Cervical Radiculopathy: First Step – RULE out Myelopathy.

November 09, 2016 - by Maggie Henjum - in Treatment & Prevention

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Unlike previously discussed conditions (upper ligamentous instability), cervical radiculopathy has had better quality research for ruling in this diagnosis. Four clinical tests combined give us 90% confidence (K = .76) that the patient is presenting with cervical radiculopathy. These include: ipsilateral rotation < 60 degrees, ULTT A (median nerve bias), distraction test, and Spurlings test.[1] Presence of pain with valsalva maneuver is also shown to be a specific test, although all testing should be of slightly questionable validity as a gold standard is lacking for the diagnosis of cervical radiculopathy. The least familiar test for physicians, and therapists is the ULTT A test. This is described as the straight leg raise of the upper extremity where the patient lays in supine, patient’s arm is placed in 90 degrees of abduction, 90 degrees of elbow flexion, shoulder external rotation, forearm supination and extension of the wrist with a slow extension of the elbow. A positive examination as described by Wainner et. al, is either symptom provocation, side to side differences of elbow extension of 10 degrees, or an increase in symptoms with contralateral side bending.[1]

Once ruled in, next stop is assessing what their outcomes may be with PT intervention. Prognosis is, in general, a challenge for therapists due to the numerous variables that can play a role in decision making and different patient caveats. Regardless – Cleland et. al, found the following factors to be correlated with success: age <54 years old, dominant arm not affected, looking down doesn’t aggravate symptoms, and multi-modal treatment for at least 50% of sessions.[2] With 3 of the 4 variables present probability of success was 85%, and with all 4 variables present post test probability of success was 90%.[2] Addressing any yellow flags will be necessary, especially with said population. Coping mechanisms, addressing any fear avoidance patterns, as well as diagnosis and pain education seems to be key in this group.

Managing these patients require an interdisciplinary approach. Medication management, injection, physical therapy or even surgery are on the radar. Clear pathway for best care and management are not clear cut for this group, and obviously writers bias runs deep in this discussion. It is important to note for patients that inherent risk is possible with all treatments stated. With recent exposure to a patient with a possible adverse reaction to a cervical steroid injection, I did look into risk with cervical TF-ESI. One study performed by Scanlon et. al, administered a survey to MD’s with a 21% reporting a neurological complication following a TF-ESI.[9] Again, all treatment patterns have risk – even the most conservative measures, but it does hold all healthcare professionals accountable to administer the appropriate treatment. As most patients have had these discussions with doctors, the occasional direct access patient will require the physical therapist to understand treatment options and refer when necessary.

Physical therapists’ treatment patterns should limit risk, and optimize time with evidence based treatments. As we know, matching patients to classification improves their outcomes, most often cervical radiculopathy patients fit the centralization classification. I base most of my treatments off of Cleland et. al study, which administered manual techniques (mobilization of cervical spine, thoracic manipulation), traction, and strengthening exercises. Full resolution of symptoms occurred in 53% of patients and 91% of patients had a clinical meaningful reduction in pain and function after 7 visits at the 6 month mark.[11] I also administer nerve flossing to most patients with cervical radiculopathy as it is easy to perform in clinic – with easy transition to a home exercise program. A 2009 systematic review agrees that neural mobilization has been shown to have benefit to treatment and outcomes.[12] Self admitting, I rarely utilize traction – probably due to lack of validated prediction criteria to identify who would benefit from it, poor quality of studies that support it, and probably partly due to time constraints. Other techniques supported in literature are ULTT with side gliding mobilization, and repetitive motion to centralize symptoms. If any therapist in our offices have question about these techniques or associated literature – please ASK. I do have a few tables that break down numerous articles’ treatments and demonstrate outcomes.

Another diagnosis that should be considered with an examination is cervical myelopathy. I regularly screen for this condition, especially in the older population as 90% of these cases occur in patients who are 70 years old and older.[8] Upper motor neuron (UMN) signs are prevalent only in cervical myelopathy, not in cervical radiculopathy. Examination of corticospinal tract, posterior column and anterior foraminal and lateral thalamic need to be assessed for associated symptoms of lower extremity weakness, ataxia, UMN signs and sensory changes respectfully.8 Clinical exam clustered items are described by Cook et. al, as gait deviation (Sp = .94), + Hoffman’s sign (Sp = .73), Inverted Supinator Sign (Sp = .99), Babinski (Sp = .73)and Age <45 (Sn = .86), with 3 out of 5 positive tests having a positive liklihood ratio of 30.9.[7] Obviously, with this diagnosis, imaging is of great added value to assess the severity of central cord compression.

Grading for cervical myelopathy plays into therapist judgment to help assess if the patient is appropriate to conservatively treat. About half of patients with cervical myelopathy end with surgical interventions.14Although an interesting preliminary research discusses the possibility of conservatively treating mild myelopathy. Browder et. al, performed a case report with 7 patients with grade 1 myelopathy and treated them with thoracic manipulation, 3 patients received traction manipulation force, and all patients received traction.[10] Two of these patients had complete cessation of symptoms, 4 patients reduced pain on NPRS to 1/10, and 3 patients resolved myotomal strength deficits – overall suggesting possible benefit of conservative care for patients with grade 1 or mild myelopathy only.[10] As stated in this study, two other studies have matched their results, but again with lower level evidence. As all UMN findings are discussed with referring physician, moderate to severe myelopthy is not something I feel comfortable managing manually in a physical therapist office.

Cervical radiculopathy is about 15% of my current caseload making this discussion of good timing. Surgery is recommended for 50% of patients with cervical myelopathy, and 35% of patients with cervical radiculopathy leaving a large sample size for us to treat non-surgically.[14,15] Thankfully, we have quality evidence to base our examination and treatment off of. Some limitations to our evidence are still apparent, with more required evidence especially on identifying prognostic factors and matching interventions appropriately. Although, we have a good ground work of evidence to start treating these conditions.

 

Original post: August 19, 2013

 

References:
1) Wainner R.S, Fritz JM, Irrgang JJ, Boniger ML, Dlitto A, A. S. (2003). Reliability of Diagnostic Accuracy of the Clinical Examination and Patient Self-Report Measures for Cervical Radiculopathy. Spine, 28(1), 52–62.
2) Cleland, J. a, Fritz, J. M., Whitman, J. M., & Heath, R. (2007). Predictors of short-term outcome in people with a clinical diagnosis of cervical radiculopathy. Physical therapy, 87(12), 1619–32.
3) Radhakrishnan K, Litchy WK, O’Fallon MW, Kurland LT. Epidemiology of cervical radiculopathy: A population-based study from Rochester, Minnesota, 1976 through 1990. Brain. 1994, 118 (2): 325-335.
4) Boden SD, McCowin PR, Davis DO, et al: Abnormal magnetic-resonance scans of the cervical spine in asymptomatic subjects. A prospective investigation. J Bone Joint Surg Am 1990 Sep; 72(8): 1178-84
5) Sidney M. Rubinstein, Jan J. M. Pool, and Henrica C. W. de Vet. A systematic review of the diagnostic accuracy of provocative tests of the neck for diagnosing cervical radiculopathy. Eur Spine J. 2007. March 16 (3); 307-319.
6) Cook, C., Brown, C., Isaacs, R., Roman, M., Davis, S., & Richardson, W. (2010). Clustered clinical findings for diagnosis of cervical spine myelopathy. The Journal of manual & manipulative therapy, 18(4), 175–80. doi:10.1179/106698110X12804993427045
7) Cook, C. E., Wilhelm, M., Cook, A. E., Petrosino, C., & Isaacs, R. (2011). Clinical tests for screening and diagnosis of cervical spine myelopathy: a systematic review. Journal of manipulative and physiological therapeutics, 34(8), 539–46. doi:10.1016/j.jmpt.2011.08.008
8) Bob Boyles. (2013, August). Cervical Spinal Stenosis. Lecture conducted through EIM
9) Scanlon, G. C., Moeller-Bertram, T., Romanowsky, S. M., & Wallace, M. S. (2007). Cervical transforaminal epidural steroid injections: more dangerous than we think? Spine, 32(11), 1249–56. doi:10.1097/BRS.0b013e318053ec50
10) Browder, D., Erhard, R., & Piva, S. (2004). Intermittent cervical traction and thoracic manipulation for management of mild cervical compressive myelopathy attributed to cervical herniated disc: a case. Journal of Orthopaedic and Sports Physical Therapy.
11) Cleland, J. a, Whitman, J. M., Fritz, J. M., & Palmer, J. a. (2005). Manual physical therapy, cervical traction, and strengthening exercises in patients with cervical radiculopathy: a case series. The Journal of orthopaedic and sports physical therapy, 35(12), 802–11. Retrieved fromhttp://www.ncbi.nlm.nih.gov/pubmed/16848101
12) Ellis RF, Phyty B. Neural Mobilization: A Systematic Review of Randomized Conrolled Trials with an Analysis of Therapeutic Efficacy. J Man Manip Ther. 2008; 16(1): 8-22.
13) Sampath P, Mohommed B, Davis JD, Ducker T Outcome of Patients Treated for Cervical Myelopathy: A Prospective, Multicenter Study With Independent Clinical Review. Spine. 2000; 25 (6) 670-676.
14) Sampath P, Mohommed B, Davis JD, Ducker T. Outcome in Patients With Cervical Radiculopathy: Prospective, Multicenter Study With Independent Clinical Review. Spine. 1999; 24 (6) 591-597.

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Maggie Henjum

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