My 32 Y 32 Year-Old C d Cyclist is N s Ner ervous s Wha hat d - - PowerPoint PPT Presentation

Cervical Radiculopathy: My 32 Y 32 Year-Old C d Cyclist is N s Ner ervous s – Wha hat d do I I do on t the in init itia ial vis isit it?

Scott D Boden, MD The Emory Spine Center Atlanta, Georgia

History of Trauma?

2

3

History of Trauma?

Sometimes the source

• f Neck

Pain is Obvious…

? Hyperextension

5

History: Red Flags

 Rarely spine pain is a harbinger of

a serious medical illness. Red flags:

 Unexplained fevers, chills, night

sweats (infection)

 Unexplained weight loss

(tumor)

 History of cancer

 Night Pain – non-mechanical

 Cancer, Tumor, Fracture

6

Upper Limb Pain

Radiculopathy

 Nerve root irritation or injury  Symptoms and signs

correspond to nerve roots

 Sensory disturbance  Motor weakness  Muscle stretch reflex may be

decreased

Facet Referral Patterns

Diagram of Pain

Upper Limb Pain (Neuropathic)

 Myelopathy (sometimes painless)  Cervical Radiculopathy  Plexopathy (uncommon)

 Compression  Parsonage Turner (Neuralgic amyotrophy)  Stingers

 Entrapment neuropathies (ulnar, median etc)  Peripheral neuropathy

10

Physical Examination

 Inspection  Palpation  Motor  Sensory  Reflexes  Special Testing

 Neural tension, UMN signs, shoulder evaluation

11

Special Testing

 Spurling’s maneuver:

 extension and rotation of the neck with downward force to

narrow the neural foramen. Evaluate for radicular pain into the upper limb.

12

Abduction Sign

(Bakody’s Sign)

Upper Motor Neuron Signs

 Hyper-reflexia  Hoffman’s  Inverted radial reflex  Clonus  Babinski

14

NECK - SHOULDER - ARM PAIN

Physical Examination

Shoulder most often confused with neck problems

 Pain with overhead activities or night pain when lying on

side at night may suggest impingement or rotator cuff injury

 Older patients – more likely to have degenerative

conditions (RTC tears, Osteoarthritis)

 Location of pain

Shoulder ROM

Apley’s Scratch Test

 Touch contralateral shoulder in front of head (internal rotation, adduction)  Reach behind head to superior aspect of contralateral scapula (abduction,

external rotation)

 Reach behind back to inferior aspect of contralateral scapula (internal

rotation, adduction)

16

Special Tests Rotator Cuff Injury Tests

 Impingement Signs:

 Neer’s Sign: patient’s

arm is internally rotated and shoulder is passively forward flexed while scapula is stabilized by examiner’s hand

 Hawkin’s Sign: forward

flex arm to 90° and then passively internally rotate arm

Hawkin’s Test Neer’s Sign

17

Motor Function Rotator Cuff

 Strength testing of RTC

muscles:

 Supraspinatus:

 90° shoulder abduction, 30°

shoulder horizontal adduction, thumb pointing downward then test shoulder abduction (“Empty Can Test”)

 Infraspinatus and Teres Minor:

shoulder external rotation

 Subscapularis: shoulder internal

rotation

Supraspinatus Testing

18

Motor Function Rotator Cuff

Subscapularis motor testing (Push-Off Test”)

19

Initial Treatment of Arm Pain

Cervical radiculopathy < 1 month of symptoms

21

BMJ 2009 Oct 7;339:b3883.

Initial Treatment

 NSAIDS  ? Qhs muscle relaxant if much spasm and not

sleeping well

 Home Stretching  Physical Therapy – if it doesn’t aggravate the

arm pain

 Soft Collar (even if only at night)  Ergonomic adjustments to avoid hyper-

extension of the neck.

22

Initial Treatment

 NSAIDS  ? Qhs muscle relaxant if much spasm and not

sleeping well

 Home Stretching  Physical Therapy – if it doesn’t aggravate the

arm pain

 Soft Collar (even if only at night)  Ergonomic adjustments to avoid hyper-

extension of the neck.

23

Initial Treatment

 NSAIDS  ? Qhs muscle relaxant if much spasm and not

sleeping well

 Home Stretching  Physical Therapy – if it doesn’t aggravate the

arm pain

 Soft Collar (even if only at night)  Ergonomic adjustments to avoid hyper-

extension of the neck.

24

Initial Treatment: Stretching

25

Initial Treatment

 NSAIDS  ? Qhs muscle relaxant if much spasm and not

sleeping well

 Home Stretching  Physical Therapy – if it doesn’t aggravate the

arm pain

 Soft Collar (even if only at night)  Ergonomic adjustments to avoid hyper-

extension of the neck.

26

27

Initial Treatment

 NSAIDS  ? Qhs muscle relaxant if much spasm and not

sleeping well

 Home Stretching  Physical Therapy – if it doesn’t aggravate the

arm pain

 Soft Collar (even if only at night)  Ergonomic adjustments to avoid hyper-

extension of the neck.

28

29

Initial Treatment

 NSAIDS  ? Qhs muscle relaxant if much spasm and not

sleeping well

 Home Stretching  Physical Therapy – if it doesn’t aggravate the

arm pain

 Soft Collar (even if only at night)  Ergonomic adjustments to avoid hyper-

extension of the neck.

30

Avoid Hyperextension

31

Initial Treatment

32

33

Summary

 Rule Out Red flag symptoms  Favorable natural history  Avoid hyperextension  Don’t forget soft cervical collar  Be patient, don’t rush to MRI  Can try a Selective Nerve Root Block to buy

time for natural history to prevail

 Remain Calm on first visit

34