European Spine Journal

, Volume 26, Issue 4, pp 1073–1081 | Cite as

C2 spondylotic radiculopathy: the nerve root impingement mechanism investigated by para-sagittal CT/MRI, dynamic rotational CT, intraoperative microscopic findings, and treated by microscopic posterior foraminotomy

  • Yasushi FujiwaraEmail author
  • Bunichiro Izumi
  • Masami Fujiwara
  • Kazuyoshi Nakanishi
  • Nobuhiro Tanaka
  • Nobuo Adachi
  • Hideki Manabe
Original Article



C2 radiculopathy is known to cause occipito-cervical pain, but their pathology is unclear because of its rarity and unique anatomy. In this paper, we investigated the mechanism of C2 radiculopathy that underwent microscopic cervical foraminotomies (MCF).


Three cases with C2 radiculopathy treated by MCF were investigated retrospectively. The mean follow-up period was 24 months. Pre-operative symptoms, imaging studies including para-sagittal CT and MRI, rotational dynamic CT, and intraoperative findings were investigated.


There were 1 male and 2 females. The age of patients were ranged from 50 to 79 years. All cases had intractable occipito-cervical pain elicited by the cervical rotation. C2 nerve root block was temporally effective. There was unilateral spondylosis in symptomatic side without obvious atlatoaxial instability. Para-sagittal MRI and CT showed severe foraminal stenosis at C1–C2 due to the bony spur derived from the lateral atlanto-axial joints. In one case, dynamic rotational CT showed that the symptomatic foramen became narrower on rotational position. MCF was performed in all cases, and the C2 nerve root was impinged between the inferior edge of the C1 posterior arch and bony spur from the C1–C2 joint. After surgery, occipito-cervical pain disappeared.


This study demonstrated that mechanical impingement of the C2 nerve root is one of the causes of occipito-cervical pain and it was successfully treated by microscopic resection of the inferior edge of the C1 posterior arch. Para-sagittal CT and MRI, rotational dynamic CT, and nerve root block were effective for diagnosis.


Occipital neuralgia Cervicogenic headache Microscopic surgery Foraminotomy Radiculopathy 



We appreciate Mr. Vincent John Hykel for his devoted support.

Compliance with ethical standards

Conflict of interest


Supplementary material

Supplementary material 1 (WMV 121381 kb)


  1. 1.
    Spurling RG, Scoville WB (1944) Lateral rupture of cervical intervertebral disc. A common cause of shoulder and arm pain. Surg Gynecol Obstet 798:350–358Google Scholar
  2. 2.
    Ehni G, Benner B (1984) Occipital neuralgia and the C1–2 arthrosis syndrome. J Neurosurg 61:961–965. doi: 10.3171/jns.1984.61.5.0961 CrossRefPubMedGoogle Scholar
  3. 3.
    Star MJ, Curd JG, Thorne RP (1992) Atlantoaxial lateral mass osteoarthritis. A frequently overlooked cause of severe occipitocervical pain. Spine (Phila Pa 1976) 17:S71–S76CrossRefGoogle Scholar
  4. 4.
    Clavel M, Clavel P (1996) Occipital neuralgia secondary to exuberant callus formation. Case report. J Neurosurg 85:1170–1171. doi: 10.3171/jns.1996.85.6.1170 CrossRefPubMedGoogle Scholar
  5. 5.
    Pakzaban P (2011) Transarticular screw fixation of C1–2 for the treatment of arthropathy-associated occipital neuralgia. J Neurosurg Spine 14:209–214. doi: 10.3171/2010.10.SPINE09815 CrossRefPubMedGoogle Scholar
  6. 6.
    Yeom JS, Riew KD, Kang SS et al (2015) Distraction arthrodesis of the C1–C2 facet joint with preservation of the C2 root for the management of intractable occipital neuralgia caused by C2 root compression. Spine (Phila Pa 1976) 40:E1093–E1102. doi: 10.1097/BRS.0000000000001031 CrossRefGoogle Scholar
  7. 7.
    Pikus HJ, Phillips JM (1996) Outcome of surgical decompression of the second cervical root for cervicogenic headache. Neurosurgery 39:63–70 (discussion 70–1) CrossRefPubMedGoogle Scholar
  8. 8.
    White JB, Atkinson PP, Cloft HJ, Atkinson JLD (2008) Vascular compression as a potential cause of occipital neuralgia: a case report. Cephalalgia 28:78–82. doi: 10.1111/j.1468-2982.2007.01427.x CrossRefPubMedGoogle Scholar
  9. 9.
    Jansen J, Bardosi A, Hildebrandt J, Lücke A (1989) Cervicogenic, hemicranial attacks associated with vascular irritation or compression of the cervical nerve root C2. Clinical manifestations and morphological findings. Pain 39:203–212CrossRefPubMedGoogle Scholar
  10. 10.
    Sharma RR, Parekh HC, Prabhu S et al (1993) Compression of the C-2 root by a rare anomalous ectatic vertebral artery. Case report. J Neurosurg 78:669–672. doi: 10.3171/jns.1993.78.4.0669 CrossRefPubMedGoogle Scholar
  11. 11.
    Poletti CE, Sweet WH (1990) Entrapment of the C2 root and ganglion by the atlanto-epistrophic ligament: clinical syndrome and surgical anatomy. Neurosurgery 27:288–291CrossRefPubMedGoogle Scholar
  12. 12.
    Lu J, Ebraheim NA (1998) Anatomic considerations of C2 nerve root ganglion. Spine (Phila Pa 1976) 23:649–652CrossRefGoogle Scholar
  13. 13.
    Bilge O (2004) An anatomic and morphometric study of C2 nerve root ganglion and its corresponding foramen. Spine (Phila Pa 1976) 29:495–499CrossRefGoogle Scholar
  14. 14.
    Yi M, Lee JW, Yeom JS et al (2014) C2 nerve root on magnetic resonance imaging of occipital neuralgia. Spine (Phila Pa 1976) 39:1077–1083. doi: 10.1097/BRS.0000000000000345 CrossRefGoogle Scholar
  15. 15.
    Cesmebasi A, Muhleman MA, Hulsberg P et al (2015) Occipital neuralgia: anatomic considerations. Clin Anat 28:101–108. doi: 10.1002/ca.22468 CrossRefPubMedGoogle Scholar
  16. 16.
    Sjaastad O, Saunte C, Hovdahl H et al (1983) “Cervicogenic” headache. An hypothesis. Cephalalgia 3:249–256CrossRefPubMedGoogle Scholar
  17. 17.
    Bogduk N, Govind J (2009) Cervicogenic headache: an assessment of the evidence on clinical diagnosis, invasive tests, and treatment. Lancet Neurol 8:959–968. doi: 10.1016/S1474-4422(09)70209-1 CrossRefPubMedGoogle Scholar
  18. 18.
    Morimoto T, Ohtsuka H, Sakaki T, Kawaguchi M (1998) Postlaminectomy cervical spinal cord compression demonstrated by dynamic magnetic resonance imaging. Case report. J Neurosurg 88:155–157. doi: 10.3171/jns.1998.88.1.0155 CrossRefPubMedGoogle Scholar
  19. 19.
    Fujimoto Y, Oka S, Tanaka N et al (2002) Pathophysiology and treatment for cervical flexion myelopathy. Eur Spine J 11:276–285. doi: 10.1007/s005860100344 CrossRefPubMedPubMedCentralGoogle Scholar
  20. 20.
    Fujibayashi S, Neo M, Nakamura T (2007) Flexion myelopathy of the thoracic spine. Case report. J Neurosurg Spine 6:68–72. doi: 10.3171/spi.2007.6.1.13 PubMedGoogle Scholar
  21. 21.
    Bogduk N (1981) Local anesthetic blocks of the second cervical ganglion: a technique with application in occipital headache. Cephalalgia 1:41–50CrossRefPubMedGoogle Scholar
  22. 22.
    Dodwad S-JM, Dodwad S-NM, Prasarn ML et al (2016) Posterior cervical foraminotomy: indications, technique, and outcomes. Clin Spine Surg 29:177–185. doi: 10.1097/BSD.0000000000000384 PubMedGoogle Scholar
  23. 23.
    Smith ZA, Khayatzadeh S, Bakhsheshian J et al (2016) Dimensions of the cervical neural foramen in conditions of spinal deformity: an ex vivo biomechanical investigation using specimen-specific CT imaging. Eur Spine J. doi: 10.1007/s00586-016-4409-4 Google Scholar
  24. 24.
    Kim CH, Kim K-T, Chung CK et al (2015) Minimally invasive cervical foraminotomy and diskectomy for laterally located soft disk herniation. Eur Spine J 24:3005–3012. doi: 10.1007/s00586-015-4198-1 CrossRefPubMedGoogle Scholar
  25. 25.
    Song Z, Zhang Z, Hao J et al (2016) Microsurgery or open cervical foraminotomy for cervical radiculopathy? A systematic review. Int Orthop 40:1335–1343. doi: 10.1007/s00264-016-3193-4 CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2016

Authors and Affiliations

  • Yasushi Fujiwara
    • 1
    Email author
  • Bunichiro Izumi
    • 1
  • Masami Fujiwara
    • 2
  • Kazuyoshi Nakanishi
    • 3
  • Nobuhiro Tanaka
    • 3
  • Nobuo Adachi
    • 3
  • Hideki Manabe
    • 1
  1. 1.Department of Orthopedic SurgeryHiroshima City Asa Citizens HospitalHiroshimaJapan
  2. 2.Department of Orthopedic SurgerySada HospitalFukuokaJapan
  3. 3.Department of Orthopaedic Surgery, Institute of Biomedical & Health SciencesHiroshima UniversityHiroshimaJapan

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