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5002 Case 5 Cheat Sheet by

C7 radiculopathy + possible associated (due to age) w/ degenerative change & potentially existing (previously asymptomatic) disc herniation

Case Hx

- 62 y.o.
- Neck & L arm pain
- L pectorals area & down L posterior arm
- L first 3 fingers
- Pushing a washing machine 6 weeks ago
Neck & shoulder
- Deep achy pain
- Hand feels numb & bit weak
- 7/10
L first 3 fingers
- Numb & sometimes tingly
AF: Working overhead, shaving, & circling head
- RF: Massaging forearm & triceps / raising arm / naproxen relieves pain
- Diagnosed w/ high BP (2004)
- Recent spell of dizziness
- Naproxen
- Atenolol (β blocker)

Physical Exam Findings

- AROM: pain + restriction
- PROM: L + R rotation pain + restriction
- PROM: pain on extension
Clinical tests
- Cx maximal compre­ssion test: arm pain + numbness in L hand
- Cx distra­ction: relieves pain (nerve root compression)
- Doorbell sign: discomfort bilaterally
- Shoulder abduction test: relieves pain w/ L hand on head
- Shoulder depres­sion: L pain
- TOS: negative
- Romberg: negative

- Median tension test: R uncomf­ort­able, L POC
- Ulnar tension test: R uncomf­ort­able, L POC
- Radial tension test: L POC
TTP (tender to palpation) + hypertonic
- L traps
- Levator scapluae
- Rhomboids
- Scalenes
- Pecs
Spinal palpat­ions:
- C5-T1 TTP & restricted
- T6-T7 restricted extension


Working diagnosis
- C7 radicu­lopathy (combi­nation of muscle weakness seen) + potential associated degene­rative change (based on age) & potential pre-ex­isting (asymp­tom­atic) disc herniation
- Traumatic sprain / strain event causing the overall symptoms we see now
NICE guidance
- Refer for MRI & consid­eration of invasive management options (most pts w/ Cx radicu­lopathy don't need surgery)
- Conser­vative manage­ment:
- Can be considered while pt is waiting for further investigation
- Need to closely monitor neurol­ogical status
- Main concern: weakness & long-term impact on pt's ADLs
- Pt should contact GP again to discuss pharma­col­ogical options
Less likely Dx
- TOS: possible from Hx but less likely as no reproduced symptoms in physical examination
- Peripheral nerve entrapment (median / radial): depending on the location of the entrap­ment, less likely to explain the whole presen­tation & the symptoms being aggravated by max. Cx compre­ssion & relieved by Cx distra­ction suggest root involvement
- Sub-acute Cx spine sprain / strain: may be initial onset of symptoms, it doesn't explain the current neurol­ogical picture
- Non-sp­ecific neck pain w/ associated myofascial involv­ement:* could account for part of the presen­tation but doesn't explain the objective neurol­ogical deficit (comment have mechanical & myofascial involv­ement in pts w/ radicu­lop­athy)*
Important not to miss
- Cardiac causes & apical lung tumour: unlikely given the whole clinical picture, including all Hx & physical examin­ation findings
- Cx radicu­lom­yel­opathy: should be considered in any pt w/ neck & arm pain, especially older pts
Separate complaint of momentary dizziness: after getting up quickly from a stooped position
- Most likely due to postural hypote­nsion (aka. orthos­tatic hypotension)
- Could be cervic­ogenic & important not to miss (causes would be vascular)

Learning Outcomes

Presen­tations of C6, C7 & C8 radicu­lopathy (nerve root)
- Radiating pain down the arm to the thumb & index finger
- Weakness in the biceps & wrist extensors
- Tingling or burning sensations in the fingers
- Difficulty w/ fine motor skills (buttoning a shirt or holding small objects)
- Radiating pain down therm to the middle finger
- Weakness in the triceps & wrist flexors
- Tingling or burning sensations in the middle finger
- Difficulty with grip strength & hand dexterity
- Radiating pain down the arm to the ring & little finger
- Weakness in the hand intrinsic muscles
- Tingling burning sensations in the ring & little fingers
- Difficulty w/ fine motor skills (typing or writing)
Presen­tation of median & radial nerve entrapment
Median nerve: (aka. carpal tunnel syndrome)
- Numbness, tingling, or burning sensation in the thumb, index, middle, & half of the ring finger
- Weakness in the hand, especially the thumb, making it difficult to grasp objects or hold into things
- Pain in the wrist &/or forearm, which can be worse at night or during repetitive tasks
- Feeling of clumsiness or a tendency to drop things
Radial nerve:(aka. radial tunnel syndrome)
- Pain or tenderness in the forearm or elbow, which can be worse when bending the wrist or fingers back or rotating the forearm
- Weakness in the wrist or fingers, making it difficult to grip or hold onto things
- Numbness or tingling sensation in the back of the hand, or the thumb, index, & middle finger
- Feeling of weakness or inability to extend the wrist or fingers
Differ­entiate between radicu­lopathy & peripheral nerve entrapment presen­tations
Location of symptoms:
- Radicu­lop­athy: usually causes symptoms in specific area of the arm or hand that corres­ponds to the location of affected nerve root (e.g. C6 causes Sx in neck, shoulders, & arms, while C8 causes Sx in the ring & little fingers)
- Peripheral nerve entrap­ment: causes Sx in specific nerve distri­bution in the arm or hand (e.g. carpal tunnel syndrome causes Sx in the thumb, index, middle, & half of the ring finger)
Pattern of Sx:
- Radicu­lop­athy: usually causes Sx that radiate along a specific nerve pathway (herniated disc causing C6 radicu­lopathy can cause pain that radiates down the arm to the thumb & index finger)
- Peripheral nerve entrap­ment: Usually causes Sx in a more localised area (carpal tunnel syndrome usually causes pain, numbness, & tingling in the thumb, index, middle, & half of ring finger)
Onset of Sx:
- Radicu­lop­athy: usually develops gradually over time (herniated disc may take weeks or months to cause noticeable Sx)
- Peripheral nerve entrap­ment: can develop suddenly or gradually (carpal tunnel syndrome can develop suddenly due to repetitive hand movements or wrist injury)
Associ­ation w/ other condit­ions:
- Radicu­lop­athy: often associated w/ other spinal conditions (e.g. herniated discs, spinal stenosis, or degene­rative disc disease)
- Peripheral nerve entrap­ment: can be associated w/ activities or conditions that put pressure on the nerves (e.g. repetitive hand movements, wrist injuries, or certain medical conditions like diabetes)
Management of pts w/ radicu­lopathy
Conser­vative manage­ment:
- Rest
- Manual therapy
- Medications
- Heat & ice therapy
Invasive manage­ment:
- Epidural steroid injections
- Surgery
Lifestyle changes:
- Mainta­ining good posture & body mechanisms
- Exercise
- Mainta­ining a healthy weight
Different types of TOS, how it's diagnosed & managed
Neurogenic TOS:
- Compre­ssion of brachial plexus
- Shoulder, arm, & hand
Venous TOS:
- Compre­ssion of subclavian vein
- Blood vessel that carries blood from arm to heart
Arterial TOS:
- Compre­ssion of the subclavian artery
- Blood vessel that carries blood from heart to arm
- Combin­ation of medical Hx, physical examin­ation, & diagnostic tests
- Tests: x-rays, MRI or CT scans, EMG, or nerve conduction studies
- Conser­vative manage­ment: manual therapy, medica­tions, lifestyle modifications
- Invasive manage­ment: surgery, vascular procedures (angio­plasty or stenting)
Presen­tations for MI, angina & apical lung tumours
MI (blood flow to heart is blocked, damage or death of heart muscle):
- Chest pain or discomfort (pressure / tightness in the chest)
- Pain or discomfort in the arms, neck, jaw, back, or stomach
- Nausea / vomiting
- Sweating
- Feeling lighth­eaded or dizzy
Angina (chest pain that occurs when heart muscle don't get enough blood flow / oxygen):
- Pressure or squeezing sensation in chest
- Pain or discomfort in the arms, neck, jaw, shoulder, or back
- Nausea / vomiting
- Sweating
- Feeling lighth­eaded or dizzy
Apical lung tumours (lung tumour that grows in the apex of lung):
- Chest pain
- Coughing up blood
- Hoarseness or difficulty speaking
- Fatigue or weakness
- Loss of appetite or weight loss
- Swelling of the face, neck, or arms
Postural hypote­nsion (aka. orthos­tatic hypotension)
- Drop in BP (≥20 mm Hg systolic and/or ≥10 mm Hg diastolic) that occurs within 3 minutes of standing
- Normally, when person stands up, body compen­sates by increasing HR & constr­icting blood vessels to maintain BP → if postural hypote­nsion, compen­satory response is inadeq­uate, leading to drop in BP & reduced blood flow to brain
- Dizziness or lightheadedness
- Fainting or near-fainting
- Blurred vision or tunnel vision
- Nausea
- Fatigue
- Headache
- Dehydration
- Medication side effect
- Diabetes
- Nervous system disorder
- Aging
Treatment* (depends on underlying cause):
- Lifestyle changes: staying hydrated, standing up slowly, wearing compre­ssion socks
- In some cases, medication adjust­ments


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