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Cervicalradiculopathypart1clinicalpresentation

Cervicalradiculopathypart1clinicalpresentation
ImagecourtesyofGoogleImages
Neckandshoulderpainarecommoncomplaintsintheprimarycaresettingandoneoftheinitialgoalsof
clinicalassessmentistodetermineiftheshoulderpainiscomingfromlocalstructuresintheshoulder
orbeingreferredfromthecervicalspine.Oneofthepossiblecausesforreferredpainintotheshoulder
andarmiscervicalradiculopathyandthefocusforthenextthreeblogsistolookcloserattheclinical
presentation,assessment,diagnosisandtreatmentforthiscondition.
Cervicalradiculopathyisthetermthatdescribescompressionofacervicalnerverootwhichresultsin
painand/orsensorimotordeficitintheupperextremity.Itcanbecausedbydischerniation,spondylosis,
instability,traumaandrarely,tumours(Caridi,Pumberger&Hughes.,2011).Inover70%ofcasesof
cervicalradiculopathyspondylosisofthecervicalspineispresentandinonly20to25%ofcasesis
diskherniationresponsible(Corey&Comeau,2014Caridi,etal.,2011Cardette,Phil&Fehlings.,
2005).

Cardette,Phil&Fehlings.,2005,p393
Predisposingfactorsforcervicalradiculopathyinclude:femalegender,whiterace,cigarettesmoking,axial
loadbearing,andpriorlumbarradiculopathy(Corey&Comeau.,2014,p.791).
Whenanerveiscompressedchangesoccurinandaroundthenervewhichinclude:aninflammatory
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response,changesinvascularflow,andintraneuraledema.Acombinationofthesethreeeventsare
thoughttoresultinthedevelopmentofradicularpain(Corey&Comeau.,2014).Thereisevidencethat
indicatesthereleaseofinflammatorymediatorscausedbyintervertebraldisksherniations,whichiswhyanti
inflammatorytreatmentiscommonlyrecommendedinthetreatmentofthiscondition(Cardette,Phil&
Fehlings.,2005).Anotherpointtonoteisthatyouneedtoconsiderboththehealthofthenerveaswellas
themovementofthenerveinthesurroundinginterfaceinordertofullyaddressthiscondition.

Decipheringreferredpain
Thediagnosisofcervicalradiculopathyisprimarilyclinicalandthefirststepindiagnosingthis
conditionisunderstandingthedifferencebetweensomaticreferredandneurogenic/radicularreferred
pain.In2012,SmartetalconductedaDelphistudyinterviewingexpertmusculoskeletalphysiotherapiststo
developalistofsignsandsymptomstheyfeltwhereindicativeofnociceptive,neurogenicandcentral
sensitizationpain.Thisisabriefoverviewofthefindingsofthisseriesofpapers(apreviousblogcovers
themingreaterdetail).

NOCICEPTIVEPAIN
Nociceptivepainiscurrentlyunderstoodtobeaprocesswheretheperipheralprimaryafferentneuronsare
activatedbyanoxiousstimuluswhichiseitherchemical,mechanical,orthermalinnature.
Thestrongestpredictorofnociceptivepainwaspainlocalisedtotheareaofinjurywithorwithoutsomatic
referral.
Clear,proportionateandmechanicalpain.
Clearaggravatingandeasingfactors.
Painisusuallyintermittentandsharpwithmechanicalprovocation.
Painmaybedulloraconstantthrobatrest.
Localsignsofinflammation(redness,heatandswelling)arepresent.
Nociceptivepainwasassociatedwiththeabsenceofdysaesthesia,nightpain,sleepdisturbances,
burningpain,shootingpain,electriclikepainandtheabsenceofantalgicpostures.
Theabovesignsandsymptomshaveasensitivityof90.9%andspecificityof91%(Smart,etal.,2012).

NEUROGENICPAIN
Thestrongestpredictorofperipheralneuropathicpainispainreferredinadermatomalorcutaneous
distribution.
Historyofnerveinjuryorpathology.
Painandsymptomreproductionwithmechanicalmovementtestsandtestsproducingneuraltissue
movement/loadingi.eneurodynamicassessment.
Painisburning,shooting,sharp,achingorelectricshocklike.
Painisassociatedwithneurologicalsymptomssuchaspins&needles,numbnessandweakness.
PatientsarelessresponsivetosimpleanalgesiaandNSAIDS.
PatientsaremoreresponsivetoLyrica(antiepileptic)andantidepressionmedication.
Highlevelsofsensitivityandirritability.(Smart,etal.,2012A,p347)
Asmentionedabove,cervicalradiculopathyisaconditionthatresultsfromcompressionofacervicalnerve
rootasitexiststheneuralforamen.Thepainfeltbypeopleisradicularinnatureandfollowsadermatomal
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patterncorrespondingtothelevelofnerverootinvolved.Itisimportanttonotethatcompressionalone
doesnotnecessarilyleadtoradicularpainunlessthedorsalrootganglionisaffected(Corey&
Comeau,2014,p.791Cardette&Fehlings,2005,p.392).

Incervicalradiculopathypainiscausedbycompressionandinvolvementofthedorsalrootganglion(outside
thespinalcord)(Googleimages)
Patienthistoryalonecandiagnosecervicalradiculopathyinover75%ofcases(Caridi,etal.,2001,p.
266).
Clinicalpresentation(Corey&Comeau,2014Caridi,etal.,2011):
Symptomstypicallyareunilateral.
Referredpaindependsonthenerverootlevelinvolved.
Whilepainiscommonlyassociatedwiththisconditionitmaybeabsentinthecaseasensoryandmotor
deficitmaybethemainissuesi.epainlessneuropathy.
Thereisnouniversallyacceptedcriteriafordiagnosisofcervicalradiculopathyhowever,since2005
severalarticleshavebeenpublishedlistingstronglypredictableclinicalsignsandsymptomstoform
clinicalpredictionrules(Cardette,Phil&Fehlings.,2005Wainner,etal.,2003).Manyoftheseresearch
papersdiscusstheclinicalassessmentforcervicalradiculopathycommentinghowaclusterof
symptomshelpstostrengthenourclinicalreasoninganddiagnosis.Beforewelookatthephysicalexam
andclinicalpredictionrule,itisimportanttohaveexpectationsofwhatyouwanttoachievebytheendof
yoursubjectiveassessment.
Thediagnosisofcervicalradiculopathylargelyremainsaclinicaldiagnosiswithouttheneedforimmediate
medicalimaging(Wainner,etal.,2003).Thismeansthatyouneedtoperformathoroughsubjective
examinationtoidentifythisconditionasapotentialsourceofthepain.Thepatienthistoryprovidesyou
withthemostvaluableinformationatitisduringthistimethatyoubegintounderstandifthepain
yourpatientisexperiencingisneurogenic/radicular.I'msureyou'veseenthesechartsmanytimes
beforebutIcomebacktothemagainandagain.Checkingthatthepaindistributionmapswhatweknow
aboutdermatomalpatternsfornerverootpain.
Asyoucanseefromthetwoimagedbelow,cutaneousanddermatomaldistributionsaredifferent,meaning
thatthenanerverootiscompresseditfollowsadifferentlinetothatofaperipheralnerve.
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Cutaneousnervesofthelowerlimb(CourtesyofGoogleImages)

Dermatomesforthelowerlimb(courtesyofGoogleImages)
ThisisthechartIkeeponmydeskandusetoclarifymymappingofpainwithmypatients.Iwon'ttellthem
whatitisbutiftheyarestrugglingtomaptheirpainImayquicklyshowthemandask"doesyourpainfollow
thispath?"Iftheyarenotgettingthetypical'lineofpain'andmorebroadandvaguepatchesthenitisless
likelytobeneurogenicinnature.

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Understandingdermatomalpatternsfortheneurologicalexamination

SUBJECTIVEEXAMINATION
Attheendofyoursubjectiveexaminationyoushouldhaveadetailedaccountof:
Wherethepainis,whatitfeelslikeandhowitbehaves.
YouhavequestionedforP&N,numbness,weakness,redflagsandcordcompression.
Youhavemappedonabodychartwherethepain(andsymptoms)are.
Youhavenotedaggravatingandeasingfactors.
Severityandirritability
24hourspattern
Responsetomedicationandprevioustreatment.
Currenthistory,pasthistory,generalhistoryandsocialhistory.
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CONSIDERATIONSforASSESSMENT
1.Gainadetaileddescriptionofthesymptoms.
Decipheringtheexactdistributionandqualityofreferredpainisveryimportantto:
Differentiatebetweensomaticandneurogenicreferredpain.
Differentiationbetweeninvolvenerveroots
Differentiateradiculopathyfromthoracicoutletsyndrome,ulnarnerveneuropathyandotherentrapment
neuropathiessuchascarpaltunnelsyndrome.

Uppermotorneuronesexistwithinthespinalcord(GoogleImages)
2.Questionforsignsofspinalcordcompression.
Myelopathy,causedbyspinalcordcompression,isalsoaveryimportantconditiontoquestionforand
assess.Droppingobjects,lossofdexterity,Hoffmansign,Babinskisign,hyperreflexia,andclonusareall
signsofuppermotorneuronelesions(Corey&Comeau.,2014,p.792).Othercompressionsignsare
sphincterdisturbances(urinaryurgencyratherthanincontinence),andbalancedisturbances(Cardette,et
al.,2005).
3.Ensureyouquestionforanyredflags.
Redflagssuchasfevers,chills,unexplainedweightloss,nightpain,previoushistoryofcancer,
immunosuppression,IVdrugabuseareallfactorsnotassociatedwithradiculopathy(Corey&Comeau,
2014,p.792Cardetteetal,2005,p.393).Otherredflagsinclude:agedbelow20orover50years,neck
rigiditywithouttrauma,dysphagia,andalteredconsciousness

Conclusion
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Thefocusforthefirstblogwastorevisittypicalsignsandsymptomsofneurogenicpainanddermatomal
mappingofnerveroots.Spendtimedoingyoursubjectiveassessmentwellasitguidessomuchofthe
physicalexam.Ifyou'renotfamiliarwithhowapatientpresentswithcervicalradiculopathythenIwould
recommendreadingthecasestudybyMichaelCostello(2008).Itisverywellwrittenandcoverstheclinical
presentation,assessment,diagnosisandprogressionoftreatmentoverthecourseofthreetreatments.
[Costello,M.(2008).Treatmentofapatientwithcervicalradiculopathyusingthoracicspinethrust
manipulation,softtissuemobilization,andexercise.JournalofManual&ManipulativeTherapy,16(3),129
135.]
Thefocusofpart2&3isphysicalexaminationandtreatmentoptionsforcervicalradiculopathy.
Sian

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