cervical radicular pain is defined as pain perceived as arising in the upper limb caused by ectopic activation of nociceptive afferent fibers in a spinal nerve or its roots or other neuropathic mechanisms

1. Cervical Radicular Pain
IN THE NAME OF GOD
DR Mohsen Abad
Pain fellowship

2. Introduction
pain perceived in the upper
limb, shooting or electric in
quality, caused by irritation
and or injury of a cervical
spinal nerve
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3. International
Association for the Study of Pain
cervical radicular pain is
defined as pain perceived as
arising in the upper limb
caused by ectopic activation
of nociceptive afferent fibers
in a spinal nerve or its roots
or other neuropathic
mechanisms
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4. Definition
• Cervical radicular pain must be
distinguished from cervical
radiculopathy.
• In the latter disorder there is
an objective loss of sensory
and/or motor function
• Radicular pain and
radiculopathy are not
synonymous
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5. Definition
• Radicular pain is a symptom
that is caused by ectopic
impulse formation, while
radiculopathy also includes
neurologic signs such as
sensory or motor changes
• These two disorders may occur
simultaneously.
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6. Diagnosis
• characterized by pain in the neck that
radiates over the posterior shoulder
into the arm and sometimes into the
hand
• The radiation follows a segment –
specific pattern.
• Pain from various dermatomes can
overlap and there is no specific region
of the arm
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7. Diagnosis
• Pain originating from C4 is confined to
the neck and suprascapular region
• C5 radiates up to the upper arm
• C6 and C7 radiates from the neck to
the shoulder, the forearm, and the
hand
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8. Diagnosis
• Radicular pain is not limited to a
particular dermatome and can be
perceived in all structures that are
innervated by the affected nerve
roots such as muscles, joints,
ligaments, and the skin
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9. Physical examination
• there is no gold standard for the
diagnosis of cervical radicular pain
• Diagnosis is made based on a
combination of history, clinical
examination, and additional test
• Sensation, strength, and tendon reflexes.
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10. Specific clinical tests
Spurling test:
Neck extended with head rotated to
affected shoulder while axially loaded.
Reproduction of the patient’s shoulder or
arm pain indicates possible cervical spinal
nerve root compression
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11. Spurling test
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12. Specific clinical tests
Shoulder abduction test
•The patient lifts a hand above his or her
head. A positive result is the decrease or
disappearance of the radicular symptom.
•Once the patient is in the testing position,
the position should be held for 5-10
seconds to allow symptoms to dissipate or
resolve
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13. Shoulder abduction test
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14. Specific clinical tests
Axial manual traction test
In supine position an axial traction force
corresponding to 10 to 15 kg is applied.
A positive finding is the decrease or
disappearance of the radicular symptom
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15. Axial manual traction test
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16. Specific clinical tests
• All of these tests have a high specifi city
(81% to 100%) but a low sensitivity.
• The Spurling test was similarly evaluated
using electromyography as the reference
test
• These three examinations are
considered valuable aids in the clinical
diagnosis of a patient with neck and arm
pain.
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17. Measurement of the
sagittal diameter of the spinal
canal is accomplished by
calculating the distance
between the posterior surface
of the vertebral body
and the spinolaminar line
(between the arrows). At the
C4-7 levels, spinal cord
compression is unlikely if the
diameter of the canal is
13 mm or more
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18. Sagittal multiple planar
gradient recalled (MPGR)
magnetic resonance image
reveals
stenosis of the lower cervical
spine related to the presence
of
osteophytes arising from the
posterior surface of the
vertebral
bodies
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19. Disc
level
Root Pain
distribution
Muscle
weakness
Sensory
loss
Reflex loss
C4 to C5 C5 Margo medialis
scapulae, lateral
upper arm to
elbow
M. deltoideus,
m.
supraspinatus,
m.
infraspinatus
Lateral
upper arm
Supinator
reflex
C5 to C6 C6 Lateral forearm,
thumb and index
finger
M. biceps
brachii, m.
brachioradialis,
wrist extensors
Thumb and
index finger
Biceps reflex
C6 to C7 C7 Medial scapula,
posterior arm,
dorsum of
forearm, third
finger
M. triceps
brachii, wrist
flexors, finger
extensors
Posterior
forearm,
third finger
Triceps
reflex
C7 to T1 C8 Shoulder, ulnar
side of forearm,
fifth finger
Thumb fl
exors,
abductors,
intrinsic hand
muscles
Fifth finger –
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24. Medical imaging
• used to exclude primary pathologies, the
so - called “ red flags ”
• tumor, infection, and fractures
• CT scans are able to reproduce the
changes in bone structure more
sensitively than MRI.
• MRI is currently regarded as the most
suitable medical imaging technique for
patients with cervical radicular pain
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25. Medical imaging
• no data available regarding the
sensitivity and specificity of the various
imaging techniques
• A direct link between the pain syndrome
and the results of medical imaging does
not exist
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26. Electrophysiologic tests
• can be requested when nerve damage is
suspected but will not provide any
information about the pain
• Quantitative Sensory Testing (QST) has
been recommended in the literature as
an electrophysiologic test that can
provide more specific information about
pain
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27. Diagnostic selective nerve root
blocks
• The diagnostic blocks are applied in
separate sessions per level
• Under radiological visualization using a
contrast dye (fluoroscopy), a small
amount of local anesthetic is injected
(0.5 mL)
• During a period of 30 to 60 minutes after
injection, the pain score is evaluated at
regular time intervals. When there is at
least a 50% decrease in pain,DR Mohsen Abad

28. Differential diagnosis
• Pancoast tumor
• spinal tumors
• carpal tunnel syndrome
• facet joints pain
• shoulder pain
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29. Treatment options
Conservative management
•NSAIDS medications are primarily
recommended for short - term treatment
•Anticonvulsants: such as carbamazepine,
oxcarbamazepine , gabapentin, and
pregabalin
•Cochrane review: patient education for
neck pain: does not show effectiveness
•Cochrane review: mechanical traction for
neck pain: no evidence to supportDR Mohsen Abad

30. Treatment options
Conservative management
Multidisciplinary rehabilitation with
physiotherapy is recommended
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31. Interventional m anagement
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32. Epidural corticosteroid administration
• Rely on the anti - inflammatory
response induced by inhibition
of the phospholipase A2 -
initiated arachidonic acid
cascade
• There are no direct
comparisons available between
interlaminar and
transforaminal administration
at a cervical level.DR Mohsen Abad

33. Epidural corticosteroid administration
• randomized study comparing
interlaminar and intramuscular
corticosteroid administration
found that 68% significant pain
relief lasting at least 1 year
compared to 12% in the group
treated intramuscularly.
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34. Interlaminar administration:
complications
• Minor complications that
spontaneously disappeared,
often within 24 hours :
increasing axial neck pain,
• posture - independent
headache,
• facial flushing,
• vasovagal episodes
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35. Interlaminar administration:
complications
Major complications included:
•epidural hematoma
•accidental subdural injection
with, as a result, hypoventilation
and hypotension
•Root damge.
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36. Practical recommendations
• The positive RCT for interlaminar
administration
• There are no studies which have
investigated the effectiveness of
the various depot corticosteroids
• The particle size of the depot
corticosteroid is possibly related to
the reported neurologic
complications
• Currently there is no evidence that
a higher dose of corticosteroids will
result in a better clinical effect.
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37. (Pulsed) radiofrequency treatment
Complications:
•transient neuritis
•burning sensation
•a slight loss of muscular
strength in the hand and arm of
the treated side was reported
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38. efficacy
• Currently preference is given to PRF where
the tip temperature of the electrode does
not exceed the critical threshold of 42 ° C
and consequently there is minimal neuro -
destruction.
• In an RCT, PRF appeared to be more
effective than placebo 3 months post -
treatment. Also 6 months post - treatment
there was a positive trend in the PRF
treatment
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39. Surgical treatment
• is indicated in cervical radiculopathy with
spinal cord compression (myelomalacia)
because of the risk for possibly irreversible
neurologic deficiency.
• In a randomized study where surgical
treatment was compared with conservative
treatment a significant improvement in pain
relief was noted 3 months after the
intervention
• A year post - treatment however there was
no difference between the two groups
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40. Spinal cord stimulation
• Up until now there is no literature on the
outcome of SCS in the treatment of cervical
radicular pain.
• SCS can be considered in clinical practice for
chronic cervical radicular pain in well -
selected patients when other types of
treatment have failed, given that the efficacy
has been demonstrated in other comparable
neuropathic pain syndromes
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41. Recommendations
1
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42. Recommendations
2
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43. Recommendations
3
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44. references
• Evidence-Based Interventional Pain
Medicine (2012)
• Third Edition (Third Edition)
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45. DR Mohsen Abad