• C7 radiculopathy: most common root affected by herniated disc. Weak triceps and numb middle finger.
• C5 radiculopathy: most common root affected by brachial neuritis and spondylosis. Weak biceps & infraspinatus (external rotation of shoulder). Numb over deltoid area.
• C8T1 radiculopathy: think of pantcoast tumor, thoracic outlet syndrome. Small muscle atrophy of the hand, minimal numbness in hand.

• Deep Tendon Reflexes: biceps/brachioradialis (C5-6), triceps (C6-7)
• Motor strength: 
  • Finger spread (abduction) C8, T1, Ulnar
  • Extension of fingers at Metacarpal-Phalanx + PIP C7-8, Radial n
  • Adduct thumb against base of index finger C8,T1,Ulnar n
  • Pinch between thumb + little finger C8, T1, Median n
  • Flex thumb C8, Median n 
  • Extend wrist C6-8, Radial n
  • Flex wrist C6-7, Median n
  • Supinate forearm with elbow straight C5-6, Radial n
  • Pronate forearm with elbow straight C6-7, Median n
  • Flex elbow with forearm supinated C5-6, musculocutaneous
  • Extend elbow C6-8, Radial n
  • Hold shoulders abducted C5-6, Axillary n
• Sensory: 2-point discrimination
  • Web space between thumb + index on back of hand C6, Radial n
  • Palmar side distal middle finger C7, Median n
  • Ulnar side of hand C8, Ulnar n
  • Ulnar side of mid-forearm T1
• Maneuvers to reproduce or intensify symptoms
  • Forced full flexion of neck - discogenic cervical radiculopathy
  • Foraminal compression (Spurling's maneuver) turn head towards involved side - cervical radiculopathy from nerve root impingement, first R/O fracture
  • Thoracic outlet maneuvers
    • Adson's maneuver (scalenus anticus) head away from involved side, arm up, hold deep inspiration - anterior scalene syndrome
    • Costoclavicular maneuver (press down on shoulders while patient moves shoulders back) - costoclavicular syndrome
    • Hyperabduction (Wright's) maneuver, hands over head - pectoralis minor syndrome
  • Phalen's maneuver - carpal tunnel syndrome

(C6-C7)

• Pain: neck, medial scapula, down to middle finger
• Most common cause: Acute disc lesions
• Motor weakness: triceps, pronator teres, wrist flexors, and finger extensors.
• Sensory loss: middle finger. 
• Reflex: decreased Triceps reflex

• Motor NCV Median & Ulnar normal.
• Median SNAP normal. Needed to rule out Median nerve dysfunction and middle trunk brachial plexopathy.
• Needle examination:
  • Best C7 muscle: Triceps
  • Also extensor digitorum communis.

• Pain: lateral forearm, thumb and index finger.
• Cause: Cervical spondylosis, disc lesions.
• Motor weakness: biceps and brachioradialis.
• Sensory loss: thumb and index finger.
• Reflex: supinator jerk.

• Motor NCV of median and ulnar nerves are normal. 
• Radial SNAP will be normal and useful to exclude a radial  neuropathy and upper trunk brachial plexopathy.
• Needle exam:  Infraspinatus, Supraspinatus.  Biceps, Brachioradialis.

 (C4-C5)

• Pain: lateral upper arm to elbow, medial scapular border.
• Cause: brachial neuritis, cervical spondylosis, upper plexus avulsion
• Motor weakness: Deltoid, Supraspinatus, infraspinatus, Rhomboids.
• Sensory loss: lateral upper arm and over deltoid.
• Reflex: biceps reflex

• Motor NCV of median and ulnar nerves are normal. 
• The lateral antebrachial  cutaneous SNAP will be normal and useful to exclude a musculocutaneous axonal neuropathy and upper trunk brachial plexopathy.
• Needle exam: Rhomboids (best). Infraspinatus, Supraspinatus.

(C7-T1)

• Pain: neck radiating to the shoulder, ulnar side of forearm and little finger.
• Cause: rare in spondylosis and disc disease.
• Motor weakness: thumb flexors, abductors, intrinsic hand muscles, and long finger flexors.
• Sensory loss: little finger, heel of hand to above wrist.
• Reflex: finger jerk.

• Median CMAP and F-response usually normal, presumably because the abductor pollicis brevis receives the bulk of its innervation from the T1 root.
• Ulnar: CMAP amplitude usually normal. F-response may be prolonged or absent.
• Ulnar SNAP if abnormal: suggest Ulnar  mononeuropathy or lower trunk brachial plexopathy, rather than radiculopathy.
• Needle exam:
  • First dorsal interosseus
  • Extensor indicis proprius (helps exclude ulnar mononeuropathy)

• Pain: deep aching pain in shoulder and axilla to olecranon.
• Cause: cervical rib, pancoast tumor, metastatic carcinoma in deep cervical nodes, outlet syndromes.
• Motor weakness: Small muscles in hand.
• Sensory loss: minimal.
• Reflex: none

• For any neck problem, always think of cervical myelopathy. 
  • Check the legs too. Patient may complain of gait disturbance.
  • Up going toes, leg spasticity, decreased position sense,  increased knee & ankle reflexes.

• Innervation of upper extremity muscles - Wash Univ
• Brachial plexus - Wash Univ
• Spinal root syndromes - UNC
• Nerves in upper limb - NL