CERVICAL RADICULOPATHY : CERVICAL RADICULOPATHY Slide 2: CERVICAL RADICULOPATHY 2 By,…… :-
Dr. Vishal B. Boricha
MPT (Sports Medicine) INTRODUCTION : CERVICAL RADICULOPATHY 3 INTRODUCTION Radiculopathy is defined as a clinical syndrome resulting from damage to either the dorsal or ventral nerve root or both.
Cervical radiculopathy is a common diagnosis classified as a disorder of nerve root and most often is the result of a compressive or inflammatory pathology from a SOL such as disc herniation, spondylotic spur or cervical osteophyte. EPIDEMIOLOGY : CERVICAL RADICULOPATHY 4 EPIDEMIOLOGY Neck pain is extremely common but non-specific symptom. Its prevalence increases with age and is higher in women than in men.
Age: degenerative process in cervical spine generally begins in 3rd decade. Symptoms of cervical spondylosis are commonly found in those aged 40-60 years.
Sex: Male to female ratio is 2:3
Race: No apparent correlation.
Occupation: Those who carry heavy loads on their head. NORMAL ANATOMY : CERVICAL RADICULOPATHY 5 NORMAL ANATOMY NORMAL ANATOMY : CERVICAL RADICULOPATHY 6 NORMAL ANATOMY 8 Cervical roots are attached to the spinal cord by dorsal and ventral roots.
The majority of axons of ventral roots originate from the cells of anterior and lateral gray columns, where as those forming the dorsal roots originate in the spinal or dorsal root ganglia.
The dorsal root ganglia are situated proximal to the point at which these join anterior roots to form spinal nerves; hence these are in the inter-vertebral foramina. NORMAL ANATOMY : CERVICAL RADICULOPATHY 7 NORMAL ANATOMY NORMAL ANATOMY : CERVICAL RADICULOPATHY 8 NORMAL ANATOMY After coming out of foramina these divide in to anterior and posterior rami.
The posterior rami supply the skin and the muscles of the back. The anterior rami of C4 – T1 form the brachial plexus.
Myotome: Muscles supplied by single nerve root.
Dermatome: Skin region receiving sensory supply from a single root. DERMATOMES : CERVICAL RADICULOPATHY 9 DERMATOMES C5 – Lateral arm
C6 – Lateral forearm, thumb, index finger
C7 – Posterior forearm, middle finger
C8 – Medial forearm, ring and little finger
T1 – Medial arm MYOTOMES : CERVICAL RADICULOPATHY 10 MYOTOMES C5 – Shoulder abduction
C6 – Elbow flexion or wrist extension
C7 – Elbow extension or wrist flexion
C8 – Grip strength, shake hands
T1 – Interossei, spread fingers and resist finger adduction CAUSES : CERVICAL RADICULOPATHY 11 CAUSES Compressive:
Acute inter-vertebral disc prolapse.
Spinal tumors: benign and malignant.
Granulomas: tubercular, sarcoid and fungal.
Hematoma: epidural, subdural & subarachnoid.
Bone diseases: tumors, infections & Paget’s disease. CAUSES : CERVICAL RADICULOPATHY 12 CAUSES Non-compressive:
Acute & chronic inflammatory demyelinating polyradiculopathy.
Neoplastic meningitis: medduloblastoma, astrocytoma, ependymoma.
Intrathecal drugs: antibiotics, anaesthetic, corticosteroid, and radio-opaque contrast.
Root avulsion & Neural tube defect.
Vasculitides. PATHOPHYSIOLOGY : CERVICAL RADICULOPATHY 13 PATHOPHYSIOLOGY Inter-vertebral discs lose hydration & elasticity with age, and these losses lead to cracks & fissures. The surrounding ligaments also loose their elastic properties and develop traction spurs.
The disc subsequently collapses as a result of biomechanical incompetence, causing the annulus to bulge outward, and the facets override. Acute disc herniation may complicate chronic spondylotic changes. PATHOPHYSIOLOGY : CERVICAL RADICULOPATHY 14 PATHOPHYSIOLOGY As the annulus bulges, the cross-sectional area of the canal is narrowed. This effect may be accentuated by hypertrophy of the facet joints (posteriorly) & the ligamentum flavum. Neck extension causes the ligaments to fold inwards, reducing the A-P diameter.
As disc degeneration occurs, the uncinate process overrides (joints of Lushka) & hypertrophies, compromising the ventro-lateral portion of the foramen. PATHOPHYSIOLOGY : CERVICAL RADICULOPATHY 15 PATHOPHYSIOLOGY Likewise, facet hypertrophy decreases the dorso-lateral aspect of the foramen. This change contribute to the radiculopathy associated with cervical spondylosis.
Marginal osteophytes begin to develop and any additional stress in the form of trauma or long term heavy loading may exacerbate this process. CLINICAL FEATURES : CERVICAL RADICULOPATHY 16 CLINICAL FEATURES Spondylosis is most commonly seen at C4-5, C5-6 & C6-7 levels, and 90% of disc herniation affect these roots.
C7 radiculopathy is the commonest accounting for 69-70%, followed by C6 for 19-25%, C8 for 4-10% and C5 is the least common accounting for only 2%. CLINICAL FEATURES : CERVICAL RADICULOPATHY 17 CLINICAL FEATURES The patient may present with one or more of the following symptoms:
Headache: occipital headache is commonly related to arthritis of C1-C2 facet joint with irritation of C2 nerve root.
Neck pain: neck pain is common and may be radiating in the dermatomal pattern.
Radicular pain: caused by the activation of sensory fibres at the level of dorsal root. Described as a thin band of sharp shooting pain along the distribution of nerve(s) supplied by the affected dorsal root. CLINICAL FEATURES : CERVICAL RADICULOPATHY 18 CLINICAL FEATURES Muscular symptoms: decreased reflexes coupled with motor weakness secondary to compromise of ventral roots.
Stiffness: neck is usually hold in the position of relief and movements are restricted on the affected side. DIAGNOSIS : CERVICAL RADICULOPATHY 19 DIAGNOSIS Patient’s History: subjective symptoms.
Cervical Compression Test.
Cervical Distraction Test.
Jackson Compression Test.
VBI Test. DIAGNOSIS : CERVICAL RADICULOPATHY 20 DIAGNOSIS Neuro-physiological Evaluation:
M-NCV & S-NCV of Upper limb.
Somato-sensory Evoked Potentials.
Nerve Root Stimulation.
Plain Cervical Radiography.
CT with Myelography.
MRI NEURO-PHYSIOLOGICAL EVALUATION : CERVICAL RADICULOPATHY 21 NEURO-PHYSIOLOGICAL EVALUATION Motor & Sensory Nerve Conduction:
Motor & sensory NCV of median, ulnar, radial, and musculo-cutaneous nerves are normal. This is because the root lesions are proximal to DRG and degeneration proceeds centrally rather than peripherally.
Ulnar & Median CMAP may be reduced if there is significant axonal degeneration of C8 and T1 roots. NEURO-PHYSIOLOGICAL EVALUATION : CERVICAL RADICULOPATHY 22 NEURO-PHYSIOLOGICAL EVALUATION Needle Electromyography:
This is the gold standard and single most useful procedure having a considerably higher diagnostic yield.
Fibrillations Potentials & Positive Sharp Waves in segmental distribution; at least in two muscles supplied by same root but different nerves
Absence of these changes in adjacent myotomes.
FPs & PSVs in paraspinal muscles.
Normal Nerve Conduction Velocity. NEURO-PHYSIOLOGICAL EVALUATION : CERVICAL RADICULOPATHY 23 NEURO-PHYSIOLOGICAL EVALUATION FPs are the most sensitive indicator of axonal loss & tend to develop in the muscles of a myotome in a proximal to distal sequence. The presence of FPs in a root distribution is the most reliable evidence of radiculopathy.
Following acute radiculopathy, FPs are found as early as 7-10 days in para-spinal muscles, and it may take up to 6 weeks for distal muscles, but may be evident from 2-5 weeks in proximal musculature.
Paraspinal EMG although useful in the evaluation of radiculopathy, but has its limitations. NEURO-PHYSIOLOGICAL EVALUATION : CERVICAL RADICULOPATHY 24 NEURO-PHYSIOLOGICAL EVALUATION Re-innervation may become evident in 6 weeks or longer after axonal degeneration.
Polyphasic motor units develop, becoming profuse by about 10 weeks post injury (increased duration & amplitude).
The time sequence of re-innervation mirrors that of denervation, as polyphasic potentials are first seen in paraspinal muscles, next in girdle musculature, and last in a distal distribution. NEURO-PHYSIOLOGICAL EVALUATION : CERVICAL RADICULOPATHY 25 NEURO-PHYSIOLOGICAL EVALUATION Other EMG changes in myotomal distribution include:
Complex repetitive discharges (CRDs).
Abnormal insertion activity.
Motor unit potential (MUP) changes.
The specific EMG abnormality in radiculopathy depend upon the duration of disease. NEURO-PHYSIOLOGICAL EVALUATION : CERVICAL RADICULOPATHY 26 NEURO-PHYSIOLOGICAL EVALUATION NEURO-PHYSIOLOGICAL EVALUATION : CERVICAL RADICULOPATHY 27 NEURO-PHYSIOLOGICAL EVALUATION C7 Radiculopathy:
C7 radiculopathy is produced by C6 disc prolapse.
Changes are found in C7 innervated muscles such as triceps, anconeus & extensor carpi radialis (Radial nerve) and pronator teres & flexor carpi radialis (Median nerve). NEURO-PHYSIOLOGICAL EVALUATION : CERVICAL RADICULOPATHY 28 NEURO-PHYSIOLOGICAL EVALUATION C5-6 Radiculopathy:
C5-6 radiculopathy is produced by C4 & C5 discs.
Abnormalities may be seen in biceps brachii, brachioradialis, deltoid, supraspinatus & infraspinatus. If the changes are also found in rhomboids, C5 radiculopathy is likely; similarly involvement of pronator teres & flexor carpi radialis suggest C6 radiculopathy. NEURO-PHYSIOLOGICAL EVALUATION : CERVICAL RADICULOPATHY 29 NEURO-PHYSIOLOGICAL EVALUATION C8-T1 Radiculopathy:
C7 disc is responsible for C8 and T1 root involvement.
Fibrillation potentials are found in one or more ulnar innervated and some radial innervated muscles such as extensor pollicis brevis, extensor indicis proprious and some median innervated muscles such as abductor pollicis brevis and flexor pollicis longus. NEURO-PHYSIOLOGICAL EVALUATION : CERVICAL RADICULOPATHY 30 NEURO-PHYSIOLOGICAL EVALUATION F Wave:
The basis for the use of F waves is their ability to assess the proximal part of the nerve and roots, which can’t be evaluated by conventional conduction studies.
F wave assesses the functional integrity of motor fibres only.
The F wave abnormality is not diagnostic of radiculopathy. NEURO-PHYSIOLOGICAL EVALUATION : CERVICAL RADICULOPATHY 31 NEURO-PHYSIOLOGICAL EVALUATION Somatosensory Evoked Potentials:
SEPs can be elicited by stimulating the peripheral nerve or dermatome.
The long distance between the stimulating & recording sites, partial involvement allowing conduction through remaining fibres, inter-subject & inter-side variation, and inability to provide information about nature or age of the lesion in the sensory pathways are the obvious limitations of SEPs. NEURO-PHYSIOLOGICAL EVALUATION : CERVICAL RADICULOPATHY 32 NEURO-PHYSIOLOGICAL EVALUATION Nerve Root Stimulation:
Nerve root stimulation can be performed either by monopolar needle or by electrical or magnetic stimulation.
For monopolar needle stimulation, the needle is inserted into para-spinal muscle near the root, and for electrical or magnetic stimulation, the cathode is placed at cervical vertebra.
Recording of the action potentials is obtained from the desired muscles. MANAGEMENT : CERVICAL RADICULOPATHY 33 MANAGEMENT Medical & Surgical Treatment:
Intra-articular Steroid Injection.
Cervical Epidural Block.
Selective Nerve Root Block.
Decompression and Stabilization.
Physiotherapy Treatment. PHYSIOTHERAPY TREATMENT : CERVICAL RADICULOPATHY 34 PHYSIOTHERAPY TREATMENT INTERMITTENT CERVICAL TRACTION:
Effects of traction: Mechanical benefits of temporarily separating the vertebrae & causing mechanical sliding of facet joints in the spine.
May relieve symptoms from a disc protrusion.
Angle of pull of traction: Flexion, Neutral or Hyper-extension.
Duration of traction: 10-15 minutes.
Traction force: 1/10 to 1/7 of patient’s body weight.
Position of patient: Supine or sitting. PHYSIOTHERAPY TREATMENT : CERVICAL RADICULOPATHY 35 PHYSIOTHERAPY TREATMENT INTERFERENTIAL CURRENT THERAPY:
Mechanism of action of IFT: Higher frequencies (100-130 Hz) close the pain gate mechanism. May act directly on the peripheral nerves by slowing the conduction. May act as placebo effect.
Duration of treatment: 10-12 minutes. PHYSIOTHERAPY TREATMENT : CERVICAL RADICULOPATHY 36 PHYSIOTHERAPY TREATMENT ISOMETRIC NECK EXERCISE:
INE is helpful for maintaining or improving strength, endurance and tone of the cervical muscles.
Alternating isometric contractions also enhance stability. PHYSIOTHERAPY TREATMENT : CERVICAL RADICULOPATHY 37 PHYSIOTHERAPY TREATMENT MAITLAND MOBILIZATION:
Grades of mobilization:
Grade I: Small-amplitude rhythmic oscillations are performed at the beginning of the range.
Grade II: Large-amplitude rhythmic oscillations are performed with in the range, not reaching the limit.
Grade III: Large-amplitude rhythmic oscillations are performed up to the limit of the available motion and are stressed into the tissue resistance.
Grade IV: Small-amplitude rhythmic oscillations are performed at the limit of the available motion and stressed into the tissue resistance.
Grade V: A small-amplitude, high velocity thrust technique is performed to snap adhesions at the limit of the available motion. PHYSIOTHERAPY TREATMENT : CERVICAL RADICULOPATHY 38 PHYSIOTHERAPY TREATMENT MAITLAND MOBILIZATION:
Neuro-physiological Effects: Small amplitude oscillatory & distraction movements are used to stimulate the mechanoreceptors that may inhibit the transmission of nociceptive stimuli at the spinal cord or brain stem levels.
Mechanical Effects: Small amplitude distraction or gliding movements of the joints are used to cause synovial fluid motion, help to maintain nutrient exchange & thus prevent the painful & degenerating effects of stasis when a joint is swollen or painful. QUESTIONS? : CERVICAL RADICULOPATHY 39 QUESTIONS? Slide 40: CERVICAL RADICULOPATHY 40 THANK YOU!