Differential diagnosis for nerve related Cx pain

When to consider neural system in cervical disorders 

Neck pain + 

1. Arm pain 

2. Paraesthesia

3. Weakness 

4. Clumsiness 

5. Gait disturbances 

6. Cord signs 

7. Widespread pain/ abnormal response 

8. Red flags/ stroke/ cardiac/ neurological disorder 

Difference in radiculopathy + radicular pain

	Causes
Radiculopathy	Block/ slowing of conduction caused by lesion/ disease of nerve root/ dorsal root ganglia
Radicular pain	Irritation of nerve → ectopic discharge + hyperexcitability of dorsal nerve root/ ganglion

Type of neural issues

1. Neuropathy → peripheral nerves 

2. Myelopathy → spinal cord 

3. Other pathologies affecting the NS → MS/ tumours/ diabetes

Definition of Cx radiculopathy

Block/ slowing of conduction caused by lesion/ disease of nerve root/ dorsal root ganglia

Causes of Cx radiculopathy

1. Foraminal narrowing → encroach onto nerve

2. Cervical disc lesions 

→ Reduced disc height 

→ Degen in uncovertebral + Z joints

1. Tumours/ spinal infection/ synovial cysts

Characteristics of radiculopathy

1. Pain 

2. Motor weakness 

3. Sensory loss 

4. Reflex changes 

v.s. somatic: X sensory/ motor/ reflex changes

Common location: 

C6-7 

Radicular pain causes + effects

Irritation of nerve → ectopic discharge + hyperexcitability of dorsal nerve root/ ganglion

Pain

Characterisitcs of radicular pain

1. Sharp 

2. Shooting 

3. Electric 

4. Tingling/ itching down arm 

5. Neck + arm pain below tip of shoulder 

6. Dermatomal distribution 

→ X always have conduction deficits in nerve 

Clues in pt interviews: 

1. Disrupted sleep 

2. High disability lvls

3. High lvls of pain/ irritability 

4. Easily aggravated 

5. Long time to settle 

6. Hard to find easing position  

→ spectrum of presentation: mild pain only w/ stretching to severe pain w/ sleep disturbance/ guarding of arm

Distribution of radicular pain  based on nerve 

C5 

C6: thumb + overlap to index 

C7: Middle finger

C8: Little finger

→ Can refer to Cloward’s areas → medial borders of scapula

Ax for radicular pain

1. History: quality + pain levels 

2. Protective postures 

3. Degree of functional impairment 

4. Mechanism of injury 

5. Mechanism of overuse/ prolonged stretch 

6. Questionnaires 

• LANSS 

• NPQ 

• Pain DETECT

Physical exams: 

1. Neurological exam → only testing large diameter fibres + overlap of dermatomes 

2. Quantitative sensory testing 

• Vibration 

• Cold + heat thresholds ( in addition to neurological exam ) 

→ testing of small fibre loss/ early deterioration 

EMG → only test large diameter fibres + X in clinics

Definition of Cx myelopathy

Progressive compression of spinal cord

Causes of myelopathy

1. Disc degeneration

→ older than 65 yr  

2. Hypertrophy of anterior longitudinal ligament 

3. Ossification of posterior longitudinal ligament 

4. Tumour 

5. Hypermobility

Characteristics of myelopathy

1. Chronic neck pain 

2. Gait imbalance → ataxic gait 

3. Loss of hand dexterity → dropping things + doing buttons 

4. Numbness/ paraesthesia in ULs/ LLs 

5. Sphincter dysfunction → continence issues/ changes in going to the toilet 

6. Atrophy of hand muscles 

→ In patient interview + observation when they walk into clinic 

7. Lhermitte’s ( neck flexion )

8. Hyper-reflexia

Ax of myelopathy

1. Neurological exam ( Dermatomes + myotomes + reflexes ) → hyper-reflexia 

→ drop the hammer for reflex 

Muscle test: build up resistance slowly to avoid pain inhibition 

2. Upper motor neuron Ax 

→ Babinski 

→ Clonus 

3. Sensory 

→ X purely dermatomal 

→ bilateral?

→ glove + sock distribution

→ more easy to rule out 

*Imaging referral immediately 

Causes of mechanosensitivity

Sensitivity of nerves to mvmts → nerves X glide freely through tissues

Characteristics of mechanosensitivity

1. Protective postures 

2. History →incident that puts stretch on the nerve 

3. Stretch mvmts aggravate pain 

4. Easily aggravated

Ax of mechanosensitivity

1. Neurodynamic test 

2. Nerve palpation along nerve trunks 

→ higher sensitivity to palpation 

3. Mvmts reducing size of intervertebral foramen 

• Spurling’s test → combined E/ LF 

1. Compression of peripheral nerve trunks by joint positioning

Somatic referred pain definition + structures

Definition	Structures
Activation of nociceptors in target tissues	Muscles  Joints  Ligaments  Fascia  Tendons

Physical exam findings for somatic referred pain

Physical exam findings: 

1. Neurological: normal 

2. ULNT: normal 

3. Palpation in Cx nerve: increase referred symptoms + X at site of pain ( consider when arm pain X responding to treatment → more proximal cause of pain referring to the arm? ) 

4. Manual exam: +ve joint signs 

5. RoM: ipsilateral restriction to side of pain 

6. Cx muscle dysfunction 

7. Reproduction of distal symptoms rather than local to site

Trauma nerve related injuries causes

1. Spinal cord injury 

2. Brachial plexus avulsion 

3. Brachial neuropraxia 

4. Stretch neuropathies → landing on neck stretch/ prolonged stretch in surgery 

5. Accessory nerve palsies/ long thoracic nerve palsies 

Nociplastic neck + arm pain characteristics

1. Widespread pain 

2. Hard to localise 

3. Unpredictable + variable symptoms