Myelopathy and radiculopathy

Myelopathy and
Radiculopathy

Sarah Williams, MD

Physical Medicine and Rehabilitation

Multiple Choice

Which of the following is the most likely diagnosis:

• Cervical Myelopathy

• Cervical Radiulopathy

• Cervical Sprain

• Whiplash-associated neck pain

6

radiating symptoms
hyporeflexia

ataxia
loss of fine motor coordination
hyper-reflexia (+ Hoffman’s)
spasticity

Upper Motor Neuron

Lower Motor Neuron

Cervical Radiculopathy Basics

9

●compression of cervical nerve root from a variety
of causes

●occurs at a rate of 107.3 per 100,000 for men and
63.5 per 100,000 for women

●most common in 40’s-50’s

●Risk factors: white race, cigarette smoking, and
prior lumbar radiculopathy, lifting heaving objects,
frequent diving from a board, driving equipment
that vibrates, and playing golf

○usually not related to trauma

Cervical Spondylosis

breakdown of the disc with age leads to decreased

disc height and foraminal narrowing

decreased disc height then results in increased
loads placed through the intervertebral joints of
Luschka (uncinate joints) as well as the vertebral

body

this leads to bony hypertrophy (especially in the

uncinate joint)

which leads to foraminal stenosis and cervical

radiculopathy

11

Signs and Symptoms of Radiculopathy

●unilateral pain (though lack of pain can be seen)

●radiation to ipsilateral arm in a dermatomal distribution

●sensory deficits in dermatomal distribution

○including dysesthesias and paresthesias

●weakness in myotomal distribution

●loss of reflexes

●relief of symptoms with shoulder abduction

Shoulder Abduction Relief Sign

●relief from pain with shoulder abduction has
been reported in lower cervical radiculopathies

●In the cervical spine, nerve roots exit the
spinal cord in a much more perpendicular
manner coursing ventrolaterally to enter the
neuroforamen

○This trajectory places the roots at risk for
neuropraxic injury particularly in the presence
of ventral pathology

○patients can have temporary relief of their
symptoms when they hold their arms above
their head, as this decreases tension on the
nerve root

13

How do you diagnose a cervical radiculopathy

●There are nouniversally agreed upon diagnostic criteria for radiculopathy

●There are no published guidelines by any professional society for the assessment
and management of cervical radiculopathy

●NEJM article from 2005 suggests largely clinical diagnosis with limited utility for
imaging and EMG/NCS and imaging used if clinical diagnosis alone is not
possible to rule out other causes

Physical Exam for Cervical Radiculopathy

●Wainner et al developed a clinical prediction rule of 4 items:

○(1) Spurling test

○(2) distraction test

○(3) ipsilateral cervical spine rotation less than 60° (using goniometer)

○(4) upper limb tension test (ULTT)

○when all 4 items were positive: 99% specificity (positive likelihood ratio, 30.3)

○when 3 of the items were positive: 94% specificity (positive likelihood ratio, 6.1)

Cervical Distraction Test

●examiner pulls upward on neck
to release pressure on cervical
nerve roots

●positive if neurological
symptoms and/or pain are
reduced

MRI in Cervical Radiculopathy

●MRI is generally consider imaging of choice in
radiculopathy, however guidelines on when imaging is
needed have not been established

●some studies recommend MRI if “red flags” in the patient’s
history (eg, persistent fever, weight loss, pain that wakes
up the patient, etc), motor weakness, evidence of
myelopathy, or at least 6 weeks of persistent symptoms
despite conservative treatment

●HOWEVER, in a study of 493 asymptomatic patients:

○7.6% had disk herniation with spinal cord
compression

○5.9% had foraminal stenosis

○> 85% of patients > 60 yo had evidence of
degenerative disk disease

●Can results in false positives

Prognosis

●Rochester study showed 90% of patients having
complete resolution or mild incapacitation from cervical
radiculopathy at final follow-up

●Another study showed condition is self-limited, with
approximately 75%–90% of patients having symptomatic
improvement with conservative treatment

○unfortunately no evidence or studies to show which
patients are at higher risk of failing conservative
treatment

●Wong et al. found 83% of patients had resolution of
symptoms with nonoperative treatment, the time to
complete recovery ranged from 24 to 36 months

○Unfortunately, high-quality evidence comparing operative
and nonoperative care is limited, but in at least 2 small
studies, there was a clear benefit to surgery in the
short-term (0–3 mo), but the results of surgery and
nonoperative care converged over time

Which is Best: PT & meds, Epidurals or both

●169 consecutive patients with cervical radiculopathy to 1 of 3 the groups

○physical therapy plus pharmacotherapy (gabapentin or nortriptyline)

○cervical epidural injections only

○ or combination of injections physical therapy and pharmacotherapy

● All 3 groups experienced a slight improvement in symptoms at 3 months, with
the patients who had combination therapy more likely to report a positive
outcome.

●At 6 months there was no significant difference found between the treatment
groups