Download Cervical Radiculopathy

Cervical Radiculopathy
Tips to sub-side the pain
So, what can you do about this? Well, I'm going to give you 3 tips you can use
from the comfort of your home to not only alleviate the pain, but also get to the
source of the problem and help the disc heal, rather than just numb the pain.
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My first recommendation would be that you use ice over the C6 C7 disc.
Using real ice rather than an artificial ice pack will provide better results.
Place the ice at the base of your neck, and leave it there for 15 minutes, or
until you feel numbness - whichever comes first.
The real key with ice is that you have to use it multiple times, and you have
to be consistent to alleviate the pain. I recommend that you repeat the ice
treatment every hour that you are awake, and you should start to notice
some relief after 3 or 4 treatments.
It usually takes about 3 days of using ice to notice considerable relief, so
stick with it - this is usually the fastest way to relief.
My next piece of advice is to be careful with your sleeping position. I am
referring to a couple of things here - first, make sure you are not sleeping
on more than 1 pillow. Elevating your head too high is a big problem with a
C6 C7 herniated disc, because this position adds a lot of extra strain on the
injured disc.
In addition to that, make sure you are not sleeping on your stomach. This
also aggravates the injured disc, and you will dramatically slow your
healing time. Always sleep on your back or sides.
My final piece of advice is to gently bounce on a therapy ball. These are the
large balls, you see people using at gyms - they usually use them to work
on their abdominal muscles. Simply sit on the ball, keep your head looking
straight ahead, and gently bounce up and down for about 5 minutes a day.
I know that sounds a bit odd, but remember when we were talking about the
nutrients and oxygen inside of the jelly of the disc. Well, the only way to get more
nutrients and oxygen into the disc for healing is to physically pump it. Bouncing
on the therapy ball is a simple way to accomplish this.
Uncomplicated neck pain and cervical strain is the result of muscular and
ligamentous factors related to posture, sleep habits, ergonomics such as computer
monitor position, stress, chronic muscular fatigue, postural adaptation to other
primary pain sources such as the shoulder, or degenerative changes of the cervical
discs or facet joints. This is termed axial neck pain (ICD-9 code 723.1.)
Axial neck pain is the most common cause of neck pain and has a high rate of
spontaneous resolution. Axial neck pain typically presents as pain or soreness in the
posterior paraspinal neck muscles, with radiation to the occiput, shoulder, or
parascapular region. Stiffness in one or more directions of motion and headache are
common along with localized areas of muscle tenderness (tender points). Neck pain
is defined in a region bounded superiorly by the superior nuchal line, laterally by the
lateral margins of the neck, and inferiorly by an imaginary transverse line through
the T1 spinous process.
Cervical radiculopathy (ICD-9 723.4) is motor and/or sensory changes in the upper
extremity resulting from extrinsic pressure on a cervical nerve root. The pressure is
usually by encroachment from annular disc bulging without frank Herniation or from
disc degeneration/spondylises (hard disc pathology) or disc material from loss of
internal containment such as Herniation or extrusion (soft disc pathology). An
inflammatory response is most likely associated with initiation or exacerbation of
symptoms and inflammatory chemical pain mediators are known to be involved with
disc Herniation.
According to Humphreys et al, foraminal heights, widths and areas were larger in
asymptomatic patients. Inferior facet, hypertrophy tended to decrease the width of
the foramen and significantly affects the available area for the exiting nerve root in
aging people.
Additionally, in Lu J, et al noted, reduction of the foramina area after a 1 mm
narrowing of the disc space was 29% to 30%. Reduction of 30% to 40% of the
foraminal area was noted with a 2 mm narrowing of the disc space. Reduction of
35% to 45% of the foramina area was noted with a 3 mm narrowing of the disc
space. Therefore, the size of the intervertebral foramen is directly related to the
height of the disc space. Sever neuroforaminal narrowing is associated with a 3 mm
vertical reduction of the disc space.
Henderson et al studied radiculopathy symptoms and noted 99% had arm pain, 85%
had sensory deficits, 79% had neck pain, 71% had reflex deficits, 68% had motor
deficits, and 52% had scapular pain.
In contrast to the patient with isolated axial neck pain, the patient with radiculopathy
more frequently has unilateral neck pain that then radiates ipsilaterally into the
distribution of the affected nerve root.
The most common levels of root involvement in cervical radiculopathy are C6 and
C7; high cervical radiculopathy (C2-C4) are less common. The absence of radiating
symptoms in a dermatomal distribution does not rule out the presence of
symptomatic nerve root compression. Regardless of the root level that is
compressed, a patient may report upper trapezial and interscapular pain. In many
patients with cervical root compression, the focal point of pain is not uncommonly
the shoulder girdle area, regardless of the root level involved, and the symptoms
may not radiate any farther down the arm.
According to Yasuhisa Tanaka et al, neck or scapular pain may often precede arm or
finger symptoms in cervical root compression. Free nerve endings have been
identified in the dural sheath of the cervical roots and are responsible for the
mediation of pain. In the author’s experience, during diagnostic root injections to
detect the involved level the patients perceive first only neck or scapular pain and
afterwards arm or finger pain as the needle is inserted deep into the root.
Accordingly, neck or scapular pain is probably the initial symptom of cervical
radiculopathy when the compression is confined to the dural sheath. In clinical
practice, it is common to see patients who have neck or scapular pain
unaccompanied by radicular symptoms in the arm or fingers.
Most physicians doubt that the pain originates from a nerve root. However, the pain
is usually the initial symptom in radiculopathy and can last alone as long as a few
weeks or more before the arm or finger symptoms develop. Therefore, neck and
scapular pain without symptoms in the arm or finger can originate in the root.
Pain in the suprascapular region indicates C5 or C6 radiculopathy. The same applies
to the relationships between the pain in the interscapular region and C7 or C8
radiculopathy, and between pain in the scapular region and C8 radiculopathy.
Crossover between myotomes and dermatomes may be present. Cervical nerve roots
exit above their correspondingly numbered pedicles; for example, the C6 root exits
between C5 and C6. The exception to this rule is the C8 root, which exits above the
T1 pedicle. In contrast to the lumbar spine, where poster lateral pathologies usually
impinge on the traversing nerve roots and foramina pathologies on the exiting nerve
roots, compressive lesions in the cervical spine tend to produce radiculopathy of the
exiting nerve root. For example, both a poster lateral C5- C6 disk Herniation and C5C6 foramina Stenosis from an uncovertebral osteophyte usually lead to C6
radiculopathy. It is possible, however, for a large central to midlateral disk
Herniation or stenosis to affect the subjacent root.
Cervical Radiculopathy Patterns
Root
Symptoms
Motor
Function
Reflex
C2
Posterior occipital
headaches, temporal pain
None
None
C3
Occipital headache, retroorbital or retro auricular
pain
None
None
C4
Base of neck, trapezial pain
None
None
C5
Laeral arm pain
Deltoid
Biceps
C6
Radial forearm pain, pain in
thumb and index fingers
Biceps, wrist
extension
Brachioradialis
C7
Middle finger pain
Triceps, wrist
flexion
Triceps
C8
Pain in ring and little fingers Finger flexors
T1
Ulnar forearm pain
None
Hand intrinsic None
As Bogduk would remind us, cervical Radicular pain has conventionally been
addressed in the context of cervical radiculopathy, but it is not synonymous with
cervical Radicular pain. Cervical radiculopathy is a neuralgic condition characterized
by objective signs of loss of neurologic function, that is, some combination of
sensory loss, motor loss, or impaired reflexes, in a segmental distribution. None of
these features constitutes pain.
Cervical radiculopathy has a common feature of compressing or otherwise
compromising a cervical spinal nerve or its roots. The axons of these nerves are
either compressed directly or are rendered ischemic by compression of their blood
supply. Symptoms of sensory loss or motor loss arise as a result of blockage of
conduction along the affected axons. The features of cervical radiculopathy,
therefore, are essentially negative in nature–they reflect loss of function. In contrast,
pain is a positive feature not caused by loss of nerve function. If compression is to be
invoked as a mechanism for pain, it must explicitly relate to compression of a dorsal
root ganglion.
Radicular pain is shooting, stabbing, or electric in nature, traveling distally into the
affected limb, consistent with a massive discharge from multiple affected axons.
Radicular pain is commonly associated with parenthesis.
Unlike the sensory loss of cervical radiculopathy, the pattern of cervical Radicular
pain is not dermatomal. Radicular pain is perceived deeply, through the shoulder
girdle and into the upper limb proper. Radicular pain from C5 tends to remain in the
arm, but pain from C6, C7, and C8 extends into the forearm and hand. These
patterns of distribution indicate that the pain is not restricted to cutaneous afferents.
It involves afferents from deep tissues, such as muscles and joints, as well. Because
the segmental innervations of deep tissues are not the same as that of skin,
Radicular pain cannot be, and is not, dermatomal in distribution.
Muscles of the shoulder girdle are innervated by C6 and C7, well away from the
dermatomes of these nerves. If anything, the segmental innervations of muscles are
a much better guide to the distribution of Radicular pain than are the dermatomes.
Dermatomes are nonetheless relevant for the distribution of the neuralgic signs of
radiculopathy, but this distribution of neuralgic signs has nothing to do with the
distribution of pain.
Let human noted that cervical radiculopathy was associated with increased tender
spots on the side of radiculopathy, with predilection toward muscles innervated by
the involved nerve root. It was stated, "The presence of tender spots that are
primarily unilateral should alert clinicians to look for a source of referral, and
radiculopathy or radiculitis should be considered as a diagnosis within a broad
differential that includes internal disk derangement and facet arthropathy. If other
confirmatory signs of cervical radiculopathy, as reflex and strength changes,
accompany tender spots the presentation should not be interpreted as 2 distinct
pathologies (e.g., C7 radiculopathy and myofascial pain syndrome). In that case,
cervical radiculopathy with referred tenderness should be considered. Injection, ice,
therapeutic ultrasound, electric stimulation, and acupressure are widely used to treat
tender spots. However, in cases of cervical radiculopathy with tender spots in the
upper extremity, our results suggest that treatment should be directed to the
cervical spine where the pathology is located."
Lack of agreement in distinguishing trigger points from tender points, even among
experienced clinicians, leads to classify both as simply “tender spots” for the purpose
of this diagram.
Cyriax proposed that tender spots could be referred from cervical disks and/or neural
structures. He noticed that tender spots in the scapula region moved to different
locations within minutes after the neck was treated with traction and manipulation.
Cannon’s law from Cannon and Rosenblatt implies that cervical radiculopathy could
cause a phenomenon of “myalgia hyperalgesia” or “denervation super sensitivity” in
the muscles supplied by its axons. If tender spots in the Para scapular and upper
extremity could be referred from cervical structures, treatment in those cases should
be directed to the spine and not to the tender spot.
Because they are innervated, all of the muscles, synovial joints, and intervertebral
discs of the neck are potential sources of neck pain, along with the cervical dura
mater and the vertebral artery.
It has been shown that stimulation of the cervical zygapophysial joints causes neck
pain and referred pain. Pain from the cervical zygapophysial joints tends to follow
relatively constant and recognizable segments patterns. From the C2-3 level pain is
referred rostrally to the head. From C3-4, and C4-5, it is located over the posterior
neck. From C5-6, it spreads over the supraspinous fossa of the scapula. From C6-7 it
spreads, further caudally over the scapula. Essentially similar patterns of pain have
been produced by mechanical stimulation of cervical Intervertebral disks. This fact
underscores the rule that, it is not the structure, that determines the pattern of pain
stemming from it; rather, the pattern of pain is determined by the nerve supply of
the structure. Thus, any structure innervated by the same cervical segmental nerves
will have the same distribution of pain. Clinically, discogenic pain cannot be
distinguished from zygapophysial joint pain, but the distribution of pain serves as a
reasonable guide to the most likely segmental location of its source.
In principle, this rule would also apply to neck muscles. Pain from muscles
innervated by a particular segment should be perceived in the same location as pain
from articular structures innervated by the same segment.
In a clinical setting, there are Provocative Tests for Radiculopathy which may help to
determine the nature of pain and the possibility of response to simple therapeutic
measures.
ttp://www.airnecktraction.com/radiculopathy.html
C-1, C-2, C-3,C-4,C-5,C-6,C-7,C-8
Pinch nerve in neck pain in arm treatment
by Nathan Wei, MD, FACP, FACR
Nathan Wei is a nationally known board-certified rheumatologist and author of the
Second Opinion Arthritis Treatment Kit. It is available exclusively at this website... not
available in stores.
A pinched nerve in the neck is one of the most common problems seen in a
rheumatologist’s office. Often, the patient will provide a history indicating a prior
whiplash injury or other trauma.
In older patients, the underlying cause is usually cervical spondylises (osteoarthritis
in the neck). A herniated or bulging disc may also be the culprit. It is helpful to
examine the anatomy of the neck to understand this problem.
The cervical spine (neck) is made up of seven vertebrae. C-1 articulates with the
occiput of the skull above and with C-2 below.
The atlanto-occipital joint primarily allows flexion and extension, while the
atlantoaxial articulation primarily provides rotation. Vertebrae C-3 through C-7 as an
interdependent group allow for varying degrees of flexion, extension, lateral bending,
and rotation. Flexion centers on C-5 and C-6 and extension on C-6 and C-7, which is
why degenerative changes and spine injuries most commonly occur at these levels.
Intervertebral disks are found from C2-3 and below and are subjected to significant
deformation during flexion and extension. Disk degeneration may be painful in its
own right, while Herniation can lead to compression of the nerve root (radiculopathy)
or spinal cord (myelopathy). The term “radiculopathy” refers to a pinched nerve.
Eight pairs of cervical spinal nerves exit bilaterally through the intervertebral
foramina. Each spinal nerve is named for the vertebra above which it exits; for
example, the C-6 nerve exits above the C-6 vertebra. Therefore, a herniated disk or
significant foramina narrowing at the C5-6 level will most commonly involve the C-6
nerve. The exception is the C-8 spinal nerve, which exits between the C-7 and T-1
vertebrae.
The posterior aspect of the cervical vertebral articulation contains the facet joints,
which are true synovial joints, while a bony lip off the lateral margin of the upper
vertebral body forms the uncovertebral joint with the vertebra below. Both joints
are subject to degenerative changes that may produce pain with cervical extension
combined with lateral bending and rotation. Hypertrophy of these joints may affect
the surrounding anatomic structures, including the spinal cord, nerve roots, and
exiting spinal nerves, as well as the vertebral artery and the sympathetic rami.
The muscles of the neck are divided into four major compartments: anterior
(flexion), posterior (extension), and the lateral groups (lateral bending).
The posterior muscles are the strongest group and most likely to be the source of
pain in conditions resulting from poor posture, in which these muscles are chronically
contracting to hold the head upright. The weaker anterior and lateral muscles are
involved more in whiplash type injuries in which they stretch suddenly. The most
common type of injury is muscle strain. Muscle strains usually resolve within a few
days to a couple of weeks, ligament sprains may take up to a couple of months, and
disk injuries or Herniation with radiculopathy can take 3 to 6 months for full
recovery.
Chronic pain beyond 6 months is likely associated with a degenerative process, be it
in the disk, bone, or ligament, or from subtle mechanical instability caused by faulty
posture or biomechanics.
Pain that increases with activity or within a few hours after activity, but settles down
with rest or a change in position is commonly referred to as mechanical pain. Pain
that persists or worsens despite rest and treatment, pain that persists around the
clock, or pain that worsens at night raises suspicion for a metabolic or neoplastic
condition or for psychosocial factors that prolong recovery. It is important to
determine whether the pain is localized or radiating; therefore, knowledge of the
anatomic region is essential.
Localized pain generally points to muscle strains, ligament sprains, and facet or disk
(degenerative) processes, although these structures commonly radiate pain to the
scapula or upper trapezius area as well. Pain that radiates into the upper limbs
frequently stems from nerve involvement, although myofascial pain radiation
patterns occur occasionally.
It is not uncommon for pinched nerves in the neck to cause bizarre symptoms such
as facial pain, ringing in the ears, headaches, and chest pain. A careful history and
physical examination are critical.
Upper cervical nerve injuries are relatively rare and refer dysesthetic (painful
numbness and tingling) pain to the head (C-1, C-2), the neck (C-3), and the upper
trapezius region (C-4). The C-5 nerve transmits pain to the shoulder and lateral arm,
and occasionally the radial forearm.
The C-6 nerve pattern is very similar but invariably includes the radial forearm and
thumb, and occasionally the index finger. The C-7 nerve refers pain to the posterior
arm, dorsal (occasionally ventral) forearm, and the index and middle fingers. The C8 nerve classically radiates pain to the medial arm, ulnar forearm, and the ring and
little fingers.
Other differential diagnostic considerations for referred pain include thoracic outlet
syndrome and ulnar neuropathy, in which pain refers to the medial arm, forearm,
and ring and little fingers, similar to a C-8 radiculopathy. Thoracic outlet syndrome
typically will involve more proximal pain as well, such as in the axilla or scapula.
Carpal tunnel syndrome characteristically causes dysesthesias (painful tingling) in
the thumb and first two fingers, and sometimes pain up the arm as high as the neck,
thereby mimicking a C-6 or C-7 radiculopathy. Shoulder degenerative joint disease
or acromioclavicular, subacromial, or rotator-cuff pathology may be confused with a
C-5 radiculopathy.
In addition to careful clinical examination, diagnostic studies such as magnetic
resonance imaging (MRI) and electromyography (MRI) are helpful.
The treatment depends on the severity of the problem. In patients where pain is the
primary problem and there is little evidence of cord compression, then a conservative
program consisting of anti-inflammatory drugs, physical therapy, soft cervical collar,
neck support pillow, and steroid injections are usually sufficient. Patients who
develop significant limb weakness or evidence of cord compression need
neurosurgical evaluation immediately.
Evaluation and Diagnosis
Neck pain and arm pain can occur simultaneously or separately over the course of
cervical radiculopathy. Your physician may attempt to provoke the pain by extending
your neck and head backward. Changes in reflexes, patches of sensation loss, and
specific muscle weakness attributable to the dysfunction of a cervical spinal nerve
may be detected on a careful physical examination.
Conventional X-ray of the cervical spine may show the margins of the bony vertebra
and bony spur formation in the area of the nerve foramen. MRI or CT scans of the
cervical spine demonstrate the spine in cross section as well as in other planes and
also can visualize surrounding soft tissue structures, such as the disc and nerves,
those are not visible on conventional X-ray. The actual dimensions of existence and
relative severity of disc Herniation and foraminal stenosis can be more formally
evaluated on these scans. Most importantly, these findings should be correlated with
the patient's symptoms and problems. A high rate of disc Herniation and spondylises
has been noted to occur in individuals who never experience symptoms. This occurs
in higher frequency, perhaps not surprisingly, as people age.(2;3)
Non-operative treatment
The logic of using nonoperative treatment is reinforced by a variety of evidence from
scientific studies. Some studies have shown that cervical radiculopathy usually
improves with time without the need for surgery. Two studies of patients treated
non-operatively for cervical radiculopathy have shown that disc Herniation had
significantly regressed after a period on repeated scans.
(4;5) Other studies demonstrated good outcome results for patients suffering with
significant cervical radiculopathy treated with nonoperative therapies using oral antiinflammatory, oral corticosteroids, collar immobilization, physical therapy, traction,
and in many cases, epidural steroid injections.
(6-8) Preliminary results from our study show that 65 % of patients with cervical
radiculopathy that have not responded to physical therapy and oral medications still
can experience significant benefits with cervical epidural steroid injection.
(9) The nature of some of these nonoperative treatment modalities are noted below.
Relative rest and collar immobilization:
It may be important to refrain from repetitive movements of the neck and forceful or
heavy lifting movements during the acute phase. A soft cervical collar is often helpful
to limit neck motion and provide splinting or rest in a position of comfort.
Medication:
Whenever possible, your physician may prescribe anti-inflammatory medication,
particularly at the outset of the problem. Some radiculopathy will respond to nonsteroidal anti-inflammatory medication alone, but a short course of oral
corticosteroid medication is often prescribed as well.
Physical therapy:
The physical therapist can administer intermittent traction to help relieve pain. If
traction is particularly effective, a patient can purchase a traction unit and selfadminister traction at home on a regular basis. When pain is reduced, range of
motion and strengthening exercises can help to gradually restore areas in the neck
and shoulder that have been weakened by disuse and pain.
IV. Epidural steroid injection treatment
In many cases, the initial therapies for cervical radiculopathy are ineffective. Epidural
steroid injection may benefit patients who would otherwise suffer with the kind of
lasting pain that would sometimes necessitate surgical treatment. The procedure can
be performed in an outpatient setting using fluoroscopy (x-ray guidance). A trained
specialist will use an MRI scan and physical exam to identify to suspected area of
injury. Under fluoroscopic guidance, a needle can be directed - in most cases under
local anesthesia alone - to the target site.
The membrane covering the spine and nerve roots is called the dura. The space
surrounding the dura is the epidural space. An epidural injection places antiinflammatory medicine into the epidural space to decrease inflammation of the nerve
roots, reducing pain and hopefully aiding the healing process. It may provide
permanent relief or pain relief for several months while the injury/cause is healing.
Improvement may occur immediately or within two weeks. Some patients will
respond with one injection, but some may require up to three, interspersed over the
course of a recovery period of one to three months. Most patients will benefit from a
gradual exercise performed simultaneously with the supervision of a physical
therapist.
Figure 1: Model showing needle positioning for transformational epidural steroid
injection.
Figure 2: Fluoroscopic image of a Left C6/7 transforaminal epidural injection.
Contrast solution outlines the epidural space and exiting cervical nerve root.
Immediately afterwards, a solution of corticosteroid and local anesthetic were
injected.
V. Surgical intervention
Most patients recover with nonoperative treatment. If pain continues in spite of these
treatments, surgical treatment may be recommended. Additionally, patients with
more severe radiculopathy can decide to have surgical treatment at an earlier point
in time.
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