[ resident’s case problem ]

David G. Greathouse, PT, PhD, ECS, FAPTA1 • Anand Joshi, MD2

Radiculopathy of the
Eighth Cervical Nerve

R
adiculopathy involving the cervical nerve roots may be caused rami.8,9 Just prior to reaching the trans-
by spondylosis (degenerative joint disease or degenerative verse process, the C8 posterior primary
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rami divides into 2 terminal branches

disc disease), with or without osteophytes, herniated nucleus
(medial and lateral) and innervates the
pulposis, a space occupying lesion (tumor or infection), or erector spinae and transversospinalis
traumatic avulsion (Erb-Duchenne C5-C6 or Klumpke palsy C8-T1).4,6 paravertebral muscles, provides cutane-
The most frequently involved cervical nerve root is C7 (31%-81%), ous innervation of the skin over and lat-
followed by C6 (19%-25%), C5 (2%-14%), and C8 (4%-12%).4,6-7 Usually eral to the vertebra, and innervates the
Copyright © 2010 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

the site of the lesion is proximal to the posterior root ganglion, formerly
named dorsal root ganglion, and, thus,
sensory nerve conduction studies (NCSs)
will be normal.4,6 A postganglionic lesion
of the nerve root may produce abnormal-
ities in the sensory NCSs.4,6
t STUDY DESIGN: Resident’s case problem.
Journal of Orthopaedic & Sports Physical Therapy®
Following the formation of the spinal
nerve containing both motor and sen-
sory components, the spinal nerve im-
mediately branches into the posterior
(dorsal) and anterior (ventral) primary
C7-T1 laminectomy, mesial facetectomy, and forami-
zygoapophyseal (facet) joint.8,9 The an-
terior primary rami of the C8 nerve root
joins with the anterior primary rami of T1
to form the inferior (lower) trunk of the
brachial plexus. The lower trunk then bi-
furcates to contribute to the anterior and
posterior divisions of the brachial plexus.
The posterior division contributes to the
posterior cord of the brachial plexus. The

t BACKGROUND: The C8 nerve root is the least

commonly encountered of cervical radiculopathies.
The purpose of this resident’s case problem is to
provide an unusual presentation of a C8 radicu-
lopathy, without cervical or proximal upper quarter
symptoms, diagnosed by a combination of physical
examination, electromyography (EMG) and nerve
conduction studies (NCSs), and imaging.
t DIAGNOSIS: A 49-year-old, right-hand–dominant
male was referred to the EMG/NCS laboratory for a
suspected left ulnar neuropathy at the elbow. A physi-
cal examination, NCS, and EMG were performed, and
a C8 radiculopathy involving both the anterior and
posterior primary rami was identified. Following the
EMG and NCS evaluation, the patient had enhanced
magnetic resonance imaging studies that confirmed
a foraminal C7-T1 herniation and associated small
central disc protrusion. The patient was then referred
to neurosurgery for further consultation and subse-
quent surgical intervention. The patient underwent a
notomy, and excision of a herniated disk using an
operating microscope. The neurosurgeon noted that
there was a large disk herniation containing some
disk material immediately anterior to the C8 motor
root, that impinged directly on the motor root. One
month postoperatively, the patient had decreased
pain and numbness and tingling in his arm and his
hand weakness had improved.
t DISCUSSION: The report illustrates the utility
of a combination of physical examination, EMG
and NCSs, and imaging in the diagnosis of a C8
radiculopathy in a patient presenting with forearm
and hand symptoms but without cervical or upper
quarter symptoms.
t LEVEL OF EVIDENCE: Diagnosis, level 4.
J Orthop Sports Phys Ther 2010;40(12):811-817.
doi:10.2519/jospt.2010.3187
t KEY WORDS: electromyography, magnetic
resonance imaging, neck nerve conduction stud-
ies, ulnar nerve
anterior division continues as the medial
cord of the brachial plexus.8,9 The medial
cord of the brachial plexus terminates in
the ulnar nerve, and nerve branches of
the medial cord include the medial pecto-
ral nerve, medial cutaneous nerve of the
arm, medial cutaneous nerve of the fore-
arm, and the medial root contribution to
the median nerve.8,9
Patients with a C8 radiculopathy typi-
cally present with pain radiating into dig-
its 4 and 5, with paresthesia (numbness/
tingling) in the palmar and dorsal sur-
face of both digits, and may present with
lower cervical pain that may radiate into
the medial arm and forearm.4,6 Patients
with a suspected C8 radiculopathy may
have weakness involving the long finger
extensors and flexors, including the flexor

1
 Director, Clinical Electrophysiology Services, Texas Physical Therapy Specialists, New Braunfels, TX; Adjunct Professor, US Army-Baylor University Doctoral Program in Physical
Therapy, Fort Sam Houston, TX. 2 Spine Specialist, Spine Diagnostic and Treatment Center, Austin, TX. The opinions or assertions contained herein are the private views
of the authors and are not to be construed as official or reflecting the views of the Department of the Army or the Department of Defense. The authors have no financial
affiliation (including research funding) or involvement with any commercial organization that has a direct financial interest in any matter included in this manuscript. Address
correspondence to Dr David G. Greathouse, 3211 Crystal Path, San Antonio, TX, 78259. E-mail: greathoused1@yahoo.com

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pollicis longus, flexor digitorum profun-
dus, and extensor pollicis longus, thenar/
hypothenar muscles, and, to a lesser ex-
TABLE 1
[ resident’s case problem ]
tent, the intrinsic hand muscles.4,6,8 (EMG) should be performed to confirm
In patients with suspected C8 radicu- or exclude the diagnosis, as well as other
lopathy, NCSs and electromyography cervical radiculopathies, ulnar nerve
Electromyography and Nerve Conduction Studies Findings for
Ulnar Neuropathy at the Wrist or Elbow, Medial Cord Plexopathy,
Inferior Trunk Plexopathy, or C8 Radiculopathy

Abnormal Findings Normal Findings*

Ulnar nerve, wrist • Prolonged ulnar nerve digit 5 and palmar distal sensory latencies †
(Guyon’s canal) • Prolonged ulnar nerve distal motor latency†
• Decreased amplitude digit 5 and palmar sensory nerve action
potentials and distal motor latency compound motor action potential‡
• EMG findings: abnormal spontaneous electrical activity and denerva-
Downloaded from www.jospt.org at on September 17, 2020. For personal use only. No other uses without permission.
• Normal ulnar nerve motor nerve conduction velocities below elbow to wrist, and
above elbow to below elbow
• Normal dorsal ulnar cutaneous nerve distal sensory latency
• EMG findings: normal abductor pollicis brevis, flexor pollicis longus, extensor pollicis
longus, flexor carpi ulnaris, flexor digitorum profundus of digits 4 and 5

tion, first dorsal interosseous, abductor digiti minimi‡

Ulnar nerve, elbow • Prolonged ulnar nerve motor nerve conduction velocity of above
(cubital tunnel) elbow to below elbow†
• Prolonged ulnar nerve sensory nerve conduction velocity above elbow
to below elbow†
• EMG findings: as for ulnar neuropathy at the wrist, plus flexor carpi
u
lnaris§ and flexor digitorum profundus of digits 4 and 5‡
Medial cord, brachial • EMG findings: as for ulnar neuropathy at the elbow plus abductor
Copyright © 2010 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
• Normal ulnar nerve distal sensory latency and distal motor latency||
• Normal ulnar nerve motor nerve conduction velocities of below elbow to wrist|| and
axilla to above elbow
• Normal medial cutaneous nerve of the forearm distal sensory latency
• EMG findings: normal abductor pollicis brevis, flexor pollicis longus, extensor pollicis
longus
• EMG findings: normal extensor pollicis longus, extensor indicis, extensor digitorum,

plexus pollicis brevis, flexor pollicis longus, flexor digitorum profundus of
digits 2 and 3, pectoralis major (sternocostal fibers)‡
• Decreased sensory nerve action potential amplitude and/or
prolonged latency ulnar nerve distal sensory latencies and distal
motor latency, dorsal ulnar cutaneous nerve distal sensory latency,
medial cutaneous nerve of the forearm distal sensory latency‡
• Slowed ulnar nerve motor nerve conduction velocity supraclavicular
to axilla†
Inferior (lower) trunk, • EMG findings: as for medial cord plexopathy plus extensor pollicis
brachial plexus longus and extensor indicis‡
• Decreased sensory nerve action potential amplitude and/or
prolonged latency ulnar nerve distal sensory latencies and distal
Journal of Orthopaedic & Sports Physical Therapy®
extensor carpi radialis, flexor carpi radialis, biceps brachii, triceps brachii, deltoid,
cervical paravertebral muscles
• Normal ulnar nerve distal motor latency and motor nerve conduction velocities of
below elbow to wrist and above elbow to below elbow¶
• Normal lateral cutaneous nerve of the forearm distal sensory latency
• EMG findings: normal extensor digitorum, extensor carpi radialis, flexor carpi radialis,
biceps brachii, triceps brachii, deltoid, cervical paravertebral muscles
• Normal ulnar nerve distal motor latency and motor nerve conduction velocities of
below elbow to wrist and above elbow to below elbow¶

motor latency, dorsal ulnar cutaneous nerve distal sensory latency, • Normal lateral cutaneous nerve of the forearm distal sensory latency
medial cutaneous nerve of the forearm distal sensory latency‡
C8 radiculopathy • EMG findings: as for inferior trunk plexopathy plus low cervical (spinal • Normal ulnar nerve distal sensory latency, distal motor latency, and motor nerve
(preganglionic) level C6-C7-T1) paravertebral muscles‡ conduction velocity of below elbow to wrist and above elbow to below elbow
• Normal medial cutaneous nerve of the forearm, lateral cutaneous nerve of the
forearm, and dorsal ulnar cutaneous nerve distal sensory latencies and sensory
nerve action potential amplitudes
• EMG findings: normal screen for C5-C7 upper extremity musculature
Abbreviation: EMG, electromyography (needle).
* Including normal sensory and motor nerve conduction and electromyography studies of the median and radial nerves, and electromyography screen of C5-C7
musculature in the upper extremity.
†
Demyelinating (myelinopathy) neuropathic process.
‡
Axon loss (axonopathy) neuropathic process.
§
An ulnar nerve axonopathy at the elbow (cubital tunnel) may occur proximal to the innervation of the flexor carpi ulnaris, thus the flexor carpi ulnaris
would be normal on EMG. Ulnar nerve lesions proximal to the innervation of the flexor carpi ulnaris may demonstrate abnormal spontaneous electrical activ-
ity and denervation in the flexor carpi ulnaris.4,6
||
A myelinopathy of the ulnar nerve at the elbow would have normal motor and sensory conduction of the below elbow to wrist forearm segment of the ulnar
nerve, as well as normal ulnar nerve distal motor and sensory latencies, sensory nerve action potentials, and compound motor action potentials. However, an
axonopathy of the ulnar nerve at the elbow may cause a slowed motor nerve conduction velocity and sensory nerve conduction velocity of the below elbow to
wrist forearm segment of the ulnar nerve and prolonged distal motor and sensory latencies of the ulnar nerve at the wrist. These changes distal to the lesion of
the ulnar nerve at the elbow may be due to the loss of large-diameter motor and sensory fibers. An axonopathy of the ulnar nerve at the elbow may also cause
decreased or absent sensory nerve action potential and compound motor action potential amplitudes of the ulnar nerve at the wrists.4,6
¶
A myelinopathy of the medial cord or inferior trunk would have normal motor and sensory conduction of the below elbow to wrist forearm segment and the
above elbow to below elbow segment of the ulnar nerve, as well as normal ulnar nerve distal motor and sensory latencies, sensory nerve action potentials, and
compound motor action potentials. However, an axonopathy of the medial cord or inferior trunk may cause a slowed motor nerve conduction velocity and
sensory nerve conduction velocity of the below elbow to wrist forearm and the above elbow to below elbow segments of the ulnar nerve, and prolonged distal
motor and sensory latencies of the ulnar nerve at the wrist. These changes distal to the lesion of the medial cord or inferior trunk may be due to the loss of large-
diameter motor and sensory fibers. An axonopathy of the medial cord or inferior trunk may also cause decreased or absent sensory nerve action potential and
compound motor action potential amplitudes of the ulnar nerve at the wrists and elbow, as well as the dorsal ulnar cutaneous nerve and medial cutaneous
nerve of the forearm.4,6

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 mononeuropathies (wrist or cubital tun-
nel), medial cord plexopathy, or inferior
trunk plexopathy.4,6 An optimal EMG
scan for cervical radiculopathy must in-
clude needle examination of the cervical
paravertebral muscles.2-4,6 For identifying
cervical radiculopathy, an optimal (96%-
to 100%-identified radiculopathy) EMG
scan should include 7 muscles sampled
(6 upper extremity and paravertebral
muscles).3 Imaging studies, including
magnetic resonance imaging (MRI) of
the cervical spine and brachial plexus,
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radiographs, computer tomography
(CT) scans, and myelograms, may also
be useful to confirm the findings of a
physical examination and NCS and EMG
testing.4,6,10
Numbness and tingling of digits 4 and
Copyright © 2010 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
5 and weakness of the hand may also be
seen in other neuropathic conditions. In
addition to a physical examination, NCSs
and EMG may assist in determining the
cause of the patient’s hand paresthesia
and weakness. The ulnar nerve may be
compromised at the wrist (Guyon’s ca-
nal) or at the elbow (cubital tunnel).4,6,8
For identifying an ulnar mononeuropa-
Journal of Orthopaedic & Sports Physical Therapy®
thy at the wrist, NCS testing of the pal-
mar and digit 5 distal sensory latencies
of the ulnar nerve, distal sensory latency
of the dorsal ulnar cutaneous nerve, and
EMG testing of the first dorsal interosse-
ous and abductor digiti minimi, as well
as other C8-T1 innervated muscles, is
performed.4,6
Ulnar mononeuropathy at the elbow
(cubital tunnel) may be localized by mo-
tor and sensory NCS testing of the ulnar
nerve as it passes through the cubital
tunnel. In addition to performing the
NCS and EMG testing for a suspected
ulnar mononeuropathy at the wrist, ad-
ditional EMG testing to confirm an ul-
nar nerve mononeuropathy at the elbow
includes examination of the flexor carpi
ulnaris and flexor digitorum profundus of
digits 4 and 5.4,6
A medial cord brachial plexopathy ex-
pands the clinical presentation and may
include possible involvement of muscles
innervated other than by the ulnar nerve
journal of orthopaedic & sports physical therapy | volume 40 | number 12 | december 2010 |
40-12 Greathouse.indd 813
(eg, abductor pollicis brevis, flexor polli-
cis longus, flexor digitorum profundus of
digits 2 and 3, and pectoralis major [ster-
nocostal fibers]). NCS testing for brachial
plexopathies includes examination of the
medial cutaneous nerve of the forearm,
lateral cutaneous nerve of the forearm,
median and ulnar F waves, and motor
nerve conduction velocity of the ulnar
nerve from the Erb’s point (supraclavicu-
lar) to the axilla.
An inferior trunk (lower trunk) bra-
chial plexopathy also includes exami-
nation of other C8 muscles innervated
proximal to the medial cord (ie, exten-
sor pollicis longus and extensor indicis).
Further EMG testing of the cervical para-
vertebral muscles is necessary to confirm
the presence of denervation in the pos-
terior primary rami innervated muscles
and thus place the lesion proximal to the
inferior (lower) trunk.4,6 TABLE 1 presents
the normal and abnormal electrodiag-
nostic findings for ulnar neuropathy at
the wrist and elbow, medial cord plexop-
athy, inferior trunk plexopathy, and C8
radiculopathy.
For the C8 radiculopathy, Levin et al7
identified the first dorsal interosseous,
abductor digiti minimi, abductor pollicis
brevis, flexor pollicis longus, and extensor
indicis as the muscles involved with this
level of nerve root compromise.
This resident’s case problem will in-
clude findings of an unusual presentation
of a C8 radiculopathy, without cervical or
upper quarter pain, that was eventually
diagnosed by a combination of physi-
cal examination, EMG and NCSs, and
imaging.
DIAGNOSIS
History
T
he patient was a 49-year-old
male, who was right hand dominant
and a self-employed contractor. The
patient was referred by his primary care
physician to the EMG/NCS laboratory
for a suspected left ulnar neuropathy at
the elbow. The information provided by
the patient included pain, numbness and
tingling in the left medial forearm and
left digits 4 and 5, left hand grip weak-
ness, and no neck or upper quarter pain.
In addition, MRI performed approxi-
mately 5 weeks prior to the EMG and
NCS testing was read by a radiologist as
“mild and moderate cervical spondylosis
including focal moderate degenerative
changes at C5-C6 and C6-C7, but with-
out confirmation of a foraminal mass at
the C7-T1 level.”
At the time of the EMG and NCS
examination, the patient reported a
3-month history of left upper extremity
pain and numbness/tingling in the left
medial forearm and left digits 4 and 5,
including both the dorsal and palmar
surfaces of the digits. The patient stated
that he experienced weakness with grip-
ping objects with his left hand. He re-
ported no history of injury or trauma to
either upper extremity or the neck. Other
than the symptoms described above, the
patient reported no other pain, numb-
ness and tingling, or weakness in the left
upper extremity, right upper extremity, or
either lower extremity. He also reported
no complaints of headache, visual prob-
lems, or difficulty with chewing or swal-
lowing his food, and normal bowel and
bladder function.
The patient had a surgical resection
of the cervical ribs, bilaterally, 10 years
prior, secondary to bilateral shoulder
pain related to thoracic outlet syndrome.
The patient stated that his general medi-
cal health was good and that he was not
being treated for any other health con-
ditions. He had no history of diabetes,
heavy metal exposure, thyroid disease,
renal disease, or alcoholism. A review
of systems was noncontributory for car-
diovascular, pulmonary, gastrointestinal,
genitourinary, or endocrine problems.
There was no family history of neuro-
muscular disease.
After completion of the patient’s histo-
ry and considering his current symptoms,
the physical examination was directed to-
ward performing a differential diagnosis,
including left ulnar mononeuropathy at
the elbow, medial cord plexopathy, infe-
813
11/22/10 3:07 PM
 [ resident’s case problem
rior (lower) trunk plexopathy, or C8 ra-
diculopathy as possibilities.
Physical Examination
The patient had normal and pain-free
cervical active range of motion in all
planes. The Spurling test was negative
for neck or radicular symptoms in both
upper extremities. A cranial nerve screen
was performed, and normal function was
determined for cranial nerves III/IV/VI,
V, VII, IX/X, XI, and XII. Active mobil-
ity of both shoulders, elbows, forearms,
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wrists and fingers in all planes of motion
was found to be normal.
Decreased strength (3+/5) was noted
for the left abductor pollicis brevis, op-
ponens pollicis, dorsal interossei 1 to 4,
palmar interossei 1 to 3, adductor pollicis,
Copyright © 2010 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
and abductor digiti minimi. There was
4/5 strength in the left extensor pollicis
longus, extensor indicis, flexor pollicis
longus, flexor carpi ulnaris, and flexor
digitorum profundus of digits 4 and 5.
The remaining musculature for the left
upper extremity was considered normal
(5/5). This included testing for the shoul-
der (flexion/extension, abduction/ad-
Journal of Orthopaedic & Sports Physical Therapy®
duction, and internal/external rotation),
elbow (flexion/extension), forearm (pro-
nation/supination), wrist (flexion and
extension), flexor digitorum superficialis,
and extensor digitorum. In comparison,
a similar comprehensive assessment for
the right upper extremity indicated nor-
mal (5/5) strength for all muscle groups
and individual muscles tested. No atro-
phy or clonus was present in either upper
extremity.
Muscle stretch reflexes were present
and equal for the biceps, triceps, and
brachioradialis bilaterally. The Hoffman
reflex was absent bilaterally. There was
decreased sensation of light touch and
pain (pinprick) for the palmar and dorsal
aspects of the left digits 4 and 5. Other-
wise, there was normal light touch and
pinprick sensation for all dermatomes
(C4-T1) and peripheral nerves bilaterally.
The Tinel sign was absent for the median
nerve (wrists) and the ulnar nerve (wrists
and elbows). The Phalen test was nega-
814 | december 2010 | volume 40 | number 12 | journal of orthopaedic & sports physical therapy
40-12 Greathouse.indd 814
]
tive for the median nerve bilaterally. No pectoralis minor/clavipectoral fascia ma-
changes in the radial pulse were noted neuvers for thoracic outlet syndrome for
during the scalene, costoclavicular, and either upper extremity.
TABLE 2 Nerve Conduction Study Measurements
Nerve Left Right Normal
Median
Sensory
Palmar distal sensory latency (ms) 2.2 2.6 2.2
Palmar amplitude sensory nerve action potential (µV) 85 63 15
2 digit distal sensory latency (ms) 3.2 3.6 3.6
2 digit amplitude sensory nerve action potential (µV) 39 18 15
Motor
Distal motor latency (ms) 3.9 4.4 4.2
Amplitude compound motor action potential (mV) 6 6 5
Motor nerve conduction velocity elbow to wrist (m/s) 59 54 50
F wave
Latency (ms) 29.6 28.3 32
Ulnar
Sensory
Palmar distal sensory latency (ms) 1.7 1.9 2.2
Palmar amplitude sensory nerve action potential (µV) 15 10 10
5 digit distal sensory latency (ms) 3.1 3.2 3.5
5 digit amplitude sensory nerve action potential (µV) 24 17 10
Sensory nerve conduction velocity below elbow to wrist (m/s) 71 Not tested 50
Sensory nerve conduction velocity above elbow to below elbow (m/s) 76 Not tested 50
Motor
Distal motor latency (ms) 2.9 2.8 3.6
Amplitude compound motor action potential (mV) 7 8 5
Motor nerve conduction velocity below elbow to wrist (m/s) 63 62 50
Motor nerve conduction velocity above elbow to below elbow (m/s) 68 76 50
F wave
Latency (ms) 27.9 27.4 32
Radial
Sensory
Distal sensory latency (ms) 2.2 2.3 2.7
Amplitude sensory nerve action potential (µV) 25 22 10
Lateral cutaneous nerve of the forearm
Sensory
Distal sensory latency (ms) 2.4 Not tested 3.2
Amplitude sensory nerve action potential (µV) 8 8
Medial cutaneous nerve of the forearm
Sensory
Distal sensory latency (ms) 2.4 Not tested 3.2
Amplitude sensory nerve action potential (µV) 9 8
Dorsal ulnar cutaneous nerve
Sensory
Distal sensory latency 1.6 Not tested 2.2
Amplitude sensory nerve action potential (µV) 28 10
11/22/10 3:07 PM

TABLE 3 Electromyography Measurements

Motor Unit
Potentials (Shape,
Fibrillation Positive Amplitude, and Interference
Muscle (Left Upper Extremity) Nerve Root Insert Potentials Waves Duration) Pattern
First dorsal interosseous Ulnar C8-T1 Increased 2+ 3+ Normal 75%
Abductor digiti minimi Ulnar C8-T1 Increased 3+ 3+ Normal 50%
Abductor pollicis brevis Median C8-T1 Increased 1+ 2+ Polyphasic 50%
Pronator teres Median C6-C7 Normal 0 0 Normal 100%
Extensor carpi radialis longus Radial C6-C7 Normal 0 0 Normal 100%
Flexor carpi ulnaris Ulnar C8-T1 Increased 1+ 1+ Normal 75%
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Flexor digitorum profundus of digits 4 and 5 Ulnar C8-T1 Increased 1+ 1+ Normal 75%
Extensor pollicis longus Radial C7-C8 Increased 1+ 2+ Normal 75%
Biceps brachii Musculocutaneous C5-C6 Normal 0 0 Normal 100%
Triceps brachii Radial C6-C7-C8 Normal 0 0 Normal 100%
Deltoid Axillary C5-C6 Normal 0 0 Normal 100%
Supraspinatus Suprascapular C5-C6 Normal 0 0 Normal 100%
Copyright © 2010 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.

Pectoralis major clavicular Lateral pectoral nerve C5-C6-C7 Normal 0 0 Normal 100%
Pectoralis major sternocostal Medial pectoral nerve C8-T1 Increased 1+ 2+ Normal 100%
Trapezius Cranial nerve XI C1-C2-C3-C4-C5 Normal 0 0 Normal 100%
Midcervical paravertebral muscles Posterior primary rami C4-C5 Normal 0 0 Normal
Low cervical paravertebral muscles Posterior primary rami C6-C7-C8 Increased 1+ 2+ Normal

At the conclusion of the physical ex- brachial plexopathy, or cervical radicu- tingling, or weakness in the right me-
amination, the findings appear to place lopathy. This protocol included perfor- dian nerve distribution.
the site of the lesion at the left C8 nerve mance of NCSs of both upper extremities
Journal of Orthopaedic & Sports Physical Therapy®

root and proximal to the left ulnar nerve,
medial cord, and inferior trunk
Nerve Conduction Studies
NCSs and EMG were performed to fur-
ther assist in confirming the diagnosis
of a left C8 radiculopathy, while also
determining the electrophysiologic sta-
tus of the left ulnar nerve, medial cord,
and inferior trunk. The Cadwell Sierra
LT electromyograph and stimulator
(Cadwell Laboratories, Inc, Kennewick,
WA) were used to perform the NCS and
EMG examinations. Specific details for
performing the NCS and EMG exami-
nations have been presented.4-6 Nerve
conduction data were collected with the
skin temperature at the wrist maintained
between 32°C to 33°C in both upper ex-
tremities. The NCS and EMG examina-
tions performed on this patient followed
a protocol established in this laboratory
for the evaluation of a patient with a sus-
pected upper extremity mononeuropathy,
for comparing NCS values between the
symptomatic and nonsymptomatic ex-
tremities, as well as comparing the NCS
values to a chart of normal values.
The nerve conduction studies were
normal for the bilateral ulnar nerves,
bilateral superficial radial nerves, and
left median, medial cutaneous nerve
of the forearm, lateral cutaneous nerve
of the forearm, and dorsal ulnar cuta-
neous nerves (TABLE 2). This included
normal motor and sensory nerve con-
duction studies of the left ulnar nerve at
the wrist, in the forearm, and across the
elbow. However, the palmar distal sen-
sory latency and distal motor latency of
the right median nerve were prolonged
(TABLE 2). These electrophysiologic find-
ings were suggestive of a right median
mononeuropathy at, or distal to, the
wrist, which is an early demyelinating
neuropathic process involving both the
motor and sensory fibers. The patient
was asymptomatic for pain, numbness,
Electromyography
The results of the needle EMG examina-
tion are provided in TABLE 3. There was
abnormal spontaneous electrical activ-
ity and denervation noted in the left first
dorsal interosseous (ulnar C8-T1), abduc-
tor digiti minimi (ulnar C8-T1), abductor
pollicis brevis (median C8-T1), extensor
pollicis longus (posterior interosseous
C7-C8), flexor carpi ulnaris (ulnar C8-
T1), flexor digitorum profundus of digits
4 and 5 (ulnar C8-T1), pectoralis major
sternocostal fibers (medial pectoral nerve
C8-T1), and low cervical (C6-C7-T1 spinal
level) paravertebral muscles. Otherwise,
EMG testing of the other muscles in the
left upper extremity was normal (TABLE 3).
NCS and EMG Evaluation
There is electrophysiologic evidence
on this exam of a left C8 radiculopathy
in the left upper extremity and left low
cervical paravertebral muscles and a
mild right median mononeuropathy at

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 [ resident’s case problem
or distal to the wrist. There was no elec-
trophysiologic evidence on this exam of a
left C5-C7 radiculopathy, a left brachial
plexopathy including the medial cord
or inferior trunk, or a left ulnar nerve
mononeuropathy.
Imaging and Radiographic Studies
Following the EMG and NCS examina-
tion, and after consultation with the
patient’s primary care provider and a
consulting neurosurgeon, the patient
was referred for computerized tomogra-
Downloaded from www.jospt.org at on September 17, 2020. For personal use only. No other uses without permission.
phy (CT) of the cervical spine with myelo-
gram, radiographs of the cervical spine,
and chest radiograph. These studies were
performed 2 weeks later and reviewed by
a radiologist.
The radiologist’s report of the cervical
Copyright © 2010 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
spine radiographs indicated that there
was mild and moderate cervical spon-
dylosis, including focal moderate degen-
erative changes at C5-C6 and C6-C7 and
perhaps minimal 2-mm anterolisthesis at
C7-T1, with minimal retrolisthesis at C6-
C7. There was no evidence of instability
at C7-T1, based on radiographs taken at
end range cervical flexion or extension.
Journal of Orthopaedic & Sports Physical Therapy®
Oblique view radiographs showed a mild
neural foraminal narrowing at C5-C6 bi-
laterally, as well as C6-C7 on the left.
Chest radiographs were ordered, to
rule out any lung pathology, including
a Pancoast lesion.10 The radiologist re-
ported no evidence of acute abnormality,
but there was evidence of postoperative
changes noted in the shoulder region on
the right and a mild elevation of the right
hemidiaphragm.
The CT with myelogram, without
and with contrast of the cervical spine,
showed a left foraminal soft tissue mass
consistent with a schwannoma, although
a foraminal herniation (disc or other soft
tissue in the neural foramina) was not ex-
cluded. There was also evidence of a small
central disc protrusion at C7-T1, a small
left foraminal herniation and stenosis at
C4-C5, and moderate bilateral foraminal
narrowing at C5-C6. The radiologist stat-
ed that, after comparing the CT cervical
spine with myelogram from a previous
816 | december 2010 | volume 40 | number 12 | journal of orthopaedic & sports physical therapy
40-12 Greathouse.indd 816
MRI study that was performed 2 months
earlier, there was no confirmation of a fo-
raminal mass at the left C7-T1 level. The
radiologist was confident that the abnor-
mality seen on the CT myelogram was not
diagnostic and recommended a follow-up
high-resolution contrast MRI.
An MRI of the cervical spine, without
and with contrast, was then performed
a week later and compared with the CT
myelogram. The radiologist’s impression
of the cervical spine MRI included left
C7-T1 disc herniation into the left neu-
ral foramina and associated small cen-
tral disc protrusion, but was negative for
left C7-T1 foraminal schwannoma. There
was also evidence of a small left disc her-
niation into the left neural foramina at
C4-C5, stenosis at C4-C5, and a bilateral
foraminal stenosis at C5-C6.
Referral to Neurosurgery and Surgical
Intervention
Following the imaging and radiographic
studies, and considering the findings of
the physical examination and EMG and
NCSs, the patient was referred to neu-
rosurgery for consultation for a left C8
radiculopathy. The patient was evalu-
ated by the neurosurgeon, who agreed
with this diagnosis. The neurosurgeon
suggested a surgical intervention for the
left C8 radiculopathy, but the patient de-
cided not to have surgery at that time and
to continue to monitor the weakness in
his left hand. No other interventions for
this problem, including physical therapy,
were provided. Approximately 1 year after
the EMG and NCS testing and imaging
studies, the patient had increased weak-
ness in the left hand and, after consulting
with his neurosurgeon, was scheduled for
surgery. The preoperative diagnosis was a
left C7-T1 herniated disk with left C8 ra-
diculopathy. The operative diagnosis con-
firmed the left C7-T1 herniated disk with
left C8 radiculopathy. The patient had a
C7-T1 laminectomy, mesial facetectomy,
and foraminotomy and excision of a her-
niated disk using an operating micro-
scope. The posterior surgical approach
was used with a linear incision made just
]
off the midline of C7-T1. The neurosur-
geon noted that there was a large disk
herniation containing some disk material
immediately anterior to the left C8 motor
root that impinged directly on the motor
root. After the overlying annulus was
opened and the disk fragment removed,
the left C8 motor nerve root was noted to
be adequately decompressed. The surgi-
cal report did not indicate impingement
of the left C8 sensory root.
Postneurosurgical Intervention Evaluation
The patient was evaluated by the neu-
rosurgeon 1 month postoperatively. The
patient reported some minimal soreness
and tightness in his neck, but that his left
arm pain was gone. The patient also stat-
ed that the numbness in the left hand and
forearm was gradually resolving and that
he continued with some weakness in the
left hand. On physical examination, the
patient was noted to have some decreased
sensation in the left digit 5 to light touch,
but this was improved from his preopera-
tive status, and the motor strength in his
left hand intrinsics had improved to 4/5.
DISCUSSION
T
he patient in this case had par-
esthesia and decreased sensation in
the palmar and dorsal aspects of left
digits 4 and 5 and the left medial forearm.
In addition, the patient had weakness on
manual muscle testing of the left dorsal
and palmar interossei, abductor pollicis
brevis, abductor digiti minimi, extensor
pollicis longus, flexor carpi ulnaris, and
flexor digitorum profundus of digits 4
and 5. However, the patient denied neck
and upper quarter pain, and assessment
of his cervical spine was normal. Fol-
lowing the physical examination of this
patient, the findings of the examination
placed the lesion proximal to the ulnar
nerve at the elbow and most likely proxi-
mal to the brachial plexus.
NCSs and EMG in this patient with a
suspected left C8 radiculopathy provided
electrophysiologic evidence that the ab-
normality was in fact at the eighth cer-
11/22/10 3:07 PM
 vical nerve root and not an ulnar nerve
mononeuropathy at the wrist or elbow,
medial cord brachial plexopathy, or infe-
rior trunk brachial plexopathy. Imaging
studies later confirmed the involvement
of the left C8 nerve root. The normal NCS
of the left upper extremity and the EMG
examination of low cervical (C6-C7 spinal
level) paravertebral muscles were key di-
agnostic findings in localizing the left C8
radiculopathy from the medial cord and
inferior trunk brachial plexopathies.4,6
Vargo and Flood10 state that the pos-
Downloaded from www.jospt.org at on September 17, 2020. For personal use only. No other uses without permission.
sibility of a Pancoast lesion should be
considered not only in the presence of
brachial plexopathy, but also when C8
or T1 radiculopathy is found. In a case
study report of a 64-year-old male with a
2-month history of left shoulder pain and
Copyright © 2010 Journal of Orthopaedic & Sports Physical Therapy®. All rights reserved.
left arm numbness at the medial aspect
of the hand and forearm, the authors de-
termined a severe left C8 radiculopathy
as documented by EMG testing.10 Motor
and sensory NCS testing was normal in
that patient. Subsequent radiographic
evaluation, including cervical myelogram
and chest radiographs, demonstrated a
left apical lung tumor (Pancoast tumor)
Journal of Orthopaedic & Sports Physical Therapy®
eroding through the C7 and T1 pedicles
and T1 vertebral body, with cut-off of the
left C8 nerve root. A Pancoast tumor has
a known tendency to locally invade the
nerve roots and spinal canal in its ad-
vanced stages.10 Vargo and Flood10 deter-
mined that the patient’s normal sensory
studies argued against any significant co-
existing lower brachial plexopathy. In this
present case report of a patient with a left
C8 radiculopathy, a chest radiograph was
performed to determine if a coexisting
Videos posted with select articles on the Journal’s website (www.jospt.org)
show how conditions are diagnosed and interventions performed. For a
list of available videos, click on “COLLECTIONS” in the navigation bar in the
left-hand column of the home page, select “Media”, check “Video”, and
click “Browse”. A list of articles with videos will be displayed.
journal of orthopaedic & sports physical therapy | volume 40 | number 12 | december 2010 |
40-12 Greathouse.indd 817
Pancoast tumor or other space-occupying
lesion was present. There was no acute
abnormality found on this patient’s chest
radiograph to suggest a Pancoast tumor.
Treatment of relevant nerve roots in-
volved in nerve sheath tumors has been
studied by Celli.1 The question involves
whether to remove the nerve sheath tu-
mor or preserve the nerve root. Surgery
for the treatment of patients with spinal
nerve sheath tumors can require com-
plete resection of the nerve roots involved
with the tumor. In this case report, a left
C8 nerve root schwannoma was suspect-
ed following the CT of the cervical spine
with myelogram. However, subsequent
MRI imaging studies confirmed a left
C7-T1 herniated disk without evidence
of a schwannoma abnormality. However,
the neurosurgeon did find a large disk
herniation containing some disk mate-
rial immediately anterior to the left C8
motor root that impinged directly on the
motor root.
The purpose of this resident’s case
problem was to provide an unusual pre-
sentation of a patient with a C8 radicu-
lopathy without cervical or proximal
upper quarter symptoms. The signifi-
cance of this report illustrates the utility
of a combination of physical examina-
tion, EMG and NCSs, and imaging in
the diagnosis of a C8 radiculopathy in
a patient presenting with forearm and
hand symptoms, but without cervical or
upper quarter pain. The positive find-
ings on the physical examination and
EMG examination, coupled with the
normal NCSs of the left upper extrem-
ity, led to a diagnosis of a left C8 cervi-
VIEW Videos on JOSPT’s Website
cal radiculopathy. The left C8 cervical
radiculopathy diagnosis was later sup-
ported by imaging studies and further
substantiated during surgical explora-
tion of the posterior cervical spine. t
REFERENCES
1. Celli P. Treatment of relevant nerve roots
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2. Czyrny JJ, Lawrence J. The importance of para-
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3. Dillingham TR, Lauder TD, Andary M, et al. Iden-
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