Transcript Impression 1-Cervical Radiculopathy

Cervical Radiculopathy
TAMI POHORENEC RN, BSN
S.U.N.Y. INSTITUTE OF TECHNOLOGY
ILDIKO MONAHAN
Subjective
CC:
My left arm hurts from my shoulder to my hand and my fingers are numb
and burn
HPI:
Patient woke up three days ago with c/o shoulder and arm pain causing
hand and fingers to be numb and tingle. No specific injury is recalled. Patient
denies lifting, turning, twisting or any activity precipitating the onset of
symptoms. Pain is rated an 8/10 . Numbness is localized to the first three digits
of left hand. Patient has tried ice, Icy Hot, heat, Tylenol and Motrin without relief.
Nothing seems to make pain/symptoms worse. Pain is alleviated with left arm
Bent at 90 degrees and behind head
Differential Diagnosis to consider:
Thoracic Outlet Syndrome
Cervical Spondylosis
Cervical Radiculopathy
Rotator Cuff Injury
Cervical Strain/Sprain
Arthritis
Nerve entrapment
Herniated Disc in neck
Bone spurs
Inflammation
Differentials/definitions
Thoracic Outlet Syndrome- caused when a nerve in the chest is compressed causing
pain in the neck and shoulder, numbness in fingers. Often caused by injury, over use (1)
Cervical Spondylosis- age related changes of spinal discs, arthritic symptoms, pain
and stiffness of neck, often characterized by inflammation (1)
Cervical Radiculopathy- pain in one or both upper extremities compressing nerve root
causing pain, weakness, numbness, tingling (1)
Rotator Cuff Injury- pain in the shoulder, usually a dull ache caused by injury, over
use (1)
Cervical Strain/Sprain- neck pain, weakness, stiffness, decreased range of motion
most often caused by accident/injury. Whiplash is frequently the cause (2)
Arthritis- inflammation in one or more joints causing pain. (1)
1- www.mayoclinic.org
2-http://emedicine.medscape.com/article/306176-overview
Nerve entrapment- pain, numbness, tingling (2)
Herniated Disc in neck- the discs ruptures, slips or bulges putting pressure on or
causing irritation or inflammation to/of nearby nerves creating pain (1)
Bone spurs- bony projections on edges of bone usually caused by wear and tear
and often associated with arthritis. When occurring on the spine can cause disc
space to narrow putting pressure on nerves- leading to pain, numbness, tingling,
weakness (1)
Inflammation- irritation, swelling caused by injury, herniated disc, sprains, strains,
tears etc. (2)
1- www.mayoclinic.org
2-http://emedicine.medscape.com/article/306176-overview
REVIEW OF SYSTEMS
General: healthy per patient- no concerns
Skin: denies rashes, lesions, bruises, temperature changes in left upper extremity
Head/Neck: denies headache, dizziness, neck stiffness or neck pain. Reports decreased range of motion
in neck when turning head side to side
Cardiac: denies chest pain, palpitations, fast heart beat, slow heart beat, murmurs, swelling, cardiac history
other than hypertension which is controlled with medication
Respiratory: denies shortness of breath, wheezing, night sweats, asthma, bronchitis
GI/GU: denies changes in bowel or bladder habits, loss of control of bowel or bladder
PV: denies cramping in extremities, clotting disorders
Musculoskeletal: denies arthritis, gout, back injuries or pain, neck injuries or pain, joint stiffness or
swelling. Reports pain of 8/10 to left upper extremity shoulder to hand with numbness and tingling of first
three fingers. Reports decreased range of motion of neck and increased pain to shoulder with internal/
external rotation and flexion and extension. Pain wakes him up at night and he reports difficulty sleeping,
getting comfortable due to the discomfort. Denies unsteady gait or gait changes.
Neurological: denies weakness or paralysis, reports numbness/tingling left upper extremity as defined prior
denies decreased sensation, tremors or involuntary movements
PMH: positive for hypertension controlled with Maxide 25 mg by mouth daily. Denies other medical
illnesses
Surgeries: denies prior surgical history
Accidents/injuries: denies prior accidents, injuries or hospitalizations
Social History: non drinker (never), non smoker (never), drinks one cup of coffee a day. Married for 25
years, two kids. Works as an accountant. Denies physical manual labor. Does exercise at the gym 4-5 days a
week running on the treadmill, denies lifting weights.
Family History: negative for any type of cancer, epilepsy, aneurysms, cardiac disease other than father is
hypertensive aged 80 and living/ mother aged 79 hypothyroidism living, two siblings living no known health
issues. Negative for joint disease, arthritis, kidney disease, blood/clotting disorders, no auto immune
disorders
Medications: Maxide 50 mg po daily, Tylenol/Motrin PRN pain over the counter as
prescribed, Icy Hot topical to left upper extremity PRN pain
Allergies: no drug, food, environmental or latex allergies
DERMATOMES
Pain localized to C5-C6, C6- C7 on further questioning/exam
Based on history, pain is localized to shoulder, arm and first three digits of
hand consistent with the C5-C6 and C6-C7 dermatomes.
This leads one to narrow differential diagnosis to include those of the neck
And spine.
Some of these include disc disease, arthritis, nodes, cervical sprain/strain,
Ankylosing Spondylitis of spine, cervical radiculopathy or impingement
The physical exam findings may help to exclude some of the above potential
differentials.
One can see by the history, we are already able to narrow in and target the
suspected focal or problem area of concern
So what does the Physical exam reveal?
Objective: The physical Exam
Vital Signs: 98.1 – 78- 14- 132/80 Ht. 6 ft 2 in Wt. 225 BMI 28.9
General: Healthy- Hypertension controlled with medication. Appears uncomfortable,
facial grimace, rubbing left neck and shoulder
Skin: no rashes, lesions, bruising, redness or erythema
HEENT: No masses, no tenderness to palpation of head, neck, no
atrophy, no lymphadenopathy
Cardiac: S1 S2 no murmurs, thrills, heaves, rubs, gallops, apical strong and regular
Respiratory: Diaphragmatic excursion equal, lung sounds clear throughout
PV: No swelling, edema.
Musculoskeletal: + Spurlings test, limited rom cervical spine with lateral movements.
Strength is equal and 5+ right upper extremity, 4+ left, tender to touch c5-c7 area on
left, no loss of lordosis, no kyphosis. Upper extremities symmetrical, no atrophy
noted. Left thumb weak as compared to right. Gait Steady.
Neurological: Reflexes 2+ right upper extremity, 1+ left upper extremity. Sensation intact to light
touch light/sharp/dull, able to localize touch. First three digits feel numb and tingle but no
loss of sensation, though has increased sensation on the left three digits with sharp touch
compared to left. Capillary refill is brisk < 3 seconds, nail beds pink, radial and
brachial pulses strong and equal bilaterally. Babinski reflex intact.
To summarize- pain to left shoulder and arm with associated numbness and
Tingling to elbow, forearm and first three digits left hand following the
c5-c6 and c6-c7 dermatomes without loss of strength, sensation.
+ Spurling’s noted. There is no loss of sensation of bladder, and gait is steady. Neck
tenderness increased with lateral movement. Patient also had less pain when
Manual cervical distraction was applied by the physician
Spurling’s test is when the head is rotated and downward pressure applied to
Head. Test is positive when pain is felt down same sided limb head is rotated to.
In this case- +Spurling’s with head rotated to left. (Malang, 2013)
Putting the puzzle together
Based on the history and physical exam findings- the working diagnosis
is cervical radiculopathy.
Cervical Radiculopathy is defined as “pain in a radicular pattern in one or both
upper extremities related to compression and or irritation of one or more nerve
roots (Bono et al., 2011, pg.66)
Typical presentation is pain to the neck, shoulder, arm with numbness, weakness
and sensory changes and abnormal reflexes to affected extremity (Thoomes et al., 2012,
pg.67)
Exam findings are- mildly decreased DTR on the left upper extremities, + Spurling test,
tenderness to palpation to left cervical spine, hyper sensation to sharp touch first three
digits left hand, pain radiating down left arm localized to c5-c6 and c6-c7 dermatome area,
mildly diminished reflexes left upper extremity, muscle strength 4+ left upper extremity
absence of bowel/bladder abnormalities, absence of gait dysfunction
Imaging studies revealed: We did send Mr. CC for an x-ray which revealed some small nodes c5-c6 and c-7
with narrowing of the C6-C7 disc space. Nerve entrapment, disc herniation was
NOT readily identified on x-ray. There was no evidence of foraminal narrowing or
encroachment on/ impingement of the nerve
PLAN
Impression
1-Cervical Radiculopathy M54.12New, acute as evidenced by pain, numbness, tingling in a radicular pattern, positive
Spurling test, decreased muscle strength and diminished reflexes left upper
extremity, pain localized to c5-c6, c6-c7 dermatomes
2-Hypertension 401.9- chronic, stable
Controlled on Maxide- Blood pressure 130/80’s within target range
3-Overweight 278.02- chronic, stable
BMI 28.9 continue to encourage weight loss, diet and exercise. Weight has been
stable last two years
Diagnostics- plain film x-ray done of cervical spine, shows nodes or bone spurs
c5-c7 areas with mild narrowing c6-c7 disc space
Therapeutic
1- Alternate heat and ice to the affected area, Prednisone taper pack, Effexor
(Venlafaxine) 37.5 mg PO daily, Tylenol 650 mg by mouth every 4-6 hours as needed
for pain, Motrin 600 mg by mouth every 8 hours as needed for pain – take with food
2- Maxide 50 mg by mouth daily- continue
3- Continue to watch portion sizes, exercise
Follow up in two weeks or sooner if worsening symptoms, increased pain,
questions, concerns. If no improvement may consider MRI at that time and referral
for Physical Therapy as well as possible orthopedic consult
Education- Exercises and stretches to do once pain is controlled for strengthening
of cervical spine, body mechanics reviewed including setting up work station to
avoid neck strain
Evidence based guidelines
A review of the literature reveals that cervical radiculopathy presents with c/o of
shoulder/ arm pain with numbness and tingling of the fingers. C5-C6 and c6-c7
involve the first three digits of left hand, ( Thoomes et al., 2012)
MRI/CT scan is not indicated until a patient has failed a course of conservative treatment.
Conservative treatment including medications, heat/ice, rest, Physical Therapy or there are
Worsening neurological symptoms (bono et al., 2011)
An X-ray of the cervical spine is the diagnostic test of choice (Eubanks, 2010)
Medication management includes steroids (to decrease inflammation), and muscle relaxers.
The steroid of choice is prednisone. Steroid injections may also be considered. Muscle relaxers
include Flexaril and Effexor. Pain management with Tylenol, Motrin. (Ghasemi, 2013)
CC presented with classic typical signs and symptoms of cervical radiculopathy.
His history and physical exam were consistent with his diagnosis and treatment
is in line with evidence based guidelines.
If he does not improve then further imaging studies may be indicated as well as
referrals for physical therapy and to an orthopedic specialist.
He does not recall any specific incident or injury.
X-Ray shows some disc narrowing, some bony prominences consistent with
arthritis.
He is to follow up in two weeks for re-evaluation.
Discussion points
As an aside we had a 95 year old man present with neck and shoulder pain later
the same day. He did not recall a specific injury, his pain was diffuse,
no associated numbness or tingling. Strength equal bilaterally and DTR’s intact.
He had a history of lymphoma so a CT scan was done- it showed arthritis.
He was treated with Celebrex for inflammation and Effexor as a muscle relaxer due
to age as well as Tylenol for pain and application of heat/ice.
What questions do you have?
References
Bickley, L. (2011). Bates guide to physical exam and history taking (10th ed.). Philadelphia, Pennsylvania: Wolters Kluer
Lippicott and Williams.
Bono, C. M., Gilbert, T. J., Ghiselli, G., Kreiner, D. S., Reitman, C., Summers, J. T., ... Toton, J. F. (2011). An evidence-based
clinicalguideline for the diagnosis and treatment of cervical radiculopathy from degenerative disorders. The Spine Journal, 11,
64-72. doi: 10.1016/j.spine.2010.10.023
Eubanks, J. D. (2010, January, 1). Cervical radiculopathy:Nonoperative management of neckpain and radicular symptoms.
American Family Physician, 81 no. 1, 33-40. Retrieved from www.googlescholar.com
Ghasemi, M., Maseli, A., Rezvani, M., Shaygannejad, V., Golabachi, K., & Norouzi, R. (2013, December 2). Oral prednisolone
in the treatment of cervical radiculopathy a randomized placebo controlled trial. Journal of Research in Medical Sciences,
s43-s46. Retrieved from www.googlescholar.com
Malnga, G. (2013). Cervical radiculopathy clinical presentation. Retrieved from
http://emedicine.medscape.com/article/94118-clinical#0217
Medscape. (n.d.). www.emedicine.medscape.com
The Mayo Clinic. (n.d.). www.mayoclinic.org
Thoomes, E. J., Scholten-Peeters, G. G., De Boer, A. J., Olsthoorn, R. A., Verkerk, K., Lin, C., & Verhagen, A. P. (2012, April).
Lack of uniform diagnostic criteria for cervical radiculopathy in conservative intervenytion studies: A systemic review. Eur
Spine, 21, 1459-1470. doi: 10.1007/s00586-012-2297-9