Cervical Radiculopathy Myelopathy Flashcards
Spinal
Motion theory: Flexion
- facets slide anterior/forward
- superior vertebrae anterior tilts, translates forward
- forward translation at the uncovertebral joints
- IV foramen enlarge
- spinal canal narrows but lengthens
- little change in overall volume
Spinal motion theory
Extension
- facets, uncovertebral joints slide down and backward
- superior vertebrae tils, translates backward
- vertebrae can step on one another
- ligaments slackened
- ligamentum flava bulges into the canal
- IV foramen narrows
- spinal canal shortens and narrows
Spinal motion theory
SB and rotation
- SB and rotation occur to the same side
- facets on SB slide down and backward bend
- facets on oppsite side slide up and forward
- upslide to downslide 2:1 ratio
Cervical IV disc
- HNP disc does occur but less common in C/S than L/S
- PLL is thicker and broader invested in disc
- nucleus is less distinct and more fibrotic in nature
- as age tends to fragments
Pathological degenerative process
DDD-aging
- loss of GAGs, dehydration, nucleus fragmentation
- intra-discal pressure falls
- loss of disc height
- ligamentous laxity
- annular radial bulging
- osteophytes form on vertebral bodies
- narrowed IV foramen, spinal canal
- may result in neurological S&S
DJD
- DDD=> DJD
- over 50
- narrowing of IV foramen, spinal canal
- 1º due to C/S spondylosis (stenosis)
C/S spondylosis
what is it and what happens
- stenosis
- increased forces. on osseous structures => DJD
- Facet joint arthropathy, osteophytes
- Uncovertebral joint osteophytes.
- Vertebral body osteophytes (lipping)
- Ligamentum flavum hypertrophy
- Decreased size of spinal canal & IV foramen
- Neurological S & S
Lateral foramenal stenosis
causes
- DDD – nucleus fragmentation, loss of disc height, radial disc bulging
- DJD – Osteophytes on facets, uncovertebral jts
- Narrowing of IV foramen
- May result in hypomobility, hypermobility, instability
Lateral foraminal stenosis
signs and symptoms
C/S
- LMN - Peripheral NR involvement:
- myotomal weakness
- sensory deficits in dermatomal pattern
- diminished reflexes
- Neurogenic pain and paresthesia
- neck, scapular, shoulder & arm regions
Clinical prediction rule with cervical radiculopathy
- Spurling’s Test – to painful side
- Distraction Test—supine C/S distraction force (relief of symptoms)
- C/S rotation less than 60 degrees ipslaterally
- ULTT(+ test) Symptom reproduction
4/4 positive = 99% specificity; 3/4 positive = 94% specificity
Central canal stenosis
causes- related to aging
- DDD =>DJD
- Ligamentum flava hypertrophy & bulging
- Increased forces on osseous spine structures
- Osteophytes - Facet, Uncovertebral joints, Vertebral bodies
- Osteophytic “lipping” of vertebral bodies protruding into spinal canal.
besides degenerative processes what can cause central canal stenosis
- Congenitally narrowed canal
- Tumors
- Hypermobility / instability (grade 3)
Central canal stenosis - cervical myelopathy
S&S
- B/L neurological S&S - perhaps in arms & legs
- Ataxic gait, loss of balance, proprioception
- Clumsiness in hands and LEs
- hypertonia
- hyperreflexia
- (+) Babinski,
- (+) Clonus
- (+) Hoffman’s sign
- (+) Inverted brachioradialis (supinator) reflex
Hoffmans signs
indicates cervical myelopathy
flick index finger DIP
(+) test is flexion of thumb
Inverted brachioradialis reflex
- tap brachioradialis
- normal response = elbow flexion
- abnormal = elicits wrist and finger flexion
- indicates UMN lesion at C5-C^
Clinical prediction rule for cervical spine myelopathy
(1) Ataxic gait
(2) + Hoffmann’s test
(3) + Inverted brachioradialis (supinator) sign
(4) + Babinski test
(5) Age > 45 years
*If 3/5 tests positive:
A post-test probability of 94%.
positive likelihood ratio of 30.9 (95%CI) *
What to look for with exam: history and interview
- red flags: Viscera referred symptoms: heart / cardiac , lungs, liver etc.
- MOI – Trauma or insidious. Hx - previous episodes
- CC – Cervical pain; and or extremity symptoms
- Radiculopathy: LMN UL Pain, paresthesia, mm weakness UL UE hypo-reflexia
- CS Myelopathy: UMN hypertonia, hyper-reflexia symptoms b/l possibly all 4 extremities, extremity clumsiness, ataxic gait
- Diagnostic tests – MRI, Xrays, NCV/EMG
- Better, Worse with certain activities, positions:
- Occupational: Looking up, driving, lifting, computer work etc.
What positions during UQS should make them better in relation to lateral foraminal stenosis
- Quadrant testing (Spurling test)
- Worse with extension/SB/rotation involved side
- Better – SB away, flexion.
- Worse with compression; Better with distraction
What other special test can be used for cervical myelopathy
- (+) Shoulder abduction sign:
- Arm on top of head may relieve traction on NR lift NR above/away from source of irritation.
Differential diagnosis for CSM
- Carpal Tunnel Syndrome: (+) exam findings and CTS Special Tests
- Other UE peripheral nerve entrapments: (+) exam findings and ULTT
- Thoracic Outlet Syndrome: (+) exam findings and TOS Tests
Lateral formainal stenosis treatment
- Exercise preference - CS retraction, extension; centralize radicular symptoms
- Distraction of foramen
- Avoid extension and quadrant positions end ranges that close foramen - radicular symptoms
- Mobil/Manip restrictions in adjacent U/C, U/T spine
- Stabilization ex’s if instability - Deep neck flexors (Jull method), CS extensors
- Modalities
- Education - posture
Positional distraction
potential treatment for lateral foraminal stensois
- patient supine
- clincian: raises patients head and neck producing FB to level to be distracted head is then supported on form pillow or books
- neck is side bent away from symptomatic side (gapping / opening involved side) Technique can be purely positional or traction may be applied in this position. Try 5 min progressing toward 20 min twice daily
Central canal stenosisCSM: referrals
Referral to MD
- Decompression Surgery-clean canal of osteophytes, foraminectomy commonly done, fusion/stabilization
If MD aware of condition & refers patient to PT:
- Posture / education – avoid CS extension activities
- Stabilization/support as appropriate
- Gait, balance activities (ataxia)
- Monitor patient’s symptoms
