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Cervical Radiculopathy

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Cervical Radiculopathy 342 REVIEW ARTICLE Cervical Radiculopathy Maury R. Ellenberg, MD, Joseph C. Honet, MD, Walter J. Treanor, MD ABSTRACT. Ellenberg M, Honet JC, Treanor WJ. Cervical radiculopathy. Arch Phys Med Rehabil 1994;75: 342-52. l The history, pathoanatomy and pathophysiology, clinical picture, differential diagnosis, diagnostic evaluation, and treatment of cervical radiculopathy are reviewed. The review is based on a lo-year Medline literature search, review of bibliographies in textbooks, and bibliographies in articles obtained through the search. Cervical radiculopathy, although recognized early in the 20th century, was first associated with disc pathology in the mid- 1930s. It is most commonly caused by disc herniation or cervical spondylosis. History and physical examination using pain location, manual muscle testing, and specialized testing (Spurling’s maneuver) will usually suffice to diagnose the radiculopathy and determine the root level involved. Diagnostic imaging such as magnetic resonance imaging, computed tomography, or myelography should be used as presurgical evaluative tools or when tumor or other etiology besides disc hemiation or spondylosis is suspected. Electromyography is of benefit in distinguish- ing various entities that clinically present similar to cervical radiculopathy and can also help to “date” the lesion. Treatment of this disorder has not been systematically studied in a controlled fashion. However, using a variety of different treatments, the radiculopathy usually improves without the need for surgery. Indications for surgery are unremitting pain despite a full trial of non-surgical management, progressive weakness, or new or progressive cervical myelopathy. Prospective studies evaluating the various treatment options would be of great benefit in guiding practitioners toward optimum cost-effective evaluation and care of the patient with cervical radiculopathy. 0 1994 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation Cervical radicular syndrome is a general term describing Medline search. Articles were selected based on historical, a set of symptoms. This symptom complex may arise from clinical, or research data they contained. several causes, including nerve root irritation, myofascial pain syndromes, and soft tissue injuries. This review will HISTORICAL PERSPECTIVE concentrate on cervical syndromes that are caused by radicu- Cervical radiculopathy or “radiculitis” particularly asso- lopathy. ciated with intervertebral disc rupture as a cause of “brachial Cervical radiculopathy is a pathologic process involving pain” was not distinguished from other causes of upper the nerve root, arising from cervical disc herniation, cervical extremity pain attributed to “neuritis,” ‘ ‘fibrositis,” and spondylosis, tumor (benign or malignant), or trauma causing “myalgia” in the early 20th century.’ As early as 1936, nerve root avulsion. Cervical radiculopathy may also occur however, there were descriptions of shoulder girdle, arm, and in a setting in which no definite cause can be determined. precordial pain attributed to “cervical arthritis” resulting in Historical, physical examination, and laboratory features “irritation or inflammation of the cervical spinal roots.“’ seen in cervical radiculopathy of any cause are addressed. Cervical disc hemiation resulting in cord compression and This review will also delineate the clinical, physical, and myelopathy was recognized as a syndrome in the early 20th laboratory features, highlight similarities, emphasize ways century, but was initially attributed to spinal cord tumors to distinguish the various etiologies, discuss differential di- termed ‘ ‘chondromas. ’ ‘3s4This syndrome of cord compres- agnosis, outline certain laboratory and testing procedures, sion was defined as a ruptured disc by Mixter and Aye? in particularly computed tomography (CT) scan, magnetic res- 1935, shortly after the report by Mixter and Barr in 1934’j onance imaging (MRI) and electrodiagnostic testing, and of disc herniation as the etiology of “sciatica” in the lumbar address treatment and prognosis. region. We review the clinical aspects of cervical radiculopathy It was not, however, until the early 1940s that Semmes and cite research performed, but this review does not repre- and Murphey’ and shortly thereafter Spurling and Scoville,8 sent a meta analysis of all research on this topic. Articles and Michelsen and Mixter’ directly related “cervical radicu- were obtained through a Medline search of the literature of litis,” in the absence of cervical myelopathy, to ruptured the past 10 years, a review of bibliographies in text books, cervical intervertebral discs. At that time, Spurling and Sco- and a review of bibliographies in the articles found in the ville also described the “neck compression test,” which has since become known as Spurling’s test. Subsequent articles From the Department of Rehabilitation Medicine, Sinai Hospital, Detroit, MI published at the end of that decade defined the relationship 482352899. between cervical radiculopathy, upper extremity pain, and Submitted for publication June 29, 1993. Accepted in revised form August 4, 1993. No commercial party having a direct financial interest in the results of the research protruded cervical intervertebral discs.‘0-12 supporting this article has or will confer a benefit upon the authors or upon any organization with which the authors are associated. ANATOMY Reprint requests to Maury R. Ellenberg, MD, Department of Rehabilitation Medi- cine, Sinai Hospital, 6767 West Outer Drive, Detroit, MI 48235-2899. There are seven cervical vertebra that articulate via the 0 1994 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation zygoapophyseal (facet) joints located at the posterior portion 0003-9993/94/7503-0100$3.00/0 of the vertebrae. The uncovertebral joints, or joints of Arch Phys Med Rehabil Vol75, March 1994 CERVICAL RADICULOPATHY, Ellenberg Luschka, are located on the lateral aspect of the vertebral The precise mechanism whereby disc herniation or spon- body and composed of the sharply defined bony margins dylosis causes radicular pain is still unclear. Experimentally, about the superior rim of each vertebra articulating with the referred pain can be generated from several structures in the facet of the vertebra above it. This area is often the site of cervical spine probably including the disc’-? (shown to have abnormal bony overgrowth that can compromise the verte- innervation to the outer third of the annulus), from the perios- bral canal or neural foramen. The eight cervical nerve roots teum, ligaments, fascia,23 or the nerve root.6.24 Direct pres- exit via intervertebral foramina, which are bordered ante- sure on the root, however, does not necessarily cause pain,” romedially by the vertebral disc, and posterolaterally by the and pure motor deficit may occur.26 Proposed mechanisms facet joints. The foramina are largest at C2-3 and progres- for pain in radiculopathy include increased discharge of dor- sively decrease in size to C6-7. The nerve root occupies sal root ganglia whose axons have undergone neurotmesis, about l-4 to l-3 of the space in the foramina, accompanied mechano-sensitivity or chemo-sensitivity of the nerve root by spinal radicular arteries and intervertebral veins.13 The itself, or direct pressure on chronically injured axons or nor- first cervical nerve root exits between the occiput and atlas mal dorsal root ganglia.25,27Causes of cervical radiculopathy (Cl vertebra) and all subsequent roots exist above their cor- other than disc herniation or cervical spondylosis include respondingly numbered cervical vertebrate except the C8 tumor,‘8 trauma,29 sarcoidosis,30 arteritis,“’ and athetoid and root, which exits below C7 and above Tl. Therefore, C5-6 dystonic cerebral palsy.32 disc herniation or foraminal narrowing will affect the C6 root, and a similar C6-7 lesion will affect the C7 root. Due CLINICAL PICTURE to differential growth of the vertebra and spinal cord, the The most commonly involved nerve roots in cervical lower cervical vertebra are at the same level as the next lower radiculopathy are the sixth and seventh cervical roots, which spinal segment. The C5-6 interspace is therefore opposite the are caused by C5-6 or C6-7 disc herniation, or spondylosis. C7 spinal level where the C7 nerve root arises and the C6 Which of these is the most commonly involved nerve seems root exits. The C7 root then descends from this level to exit to depend on the case series. 0dom,18 in a series of 246 between the C6 and C7 vertebrae. Myotomal and dermato- cases, found C7 root with C6-7 disc involvement in 70% of ma1 distributions of the cervical nerve roots are depicted in cases, the C6 root with C5-6 disc in 24% of cases, whereas table 1 (myotomes) and the figure (dermatomes). Lundsford,‘” in a series of 334 patients, found 48% C6 root PATHOANATOMY AND PATHOPHYSIOLOGY with C5-6 herniation, and 37% C7 root with C6-7 herniation. The nerve root is vulnerable to compression in the inter- The series of 846 patients by Henderson and colleagues33 vertebral foramen by three structures: the facet joint, the demonstrated some of the difficulty in determining the level uncovertebral joints, and the disc. The most common cause of the radiculopathy. Triceps weakness (C7) was present in of cervical radiculopathy is a herniated cervical disc,14 fol- 37% of the patients, and biceps (C6) weakness in 28%. Surgery
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