Cervical radiculopathy: Difference between revisions
No edit summary |
(Text replacement - "-->" to "→") |
||
(8 intermediate revisions by 3 users not shown) | |||
Line 1: | Line 1: | ||
==Background== | ==Background== | ||
* | *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 | **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 | |||
===[[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 | ||
*brachial plexitis | *brachial plexitis, [[Brachial plexus injury]] | ||
* | *[[Shoulder and upper arm diagnoses|Shoulder pathology]] | ||
** | **[[Adhesive capsulitis]] | ||
** | **Recurrent [[Anterior shoulder dislocation|anterior subluxation]] | ||
** | **[[Impingement syndrome]] | ||
* | *Entrapment neuropathy | ||
** | **[[Carpal tunnel syndrome]] | ||
** | **[[Thoracic outlet syndrome]] | ||
==Evaluation== | ==Evaluation== | ||
*Full neuro exam | *Full [[neuro exam]] | ||
**motor weakness | **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 | ***Performed non-urgently | ||
***spondylararthrosis | ***spondylararthrosis | ||
***Herniated disc | ***Herniated disc | ||
==Management== | ==Management== | ||
* | *Primary treatment typically utilizes [[NSAIDS]] | ||
*6 weeks of nonsurgical treatment | **6 weeks of nonsurgical treatment with pain control | ||
** | **May consider [[steroids]], [[gabapentin]], [[nortriptyline]], SNRIs (e.g. [[venlafaxine]], [[duloxetine]]) and muscle relaxers (e.g. [[cyclobenzaprine]]) | ||
* | *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== | ==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
- Spurling sign - closes the neural foramens
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
- Lateral disc herniation
- brachial plexitis, Brachial plexus injury
- Shoulder pathology
- Entrapment neuropathy
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
- Cervical xray
Management
- Primary treatment typically utilizes NSAIDS
- 6 weeks of nonsurgical treatment with pain control
- May consider steroids, gabapentin, nortriptyline, SNRIs (e.g. venlafaxine, duloxetine) and muscle relaxers (e.g. cyclobenzaprine)
- 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
- http://www.bmj.com/content/bmj/339/bmj.b3883.full.pdf
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3116771/