EXAMINATION: CERVICAL NERVE ROOTS
CAUTION: History and examination cannot easily separate neck from shoulder problems and some more distal problems.
REFLEXES - CERVICAL NERVE ROOT
Biceps C5-6 Brachio-radialis C5-6 Triceps C7
Hoffman reflex: finger flexion with long finger when fingernail is flicked hinting at upper motor neuron lesion.
[Usually the examiners opposite thumb & index finger hold the long finger at the middle phalanx to support the relaxed hand]
Babinski plantar response : Great toe extends and others flair upon scrapping bottom of the foot when seeking hints of upper motor neuron lesion.
Cervical examinations should always included Babinski plantar response seeking upper motor neuron issues.
C4 - Shrug (C4) = Shoulder hikers]
C5 - Saber (C5) = [Shoulder ABduct/Ext.Rot]
Sadir (C6-8) = [Shoulder Adduct/Int.Rot]
C6 – Forearm sup serving position(C6/C5) = [No Fingers, Wrist= ext., Elbow= flex., Supinated]
C7 – Forearm Pron tip position (C7) = [Finger= ext., Wrist= flex., Elbow= ext.,Pronated]
C8 - Fingers grasp (C8) = [Finger Flexors]
T1 -Thumb out & away (T1) = [Thumb Abduction] & finger Abductors, interossei
C4 chest mantle above nipples, C7 middle finger,
C5 deltoid, C8 ulno-volar arm and 2 fingers,
C6 volar radial arm and thumb, T1 medial arm to elbow
Above upper extremity illustrations provided with the permission of Dr. Brad Hayes
Epidemiology of Neck Problems
In 1995, the Québec Task Force **(Spitzer
) did a momograph on whiplash but could rely upon less than 50 articles. Since then the epidemiological picture of neck pain has been further clarified. The lifetime reminiscence (66%), point prevalence (20%) and significant disability (5%) of neck symptoms parallel the prevalence of back problems
). As with back issues, a major controversy revolves around neck symptoms been due to trauma especially "whiplash." The following epidemiological and cohort efforts address the question of residual disability being related to trauma.
After significant neck trauma (whiplash), comparisons did not find chronic neck pain and/or headache any more prevalent than in the general population unless also related to a social construct expecting disability, a positive family history or prior attribution of trauma related neck symptoms (Schrader
). Another study noted that the elimination of compensation for pain and suffering from neck trauma reduces incidence, as well as, improve prognosis (Cassidy
). One epidemiologic study of neck problems found chronic disorders tend to cluster, finding more than 50% of the surveyed population of had neck pain in the last six months (5% highly disabled). Those with neck symptoms and those disabled were both associated with headache, low back pain, and history of MVA. Mild symptoms were also associated with better education and general health. More intense symptoms included weak associations with digestive disorders and smoking. The disabling symptoms were additionally associated with cardiovascular disorders, digestive disorders (Cote
). A subsequent Canadian study of 7462 whiplash subjects one month post-collision, that neck pain was only one of many diffuse and intense symptoms, often including back pain, fatigue, dizziness, paraesthesia, headache, spinal pain, nausea, and jaw pain, with a subset completing the SF-36 with low physical and mental functioning(Ferrari et al.,`05
). British prospective cohort of 1,359 survey responders age 18 to 77 determined 48% to have 1-year "persistent" neck pain (chronic, recurrent, or continuous) associated with bring off work, age 45 to 59 years, co-morbid low back pain, and cycling (Hill et al.,`04).
Specific to whiplash neck trauma in a cohort of 5398, shorter time to claim closure is associated with less pain, better function and absence of depression (Cote
et al. Mar `01
). A prospective study of "whiplash" patients found neck mobility not significantly related to car speed at the time of collision and while cervical motion may measure less acutely, by 3 months motion is similar to those with an ankle fracture (no neck symptoms) and inversely related to complaints of headaches and the report of neck mobility (Krasch
). Another epidemiological effort found only 25% of individuals with neck or low back pain sought care while those with more co-morbidity tended to see medical doctors. Patients in the rural areas or those not reporting arthritis with better social economic and physical functioning tend to see chiropractors. Those who sought both medical doctors and chiropractors reported more disability (Cote
et al.Sept `01
). Women seemed more commonly affected than men with longer duration and less resolution (Cote
). Another cohort of 1,693 Saskatchewan whiplash injuries from the last 6 months of 1994 analyzed for 8 initial care patterns found early intensive health care to significantly slower recovery, especially when chiropractic and general practitioner care were combined (Côté
et al, 07).
32 selected trials had an overall methodological quality of mean 3.2/5.
For acute whiplash, administering intravenous methylprednisolone within 8 hours reduced pain at one week [SMD -0.90 (95% CI -1.57 to -0.24)], and sick leave but not pain at 6 months compared to placebo.
For chronic MND at short-term followup, intramuscular injection of lidocaine was superior to placebo [SMD 1.36 (95% CI -1.93 to -0.80)].
In chronic MND with radicular findings, epidural methylprednisolone and lidocaine reduced neck pain [SMD -1.46 (95% CI -2.16 to -0.76)] and improved function at one-year followup compared to the intramuscular route.
In subacute/chronic MND, we found conflicting evidence for oral psychotropic agents.
In chronic MND with or without radicular findings or headache, there was moderate evidence from 5 high quality trials showing that botulinum toxin (Botox A) intramuscular injections were not better than saline in improving pain [SMD pooled -0.39 (95% CI -1.25 to 0.47)], disability, or global perceived effect.
Neck Imaging Considerations
The above three concerns (role of fusion, long term decompression results and lack of support for other invasive techniques) are all complicated by the lack of a diagnostic gold standard. As in lumbar spine imaging
, there is a high propensity for disc and canal changes to be found in the cervical spines asymptomatic people with increasing age (Boden
). This further necessitates considering only strong concurrent focal preoperative findings in the presence of severe symptoms should surgery be contemplated after the patient is fully briefed on the above information to be considered informed consent.
Review by Nordin et al.`08
found in nonemergency neck pain without radiculopathy, the validity of most commonly used objective tests to be lacking with only support for subjective self-report assessment in monitoring patients' course, response to treatment, and in clinical research.
Decompression of compromised cervical nerve roots or spinal cord can be approached either posterior between the laminae (similar to the lumbar spine approach) or anterior on either side of the trachea and esophagus through the intervertebral disc space. Fusion is more commonly associated with the anterior decompression cervical nerve root or spinal cord. Prior appeal for the anterior approach relates to the opportunity to place a piece of bone shaped to maintain the normal intervertebral disc space intended to maximize the opening of the nerve root foramen.
The most reliable data about elective cervical spine procedures raise three concerns about the role of fusion
, long term results of decompression
of reliable data to support other invasive
, prospective studies question the necessity of fusion with elective decompressions [similar to the lumbar spine fusion seeming to add only complications] (Savolainen
et al.`99, Dowd et al. `99).
As in the lumbar spine hardware seems only to add complications without improving clinical outcomes (Samrtzis
Multiple studies indicate fusion increases the rate of aging adjacent to the fusion (Baba
, Cherubino et al.`90
). Also, recent articles find surveying post-anterior cervical fusion patients about dysphasia
indicate a much higher rate of complications than estimated by the treating surgeon (Edwards
et al,`01, Bazaz
). Yet, the rates of fusion in elective cervical spine surgery has significantly increased in the 1990s (Angevine
, randomized trials indicate no significant long term difference in the clinical result from surgical decompression of radiculopathy after 1 year and myelopathy (mild symptoms of spinal cord compromise) after 2 and 3 years performed for either to cervical disc or canal changes compared to conservative care (Fouyas
). Now as in the lumbar s
is the lack of reliable clinical studies available in the cervical region to justify other common invasive techniques. Injections in the cervical spine are less well documented than in the lumbar spine for either diagnostic or therapuetic use. At best one study suggests but short term relief with facet rhizotomy against which clinicians must balanced potential complications (Lord
) without such evidence for other invasive cervical spine techniques (Niemisto
A review by Carragee
et al.`08 found 31 articles indicating radiofrequency neurotomy, cervical facet injections, cervical fusion and cervical arthroplasty for neck pain without radiculopathy are not supported. Cervical foramenal or epidural injections have relatively frequent minor adverse events (5%-20%); however, serious very uncommon (<1%). Serious acute complications for open surgical procedures are approximately 4%. Surgical treatment and limited injections for cervical radicular pathology may be
reasonably only in severely impairments patients with clear obvious radicular pathology. Invasive treatment
for neck pain alone without clear radicular pathology, lacks scientific support.
Now as in the lumbar spine we have some data about the cervical total disk replacement. A prospective randomized controlled study by Coric et al.`06 preliminary 24 months reported results in 33 patients and Hacket`05 randomized 46 patients cervical radiculopathy and/or myelopathy to either arthroplasty or fusion are now available. Both proclaimed total disk replacement as a reasonable alternative to the dismal results and complications of cervical fusion noted above with numbers and follow up that cannot address the additional complications. Not dissimilar to the lumbar total disk replacement experience of from one questionable procedure based upon fleeting logic and soft indications with a newer more expensive approach.
SRC Spinemate - only used or reproduced with written permission from SResourceC@aol.com