Cervical foraminal stenosis is a common condition that is mostly asymptomatic but in some patients results in cervical radiculopathy.
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Clinical presentation
Cervical foraminal stenosis is most commonly asymptomatic (found in ~20% of the population 8,10) but can result in cervical nerve root compression, which in turn results in cervical radiculopathy (brachalgia) 1 classically presenting as dermatomal distribution neck/arm pain, sensory changes, and/or motor weakness 11.
Pathology
Cervical neural exit foraminal stenosis is most commonly from disc degeneration (reduced foraminal height, uncovertebral arthrosis) or facet joint arthropathy with disc herniation less common 4,11. Less common causes include tumors, trauma, tortuous vertebral artery, meningeal or synovial cysts 11.
Classification
There are a number of proposed grading systems for cervical foraminal stenosis with excellent inter-reader correlation 1. Using the Park system, grades 2 and 3 are associated with positive neurologic manifestations with low sensitivity (~40%) and high specificity (~99%) 5,6.
Kim et al.
This grading is performed on axial T2WI at the level of the disc 2:
grade 0 (normal): narrowest width of the neural foramen is more than the extraforaminal nerve root width at the level of the anterior margin of the superior articular process
grade 1 (moderate or non-severe stenosis): narrowest width of the neural foramen is 51–100% of the width of the extraforaminal nerve root at the level of the anterior margin of the superior articular process
grade 2 (severe stenosis): narrowest width of neural foramen ≤50% of
extraforaminal nerve root width
Park et al.
This grading is performed on sagittal oblique T2WI 3:
grade 0: absent stenosis
grade 1 (mild stenosis): partial (<50% of root circumference) perineural fat obliteration surrounding the nerve root without nerve root morphological change
grade 2 (moderate stenosis): near-complete (>50% of root circumference) perineural fat obliteration without nerve root morphological changes
grade 3 (severe stenosis): nerve root morphological change, e.g. collapse, combined with perineural fat obliteration
Radiographic features
Due to the angulation of the neural exit foramina, oblique CT reconstructions or dedicated oblique sequences angled to 45º are required 8.
MRI
Dedicated T2 FSE sagitall oblique sequences or sagitall oblique T2 SPACE reconstructions are equivalent for the in-plane assessment of neural exit foramina 8.
Treatment and prognosis
Conserative options for acute and mild symptoms include analgesia and physiotherapy 10,11. Transforaminal epidural steroid injection is considered second-line if conserative measures fail at 4-6 weeks 11 and are an effective treatment option but pain reduction may not be associated with the severity of foraminal stenosis 8. Surgery (e.g. ACDF, cervical disc arthroplasty, posterior cervical foraminotomy) is indicated for severe symptoms or symptoms refractory to conservative treatments 10,11.