Cervical DDD with foraminal stenosis

Cervical DDD with foraminal stenosis: 

Cervical DDD with foraminal stenosis Shavon Theriot October 12, 2011

General description of cervical degenerative disc disease(DDD) with foraminal stenosis  : 

General description of cervical degenerative disc disease(DDD) with foraminal stenosis Lateral cervical stenosis results from encroachment on the lateral recess and the neuroforamina of the cervical region, primarily as a result of hypertrophy of the uncovertebral joints, lateral disc annulus bulging, and facet hypertrophy. 5

Differentials and other problems to be considered : 

Differentials and other problems to be considered The differential diagnosis includes achondroplasia , osteogenesis imperfecta , involutional osteoporosis , rheumatoid arthritis of the spine , and spondylodiskitis . Other conditions to be considered include metastatic breast cancer , prostate cancer , and Paget disease . 5

Signs: 

Signs Postural Assessment- Forward head and rounded shoulders. AROM- Limited in forward and backward bending with pain. 3 Limited in left rotation and side bending with pain at endrange. 2 PROM- Limited P/A glide at C2/C3. Limited P/A and A/P glides at C4/C5. Special Test: Spurling ’ s Cervical Compression test- will reproduce patient ’ s symptoms. 2 Cervical distraction- Will relieve patient ’ s symptoms. 2 Reflexes- Diminished /absent brachioradialis or biceps reflex. 2

Symptoms: 

Symptoms Patient may report numbness and tingling in the C3, C4, and C5 dermatome pattern. 3 Patient may report cervical neck pain and stiffness that can radiate into the shoulder, scapula, arm and hand. 2 Patient may report pain when coughing, sneezing, jarring or straining. 2 Patient may report cervical neck pain that radiates down the upper extremity. 2 Patient may report a decrease in strength in the upper extremity.

Incidence: 

Incidence Cervical spine lateral foraminal stenosis are usually the result of spondylogenic degenerative arthrosis. 6 Neurological signs usually arise in patient’s who over 50 years of age. 6

Diagnosis: 

Diagnosis Lateral Foraminal Stenosis at C3/4 and C4/5 cervical spine. Therefore, C3 and C4 nerve roots would be involved.

Prognosis: 

Prognosis The prognosis is good for this 55 year old female who is motivated to participate in therapy and return to normal functional activities of daily living.

Impact on Function: 

Impact on Function Patient will have a difficult time lifting objects overhead. Patient may have a sleep disturbance. Patient will have pain radiating down left arm causing aberrant movement. Patient will have left upper extremity weakness.

Recommended imaging to manage cervical disc disease: 

Recommended imaging to manage cervical disc disease MRI is the best diagnostic tool for detecting the progression of foraminal stenosis caused by disc degeneration. MRI reveals the nerve roots, spinal cord, bone and bone marrow. 3

Recommended imaging to manage cervical disc disease with disc herniation: 

Recommended imaging to manage cervical disc disease with disc herniation Conventional radiographs are an excellent tool to evaluate the degenerative changes that can occur in the cervical spine. 3 Lateral views are most sensitive for central spinal stenosis. 5 Oblique views of the cervical and lumbar areas better demonstrate lateral stenosis syndromes. 5

Recommended imaging to detect cervical degenerative disc disease : 

Recommended imaging to detect cervical degenerative disc disease CT is a great tool for the evaluation of occult fractures, osseous structures, or degenerative changes. 1 MRI is better for visualization of the central nervous system, the cervical vessels, and soft tissues. 1 Spinal MRI is the most universally suitable technique for the diagnosis of spinal stenosis. 5

Imaging: 

Imaging http://www.mypacs.net/cgi-bin/repos/mpv3_repo/wrm/repo-view.pl?cx_subject=3386267&cx_repo=mpv4_repo

ABC’s: 

ABC’s Alignment: The bone size for the vertebrae appear to be normal size. However, the anterior bodies of C2-C7 are abnormally shaped. There abnormal shape is possibly due to stress placed on the anterior side of spine due to the Anterior Longitudal Ligament. Patient has a decrease in cervical lordosis from C2-C6. There appears to a decrease in space between C1-C2. Subcondral sclerosis is evident throughout the cervical spine. There is an anterior traction spur on the C6 vertebrae body. There are spondylophytes on the anterior bodies of C5/C6 and C6/C7. C2/C3 appears to be anterior displaced. Patient has decreased spinous process spacing at C2-C3, which could cause a narrowing of the vertebral foramen. There are osteophyte formations on C5 and C6. C4/C5 disc bulge and C3/C4 hypertrophied zygaphophyseal joint. Bone Density: There appears to be ample contrast within each bone. The vertebrae appear to be aging normally. There appears to be altered shape on the vertebral bodies of the trabecular bone. Cartilage: Patient has decreased joint space width between C4/C5, C5/C6, and C6/C7. There are tractions spurs between C3/C4, C4/C5, and C5/C6. Soft Tissue: The trachea can be seen anterior to the cervical spine within the soft tissue. The contour of the soft tissue surrounding the cervical spine appears to be normal. There does not appear to be any wasting.

Questions: 

Questions 1.  If your patient was contemplating surgery, what plan of care could you implement to help them to realize that surgery was the last resort? 2.  How could you utilize imaging to assist in educating them on the benefits of your plan of care for their specific condition?

References: 

References 1. Unit 2: Cervical and thoracic spine. Imaging course notes online. Available at: http://www.learnhost.org/EASEv4_5/Campus/API/ScormDisplayFrame.cfm. Accessed October 12 , 2011 2. Magee D. Orthopedic Physical Assessement, 5 th ed. Missouri: Saunder;2008: 135-199 3. Wainner R, Gill H. Diagnosis and Nonoperative Management of Cervical Radiculopathy. J Ortho & Sports PT 2000;30(12):728-744 Fritsch, Thomason. Cervical disc degeneration & facet arthrosis with neuroforamina stenosis. McKesson Corporation. 2011. Available at: http://www.mypacs.net/cgi-bin/repos/mpv3_repo/wrm/repo-view.pl?cx_subject=3386267&cx_repo=mpv4_repo . Accessed October 12, 2011. Nadalo L, et al. Spinal Stenosis Imaging. Medscape reference. 2011. Available at:http://emedicine.medscape.com/article/344171-overview. Accessed on October 12, 2011 Paris SV. S1 Introduction to Spinal Evaluation and Manipulation. University of St. Augustine for Health Sciences, 4th Edition. 1997: 171.