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Disclosures I have nothing to disclose Diane M. Rowles, MS, ACNP, BC, CRRN Nurse Practitioner, University Neurosurgery Rush University Medical Center Adjunct Assistant Professor, Feinberg School of Medicine Northwestern University Objectives Radiculopathy ‐ Definition Participants will identify 3 causes of radicular spine pain Participants will be able to identify location of nerve root impingement location given symptom complaints when it is a single nerve root problem. Participants will be able to differentiate myelopathy from radiculopathy. damage or disturbance of nerve function that results due to nerve root compression Reeves A, Swenson R. (2008). Disorders of the Nervous System. Dartmouth Medical School. Chapter 9. www.dartmouth.edu/~dons/part_1/chapter_9.html. Radiculopathy ‐Presentation Sharp, Shooting, Burning pain along the course of the nerve root Can also be describes as ache Occasionally it can be diffuse (all over) pain Paresthesia (tingling or pins and needles) especially distally Slight sensory loss Hyperesthesias Muscle weakness – indicates nerve damage Cauda equina often produces a "saddle" distribution of sensory loss by affecting the lower sacral nerve roots. This saddle distribution of sensory loss can also be seen in anterior spinal cord damage Pain can also "refer“ – (less localized) and is often felt in the muscles (myotomal) or skeletal structures (sclerotomal) that are innervated by the nerve root. The person usually complains of a deep aching sensation. Reeves A, Swenson R. (2008). Disorders of the Nervous System. Dartmouth Medical School. Chapter 9. www.dartmouth.edu/~dons/part_1/chapter_9.html. Anatomy Cervical Radiculopathy Anatomy of Thoracic Radiculopathy More rare with support of ribs Wraps around to chest Upper vs Lower Anatomy of Lumbar Radiculopathy Diagnosis of Radiculopathy Medical History – knowing the exact location of the symptoms helps localize the nerve responsible Type of symptoms (pain, tingling, numbness) Location of symptoms When did it start What makes it better or worse Other medical problems Physical examination ‐ focus on the central location and on the extremity involved. Diagnosis of Radiculopathy Imaging studies Plain xrays ‐ identify the presence of trauma or osteoarthritis and early signs of tumor or infection. (More likely to check stability). MRI scan ‐ soft tissues around the spine including the nerves, the disk and the ligaments CT scan ‐ explore possible compression of the nerves and better boney structure Myelogram and Post Myelogram CT – improvement of MRI and CT EMG/NCV ‐ electrical activity along the nerve and can show if there is damage to the nerve Radiculopathy vs. Myelopathy Radiculopathy describes the loss of function in a specific region that is secondary to compression and/or irritation of a spinal nerve root Myelopathy describes a loss of function in a person’s upper and lower extremities because of compression of the spinal cord. Radiculopathy vs. Myelopathy Symptoms Cervical radiculopathy presents as pain traveling from the neck to a particular region of a patient’s arm, forearm or hand. This may be accompanied by numbness or weakness in specific muscle groups in the arm, forearm or hand. Cervical Radiculopathy Cervical myelopathy may present subtly at first, causing slight changes in the way a patient’s hands work—a patient may feel their hands being clumsier, or their handwriting worsens, or may find themselves dropping things or finding it harder to button their shirts. Other symptoms may include: Unsteady gait Loss of sense of body consciousness, where hands and feet are relative to things around them In extreme cases, symptoms may include: Pronounced weakness and numbness in arms and legs Loss of bladder or bowel control (www.NMH .org) Cervical Radiculopathy Clinical Evaluation Causes of Cervical Radiculopathy Arm pain (99.4%), neck pain (79.7%), scapular pain (52.5%), anterior chest pain (17.8%) and headache (9.7%). (Henderson CM, Neurosurgery. 1983;13:504) Pain / paresthesia in a dermatomal pattern (53.9%), diffuse/nondermatomal pattern (45.5%) Sensory change to pinprick (85.2%) , motor deficit (68%), decrease in a DTR (71.2%). Cervical angina = left chest and arm pain Neck, shoulder, arm pain, paresthesias and numbness in a dermatomal distribution weakness in a myotomal distribution, +/‐ occipital headache Atypical findings such as deltoid weakness, scapular winging, weakness of the intrinsic muscles of the hand, chest or deep breast pain, headaches Spurling’s test positive(increased symptoms with rotation and lateral bend with a vetical compressive force) Abduction relief sign: relief of pain when the arm is placed overhead. (eORIF 2008) Cervical Radiculopathy Testing Certain movements, like bending the back or forward, side to side, or rotating (cervical), may increase the pain. Some patients report that pain decreases when they place a hand behind their head; the movement may be relieving the pressure and traction on the nerve root which then lessens their symptoms (Ben‐Yishay, 2012) Any condition that injures or somehow irritates the cervical nerve. The most common causes include: Cervical Herniated Disc ‐ inner material of the cervical disc herniates, or leaks out, and inflames and/or impinges on the adjacent nerve, it can cause a cervical radiculopathy. Cervical Spinal Stenosis ‐ degenerative process of the cervical spine, changes in the spinal joints can lead to tightening of the space for the spinal canal. Cervical Spondylosis ‐ degenerative changes that occur in the spine, including degeneration of the joints, intervertebral discs, ligaments and connective tissue of the cervical vertebrae Cervical Degenerative Disc Disease ‐ cervical spine degenerates over time, it can result in degenerated discs and a pinched nerve. Other conditions: tumor, fracture or sarcoidosis, scoliosis, osteophytes, osteoarthritis, infection, which can compress or cause damage to the cervical nerve roots C2, C3, C4 Cervical Radiculopathy C2: extremely rare‐jaw pain and occipital headaches, but no motor deficit is seen. C3: most often caused by disk disease at C2‐3, is not common‐ headaches and pain along the posterior aspect of the neck that extends to the posterior occipital region and occasionally to the ear. There are no motor deficits. DDX:tension headaches. C4: typically C3‐4 HNP‐posterior neck and trapezial pain, decreased sensation in C4 dermatome, no motor deficits, and diaphragmatic involvement has not been well documented. Patients occasionally complain of numbness and pain at the base of the neck that extends to the shoulder and scapular region. (eORIF 2008) C5 Cervical Radiculopathy C5 radiculopathy can cause pain and/or weakness in the shoulders and upper arms. Especially may cause discomfort around the shoulder blades. It rarely causes numbness or tingling (Ben‐Yishay, 2012) C6 Cervical Radiculopathy C6 radiculopathy (one of the most common) , causes pain and/or weakness along the length of the arm, including the biceps (the muscles in front of the upper arms), wrists, and the thumb and index finger. C5: pain and/or numbness in an “epaulet” pattern that includes the superior aspect of the shoulders (suprascapular) and the lateral aspect of the upper arm. Deltoid motor function is often weakened, as in an intrinsic shoulder disorder; the diagnosis of radiculopathy at this site is crystallized by observing the absence of impingement signs or pain with passive shoulder motion. Patients may complain of difficulties with activities of daily living if there is involvement of the supraspinatus, infraspinatus, or elbow flexors. Depression of the biceps reflex is an inconsistent finding. (eORIF2008) (Ben‐Yishay, 2012) C6: pain or sensory abnormalities extending from the neck to the biceps region, down the lateral aspect of the forearm to the dorsal surface of the hand, between the thumb and index finger, and including the tips of these fingers. May have suprascapular shoulder pain. The brachioradialis reflex may be depressed, and wrist extensor weakness is usually present. The infraspinatus, serratus anterior, triceps, supinator, and extensor pollicis muscles may also be affected. (eORIF 2008) C7 Cervical Radiculopathy C7 radiculopathy (the most common) causes pain and/or weakness from the neck to the hand and can include the triceps (the muscles on the back of the upper arms) and the middle finger (Ben‐Yishay, 2012) C8 Cervical Radiculopathy C8 radiculopathy causes pain from the neck to the hand. Patients may experience weakness in handgrip, and pain and numbness can radiate along the inner side of the arm, ring, and little fingers. (Ben‐Yishay, 2012) C7: most common. Pain and sensory abnormalities extend down the posterior aspect of the arm and the posterolateral aspect of the forearm and typically involve the middle finger, which is rarely affected in C6 disorders. May have interscapular shoulder pain. Absence of the triceps reflex is common, and triceps weakness is almost always present. The wrist flexors, wrist pronators, finger extensors, and latissimus dorsi may also be affected. May have scapular winging. C8: least likely to be associated with pain, but may have interscapular or scapular shoulder pain. Sensory changes usually restricted to below the wrist; interossei motor involvement. DDX: ulnar neuropathies, intrinsic hand disorders, myelopathy. (eORIF 2008) (eORIF2008) Myelopathy Diagnosis of Lumbar Radiculopathy A radiculopathy is caused by compression, inflammation and/or injury Long Track signs indicate myelopathy ‐Babinski's Reflex: upturning and splaying of the toes with plantar stimulus ‐Hoffman's sign: flexion of the thumb and index fingers in response to flicking the tip of the outstretched middle finger ‐Lhermitte's sign: shooting sensations down the arm with rapid neck flexion. to a spinal nerve root in the low back. Causes of this type of pain, in the order of prevalence, include: Herniated disc with nerve compression ‐ by far the most common cause of radiculopathy Foraminal stenosis (narrowing of the hole through which the spinal nerve exits due to bone spurs or arthritis) – more common in elderly adults Diabetes Nerve root injuries Scar tissue from previous spinal surgery that is affecting the nerve root (Ben‐Yishay, 2012) ‐Clonus Lumbosacral radiculopathy Diagnosis Lumbar Radiculopathy Examination of the Back Asymmetry Back Pelvis Lumbar ROM Look for radicular symptoms with The lumbosacral spine is the most commonly affected area for disorders of the spinal nerve roots. Lumbosacral radiculopathies comprise 62% to 90% of all radiculopathies. More than 75% of all herniated discs compressing nerve roots along the entire spinal column involve the L5 and S1 nerve roots. Dumitru D. Radiculopathies. In: Dumitru D, editor. Electrodiagnostic medicine. Philadelphia: Hanley & Belfus; 1995. p. 523–84. Milbourn AJ, Aminoff MJ. AAEM minimonograph #32: the electrodiagnostic examination in patients with radiculopathies. Rochester (MN): American Association of Electrodiagnostic Medicine; 1998. p. 1–26. Lumbar Radiculopathy Sciatica Pain is often deep and steady, and can usually be reproduced with certain activities and positions, such as sitting or walking. Radicular pain may also be accompanied by numbness and tingling, muscle weakness and loss of specific reflexes. Radicular pain radiates into the lower extremity (thigh, calf, and occasionally the foot) directly along the course of a specific spinal nerve root. The leg pain is typically much worse than the low back pain, and the specific areas of the leg and/or foot that are affected depends on which nerve in the low back is affected. Compression of higher lumbar nerve roots such as L2, L3 and L4 can cause radicular pain into the front of the thigh and the shin. (Ben‐Yishay, 2012) Sciatica, the term commonly used to describe radicular pain along the sciatic nerve, describes where the pain is felt but is not an actual diagnosis. The clinical diagnosis is usually arrived at through a combination of the patient’s history (including a description of the pain) and a physical exam. Imaging studies (MRI, CT‐myelogram) are used to confirm the diagnosis and will typically show the impingement on the nerve root (Ben‐Yishay, 2012) L1 Lumbar Radiculopathy L2 Lumbar Radiculopathy Nerve Root: L1 Nerve Root: L2 Pain Radiation: Pain Radiation: Gait Deviation: Gait Deviation: Motor Weakness: Hip flexors Motor Weakness: Hip flexors Sensory Loss:Inguinal Sensory Loss: Anterior mid‐thigh Reflex Loss: Reflex Loss: L3 Lumbar Radiculopathy L4 Lumbar Radiculopathy Nerve Root: L3 Nerve Root: L4 Pain Radiation: Anterior thigh or knee, or upper Pain Radiation: Groin and inner thigh Gait Deviation: Sometimes antalgic Motor Weakness: Hip flexion Sensory Loss: Anteromedial thigh Reflex Loss :Patellar (variable) medial leg Gait Deviation: Sometimes antalgic, difficulty rising onto a stool or chair with one leg Motor Weakness: Knee extension, hip flexion and adduction Sensory Loss: Lateral or anterior thigh, medial leg and knee Reflex Loss: Patellar L5 Lumbar Radiculopathy S1 Lumbosacral Radiculopathy Nerve Root: L5 Nerve Root: S1 Pain Radiation: Buttocks, anterior or lateral leg, dorsal foot Pain Radiation: Posterior thigh, calf, plantar foot Gait Deviation: Difficulty heel walking; if more severe, Gait Deviation: Difficulty toe walking or cannot rise on then foot slap or steppage gait Trendelenburg gait Motor Weakness: Ankle dorsiflexion, foot eversion and inversion, toe extension, hip abduction Sensory Loss: Posterolateral thigh, anterolateral leg, and mid‐dorsal foot Reflex Loss: Medial hamstring (variable) Cauda Equina Rectal examination and perianal and inguinal sensory testing should be done if there is history of bowel or bladder incontinence or retention or recent onset of erectile dysfunction. (Ellenberg M et al 2008) Although relatively rare, cauda equina syndrome is a serious condition resulting from a central prolapse of a nucleus pulposus in the lumbar region. Cauda equina syndrome will present as bowel and bladder impairments, saddle area paresthesia (S4), and possible gross limitation of all lumbar movement. This condition constitutes an immediate referral to the physician. (Dutton, M. (2008). Orthopaedic Examination, Evaluation, and Intervention, 2nd edition. McGraw Medical, New York) toes 20 times Motor Weakness: Foot plantar flexion Sensory Loss: Posterior thigh and calf, lateral and plantar foot Reflex Loss: Achilles Lumbar Radiculopathy ‐ Treatment Non‐Surgical Oral Medications NSAIDs Medrol dose pack Oral Steroids Physical Therapy Injections Lumbar Radiculopathy ‐ Treatment Thoracic Radiculopathy Rare when compared to lumbar and cervical radiculopathy. Relative rigidity of the thoracic spine, which serves as an anchor Surgical Decompressive surgery: laminectomy and/or for the ribs as well as support for the torso and upper body. discectomy/microdiscectomy Relative lack of flexibility,exposes the thoracic vertebrae to far This type of surgery typically provides relief of radicular pain/leg less stress as the body ages as contrasted with the cervical and lumbar regions. pain for 85% to 90% of patients. For patients with severe leg pain or other serious symptoms such as Patients complaining of back or neck pain can’t rule out the progressive muscle weakness, this type of surgery may be recommended prior to six weeks of non‐surgical treatment. thoracic region as the origin without a proper radiculopathy diagnosis. Consider MRI or CT scan to determine the location of an impinged or irritated nerve root. Back surgery for relief of radicular pain (leg pain) is much more reliable than the same surgery for relief of low back pain. (Laser spine institute ref rad #3) The decision to proceed with surgery is based on severity of leg pain and/or the presence of significant muscle weakness. It is important to note that if definitive nerve compression cannot be documented on an MRI or CT‐myelogram, then back surgery is ill advised and unlikely to be successful. Always check for stability on xrays prior. If not stable may require fusion. Thoracic Radiculopathy Causes Thoracic Radiculopathy Management Potential conditions that might impinge on a nerve root and cause thoracic The symptoms of thoracic radiculopathy normally can be managed through a course of conservative treatment. exercise physical therapy pain medications behavior modification therapeutic massage radiculopathy include: Degenerative disc disease Bulging disc Herniated disc Osteoarthritis Bone spur Spinal injury, especially from repeated twisting or rotating Spinal stenosis Foraminal stenosis Diabetes, especially in older patients If chronic back pain persists even after weeks or months of conservative treatment. A doctor might present surgery as an option. (Laser Spine Institute) (Laser Spine Institute) Differential Diagnosis References Lumbar: Herpes Zoster‐thoracic Other Neurological Conditions Cervical: Carpal tunnel syndrome Cubital tunnel syndrome Thoracic outlet syndrome Myelopathy Cauda Equina Syndrome Ulnar tunnel syndrome Lumbosacral Disc Injuries Thoracic Disc Injuries Trochanteric Bursitis Anserine bursitis Hamstring strain Lumbosacral plexopathy Diabetic amyotrophy Peripheral neuropathy: sciatic, tibial, peroneal, femoral Avascular necrosis of the hip Hip osteoarthritis Shin splints Lateral femoral cutaneous neuropathy (meralgia paresthetica) Spinal stenosis Cauda equina syndrome Demyelinating disorder Lumbar facet syndrome Piriformis syndrome Bahngle, S, Sapru, S, Panush R. (2013). Back Pain Made Simple: An Approach Based on Principles and Evidence. Cleveland Clinic Journal of Medicine 80 (9). Pandyan AD, Johnson GR, Price CI, Curless RH, Barnes MP, Rodgers H. (1999). A review of the properties and limitations of the Ashworth and modified Ashworth Scales as measures of spasticity. Clin Rehabil 13(5):373‐83. Reeves A, Swenson R. (2008). Disorders of the Nervous System. Dartmouth Medical School. Chapter 9. www.dartmouth.edu/~dons/part_1/chapter_9.html Blumenfeld H. (2010). Neuroanatomy through Clinical Cases, Second Edition. Sinauer Associates Publishers. (NASS 2010 Guideline) North American Spine Society,Evidence‐Based Clinical Guidelines for Multidisciplinary Spine Care,Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders,Copyright c 2010 North American Spine Society, www.spine.org Eck J, Shiel W. www.medicinenet.com; Radiculopathy Ref eORIFCopyright © 2008 by eORIF.com LLC. Dumitru D. (1995) Radiculopathies. In: Dumitru D, editor. Electrodiagnostic medicine. Philadelphia: Hanley & Belfus. p. 523–84. Milbourn AJ, Aminoff MJ.(1998). AAEM minimonograph #32: the electrodiagnostic examination in patients with radiculopathies. Rochester (MN): American Association of Electrodiagnostic Medicine; p. 1–26. Schnuerer T, Mummaneni P. Cervical Spine Surgery: Will You Need Surgery for Your Neck Pain? Anatomy, Cervical Spine Conditions, and Surgery Techniques. www.spineuniverse.com. Lauder T. (2002). Physical examination signs, clinical symptoms, and their relationship to electrodiagnostic findings and the presence of radiculopathy. Phys Med Rehabil Clin N Am 13 (2002) 451–467 Ellenberg M, Honet J. (2008) Frontera: Essentials of Physical Medicine and Rehabilitation, 2nd ed. Lumbar Radiculopathy, Ch 43 Saunders, An Imprint of Elsevier. Dutton, M. (2008). Orthopaedic Examination, Evaluation, and Intervention, 2nd edition. McGraw Medical, New York http://www.webmd.com/pain‐management/pain‐management‐cervical‐radiculopathy Ben‐Yishay A. (2012) Lumbar Radiculopathy. www.spinehealth.com www.nmh.org. Cervical Radiculopathy Laser Spine Institute. Thoracic Radiculopathy. www.laserspineinstitute.com Symptoms of Radiculopathy depend on which nerves are affected. The nerves exiting from the neck (cervical spine) control the muscles of the neck and arms and supply sensation there. The nerves from the middle portion of the back (thoracic spine) control the muscles of the chest and abdomen and supply sensation there. The nerves from the lower back (lumbar spine) control the muscles of the buttocks and legs and supply sensation there. The most common symptoms of radiculopathy are pain, numbness and tingling in the arms or legs. It is common for patients to also have localized neck or back pain as well. Lumbar radiculopathy that causes pain that radiates down a lower extremity is commonly referred to as sciatica. Thoracic radiculopathy causes pain from the middle back that travels around to the chest. It is often mistaken for shingles. Some patients develop a hypersensitivity to light touch that feels painful in the area involved. Less commonly, patients can develop weakness in the muscles controlled by the affected nerves. This is can indicate nerve damage. How is radiculopathy diagnosed? Comment on thisShare Your Story The diagnosis of radiculopathy begins with a medical history and physical examination by the physician. During the medical history, the doctor will ask questions about the type and location of symptoms, how long they have been present, what makes them better and worse, and what other medical problems present. By knowing the exact location of the patient's symptoms, the doctor can help localize the nerve that is responsible. The physical examination will focus on the extremity involved. The doctor will check the patient's muscle strength, sensation, and reflexes to see if there are any abnormalities. The patient may then be asked to obtain imaging studies to look for a source of the radiculopathy. Plain X‐rays are often obtained first. These can often identify the presence of trauma or osteoarthritis and early signs of tumor or infection. An MRI scan may then be obtained. This study provides the best look at the soft tissues around the spine including the nerves, the disk and the ligaments. If the patient is unable to obtain an MRI, they may obtain a CT scan instead to explore possible compression of the nerves. In some cases the doctor may order a nerve conduction study or electromyogram (EMG). These studies look at the electrical activity along the nerve and can show if there is damage to the nerve. Ref rad #2 spine health Cervical radiculopathy is the clinical description of pain and neurological symptoms resulting from any type of condition that irritates a nerve in the cervical spine (neck). Cervical nerves exit the cervical spine (neck) at each level, C1 – C7, (nerves in the neck exit above the designated vertebral level at all levels except the last one; C8 exits below C7 vertebra) and then branch out to supply muscles that enable the shoulders, arms, hands and fingers to function. They also carry sensory fibers to the skin and muscles that provide sensation. When any nerve root in the cervical spine is irritated through compression or inflammation, the symptoms can radiate along that nerve’s pathway into the arm and hand. The patient’s specific cervical radiculopathy symptoms will depend primarily on which nerve is affected. The symptoms may also be referred to as radicular pain. medicineNet. Com Radiculopathy eck, J; Shiel, w Radiculopathy Definition Ref #1 What Is Cervical Radiculopathy? Cervical radiculopathy is the damage or disturbance of nerve Spinal cord Spinal cord damage is characterized by both sensory and motor symptoms, both at the level of involvement, as well as below, by affecting the tracts running through the cord. Symptoms referable to the level of injury appear in the pattern of dermatomes and myotomes and, when present, are very useful for localizing the level of spinal cord damage. The symptoms of damage to the long sensory tracts (the dorsal columns and the spinothalamic tract) are less helpful in localizing the lesion because it is often impossible to determine the precise level of the sensory loss and also because, particularly in the case of the spinothalamic tract, there is considerable dissemination of the signal in the spinal cord before it is relayed up the cord. Similar difficulties make it difficult to localize the level of spinal cord damage by examining for damage to the descending (corticospinal) motor tracts. Therefore, when long tract damage is identified, one can only be certain that the lesion is above the highest level that is demonstrably affected. Compression of the spinal cord from the anterior side first involves the spinothalamic paths from the sacral region, and a "saddle" loss of pain and temperature perception is usually the first symptom even with lesions high in the spinal cord (Fig. 9‐4). In this case, as symptoms progress with greater degrees of compression, symptoms progressively ascend the body up toward the level of the actual cord damage (see Fig. 9‐4). Intramedullary lesions of the spinal cord (such as syrinx, ependymoma, or central glioma) may present with a very unusual pattern of "suspended sensory loss". This consists of an isolated loss of pain and temperature perception in the region of the expanding lesion because of damage to the crossing spinothalamic tract fibers (Fig. 9‐5). In this pattern of sensory loss due to expanding intramedullary lesions, there is "sacral sparing" of pain and temperature because the more peripheral spinothalamic fibers (the ones from the sacrum) are the last to be involved (see Fig. 9‐4). With intramedullary lesions, the dorsal columns are also usually spared until extremely late in the course of expansion, leaving touch, vibration, and proprioception intact. The loss of one or two sensory modalities (such as pain and temperature sense, in this case) with preservation of others (such as touch, vibration and joint position sense) is termed a "dissociated sensory loss" and is in contrast to the loss of all sensory modalities associated with major nerve or nerve root lesions or with complete spinal cord damage. Complete hemisection of the cord is seen occasionally in clinical practice and is quite illustrative of the course of spinal cord sensory pathways. This lesion results in a characteristic picture of sensorimotor loss (Brown‐Sequard syndrome), which is easily recognized due to the loss of dorsal columns sensations (vibration, localized touch, joint position sense) on the ipsilateral side of the body and of spinothalamic sensations (pain and temperature) on the contralateral side (Fig. 9‐6). function that results if one of the nerve roots near the cervical vertebrae is compressed. Damage to nerve roots in the cervical area can cause pain and the loss of sensation in different parts of the upper extremities, depending on where the damaged roots are located. Causes of Cervical Radiculopathy Symptoms of Cervical Radiculopathy The main symptom of cervical radiculopathy is pain that spreads into the arm, neck, chest, upper back and/or shoulders. A person with radiculopathy may experience muscle weakness and/or numbness or tingling in fingers or hands. Other symptoms may include lack of coordination, especially in the hands. Reeves et al Ref eORIFCopyright © 2008 by eORIF.com LLC. Ref eORIFCopyright © 2008 by eORIF.com LLC. (cont) Cervical Radiculopathy Definition: pain in a radicular pattern in one or both upper extremities related to compression and/or irritation of one or more cervical nerve roots. Frequent signs and symptoms include varying degrees of sensory, motor and reflex changes as well as dysesthesias and paresthesias related to nerve root(s) without evidence of spinal cord dysfunction (myelopathy). (NASS 2010 Guideline) Natural History has not been conclusively determined. The symptoms are often self‐limited and resolve spontaneously without specific treatment. Symptom length is variable. Commonly caused by disc herniation and spondylosis. Cervical Radiculopathy Anatomy Symptoms are produced in the root exiting at the level of pathlogy. Example: C6 root symptoms from C5‐6 herniation. Cervical Radiculopathy Clinical Evaluation Arm pain (99.4%), neck pain (79.7%), scapular pain (52.5%), anterior chest pain (17.8%) and headache (9.7%). (Henderson CM, Neurosurgery. 1983;13:504) Pain / paresthesia in a dermatomal pattern (53.9%), diffuse/nondermatomal pattern (45.5%) Sensory change to pinprick (85.2%) , motor deficit (68%), decrease in a DTR (71.2%). Cervical angina = left chest and arm pain Neck, shoulder, arm pain, paresthesias and numbness in a dermatomal distribution weakness in a myotomal distributionn, +/‐ occipital headache Atypical findings such as deltoid weakness, scapular winging, weakness of the intrinsic muscles of the hand, chest or deep breast pain, headaches Spurling’s test positive(increased symptoms with rotation and lateral bend with a vetical compressive force) Abduction relief sign: relief of pain when the arm is placed overhead. C2: extremely rare‐jaw pain and occipital headaches, but no motor deficit is seen. C3: most often caused by disk disease at C2‐3, is not common‐headaches and pain along the posterior aspect of the neck that extends tothe posterior occipital region and occasionally to the ear. There are no motor deficits,. DDX:tension headaches. C4: typically C3‐4 HNP‐posterior neck and trapezial pain, decreased sensation in C4 dermatome, no motor deficits, and diaphragmatic involvement has not been well documented. Patients occasionally complain of numbness and pain at the base of the neck that extends to the shoulder and scapular region. C5: pain and/or numbness in an “epaulet” pattern that includes the superior aspect of the shoulders (suprascapular) and the lateral aspect of the upper arm. Deltoid motor function is often weakened, as in an intrinsic shoulder disorder; the diagnosis of radiculopathy at this site is crystallized by observing the absence of impingement signs or pain with passive shoulder motion. Patients may complain of difficulties with activities of daily living if there is involvement of the supraspinatus, infraspinatus, or elbow flexors. Depression of the biceps reflex is an inconsistent finding. C6: pain or sensory abnormalities extending from the neck to the biceps region, down the lateral aspect of the forearm to the dorsal surface of the hand, between the thumb and index finger, and including the tips of these fingers. May have suprascapular shoulder pain. The brachioradialis reflex may be depressed, and wrist extensor weakness is usually present. The infraspinatus, serratus anterior, triceps, supinator, and extensor pollicis muscles may also be affected. C7: most common. Pain and sensory abnormalities extend down the posterior aspect of the arm and the posterolateral aspect of the forearm and typically involve the middle finger, which is rarely affected in C6 disorders. May have interscapular shoulder pain. Absence of the triceps reflex is common, and triceps weakness is almost always present. The wrist flexors, wrist pronators, finger extensors, and latissimus dorsi may also be affected. May have scapular winging. C8: least likely to be associated with pain, but may have interscapular or scapular shoulder pain. Sensory changes usually restricted to below the wrist; interossei motor involvement. DDX: ulnar neuropathies, intrinsic hand disorders, myelopathy. Long Track signs indicate myelopathy ‐Babinski's Reflex: upturning and splaying of the toes with plantar stimulus ‐Hoffman's sign: flexion of the thumb and index fingers in response to flicking the tip of the outstretched middle finger ‐Lhermitte's sign: shooting sensations down the arm with rapid neck flexion. ‐Clonus Cervical Radic C5‐C8 ‐Spine health ref rad2 Cervical radiculopathy symptoms differ depending on which nerve is affected. For example, if the nerve root that runs above the C6 vertebra is affected, a physician will use the term “C6 radiculopathy”. While any patient’s specific symptoms can vary widely, the following are common descriptions for the types and symptoms of cervical radiculopathy: C5 radiculopathy can cause pain and/or weakness in the shoulders and upper arms. Especially may cause discomfort around the shoulder blades. It rarely causes numbness or tingling. C6 radiculopathy (one of the most common1) , causes pain and/or weakness along the length of the arm, including the biceps (the muscles in front of the upper arms), wrists, and the thumb and index finger. C7 radiculopathy (the most common2) causes pain and/or weakness from the neck to the hand and can include the triceps (the muscles on the back of the upper arms) and the middle finger. C8 radiculopathy causes pain from the neck to the hand. Patients may experience weakness in handgrip, and pain and numbness can radiate along the inner side of the arm, ring, and little fingers. ExamCervical Radiculopathy Clinical Presentation Author: Gerard A Malanga, MD; Chief Editor: Sherwin SW Ho, MD more... Medscape.com Deep tendon reflexes The deep tendon reflexes—or, more properly, muscle stretch reflexes, because the reflex occurs after a muscle is stretched (most commonly by tapping its distal tendon)—are helpful in the evaluation of patients who present with limb symptoms that are suggestive of a radiculopathy. The examiner must position the limb properly when obtaining these reflexes, and the patient needs to be as relaxed as possible. Any grade of reflex can be normal, so asymmetry of the reflexes is most helpful finding. The biceps brachii reflex is obtained by tapping the distal tendon in the antecubital fossa. This reflex occurs at the C5‐C6 level. The brachioradialis reflex is obtained by tapping the radial aspect of the wrist. It is also a C5‐C6 reflex The triceps reflex can be obtained by tapping the distal tendon at the posterior aspect of the elbow, with the elbow relaxed at about 90° of flexion. This tests the C7‐C8 nerve roots. The pronator reflex can be helpful in differentiating C6 and C7 nerve root problems. If this reflex is abnormal in conjunction with an abnormal triceps reflex, then the level of involvement is more likely to be C7. The pronator reflex is performed by tapping the volar aspect of the distal radius with the forearm in a neutral position and the elbow flexed. This results in a stretch of the pronator teres, resulting in a reflex pronation. In patients whose clinical picture raises concern about possible myelopathy, the lower‐extremity reflexes and Hoffman and Babinski reflexes should also be assessed. Diffuse hyperreflexia and/or positive Hoffman and abnormal Babinski reflexes would indicate that the patient has a cervical myelopathy. Provocative tests The foraminal compression test, or Spurling test, is probably the best test for confirming the diagnosis of cervical radiculopathy. It is performed by positioning the patient with the neck extended and the head rotated, and then applying downward pressure on the head. The test is considered positive if pain radiates into the limb ipsilateral to the side to which the head is rotated. The Spurling test has been found to be very specific (93%), but not sensitive (30%), in diagnosing acute radiculopathy.[11] Therefore, it is not useful as a screening test, but it is clinically useful in helping to confirm cervical radiculopathy.[14] Manual cervical distraction can be used as a physical examination test. With the patient in a supine position, gentle manual distraction often greatly reduces the neck and limb symptoms in patients with radiculopathy. Lhermitte sign is an electric shock‐like sensation radiating down the spine, and in some patients into the extremities, elicited by flexion of the neck. This sign has been found in patients with cervical cord involvement or cervical spondylosis, and also in patients with tumor and multiple sclerosis (MS); however, the Lhermitte sign should be negative in those with cervical radiculopathy. Manual distraction may reduce the neck and limb symptoms in patients with cervical radiculopathy. Previous Cervical Radiculopathy Symptoms Ref eORIF Cervical Radiculopathy Xray / Diagnositc Tests Xray Indications: trauma, systemic disease(RA), cancer, pain for >6weeks, night pain, neuroligc findings. Xrays are oftern not indicated initially. A/P, Lateral, Odontoid, flexion / extention lateral views. Evaluated for instability, pseudarthrosis, atlantoaxial arthrosis. Typically shows loss of disk height, end‐plate osteophytosis, malaignment. A/P vew may demonstrate uncovertebral DJD or scoliosis CT: useful for fracture, foraminal stenosis, facet arthropathy. MRI: demonstrates disc degeneration, neruologic compression, infection, tumor. Facet injections: helpful to diagnosis facet mediated pain. EMG/NCV. Cervical Radiculopathy Classification / Treatment Non‐op treatment= traction, physcial therapeutic exercise, traction, NSAIDs, patient education (Saal, Spine 21:1877, 1996). Surgical: ‐Laminoforaminotomy: Indicated for foraminal stenosis or lateral to foraminal disk herniations without significant neck pain or instability. posterior approach, remove lateral edge of superior and inferior lamina and dorsal aspect of exiting neuroforamen, remove disc fragments. If >50% of facet is removed consider fusion. (Adamson TE, J Neurosurg 2001;95suppl 1:51). ‐ACDF (anterior diskectomy and fusion): Indicated for spondylosis and/or central or paracentral disc pathology. (Bohlman HH, JBJS 1993;75A:1298). Total disk replacement: long term outcomes unknown. Cervical Radiculopathy Associated Injuries / Differential Diagnosis Carpal tunnel syndrome Cubital tunnel syndrome Thoracic outlet syndrome Myelopathy Cauda Equina Syndrome Ulnar tunnel syndrome Cervical Radiculopathy Complications Recurrent laryngeal nerve palsy (more common with right sided anterior approaches) Horner's syndrome (sympathetic chain neuropraxia) Dysphagia Dysphonia Vertebral artery injury Pseudoarthrosis Adjacent segment degeneration: 2.9%/yr (Hilibrand AS, JBJS 1999;81A:519). Cervical Radiculopathy Follow‐up Care Cervical Radiculopathy Review References NASS Evidence‐Based Clinical Guideline: Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders. 2010 Treatment of Radiculopathy ref #1 Treatments of Cervical Radiculopathy Cervical radiculopathy may be treated with a combination of pain medications such as corticosteroids (powerful anti‐ inflammatory drugs) or non‐steroidal pain medication like ibuprofen (Motrin or Aleve) and physical therapy. Steroids may be prescribed either orally or injected epidurally (into the space above the dura, which is the membrane that surrounds the spinal cord). Physical therapy might include gentle cervical traction and mobilization, exercises, and other modalities to reduce pain. If significant compression on the nerve exists to the extent that motor weakness results, surgery may be necessary to relieve the pressure. Cervical Radiculopathy Exam – more hints Increased pain with lateral bending away from the affected side can result from increased displacement of a herniated disc onto a nerve root, whereas ipsilateral pain suggests impingement of a nerve root at the site of the neural foramen. Certain neck movements, like bending the neck back, side to side, or rotating it, may increase the pain. Some patients report that pain decreases when they place a hand behind their head; the movement may be relieving the pressure and traction on the nerve root which then lessens their symptoms. (SpineHealth.com) Palpation ‐ tenderness is usually noted along the cervical paraspinal muscles, and it is usually more pronounced along the ipsilateral side of the affected nerve root. Muscle tenderness may be present along the muscles where the symptoms are referred (eg, medial scapula, proximal arm, lateral epicondyle). Associated hypertonicity or spasm on palpation in these painful muscles may occur. Letchuman et al showed that cervical radiculopathy is associated with increased tender spots (both trigger and tender points) on the side of the radiculopathy, with a predilection toward the muscles innervated by the involved nerve root.[13] This study revealed that not only pain, but also tenderness, may be referred in radiculopathy. Motor Manual muscle testing is an important aspect of determining an affected nerve root level on physical examination. Perform manual muscle testing to detect subtle weakness in a myotomal distribution. Place the limb of the affected side in the antigravity position and apply resistance proximal to the next distal joint. For example, to test the extensor carpi ulnaris muscle, have the patient's forearm in full pronation and resting on a table or supported. The patient is then instructed to extend the hand and deviate it toward the ulnar side, while the examiner applies resistance against the dorsum of the fifth metacarpal bone.
