Rotator cuff tears with cervical radiculopathy

1 REVIEW ARTICLESR otator cuff tears with cervical radiculopathySteven J. Hattrup, MDa,*, Robert H. Cofield, MDbaDepartment of Orthopedic Surgery, Mayo Clinic Arizona, Phoenix, AZbDepartment of Orthopedic Surgery, Mayo Clinic, Rochester, MNIntroductionShoulder pain is commonly attributed to Rotator cuff tears , with an estimated million US physician visits in 2002for cuff the tear may be treatedconservatively at times, surgical repair is also a treatmentoption. The timing of such surgery and a reasonable esti-mation of the chances of success of such surgery areimportant considerations for the surgeon and pain can also be produced by an extrinsic causesuch as cervical radiculopathy . Such a source of pain cancoexist with a Rotator cuff tear and have some influence onthe treatment process for the cuff tear. The purpose of thisreview is to examine the overlap of these 2 problems andtheir cervical spine is composed of 7 cervical the first (the atlas) and second (the axis) cervicalvertebrae are quite distinct in their appearance, theremaining third to seventh vertebrae are similar to eachother.

2 They articulate anteriorly via the intervertebral , these vertebrae articulate through the facetjoints, also known as zygapophyseal joints. The unco-vertebral joints, or joints of Luschka, are found morelaterally on the vertebral bodies and also articulate with thesuperior facet. The foramina for the nerve roots are formedby the facet posterolaterally and uncovertebral joints ante-romedially, the pedicles, and the edge of the intervertebraldisk and vertebral end ,53 There are 8 cervicalnerve roots; they exit superior to their respective vertebralbody, with the exception of the eighth nerve root, whichexits inferior to the seventh cervical vertebral body. Thefifth through eighth cervical roots, together with the firstthoracic nerve root, combine to form the trunks, divisions,and cords of the brachial plexus and, ultimately, theperipheral nerves of the upper Rotator cuff is composed of the subscapularis,supraspinatus, infraspinatus, and teres minor originating from the subscapular fossa on thescapula, the subscapularis inserts on the lesser tuberosity ofthe proximal humerus.

3 The supraspinatus originates in thesuprascapular fossa, the infraspinatus in the infrascapularfossa, and the teres minor from the lateral border of thescapula. These 3 muscles all insert on the greater nerve supply to the Rotator cuff muscles includes theupper and lower subscapular nerves, which innervate thesubscapularis muscle. The suprascapular nerve passes underthe suprascapular ligament into the suprascapular fossa toinnervate the supraspinatus muscle and then around the spi-noglenoid notch to supply the infraspinatus muscle. The teresminor is supplied by the axillary nerve. These nerves receivefibers from the C5 and C6 spinal roots (Figure 1).The Rotator cuff muscles assist in shoulder subscapularis is an internal Rotator of the glenohumeraljoint, the supraspinatus is an abductor, and the infraspinatusand teres minor are external rotators. In addition, the rotatorcuff muscles act in concert to stabilize the glenohumeraljoint and provide an effective center of rotation for thedeltoid and other shoulder girdle ,10 Rotator cuff tearsThe prevalence of Rotator cuff tears increases with the ageof the examined ,60,61,65,67 Tempelhof et al,61*Reprint requests: Steven J.

4 Hattrup, MD, Department of OrthopedicSurgery, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ Hattrup).J Shoulder Elbow Surg (2010) 19, $ - see front matter 2010 Journal of Shoulder and Elbow Surgery Board of a study of asymptomatic volunteers, reported thefrequency of a tear at 13% in the sixth decade of life, 20%in the seventh decade, 31% in the eighth decade, andfinally, 51% in the ninth decade. Moosmayer et al47simi-larly examined the age-related frequency of full-thicknessrotator cuff tears in asymptomatic volunteers. The overallprevalence was , increasing from at age 50 to 59years, to at 60 to 69 years, and to 15% at 70 to 79years. Worland et al65reported a much higher prevalence offull-thickness tearing, at 40%, over the age of 50 presentation of a Rotator cuff tear can be quitevariable. Some patients are asymptomatic with preservedfunction and little if any ,51,56At the other extreme,patients may have severe pain with use, sleep disturbance,and profound dysfunction.

5 Irrespective of symptoms, thepresence of a Rotator cuff tear has been associated with bothmuscle atrophy and fatty ,48 These factorshave been shown by Gerber et al23to be inversely related toloss of strength in the shoulder. Successful repair of the cufftear has been shown only to retard the advancement of fattyinfiltration and modestly improve the degree of ,24 Conversely, both conservative management ofthe tear and failure of the surgical repair lead to increasedatrophy and ,69 Although patients tend tohave superior outcomes if the repair heals, patients are stilloften clinically improved with unsuccessful Rotator ,35 Nevertheless, fatty infiltration of the supra-spinatus and infraspinatus, atrophy of the supraspinatus,and glenohumeral osteoarthritis all worsen after a ,35 Increased atrophy and fatty infiltration are inturn related to estimates of residual muscle function basedon motor unit amplitude on electromyograms (EMGs).

6 49 The increased prevalence of tears over time, thecommon finding of an increase in tear size, and the wors-ening of the muscle functional capacity with progressiveatrophy and fatty infiltration have led some surgeons tobelieve that Rotator cuff tears should be repaired early intheir ,66 Ellman et al22showed poorer results withsurgery with increased preoperative weakness of theshoulder, less active range of motion, and narrowing of theacromiohumeral distance suggestive of a larger tear. Bur-khart et al,11while finding that patients with advanced fattyinfiltration of the cuff muscles can often benefit fromrotator cuff repair, also found that the improvement wasnot nearly as good in the patients with more advancedfatty infiltration. Other authors have believed that thesymptoms from Rotator cuff tears , especially from chronictears, can often be successfully treated with ,43,51,56,69As noted previously, progressivedeterioration of the torn musculotendinous unit radicular diseaseSimilar to Rotator cuff disease, degenerative disk disease isage in the third decade of life, thehydration of the nucleus starts to diminish, accompanied byfissuring of the ,42,50 Subtle instability of thediskevertebral body complex can result, followed bydevelopment of osteophytes in the facet joints and joints ofFigure 1 Anterior (A) and posterior (B) views of shoulder muscles and their nerve supply.

7 The deltoid and teres minor muscles areinnervated by the axillary nerve, a branch of the posterior cord of the brachial plexus. The subscapularis is supplied by the upper and lowersubscapular nerves. The supraspinatus and infraspinatus muscles are innervated by the suprascapular nerve, which is a branch of the uppertrunk of the brachial plexus. These nerves all contain fibers from the fifth and sixth cervical nerve Hattrup, CofieldLuschka and, ultimately, narrowing of the spinal sum of these age-related degenerative changes in thespinal column is termed spondylosis. 55It is extremelycommon, evidenced in approximately 80% to 85% ofindividuals as they approach the mid-sixth to seventhdecade of ,39,44 Degenerative disk disease is mostcommonly found at the C5-6 can result in axial neck pain, as well ascervical radiculopathy and cervical Radi-culopathy refers to the presence of pain, sensory changes,or motor deficits in a dermatomal distribution and can existwith or without neck pain.

8 Myelopathy is diagnosed whenlong track signs in the upper and lower extremities arepresent. radiculopathy is generally produced by 1 of ,50 Most commonly, disk herniation occursthrough an annular fissure, typically through the posteriorlateral , foraminal stenosis due to thedegenerative changes can impinge on the nerve root(Figure 2). Other potential etiologies of compressive radi-culopathy include trauma, synovial cyst, tumor, meningealcyst, and arteriovenous clinical presentation of cervical radiculopathy wasexamined by Henderson et analyzing over 700patients, they found that arm pain was present in 99%,sensory changes in 85%, and neck pain in 80%. In addition,reflex changes were present in 71% and motor deficits in68%. The localization of the arm pain is related to the levelof root compression. A C4 radiculopathy can produce painradiating from the neck to the superior aspect of theshoulder and posteriorly to the findingscan be difficult to detect with this level of a lesion.

9 Rotatorcuff disease is more commonly mimicked by a C5radiculopathy. Pain in this situation is commonly localizedto the shoulder and weakness found in abduction andexternal rotation of the from cervicalradiculopathy is usually incomplete; profound weaknessand atrophy are uncommon except in chronic pattern of pain and weakness can also beproduced by a suprascapular ,57 The diagnosis of a radiculopathy can be made with well-defined symptoms and neurologic examination with a cor-responding structural lesion on an imaging study, generallya magnetic resonance imaging ,6 Electrophysiologicstudies can be useful to confirm the diagnosis and toexclude other neurologic ,45,46,55In a radicul-opathy, fibrillation potentials and positive sharp waves willtypically be present in the paraspinal muscles and themuscles of the involved myotome. Alrawi et al3showedthat the use of neurophysiologic testing led to superiorresults when the clinical and imaging examinations wereinconclusive.

10 Nerve conduction and electromyographicstudies can also be useful to detect the presence of coex-isting nerve entrapment such as carpal tunnel by Upton and McComas,62this double-crush phenomenon results from increased sensitivity of a nerve tocompression injury distal to a more proximal the presence of spondylosis becomesprogressively more common through life, the peak inci-dence and prevalence of cervical radiculopathy are both inthe sixth decade of life and then ,59 Researchersat the Mayo Clinic found the annual incidence of radicul-opathy to be 83 per 100,000 population in a study ofOlmsted County, most common level ofradiculopathy was found to be at the C7 root, followed byFigure 2 Anteroposterior (A) and lateral (B) computed tomography images of this cervical spine show unusually prolific hypertrophicarthrosis of the facet joint producing severe narrowing of the left C4-5 foramina consistent with a C5 cuff tears with cervical radiculopathy939the C6 nerve root.