Jonathan Wray presents a case that reflects evidence-guided clinical reasoning while incorporating patient preference to achieve optimal clinical outcomes.
Cervical radiculopathy (CR) is a condition resulting from foraminal encroachment of the cervical nerve roots.1 The clinical manifestations of CR are variable and include neck pain, upper limb pain, sensory changes such as paraesthesia and numbness, motor deficits, diminished reflexes or any combination of these.2 A common cause of foraminal encroachment in CR is cervical spondylosis.1 Degenerative changes at the facet joints affect the posterior aspect of the nerve root, and at the uncovertebral joints, the anterior aspect. Degenerative loss of disc height with associated arthritic joint changes can reduce the diameter of the neural foramen, contributing to nerve root impingement.3 Nerve roots C6 and C7 are most commonly affected.2 Herniation of the cervical disc is only responsible in 25 per cent of cases.4 Other causes include trauma, but these are relatively uncommon.4 Nerve root compression in isolation does not necessarily lead to radicular pain unless the dorsal root ganglion is involved.1 Some evidence suggests that inflammatory mediators released by the cervical discs during the degenerative process are responsible for symptoms of radicular pain.5
The age-adjusted incidence is approximately 83 per 100,000 persons, making it considerably less common than lumbar radiculopathy (1.44 per 100 persons).6,7 There is limited evidence that documents the natural history of CR2. A systematic review by Wong et al8 that evaluated untreated CR concluded most patients report substantial improvements 4–6 months after onset and such improvements are maintained over 2–3 years. However, there is a poorer prognosis for those with workers’ compensation claims.2,8 Conservative management for CR includes manual therapy, manipulation, traction, exercise, pharmacology and cervical steroid injection.2 Authors have reported good to excellent results with conservative management.9 However, it is suggested that an estimated 26 per cent of patients with CR require surgery.4 Surgery should be considered if pain persists after 6–12 weeks of conservative treatment or if there is evidence of progressive neurological deficit.10 Additional features that may warrant early surgical intervention include myelopathy or signs of cervical instability.2
There are no studies that directly address the question of whether surgery, non-surgical treatment, or a wait-and-see approach should be used to manage patients with CR. Clinical guidelines have been based on clinical expertise, indirect evidence as well as patient preference.10 National guidelines for the non-operative management of CR from North America, based on low-quality evidence or consensus from a systematic review,11 support the use of patient education, non- steroidal anti-inflammatory medication, individualised physical activity, motor control exercise, manual therapy and traction, which has been well described.
A 43-year-old female office worker presented with a seven-week history of right neck pain, upper limb pain, and paraesthesia extending to the level of the right index finger. She reported intermittent pain of up to eight on a 0–10 numerical rating scale (Figure 1).
Symptom onset was insidious, and the patient attributed this to poor posture sitting at work. Her symptoms exacerbated two weeks after onset, after she fell on steps.
An MRI and CT scan organised by the treating GP identified a disc herniation at C6/7 (Figure 2). At the time of the initial consultation, the patient was unable to work due to her symptoms and she was worried about the financial implications. Married with two teenage children, prior to injury she enjoyed yoga and walking. The patient was fearful of her diagnosis and the long-term implications, and she was quite distressed by other findings on her imaging reports, such as, ‘multilevel disc degeneration’ and ‘degenerative disc disease’. The patient had attended for other interventions such as chiropractic, massage, acupuncture and Bowen therapy, which had not afforded symptom relief nor provided a long-term strategy for managing her condition. She was using pain medication as directed by her GP, which included paracetamol, Lyrica and Celebrex. An appointment with a neurosurgeon was pending.
Aggravating factors were holding the right upper limb on the steering wheel while driving, associated with weakness and production of pain in the neck (PN) and pain in the shoulder (PS) after five minutes. Working at a computer using a mouse reproduced PN, PS and a sensation of swelling in the right index finger after 15 minutes. The patient reported weakness if she maintained her upper limb in these positions and when lifting a washing basket. She avoided activities of daily living with her right upper limb. Easing factors were avoiding the aggravating positions and using anti-inflammatory medication (Celebrex), and greatest relief was achieved from lying prone over a gym ball in cervical spine flexion. Her physiotherapy goals were to gain help in resolving her condition without surgery and to get ‘strong again’. She was concerned that her neck and upper limb pains would prevent her from achieving this and that her current presentation would become chronic.
The patient’s usual seated position was slumped with a head-forward posture. Cervical active range of motion was limited with a consistent pattern of restriction to the right side (see Table 1). All movements were guarded and slow. When low cervical extension was biased, movement was minimal due to guarding and reproduction of PN and PS. Shoulder range of motion was full without pain. Neurological examination demonstrated reduced muscle strength assessed as four using a 0–5 scale (American Spine Injury Association) for the C7 myotome, with absent triceps reflex. Palpation over the radial and median nerves demonstrated hyperalgesia in response to palpation at the levels of the proximal upper limb, elbow and forearm, which was not the case for the left side.
Neurodynamic testing highlighted mechanosensitivity of the radial and median nerve at 30 degrees of abduction on the right side, which was not present when testing the left upper limb. Sensation to light touch and pin prick was normal for the hand and upper limb, although hyperalgesia was noted over the locations of PS and PN. Strength and endurance of elbow extension was assessed using a two kilogram weight in supine. The patient was able to achieve 15 repetitions to fatigue on the left side and five repetitions on the right. This was used as an objective measure to monitor neurological deficit. When the patient moved from supine to sitting, she assisted cervical flexion with her hand because she reported that her head felt heavy. Craniocervical flexion endurance assessed in supine was four seconds. Assessment of shoulder control demonstrated reduced endurance of shoulder flexion at 90 degrees on the right and reduced scapulothoracic control in four-point kneeling through the right upper limb. This was partly due to reproduction of PS and reporting of weakness by the patient. Spurling’s test was initiated; PN and PS were reproduced with combined cervical right rotation and right-side flexion.
On the first visit the patient completed the Leeds Assessment of Neuropathic Signs and Symptoms questionnaire (S-LANSS) and the Short Form Orebro (SFO). At the second visit the patient completed the Neck Disability Index (NDI) and Patient Specific Functional Scale (PSFS) as recommended by North American Guidelines.12 On the S-LANSS she scored six, on the SFO she scored 48/100 and on the NDI she scored 18/50, which put her in the moderate disability group.13 The PSFS highlighted difficulty with activities of daily living (see Table 2).
Hypothesis regarding the patient’s presentation
Loss of triceps reflex and weakness in the C7 myotome identified during the physical examination, combined with the MRI evidence of a C6/7 disc extrusion, supported a hypothesis of C7 cervical radiculopathy.
Due to the presence of a C6/7 disc extrusion and the fact that the patient gained relief from non-steroidal anti-inflammatory medication, it was hypothesised an inflammatory process was the main cause of her symptoms.5 Neurodynamic and neural tissue provocation testing were indicative of neural tissue mechanosensitivity. The SFO identified an elevated level of concern relating to the long-term prognosis. Interpretation of the NDI and PSFS identified that the patient’s presentation was having a significant impact.
Treatment and management plan
Management of this patient began with education on contemporary pain science to help her understand her symptoms and to reduce the fear around them. In a systematic review of pain neuroscience education (PNE) in chronic low back pain, Wood and Hendrick14 found moderate evidence that PNE added to usual physiotherapy improved disability in the short term. Also discussed were current research findings relating to CR and the favourable natural prognosis to reduce her concern as highlighted on her SFO.4,15
Manual therapy was provided initially to reduce symptoms of neural tissue mechanosensitivity, to increase cervical spine active range of motion and to reduce neck pain. This approach has been shown to be effective in individuals with CR.16 Manual therapy techniques included cervical lateral oscillatory glides at C6 to reduce neural tissue mechanosensitivity, and manual cervical traction at C6 to reduce pain.
An exercise program was commenced to retrain motor control of the cervical spine and right upper limb:
- cervical rotation in supine with head supported to reduce axial compressive loading of the cervical spine—this exercise was used to address bracing of the cervical musculature and improve active range of motion. The patient was instructed not to move into a provocative range
- deep cranial cervical flexion in supine was deemed appropriate as it had a pain- relieving effect, and reduced endurance was noted in the physical examination
- cervical extension motor control in four-point kneeling was given with the patient moving from a fully flexed cervical position (ie, head down to a neutral cervical position while demonstrating optimal craniocervical control). This was for postural endurance in a neutral cervical spine position and for weight bearing control through her right upper limb
- supine bilateral shoulder flexion was given for neural mobilisation as it was less provocative than abduction and because it related to functional restrictions identified in the physical exam
- a supine triceps extension exercise performed with a two kilogram dumbbell was given as an objective measure of progression or worsening of neural deficit, and also to encourage strength retraining of muscle fibres as neuromuscular activity started to resolve.
The patient was treated 14 times over 12 weeks during which time her exercise program was progressed. This progression was to target reduced endurance and control of the upper limb and cervical spine in functional positions (ie, using a computer mouse, moving from supine to sitting and lifting up to five kilograms). Exercises included:
- standing resisted shoulder flexion and extension for right upper limb functional deficits highlighted in the physical exam
- craniocervical endurance combined with moving supine to sitting
- progression of cervical motor control combining coordination of the cervical extensors and craniocervical flexors in a neutral spine position while adding upper cervical rotation. This was performed in an elbow-propped position
- bicep curl and shoulder press combined with a split squat to target lifting-related activities.
During this time the patient had a review with a neurosurgeon who made a case for surgical intervention, primarily based on her motor deficits. This alarmed the patient, as her preference was a non-surgical approach.
Over a 12-week treatment period and 14 sessions of physiotherapy, this patient made significant improvements in NDI, PSFS, active range of motion and motor weakness after being treated with a combination of manual therapy and therapeutic exercise.
Limited high-quality evidence is available on best management strategies for patients with CR.2,11 This can lead to confusion both for the referring GP and for the patient, which may lead to conflicting advice given by healthcare providers. Some reports suggest that surgery is most effective if conducted within 12 weeks from onset of symptoms.1 Others suggest a shorter time frame of eight weeks7 and that the longer the duration of symptoms the poorer the clinical outcomes are after surgery.17 This may put pressure on primary healthcare providers and patients to proceed to surgery sooner rather than later due to fear of not achieving optimal outcomes. However, apart from progressive neurological deficit, indications for surgery include failure of resolution of symptoms with a conservative approach.1 With regard to early surgical intervention due to motor deficit, Overdevest et al18 found surgical intervention demonstrated faster improvements in motor weakness in lumbar disc herniations. However, this improvement was no longer significant after 26 weeks between surgical and non-surgical groups. Imaging has also shown spontaneous resolution of disc herniations and large disc protrusions in the cervical and lumbar spine with clinical improvements correlating with these changes.19
Definitive treatment protocols for physiotherapeutic management of patients with CR have not been developed and there are deficits in the literature for physiotherapy treatment approaches.12 In a systematic review of the literature, Boyle et al20 report a general consensus exists in the literature that manual therapy combined with therapeutic exercise is effective in reducing pain and disability while increasing function in patients with CR. In this case key attributes of this patient presentation guided the management approach, for example, her age and absence of other comorbidity; her S-LANSS score was low, indicating a favourable prognosis and higher likelihood of responding to manual therapy;21 her SFO was 48/100, and scores greater than 50 indicate a less favourable prognosis;22 and her preference was for a non-surgical treatment approach. The use of manual therapy in patients with cervicobrachial pain, particularly passive cervical lateral glides of the associated motion segment, have been shown to be effective in reducing pain and disability.21,23 The same technique has been shown to improve range of motion in upper limb neurodynamic testing.23,24 Traction of the involved cervical motion segment has been shown to decrease pain and perceived disability in patients with CR.24 These techniques were chosen as pain- relieving techniques and to reduce neural tissue mechanosensitivity. They were then combined with exercises directed at the patient’s functional limitations highlighted in the physical exam and the PSFS. This management strategy was in line with current opinion and the evidence base.
It also supports the opinion that delaying surgery beyond the current 12-week time frame may be appropriate.
This case illustrates that physiotherapy combining manual therapy, exercise and PNE was an effective approach in the management of a patient with CR and should be considered prior to surgery. The patient provided informed consent prior to writing this case study.
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APA Musculoskeletal Physiotherapist Jonathan Wray is in his second year of specialisation training with the Australian College of Physiotherapists. He is a director and principal physiotherapist at Next Wave Therapy in Fremantle and also works as a clinical tutor for the Master of Clinical Physiotherapy program at Curtin University.
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