Difference between revisions of "Cervical radiculopathy"

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*Risk factors
 
*Risk factors
 
**White race
 
**White race
**female gender
+
**Female gender
**cigarette smoking
+
**Cigarette smoking
**prior lumbar radiculopathy
+
**Prior lumbar radiculopathy
*Neck pain radiating to the upper extremities
+
*[[Neck pain]] radiating to the upper extremities
**can have associated weakness or numbness
+
**can have associated [[weakness]] or numbness
 
*Compression and inflammation of the spinal nerve  
 
*Compression and inflammation of the spinal nerve  
 
*Most commonly affects C5-C6 or C6-C7
 
*Most commonly affects C5-C6 or C6-C7
  
 
==Clinical Features==
 
==Clinical Features==
*Follows a dermatome or myotome distribution
+
*Follows a [[dermatome]] or myotome distribution
 
**Diminished muscle tendon reflexes
 
**Diminished muscle tendon reflexes
 
**Sensory changes
 
**Sensory changes
**Motor weakness
+
**Motor [[weakness]]
 
*If C6 is affected: diminished brachioradialis reflex, bicep muscle weakness, paresthesias in the arms to the thumb/index finger
 
*If C6 is affected: diminished brachioradialis reflex, bicep muscle weakness, paresthesias in the arms to the thumb/index finger
 
*If C7 is affected: diminished triceps reflex, tricep muscle weakness, paresthesias radiating in the arms to the middle finger  
 
*If C7 is affected: diminished triceps reflex, tricep muscle weakness, paresthesias radiating in the arms to the middle finger  
**Spurling sign - closes the neural foramens
+
*Spurling maneuver (neck compression test)
***if pain is worse with lateral bending to the painful arm--> radiculopathy
+
**With patients head extended and rotated to affected side, apply pressure to top of head
***if pain is worsen when bending to the contralateral arm--> nonspecific soft tissue injury
+
**Positive if it produces pain or parasthesias beyond the shoulder
**Pt looks straight ahead and attempts to touch the ear to the shoulder
+
**High specificity (0.89-1.00) with variable sensitivity (0.38-0.97)<ref>Thoomes EJ, van Geest S, van der Windt DA, et al. Value of physical tests in diagnosing cervical radiculopathy: a systematic review. Spine J. 2018;18(1):179-189. doi:10.1016/j.spinee.2017.08.241</ref>
 +
 
 +
===[[Spinal cord levels|Cervical Exam by Level]]===
 +
{|  class="wikitable"  style="text-align:center"
 +
! Radiculopathy
 +
! Motor Deficit
 +
! Sensory Deficit
 +
! Diminished Reflex
 +
|-
 +
!C4
 +
||Levator Scapulae & Shoulder elevation||||
 +
|-
 +
!C5
 +
||Deltoid & Biceps||||Biceps
 +
|-
 +
!C6
 +
||Brachioradialis & Wrist extension||Thumb Paresthesia||Brachioradialis
 +
|-
 +
!C7
 +
||Triceps & Wrist flexion||Index/Middle/Ring Paresthesia||Triceps
 +
|-
 +
!C8
 +
||Index/Middle distal phlnx flexion||Small Finger Paresthesia||
 +
|}
  
 
==Differential Diagnosis==
 
==Differential Diagnosis==
*lateral disc herniation
+
{{Neck pain DDX}}
*brachial plexitis, [[Brachial plexus injury]]
+
 
*shoulder pathology
+
{{Shoulder DDX}}
**adhesive capsulitis
 
**recurrent anterior subluxation
 
**impingement syndrome
 
*entrapment neuropathy
 
**[[Carpal tunnel syndrome]]
 
**[[Thoracic outlet syndrome]]
 
  
 
==Evaluation==
 
==Evaluation==
*Full neuro exam
+
*Full [[neuro exam]]
**motor weakness --> early surgical referral
+
**motor weakness early surgical referral
 +
*Spurling maneuver
 +
**generally avoid in patients w/ [[rheumatoid arthritis]], cervical malformations, or metastatic disease
 
*Imaging
 
*Imaging
 
**Cervical xray
 
**Cervical xray
Line 48: Line 67:
  
 
==Management==
 
==Management==
*Primary treatment typically utilizes NSAIDS  
+
*Primary treatment typically utilizes [[NSAIDS]]
 
**6 weeks of nonsurgical treatment with pain control
 
**6 weeks of nonsurgical treatment with pain control
**May consider steroids, gabapentin, nortriptyline, SNRI's, and muscle relaxers
+
**May consider [[steroids]], [[gabapentin]], [[nortriptyline]], SNRIs (e.g. [[venlafaxine]], [[duloxetine]]) and muscle relaxers (e.g. [[cyclobenzaprine]])
 
*Short term immobilization and rest may calm symptoms of CR
 
*Short term immobilization and rest may calm symptoms of CR
 
**Recent literature review showed that exercise is beneficial for improving function and activity levels
 
**Recent literature review showed that exercise is beneficial for improving function and activity levels
**Outpatient PT evaluation may be beneficial but home exercises should be recommended to patients in the interim
+
**Outpatient physical therapy evaluation may be beneficial but home exercises should be recommended to patients in the interim
  
 
==Disposition==
 
==Disposition==
 
*Outpatient follow up with primary care/orthopedics
 
*Outpatient follow up with primary care/orthopedics
 
*Majority of patients approx 75% in one study reported pain relief in 4 weeks
 
*Majority of patients approx 75% in one study reported pain relief in 4 weeks
*pain control with NSAIDS
+
*Pain control with [[NSAIDS]]
  
 
==See Also==
 
==See Also==
 
+
*[[Neck pain]]
  
 
==External Links==
 
==External Links==

Latest revision as of 08:36, 18 March 2021

Background

  • Cervical radiculopathy (CR) is commonly seen in the ED
    • Incidence of 107.3/100,000 men and 63.5/100,000 women
    • Peak incidence at age 50-54
  • Risk factors
    • White race
    • Female gender
    • Cigarette smoking
    • Prior lumbar radiculopathy
  • Neck pain radiating to the upper extremities
    • can have associated weakness or numbness
  • Compression and inflammation of the spinal nerve
  • Most commonly affects C5-C6 or C6-C7

Clinical Features

  • Follows a dermatome or myotome distribution
    • Diminished muscle tendon reflexes
    • Sensory changes
    • Motor weakness
  • If C6 is affected: diminished brachioradialis reflex, bicep muscle weakness, paresthesias in the arms to the thumb/index finger
  • If C7 is affected: diminished triceps reflex, tricep muscle weakness, paresthesias radiating in the arms to the middle finger
  • Spurling maneuver (neck compression test)
    • With patients head extended and rotated to affected side, apply pressure to top of head
    • Positive if it produces pain or parasthesias beyond the shoulder
    • High specificity (0.89-1.00) with variable sensitivity (0.38-0.97)[1]

Cervical Exam by Level

Radiculopathy Motor Deficit Sensory Deficit Diminished Reflex
C4 Levator Scapulae & Shoulder elevation
C5 Deltoid & Biceps Biceps
C6 Brachioradialis & Wrist extension Thumb Paresthesia Brachioradialis
C7 Triceps & Wrist flexion Index/Middle/Ring Paresthesia Triceps
C8 Index/Middle distal phlnx flexion Small Finger Paresthesia

Differential Diagnosis

Neck pain

Shoulder and Upper Arm Diagnoses

Traumatic/Acute:

Nontraumatic/Chronic:

Refered pain & non-orthopedic causes:

Evaluation

  • Full neuro exam
    • motor weakness → early surgical referral
  • Spurling maneuver
  • Imaging
    • Cervical xray
      • can be obtained to exclude frank instability
    • MRI
      • Performed non-urgently
      • spondylararthrosis
      • Herniated disc

Management

  • Primary treatment typically utilizes NSAIDS
  • Short term immobilization and rest may calm symptoms of CR
    • Recent literature review showed that exercise is beneficial for improving function and activity levels
    • Outpatient physical therapy evaluation may be beneficial but home exercises should be recommended to patients in the interim

Disposition

  • Outpatient follow up with primary care/orthopedics
  • Majority of patients approx 75% in one study reported pain relief in 4 weeks
  • Pain control with NSAIDS

See Also

External Links

References

  1. Thoomes EJ, van Geest S, van der Windt DA, et al. Value of physical tests in diagnosing cervical radiculopathy: a systematic review. Spine J. 2018;18(1):179-189. doi:10.1016/j.spinee.2017.08.241