (C5-C7), radial (C5-T1), median (C5-T1), ulnar (C5-T1), thoracodorsal (C5-C8), lateral thoracic (C7-T1) and long thoracic (C6-C7). In general, the brachial plexus in the M. tridactyla is similar to the plexuses in mammals, but the number of rami contributing to the formation of each nerve in the M. tridactyla was found to be larger than those of most mammals. This feature may be related to the very distinctive anatomical specializations of the forelimb of the anteaters., (© 2013 Blackwell Verlag GmbH.)

Contralateral C7 (cC7) root transfer to reconstruct brachial plexus injury (BPI) has been widely used. A revised technique that cC7 root was transferred to lower trunk via the prespinal route with direct neurorrhaphy has been reported clinically. The aim of this experimental study was to develop an animal model of the modified surgical approach in order to obtain quantification index of postoperative nerve regeneration and muscle morphology. Sixty adult Sprague-Dawley rats randomized into experimental and control groups of 30 each. In the experimental group, after total brachial plexus injury (BPI) the cC7 root was transferred to lower trunk via the prespinal route with direct neurorrhaphy, and in the control group the brachial plexus was only exposed without intervention. Electrophysiological study, muscle tension test, neuromorphology, muscle wet weight, and muscle fiber cross-sectional area measurements were obtained 4, 8, and 12 weeks postoperatively. Median and ulnar nerve regeneration and the forearm flexor muscles functional recovery were obtained by cC7 root transfer to lower trunk via the prespinal route when measured at 12 weeks following the operation though the parameters had not recovered to normal value. We concealed the control and experimental groups from those who did the evaluations., (Copyright © 2014 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.)

Objective: Progressive atrophy and loss of motor axons is a hallmark of amyotrophic lateral sclerosis (ALS). Limited sonographic data are available on potential detection of atrophy of peripheral nerves and nerve roots in ALS., Methods: Patients with either definite or probable ALS and control subjects underwent sonographic evaluation of the cervical roots (C5, C6, and C7) and peripheral nerves (median and ulnar nerves) on the right. These diameters and cross-sectional areas (C6, median, and ulnar nerves) were compared., Results: The diameters and cross-sectional areas were consistently smaller in ALS than in controls. No correlation was present between the sonographic parameters and the disease severity, disease duration, age, or gender. The overall sensitivity and specificity tended to be greater in the cervical nerve roots than in the peripheral nerves., Conclusions: This study shows atrophy of cervical nerve roots and peripheral nerves in ALS detected by sonography. Cervical nerve roots might be more appropriate to detect motor axon loss than peripheral nerves., Significance: Sonographic evaluation of nerve roots and peripheral nerves may be a useful disease marker in ALS to confirm the diagnosis and to potentially monitor the disease progression., (Copyright © 2014 International Federation of Clinical Neurophysiology. Published by Elsevier Ireland Ltd. All rights reserved.)

The denticulate ligaments (DL), 20 or 21 pairs of meningeal extensions, spread from the lateral aspect of the spinal cord to the internal aspect of the spinal dura mater. The aim of this study is to define the specific relationship of the DL with adjacent axilla of the spinal nerve roots and to investigate the anatomical features of the DLs and their variations. The topographical anatomy of the DLs and their relationships with the adjacent axilla of the spinal nerve roots was examined on 16 formalin-fixed adult cadaveric spinal cords. The distances from the dural attachment of the DL to the axilla of the superior and inferior spinal nerve roots were measured bilaterally at every spinal level. Also the distances from the dural attachment of the DL to the lateral aspect of the spinal cord were measured bilaterally. Cervical DLs showed a triangular shape, while in the thoracic segment the ligament changes the shape to "Y." Also the most caudal DL was identified to be at the L1-2 level. Our study revealed that the distances from the dural attachment of the DL to the superior and inferior spinal nerve root axilla were different at the cervical, upper thoracic and the lower thoracic segments. Both distances to the superior and inferior spinal nerve root axilla were shown to increase from cervical to lower thoracic segments. This study provides a detailed anatomy of the DLs and their relationship with the adjacent spinal nerve root axilla., (Copyright © 2013 Wiley Periodicals, Inc.)

Study Design: Immunohistological analysis of the cervical dorsal root ganglia (DRG)., Objective: To investigate immunohistologically in rats whether intradiscal administration of anti-nerve growth factor (NGF) antibody in injured cervical intervertebral discs (IVDs) suppresses pain-related peptide expression in DRG neurons., Summary of Background Data: Neck pain can involve the entire neck and become chronic and intractable. Cervical disc degeneration is a primary cause of neck pain, and pain-related mediators, such as NGF, have been correlated with discogenic pain., Methods: We examined Sprague-Dawley rats that received 10 punctures in the C5-C6 IVD, and were treated with saline (puncture group) or an anti-NGF antibody (anti-NGF group). The retrograde neurotracer Fluoro-Gold (FG) was then injected into the C5-C6 IVD. In addition, we examined a sham group that did not receive punctures (disc nonpuncture). The C2-C7 DRG were harvested 1 week after surgery and immunostained for calcitonin gene-related peptide (CGRP), a marker for peptide-containing neurons. We determined for each group the percentages of FG-labeled DRG neurons that were CGRP-immunoreactive (CGRP-ir)., Results: FG-labeled neurons innervating the C5-C6 IVD were found in all C2-C7 DRG examined. The percentage of FG-labeled CGRP-ir DRG neurons in the puncture group was significantly higher than that observed in the sham (P < 0.001) and anti-NGF groups (P < 0.001), but there was no significant difference between the sham and anti-NGF groups (P > 0.05). Therefore, intradiscal administration of anti-NGF antibody suppressed CGRP expression the cervical DRG., Conclusion: Neurons located in the C2-C7 DRG innervated the C5-C6 IVD. These findings indicate that neck pain may be derived from degenerated IVDs. Furthermore, intradiscal administration of anti-NGF antibody suppressed CGRP expression in the cervical DRG innervating the injured IVD. Therefore, inhibiting NGF upregulation in the cervical IVD may be an efficient treatment for discogenic neck pain., Level of Evidence: N/A.