Radiculopathy

• Radiculopathy:

  • neurological condition, dysfunction of a cervical spinal nerve and/or the nerve roots that can lead to pain, sensory deficits, motor deficits, reduced reflexes
  • can occur due to:
  • foraminal encroachment of spinal nerve due to degenerative changes (70 - 75%)
  • disc herniation (20 - 25%)
  • C5 to T1 are most commonly affected
  • pain may be nociceptive from local neck structure (e.g. zygapophyseal joints) as well as neuropathic from the affect nerve root

  
• Radiculopathy:

  • Manifestation:
  • objective neurological signs: loss of function in reflexes, power and sensation
  • it is not necessarily painful all the time
  • Mechanism:
  • compression and/or inflammation leads to demyelination and axonal damage, causing a decrease in impulse conduction along the nerve

  
• Radiculopathy - clinical presentation:

  • history:
  • common in 40 to 50 year olds
  • neck and arm pain (usually unilateral) with a combination of sensory/motor changes
  • white people
  • smokers
  • having a prior lumbar radiculopathy
  • heavy lifting, golf
  • not common to follow after trauma, so usually insidious onset

  
• Radiculopathy - clinical presentation:

  • subjective:
  • pain beyond the shoulder
  • arm pain is worse than neck pain
  • pins and needles, numbness
  • neck and arm pain is usually on the same side, commonly unilateral
  • symptoms may be in a dermal distribution, but pain doesn't always follow the pattern

  
• Radiculopathy - clinical presentation:

  • objective findings:
  • sensory loss, motor loss, or reflex changes in the affected nerve root distribution
  • positive neurodynamic assessment
  • people may walk in holding their arm up like in a sling to support it, arm may be held above their head
  • Babinski and Clonus (both are UMN tests) would be normal
  • myotomes and dermatome tests would be affected, so reduced power in the affected myotome and altered sensations of the affected dermatome

  
• Radiculopathy - clinical presentation:

  • objective findings:
  • e.g. a C7 radiculopathy: if the nerve root is tested, because radiculopathy is part of the peripheral nervous system and so is a LMN problem, there will be reduced reflexes in your C7, which is your triceps, only on the affected side, whereas UMN tests (Babinski and Clonus) would be normal. For myotomes, the C7 myotome, which is elbow extension, would be weaker on the affected side. When sensation is tested, the C7 dermatome would have altered sensation on the affected side

  
• Radiculopathy - clinical presentation:

  • radiculopathy refers to the change in conduction of nerves and neural integrity tests the conduction of nerves, so can be used to confirm a radiculopathy if the findings are abnormal
  • neural provocation tests moves the nerve to see if it hurts, and you would expected a nerve root with radiculopathy to hurt (on the arm) when put under tension, but this could hurt and further harm the pts due to the nerve already being demyelinated and inflamed
  • so a positive neural integrity would mean that there's not much need for a neural provocation test

  
• Radiculopathy - clinical presentation:

  • key impairments:
  • neural integrity test
  • neural provocation test
  • cervical ROM
• Radiculopathy - clinical presentation:

  • further testing is not usually needed to confirm radiculopathy as history, clinical presentation and objective findings are enough
  • but EMG's can differentiate between peripheral nerve entrapment and radiculopathy
  • MRI's can help find site of compression
• Radiculopathy - management:

  • 90% conservative management, 10% need surgery
  • advice and education (explain symptoms, don't scare pts, say crowded instead of trapped nerve, neuropathic night pain), distinction between radiculopathy and radicular pain, activity modification, pacing
  • symptoms control: analgesics
  • build capacity:
  • ROM - start pain free positions
  • manual therapy: lateral glides, neurodynamic glides (mobilise nerves, only done if SIN is low), strengthening flexors and extensors
  • return to function: functional ROM, strengthening in functional positions, return to pts goal
• Radiculopathy - Prognosis:

  • symptoms can be present for a year, so need to be realistic
  • but need to be positive and assure pts of a full recovery
  • if symptoms are worsening, especially neural integrity (e.g. reduction in power, sensations are worsening) then send pts to A&E - may need to get surgery
  • if pts symptoms are not getting better over time, send pts to A&E