Nerve Root Pain
Reflex Changes Triceps.
Self-Assessment Quiz Question #37 Typically, compression to the nerve root at a given cervical level manifests itself in predicable radicular symptoms, which can help with differential diagnosis. However, nerve root compression at certain levels is uncommon, and motor deficits at this/these levels may be hard to detect. Which level(s) is/are this/these? a. C2–4. Case Study: Carl Cooper Client is a 34-year-old letter carrier who presents to physical therapy complaining of right-sided neck pain with numbness in his right hand. The client states that the neck pain started about three weeks ago, and the numbness in his hand started four or five days ago. The symptoms in his hand come on when he carries his mail bag on his right shoulder. The patient localizes pain and numbness to the thumb and index finger. Question What cervical spine level correlates with pain/numbness in this area? In addition, weakness in which upper extremity muscles correlates with this spine level? What reflexes correlate with this b. C5. c. C6. d. C7. spine level? Discussion Pain and/or numbness in the thumb and index finger is consistent with involvement of the C6 nerve root. In addition, pain and numbness might be expected in the lateral forearm. Weakness may be present in the biceps (elbow flexion, forearm supinators) and wrist extensors. Finally, the biceps and brachioradialis reflexes may be affected (hypoactive). Special tests to confirm cervical radiculopathy Childress et al. (2016) outline three special test to confirm diagnosis of cervical radiculopathy: Spurling test, shoulder abduction test, and upper limb tension test. Spurling’s test has been shown to be highly specific and sensitive in diagnosing cervical radiculopathy, as confirmed by magnetic resonance imaging (MRI) and electrodiagnostic findings (Childress et al., 2016). For this test, the patient is seated, and the assessor side bends the neck toward the affected side then applies compression force downward from the top of the head. The purpose of this test is to constrict the patency of the neural foramen, thus increasing compression on the nerve root. The test is considered positive if the client’s symptoms are reproduced (Flynn et al., 2016). The shoulder abduction test has been shown via electrodiagnostic testing to have specificity that is like the Spurling test. For this test, the client could be sitting or lying supine. The assessor puts the palm of the affected arm on top of the patient’s head. If radicular symptoms are relieved, this is a positive result. The suggested mechanism for reduction of pain is that this position relieves mechanical traction to the nerve. The upper limb tension test is the most sensitive for ruling out cervical radiculopathy. For this test, the patient is supine and the examiner performs the following movements with the ipsilateral upper extremity: Begin with scapular depression and then, with the shoulder in 90 degrees abduction and external rotation and with the elbow flexed, put the forearm in supination and the wrist and fingers in extension. Now extend the elbow while side bending the head toward and away from the arm. A positive test occurs when one or more of the following occurs: Symptoms are reproduced, there is a side-to-side difference in elbow extension greater than 10 degrees, and/or contralateral side bend of the neck increases symptoms while ipsilateral side bend of the neck decreases them.
Weakness
C7
Lower neck, intrascapular, posterior forearm, middle finger. Inter- and infrascapular, medial forearm, fourth and fifth finger.
Elbow extension, forearm pronation, wrist flexion, finger extension. Hand intrinsic, finger flexion.
C8
C2–C4 radiculopathy Radiculopathy is not common at cervical spine levels 2 through 4, and motor deficits may be hard to detect (Kang et al., 2020). The C3 and C4 roots innervate the diaphragm, so radiculopathy at these levels can lead to diaphragmatic weakness and a pattern of breathing referred to as paradoxical respiration (Kang et al., 2020). In addition, differentiating pain in the head caused by radiculopathy at these levels from migraine may be indicated. For migraine headaches, differentiating symptoms include bitemporal throbbing pain, aura (sensitivity to light), nausea and vomiting, and visual disturbance (Kang et al., 2020). C5 radiculopathy C5 radiculopathy leads to symptoms similar to a rotator cuff tear (Kang et al., 2020). Both these conditions can cause weakness with shoulder abduction. However, C5 radiculopathy can be differentiated by determining if there is pain with resistance to shoulder abduction and/or tenderness in the rotator cuff, as these symptoms are not typically present with C5 radiculopathy. In addition, reflexes would be intact with a rotator cuff tear. Another condition that may mimic C5 radicular symptoms is acute brachial plexus neuritis (Parsonage–Turner syndrome). This condition is characterized by acute onset of pain in the neck, shoulder, and arm, which is followed by marked numbness and weakness of the arm within a few days to weeks (Kang et al., 2020). By contrast, pain and neurologic deficits occur simultaneously in cervical radiculopathy (Kang et al., 2020). C6 radiculopathy C6 radiculopathy symptoms are similar to carpal tunnel symptoms. Both conditions can create weakness and numbness in the hand. However, with C6 radiculopathy, pain is also typically present in the neck, radial side of the biceps, and/ or forearm, and motor deficits may be present in the wrist extensors and biceps. In addition, brachioradialis and bicep reflexes may be diminished. By contrast, carpal tunnel syndrome typically involves thenar muscle atrophy and can be reproduced with Tinel’s sign (Kang et al., 2020). C7 radiculopathy C7 is the most frequently occurring cervical radiculopathy and causes weakness in the triceps, wrist flexors, and finger extensors (Kang et al., 2020). Differential diagnosis includes posterior interosseous nerve entrapment, which can also cause finger extension weakness. However, with posterior interosseous nerve entrapment, the triceps and wrist flexors would have normal strength and there would not be any sensory changes (Kang et al., 2020). C8 radiculopathy C8 radiculopathy symptoms may present with certain characteristics in common with both cubital tunnel syndrome (or ulnar neuropathy) and Pancoast syndrome. With cubital tunnel syndrome, there is tenderness at the medial side of the elbow, hypothenar muscles and adductor pollicis weakness, and sensory changes in the hand and fourth and fifth fingers (Kang et al., 2020). With C8 radiculopathy, adductor pollicis muscle function is intact. The symptoms of Pancoast syndrome include weakness or incoordination in the hand muscles, but they also include swelling in the upper arm and chest tightness.
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