Epidemiology Cervical Radiculopathy

Epidemiology Cervical Radiculopathy

Cervical radiculopathy Cervicale radiculopathy gives irritation of the nerve root, in most cases, caused by impingement or compression of the nerve root and causes specific radiation in the dermatome(s) of the arm(s).20
Incidence: Most recent study shows that the incidence for cervical radiculopathy is 83.2 per 100,000 persons a year.18

Earlier dated articles show an incidence rate of 203 per 100,0001-8

Prevalence Cervical radiculopathy doesn’t occur much, but most affected are C6/C713,15
Sex: Male > Female = 2:113,15,16,19,21
Age: Cervical radiculopathy is an age bound pathology and usually occurs at elder age (>50 years).13,15,16,19
Pain location: The location of pain in a rupture of the Achilles tendon is located in the ankle and calf muscle.
Pain sensation/ Symptoms: Pain in upper extremities, dull- and/or weakness, sometimes results in significant functional impairment and disfunctions.9-12
Provocation: 3D extensie homoniem
Reduction: Flexing away from the side of the pain.(also differentiates it from cervical HNP)
History of injury / Etiology: Cervical radiculopathy occurs mostly intraforaminal on the spinal ganglion. Mostly caused by osteophytes and trauma.13,15

Impingement of a nerve root mostly occurs because of decreased discus hight and degenerative changes of uncovertebral- and zygapophyseale joints that are positioned anterior and posterior.16

Osteophytes near the foramen, HNP and hard parts of the active system are mostly the reasons for CR. Spondylartrosis is the most common reason for elder age and for younger age HNP are the cause of CR.19,22

Physical Exam / Anamnesis: Patiënt had multiple complains in the neck, heavy physique work and neurologic signs13,15

Symptoms in cervical radiculopathy14

Arm pain in dermatomes, pain gets worse with extension rotation and lateroflexion, pain reduction with hand on C5-C6, Sensations in affected dermatomes, gait not effected, changed hand functions, weakness in myotomes but no spasms, deep tendon reflexes hypo-active, negative pathologic reflex, negative superficial reflex.

Prognosis: Radiculopathy patiënts younger than 54 years of age which don’t have their dominant side affected and can lift their chin to their chest have a better prognosis for recovery. An operation also gives a “great improvement” in most cases8.It is said that 90% of the patiënts with CR experience show light complains about their symptoms after 4,9 years. 8

CR seems to occur more in patients with diabetes related diseases.22

Literature 1 Heckmann J, Lang J, Zobelein I, et al. Herniated cervical intervertebral discs with radiculopathy: an outcome study of conservatively or surgically treated patients. J Spinal Disord. 1999;12:396–401.

2 Wainner R, Gill H. Diagnosis and nonoperative management of cervical radiculopathy. J Orthop Sports Phys Ther. 2000; 12:728–744.

3 Muhle C, Bischoff L, Weinert D, et al. Exacerbated pain in cervical radiculopathy at axial rotation, flexion, extension, and coupled motions of the cervical spine. Invest Radiol. 1998;5:279 –288.

4 Ellenberg M, Honet J, Treanor W. Cervical radiculopathy. Arch Phys Med Rehabil. 1994;75:342–352.

5 Tanaka N, Fujimoto Y, An H, et al. The anatomic relation among the nerve roots, intervertebral foramina, and intervertebral discs of the cervical spine. Spine. 2000;25:286–291.

6 Farmer J, Wisneski R. Cervical spine nerve root compression: an analysis of neuroforaminal pressures with varying head and arm positions. Spine. 1994;19:1850–1855.

7 Radhakrishnan K, Litchy WJ, O’Fallon WM, et al. Epidemiology of cervical radiculopathy: a population-based study from Rochester, Minnesota, 1976 through 1990. Brain. 1994;117:325–335.

8 Cleland J.A., Fritz J.M., Whitman J.M., Heath R. Predictors of Short-Term Outcome in People With a Clinical Diagnosis of CervicalRadiculopathy. American Physical Therapy Association 2007.

9 Benini A. Clinical features of cervical root compression C5-C8 and their variations. Neuro-Orthopedics. 1987;4:74–88.

10 Honet J, Puri K. Cervical radiculitis: treatment and results in 82 patients. Arch Phys Med Rehabil. 1976;57:12–16.

11 Caplan L. Management of cervical radiculopathy. Eur Neurol. 1995;35:309–320.

12 Sampath P, Bendebba M, Davis JD, et al. Outcome in patients with cervical radiculopathy: prospective, multicenter study with independent clinical review. Spine. 1999;24:591–597.

13 http://www.ntvg.nl/publicatie/cervicale-radiculopathie-een-epidemiologisch-onderzoek-rochester/volledig / Radhakrishnan K, Litchy WJ, O’Fallon WM, Kurland LT.Epidemiology of cervical radiculopathy. A population-based study fromRochester, Minnesota, 1976 through 1990. Brain1994;117:325-35. /

14 David J. Magee. Orthopedic Physical Assessment (Orthopedic Physical Assessment – page: 140

15 http://ptjournal.apta.org/content/87/12/1619.full

16 Carette.S, M.D., M.Phil, and Michael G. Fehlings, M.D., Ph.D. Cervical radiculopathy. The New England Journal of Medicine 2009.

17 Cleland J.A., Fritz J.M., Whitman J.M., Heath R. Predictors of Short-Term Outcome in People With a Clinical Diagnosis of Cervical Radiculopathy. American Physical Therapy Association 2007.

18 Costello, M. Treatment of a Patient with Cervical Radiculopathy using thoracic spine thrust manipulation, soft tissue mobilization and exercise. Journal of manual and manipulative therapy, Volume: 16, Issue: 3 2008.

19 Kuijper B., Tans J., Schimsheimer R.J., Van der Kallen B.F.W. , Beelen A., Nollet F. and Visser M. Degenerative cervical radiculopathy: diagnosis and conservative treatment. A review. European Journal of Neurology 2009, 16: 15–20

20 Maj. Robert S. Wainner. Diagnosis and Nonoperative Management of Cervical Radiculopathy. Journal of Orthopaedic & Sports Physical Therapy 2000;30 (12) :728- 744.

21 Peloso, P., Hogg-Johnson, S., Velde, G., Carroll, L.J., et al. The Burden and Determinants of Neck Pain in the General Population 2000 – 2010 Task force on Neck Pain and Its Associated Disorders. European spine journal, Volume 33, Number 4S, pp S39–S51.

22 RAJ RAO, MD. Neck Pain, Cervical Radiculopathy, and Cervical Myelopathy. The Journal of bone & joint surgery volume 84-A number 10 October 2002.

 

Psychical Examination

Reflex tests:
– Biceps Deep Tendon Reflex- Triceps Deep Tendon Reflex

– Brachioradialis Deep Tendon Reflex

– muscle strength test C1 – T1

– Sensibility tests (Pin prick)

Cervical Distraction Test      
  1. The patient lies on his/her back. Thetherapist must continuously ask about the symptoms of the patiënt.
  2. The therapist takes the chin with one hand with his or her pink, ring finger and forefinger and with the other hand specifically the occiput edge of the neck.
  3. A traction is given and the symptoms are reassessed. During the test, pain respected.
  4. A positive test is a reduction in the symptoms during the transmission of the traction.
Upper Limb Tension Test(ULTT)
  1. The patient lies on his or her back. The therapist assesses symptoms.
  2. The therapist is blocking the shoulder girdle and stabilizes the scapula. Then the therapist assesses the symptoms again.
  3. If no reproduction of symptoms, the glenohumeral joint in abducted 110 degrees with a slight extension. Then the therapist assesses the symptoms again.
  4. If no reproduction of symptoms, the forearm in full supination and fingers and wrist are put in full extension. Subsequently, there is an ulnar deviation applied. The therapist assesses the symptoms again after this action.
  5. If no reproduction of symptoms is present, elbow extension is made. Symptoms are then assessed. During this action, one can try to measure the extension.
  6. Lateral flexion of the neck provides even greater stress. A positive test is reproduction of symptoms during distal movements.
Cervical Hyperextension (Jackson´s Test)
  1. The patientsits onthetreatment table.
  2. The patient is instructed to to extend his / her neck to where the first pain point is felt. If no pain, the patient is asked to create full extension.
  3. Reproduction of symptoms is seen as a positive test.
Spurling’s Compressie Test
  1. Thepatient takesa neutralcervicalposturewhile heor shesits. The therapistasksfor symptoms.
  2. The therapist asks the patient to make lateral flexion to the side where the symptoms occur. If radicular pain occurs, the test is positive.
  3. If no symptoms occur, the therapist gives a pressure from the neutral position and combines this with a lateral flexion to the affected side. If radicular pain occurs, the test is positive
Valsalva maneuver
  1. The patienthasa sittingposition.
  2. The patient is asked to hold his or her breath to keep pressure as if he or she is sitting on the toilet.
  3. Reproduction of the pain during the exercise of the pressure means is a positive test.
Cervicale Hyperflexie Test
  1. The patienthasa sittingposition
  2. The patient is instructed to flex his or her neck until pain is felt. If there is no pain, the patient is instructed to flex into the spinal limit.
  3. Reproduction of radicular symptoms during hyperflexion is seen as a positive test.
CLUSTER: In order to exclude the existence of radiculopathy in the cervical spine, the cluster of wainner is used. In this cluster the Spurling test, ULTT, Valsalva maneuver and distraction test are used.

Positive Specificity
two tests 0.56
three tests 0.94
all the tests are positive 0.99

In two tests, but the specificity is 0.56, with three positive test the specificity is 0.94, and if all the tests are positive, there is specificity of 0.99.

 

Video’s

Spurling:


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ULTT:

B


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Valsalva:


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Distraction test:

Table: Validity van radicular tests

 

Evidence Based Practice

Sensitivity Specificity LR?* LR+*
Distraction test 0,44 (0,22-0,67) 0,90 (0,82-0,98) 0,62 (0,40-0,90) 4,4 (1,8-11,1)
ULTT?A 0,97 (0,90-1,0) 0,22 (0,12-0,33) 0,12 (0,01-1,9) 1,3 (1,1-1,5)
ULTT-B 0,72 (0,52-0,93) 0,33 (0,21-0,45) 0,85 (0,37-1,9) 1,1 (0,77-1,5)
Valsalva maneuver 0,22 (0,03-0,41) 0,94 (0,88-1,0) 0,83 (0,64-1,1) 3,5 (0,97-12,6)
Spurling-A 0,50 (0,27-0,73) 0,86 (0,77-0,94) 0,58 (0,36-0,94) 3,5 (1,6-7,5)
Spurling-B 0,50 (0,27-0,73) 0,74 (0,63-0,85) 0,67 (0,42-1,1) 1,9 (1,0-3,6)
Literature
  1. Rubinstein S., Sidney M., Pool. J.M., van Tulder M.W., Riphagen I.I. A systematic review of the diagnostic accurancy of provocative tests of the neck for diagnosing cervical radiculopathy. European Spine Journal 2006, Volume: 16, Issue: 3
  2. Ltcol Robert S, Wainner et al. Reliability and Diagnostic Accuracy of the Clinical Examination and Patient Self-Report Measures for Cervical Radiculopathy. Spine Volume 28, Number 1, pp 52–62 2003.

 

Quadas: Quality Assesment of Diagnostic Accuracy Studies
The Quadas helps the reader to gain clarity about what impact the BIAS had in a study. When a Quadas score is low, a critical look at the value of the study should be taken. The Quadas consists of a scoring system of 14 points that are tested.
Utility scores:
  1. Evidence strongly supports the use of this test.
  2. Evidence moderately supports the use of this test
  3. Evidence minimally supports or does not support the use of this test
  4. ? The Test has not been researched sufficiently so we are unsure of its value

 

Biceps Deep Tendon Reflex  Utility 2
Study Sensitivity (show) Specificity (exclude) QUADAS Score 0-14
Wainner et al.6 24 95 10

 

Triceps Deep Tendon Reflex Utility 2
Study Sensitivity (show) Specificity (exclude) QUADAS Score 0-14
Wainner et al.6 3 93 10
Lauder et al.3(C7) 14 92 9

 

Brachioradialis Deep Tendon Reflex Utility 3
Study Sensitivity (show) Specificity (exclude) QUADAS Score 0-14
Wainner et al.6 6 95 10
Lauder et al.3(C6-7) 17 94 9

 

Muscle Power Test C1 t/m T1 Utility 2
Study Sensitivity (show) Specificity (exclude) QUADAS Score 0-14
Wainner et al.6
Deltoideus 12 90 10
Biceps 24 94 10
Ext. Carpi Radialis 12 90 10
Triceps Brachii 12 94 10
Flex. Carpi Radialis 6 89 10
Abductor Pollicis Brev. 6 84 10
1e Dorsale interosseus 3 93 10

 

Sensibiliteit tests (Pin prick) Utility 2
Study Sensitivity (show) Specificity (exclude) QUADAS Score 0-14
Wainner et al.6      
C5 29 86 10
C6 24 66 10
C7 28 77 10
C8 12 81 10
T1 18  79  10

 

Cervical Distraction Test Utility 2
Study Sensitivity (show) Specificity (exclude) QUADAS Score 0-14
Wainner et al.6 44 90 10
Viikari/Juntura et al.5 40 100 11
Comment: Although this test is average, this test gives one of the best diagnostic information when testing for cervical radiculopathy. This test is particularly high specific and is therefore good to be able to exclude a radiculopathy.

 

Upper Limb Tension Test(ULTT) Utility 2
Study Sensitivity (show) Specificity (exclude) QUADAS Score 0-14
Wainner et al.6
Medianus 97 22 10
Radialis 72 33 10
Sandmark & Nisell1 77 94 9
Comment: Although this test is average, this test gives one of the best diagnostic information when testing for cervical radiculopathy. This test is particularly highly sensitive and is therefore good to be able to rule in a radiculopathy.

 

Cervical Hyperextension (Jackson´s Test) Utility 2
Study Sensitivity (show) Specificity (exclude) QUADAS Score 0-14
Uchihara et al.3 25 90 10
Sandmark en Nisell1 27 90 11
Commentaar: Hoewel deze test erg specifiek is, moet de therapeut blijven differentiëren tussen lokale pijn en radiculaire pijn.

 

Spurling’s Compressie Test Utility 2
Study Sensitivity (show) Specificity (exclude) QUADAS Score 0-14
Viikari-Juntura et al.5Rechter zijdeLinker zijde 3639 9292 1111
Wainner et al.6 50 86 10
Wainner et al.6(met side flexion richting rotatie en extensie) 50 74 10
Comment: The Spurling maneuver appears mainly to be specific and not sensitive. Some researchers describe the test with ipsilateral rotation and lateral flexion while other extension used. The original version is from Spurling and Scoville.2

 

Valsalva maneuver Utility 2
Study Sensitivity (show) Specificity (exclude) QUADAS Score 0-14
Wainner et al.6 22 94 10
Comment: The test shows moderate reliability and is especially specific in patients with cervical radiculopathy.

 

Cervicale Hyperflexie Test Utility 2
Study Sensitivity (show) Specificity (exclude) QUADAS Score 0-14
Wainner et al.6 89 41 10
Uchihara et al.3 8 100 8
Comment: The drastic difference between the two studies is inexplicable. Wainner et al.6 his research has used better methodology and its results are more linked to the population of people with cervical radiculopathy. The studies also differ in terms of nine years of date from each other and it is assumed that Wainner et al.6 is more reliable.

 

Literature
  1. Sandmark H, Nisell R. Validity of five common manual neck pain provoking tests. Scand J rehabil Med. 1995
  2. Spurling RG, Scoville WB. Lateral rupture of the cervical intervertebral disc. Surg Gynecol Obstet. 1944;78:350-358
  3. Uchihara T, Furukawa T, Tsukagoshi H. Compression of brachial plexus as a diagnostic test of cervical cord lesion. Spine 1994
  4. Lauder T, Dillingham T, Andary M, Kumar S, Pezzin L, Stephens R. Predicting electrodiagnostic outcome in patients with upper limb symptoms± are the history and physical examination helpful= Arch Phys Med Rehabil. 2000
  5. Viikari/Juntura E, Takal E, Riihimaki H, Martikainen R, Jappinen P. Predictive vailidty of symptoms and signs in the neck and shoulders. J Clin Epidemiol. 2000
  6. Wainner RS, Fritz JM, Irrgang JJ, Boninger ML, Delitto A, Allison S. Reliability and diagnostic accuracy of the clinical examination and patient self-report measures for cervical radiculopathy. Spine. 2003;28(1):52
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