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Spine > Cervical Radiculopathy > Flashcards

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
Q

Cervical Radiulopathy Objective

A

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
Q

Differential Preference vs Centralization

A

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
Q

Directional preference and centralization prevalence

A

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
Q

Cervical Radiculopathy Irritability

A

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

Two big indicators are NDM testing and how they respond to traction

29
Q

Tx for CR

A
  • Education!!
  • Manual therapy
    – Manual traction (acute irritable)
    – Cervical mobilizations (with neurodynamic mobilization) (acute to chronic)
    – Thoracic mobilizations as needed
  • Neuro dynamicmobilizations (chronic
  • Mechanical traction (acute/irritable)
  • Neuromuscular re-ed and endurance exercises
30
Q

Education with CR

A
  • 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
Q

Cervical Side Glides with ULTT

A
  • “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
Q

Within Session Changes for Cervical Slide Glides with ULTT

A
  • Increased ROM of elbow w/ ULTT
  • Decreased pain intensity
  • More motion prior to provocation of symptoms
33
Q

Between Session Changes compared to NDM

A
  • No significant differences over 2 weeks between cervical sideglides and NDM
34
Q

Follow up with NDM for Tx

A

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
Q

Mechanical Traction Guidelines

A
  • 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
Q

Evidence for Traction

A
  • 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
Q

Summary of CR Assessment

A

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?

Arm = highly irritable; focus on taking pressure off nerve
Neck = Joint mobs and neurodynamic mobilization techniques

38
Q

Tx for CR

A

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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