Cervical radiculopathy: Difference between revisions

 
(15 intermediate revisions by 4 users not shown)
Line 14: Line 14:


==Clinical Features==
==Clinical Features==
*Follows a dermatome or myotome distribution
[[File:Grant 1962 664.png|thumb|Nerve roots that supply sensation to the upper extremities.]]
*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>
 
{{Cervical radiculopathy table}}


==Differential Diagnosis==
==Differential Diagnosis==
*lateral disc herniation
{{Neck pain DDX}}
*brachial plexitis, [[Brachial plexus injury]]
{{Shoulder DDX}}
*shoulder pathology
**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 46:


==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 15:12, 5 February 2022

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

Nerve roots that supply sensation to the upper extremities.
  • 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