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Cervical Radiculopathy Flashcards

1
Q

Common MD Dx for this pt group

A
  • Herniated, bulging, slipped, prolapsed, “torn”disc (and others)
  • Spondylosis
  • Cervical radiculopathy (radiating pain stemming from cervical spine)
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2
Q

Radiating Pain - Subjective

A
  • Follows a nerve pattern
  • COMMONLY, peripheral symptoms below the elbow
  • Sharp, stabbing, shooting pain (“lancinating”)
  • Associated numbness/ tingling
  • MAY have associated muscle weakness
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3
Q

Radiating Pain - Objective

A
  • Positive Cluster of 4 tests
  • Other tests
  • Neurologic findings:
    – Myotomal weakness (Sp: 89%)
    – Dermatomal sensory deficits (Sp: 51-86%)
    – Altered deep tendon reflexes
  • Directional preference/Centralization with ROM (strong variable for prognosis)
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4
Q

Nerve Conditions

A
  • Neuropraxia
  • Axonotmesis
  • Neurotmesis
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5
Q

Neuropraxia

A
  • Transient episode which damages myelin sheath preserving the axon and connective tissue
  • Numbness/tingling
  • Rapid recovery of days to weeks
  • “Entrapments”
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6
Q

Axonotmesis

A
  • Injury more severe and involves the axon but preservation of the Schwan sheath
  • Motor and sensory changes
  • Recovery of several months
  • Prolonged entrapments, crush or traction injury OR sustained exposure to inflammatory condition
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7
Q

Neurotmesis

A
  • Nerve and sheath are disrupted
  • Motor and sensory loss
  • Long term deficits
  • Lacerations
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8
Q

Causes of Radiating Pain

A
  • Mechanical Pressure
  • Chemical Irritation
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9
Q

Mechanical Pressure - Radiating Pain

A

“Space Occupying Lesion” (May cause inflammation around nerve

Cause:
* Disc Bulge (Most Common)
* Osteophyte encroachment
* Spondylosis
* Tumor (Most Dangerous)

Sx:
- Intermittent neck and arm pain
- Numbness and tingling but not always neuro findings
- Able to alleviate Sx with position and/or traction

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10
Q

Disc Bulge

A

Annular wall encroaches on the nerve. Intact.

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11
Q

Spondylosis

A

small shift in vertebral body, leads to encroachment

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12
Q

Tumor

A

Bony or Soft Tissue

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13
Q

Osteophyte encroachment

A

Bone Spur encroachment on nerve

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14
Q

Chemical Irritation - Radiating Pain

A

Disc Sequestration (Annular wall compromised)

Cause of irritation:
* Human discs conrain high levels of phospholipase A2 (PLA2) which has large inflammatory potential and has been found to be a neurotoxin
* Disc Sequestration: PLA2 leaks into the epidural space in the vicinity of the nerve roots and causes chemical irritation

Sx:
- Arm dominant pain with neuro findings
- More constant. Does not respond to traction.

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15
Q

Other causes of nerve pain down arm

A
  • Cervical Myelopathy (Bilateral Sx)
  • Lung tumors (Mimics Cervical Radiculopathy
  • Thoracic Outlet Syndrome (Brachialgia)
  • Peripheral nerve injury
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16
Q

Confirming Radiculopathy due to space occupying lesion

A

The presence of positive findings of four variables significantly increased the likelihood the patient presented with cervical radiculopathy:
* Ipsilateral cervical rotation <60°
* + ULTT (for median nerve)
* + Distraction test
* + Spurling’s test (highest sensitivity: 97%)

All four tests positive: .99 specificity and a +LR of 30.3

Ipsilateral for same side of Sx

17
Q

Clinical Tests to Screen for “Space Occupying Lesion”

A

Cluster of tests for diagnosis of cervical radiculopathy:
* Cervical rotation < 60°to side of sxs
* Positive distraction
* Positive Spurling test
* Positive Upper Limb Tension Test

Ruling in Radiculopathy:
- 3/4 - SP 94% (Probability 65%)
- 4/4 - SP 99% (Probability 90%)

18
Q

Other tests that RELIEVE Sx

A
  • Shoulder Abduction Test: More comfortable with hand on head
  • Positional Distraction: Takes relief off the side you rotate away from with traction
19
Q

C5 Nerve Root Presentation

A

Sensory Distribution
* Anterolateral Shoulder
* Anterior upper arm

Muscles Innervated
* Deltoid
* Rotator Cuff

Reflexes:
* Biceps

20
Q

C6 Nerve Root Presentation

A

Sensory Distribution
* Lateral upper arm, forearm and thumb

Muscles Innervated
* Rotator Cuff
* Biceps
* Wrist extensors

Reflexes:
* Brachioradialis

21
Q

C7 Nerve Root

A

Sensory Distribution
* Dorsal forearm
* Digits 2 and 3

Muscles Innervated
* Triceps
* Wrist flexors

Reflexes:
* Triceps

22
Q

C8 Nerve Root

A

Sensory Distribution
* Ulnar forearm
* Digits 4 and 5

Muscles Innervated
* Thumb extension

Reflexes:
* None

23
Q

Guidelines for MRI of Cervical Spine

A

Neck pain with non-radiating pain: In the absence of red flags, no imaging indicated

Neck pain with radiating pain, imaging indicated when:
* Signs of myelopathy (weakness, mm wasting, clonus, sensory loss, hyperactive reflexes)
* Progressive neurological findings (sensory deficits, weakness and reflex changes)
* Radiating pain not responding to conservative care after 4-6 weeks (this is VARIABLE)

24
Q

Cervical Radiculopathy Subjective

A
  • Acute to chronic symptoms
  • Associated with radiating pain usually along the dermatome (most common is lateral forearm, C6)
  • Deep ache or shooting pain in the arm
  • Symptoms affected by neck or arm position
  • Lying down relieves symptoms
  • May have pins and needles
  • May describe weakness
25
Cervical Radiulopathy Objective
AROM Assessment in Sitting:   * Restricted motion and/or pain when moving **TOWARD side of symptoms and/or extension** PROM Assessment in Supine:  * Improved motion compared to AROM but still may provoke symptoms AROM and/or PROM: * May show a direction of motion that alleviates symptoms (directional preference) with repeated motions (centralization) Joint Mobility:   * Manual traction alleviates * Cervical: Hypomobility and or pain mid to end range of down slide assessment to the side of symptoms Cluster of 4 tests for space occupying lesion: * Positive Neuro: * Potential positive neuro findings (sensation, strength, DTR)
26
Differential Preference vs Centralization
Directional Preference: - Direction of movement described by the patient OR observed during motion assessment that results in a **decrease in pain intensity, with or without the pain changing location, and/or an increase in previously limited movement** Centralization: - **progressive decrease of abolishment of the most distal symptoms** as symptoms at or close to midline of the spine are being produced or increased. The change of the distal symptoms is better with the application of mechanical forces and **remains better** once the forces are ceased.
27
Directional preference and centralization prevalence
Centralization: * Not as common a slumbar * 20-40% * Decreases with chronicity and age * **Prognosis is enhances if present** DP: * More prevalent - 70% * Enhanced function if exercise matches directional preference
28
Cervical Radiculopathy Irritability
High Irritability: * Sx's more constant. Arm pain dominant. Traction may alleviate (associated more with axonotmesis) * **Noticeable limitation with neurodynamic testing** * Once aggravated, takes a long time to resolve Moderate Irritability: * Sx's intermittent. Traction alleviates symptoms completely * **Moderate limitation with neurodynamic testing** * 1:1 ratio of time to come on and time to alleviate Low Irritability: * Symptoms intermittent (associated more with neuropraxia) * **End range limitation with neurodynamic testing** * Able to alleviate immediately with change in position ## Footnote Two big indicators are NDM testing and how they respond to traction
29
Tx for CR
* Education!! * Manual therapy -- Manual traction  (acute irritable) -- Cervical mobilizations (with neurodynamic mobilization) (acute to chronic) -- Thoracic mobilizations as needed * Neuro dynamic mobilizations (chronic * Mechanical traction (acute/irritable) * Neuromuscular re-ed and endurance exercises
30
Education with CR
* Constant vs. intermittent symptoms: **if intermittent, disc is likely still intact**. * Disc injuries can HEAL over a period of time! * Even if you have a disc bulge on an MRI, that can change its appearance over time * In the absence of weakness and reflex changes, PT is effective at managing symptoms * If neurological symptoms progress in the arm, will refer for MD consult
31
Cervical Side Glides with ULTT
* “Close down” or “open up” the side of symptoms in supine position * No difference in which is used * Assess effectiveness with ULTT * Physiologically: -- Improve mobility of joint structures around the nerve
32
**Within Session Changes** for Cervical Slide Glides with ULTT
* Increased ROM of elbow w/ ULTT * Decreased pain intensity * More motion prior to provocation of symptoms
33
**Between Session Changes** compared to NDM
* No significant differences over 2 weeks between cervical sideglides and NDM
34
Follow up with NDM for Tx
Gliding: * High irritability * As place tension on tissue distally, remove tension proximally (nerve never is tensioned) Tensioning: * Low irritability Gently have patient move into resistance and back off (pressure on/off proximally or distally Improvements may be due to bloof flow, axonal transport, temperature and remyelination of the nerve; gliding movement reduces the probability of adhesions in the nerve
35
Mechanical Traction Guidelines
* Frequency: daily vs. 2-3x/week (minimum) (Home traction vs. clinic traction) * Duration: 15 minutes * Angle of pull: 15°-25° * Amount of pull: Incremental based on pt. comfort; but requires a minimum of 10 lbs to lift head * Constant vs. Intermittent (45-60 sec on, 10-15 sec off)
36
Evidence for Traction
* Tx must be used in combination of other interventions * Must focus on subgrouping of patients (heterogenous vs homogenous population) * Variation in parameters **Mechanical TX with exercise** has been found to decrease disability score and pain intensity compared to only exercise in a subgroup of patients | Beneficial for radiating patients.
37
Summary of CR Assessment
Radiating symptoms? If yes… * Confirm a space occupying lesion with use of 4 tests? * Rule out other conditions? * Is Imaging needed? If radiculopathy, severity and irritability of arm symptoms dictate intervention? * Arm dominant (irritable) vs. neck dominant (less irritable)? * Able to find position to alleviate? If not, high irritability * Consideration of MD interventions if high irritability? ## Footnote Arm = highly irritable; focus on taking pressure off nerve Neck = Joint mobs and neurodynamic mobilization techniques
38
Tx for CR
Treat cervical radiculopathy with a **multimodal approach** addressing: * Thoracic mobility as needed * Cervical mobility moving away from symptoms first and eventually moving into symptoms * Neurodynamic mobilization beginning with gliding and progressing to tensioning * Traction * Deep cervical flexor and lower trapezius strengthening when symptoms subside Continually assess neurologic findings if not responding to conservative care… if progressing then refer.

Spine (19 decks)

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