Monday, May 12, 2008

Cervical radiculopathy

Carette S, Phil M, Fehlings MG. Clinical practice. NEJM 2005; 353:392-399.

The etiology in 70-75% is encroachment of the foramen due to cervical spondylosis or other cause of degeneration, whereas HNP is much less frequent (20-25 %) and tumors and other causes even less frequent. Pain occurs only if the dorsal root ganglion (DRG) is compressed. Hypoxia of the nerve root and DRG exacerbates the pain. Inflammatory mediators including MMP's, PGE2, IL6 and NO. Nonsurgical management resolution correlates with imaging improvement.

Neck and arm pain predominate. Sensory symptoms (burning, tingling) follow a dermatomal distribution, but pain follows a myotomal pattern. C7 pain for example includes radicular pain to forearm, and N/T to the third digit. Pain is relieved by looking to opposite contralateral side and holding hand on top of the hand and exacerbated by turning the head towards the pain. Red flags including systemic signs of illness (fever, chills, weight loss), diffuse hand numbness attributed to CTS, clumsiness, urinary urgency or frequency not retention or incontinence. Provocative tests for radiculopathy are mostly unreliable. C7 is most commonly affected followed by C6.

Signs of C5 involvement include pain in the medial scapular border radiating to the elbow, weakness of the deltoid, supraspinatus and infraspinatus, sensory loss in the lateral arm, and loss of the supinator reflex.Signs of C6 involvement include pain in lateral forearm, thumb and index finger, weak biceps, b-r, and wrist extensors, thumb and index finger sensory loss and loss of biceps reflex.

Signs of C7 involvement ae pain in medial scapula, posterior arm, dorsum of forearm, third finger, weak triceps, wrist flexors, finger extesnors, sensory loss in posterior forear and third finger, and loss of triceps reflex.

Signs of C8 involvementare pain in shoulder, ular side of forearm, fifth finger, weak thumb flexors, abductors, and intrinsic hand muscles,and sensory loss of the fifth finger.

Treatment is not proved in large trials. Analgesics including opiates and NSIAA's are first line sometimes with prednisone. Epidural injections result in relief that is longstanding in many patients but complications include spinal cord and brainstem infarction. Hard/soft cervical collar for short term or cervical pillow at night are used. Cervical traction is unproved. Exercise therapy including active AROM, aerobic conditioning with isometric and progressive resistive exercises are usually recommended after initial period.

Indications for surgery include cervical root compression on imaging, concordant pain or dysfunction, persisting pain, or functional motor deficit, or compression of the cord. Anterior decompression with strut reconstruction is common.

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