New York Physical Therapy Ebook Continuing Education

Flynn et al. (2016) list a cluster of tests that can be used to diagnosis cervical radiculopathy. When three of these four tests are positive, the likelihood ratio for the presence of cervical radiculopathy is 6.1. When four of them are positive, the likelihood ratio goes up to 30.3. This cluster of test items includes: ● Upper limb tension test. ● Cervical rotation less than 60 degrees to the ipsilateral side. The distraction test is performed by putting the patient supine with the examiner sitting at their head. While grasping under the chin with one hand and the occiput with the other hand, the patient’s neck is flexed slightly and a distraction force of approximately 14 pounds is applied. This test is positive if it reduces the client’s symptoms. Self-Assessment Quiz Question #38 ● Spurling’s test. ● Distraction test. Cervical myelopathy Cervical myelopathy is a spinal cord dysfunction that occurs when the spinal cord is compressed by narrowing of the spinal canal (McCartney et al., 2018). This condition was referred to as cervical spondylotic myelopathy (CSM) in the past but is now called degenerative cervical myelopathy (DCM). Typically, the cause is a combination of congenital stenosis (narrowing) of the spinal canal, disc herniation, and spondylosis (McCartney et al., 2018). Dynamic factors that influence the onset of myelopathy include repetitive flexion and extension of the cervical spine, which causes spinal cord irritation and compression (Milligan et al., 2019). Flexion can cause compression of the spinal cord against anterior osteophytes and intervertebral discs, while end range extension can lead to spinal cord pinching between the posterior margins of the vertebral body anteriorly and the hypertrophied buckled ligamentum flavum posteriorly (Milligan et al., 2019).

The levels of the cervical spine most often involved in cervical radiculopathy are:

a. C6 and C7. b. C5 and C6. c. C4 and C5. d. C3 and C4.

Self-Assessment Quiz Question #39 Which special test is highly sensitive and highly specific for diagnosing cervical radiculopathy as confirmed by magnetic resonance imaging and electrodiagnostic findings? a. Cervical side bend less than 30 degrees to the ipsilateral side.

b. Shoulder abduction test. c. Upper limb tension test. d. Spurling test.

Nouri et al. (2020) consider disc changes as the initial step in the onset of cervical myelopathy. With age, the disc becomes less compliant, resulting in increased stresses to the vertebral endplates. As a result, bone remodeling creates osteophytes and changes in the structure of the vertebrae. These processes lead to a loss of disc and vertebral height, resulting in the infolding of the ligamentum flavum, which may also undergo resultant hypertrophy and ossification. Ossification and hypertrophy of the posterior longitudinal ligament is also common (Gibson et al., 2018). These changes can occur at a single or multiple levels (Nouri et al., 2020). Continuous compression of the spinal cord leads to initiation of an inflammatory reaction and vascular changes, which may result in ischemia and loss of neuronal cells (Manko et al., 2022). Chronic cord compression can lead to neuronal cell loss, degeneration of the posterior columns and anterior horn cells, and endothelial damage that results in a compromised blood–spinal cord barrier (Milligan et al., 2019). Often the onset of this condition is insidious, leading to upper and lower motor and sensory changes of the arms and legs (McCartney et al., 2018). Cervical myelopathy is progressive and can lead to paralysis (Yanez Touzet et al., 2022). This condition affects up to 2% of adults (Manko et al., 2022). Most patients with cervical myelopathy are diagnosed in their 50s; this condition is considered uncommon before the age of 40 (Davies et al., 2018). Self-Assessment Quiz Question #40 Most patients with degenerative cervical myelopathy are diagnosed in their ________. This condition is considered uncommon before the age of ______.

Evidence-based practice: Special tests are an important part of differential diagnosis when the assessing clinician suspects cervical radiculopathy. When testing for weakness that corresponds to myotomes, motor examination may or may not show a grade of muscle weakness that corresponds to the involved nerve. Furthermore, no myotomes correspond to the upper cervical nerves (Cervical Radiculopathy, n.d.). When assessing dermatomes, the assessing clinician should know that they can vary from individual to individual and that overlap is common (Seladi-Schulman, 2019). Special tests add significant clarity to differential diagnosis for cervical radiculopathy. Flynn describes a cluster of four special tests for determining the presence of cervical radiculopathy. These include the upper limb tension test, Spurling’s test, the distraction test, and cervical rotation that is less than 60 degrees on the same side as the neck pain. When three of these four tests are positive, there is a 65% chance that cervical radiculopathy is present. When all four are positive, the chances go up to 90% (Cervical Radiculopathy, n.d.).

a. 80s; 60. b. 70s; 50. c. 50s; 40. d. 40s; 20. Signs and symptoms of cervical myelopathy

The presenting symptoms of cervical myelopathy are often nonspecific and include clumsiness of the hands and feet, decreased manual dexterity, and an unsteady gait. Although both lower and upper extremity symptoms may be present, typically upper extremity symptoms are predominant. Patients may have difficulty doing routine tasks such as holding a coffee cup or climbing the stairs (McCartney et al., 2018). These symptoms often generate a referral to physical and occupational therapy, and clinicians should always consider whether an undiagnosed myelopathy might be present in clients with these types of symptoms. Another clinical scenario where myelopathy should at least be considered is in clients with frequent falls.

The most obvious risk factor for degenerative cervical myelopathy is age, given that the development process for this condition is age dependent. Males are more affected than females. A narrow spinal canal has been shown to be a risk factor, as has a history of trauma to the neck. Genetic risk factors also exist (Nouri et al., 2022).

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Book Code: PTNY1024 Physical-Therapy

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