1. Cervico-brachial neuralgia Iraj Salehi-Abari MD
Cervico-brachial neuralgia Iraj Salehi-Abari MD., Internist Rheumatologist

2. 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

3. 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%

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

7. 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

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

9. 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

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

11. 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

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

14. 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

15. 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

17. Cervical Radiculopathy:

18. Cervical Radiculopathy:

19. A A

22. 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

24. 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)

26. 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

28. 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

30. 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

31. 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

32. 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

33. 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

34. 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

35. 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

36. Clinical features:
Chronic Cervical Myelopathy:

37. Clinical features:
Chronic Cervical Myelopathy:

38. 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

39. 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

40. 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)

41. 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

42. 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

43. The Hoffmann Test or Reflex:

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

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

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

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

48. 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

49. 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

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

52. 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

55. 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

56. 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

57. 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

58. 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