Cervical Nerve Root Impingement By: Michael Cox

Overview Anatomy of cervical spine and nerve roots Reasons for impingement Signs and symptoms associated with nerve root impingement Acute treatment of injury Rehabilitation Return to play criteria

Anatomy Primary Function: Mobility, support, and protection of spinal canal and neural structures 7 cervical vertebrae 8 nerve roots 6 intervertebral discs Foramina Nerve root occupies 25-33% over the foramina space Lordotic curve most of lordosis occurs at C1-C2 Some Biomechanics: 50% of flexion and extension occurs at occipitoatlantal joint 50% of rotation occurs at C1-C2

Anatomy

Anatomy Vertebral Disc Located between C2-C7 Composed of annulus fibrosis, which is the outer layer made up of thick fibrous cartilage Nucleus pulposus is the inner layer which is a water gelatin Discs serve as shock absorbers and allow the spine to bend

Anatomy Nerve roots Myotomes Dermatomes C1: Cervical flexion C3: Cervical lateral bending C4: Shoulder elevation C5: Shoulder Abduction C6: Elbow Flexion/wrist extension C7:Elbow extension/wrist flexion C8: Ulnar deviation/thumb extension T1: Finger abduction/adduction Dermatomes C1: Top of head C2: Side of face C3: Down mandible C4: Lateral neck C5: lateral upper arm C6: Lateral forearm to thumb C7: Middle forearm to 3rd C8: 5th to medial forearm T1: Medial upper arm

Anatomy Muscles SCM Splenius muscles Levator scapula Scalenes Upper trapezius

Mechanism for Impingement This injury can occur from an extension, lateral bending, or rotation mechanism, which causes a narrowing of the neural foramen and results in ipsilateral nerve root injury Disc herniation can cause the nucleus pulposus to leak into the foramen and cause impingement on the nerve

Signs and Symptoms Neck and shoulder pain and discomfort that can radiate down the arm Tingling or numbness along the nerve root involved Motor weakness in affected nerve root (manual muscle testing) Depending on reason for impingement certain motions (AROM) can cause pain Point tenderness is usually located along the lateral and posterior cervical muscles on the affected side Muscle tenderness and spasm on affected side is usually present

Special Test’s Deep Tendon Reflexes Foraminal Compression Test Biceps Brachii reflex: C5-C6 Brachioradialis reflex- C5-C6 Triceps reflex: C7-C8 Foraminal Compression Test Manuel Distraction Shoulder Abduction Test

Acute Treatment “A best-evidence synthesis by the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders concluded that there is not clear evidence that surgical treatment of cervical radiculopathy provides better long-term outcomes than nonoperative measures.” Icing NSAIDS Rest Take measures that reduce force compressing the nerve root Avoiding positions that increase symptoms

Rehabilitation Early Phase Main goal is reducing symptoms: controlling pain and inflammation Cervical collar Restricts motions that cause pain Patient comfort Cervical pillow at night can help can help maintain the neck in a neutral position and limit head positions that cause narrowing of the neural foramen Ice- help reduce muscle spasm and pain NSAIDS

Rehabilitation Early Phase Traction- Decreases pressure caused by axial loading Manuel traction Mechanical traction Positional traction Self administered, body positioning Disc Protrusion- Intermittent traction Force pulposus back in Impingement- Sustained traction Removes mechanical pressure on nerve root and allows for inflammation of nerve root to decrease Reducing adhesions within Dural sleeve by elongating the surrounding structure Restoring normal slack in the neuromeningeal structures

Rehabilitation Moderate Phase Goals: Restoring ROM Maintaining pain free symptoms Light strengthening Criteria for progression Pain and inflammation have been controlled

Rehabilitation Moderate Phase Continued Traction Stretching: Sustained stretching in all directions Flexion, extension, lateral bending, rotation Home stretching exercises Soft Tissue Mobilizations Spleni muscles, posterior cervical muscles, scalenes, upper trap, levator scapulae, SCM AROM exercises Go until pain then return to neutral All directions

Rehabilitation Moderate Phase Joint Mobilizations Cervical lateral glides in upper limb neurodynamics position Upper and Midthoracic spine manipulation in supine: “an association exists between mobility in the thoracic spine and neck/shoulder pain.” “thoracic manipulation can help increase cervical ROM” Central PA’s

Rehabilitation Moderate Phase Strengthening At this time rehab should focus on isometric strengthening only until full ROM is achieved Flexion Extension Lateral bending Rotation Deep flexor strengthening Scapular muscle strengthening Rhomboids: rows Serratus anterior: push up plus Middle and upper trap: fly’s

Rehabilitation Progressive Phase Goals: Maintain ROM Maintain pain free symptoms Cervical muscle strengthening Cervical Stabilization Nerve root strengthening Functional Activity Criteria for progression Pain free ROM Diminished inflammation

Rehabilitation Progressive Phase Strengthening: Isotonic cervical strengthening All directions: can be done using a cervical machine, pulley system, or Thera-band Involved nerve root strengthening Isotonic motions Can use either dumbbells, Thera-band, tubing, mechanically

Rehabilitation Progressive Phase Cervical stabilization All directions Hold for 30 sec 3 sets PNF Patterns Functional Activity

Return to Play Criteria Full pain-free ROM Full strength and stabilization No tingling or numbness with ROM Full cardiovascular endurance

Summary Cervical nerve root impingement can occur from a herniated disc or from narrowing of the neural foramen Patient may complain of neck pain and tingling or numbness radiating down the arm Progression is based on patient symptoms Pain management is important