CERVICAL ROOT SYNDROME

By : Hermilawaty, MD

Definition
An abnormal condition resulting from compression of spinal nerve roots in the neck region; involves neck pains and muscular weakness and paresthesia [syn: cervical disc syndrome]
.

Pathophysiology
The cervical nerve root can be compressed in the neural foramen by the intervertebral disc, degenerative change affecting vertebra or uncovertebral joint, or in a combined fashion. Radicular pain : stimulation of sensoric fiber at the radix level and intervertebral foraminal, result pain radiated along the dermatomes.

Pain are usually come from soft tissue : ligament, nerves root, facet joint, capsule and muscles. Pain can cause by degeneratif process, infection, iritation and trauma.

Diagnosis
Patient complain pain, weakness, paresthesias, or a combination of sensorimotor deficits. Findings at physical examination : Tenderness or spasm is usually noted along the cervical paraspinal muscles Weakness in a myotomal distribution.

Diagnosis .
Decreased ROM in the cervical spine, especially with neck extension Hand clumsiness Loss of sensation Spurling sign

Therapy : Non Surgical : * Physical therapy : heat and ultrasound modalities, cervical traction and streching exercise. * NSAID drugs. * Epidural and selective nerve root steroid injections. * Soft collar imobilization. Surgical

Case Report
I. Database ( October 8, 2009) I.1 Patient Identity Name : Mr SM Sex : Male Age : 36 years old Address : Surabaya Occupation : Cleaning service Religion : Moslem Etnic : Javanese

I.2. Refered from neurologic outpatient clinic with CRS (spondylosis cervicalis) I.3. Chief complain : sakit pada leher, bahu dan tangan kiri. I.4. History of present illness : He felt pain on neck radiated to the left shoulder & arm since 2 weeks ago. He felt pain on his neck especialy when he turn his head to the right side. He felt numb on his thumb & index finger left manus so he do his job as cleaning service slowly than usual but he still can do daily activity.

I.5. Past history No hipertension, no DM No history of trauma

I.6. Physical Examination (October 8, 2009) I.6.1. General Status Composmentis, ambulation independent, normal gait, right handed. Weight : 75 kg, Height : 175 cm, BMI : 24,5 BP : 120/80 mmHg HR : 76 x/minute RR : 20 x/minute normal temperature

- Head and neck : anemi -, jaundice -, cyanosis -, udem - Chest : heart : S1 S2 single, regular, murmur -, lung : vesicular +/+, wheezing -/-, ronkhi -/- Abdomen : flat, supple, briut -, liver and spleen not palpable - Extremities : normal

I.6.2 Physiatric Examination Musculoskeletal Examination ROM Cervical Flexion F (0 45) Extension F (0 45) Lateral Flexion F/F (0 45) Rotation aktif (0-40)/F (0 60) pasif F/F (0 60)

MMT 5 (pain) 5 (pain) 5/5 (pain) 5/5 (pain) 5/5 (pain)

Trunk Flexion Extension Lateral Flexion Rotation Shoulder Flexion Extension Abduction Adduction Ext. Rotation Int. Rotation

F/F (0 80) F/F (0 30) F/F (0 35) F/F (0 45) F/F (0 180) F/F (0 80) F/F (0 180) F/F (0 45) F/F (0 45) F/F (0 55)

5/5 5/5 5/5 5/5 5/5 5/5 5/5 5/5 5/5 5/5

Elbow Flexy Extension Forearm supination Forearm pronation Wrist Flexion Extension Radial Deviation Ulnar Deviation

F/F (0 -150) F/F (150 -0) F/F (0 80) F/F (0 80)

5/5 5/5 5/5 5/5

F/F (0 80) F/F (0 70) F/F (0 20) F/F (0 30)

5/5 5/5 5/5 5/5

Finger
Flexion MCP PIP DIP Extension Abduction Adduction

F/F (0 90) F/F (0 100) F/F (0 90) F/F (0 15) F/F (0 20) F/F (20 0)

5/5 5/5 5/5 5/5 5/5 5/5

Thumb
Flexion extension
MCP IP Abduction adduction F/F (0-60) F/F (0-65) F/F (0 50) 5/5 5/5 5/5

Hip
Flexion Extension Abduction Adduction Ext. Rotation Int. Rotation F/F (0 125) F/F (0 30) F/F (0 45) F/F (0 20) F/F (0 45) F/F (0 45) 5/5 5/5 5/5 5/5 5/5 5/5

Knee Flexy Extension External rotation Internal rotation

F/F (0 135) F/F (0 10) F/F (0 10) F/F (0 45) F/F (0 35) F/F (0 35) F/F (0 25)

5/5 5/5 5/5 5/5 5/5 5/5 5/5

Ankle Plantar Flexion Dorsi flexion Inversion Exversion

Toes Flexion MTP IP Extension

Big Toe Flexion MTP IP Extension

F/F (0 30) F/F (0 50) F/F (0 80)

5/5 5/5 5/5

F/F (0 25) F/F (0 25) F/F (0 80)

5/5 5/5 5/5

Neurological Examination
Cranial Nerves DTRS : Normal : BPR ++/++ KPR ++/++ TPR ++/++ APR ++/++ Pathological Reflexs : Babinsky -/-, Chaddock -/, HT -/VAS : 6

Sensory
100 % C5 60%

100 %
100 % 100 % 100 %

C6
C7 C8 T1

70%
100% 100% 100%

Local status
Inspection : inflamatory sign -, deformity -/- , Atrophy -/-, swelling -/Palpation : - tender point on upper trapezius sinistra, - spasme on paracervical upper trapezius dextra sinistra - warmth -/-

Special examination : Head compression test (Spurlings test) Head distraction test Valsava test Drop arm test Yergason test

:-/+ :-/+ :-/+ :-/:-/-

X ray AP/Lateral : - Spondylosis C4 dan C5 - paracervical musle spasme

II. Diagnose
Medical : CRS sinistra root C5, C6

Functional diagnose : - Impairment : cervical root C5, C6 disorder with numb on thumb and index finger left manus - Disability : he do his job slowly than usual - Handycap : -

III. Problem List

Medical : CRS sinistra root C5, C6 Surgical : Rehabilitation Medicine :

R1 (Ambulation) R2 (ADL)

: : -

R3 (Communication) : -

Problem list..

R4 (Psycological)

: worried about his disease

R5 (Social Economy) : -

R6 (Vocational)

: he do his job slowly than usual

R7 (Others) : Pain on neck, shoulder and arm left side (VAS 6) Spasme paracervical and upper trapezius muscles dextra sinistra. Sensory defisit root C5, C6 sinistra.

IV. Planning Medical : continue medicine from neurology outpatient clinic (Na diclofenac 2 x 15 mg) Surgical : (-) Rehabilitation Medicine : - PDx : - PTx : - USD at paracervical and upper trapezius sinistra - Resensitisasi sensoris thumb & indeks finger left manus - Neck caillet exercise - Cervical collar - PMx : Clinical sign and symptom, VAS

- PEx

: - warm compres twice a day for 20 minute. - Friction massage at paracervical and uppertrapezius - Neck cailliet exercise at home - Proper neck mecanism such as use a pillow when sleep, avoid hiperekstensi and hiperflexy of the neck, etc.

Summary

It has reported that male 36 years old who referred from neurology outpatient clinic with CRS (spondylisis cervicalis). Chef complain sakit pada leher, bahu dan tangan kiri. He felt pain on neck radiated to the left shoulder & left arm since 2 weeks ago. He felt pain on his neck especialy when he turn his head to the right side. He felt numb on his thumb & index finger left manus so he do his job as cleaning surface slowly than usual but he still can do daily activity.

Musculoskeletal Examination ROM Cervical Flexion F (0 45) Extension F (0 45) Lateral Flexion F/F (0 45) Rotation aktif (0-40)/F (0 60) pasif F/F (0 60) MMT 5 (pain) 5 (pain) 5/5 (pain) 5/5 (pain) 5/5 (pain)

Defisit sensoris : 100 % C5 60 % 100 % C6 70 % 100 % C7 100 % 100 % C8 100 % 100 % T1 100 % tender point on upper trapezius sinistra, spasme on paracervical upper trapezius dextra sinistra. Diagnose : CRS sinistra root C5, C6

Planning therapy : - USD at paracervical and upper trapezius sinistra. - Resensitisasi sensoris thumb & index finger left manus. - Cervical collar - Neck caillet exercise PMx : Clinical sign and symptom, VAS PEx : - warm compres twice a day for 20 minute. - Friction massage at paracervical and uppertrapezius - Neck cailliet exercise at home - Proper neck mecanism such as use a pillow when sleep, avoid hiperekstensi and hiperflexy of the neck etc.

THANK YOU

Spurling sign - Radicular pain is exacerbated by extension and lateral bending of the neck toward the side of the lesion, causing additional foraminal compromise. Lhermitte sign - This generalized electrical shock sensation is associated with neck extension.

Epidemiology

The annual incidence of cervical radicular pain is 5.5 per 100.000. Patients younger than 55 are more likely to present with radiculopathy arising from acute disc herniations. Patients older than 55 are more likely to demonstrate symptoms arising from degenerative foraminal or central canal stenosis.

Pathophysiology

Radicular pain arising from a herniated disc is more common than from the more slowly evolving degenerative foraminal stenosis. Tears in the annulus can allow for the displacement of the nucleus. Anterior disc herniations are less common as the anterior longitudinal ligament is wider and stronger than the posterior longitudinal ligament.

Diagnose study : Ro foto, EMG, MRI Differential diagnose : Cervical disc injuries Cervical facet syndrome Cervical spine sprain / strain injuries

Cervical traction

Cervical collar

Outer annulus fibrosus

Nucleus pulposus

Inner annulus fibrosus

STRUCTURES OF IVD :
1.Outer Annulus 2.Inner Annulus : Fibroblast cells Collagen I : Chondrocyte-like cells Collagen II

3.Central Nucleus Pulposus 4.Vertebral endplate : hyaline calcified cartilage

IV. Planning Medical : continue medicine from neurology outpatient clinic (Na diclofenac 2 x 15 mg) Surgical : (-) Rehabilitation Medicine : R1 ( Ambulasion ) : R2 ( ADL ) : PDx : PTx : PMx : PEx : -

R4 (Psychology) : PDx : PTx : give support for patient and his family. PMx : Psychological condition PEx : Education about her disease. R5 (Social Economic ) : R6 ( Vocational ) : ????

R7 (others)
PDx : PTx : - USD at paracervical and upper trapezius sinistra - Neck caillet exercise PMx : Clinical sign and symptom, VAS PEx : - warm compres - Friction massage - Neck cailliet exercise at home - Proper neck mecanism