Cervico-brachial neuralgia Iraj Salehi-Abari MD Cervico-brachial neuralgia Iraj Salehi-Abari MD., Internist Rheumatologist salehiabari@sina.tums.ac.ir

Introduction: Neck pain: Common Common causes: Cervical spondylosis (OA) Disc herniation Cervical disc-arthrosis  Cervical radiculopathy Today, Cervical radiculopathy is a common source of arm pain + sensory and motor dysfunction Diameter of cervical canal is a little more than cervical cord: Myelopathy is common

Pathophysiology: Radiculopathy: nerve root injury Causes of radiculopathy: Compressive etiologies Noncompressive etiologies Majority of radiculopathy is Compressive Two predominant compressive mechanisms: Cervical spondylosis &/or Disc herniation: 22%

Pathophysiology: Noncompressive causes: Infectious: Herpes zoster, Lyme disease Nerve root infarction Root avulsion Infiltration by tumor Infiltration by granulomatous tissue Demyelination

Epidemiology: Mean age at diagnosis: 48 years Range of age: 13 to 91 years Annual incidence for men: 100/100,000 Annual incidence for women: 60/100,000 Male/Female ratio: 1.7 Computer (Internet) abuse: Decreasing age at diagnosis Increasing incidence and prevalence Two decades later: Neck pain > LBP

Epidemiology: Cervical Radiculopathy: C7 root: 70% C6 root: 20% C5, C8 & T1 together: 10% Others: very rare

Clinical patterns of neck pain: Pure disc herniation: “Acute pattern” Pure spondylosis: “Chronic pattern” Mixed disc herniation and spondylosis: “Acute on chronic pattern” The most common pattern

Trigger factors: Physical exertion or trauma: may be Prolonged flexion of neck Psychologic stress (anxiety) Motor vehicle accidents: With spinal fracture or Root avulsion

Clinical features: Pain in the neck or arm: almost all Pain in cervical region Pain in upper limb Pain in shoulder Pain in interscapular region Paresthesia or numbness in a root distribution: 80% Subjective weakness: less common

Clinical features: Acute neck pain: Severe acute pain Severe Limitation Of Motion (LOM) Paraspinal muscle spasm Paraspinal point tenderness Torticollis Trigger points

Cervical Range Of Motion-Screening: Flexion, Extension, Lateral Bendings, Rotation Active/Passive Motion With Hx. Of Trauma or Accidents: No ROM tests or May be only Active ROM (gently) With Aging: ROM decreases except C1-C2 Rotation Female have a greater active ROM except Flexion ROM in supine position is greater than ROM in sitting position

Clinical features: Chronic neck pain: Mild to moderate chronic pain With remission and exacerbation With shoulder and scapular pain Normal neck examination Mild to moderate LOM Mild paraspinal spasm or point tenderness

Cervical Radiculopathy:

Cervical Radiculopathy:

A A

Cervical Radiculopathy: C5 dermatome: Lateral aspect of the more cephalad portion of the upper extremity C5 myotome: Deltoid muscle abduction test Biceps muscle flexion test The biceps DTR

Cervical Radiculopathy: C6 dermatome: Lateral aspect of the more distal portion of the upper extremity including thumb finger C6 myotome: Radial Wrist Extensor muscles test The Brachioradialis DTR (Supinator Jerk)

Cervical Radiculopathy: C7 dermatome: Midline posterior aspect of whole upper extremity including index and middle fingers C7 myotome: The Flexor Carpi Radialis muscle test Ulnar Wrist Extensor muscles test Triceps Elbow Extension test The Finger Extensor musles test The Triceps DTR

Cervical Radiculopathy: C8 dermatome: The ulnar aspect of whole upper extremity including ring and little fingers C8 myotome: The Finger Flexor muscles test The Interossei muscles test Finger Jerk

Cervical spine tests: Cervical Range Of Motion-Screening Test of Head Rotation in Maximum Extension Test of Head Rotation in Maximum Flexion Soto-Hall Test Percussion Test O’Donoghue Test Valsalva Test Spurling’s maneuver Cervical Spine Distraction Test

Cervical spine tests: Shoulder Press Test Brachial Plexus Tension Test Shoulder Abduction Relief (Bakody) Test Test of Maximum Compression of the Intervertebral Foramina Jackson Compression Test Intervertebral Foramina Compression Test Flexion Compression Test Extension Compression Test

Cervical Radiculopathy: Spurling’s maneuver (neck compression test): Extension, Bending & Rotation of neck to the side of the pain Downward pressure on the head Positive test = Exacerbation or reproduction of limb pain or paresthesia Sensitivity: 30%, Specificity: 93% Positive test confirms radiculopathy Negative test can not rule out radiculopathy

Cervical Radiculopathy: Spurling’s maneuver should never be performed in: Instability of the cervical spine: Advanced RA or AS Trauma & Accidents (Fracture?) Cervical malformation Cervical metastasis When cervical myelopathy is suspected

Cervical Radiculopathy: Shoulder Abduction Relief (Bakody)Test: The patient is asked to lift the symptomatic arm above the head and resting it on the top of head Cervical Spine Distraction Test: The patient is seated. The examiner grasps the patient’s head about the jaw and the back of the head and applies superior axial traction Positive test = Decrease or disappearance of limb pain or radiculopathy

Clinical features: Compressive radiculopathy: Single or may be more than single dermatomes + myotomes Sensory + motor deficits Non-compressive radiculopathy: Multiple myotomes and dermatomes Sensory and motor (both) deficits Electrodiagnostic studies may be important to confirm it

Clinical features: Chronic Cervical Myelopathy:

Clinical features: Chronic Cervical Myelopathy:

Clinical features: Chronic Cervical Myelopathy: C3 – C5 myelopathy: The upper motor neuron features in upper extremity C6 – C8 myelopathy: The upper motor neuron features in lower extremity or both upper and lower extremity

Clinical features: Chronic Cervical Myelopathy: Gait disturbance: Spastic scissoring gait Upper motor neuron features: Spastic muscle weakness Hyperreflexia Babinski sign and its equivalents: The Chaddock sign The Oppenheim sign The Gordon sign

Clinical features: Chronic Cervical Myelopathy: Reduced joint position and vibratory sense Loss of pain sensation Bladder dysfunction, urgency, frequency, and/or retention Bowel dysfunction Lhermitte’s sign The Hoffmann Test or Reflex: Trunkal symptoms (sensory level)

Clinical features: Lhermitte’s phenomenon: An electric shock-like sensation in the neck, radiating down the spine or into the arms, produced by flexion of the neck Ominous sign May be present due to cervical myelopathy May be due to intramedullary pathology such as MS plaque

Clinical features: Chronic Cervical Myelopathy: The Hoffmann Test or Reflex: The patient is in a comfortable, relaxed sitting position The patient’s hand is cradled gently in the examiner’s hand The examiner then flicks the nail of the patient’s middle finger  Reflex flexion of the thumb and index finger

The Hoffmann Test or Reflex:

Clinical features: Features suggestive of tumor or infection as the cause of cervical radiculopathy: Fever and chills Unexplained weight loss Immunosuppression IV drug abuse

Clinical features: Vertebro-basilary system insufficiency: “Flying Plate” Sign: Faint & sudden drop off Diplopia Ataxia Vertigo

Clinical features: Atypical features: Chest pain: Pseudo-angina: C8-T1 Breast pain Facial pain: C3 Occipital pain (headache): C1-C2 Dysphagia and Stridor

Diagnosis: History Physical examination Imaging studies: Plain X-Ray MRI CT with myelography Electrodiagnostic studies (EMG & NCV)

Plain X-Ray: AP, Lateral, Rt. Oblique, Lt. Oblique AP view: Luschka J., Vertebral body, Transverse process Lateral view: Intervertebral disc space, Facet J., Spinous process Oblique view: Intervertebral foramina

Plain X-Ray: In asymtomatic individuals: In Cervical Trauma: 5th decade: 25% Spondylosis in X-Ray 7th decade: 75% Spondylosis in X-Ray In Cervical Trauma: It is very important It is useful for detecting subluxation and spondylolisthesis

Cervical MRI Indicated in: Cervical Radiculopathy Cervical Myelopathy Suspicious to cervical Tumor, Metastasis or Infection: Gadolinium-enhanced T1 sequences C1 – C2 subluxation

Cervical MRI T2 more useful than T1 sequences False-positive & False-negative Within patients with positive Hx. and Ph. Exam. But normal MRI, CT myelography will be recommended CT myelography is superior to MRI for evaluating of Bones and hard tissue

Electrodiagnostic studies: EMG and NCV both must be performed NCV alone is not sensitive for Radiculopathy Sensory nerve action potentials are normal when the lesion is proximal to the dorsal root ganglion, as it is in radiculopathy NCV are most useful to exclude CTS

Treatment: Conservative therapy Surgical therapy: The Benefit of surgery for the treatment of Cervical Radiculopathy and Myelopathy has not been clearly established In Cervical Radiculopathy In Cervical Myelopathy Recurrency: 1/3 of cases

Surgery for Radiculopathy: For patients with Cervical Radiculopathy who have all of below conditions Surgery is recommended: Symptoms and signs of Radiculopathy Cervical nerve root compression by MRI or CT myelography Persistence of Radicular pain despite Conservative therapy for at least 6-12 weeks, or progressive motor weakness that impairs function

Surgery for Myelopathy: For patients with Cervical Myelopathy who have at least one of below conditions Surgery is recommended: Neuroimaging evidence of Cord Compression Objective motor or sensory signs of Myelopathy Progressive weakness or disability