Neck P! with Radiating Pain

Question 1

What are the 2 pathoanatomical conditions that may cause Neck P! with radiating pain?

Answer 1

• Lateral Foraminal Stenosis (Most common; 70-75%)
• Herniated Nucleus Pulposus (25%)

Question 2

With Neck Pain with Radiating pain, what is Lateral Foraminal Stenosis?

Answer 2

A condition that is the result of a space-occupying lesion in the intervertebral foramen, this may be caused by:
- Decreased disk height
- Degenerative disk height (Spondylosis)
–Uncovertebral joint anteriorly
–Zygopophyseal joints posteriorly
This reduces the space the nerve root has to exit

Question 3

With Neck Pain with Radiating pain, what is Herniated Nucleus Pulposus?

Answer 3

This condition is less prevalent than lateral foraminal stenosis.
- This is due to the structural differences in the cervical disk compared to the lumbar spine
–There are vertically oriented posterior annular fibers
–Posterior annulus reinforcement (PLL, uncovertebral, joints)

Question 4

What other conditions should be considered with patients with Neck P! with Radiating pain?

Answer 4

• Mobility deficit or movement coordination impairments
• Thoracic Outlet Syndrome (TOS)
• Rotator cuff related shoulder pain
• Lateral Epicondylalgia
• Radial nerve entrapment
• Carpal tunnel entrapment

Question 5

What system, structure, pain mechanism, and phases of healing are unique to patients with Neck P! Radiating Pain?

Answer 5

System
- Neuromusculoskeletal

Structure
- Nerve Root and Disk (if HNP)

Pain Mechanism
- Neuropathic (Nerve Root), Nociceptive (Disk)

Phase of Healing
- Disk/annulus tear 10-12 weeks

Question 6

What are common subjective reports with patients with radiating pain (Lateral Foraminal Stenosis)?

Answer 6

Gradual onset of worsening lancinating arm pain

Question 7

What are common subjective reports with patients with radiating pain (Herniating Nucleus Pulposus)?

Answer 7

May be gradual or immediate onset of local and/or somatic referred neck pain and lancinating arm pain

Question 8

With Neck Pain with Radiating Pain, what are the Aggravating and Easing Factors for Lateral Foraminal Stenosis?

Answer 8

Aggravating
- Intensification and/or peripheralization of radicular symptoms into the UE with activities and movements that place a mechanical load on the neural structure
- Cervical extension, ipsilateral rotation and lateral flexion, axial compression
–Looking up or over the ipsilateral shoulder
- Positions of the upper quarter that tension the nerve root

Easing
- Reduction and/or centralization of radicular symptoms into the UE with activities and movements that reduce the mechanical load on the neural surface
- Cervical flexion, contralateral rotation and lateral flexion, axial distraction
–Looking down or over the contralateral shoulder
- Positions of the upper quarter that reduce tension to the nerve root
–Shoulder abduction sign/babinski sign

Question 9

With Neck P! with Radiating Pain, what is the 24 hour pain behavior, with Lateral Foraminal Stenosis?

Answer 9

Morning
- Sleeping in cervical extension, ipsilateral rotation or lateral flexion or in an upper extremity position the tensions the nerve root, they may wake up with arm pain

Noon to evening
- Symptoms will vary through the day depending on the patients activities

Night
- Sleeping in cervical extension, ipsilateral rotation or lateral flexion or in an upper extremity position the tensions the nerve root, they may wake up with arm pain
- Neuropathic pain is often worse at night
- May have disrupted sleep

Question 10

With Neck Pain with Radiating Pain, what are the Aggravating and Easing Factors for Herniated Nucleus Pulposus?

Answer 10

Aggravating Factors
- Intensification and/or peripheralization of radicular symptoms into the UE with activities and movements that place mechanical load on the disk and nerve root
- Cervical protraction and flexion
–Forward head position (often sitting) of looking down to read
- Positions of the upper quarter that tension the nerve root
–Median nerve upper limb tension position of the UE

Easing
- Reduction and/or centralization of radicular symptoms into the UE with activates and movements that reduce mechanical load on the disk and nerve root
- Cervical retraction and extension
–Neutral to extended head position (often during standing/walking) or looking up
- Positions of the upper quarter that reduce tension to the nerve root
–Shoulder Abduction sign/Bakody’s sign

Question 11

With Neck P! with Radiating Pain, what is the 24 hour pain behavior, with Herniated Nucleus Pulposus?

Answer 11

Morning
- Sleeping in cervical flexion or in an UE position that tensions the nerve root, they may wake up in arm pain

Noon to evening
- Symptoms may vary throughout the day depending on the patients activities

Night
- Sleeping in cervical flexion or in an UE position that tensions the nerve root, they may wake up with arm pain
- Neuropathic pain is often worse at night
- May have disrupted sleep

Question 12

With Neck P! and Radiating pain, what should take place in the Neurological Examination?

Answer 12

DTRs
- Bicep, Tricep, Brachioradialis

Dermatomes
- C4-T1
- Sharp/Dull

Myotomes
- C4-T1

Question 13

During the Movement and Provocation examination with Neck P! with Radiating Pain, what would you see with Active ROM?

Answer 13

ROM limitations and symptom provocation will depend on individual patient presentation

Question 14

During the Movement and Provocation examination with Neck P! with Radiating Pain, what would you see with Passive Intervertebral Motion (PIVM)?

Answer 14

• Hypomobility and symptom reproduction at the involved segment(s)
• Possible hyper or Hypomobility at adjacent segments

Question 15

During the Movement and Provocation examination with Neck P! with Radiating Pain, what Orthopaedic examination test would you do?

Answer 15

• Spurling A
• Distraction Test
• Arm Squeeze Test

Question 16

During Neurodynamic Testing, what test are you going to conduct and what are they for?

Answer 16

• ULTTA/ULND1 & 2a (For Median Nerve)
• ULTTB/ULND2b (For Radial Nerve)
• ULND 3 (For Ulnar Nerve)
• Shoulder Abduction Test (Symptom relief)

Question 17

With Neck P! with Radiating Pain, what is the Diagnostic Test-Item Cluster?

Answer 17

Wainner Cluster:

• (+) ULTTA
  –Reproduction of symptoms or sensitization with distal maneuver or side to side difference of 10° elbow extension
• Ipsilateral Rotation Less than 60°
• (+) Distraction
  –Alleviation of distal symptoms
• (+) Spurling A
  –Reproduction of distal symptoms

3/4 (65% probability)
4/4 (90% probability)

Question 18

What is the Clinical course and Prognosis with Neck P! with Radiating Pain?

Answer 18

• The condition is self-limiting with a favorable prognosis with resolution of symptoms occurring weeks to months
• 70-90% of patients experience improvement without surgery
• Most patients will see symptom improvement over time in both lateral foraminal stenosis and herniated nucleus pulposus
• Spontaneous resolution of disk herniations are common
• Patients should be monitored for progressive neurological dysfunction

Question 19

What are factors that may impact prognosis?

Answer 19

• High pain intensity (NPRS >/=6/10)
• High self-reported disability (NDI >/= 30%)
• High pain catastrophizing (PCS >/= 20)
• Older age
• Prior health
• Previous exercise
• History of previous neck pain
• History of other musculoskeletal disorder

Question 20

A patient with Neck P! with headache, how would they present when they are in the Acute stage?

Answer 20

• Severity and Irritability are often high
• Pain at rest or with initial to mid-range spinal movements: before tissue stretch
• Pain control is often the intervention goal at this stage

Question 21

A patient with Neck P! with headache, how would they present when they are in the Subacute stage?

Answer 21

• Severity and Irritability are often moderate
• Pain experiences with mid-range motions that worsens with end-range spinal movements: at tissue resistance
• Movement control is often the intervention goal at this step

Question 22

A patient with Neck P! with headache, how would they present when they are in the Chronic stage?

Answer 22

• Severity and Irritability are often low
• Pain that worsens with sustained end-range spinal movements or positions overpressure: Overpressure into tissue resistance
• Functional optimization is often the intervention goal at this stage

Question 23

With Neck P! with Radiating Pain, what are the recommended interventions in the Acute Stage?

Answer 23

Education
- Possible short-term semi-rigid collar use

Exercise
- Exercise with mobilizing and stabilizing elements

Biophysical Agents
- Low-level laser

Question 24

With Neck P! with Radiating Pain, what are the recommended interventions in the Chronic Stage?

Answer 24

Education
- Education counseling to encourage participation in occupational and exercise activity

Exercise
- Combined exercise: stretching and strengthening elements

Manual Therapy
- Mobilization or manipulation to cervical and thoracic region

Biophysical Agents
- Intermittent Traction

Question 25

With Neck P! with Radiating Pain, what are additional interventions that are recommended?

Answer 25

Exercise
- Craniocervical flexion exercises
- Exercises that promote the accessibility of an upright posture
- Repeated or sustained motions in the direction of symptoms centralization

Manual Therapy
- Upper quarter nerve mobilization procedures
- Manual traction
- Cervicothoracic manipulation

Biophysical agents
- Mechanical traction

Question 26

With interventions, what is the Clinical Prediction Rule for Raney CPR (Cervical Traction)?

Answer 26

• Peripheralization of symptoms with a PA at C4-C7
• Positive Shoulder Abduction Test
• Age > 55 years
• (+) ULTTA/ULND 1
• (+) Neck Distraction Test

3/5 (79.2% probability to do cervical traction)
4/5 (94.8% probability to do cervical traction)

Question 27

When should we consider interprofessional or Intraprofessional referral and what are other treatment options?

Answer 27

Imaging
- Patients with progressive neurological deficits or those without improvement over 4-6 weeks should be referred for imaging
- Preferred modality for patient who do not respond to conservative care

Medical Intervention
- Medications/Injections
–SSRIs/SNRIs, antiepileptics
–Spinal Injections

Surgical
- Laminectomy/discectomy with cervical fusion