---
title: 'Discussion'
type: 'lesson'
url: 'https://doc.social/courses/cervical-radiculopathy-spectrum-of-presentation-and-continuum-of-care/discussion'
course: 'Cervical Radiculopathy: Spectrum of Presentation and Continuum of Care'
course_url: 'https://doc.social/courses/cervical-radiculopathy-spectrum-of-presentation-and-continuum-of-care'
position: '5 of 6'
author: 'Dr. Paul Houle'
transcript: 'yes'
---

# Discussion

## Summary

_This lesson is a recording without a written summary._

## Transcript

1,622 words · 9 min · 5 speakers · automatically transcribed (aws-transcribe) and not checked by a person; it may contain errors, particularly in names, drugs and dosages. The recording is the source.

[0:00] Speaker 1: Well, that was, uh, quite an interesting discussion. Now before, as I mentioned before we started, uh, this, people voted, uh, based upon just the imaging what they would do in terms of posterior cervical foraminotomy, ACDF versus, um, arthroplasty, and I'd ask the audience to just type in, uh, to the comment section now after listening, uh, what they would do, but, uh, since we went through this case, um.
[0:29] Speaker 1: I'd like to hear, uh, from each of you, if this were your patient, now, what would you do? And maybe we could start, is Cig are you still there?
[0:39] Speaker 2: Yeah, yeah, Paul, um,
[0:43] Speaker 2: yeah, Paul, I, I'm here, terrific, uh, set of presentations there, and, uh, and in terms of just going round table for a vote, I, I think in somebody who's, who's presenting, uh, as this patient does, um, uh, with, with, with, uh, radicular Pain, a degree of weakness, and, uh, a foraminal stenosis, I, I think a posterior cervical foraminotomy is a, is a nice motion preserving option that doesn't burn a bridge. I think I, I would start with that with the expectation that that would get a good, good result.
[1:09] Speaker 1: Tom, we, we already know what you're gonna say.
[1:14] Speaker 3: Well, if it wasn't comp, I'll tell you, my, uh, if, if, if based on the patient's age, if it wasn't a comp patient, I really, that ACDF would be my last choice. Uh, but if you're in a comp patient with, you know, where you're looking for a more definitive procedure, I would go with ACDF first. Uh, I think that.
[1:31] Speaker 3: That you picked a a case with great equipoise because I do think that every one of these would do well. Um, but if it was just, uh, uh, you know, kind of a young, active, healthy person, I would either do uh arthroplasty or, or a cervical foraminotomy. Debate aside.
[1:51] Speaker 1: Doctor Hartle.
[1:53] Speaker 1: You're not coming through your audio is off, Doctor Harle.
[1:59] Speaker 4: So, so, yeah, so this is a great case. I agree there's a, it could go either way. Uh, the one thing I can tell you is that, you know, if, if the patient, you know, a lot of patients shop around, they see 345 different surgeons, and especially in this case, if, if, if you're the surgeon who can offer a cervical foraminotomy, most patients will gravitate towards, towards that option because no, no, nobody really.
[2:22] Speaker 4: I, I haven't met a patient yet who really likes having implants inserted into their Spine. Uh, obviously it has to be a reasonable option, and I totally agree with Dom and, and with Richard that we have to make sure that residents, fellows don't lose the ability to do this operation.
[2:39] Speaker 4: Uh, as exciting as the Technology is and, and Richard's data is, is, it's really striking. I mean, all the, the Research that has gone into that, the techno technological refinements over the years, if you watch that over the last 15 years, it's amazing, but we gotta make sure we maintain our ability to operate the spectrum, meaning through decompression, disc arthroplastic fusion as indicated.
[3:05] Speaker 5: All right, my turn.
[3:07] Speaker 5: Well, you know, I, I actually side more with Tom, but if he was a reasonable patient and he loved his job, he was going to go back to his job because he had neck Pain and the arm Pain. I would offer him the arthroplasty. Now we have all of our patients see the psychologist. We don't want any baggage. Don't want them on narcotics or anything like that. If he had any of those things, I would do the
[3:31] Speaker 5: ACF for the reason that Dom said is that you don't want to give him a reason to have further complaints. And you know, although the frainotomy, if he wasn't work comp, I, I would have no problem telling a patient, look, you know, we can get rid of your arm Pain and you'll do great and it will work, your rehab and you can, you know, hopefully get rid of your neck Pain. So as Dom said, it was, it was one of
[3:54] Speaker 5: that it can go any of three directions, but you know, I would lean more towards Arthroplasty if he's a reasonable candidate and I felt good about him and wanting to get better and go back to work. Unfortunately, work comp, work comp has a lot of negative, and we don't see so much anymore because they changed the work comp laws. And so the people that we do see are really pretty reasonable people that want to get back to work.
[4:18] Speaker 2: And Dominic, both of you discussed, uh, really patient assessment, patient motivation, and is there a screening tool? Is there, uh, some type of a questionnaire, or what, what are you really looking for there to try and quantify that? Because, uh, in so many cases, it's a bit of a gestalt. But do you, do you have some type of a screening tool Other than, uh, using the, the psychologist that, uh, might be able to assess motivation, might be able to assess, uh, uh, somebody's stick to itiveness or, or their grit.
[4:45] Speaker 5: Well, you know, we do have a psychologist. Andy Block has perfected what we call pre-surgical screening.
[4:52] Speaker 5: And he has a series of tests that they go through, and he will rate them either as a poor candidate or a poor candidate and don't operate, or an OK candidate but needs to see me a little bit longer or perhaps needs to be put on antidepressants, and that's not this case where it's only a couple months, but we do do that. The gestalt I, I use, and you know everybody has their own way, you sort of get a feel for the patient, you know, if they come with their family members, you see a nice relationship. If they
[5:21] Speaker 5: Working if they've not been taking narcotics, if they love their job, those are key things to me. And in fact, years ago we published a paper on the 10 best and the 10 worst lumbar artificial disc patients and try to determine characteristics. We looked at X-rays. We looked at how that was positioned. We looked at all sorts of things, the positioning, for example, sometimes we we put them in and we'd go, Oh my God, that looks terrible. It had no relation. The only thing that made a difference was whether or not.
[5:51] Speaker 5: The patient was working 13 weeks prior to Surgery. It wasn't a great study, but it was interesting. We took our 10 best and our 10 worst, and that's the only thing that made a difference. So I think that that tells you a lot about the patient's motivation and, and what they enjoy.
[6:06] Speaker 2: Rick, Rick, you're, you're, you're directing a uh Spine arthroplasty center there, and, uh, so I'm imagining a good number of your patients coming with the expectation of getting an arthroplasty. When do you say no to arthroplasty? When do you say no, this, this just wouldn't be a good option for you?
[6:21] Speaker 5: Well, you know, Dom sort of alluded to a little bit. For example, if they have facet Arthritis, there is no way you're going to put an artificial disc in them. And if they had no preoperative range of motion, there's no way. Although I must admit that, you know, some of my colleagues that, you know, do a lot of cervical arthroplasty, they're starting to do more and more spondylytic patients. And just like in lumbar arthroplasty, we will do patients that
[6:44] Speaker 5: Almost have bone on bone and you can still get motion back with them, but it requires getting a CT scan to assess those facet joints. The Other thing that Dom talked about is they have significant cervical kyphosis. Now, you know, an arthroplasy is not going to correct them. That's somebody you ought to do a fusion on.
[7:01] Speaker 5: And you know, he also mentioned about bone density. We routinely would screen all our lumbar and cervical patients, and we found that less than 3% of our cervical patients did we kick out because of osteopenia, because unlike the lumbar Spine where you need normal bone density, all the cervical arthroplasty studies basically said that they couldn't have osteoporosis. Now some were different. Osteoporosis is a T score that compares them to a.
[7:29] Speaker 5: 25 year old that should be less than -2.5. Some of the studies were -1.5, some were -2.0, um, but even the ones that went up to, you know, the osteopenia level, uh, didn't really have a significant amount of, um, collapse or subsidence. So we, we look for the reason not to do them. And of course if they have autoimmune disease and if they're on, you know, steroids and, uh, various immunosuppressants, you don't want to be doing them, doing.
[7:57] Speaker 3: What, what is your cutoff for T score for arthroplasty?
[8:01] Speaker 5: Well, lumbar arthroplasty in the lumbar Spine is -1.0, and in the cervical, uh, we stopped doing them unless they had a history of a Fracture. Then we'll go and do a bone density. But if they have had a Fracture, then they probably have osteoporosis. So, you know, we, we recently changed that do, and it was only after we looked at all our patients and, and we presented that actually, and it's, it's going to be published soon.
[8:25] Speaker 5: Um, so we're much more liberal in the cervical Spine because remember a lot of these patients, uh, even if they're older, they'll have some sclerotic end plates and as long as you don't violate them, they'll be OK.

## In this course

- [Previous: Dr. Guyer - CDR](https://doc.social/llms/courses/cervical-radiculopathy-spectrum-of-presentation-and-continuum-of-care/dr-guyer-cdr.md)
- [Next: Treatment Reveal](https://doc.social/llms/courses/cervical-radiculopathy-spectrum-of-presentation-and-continuum-of-care/treatment-reveal.md)
- [All lessons: Cervical Radiculopathy: Spectrum of Presentation and Continuum of Care](https://doc.social/llms/courses/cervical-radiculopathy-spectrum-of-presentation-and-continuum-of-care.md)