cervical radiculopathy. normal anatomy cervical spinal nerves exit via the intervertebral foramen...

Cervical Radiculopathy

Normal Anatomy• Cervical spinal nerves exit

via the intervertebral foramen

• Intervertebral foramen is the gap between the facet joint and vertebral body

• Cervical nerves are named corresponding to the vertebral body below, up to C8 nerve root which exits between C7 and T1

Pathophysiology

• Cervical radiculopathy is a syndrome of radiating pain and sensory and/or motor deficit due to compression or injury of a cervical nerve root

• Injury or compression of the nerve root can be caused by anything that occupies the intervertebral foraminal space

• Radiculopathy– state of neurological loss i.e sensation, reflex, motor due to

blocked axon conduction in the nerve

• Radicular pain – pain that arises due to irritation of the spinal nerve or nerve

root

Mechanism Of Injury

• Insidious– Degenerative Disc

Disease/Spondylosis– Intervertebral Disc Herniation– Osteophytes– Ossification of longitudinal

ligament– Instability– Tumor

• Traumatic– Road Traffic Accident– Direct impact or compression

Subjective

• Paraesthesia, numbness or motor changes in a nerve root pattern +/- arm pain

• Neck and/or scapular pain• Coughing and sneezing may worsen the pain or tingling in

the arm• Aggravated by long static position, first thing in the

morning or ipsilateral rotation• Pain may be unrelenting causing restlessness and loss of

sleep• May find short term relief by raising the arm above the

head

Objective

• Pain and/or aggravation of neurological symptoms with movements that close down intervertebral foramen (Extension, ipsilateral rotation, ipsilateral side flexion)

• Reduced sensation, power and reflex’s in a nerve root pattern

• Abnormal upper limb tension testing• Rarely movements towards the side of pain relieve

symptoms • Antalgic postures that correspond to unloading of

sensitive neural tissues

Special Tests

• Spurling’s test• Valsalva Maneuver• Shoulder abduction sign• Upper limb tension test• Neck distraction

Clinical prediction rule

Positive findings on 3 of the following:• Positive Spurlings test• Positive distraction test• Ipsilateral cervical spine rotation less than 60

degrees.• Positive upper limb tension test-median nerve

bias.

Further Investigation

• MRI• CT myelography• Electromyography or

nerve conduction studies

General Management

• Conservative management usually effective in• Education on cause of pain very important in

these cases• Priority to improve neurological or peripheral

symptoms

Conservative Management• Reduce Inflammation

– Ice, NSAID’s, Massage• Restore Normal ROM

– Cervical, Thoracic and Shoulder– Soft Tissue Techniques– Joint mobilisations, manipulations, tractions– Neurodynamic mobilisations– Cervical and Thoracic Stretches

• Restore Normal Muscle Activation– Cervical, Thoracic and Shoulder/Scapular– Deep Cervical flexors and extensors, scapular stabilisers

• Restore Dynamic Stability and Proprioception• Global shoulder girdle strengthening

Surgical Management• Indications of surgery

– Failure of conservative management after at least 6-12 weeks trial

– Progressive neurological deficit

• Epidural Steroid injection• Anterior decompression and

fusion• Discectomy with or without

fusion• Posterior laminoforaminotomy• Facetectomy