Cervical radiculopathy is caused by cervical nerve root
compression. The patient will have pain and/or progressive neurological deficit
that results from conditions such as disc herniation that irritates a nerve in
the cervical spine. Cervical radiculopathy is an irritation of the cervical
nerve root. Cervical spine and shoulder problems overlap. The condition is of
cervical spine etiology if the patient’s symptoms are relieved by shoulder
abduction, by placing the hand over the head. The relief of the symptoms occurs
due to decreased tension on the nerve roots. In cervical disc problems, be
aware of false positive MRIs especially if the patient is above the age of 40
years old. Nerve conduction studies are not useful; they have a high false
negative rate. EMG and nerve studies may differentiate radiculopathy from
peripheral nerve entrapment. Cervical disc problems usually affect the lower
numbered nerve root.
When you see the middle finger numbness, then this is C7.
When compression of the C7 nerve root, there will be middle finger numbness,
triceps weakness, and the triceps reflex will be affected. The cervical nerve
roots are horizontal in orientation. It does not matter if cervical disc
herniation is central or foraminal, it will compress the same nerve root. C7
nerve root runs above the pedicle of the C7 vertebra. C5-C6 is the most
commonly affected disc and that will compress the C6 nerve root. The patient
will come to the doctor with unilateral arm pain that is relieved by arm
elevation. The numbness and paresthesia will occur in specific dermatomes. The
patient may also have upper trapezius pain or interscapular pain. The patient
may complain of occipital headache. When you examine the patient, do
provocative tests such as the spurling’s test and the shoulder abduction test.
The Spurling’s test is done by extending and rotating the neck towards the
involved side. It reproduces the symptoms by narrowing the neuroforamen. The
Spurling’s test differentiates cervical radiculopathy from peripheral nerve
entrapment. Lifting the arm above the head relieves the symptoms if the
cervical nerve roots are irritated. The Shoulder Abduction test differentiates
cervical pathology from other causes of painful shoulder etiology. Make sure
that you do not have a double crush syndrome, one in the neck and one in the
peripheral nerve. Make sure that you differentiate radiculopathy from
myelopathy. Make sure that you exclude a coexisting myelopathy. Examine the
patient for upper motor neuron signs or cervical
myelopathy. Test the patient
for gait instability. Test the patient for Hoffman’s sign. Test the patient for
Babinski reflex. Test the patient for ankle Clonus. Check to see if the patient
has hyperflexia in the upper and lower extremities (triceps/quadriceps). Even
if there is a bad cervical spine disc problem on the MRI, treat it
conservatively for about 3 months. Give the patient therapy and nonsteroidal
anti-inflammatory medication (NSAIDS). 75% of the patients will improve with
nonoperative treatment. Cervical radiculopathy is generally treated
nonoperatively, in contrast to cervical myelopathy. Do surgery when there is
persistent, severe pain for 6-12 weeks and/or progressive neurological deficit
such as weakness or numbness. The procedure to treat cervical radiculopathy
surgically is usually done anteriorly with direct removal of the lesion that
causes the radiculopathy such as a herniated disc or spurs. When you place the
anterior bone graft or the allograft in the disc space, you open the
nueroforamen, and that will indirectly relieve the nerve. Then you will add the
anterior plate. Some surgeons prefer to do a posterior approach.
Low back pain is a common condition. 90% of patients with
low back pain will improve without surgery. Usually they get better with
spontaneous resolution of the symptoms within 12 weeks. We usually advise the
patient for early return to activity and function as the symptoms and the pain
permits. The risk factors for development of low back pain are numerous, some
include: vibration exposure, poor physical fitness, smoking and obesity,
anxiety and depression, job dissatisfaction, or repetitive bending or “stooping”
on the job. The worst pressure on the disc occurs with prolonged sitting and
bending over.In summary, if the patient has no red flags
and has a normal neurological exam, there is no reason to get early
radiological studies. Getting early x-rays and early MRIs leads to a better
patient satisfaction but does not give a better patient outcome. If there is no
specific pain pattern, then there is no need for further workup. MRIs are good
studies, but they give false positives. There is degeneration or a bulge of a
disc in 35% of all asymptomatic subjects between 25-39 years of age. In patients
60 years old or older, the majority of the patients will have changes in the
MRI. MRI abnormalities are common and must be correlated with the age and the
clinical signs and symptoms of the patient. An MRI is good for diagnosing the
lumbar disc herniation, which is sometimes called a ruptured disc, a slipped
disc, or a herniated disc. The most common location of a disc herniation is a
posterolateral herniation involving one nerve root. A foramninal L4-L5
herniation occurs in about 8%-10% of the cases. It involves the exiting nerve. A
central herniation involves multiple nerve roots. It predominantly causes low
back pain more than leg pain. It may cause bladder and bowel symptoms. This type
of disc herniation causes Cauda Equina Syndrome which needs urgent diagnosis
and surgical treatment. Clinical evaluation for a herniated disc examines
sensory and motor reflexes. The Straight Leg Raising Test is the most important
finding. It can be done in either the sitting or supine position. The test is
positive as indicated by pain in the leg when the patient’s leg is raised to
flex the hip with the knee extended. A positive straight leg test means a tension
sign, something is putting tension or stress on the sciatic nerve. When the
test is positive, it indicates possible disc herniation. Treatment is typically
non-operative. First, reassure the patient. Let the patient take some rest (no
more than a few days), give the patient anti-inflammatory medication, and
instruct them to attend physical therapy. Indications for surgery include
progressive neurological deficits, Cauda Equina Syndrome, the patient is not
getting better with time and treatment or if the symptoms are not getting better
with conservative treatment, or the patient has a positive tension sign with
persistent sever pain. Patients with sciatica and positive tension signs or
patients with positive neurological findings on clinical exam with positive MRI
findings make ideal surgical candidates. Surgery results in relief of leg pain
in the majority of patients. Back pain may persist in some patients.
Surgery results
in neurological improvement, 50 % motor and sensory and 25% reflexes. In patients
with discogenic back pain, they may need fusion which is a major procedure.This is the position that produces the highest pressure on the
disc. If a patient has back pain but no radiation, by the patient’s history or
physical examination and there are no red flags, then there is no reason to get
x-rays or MRI early in the treatment of the patient. Red flags include a
history of trauma, a tumor, infection, or Cauda Equina Syndrome symptoms. To rule
out a history of trauma you should rule out fractures with x-rays, MRI, or CT
scans. Tumors are a risk if the patient is older than 50 years old, if the
patient had weight loss, or if the patient has pain at rest or at night. An infection
may be present if the patient has fever and chills, if the patient has a
history of diabetes, or if the patient has a history of IV drug abuse. Cauda
Equina Symptoms may be present if the patient has back pain more than leg pain
or if the patient also has bladder and bowel symptoms. Cauda Equina Syndrome
needs to be diagnosed and surgically treated early. An MRI needs to be ordered
urgently in the course of treatment. The MRI should be ordered STAT. There may
need to be a wet read; a wet read is an early preliminary read of the
radiographs. A wet read needs to be communicated with the physician and can be
done while the patient is still on the table of the MRI.
The DISH has flowing ossification along anterolateral aspect
of at least four continuous vertebrae. When you look at the x-ray, you find
ossification along the anterior aspect of the body but separate from the
vertebrae and the disc height is preserved. It occurs in older patients (50
years and above). It affects all of the spine (more in the thoracic spine),
especially on the right side, which is typical of DISH. The syndesmophytes are
equal on the right and left sides in the lumbar and cervical vertebrae.
There is
no involvement of the discs and there is no facet fusion or sacroiliac joint involvement.
The patient may have other comorbidities such as gout or diabetes, and you need
to get the hemoglobin A1c (HbA1c test) in these patients. Some patients may
have high cholesterol levels. The patient will complain of back pain and spinal
stiffness. DISH will have large syndesmophytes, and if the condition occurs in
the neck, it will cause dysphagia, hoarseness of the voice, and sleep apnea. Diagnosis
can be established by x-ray of the spine. On lateral x-ray of the cervical
spine, you will find anterior bony fragments and the discs are preserved. The fractures
in the spine are usually due to a hyperextension injury and can be occult,
resulting from minor trauma and may have major instability. There is an
increased mortality in c-spine trauma in DISH, high mortality especially in non-operative
treatment. If the patient has a history of sudden neck or back pain, then the
patient will be assumed to have an occult fracture, so try to get a CT scan or
an MRI even if the pain is minimal and even if the x-rays appear normal. Heterotopic
ossification after total hip arthroplasty is more in patients with DISH.
What is the difference between DISH and Ankylosing
Spondylitis?
DISH
-Flowing large syndesmophytes
-No bamboo spine
-Sacroiliac (SI) join will not be involved
-Occurs in older patients
-some patients may have diabetes, check hemoglobin A1c
Ankylosing Spondylitis
-Diffuse ossification of the disc space without large
osteophytes
Disc herniations usually occurs posterolaterally, but it may
also be central. The cauda equina is composed of several nerves within the
lower end of the spinal canal. The top of the spinal cord is a tubular bundle
of nervous tissue extending from the brain.
The following section of the spinal
cord is called the Conus Medullaris and is the lower end of the spinal cord.
The Cauda Equina is made up of multiple nerve roots beginning at the level of
L1.
The most common disc herniation is the Posterolateral Disc
Herniation. This type of herniation is a nerve root injury, which will cause
changes to both the sensory and motor skills as well as the reflexes. A
posterolateral disc herniation usually affects the foot and ankle, and may
cause unilateral leg pain and weakness. Observe for a positive straight leg
raising test. These herniations are usually initially treated with conservative
methods.
A central disc herniation will cause cauda equina syndrome,
which is a compression over the lumbosacral nerve roots. This compression will
cause more back pain than leg pain, and bladder and bowel symptoms will be
evident. This herniation is considered a surgical emergency.
