Cervical radiculopathy

PMR PG teaching

1. CERVICAL RADICULOPATHY
SPINAL NERVE ROOT DYSFUNCTION CAUSING -
DERMATOMAL PAIN & PARASTHESIAS, MYOTOMALWEAKNESS, AND/OR IMPAIRED DTRS

2. RADICULOPATHY
RADICULAR PAIN
Painperceived 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)
RADICULOPATHY
Neurological 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 together
•Radicular pain may or may not occur with radiculopathy

4. Typical cervical vertebra

5. Facet Joints (ZygapophysealJoints)
VxC3 -C7
Pillars at Pedicle –
Lamina
Posterior to exiting
nerve root
Synovial with capsule
Medial branch of dorsal
primary ramus
Directional stability and
prevent translation of
vx

6. Intervertebral disc
six
Each named after vx
aboveit
annulus fibrosus+
nucleus pulposus+ 2
cartilaginous endplates
Thicker anteriorly than
posteriorly –lordosis

7. Uncovertebralarticulations (joints of Luschka)
Lateral aspect of lower Vx
body has superior
projection (uncinate
process) &
lateral part of inferior
surface of upper vxbody
facing it is slightly concave
On posterolateralborder
of disc & anteromedial
portion of IVF
Not true synovial joints
Can hypertrophy
associated with disc
degeneration, and result
in narrowing of IVF

8. Intervertebral foramina
GATEWAY OF THE
SPINAL NERVE TO
THE BODY
C1
C2
C3
C4
C5
C6
C7
C8
C1
C2
C3
C4
C5
C6
C7

9. Note
•There is no C1 dermatome marked on the skin
The sensory fibersentering are from the meninges around the
cerebellum and medulla, not from the skin
•The 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.

10. Unique -2 joints form boundary
Allows to dynamically change
configuration according to
movements
roof –inferior
aspect of notch
of pedicle
floor -superior
notch of pedicle
Posterior aspect of vxbodies, disc,
lateral expansion of PLL, venous
sinus
superior and
inferior
articular
process of ZP
joint ,lateral
prolongation
of LF

11. Spinal nerve root
DRG
Spinal arteryof segmental artery
Communicating veins
Recurrentmeningeal (sinu-vertebral) nerve
Transforaminalligament
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 RAMUS
DORSAL
RAMUS
Recurrentm. N

14. Degeneration,
spondylosis,
hypertrophy of ZP
joint or
uncovertebraljoint
Disc herniation
Spinal instability
Trauma
Tumors
Disc herniation
Degeneration,
spondylosis,
hypertrophy of ZP
joint or
uncovertebraljoint

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

16. Irritation of the spinal dorsal ramus system
-a potential source of pain
Each spinal dorsal ramus arises from the spinal
nerve and then divides into a medial and lateral
branch
Medial 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 ramus
Diagnosis can be confirmed by performing a
single dorsal ramus block that results in relief of
pain
Treatment -spinal dorsal ramus injection
therapy

17. 1.Dermatomaltesting
2.Myotomaltesting
3.Special tests

18. Classic Patterns
ABNORMALITIES
NERVE ROOT MOTOR SENSORY REFLEX
C5 Deltoid, elbow flexionLateral arm Biceps
C6 Biceps, wrist extensionLateral forearm, thumbBrachioradialis
C7 Triceps, wrist flexionDorsal forearm, long
finger
Triceps
C8 Finger flexors Medial forearm, ulnar
digits
NA

19. C5 Neck, shoulder, lateral
arm
C6 Neck, dorsal lateral
(radial) arm, thumb
C7 Neck, dorsal lateral
forearm, middle finger
C8 Neck, medial forearm,
ulnar digits
Distribution of Pain

20. Spurlingtest/ Foraminalcompression test/ Neck
compression test/ Quadrant test
◦Neck extension + Rotation +
Downward pressure on head
◦Positive finding eliciting
reproduction of radicular pain into
ipsilateralarm of head rotation
◦92% sensitive, 95% specific
Low sensitivity but high specificity-
not useful as a screening tool, but it
does help confirm the diagnosis

21. Shoulder abduction test/ Shoulder abduction relief
sign/Bakody’ssign
◦Active/passive abduction of
ipsilateralshoulder
◦Relief of radicular symptoms
◦takes stretch off of the affected
nerve root and may decrease or
relieve radicular symptoms

22. Cervical spine tests
Neck distraction test/ Manual traction
test

23. Lhermittesign/ Barber chair phenomenon
◦Flexion of neck producing electric
shock like sensations that extend
down the spine and shoot into the
limbs
◦Usefulness is limited
◦Indicates spinal canal stenosis, disc
impingement, multiple sclerosis, or
tumor

24. Anterior doorbell sign
•Indicates nerve root
tension/radiculopathy
•Deep palpation over C5
segment produces pain in
superior scapulovertebral
border that radiates to upper
limb

25. Others
NAFFZIGER'STEST
(for nerve root compression)
Manual compression of the jugular
veins bilaterally
An 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
VALSALVAMANEUVER
Deep breath and hold it while
attempting to exhale for 2-3
seconds
Positive response -reproduction of
symptoms
The pushing increases intrathecalor
intraspinalpressure revealing
presence of a space occupying mass
such as and extruded intervertebral
disc, or narrowing due to
osteophytes

26. Hoffman sign
◦UMN sign indicating
pyramidal tract
involvement
◦Indicates myelopathy

27. 1.Plain Radiographs
2.MRI
3.Cervical myelogram
4.Cervical myelogram+ CT

28. Plain radiography
Role somewhat limited in evaluation
of nerve roots
Initial study to rule out instability or
pathologic changes in bone
Oblique views can show narrowing
of the neuroforaminasecondary to
degenerative changes

29. MRI
MRI 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 radiographs
Sagittal T1 -Hypointensesignal is common for herniated degenerative disks,
calcified ligaments, and bone spurs, making differentiation of these structures
more difficult
Axial T1 -Insight into both intraspinaland extraspinaldisorders, as well as the
intrathecalnerve root anatomy
T2-weighted sequence or variants -“myelo-graphic” view

30. Cervical myelogram
Outlines SC and exiting nerve roots
with radiopaque dye
Water-soluble agent may be injected
via the C1-2 interval, allowing the dye
pool to gravitate caudally
Accuracy has been estimated 67% to
92%. For this reason, cervical
myelographyis often accompanied by
CT
Excellent visualization of nerves in
relation to surrounding osseous
structures

31. Electrodiagnosisplays a critical role
Referred to as an extension of neurologic examination, as it is able to
provide physiologic evidence of nerve dysfunction
1. EMG
2. Motor and sensory nerve conduction studies
3. Late responses

32. ELECTROMYOGRAPHY
EMG is the most useful test
Localize lesions to a particular root level
The goal --find a pattern of spontaneous and/or chronic motor unit changes in a
clear myotomalpattern
Limitations –
◦can only detect change in the motor nervous system

33. Diagnostic Criteria for Needle EMG
To 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

34. NERVE CONDUCTION STUDIES
The primary role --determine if other neurologic processes exist as
an explanation for a patient’s clinical picture, or if another process
coexists with a root level problem
In 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

35. LATE RESPONSES
The 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 disease
only tests motor fibers
not well tolerated by patients(supramaximalstimulation)

37. Myofacial pain
syndrome
No dermatomaldistribution
Has tender points
Cervical spondylotic
myelopathy
Changes in gait
Falls
Bowel, bladder, sexual dysfunction
Difficulty using the hands
UMN findings like spasticity
Facet joint
arthropathy
Axial pain
Tenderness over facet joints or
paraspinalmuscles
Pain with cervical extension or
rotation
No neurologic abnormalities
CRPS
Pain and tenderness of the
extremity, out of proportion with
examination findings
Skin changes, vasomotor
fluctuations, or dysthermia
LimitedROM, stiffness
Entrapment
syndromes
For example, carpal tunnel
syndrome (median nerve) and
cubitaltunnel syndrome (ulnar
nerve)
Parsonage-Turner
syndrome (neuralgic
amyotrophy)
Acute onset of proximal upper extremity
pain
Usually followed by weakness typically in
the C5–C6 region and sensory disturbances
Typically involves upper brachial plexus
(unlike in cervical radiculopathy, in which
pain and neurologic findings occur
simultaneously)
Herpes zoster
(shingles)
Acute inflammation of DRG
Painful, dermatomalradiculopathy
Followed by appearance of typical
vesicular rash
Rotator cuff
pathology
Shoulder and lateral arm painonly
rarely radiates below the elbow
Aggravated by active and resisted
shoulder movements, rather than
by neck movements
Normal sensory examination,
reflexes
Thoracic outlet
syndrome
Median 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 pain
Radiating upper extremity pain,
particularly in the left shoulder and
arm, that has possible cardiac origin

38. 1.Immobilization
2.Traction
3.Pharmacological management
4.Spinal manipulation
5.Epidural Steroid injection
6.Surgery

39. Immobilization
Some advocate short course (one week) of
neck immobilization may reduce symptoms
in the inflammatory phase
Cervical collar has not been proven to
alter the course or intensity of the disease
process
Adverse 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

40. Traction
Distracts neural foramen and
decompresses nerve root
Typically, 8 to 12 lbof traction at
approximately 24 degrees of
flexion for 15-to 20-minute
intervals
Most beneficial when acute
muscular pain has subsided
Not be used in patients who have
signs of myelopathy!

41. Neck traction

42. Physical therapy
A graduated physical therapy
program --restoring range of
motion and overall conditioning
of the neck musculature
As the pain improves, a
gradual, isometric strengthening
program may be initiated 
active range-of-motion and
resistive exercises as tolerated.

43. Pharmacological management
NSAIDs-effects on pain and inflammation
In general, 10-14 days of regular dosing is all that is needed to
control pain and inflammation
Oral steroids -reduce the associated inflammation from
compression
No controlled study exists
Longer-term use is not recommended
Tricyclic antidepressants -adjunct in controlling radicular pain
Opioid medications -generally not necessary for pain relief, but can
be used when other medications fail to provide adequate relief

44. SPINAL MANIPULATIVE THERAPY &
MOBILIZATION
Descrbedas 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 movement
Evidence low in quality

45. Epidural Steroid injection
Principle-steroid decreases pain and
inflammation at the site, decreases PG
Indication –
◦Radicular pain unresponsive to non-
interventional care for 1-2 months
◦Patients without progressive neurological
deficit or cervical myelopathy can be
considered before sx
Complications
◦Dural 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

46. Surgery
RED FLAGS!!!
Persistent or recurrent unresponsive to nonoperative
management for at least 6 weeks
Disabling of 6 weeks’ duration or less (i.e., deltoid palsy, wrist
drop)
Progressive
Static or referred pain
or deformity of functional spinal unit +
Surgical Management of Cervical Radiculopathy, Todd J. Albert, MD, and Samuel E. Murrell, MD, J Am AcadOrthopSurg1999;7:368-376

47. Posterior lamino-foraminotomy(with or
without diskectomy)
◦Burr thins lamina over nerve root
◦Nerve root exposed
◦Angled curette can remove
additional bone & expand
foraminotomy
◦Disk material can be exposed &
removed

48. Anterior cervical diskectomyand fusion
(ACDF)
◦Most widely used
◦Removes ventral compressive lesion
WITHOUT need for retraction of SC
◦Disc removed and iliac crest bone
autograftplaced to ENCOURAGE
FUSION
◦Nowadays, allografts (no donor site
morbidity)
◦In 1990s, cervical plates were added
to INCREASE stability and decrease
post op bracing

49. Anterior cervical diskectomywithout
fusion
◦Because of high incidence of
pseudarthrosisafter 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
structure
Post anterior cervical diskectomywithout fusion Lateral cervical radiograph shows
increase in kyphosis. T2-weighted MRI -stenosis, ligamentumand disk bulging,
spondylosis, and cord compression

50. Cervical Disc Arthroplasty
Bryan cervical disk (Medtronic, USA)
Flexicore
ProDisc-C (Synthes
Spine Company,
USA)