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CERVICAL RADICULOPATHYSpinal nerve root dysfunction causing - Dermatomal pain & parasthesias, Myotomal weakness, And/or impaired DTRs

RADICULOPATHY RADICULAR PAINPain perceived as arising in a limb or the trunk wall caused by ectopic activation of nociceptive afferent fibers in a spinal nerve or its roots or other neuropathic mechanisms. (IASP taxonomy) RadiculopathyNeurological state in which conduction is blocked along a spinal nerve or its roots => muscle weakness & sensory changes (Vervest, 1988; Bogduk, 2009)Radiculopathy and radicular pain commonly occur togetherRadicular pain may or may not occur with radiculopathy

ANATOMY

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Typical cervical vertebra

Facet Joints (Zygapophyseal Joints)

Vx C3 - C7 Pillars at Pedicle LaminaPosterior to exiting nerve rootSynovial with capsuleMedial branch of dorsal primary ramus Directional stability and prevent translation of vx

Intervertebral disc

six Each named after vx above itannulus fibrosus + nucleus pulposus + 2 cartilaginous endplatesThicker anteriorly than posteriorly lordosis

Uncovertebral articulations (joints of Luschka)

Lateral aspect of lower Vx body has superior projection (uncinate process) &lateral part of inferior surface of upper vx body facing it is slightly concaveOn posterolateral border of disc & anteromedial portion of IVFNot true synovial jointsCan hypertrophy associated with disc degeneration, and result in narrowing of IVF

Intervertebral foramina

GATEWAY OF THE SPINAL NERVE TO THE BODY

C1C2C3C4C5C6C7C8C1C2C3C4C5C6C7

NoteThere is no C1 dermatome marked on the skin The sensory fibers entering are from the meninges around the cerebellum and medulla, not from the skinThe C1 spinal nerve sends motor axons to a few muscles in 3 locations, the mouth, the front of the neck and the back of the skull.

Unique - 2 joints form boundary

Allows to dynamically change configuration according to movementsroof inferior aspect of notch of pediclefloor - superior notch of pediclePosterior aspect of vx bodies, disc,lateral expansion of PLL, venous sinus

superior and inferior articular process of ZP joint ,lateral prolongation of LF

Spinal nerve rootDRGSpinal artery of segmental arteryCommunicating veins Recurrent meningeal (sinu-vertebral) nerveTransforaminal ligament Fat

skin & muscles of back

remaining ventral parts of the trunk and the upper and lower limbs(cervical and brachial plexus) ligaments, dura, blood vessels, discs, facet joints, periosteum

VENTRAL RAMUSDORSAL RAMUSSPINAL NRecurrent m. N

Pedicle notches - slight superiorly, inferiorly deeply

thick anterior arch the two lateral masses, on which - superior atlantal joint facets----- occipital condyles; and the inferior joint facets of the axis. posterior arch is thinner transverse processes contain a transverse foramen through which the vertebral artery passes before it loops back above the upper surface of the posterior archposterior aspect of the anterior arch has a facet ----odontoid process of the axis, which is held in place by ligament

Anterior tubercleAnterior archsuperior articular facetposterior archtransvers processvertebral foramen

foramen transversum

CAUSES

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Degeneration, spondylosis, hypertrophy of ZP joint or uncovertebral jointDisc herniationSpinal instabilityTraumaTumors

Disc herniationDegeneration, spondylosis, hypertrophy of ZP joint or uncovertebral joint

Herniation of an intervertebral disk may be caused by degenerative processes or trauma.3 Disk herniations may occur centrally or laterally. Central disk herniations may compress the cervical cord directly; lateral disk herniations result in compression of a cervical nerve root. - See more at: http://www.rheumatologynetwork.com/articles/identifying-musculoskeletal-causes-neck-pain#sthash.r7bQLpXS.dpuf

Irritation of the spinal dorsal ramus system - a potential source of painEach spinal dorsal ramus arises from the spinal nerve and then divides into a medial and lateral branchMedial branch supplies the tissues from the midline to the ZP joint line and innervates two to three adjacent ZP joints and their related soft tissues. Lateral branch innervates the tissues lateral to the ZP joint line

Clinical pain presentations follow these anatomic distributions, which can be used for localizing involved ramusDiagnosis can be confirmed by performing a single dorsal ramus block that results in relief of painTreatment - spinal dorsal ramus injection therapy

EXAMINATION

Dermatomal testingMyotomal testingSpecial tests

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Classic PatternsABNORMALITIESNERVE ROOTMOTORSENSORYREFLEXC5Deltoid, elbow flexionLateral armBicepsC6Biceps, wrist extensionLateral forearm, thumbBrachioradialisC7Triceps, wrist flexionDorsal forearm, long fingerTricepsC8Finger flexorsMedial forearm, ulnar digitsNA

C5Neck, shoulder, lateral armC6Neck, dorsal lateral (radial) arm, thumbC7Neck, dorsal lateral forearm, middle fingerC8Neck, medial forearm, ulnar digits

Distribution of Pain

Spurling test/ Foraminal compression test/ Neck compression test/ Quadrant testNeck extension + Rotation + Downward pressure on headPositive finding eliciting reproduction of radicular pain into ipsilateral arm of head rotation 92% sensitive, 95% specificLow sensitivity but high specificity- not useful as a screening tool, but it does help confirm the diagnosis

Shoulder abduction test/ Shoulder abduction relief sign/Bakodys signActive/passive abduction of ipsilateral shoulderRelief of radicular symptomstakes stretch off of the affected nerve root and may decrease or relieve radicular symptoms

Cervical spine testsNeck distraction test/ Manual traction test

Lhermitte sign/ Barber chair phenomenonFlexion of neck producing electric shock like sensations that extend down the spine and shoot into the limbsUsefulness is limitedIndicates spinal canal stenosis, disc impingement, multiple sclerosis, or tumor

Anterior doorbell signIndicates nerve root tension/radiculopathyDeep palpation over C5 segment produces pain in superior scapulovertebral border that radiates to upper limb

OthersNaffziger's test(for nerve root compression) Manual compression of the jugular veins bilaterallyAn increase or aggravation of pain or sensory disturbance over the distribution of the involved nerve root confirms the presence of an extruded intervertebral disk or other mass

Valsalva ManeuverDeep breath and hold it while attempting to exhale for 2-3 secondsPositive response - reproduction of symptomsThe pushing increases intrathecal or intraspinal pressure revealing presence of a space occupying mass such as and extruded intervertebral disc, or narrowing due to osteophytes

Hoffman signUMN sign indicating pyramidal tract involvementIndicates myelopathy

DIAGNOSISPlain RadiographsMRICervical myelogramCervical myelogram + CT

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Plain radiographyRole somewhat limited in evaluation of nerve rootsInitial study to rule out instability or pathologic changes in boneOblique views can show narrowing of the neuroforamina secondary to degenerative changes

MRIMRI has become the method of choice for imaging the neck to detect significant soft-tissue pathology, such as disc herniation. The American College of Radiology recommends routine MRI as the most appropriate imaging study in patients with chronic neck pain who have neurologic signs or symptoms but normal radiographsSagittal T1 - Hypointense signal is common for herniated degenerative disks, calcified ligaments, and bone spurs, making differentiation of these structures more difficultAxial T1 - Insight into both intraspinal and extraspinal disorders, as well as the intrathecal nerve root anatomyT2-weighted sequence or variants - myelo-graphic view

Cervical myelogram Outlines SC and exiting nerve roots with radiopaque dyeWater-soluble agent may be injected via the C1-2 interval, allowing the dye pool to gravitate caudallyAccuracy has been estimated 67% to 92%. For this reason, cervical myelography is often accompanied by CTExcellent visualization of nerves in relation to surrounding osseous structures

Electrodiagnosis plays a critical roleReferred to as an extension of neurologic examination, as it is able to provide physiologic evidence of nerve dysfunction1. EMG 2. Motor and sensory nerve conduction studies3. Late responses

ELECTROMYOGRAPHYEMG is the most useful test Localize lesions to a particular root levelThe goal -- find a pattern of spontaneous and/or chronic motor unit changes in a clear myotomal patternLimitations can only detect change in the motor nervous system

Diagnostic Criteria for Needle EMGTo diagnose radiculopathy electrodiagnostically, needle study of 2 muscles that receive innervation from the same nerve root, preferably via different peripheral nerves, should be abnormal. Adjacent nerve roots should be unaffected unless a multilevel radiculopathy is present

NERVE CONDUCTION STUDIESThe primary role -- determine if other neurologic processes exist as an explanation for a patients clinical picture, or if another process coexists with a root level problemIn pure radiculopathy, the sensory nerve studies should be normal. Pathologic lesion in radiculopathy typically occurs proximal to the DRG. Since the DRG houses the cell bodies for the sensory nerves, the sensory nerve studies should be normal. common nerve entrapments such as median neuropathy at the wrist or ulnar neuropathy at the elbow

LATE RESPONSESThe utility of late responses such as F-waves and H-reflexes in diagnoses of cervical radiculopathy is debated. While H-reflexes can be useful in diagnosing S1 radiculopathies, there is less evidence to support use of late responses in the upper extremity.F-waves are not sensitive tend to be abnormal in severe diseaseonly tests motor fibersnot well tolerated by patients(supramaximal stimulation)

DIFFERENTIAL DIAGNOSIS

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Myofacial pain syndromeNo dermatomal distributionHas tender points

Cervical spondylotic myelopathyChanges in gaitFallsBowel, bladder, sexual dysfunctionDifficulty using the handsUMN findings like spasticity

Facet joint arthropathyAxial pain Tenderness over facet joints or paraspinal musclesPain with cervical extension or rotationNo neurologic abnormalities

CRPSPain and tenderness of the extremity, out of proportion with examination findingsSkin changes, vasomotor fluctuations, or dysthermiaLimited ROM, stiffness

Entrapment syndromesFor example, carpal tunnel syndrome (median nerve) and cubital tunnel syndrome (ulnar nerve)

Parsonage-Turner syndrome (neuralgic amyotrophy)Acute onset of proximal upper extremity painUsually followed by weakness typically in the C5C6 region and sensory disturbancesTypically involves upper brachial plexus(unlike in cervical radiculopathy, in which pain and neurologic findings occur simultaneously)

Herpes zoster (shingles)Acute inflammation of DRGPainful, dermatomal radiculopathyFollowed by appearance of typical vesicular rash

Rotator cuff pathologyShoulder and lateral arm pain only rarely radiates below the elbowAggravated by active and resisted shoulder movements, rather than by neck movementsNormal sensory examination, reflexes

Thoracic outlet syndromeMedian and ulnar nerve (lower brachial plexus nerve roots, C8 and T1) dysfunction Compression by vascular or neurogenic causes, often a tight band of tissue extending from first thoracic rib to C7 transverse process

Cardiac painRadiating upper extremity pain, particularly in the left shoulder and arm, that has possible cardiac origin

TREATMENTImmobilizationTractionPharmacological managementSpinal manipulationEpidural Steroid injectionSurgery

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ImmobilizationSome advocate short course (one week) of neck immobilization may reduce symptoms in the inflammatory phaseCervical collar has not been proven to alter the course or intensity of the disease processAdverse effects - especially when used for longer periods of time. It is feared that a long period of immobilization, can result in atrophy-related secondary damage

TractionDistracts neural foramen and decompresses nerve rootTypically, 8 to 12 lb of traction at approximately 24 degrees of flexion for 15- to 20-minute intervalsMost beneficial when acute muscular pain has subsided Not be used in patients who have signs of myelopathy!

Neck traction

Physical therapyA graduated physical therapy program -- restoring range of motion and overall conditioning of the neck musculatureAs the pain improves, a gradual, isometric strengthening program may be initiated active range-of-motion and resistive exercises as tolerated.

Pharmacological managementNSAIDs - effects on pain and inflammationIn general, 10-14 days of regular dosing is all that is needed to control pain and inflammation Oral steroids - reduce the associated inflammation from compressionNo controlled study exists Longer-term use is not recommendedTricyclic antidepressants - adjunct in controlling radicular painOpioid medications - generally not necessary for pain relief, but can be used when other medications fail to provide adequate relief

SPINAL MANIPULATIVE THERAPY & MOBILIZATIONDescrbed as external force applied to the patient by the hand, an instrumental device or furniture resulting in movement and/or separation of the joint articular surfaces with high or low velocity of joint movementEvidence low in quality

Epidural Steroid injectionPrinciple- steroid decreases pain and inflammation at the site, decreases PGIndication Radicular pain unresponsive to non-interventional care for 1-2 monthsPatients without progressive neurological deficit or cervical myelopathy can be considered before sxComplicationsDural puncture, vasovagal reaction, facial flushing, fever, nerve root injury, pneumocephalus, epidural hematoma, subdural hematoma, stiff neck, transient paresthesias, hypotension, respiratory insufficiency, transient blindness and death

SurgeryRED FLAGS!!!Persistent or recurrent radicular symptoms unresponsive to nonoperative management for at least 6 weeksDisabling motor weakness of 6 weeks duration or less (i.e., deltoid palsy, wrist drop)Progressive neurologic deficitStatic neurologic deficit + radicular or referred painInstability or deformity of functional spinal unit + radicular symptoms

Surgical Management of Cervical Radiculopathy, Todd J. Albert, MD, and Samuel E. Murrell, MD, J Am Acad Orthop Surg 1999;7:368-376

Posterior lamino-foraminotomy (with or without diskectomy)Burr thins lamina over nerve rootNerve root exposedAngled curette can remove additional bone & expand foraminotomyDisk material can be exposed & removed

Anterior cervical diskectomy and fusion (ACDF)Most widely used Removes ventral compressive lesion WITHOUT need for retraction of SCDisc removed and iliac crest bone autograft placed to ENCOURAGE FUSIONNowadays, allografts (no donor site morbidity)In 1990s, cervical plates were added to INCREASE stability and decrease post op bracing

Anterior cervical diskectomy without fusionBecause of high incidence of pseudarthrosis after ACDF Reported outcomes comparable Disk-space collapse and osseous fusion There is stress on removal of PLL (buckling of ligament as disk space collapses produces compression of the neural elements) but removes another stabilizing structurePost anterior cervical diskectomy without fusion Lateral cervical radiograph shows increase in kyphosis. T2-weighted MRI - stenosis, ligamentum and disk bulging, spondylosis, and cord compression

Cervical Disc Arthroplasty

Bryan cervical disk (Medtronic, USA)

FlexicoreProDisc-C (Synthes Spine Company, USA)