Spine ICF - Cervical Radiculopathy: Neck Pain with Radiating Pain

Classification

• Neuropathic pain disorder of spinal n. roots caused by some form of impingement or inflammation

  • Most common cause: age-related changes leading to narrowing of foramen (70-75%)

    • Decreased disc height

    • Changes in uncovertebral and facet joints

  • Other causes:

    • Disc herniation (25%)

    • Osteophytes/bone spurs

    • Tumors (rare)

• Due to UE involvement, must be differentiated from other conditions in examination

  • Thoracic outlet, shoulder/elbow/wrist impairments, referral patterns to UE

Symptoms & impairments

• Symptoms

  • Neck pain w associated radiating (narrow band of lancinating) pain in involved upper extremity

    • Lancinating = sudden sharp stabbing pain sensation

  • Upper extremity paresthesia

    • Sensation of tingling, pins and needles, or numbness

  • UE numbness

  • UE strength deficits

  • Painful neck movements

    • W pain likely being worse in ext w a lateral bend toward the affected side

  • Muscle spasm

• Most common n. roots affected in cervical radiculopathy are

  • C7 n. root followed by C6 n. root

• Diminished deep tendon reflexes are also a common neurologic symptom w their associated n. roots

  • Triceps involvement is the most commonly diminished reflex

• Neck and neck related radiating pain will be reproduced w the following:

  • Spurling A test

  • ULNT test 1

• Neck and neck related radiating pain relieved w cervical distraction

Diagnosis

• Wainners cluster

  • Upper limb neurodynamic test 1

  • Spurling A test

  • Neck distraction test

  • Ipsilateral cervical spine AROM rotation of 60 deg or less

• Shoulder abduction test

Upper limb neurodynamic test 1

• Single best test

  • If UNLD test 1 is negative, cervical radiculopathy can be ruled out

• Purpose: to apply tension through brachial plexus, specifically median nerve (C5-T1)

• Positive test: Symptom reproduction

• Sensitive 97%

Spurling A test

• Purpose: to assess for cranial n. root irritation

• + test: symptom reproduction in neck or arm reported at any point during test

• Specificity 86%

Neck distraction test

• Purpose: diagnose cervical radiculopathy

• Positive test: reduction of symptoms

• Specificity 90%

Ipsilateral cervical spine AROM rotation of 60 deg or less

• Stationary arm: lateral border of acromion

• Axis of rotation: superior surface of center of the cranium

• Moving arm: parallel with the nose

• Normal ROM: 0-60 degrees

Shoulder abduction test

• Purpose: suggest nerve root irritation as cause if symptoms are alleviated in position

• Positive test: reduction of symptoms

• Specificity 92%

Differential diagnosis

• Peripheral n. entrapment

  • Ex. carpal tunnel or cubital tunnel syndrome

  • Peripheral n. distribution, not dermatomal

    • Tinel’s test

  • No cervical movement reproduction

• Shoulder pathology

  • Ex. rotator cuff tear

  • Pain localized to shoulder

  • No neurological deficits

• Thoracic outlet syndrome

  • Symptoms w overhead activity

  • Vascular signs

Treatment

• = Reduce nerve root compression

• Factors for success

  • Multimodal approach

    • Combination of treatments outperform single outcome

    • 71.3% success rate

    • Traction, exercise, manual therapy, education

  • <54 yrs old

  • Dominant arm not involved

  • Looking down does not worsen

    • Flexion

Cervical traction

• Long axis force to increase space btwn vertebrae

  • Open IV foramen

  • Reduce n. root compression

• CPR for positive response

  • Peripheralization w lower c-spine PA mobility testing

  • >55 yr

  • Positive tests

    • Shoulder abd, ULND1, distraction

• Best paired w exercise

  • Relief vs change

• Success rates:

  • 3/5 ~79.2%

  • 4/5 ~94.8%

Exercise

• Strengthening

  • Increase stability

  • Less compression

    • Deep neck

    • Scapular control

    • Posture

• Neurodynamics

  • Decrease irritability

  • Facilitates n. course

    • Median n. glide

      • Hits all the roots

Manual therapy + education

• Cervical

  • Facilitate cervical movement

• Thoracic

  • Improve cervical measures

    • Decrease pathologizing cervical laod

• Education

  • Anti-FAB

    • Pain neuroscience education

  • Encourage activity participation