The examiner passively abducts the patient's shoulder to 90 degrees, flexes the elbow to 90 degrees, and positions the forearm in neutral. The examiner then applies a gentle, sustained posteroanterior glide to the wrist while maintaining the shoulder and elbow positions.
- A positive test reproduces symptoms in the median nerve distribution.
- This test is useful for evaluating cervical radiculopathy involving C6 nerve root as it innervates the median nerve. A positive test suggests nerve root compression.
- The test is considered positive if symptoms are reproduced or increased with the maneuver.
- It has a sensitivity of 80-90% and specificity of 70-80% for cervical radiculo
2. ANATOMY
Parts of a Typical Vertebra
• Vertebrae in different regions of the spinal column vary in size, shape,
and details.
• Vertebrae typically consist:
1. Body
2. Vertebral arch
3. Processes
4. Body
• Thick, Disc shape anterior portion
• Weight bearing part of the vertebrae.
• Superior & inferior surface are roughened – attachment of cartilaginous
intervertebral disc.
• Anterior and lateral surface contain nutrient foramina, opening for blood vessels
deliver nutrient and O2 and remove CO2 and wastes from bone tissues.
5. Vertebral Arch
• 2 short, thick processes called the pedicles, project posteriorly from the
vertebrae body to unite with the flat laminae, to form the vertebrae arch.
• Vertebral arch extend posteriorly from the body of the vertebra, together with
the body and vertebral arch surround the spinal cord by forming the vertebral
foramen.
• Vertebral foramen contain spinal cord, adipose tissue and areolar connective
tissue and blood vessels.
6. Vertebral Arch
• Collectively, the vertebral foramina of all vertebrae form the vertebral
(spinal) cavity.
• The pedicles exhibit superior and inferior indentation called vertebral
notches.
• Superior and inferior vertebral notch are stacked on top of ones another
to form intervertebral foramen.
• Intervertebral foramen permits the passage of single spinal nerve that
passes to a specific region of the body.
7.
8. Processes
• 7 processes arise from the vertebral arch.
• At the point where lamina and pedicle join, a transverse process extends
laterally on each side.
• A single spinous process projects posteriorly from the junction of the
laminae.
• These 3 processes serve as points of attachments for muscles.
9. Processes
• The remaining 4 processes forms joints with other vertebrae above and
below.
• 2 superior articular processes articulate with the 2 inferior articular
processes of vertebrae above them.
• The articulating surfaces of articular processes called facets.
• Articulation between the bodies and articular facets of successive
vertebrae are called intervertebral joint.
10. • Neural foramen
• Notches between adjacent
vertebrae.
• Allows for the passage of the
spinal nerve roots, spinal artery,
veins, nerve plexus, and
ligaments
Intervertebral Foramen
11. Intervertebral Discs
• Fibrocartilage.
• Lie between adjacent
vertebrae in the spine.
• Each disc forms a
cartilaginous joint to allow
slight movement of the
vertebrae
• Acts as a ligaments to hold
the vertebrae together.
12. Hermizan Halihanafiah
Intervertebral Disc
• Absorb shock
• Discs consist of an outer annulus fibrosus, which surrounds the
inner nucleus pulposus.
• As people age progresses, the nucleus pulposus begins to
dehydrate, which limits its ability to absorb shock. The annulus
fibrosus gets weaker with age and begins to tear.
13. Cervical Vertebrae
▪ Seven vertebrae (C1-C7) are the smallest, lightest vertebrae
▪ C1, C2 and C7 are atypical
▪ C3-C6 are typical
▪ Oval body & wider side to side
▪ short spinous processes and is bifid
▪ vertebral foramina is large and triangular
▪ Each transverse process contains a transverse foramen through which the vertebral
arteries pass to the brain
▪ C7 spinous process is larger and not bifid
▪ C7 vertebra prominence (can be seen through the skin) is the landmark for counting.
15. Cervical Vertebrae: The Atlas (C1)
▪ No intervertebral disc between C1 &C2
▪ The atlas has no body and no spinous process
▪ It consists of anterior and posterior arches, and two lateral masses.
▪ Each lateral mass has articular facets on both its superior and inferior surfaces
▪ The superior surfaces of lateral masses articulate with the occipital condyles of occipital
bone to form atlanto – occipital joint.
▪ These articulation permits the movement for “YES”.
▪ The inferior surfaces articulate with the Axis (C2) to form atlanto-axial joint
▪ These articulation permits the movement for “NO”.
17. Cervical Vertebrae: The Axis (C2)
▪ The axis has a body, spine, and vertebral arches as do
other cervical vertebrae
▪ Unique to the axis is the dens, or odontoid process,
which projects superiorly from the body and is cradled
in the anterior arch of the atlas
▪ The dens fuses with axis during embryonic
development
▪ The dens is a pivot for the rotation of the atlas
21. Cervical Nerve Roots
• Eight pairs of cervical nerve roots are formed directly from multiple tiny rootlets that
originate directly from the spinal cord.
• These tiny rootlets coalesce immediately within the intraspinal canal and form the
dorsal (sensory) and the ventral (motor) roots.
• These join together just before passing through the intervertebral foramen and form
the spinal nerve root.
• On exiting the foramen, the nerve root splits into the small posterior ramus and the
larger anterior ramus.
• In contrast to the roots, there are only seven cervical vertebra whereas the eight
root exits below the seventh cervical vertebra and above the first thoracic vertebra.
22. Cervical Nerve Roots
• The neuroforamen are bordered anteromedially by the uncovertebral joint,
posterolaterally by the facet joint, superiorly by the pedicle of the vertebral body
immediately above, and inferiorly by the pedicle of the vertebral body immediately
below.
• The medial section of the foramen is derived from the intervertebral discs and the
vertebral endplates.
• The roots originate in close proximity to the level at which they exit the intraspinal
canal.
• The cervical roots generally pass through the canal and in a somewhat more
horizontal fashion.
• This arrangement causes the neuroforamen to originate more medially and the
cervical root and the cervical spinal cord to be in close proximity, thereby susceptible
to abnormalities of these medial structures such as osteophytes or disc herniations,
leading to the symptoms of cervical radiculopathy.
24. Cervical radiculopathy
• Cervical radiculopathy is the term that describes compression of a
cervical nerve root which results in pain and/or sensorimotor deficit
in the upper extremity. It can be caused by disc herniation,
spondylosis, instability, trauma and rarely, tumors.
• The C7 (60%) and C6 (25%) cervical nerve roots are the most
commonly affected.
29. PATHOPHYSIOLOGY
• Beginning in the third decade of life, a progressive decline in the water content of the
intervertebral disc occurs and continues with age. The nucleus pulposus becomes an
indistinct fibrocartilaginous mass.
• In patients younger than 30 years, the water content of the intervertebral disc
approaches 90%, and it decreases to less than 70% by the eighth decade of life.
• The basic structural unit of the nucleus pulposus is glycosaminoglycan protein, which
consists of a proteoglycan protein core and bulky, sterically active polysaccharide
attachments of chondroitin sulfate and keratin sulfate.
• Because of their high molecular weight and overall negative charge, glycosaminoglycan
proteins have a strong attraction for water molecules.
30. PATHOPHYSIOLOGY
• With aging, these large, sterically active glycosaminoglycan proteins gradually diminish in
size and number.
• As a result, the intervertebral disc’s ability to retain water also diminishes. These age-
related changes in the chemical composition of the nucleus pulposus and annulus fibrosus
cause the degenerated disc to become more compressible and less elastic.
• Consequently, the disc loses height and bulges dorsally into the spinal canal. As the
vertebral bodies drift toward one another, the ligamentum flavum and facet joint capsule
fold in dorsally, causing a further decrease in the canal and foraminal dimensions.
• This approximation of adjacent vertebral bodies leads to a reactive process that produces
osteophytes around the disc margins and at the uncovertebral and facet joints.
31. PATHOPHYSIOLOGY
• Compressive radiculopathies occur as a result of mechanical distortion of the nerve
root by either the hypertrophied facet joint or uncovertebral joints, disc protrusion,
spondylotic spurring of the vertebral body, or a combination of these factors.
• Pressure on the nerve root may lead to sensory deficits, motor weakness, or radicular
pain.
• When a nerve is compressed changes occur in and around the nerve which
include: an inflammatory response, changes in vascular flow, and intra-neural edema.
A combination of these three events are thought to result in the development of
radicular pain.
32. Clinical Presentation
• Radiculopathy can be divided into acute, subacute, and chronic.
• Acute cervical radiculopathy occurs in relatively young patients in the setting of a
tear in the annulus fibrosus and subsequent prolapse of the nucleus pulposus.
• Subacute radiculopathy occurs in patients with pre-existing cervical spondylosis,
without persistent symptoms except for occasional neck pain. Patients develop
insidious symptoms, which are often polyradicular in nature.
• Chronic radiculopathies materialize from acute or subacute radiculopathies that
have failed to respond to treatment.
33. • Pain is most prominent in acute cervical radiculopathy and diminishes as the
condition becomes more chronic.
• It may be described as sharp, achy, or burning and may be located in the neck,
shoulder, arm, or chest, depending on the nerve root involved.
• Classically, an acute radiculopathy presents with pain radiating in a myotomal
distribution.
• Sensory symptoms, predominantly parasthesias and numbness, are more common
than motor loss and diminished reflexes.
35. Physical Exam
C3 Radiculopathy
• Between the C2 and C3 vertebrae and not common.
• Pain in the suboccipital region, often extending to
the back of the ear, and in the dorsal or lateral
aspect of the neck.
• Distinguish from Headache
• Numbness may be present along the occiput and in
the distribution of the great auricular and lesser
occipital nerves.
• Supplies, in part, the suboccipital muscles, the
trapezius, the levator scapulae, the
sternocleidomastoid, and the strap muscles, an
isolated motor deficit generally cannot be detected
clinically.
36. Physical Exam
C4 Radiculopathy
• C3-C4 level
• Unexplained pain along the base of the neck
that radiates to the superior aspect of the
shoulder and posteriorly to the scapula
• The rhomboid, trapezius, and levator
scapulae muscles are supplied, in part, by the
fourth nerve root, but a motor deficit may be
hard to detect.
• Sensory loss along anterolateral aspect of the
neck, along the distribution of the transverse
cervical and supraclavicular nerves
37. Physical Exam
C5 Radiculopathy
• C4-C5 level
• 3rd most common
• Present with numbness and localized shoulder
pain that can be confused with a pathological
shoulder condition.
• Radicular pain is not significantly affected by
motion of the shoulder
• Sensory distribution, which is located over the
top of the shoulder along its midportion, and
extends laterally to the midportion of the arm.
• Supraspinatus and deltoid muscle weakness
with impaired shoulder abduction.
• Biceps reflex
38. Physical Exam
C6 Radiculopathy
• C5-C6 level, 2nd most common
• Common cause Disc herniations or spondylosis at
the C5–C6 level
• Pain and/or numbness radiating from the neck to
the lateral aspect of the biceps, the lateral aspect
of the forearm, the dorsum of the hand at the
web space between the thumb and index finger,
and into the tips of those digits.
• Motor deficits in the wrist extensors and biceps
• Brachioradialis reflex and biceps reflexes may be
decreased or absent.
• May mimic carpal tunnel syndrome, which is
caused by median nerve entrapment
39. Physical Exam
C7 Radiculopathy
• C6-C7 level, most common
• Pain and/or numbness radiating across the
back of the shoulder, over the triceps, the
dorsolateral aspect of the forearm, and over
the dorsum of the long finger
• Weak triceps, wrist flexion, finger extension
• Triceps reflex decreased or absent
• Confused with entrapment of the posterior
interosseous nerve, does not cause sensory
changes, and the triceps and wrist flexors are
not affected
40. Physical Exam
C8 Radiculopathy
• C7-T1 level, Infrequent
• The medial aspect of the arm and forearm
and into the medial hand and the last two
digits.
• Numbness usually involves both the dorsal
and volar aspects of the digits and hand
and may extend proximal to the wrist over
the medial aspect of the forearm
• Weak grip
• Mimic ulnar entrapment at the elbow.
41. Physical Exam
T1 Radiculopathy
• T1-T2 level, Very uncommon
• Weak hand intrinsic muscles
• Axillary numbness is common, and
Horner’s syndrome can occur
ipsilaterally
42.
43. Physical Exam
Provocative Tests
• Reduced cervical rotation <60 degrees to the affected side.
• Reduction of symptoms with shoulder abduction
• Reduction of symptoms with cervical distraction
• Provocation of symptoms with the Spurling test
• Provocation of symptoms with the median nerve biased neurodynamic test which
is done by performing Upper Limb Neural Tension Test (ULNTT).
• Provocation of symptoms with the Valsalva maneuver – less commonly included.
• L’hermitte’s Sign – less commonly included
• Spurling test, distraction test, ipsilateral rotation <60 degrees and ULNTT have a
99% specificity when all four items are positive and 94% specificity when 3 items
are positive (Waldrop, 2006)
44.
45. Physical Exam
Spurling Test/Foraminal compression test/
Neck compression test/ Quadrant test
• Extending the neck
• Rotating head
• Downward pressure on head
• Positive finding eliciting reproduction of
radicular pain into ipsilateral arm of head
rotation
• 92% sensitive, 95% specific
• Low sensitivity but high specificity- not
useful as a screening tool, but it does help
confirm the diagnosis
46. Physical Exam
Cervical Distraction
• Supine patient
• Gentle manual axial distraction
• Up to 14kg
• Positive response by reduction in
neck and limb symptoms
47. Physical Exam
Upper Limb Neural Tension Test (ULNTT)
• The patient is positioned in supine. During the ULNTT that places a bias
towards testing the patient’s response to tension placed on the median
nerve
• Scapular depression
• Shoulder abduction to approximately 90 degrees with the elbow flexed
• Shoulder external rotation
• Forearm supination, wrist and finger extension
• Elbow extension
• Contralateral then ipsilateral cervical side-bending
• A positive test is indicated by
• Reproduction of all or part of the patient’s symptoms
• On the symptomatic side, contralateral cervical side-bending increases
the patient’s symptoms, or ipsilateral side-bending decreases the
patient’s symptoms
48. Physical Exam
Valsalva Test
• The patient is seated and instructed to
take a deep breath and hold it while
attempting to exhale for 2 – 3 seconds.
• Increased intrathecal pressure revealing
presence of a space occupying mass
such as and extruded intervertebral disc,
or narrowing due to osteophytes
• Symptoms reproduced
49. Physical Exam
Shoulder abduction test/ Shoulder abduction relief sign/Bakody’s sign
• Active/passive abduction of ipsilateral
shoulder
• Relief of radicular symptoms
• takes stretch off of the affected nerve root
and may decrease or relieve radicular
symptoms
50. • Flexion of neck producing
electric shock like sensations
that extend down the spine
and shoot into the limbs
• Usefulness is limited
• Indicates spinal canal stenosis,
disc impingement, multiple
sclerosis, or tumor
Physical Exam
Lhermitte sign/ Barber chair phenomenon
51. Others
• NAFFZIGER'S TEST(for nerve root
compression)
• Manual compression of the jugular veins
bilaterally
• An increase or aggravation of pain or
sensory disturbance over the distribution of
the involved nerve root confirms the
presence of an extruded intervertebral disk
or other mass
52. Hoffman sign
• Indicates myelopathy
• Elicited by flipping either the volar or
dorsal surfaces of the middle finger and
observing the reflex contration of the
thumb and index finger
• UMN sign indicating pyramidal tract
involvement
54. Plain radiography
Role somewhat limited in evaluation of
nerve roots
Initial study to rule out instability,
congenital abnormalities, fractures,
deformity or pathologic changes in bone
Oblique views can show narrowing of
the neuroforamina secondary to
degenerative changes
INVESTIGATIONS
55. MRI
MRI has become the method of choice for imaging the neck to detect
significant soft-tissue pathology, such as disc herniation and spinal stenosis is
due to the intrinsic contrast and good spatial resolution
The American College of Radiology recommends routine MRI as the most
appropriate imaging study in patients with chronic neck pain who have
neurologic signs or symptoms but normal radiographs
Sagittal T1 - Hypointense signal is common for herniated degenerative disks,
calcified ligaments, and bone spurs, making differentiation of these structures
more difficult
Axial T1 - Insight into both intraspinal and extraspinal disorders, as well as the
intrathecal nerve root anatomy
T2-weighted sequence or variants - “myelo-graphic” view
56. T1- Weighted image T2- Weighted image
CSF is Dark CSF is Bright
Mid Sagittal View is the Optimal view to visualize the spinal cord, CSF and Vertebral
Bones. But it may not be optimal view the disk herniation as most are posterolateral as
opposed to straight posterior.
60. Cervical myelogram
• Outlines Spinal Cord and exiting nerve roots with
radiopaque dye
• Water-soluble agent may be injected via the C1-2
interval, allowing the dye pool to gravitate caudally
• Accuracy has been estimated 67% to 92%. For this
reason, cervical myelography is often accompanied
by CT
• Excellent visualization of nerves in relation to
surrounding osseous structures
• Because the diagnosis of neural compression is
inferred only indirectly, the exact nature of the
compression is not always clear. For example,
with myelography alone, it can be difficult to
distinguish between a “hard disc” with bony
osteophytes and a “soft disc” herniation
61. Computed Tomography
• CT allows for the direct
visualization of pathology
causing compression of neural
structures
• CT also has a high spatial
resolution and is especially
helpful in visualizing the
foraminal region.
• Distinguish neural compression
caused by soft tissue from
compression related to bony
structures
62. Electrodiagnosis plays a critical role
• Referred to as an extension of neurologic examination, as it is able to
provide physiologic evidence of nerve dysfunction
1. EMG
2. Motor and sensory nerve conduction studies
63. ELECTROMYOGRAPHY (EMG)
• Localize lesions to a particular root level
• The goal -- find a pattern of spontaneous and/or chronic motor unit changes in a clear
myotomal pattern
• The needle electrode portion of the EMG is performed by analyzing multiple muscles
within the same myotome and in adjacent myotomes.
• The presence of fibrillation potentials and positive sharp waves at rest is indicative of
denervation, but these changes may not occur until 3 weeks after the onset of neural
injury.
• Limitations –can only detect change in the motor nervous system
• Todiagnose radiculopathy electrodiagnostically, needle study of 2 muscles that receive
innervation from the same nerve root, preferably via different peripheral nerves, should be
abnormal.
• Adjacent nerve roots should be unaffected unless a multilevel radiculopathy is present
64. NERVE CONDUCTION STUDIES
• Nerve conduction studies are performed to exclude peripheral nerve pathology.
• The amplitude, distal latency, and conduction velocity can be measured.
• The amplitude corresponds to the number of intact axons.
• The distal latency and conduction velocity reflect the degree of myelination.
• The primary role -- determine if other neurologic processes exist as an explanation for a
patient’s clinical picture, or if another process coexists with a root level problem
• In pure radiculopathy, the sensory nerve studies should be normal.
• Pathologic lesion in radiculopathy typically occurs proximal to the dorsal root ganglion
(DRG). Since the DRG houses the cell bodies for the sensory nerves, the sensory nerve
studies should be normal.
• Common nerve entrapments such as median neuropathy at the wrist or ulnar neuropathy at
the elbow
68. Immobilization
Soft Collar
• The aim is to reduce pressure on the nerve root
and improve the pathophysiology resulting from
compression i.e. the health of the nerve
• Some advocate short course (one week) of neck
immobilization may reduce symptoms in the
inflammatory phase
• Cervical collar has not been proven to alter the
course or intensity of the disease process
• Adverse effects - especially when used for longer
periods of time. It is feared that a long period of
immobilization, can result in atrophy-related
secondary damage
69. PATIENT EDUCATION
• Minimal driving as it will continue aggravating their neck from turning
too far into painful range.
• Educate about typical aggravating and easing factors as well as
appropriate positions for rest and sleeping.
• Follow the guidelines given by doctor for each medication and not to
stray from the dosage.
70. Traction
• Distracts neural foramen and decompresses nerve root
• Typically, 8 to 12 lb of traction at approximately 24 degrees of flexion for 15- to
20-minute intervals
• Most beneficial when acute muscular pain has subsided
• Not be used in patients who have signs of myelopathy!
• “Some studies have shown mechanical traction to be effective within the first 6
weeks of injury” (Caridi, Pumberger & Hughes., 2011, p. 268).
• “Five studies have looked at traction as a treatment for radiculopathy. Traction
was temporarily efficacious in relieving patient’s symptoms; however, none of
the studies included standardized outcome measures” (Caridi, Pumberger &
Hughes., 2011, p. 268).
72. SPINAL MANIPULATIVE THERAPY &
MOBILIZATION
Descrbed as external force applied to the patient by the hand, an
instrumental device resulting in movement and/or separation of the
joint articular surfaces with high or low velocity of joint movement
Evidence low in quality
73. Pharmacological management
NSAIDs - effects on pain and inflammation
In general, 10-14 days of regular dosing is all that is needed to
control pain and inflammation
MUSCLE RELAXANTS Cyclobenzaprine and Chlorzoxazone
Oral steroids - reduce the associated inflammation from
compression
No controlled study exists
Longer-term use is not recommended
Tricyclic antidepressants - adjunct in controlling radicular pain
Opioid medications - generally not necessary for pain relief, but can
be used when other medications fail to provide adequate relief
74. The Neuropathic Pain Special Interest Group. (NeuPSIG) Pharma
Recommendations
Finnerup et al 2015
75. Epidural Steroid injection
Principle- steroid decreases pain and
inflammation at the site, decreases PG
Indication –
◦ Radicular pain unresponsive to non-
interventional care for 1-2 months
◦ Patients without progressive neurological
deficit or cervical myelopathy can be
considered before sx
Complications
◦ Dural puncture, vasovagal reaction, facial
flushing, fever, nerve root injury,
pneumocephalus, epidural hematoma,
subdural hematoma, stiff neck, transient
paresthesias, hypotension, respiratory
insufficiency, transient blindness and
76. Surgery
Disabling motor weakness of 6 weeks duration or less (i.e., deltoid palsy, wrist drop)
Progressive neurologic deficit
Static neurologic deficit + radicular or referred pain
Instability or deformity of functional spinal unit + radicular
symptoms
Surgical Management of Cervical Radiculopathy, Todd J. Albert, MD, and Samuel E. Murrell, MD, J Am Acad Orthop Surg 1999;7:368-376
RED FLAGS!!!
Persistent or recurrent radicular symptoms unresponsive to non-operative
management for at least 6 weeks
77. Posterior lamino-foraminotomy (with or
without diskectomy)
◦ Burr thins lamina over nerve root
◦ Nerve root exposed
◦ Angled curette can remove
additional bone & expand
foraminotomy
◦ Disk material can be exposed &
removed
78. Anterior cervical diskectomy and fusion (ACDF)
• Most widely used
• Removes ventral compressive
lesion WITHOUT need for
retraction of SC
• Disc removed and iliac crest
bone autograft placed to
ENCOURAGE FUSION
• Nowadays, allografts (no donor site
morbidity)
• In 1990s, cervical plates were
added to INCREASE stability and
decrease post op bracing
79. Anterior cervical diskectomy without fusion
• Because of high incidence
of pseudarthrosis after
ACDF
• Reported outcomes comparable
• Disk-space collapse and osseous fusion
• There is stress on removal of PLL
(buckling of ligament as disk space
collapses produces compression of the
neural elements) but removes another
stabilizing structure
Post anterior cervical diskectomy without fusion Lateral cervical radiograph shows
increase in kyphosis. T2-weighted MRI - stenosis, ligamentum and disk bulging,
spondylosis, and cord compression
