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Ulnar nerve entrapment at Guyon's canal or the cubital tunnel AIN palsy Lower trunk BPN

AIN, anterior interosseous nerve; BPN, brachial plexus neuropathy.

AIN, anterior interosseous nerve; BPN, brachial plexus neuropathy.

The physical exam should be focused on identifying a dermatomal distribution of radicular complaints and sensory changes. Specific muscle group weakness and reflex changes as compared with the opposite side should also be recorded. Special tests like the previously mentioned Spurling's sign and the Valsalva maneuver can reproduce a patient's radicular complaints by decreasing the size of the neuroforam-ina. Davidson's shoulder abduction relief sign functions to relieve a patient's radicular complaints with abduction of the shoulder and presumably decreased tension on the cervical root.

In this patient's presentation a typical C6 radiculopathy is present with neck pain radiating down the biceps region of the arm to the lateral aspect of the forearm into the thumb and index fingers. Although he did not exhibit weakness on testing, he did report difficulty maintaining biceps strength with repetitive motion, and he had a depressed biceps reflex. Spurling's maneuver was provocative for reproducing his radicular pain. The radiographs and MRI are significant for loss of C5—6 disk space, C6 neural foramen narrowing, encroachment on the foramina by osteophyte, and focal cord edema at the C5—6 level. The EMG confirmed denervation at the C6 level.

Differential Diagnosis

Other conditions that may mimic C6 radiculopathy include other level radiculopathies, carpal tunnel syndrome, rotator cuff tendinopathies, brachial neuritis, and thoracic outlet syndrome.

Clinical neurophysiology testing is very important for differentiating radiculopathy from peripheral neuropathies. Needle EMG has traditionally been the most useful electrophysiologic tool for diagnosing cervical radiculopathy. If compression produces axonal interruption in some fibers, the EMG reveals changes in muscles from decreases in motor unit action potentials to fibrillation potentials of muscles. In radiculopathy the nerve compression is proximal to the dorsal primary ramus, which should produce changes in the paraspinal muscles, differentiating this lesion from a brachial plexus injury or more distal nerve compression.

The sensory changes involving the thumb and index finger seen in C6 radicu-lopathy are also present in carpal tunnel syndrome. The differences can be seen in the dorsal and volar distribution of sensory changes in the hand and the proximal findings associated with radiculopathy.

Coexisting distal nerve entrapment and cervical radiculopathy can occur, known as the double crush phenomenon. EMG is useful for differentiation of proximal versus distal nerve entrapment, with nerve conduction velocities identifying peripheral neuropathy.

Pain that originates in the neck and extends to the shoulder and arm is very typical for radiculopathy, but patients with rotator cuff disease often have associated neck pain due to shoulder weakness and trapezium muscle spasm. In addition, biceps weakness may be a subjective complaint with rotator cuff disease due to an associated biceps tendinopathy causing pain and restricted motion. Specific testing of the rotator musculature and an MRI of the shoulder are helpful in diagnosing a rotator cuff tear.

Proximal arm pain and weakness may be present in brachial neuritis. In this condition of unknown etiology a patient might awaken with shoulder pain and arm weakness without an inciting event. The symptoms are usually self-limited and treated symptomatically. Again, electrodiagnostic testing along with a thorough history and physical examination should differentiate this entity from radiculopathy.

Thoracic outlet syndrome may involve nerves ofthe brachial plexus and may present with weakness and numbness of the hand. Physical findings of asymmetric pulses, vascular bruits, and a positive Adson's test are tips to suspect thoracic outlet syndrome.

Nonsurgical Management

The majority of patients with first-time symptoms of radiculopathy may be managed nonoperatively. Initial management should include immobilization in a soft collar with the neck slightly flexed, antiinflammatory medications, and physical therapy. Narcotic medications may be used in conjunction with nonsteroidal anti-inflammatory drugs (NSAIDs) in the acute period in cases of severe pain. Physical therapy consists of heat and ultrasound modalities to make the patient more comfortable, cervical traction, and stretching exercises when tolerated. Epidural or selective nerve root corticosteroid injections are also an option, but require accurate needle placement around an irritated nerve root. Improvement in symptoms should be seen within 2 weeks; if symptoms worsen or marked neurologic deficits are present, more aggressive management should be considered.

Surgical Management

Cases of cervical radiculopathy that require surgical intervention are those with unrelenting pain despite conservative management, progressive neurologic deficit, upper extremity weakness, and nerve root compression that is proven diagnostically and correlates clinically.

Surgical choices include anterior cervical diskectomy and fusion as described by Robinson, or posterior diskectomy involving a hemilaminectomy or foraminotomy. The anterior approach is considered the best option for the acute disk herniation to decompress the nerve root from impinging disk fragments in the intervertebral foramen, and for cases where the nerve root is compressed by osteophytes from the joints of Luschka (Fig. 18—3). This anterolateral approach in the neck takes advantage of the fascial plane between the carotid sheath laterally and the trachea and esophagus medially, which affords visualization of the entire surgical spine. The posterior approach is useful for cases of chronic compression due to degenerative changes at the facet joints, and for cases where several levels need to be addressed. Both approaches produce excellent results for relieving radiculopathy, but the anterior approach is more consistent for relieving axial neck pain. Postoperatively, the patients are immobilized in a hard collar in cases of fusion and a soft collar if a simple diskectomy is performed.

Suggested Readings

An HS. Cervical root entrapment. Hand Clin 1996;12:719-730.

Bohlman HH, Emery SE, Goodfellow DB, et al. Robinson anterior cervical dis-cectomy and arthrodesis for cervical radiculopathy. J Bone Joint Surg 1993;75A: 1298-1307.

Dumitru D. Electrodiagnostic Medicine. Philadelphia: Hanley & Belfus; 1995.

Levine MJ, Albert TJ, Smith MD. Cervical radiculopathy: diagnosis and nonoperative management. J Am Acad Orthop Surg 1996;4:305-316.

Lomen-Hoerth C, Aminoff MJ. Clinical neurophysiologic studies: which test is useful and when? Neurol Clin 1999;17:65-74.

Morgan G, Wilbourn AJ. Cervical radiculopathy and coexisting distal entrapment neuropathies: double-crush syndromes? Neurology 1998;50:78-83.

Persson LC, Moritz U, Brandt L, Carlsson CA. Cervical radiculopathy: pain, muscle weakness and sensory loss in patients with cervical radiculopathy treated with surgery, physiotherapy, or cervical collar. A prospective, controlled study. Eur Spine J 1997;6:256-266.

Saal JS, Saal JA, Yurth EF. Nonoperative management of herniated cervical intervertebral disc with radiculopathy. Spine 1996;21:1877-1883.

Stewart JD. Focal Peripheral Neuropathies. 2nd ed. New York: Raven Press; 1993.

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