Cervical radiculopathy: Difference between revisions
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==Clinical Features== | ==Clinical Features== | ||
[[File:Grant 1962 664.png|thumb|Nerve roots that supply sensation to the upper extremities.]] | |||
*Follows a [[dermatome]] or myotome distribution | *Follows a [[dermatome]] or myotome distribution | ||
**Diminished muscle tendon reflexes | **Diminished muscle tendon reflexes | ||
Line 25: | Line 26: | ||
**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> | **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== | ||
{{Neck pain DDX}} | |||
{{Shoulder DDX}} | |||
==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 81: | Line 56: | ||
*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]] | ||
==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
- 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
- Musculoskeletal
- Torticollis
- Dystonic reaction
- Cervical spondylosis
- Cervical stenosis
- Cancer
- Epidural abscess
- Vertebral osteomyelitis
- Transverse myelitis
- Temporal arteritis
- Epidural hematoma (anticoagulation, hemophilia)
- Cervical disk herniation
- Blunt neck trauma
- Anterior horn disease
- Cervical fractures and dislocations
- Cervical radiculopathy
Shoulder and Upper Arm Diagnoses
Traumatic/Acute:
- Shoulder Dislocation
- Clavicle fracture
- Humerus fracture
- Scapula fracture
- Acromioclavicular joint injury
- Glenohumeral instability
- Rotator cuff tear
- Biceps tendon rupture
- Triceps tendon rupture
- Septic joint
Nontraumatic/Chronic:
- Rotator cuff tear
- Impingement syndrome
- Calcific tendinitis
- Adhesive capsulitis
- Biceps tendinitis
- Subacromial bursitis
- Cervical radiculopathy
Refered pain & non-orthopedic causes:
- Referred pain from
- Neck
- Diaphragm (e.g. gallbladder disease)
- Brachial plexus injury
- Axillary artery thrombosis
- Thoracic outlet syndrome
- Subclavian steal syndrome
- Pancoast tumor
- Myocardial infarction
- Pneumonia
- Pulmonary embolism
Evaluation
- Full neuro exam
- motor weakness → early surgical referral
- Spurling maneuver
- generally avoid in patients w/ rheumatoid arthritis, cervical malformations, or metastatic disease
- Imaging
- Cervical xray
- can be obtained to exclude frank instability
- MRI
- Performed non-urgently
- spondylararthrosis
- Herniated disc
- Cervical xray
Management
- Primary treatment typically utilizes NSAIDS
- 6 weeks of nonsurgical treatment with pain control
- 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
- 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
- http://www.bmj.com/content/bmj/339/bmj.b3883.full.pdf
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3116771/
References
- ↑ 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