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Musculoskeletal Medicine for Medical Students

 

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Description

Cervical radiculopathy . Compression of the root of a nerve in your neck, leading to pain, numbness, and/or tingling. Often can be caused by a “slipped disc” in your neck that puts pressure on nearby nerves..

UptoDate, E-medicine

http://emedicine.medscape.com/article/94118-overview

Pathology (organ, cell, system)

In the younger population, cervical radiculopathy is typically a result of a disc herniation or an acute injury causing foraminal impingement of an exiting nerve. Disc herniation accounts for 20-25% of the cases of cervical radiculopathy. In the older patient, cervical radiculopathy is often a result of foraminal narrowing from osteophyte formation, decreased disc height, degenerative changes of the uncovertebral joints anteriorly and of the facet joints posteriorly.

 

What is seen in the tissue, either grossly or microscopically? Note whether the finding is a cause or an effect of the condition. Mark speculations as such

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Pathophysiology

Cervical radiculopathy involves an inflammatory process initiated by nerve root compression. Evidence has been found that inflammatory mediators, including nitric oxide, prostaglandins, interleukins, TNF-alpha, and matrix metalloproteinases, are released by herniated intervertebral discs, leading to nerve root swelling. The compression may be from a disc herniation, degenerative changes about the neural foramen, or a combination. Macrophages respond to the displaced foreign material and seek to clear the spinal canal. Subsequently, a scar is produced, and substance P, which is associated with pain, is detected. Neural compression by the herniated material is responsible for sensory and motor dysfunction, while radicular pain is caused by inflammation of the nerve (which can explain the lack of correlation between the size of a herniation, or even the degree of neural compression, and the associated clinical symptoms). Furthermore, disc degeneration may result in radial tears and leakage of the nuclear material, which leads to further neural toxicity and symptoms, even without compression.

Describe the   processes that   have gone awry. To do so best, describe the normal physiology

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Differential Diagnosis

DDx includes other joint pain of the neck or shoulder. Entrapment neuropathy of the median, ulnar, or other nerves, or other nerve lesions, including MS. A history of difficulty walking, lower extremity or trunk symptoms, or bowel and bladder dysfunction are suggestive of myelopathy, while a history of fever, chills, unexplained weight loss, immunosuppression, cancer, or intravenous drug use should raise suspicion for tumor or infection.

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Epidemiology

The annual incidence is approximately 85 cases per 100,000 population. Disk herniation occurs more frequently in middle-aged and older men, especially those involved in strenuous physical activity. According to one study, the mean age at diagnosis was 47.9 years, and there was a 1.7:1 M:F ratio.Age-specific incidence rates were highest for the 50-54 year age group, and declined steeply after age 60. C7 is the most frequently affected nerve around, accounting for around 70% of patients, followed by C6 (20%), and then C5, C8, and T1 accounting for the last 10%.

Radhakrishnan, K, Litchy, WJ, O'Fallon, WM, Kurland, LT. “Epidemiology of cervical radiculopathy. A population-based study from Rochester, Minnesota, 1976 through 1990.” Brain 1994; 117 ( Pt 2):325.

Emedicine

Etiology

Trauma and straining/exertion are often precursors for disc herniation and radiculopathy, and it can frequently be seen with playing golf, shoveling snow, diving, or prolonged exposure to vibration (especially with driving for extended periods of time). While radiculopathy often occurs after car accidents, no evidence for associated disc herniation has been found. Often, however, there is no specific, identifiable precipitating event, suggesting that the cause is more than just a single incident of stress. It could be that there is a genetic predisposition related to the relative strength of the spinal column that, when combined with prolonged exposure to detrimental circumstances (leading to muscle or ligament weakening) or a traumatic event, causes the disc herniation and associated radiculopathy.

What causes the disease? Mention some popular theories if definite cause is not known. Discuss the plausibility of these theories. Suggest your own, too

UptoDate, E-medicine

Clinical manifestations

Pain, numbness/loss of sensation, and tingling in the neck, shoulder, and down one arm, along the path of the affected nerve root. Pain is generally a universal sign, and may be present in the neck, shoulder, or arm independent of the others. Paresthesia occurs in approximately 80% of patients, and weakness may also present, though it is less common. Reduced range of motion and increased pain with motion of the neck, particularly with extension, rotation, and lateral bending. Pain with bending away from the affected side suggests displacement of the herniated disc onto a nerve root, whereas pain on bending towards the affected side suggests impingement at the neural foramen. Typically, patients tilt their head away from the side of injury and hold their neck stiffly.Muscle tenderness may occur along the path of referred symptoms, and can have associated hypertonicity or spasm. Onset of symptoms is most frequently acute, but in some cases can be more gradual.
 

What are the signs and symptoms?   Try to be as descriptive as possible, and comment on the importance (ie sensitivity/specificity) of given findings. Hone in on findings unique to the condition. (pain is ubiquitous in orthopedics!) Try to relate the signs and symptoms to the pathology.

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Late presentation, complications

How does the disease appear in its late stages. Contrast treated and untreated disease.

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Nutritional factors

Not applicable

 

Radiographic evidence

On x-ray: You can see disc-space narrowing, subchondral and foraminal sclerosis, and osteophyte formation. “Correlations of findings on plain radiographs and cadaver dissections have found a 67% correlation between disc-space narrowing and anatomic findings of disc degeneration. However, radiographs identified only 57% of large posterior osteophytes and only 32% of abnormalities of the apophyseal joints that were found on dissection.”

On CT: The accuracy of CT imaging of the cervical spine ranges from 72-91% in the diagnosis of disc herniation. CT scanning with myelography has an accuracy approaching 96%.

MRI: Test of choice for diagnosis. Can detect ligament and disc disruption, which cannot be demonstrated by other imaging studies. However, MRI has been shown to find abnormalities in 8-20% of asymptomatic patients

What does one see on xrays and other modalities? Try to be as descriptive as possible, and comment on the   sensitivity/specificity) of the study. Try to relate the radiographic   signs   to the pathology and pathophysiology

UptoDate, E-medicine

Laboratory evidence

EMG may be done to determine the exact nerve root that is involved, and nerve conduction velocity tests may also be done. Myelogram may be done to determine the size and location of disk herniation.Nerve conduction studies alone are not sensitive for radiculopathy, but can be useful in ruling out entrapment neuropathies, such as carpal tunnel syndrome.

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Psychosocial impact of disease

Can cause difficulties in performing daily activities, specifically with regard to lifting or carrying objects, making the patient either dependent on others to perform these tasks, or unable to do them entirely. May prevent patient from being able to live independently. Also, supportive devices such as a neck brace may make the patient feel awkward if worn in public.

 

Risk factors

Age, specifically middle-aged and older men, though there is a drop-off after age 60.

Strenuous physical activity.

Congential conditions affecting the size of the spinal canal.

Driving long distances is also a risk factor “because of the resonant coupling of 5-Hz vibrations from the road to the spine.” Truck drivers have the additional risk of spinal problems from lifting during loading and unloading, which is frequently done after prolonged driving.

List here risk factors, especially those that are not part of “etiology”.  “Falling” is not a risk factor for fracture; it is the cause. “Propensity for falling (eg due to alcoholism or neuromuscular disease)” is a risk factor. List also patient features associated with higher prevalence of disease Example: osteoporosis = ‘northern European ethnicity’

CITE, if possible a primary source

Prevention

“Safe work and play practices, proper lifting techniques, and weight control may help prevent back injury in some people.

Some health care providers recommend the use of back braces to help support the spine. Such braces can help prevent injuries in people whose work requires them to lift heavy objects. However, overuse of these devices can weaken the abdominal and back muscles, making the problem worse.”

 

What can be done to prevent this? Is this cost effective? Does it work?

UptoDate, E-medicine

Treatment options

Note the treatment options, the  rationale/method for each treatment, and whether it is evidence based

Initial treatment should be directed at reducing pain and inflammation. The treatment can begin with local icing, NSAIDs, and reducing the compressive forces through rest, positioning, and manual or mechanical traction. Additional treatment may include physical therapy, oral corticosteroids, TCAs, or in more severe cases, steroid injections, all aimed at reducing pain and inflammation. Trials have also shown possible benefits with acupuncture. Continued physical therapy during recovery should focus on increasing flexibility and range of motion, as well as strengthening stabilizer muscles, to reduce future nerve compression.

There is not clear evidence that surgical treatment provides better long-term outcomes than nonoperative measures in the acute phase, although surgery is recommended for athletes with cervical instability or progressive neurologic deficits, and for those who fail more conservative therapy. Surgical techniques include excision of disc fragments, vertebral body fusion, laminectomy, artificial disc replacement, and microdiscectomy, which is now the most common due to it being a less invasive procedure. Patients with more severe disk degeneration, particularly myelopathy, will more often undergo fusion. Interbody cages are being considered as a way of promoting more rapid rehabilitation and more consistent results.

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Outcomes  of treatment

The prognosis for is generally excellent with 80-90% of patients improving with nonoperative treatment. Surgery is indicated when nonoperative treatment has failed, but studies have shown mixed results on its effectiveness. One small RCT of 81 patients showed an advantage in pain reduction, muscle strength, and sensation in surgically treated patients (vs. immobilization with a cervical collar) at 4 months, but only a difference in muscle strength at one year. However, two different prospective studies found substantial improvement in pain and weakness with approximately 75% of surgically treated patients.

Emedicine, UptoDate

Fouyas, IP, Statham, PF, Sandercock, PA, Lynch, C. “Surgery for cervical radiculomyelopathy.” Cochrane Database Syst Rev 2001; :CD001466.

Potential
Complications of treatment

Complications of surgical treatment include spinal cord injury (<1%), nerve root injury (2-3%), and device failure (<4%), as well as transient dysphagia (10%), recurrent laryngeal nerve injury (2-3%), esophageal perforation (<1%), vertebral artery injury (<1%), and wound infection (<1%). In addition, symptoms may recur in up to 1/3 of patients, despite treatment.

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Misc

In my experience these random factoids help you remember important stuff. E.g.: Why are sailors called “limey”? Sailors at sea where prone to scurvy from VitC deficiency (imagine the toothless deck hand). Once that was known, they were issued limes to eat---to help the collagen cross link

CITE, if possible a primary source

 

 

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