Transcript Cervical Nerve Root Impingement By: Michael Cox Overview • Anatomy of cervical spine and nerve roots • Reasons for impingement • Signs and symptoms associated.

Cervical Nerve Root Impingement
By: Michael Cox
Overview
• Anatomy of cervical spine and nerve
roots
• Reasons for impingement
• Signs and symptoms associated with
nerve root impingement
• Acute treatment of injury
• Rehabilitation
•Return to play criteria
Anatomy
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Primary Function: Mobility, support, and protection of spinal canal and neural
structures
7 cervical vertebrae
8 nerve roots
6 intervertebral discs
Foramina
– Nerve root occupies 25-33%
over the foramina space
Lordotic curve
– most of lordosis occurs at C1-C2
Some Biomechanics:
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50% of flexion and extension occurs at occipitoatlantal joint
50% of rotation occurs at C1-C2
Anatomy
Anatomy
• Vertebral Disc
– Located between C2-C7
– Composed of annulus fibrosis, which is the outer layer made up of
thick fibrous cartilage
– Nucleus pulposus is the inner layer which is a water gelatin
– Discs serve as shock absorbers
and allow the spine to bend
Anatomy
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Nerve roots
– Myotomes
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C1: Cervical flexion
C2: Cervical flexion
C3: Cervical lateral bending
C4: Shoulder elevation
C5: Shoulder Abduction
C6: Elbow Flexion/wrist extension
C7:Elbow extension/wrist flexion
C8: Ulnar deviation/thumb extension
T1: Finger abduction/adduction
– Dermatomes
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C1: Top of head
C2: Side of face
C3: Down mandible
C4: Lateral neck
C5: lateral upper arm
C6: Lateral forearm to thumb
C7: Middle forearm to 3rd
C8: 5th to medial forearm
T1: Medial upper arm
Anatomy
• Muscles
– SCM
– Splenius muscles
– Levator scapula
– Scalenes
– Upper trapezius
Mechanism for Impingement
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This injury can occur from an extension, lateral bending, or rotation mechanism, which
causes a narrowing of the neural
foramen and results in ipsilateral nerve root injury
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Disc herniation can cause the nucleus
pulposus to leak into the foramen and cause
impingement on the nerve
Signs and Symptoms
• Neck and shoulder pain and discomfort that can
radiate down the arm
• Tingling or numbness along the nerve root involved
• Motor weakness in affected nerve root (manual muscle
testing)
• Depending on reason for impingement certain motions
(AROM) can cause pain
• Point tenderness is usually located along the lateral
and posterior cervical muscles on the affected side
• Muscle tenderness and spasm on affected side is
usually present
Special Test’s
• Deep Tendon Reflexes
– Biceps Brachii reflex: C5-C6
– Brachioradialis reflex- C5-C6
– Triceps reflex: C7-C8
• Foraminal Compression Test
• Manuel Distraction
• Shoulder Abduction Test
Acute Treatment
• “A best-evidence synthesis by the Bone and Joint Decade 20002010 Task Force on Neck Pain and its Associated Disorders
concluded that there is not clear evidence that surgical
treatment of cervical radiculopathy provides better long-term
outcomes than nonoperative measures.”
• Icing
• NSAIDS
• Rest
• Take measures that reduce force compressing the nerve root
• Avoiding positions that increase symptoms
Rehabilitation Early Phase
• Main goal is reducing symptoms: controlling pain and inflammation
• Cervical collar
– Restricts motions that cause pain
– Patient comfort
• Cervical pillow at night can help can help maintain the neck in a
neutral position and limit head positions that cause narrowing of
the neural foramen
• Ice- help reduce muscle spasm and pain
• NSAIDS
Rehabilitation Early Phase
• Traction- Decreases pressure caused by axial loading
– Manuel traction
– Mechanical traction
– Positional traction
• Self administered, body positioning
Disc Protrusion- Intermittent traction
– Force pulposus back in
Impingement- Sustained traction
– Removes mechanical pressure on nerve root and allows for
inflammation of nerve root to decrease
– Reducing adhesions within Dural sleeve by elongating the
surrounding structure
– Restoring normal slack in the neuromeningeal structures
Rehabilitation Moderate Phase
• Goals:
– Restoring ROM
– Maintaining pain free symptoms
– Light strengthening
• Criteria for progression
– Pain and inflammation have been controlled
Rehabilitation Moderate Phase
• Continued Traction
• Stretching:
– Sustained stretching in all directions
• Flexion, extension, lateral bending, rotation
– Home stretching exercises
• Soft Tissue Mobilizations
– Spleni muscles, posterior cervical muscles, scalenes,
upper trap, levator scapulae, SCM
• AROM exercises
– Go until pain then return to neutral
• All directions
Rehabilitation Moderate Phase
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Joint Mobilizations
– Cervical lateral glides in upper
limb neurodynamics position
– Upper and Midthoracic spine
manipulation in supine:
• “an association exists between mobility
in the thoracic spine
and neck/shoulder pain.”
• “thoracic manipulation can help
increase cervical ROM”
– Central PA’s
Rehabilitation Moderate Phase
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Strengthening
– At this time rehab should focus on isometric strengthening only until full ROM
is achieved
• Flexion
• Extension
• Lateral bending
• Rotation
Deep flexor strengthening
Scapular muscle strengthening
– Rhomboids: rows
– Serratus anterior: push up plus
– Middle and upper trap: fly’s
Rehabilitation Progressive Phase
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Maintain ROM
Maintain pain free symptoms
Cervical muscle strengthening
Cervical Stabilization
Nerve root strengthening
Functional Activity
• Criteria for progression
– Pain free ROM
– Diminished inflammation
Rehabilitation Progressive Phase
• Strengthening:
– Isotonic cervical strengthening
• All directions: can be done using a cervical machine, pulley
system, or Thera-band
• Involved nerve root strengthening
– Isotonic motions
• Can use either dumbbells, Thera-band, tubing, mechanically
Rehabilitation
Progressive Phase
• Cervical stabilization
– All directions
• Hold for 30 sec
– 3 sets
• PNF Patterns
• Functional Activity
Return to Play Criteria
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Full pain-free ROM
Full strength and stabilization
No tingling or numbness with ROM
Full cardiovascular endurance
Summary
• Cervical nerve root impingement can occur
from a herniated disc or from narrowing of
the neural foramen
• Patient may complain of neck pain and
tingling or numbness radiating down the arm
• Progression is based on patient symptoms
• Pain management is important