Cervical Radiculopathy

Quick synopsis

	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.

Key exams in upper limbs

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

Root (Disk level)

Clinical & Electrodiagnosis

(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.

C6 (C5-C6)

	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)

T1 (T1-T2)

	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