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Tan: Cervical Angina
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The authors reported an interesting case of cervical angina due to C6–7 disc herniation that was successfully treated with cervical arthroplasty [1]. I commend the authors for their astuteness in clinical diagnosis and great clinical outcome. Even though cervical angina is a well-documented condition, it is often underdiagnosed in the clinical setting, and certainly a condition worth highlighting. Cervical angina was first described in 1934 by Nachlas [2], but has been underrecognized since its initial publication. Its exact prevalence is still unknown, but Ozgur and Marshall [3] reported a 5% prevalence in their large cohort of patients with C7 radiculopathy.
In clinical practice, the presentations of cervical radiculopathy very often may deviate from the dematomal and myotomal distributions of classical teaching. This phenomenon is well documented in the study by Rainville et al. [4], in which they showed overlapping symptoms of C6 and C7 radiculopathies, that further complicated the clinical diagnosis and management. Furthermore, pre- and postfixed brachial plexuses [5] must also be taken into consideration in evaluation of cervical radiculopathy. In a recent cadaveric study by Guday et al. [6], anatomical variations were found to be present in 25% of specimen (17.5% prefixed and 7.5% postfixed). These anatomical variations could certainly lead to symptoms in atypical dematomal and myotomal areas. For example, in a patient with prefixed brachial plexus, a left C6–7 disc herniation may actually cause radiculopathy in the classic T1 dermatomal distribution. In these situations, cervical transforaminal epidural steroid injection and nerve block can be a useful tool for both diagnostic and therapeutic purposes. If symptom relief is obtained from the nerve block, the clinicians can be much more confident about the pain generator and thus formulating treatment plans accordingly.
Cervical angina is an uncommon manifestation of a common pathology. Spine surgeons should be familiar of this entity in their clinical practice to ensure optimal patient outcome.

REFERENCES

1. Al Jammal OM, Diaz-Aguilar LD, Srinivas S, et al. Cervical arthroplasty in the treatment of cervical angina: case report and review of the literature. Neurospine 2020;17:929-38.
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2. Nachlas IW. Pseudo-angina pectoris originating in the cervical spine. JAMA J Am Med Assoc 1934;103:323.
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3. Ozgur BM, Marshall LF. Atypical presentation of C-7 radiculopathy. J Neurosurg 2003;99:169-71.
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4. Rainville J, Joyce AA, Laxer E, et al. Comparison of symptoms from C6 and C7 radiculopathy. Spine 2017;42:1545-51.
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5. Pellerin M, Kimball Z, Tubbs RS, et al. The prefixed and postfixed brachial plexus: a review with surgical implications. Surg Radiol Anat SRA 2010;32:251-60.
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6. Guday E, Bekele A, Muche A. Anatomical study of prefixed versus postfixed brachial plexuses in adult human cadaver: Prefixed versus postfixed brachial plexuses in adult human cadaver. ANZ J Surg 2017;87:399-403.
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