Cervical radiculopathy: Difference between revisions

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==Background==
==Background==
*neck pain radiating to the upper extremities
*Cervical radiculopathy (CR) is commonly seen in the ED
**can have associated weakness or numbness
**Incidence of 107.3/100,000 men and 63.5/100,000 women
**Peak incidence at age 50-54
*Risk factors
**White race
**Female gender
**Cigarette smoking
**Prior lumbar radiculopathy
*[[Neck pain]] radiating to the upper extremities
**can have associated [[weakness]] or numbness
*Compression and inflammation of the spinal nerve  
*Compression and inflammation of the spinal nerve  
*Most commonly affects C5-C6 or C6-C7
*Most commonly affects C5-C6 or C6-C7


==Clinical Features==
==Clinical Features==
*Follows a dermatome or myotome distribution
*Follows a [[dermatome]] or myotome distribution
**Diminished muscle tendon reflexes
**Diminished muscle tendon reflexes
**Sensory changes
**Sensory changes
**Motor weakness
**Motor [[weakness]]
*If C6 is affected: diminished brachioradialis reflex, bicep muscle weakness, paresthesias in the arms to the thumb/index finger
*If C6 is affected: diminished brachioradialis reflex, bicep muscle weakness, paresthesias in the arms to the thumb/index finger
*If C7 is affected: diminished triceps reflex, tricep muscle weakness, paresthesias radiating in the arms to the middle finger  
*If C7 is affected: diminished triceps reflex, tricep muscle weakness, paresthesias radiating in the arms to the middle finger  
**Spurling sign- closes the neural foramens so if pain is worse w/ lateral bending tothe painful arm--> radiculopathy; if pain is worsen when bending to the contralateral arm--> nonspecific soft tissue injury
**Spurling sign - closes the neural foramens
***Pt looks straight ahead and attempts to touch the ear to the shoulder
***if pain is worse with lateral bending to the painful arm→ radiculopathy
 
***if pain is worsen when bending to the contralateral arm→ nonspecific soft tissue injury
**Patient looks straight ahead and attempts to touch the ear to the shoulder
===[[Spinal cord levels|Cervical Exam by Level]]===
{|  class="wikitable"  style="text-align:center"
! Radiculopathy
! Motor Deficit
! Sensory Deficit
! Diminished Reflex
|-
!C4
||Levator Scapulae & Shoulder elevation||||
|-
!C5
||Deltoid & Biceps||||Biceps
|-
!C6
||Brachioradialis & Wrist extension||Thumb Paresthesia||Brachioradialis
|-
!C7
||Triceps & Wrist flexion||Index/Middle/Ring Paresthesia||Triceps
|-
!C8
||Index/Middle distal phlnx flexion||Small Finger Paresthesia||
|}


==Differential Diagnosis==
==Differential Diagnosis==
*lateral disc herniation  
*Lateral disc herniation  
*brachial plexitis  
*brachial plexitis, [[Brachial plexus injury]]
*shoulder pathology  
*[[Shoulder and upper arm diagnoses|Shoulder pathology]]
**adhesive capsulitis  
**[[Adhesive capsulitis]]
**recurrent anterior subluxation  
**Recurrent [[Anterior shoulder dislocation|anterior subluxation]]
**impingement syndrome  
**[[Impingement syndrome]]
*entrapment neuropathy  
*Entrapment neuropathy  
**carpal tunnel syndrome  
**[[Carpal tunnel syndrome]]
**thoracic oulet syndrome
**[[Thoracic outlet syndrome]]


==Evaluation==
==Evaluation==
*Full neuro exam
*Full [[neuro exam]]
**motor weakness --> early surgical referral
**motor weakness → early surgical referral
*Imaging
*Imaging
**Cervical xray
**Cervical xray
***can be obtained to exclude frank instability
***can be obtained to exclude frank instability
**MRI  
**MRI  
***Performed nonurgenly
***Performed non-urgently
***spondylararthrosis
***spondylararthrosis
***Herniated disc
***Herniated disc


==Management==
==Management==
**NSAIDS  
*Primary treatment typically utilizes [[NSAIDS]]
*6 weeks of nonsurgical treatment w/ pain control
**6 weeks of nonsurgical treatment with pain control
**Recent studies show no benefit for physiotherapy versus cervical collar
**May consider [[steroids]], [[gabapentin]], [[nortriptyline]], SNRIs (e.g. [[venlafaxine]], [[duloxetine]]) and muscle relaxers (e.g. [[cyclobenzaprine]])
*Study comparing semi-hard cervical collar w/ as much rest as possible versus physiotherapy and at home exercise compared to wait and see
*Short term immobilization and rest may calm symptoms of CR
**In patients with acute cervical radiculopathy symptoms, a semi hard collar w/ as much rest as needed and physiotherapy w/ at home exercise program over 6 weeks reduced pain compared to wait and see policy
**Recent literature review showed that exercise is beneficial for improving function and activity levels
**Outpatient physical therapy evaluation may be beneficial but home exercises should be recommended to patients in the interim


==Disposition==
==Disposition==

Revision as of 14:45, 17 November 2017

Background

  • Cervical radiculopathy (CR) is commonly seen in the ED
    • Incidence of 107.3/100,000 men and 63.5/100,000 women
    • Peak incidence at age 50-54
  • Risk factors
    • White race
    • Female gender
    • Cigarette smoking
    • Prior lumbar radiculopathy
  • Neck pain radiating to the upper extremities
    • can have associated weakness or numbness
  • Compression and inflammation of the spinal nerve
  • Most commonly affects C5-C6 or C6-C7

Clinical Features

  • Follows a dermatome or myotome distribution
    • Diminished muscle tendon reflexes
    • Sensory changes
    • Motor weakness
  • If C6 is affected: diminished brachioradialis reflex, bicep muscle weakness, paresthesias in the arms to the thumb/index finger
  • If C7 is affected: diminished triceps reflex, tricep muscle weakness, paresthesias radiating in the arms to the middle finger
    • Spurling sign - closes the neural foramens
      • if pain is worse with lateral bending to the painful arm→ radiculopathy
      • if pain is worsen when bending to the contralateral arm→ nonspecific soft tissue injury
    • Patient looks straight ahead and attempts to touch the ear to the shoulder

Cervical Exam by Level

Radiculopathy Motor Deficit Sensory Deficit Diminished Reflex
C4 Levator Scapulae & Shoulder elevation
C5 Deltoid & Biceps Biceps
C6 Brachioradialis & Wrist extension Thumb Paresthesia Brachioradialis
C7 Triceps & Wrist flexion Index/Middle/Ring Paresthesia Triceps
C8 Index/Middle distal phlnx flexion Small Finger Paresthesia

Differential Diagnosis

Evaluation

  • Full neuro exam
    • motor weakness → early surgical referral
  • Imaging
    • Cervical xray
      • can be obtained to exclude frank instability
    • MRI
      • Performed non-urgently
      • spondylararthrosis
      • Herniated disc

Management

  • Primary treatment typically utilizes NSAIDS
  • Short term immobilization and rest may calm symptoms of CR
    • Recent literature review showed that exercise is beneficial for improving function and activity levels
    • Outpatient physical therapy evaluation may be beneficial but home exercises should be recommended to patients in the interim

Disposition

  • Outpatient follow up with primary care/orthopedics
  • Majority of patients approx 75% in one study reported pain relief in 4 weeks
  • pain control with NSAIDS

See Also

External Links

References

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