Cervical Root Syndrome

Indah ariefani

Data base (April 18th, 2012)

Identity
Name Sex : Mrs. N : woman

Age
Address Occupational

: 37 years old
: Surabaya : Employe PT. Sampoerna

Religion
Ethnic Marital status

: Moslem
: Javanese : Married

Referred from PT.Sampoerna clinic with nyeri leher kiri

Chief complain : nyeri leher kiri

History of present illness :

She felt pain since 11 years ago, pain was mild and only occur if too tired to work but pain was increase since 3 months ago. Pain felt continuously, radiated from left neck to shoulder, arm and left fingers Tingling sensation was felt periodically, especially when she was working. She felt numbness on her left upper extremity No weakness of the upper extremity When she was working (cutting out cigarettes on sampoerna factory), the pain was increase Since her pain is increase (since 3 months ago) she felt her work more slowly. (Usually once scissors, left hand can hold 6-8 cigarettes at a time, but now she hold one by one She felt worried about her disease

History of past illness : - No diabetes mellitus - Hypertension (+) since 1 years ago, routin countrol in cardiovasculer outpatient clinick but she forget the name of medicine - No trauma

Physical Examination (18/04/12)

General Status CM, independent ambulation, normal gait, right handed

Body Weight : 45 Kg, Body height : 146 cm, BMI = 21,1

BP : 120/80 mmHg, HR : 76 x/minute, RR : 20 x/minute Head and Neck : No Anemia, Icterus, Cyanosis, Dyspneu Thorax : Cor : S1S2 sound, murmur -, gallops Pulmo : vesicular/vesicular, wheezing -/-, ronchi -/Abdomen : Meteorismus (-), Liver / Spleen : unpalpable Extremities : warm acral +/+, edema -/-

Physiatric Examination Musculoskeletal examination Cervical Flexion Extension Lateral Flexion Rotation Trunk Flexion Extension Lateral Flexion Rotation ROM F (0-450) F (0-450) F/F (0-450) F/F (0-600) ROM Full (0-80:) Full (0-30:) F/F (0-35:) F/F (0-45:) MMT 5 (pain) 5 (pain) 5/ 5(pain) 5/ 5(pain) MMT 5 5 5/5 5/5

 Shoulder Flexion Extension Abduction Adduction Ext. Rot. Int. Rot.

ROM F/F (0-180:) F/F (0-60:) F/F (0-180:) F/F (0-45:) F/F (0-70:) F/F (0-90:)

MMT 5/5 (pain) 5/5 (pain) 5/5 (pain) 5/5 (pain) 5/5 (pain) 5/5 (pain) MMT 5/5 5/5 5/5

Elbow ROM Extension-Flexion F/F (0-1350) Forearm supination F/F (0-900) Forearm pronation F/F (0-900)

 Wrist Flexion Extension Radial deviation Ulnar deviation Fingers Flexion MCP PIP DIP Extension Abduction Adduction

ROM F/F (0-800) F/F (0-700) F/F (0-200) F/F (0-350) ROM F/F (0-900) F/F (0-1000) F/F (0-900) F/F (0-300) F/F (0-200) F/F (200-0)

MMT 5/5 5/5 5/5 5/5 MMT 5/5 5/5 5/5 5/5 5/5 5/5

 Thumb Flexion MCP IP Extension Abduction Adduction Opposition Hip Flexion Extension Abduction Adduction Ext. Rotation Int. Rotation

ROM F/F (0-900) F/F (0-800) F/F (0-300) F/F (0-700) F/F (500-0) ROM F/F (0-1200) F/F (0-300) F/F (0-450) F/F (0-200) F/F (0-450) F/F (0-450)

MMT 5/5 5/5 5/5 5/5 5/5 5/5 MMT 5/5 5/5 5/5 5/5 5/5 5/5

 Knee Extension-Flexion Ankle Plantar Flexion Dorsi Flexion Inversion Eversion Toes Flexion MTP IP Extension Big Toe Flexion MTP IP Extension

ROM F/F (0-1350) ROM F/F (0-500) F/F (0-200) F/F (0-350) F/F (0-150) ROM F/F (0-300) F/F (0-500) F/F (0-800) ROM F/F (0-250) F/F (0-250) F/F (0-800)

MMT 5/5 MMT 5/5 5/5 5/5 5/5 MMT 5/5 5/5 5/5 MMT 5/5 5/5 5/5

 Neurological Examination
N. Cranialis I XII Deep tendon Reflex : within normal limit : BPR +2/+2 TPR +2/+2 KPR +2/+2

APR +2/+2
Pathological Reflex : Babinski -/-, HT -/-

sensory
100% 100% C5 C6 75% 75%

100%
100% 100%

C7
C8 T1

75%
75% 75%

 Locally status Regio Cervical - Shoulder:

Inspection : deformity -/-, inflamatory sign -/-, atrophy -/-, swelling -/-

Palpation : paracervical muscles spasm +/+

uppertrapezius muscle spasm +/+,

tender point -/-

 Special test

Head compression test Head distraction test spurling test TOS I, II, III Phallen test :+ : -/+ : -/: -/-

:-

Prayer test
Tinel sign

: -/: -/-

Diagnosis :
Medical Impairment : CRS root C5,6,7,8,T1 sinistra Functional diagnosa : : - paracervical muscles spasm - uppertrapezius muscle spasm

- sensory deficit in dermatom

C5,6,7,8,T1 sinistra Disability Handicap :: reduced of efficiency on work

Problem list :
1. Medical : CRS root C 5,6,7,8,T1 sinistra

2. Surgical

: (-)

3. Rehabilitation Medicine: R1 (Ambulation) :R2 (ADL) :R3 (Communication) : R4 (Psychological) : worried about her disease R5 (Social Economic) : income decreases

R6 (Vocational) R7 ( Others )

: reduced of efficiency on work : - pain on neck, shoulder until fingers sinistra - paracervical muscles spasm +/+ - uppertrapezius muscles spasm +/+ - Sensory deficit in dermatom C 5,6,7,8, T1 sinistra - spurling test -/+ distraction test -/+ - HT terkontrol

Planning : 1. Medical : meloxicam 1x15mg, diazepam 1x1 ,

neurotropic
2. Surgical : (-)

3. Rehabilitation Medicine :
P. Dx P. Tx : foto radiologi cervical ap/lat : modalitas: USD area upper trapezius 1 MHZ frequency 2x/week OT : resensitisasi sensoris

P.Mx : klinis, simptom : vas, defisit sensoris P.Ex : explain abouth her disease postur correction neck cailliet exercise (precaution HT ) resensitisasi sensoris

Summary
It has been reported that a women 37 years old. Referred from PT.Sampoerna clinic with nyeri leher kiri She felt pain since 11 years ago, pain was mild and only occur if too tired to work but pain was increase since 3 months ago. Pain felt continuously, radiated from left neck to shoulder, arm and left fingers. Tingling sensation was felt periodically, especially when she was working. She felt numbness her left upper extremity. No weakness of the upper extremity. When she was working, the pain was increase. Since her pain is increase (since 3 months ago) she felt her work more slowly. She felt worried about her disease

From physical examination was found paracervical and upper trapezius muscles spasm, and there was sensory deficit dermatom C5,6,7,8,T1 sinistra. Positif spurling test and distraction test. Planning diagnose was doing foto radiology Cervical AP/LAT. Planing terapi were give modalitas : area upper trapezius and OT: resensitisasi sensoris. Planning Monitoring: Clinical signs and symptoms. Planing education: explain abouth her disease, postur correction, neck cailliet exercise (precaution HT ), resensitisasi sensoris.

THANX YOU

Definition:
Group of symptoms are occured from nerve root entrapment/ irritation within the foramen intervertebralis and give subjective and or objective dermatome or myotome distribution.

PATOGENESA
the cervical nerve root compression symptoms of neck pain which followed spread to the shoulders, upper arms / forearm, paresthesia, weakness

etiology
Inflamasion : edema can cause pressure Trauma : bledding / blood clot Osteofit Herniasi diskus

Clinical Symptom:
Pain and tingling in the neck, radiated to shoulder, pectoral, scapulae, arm and forearm on the affected side. Sensoric symptom : parestesia and hipoestesia. Weakness in the neck muscle, arm and forearm, until intrinsic hand muscle atrophy

DISC

ROOT

REFLEX

MUSCLES

SENSATION

C4-C5

C5

Biceps

Deltoid Biceps Wrist extension Biceps Wrist flexor Finger extension Triceps Finger flexion Hand intrinsic Hand intrinsic

Lateral arm

C5-C6

C6

Brachioradialis (Biceps) Triceps

Lateral forearm, thumb, index finger Middle finger

C6-C7

C7

C7-C8

C8

Medial forearm, ring, small finger Medial arm

C8-T1

T1

34

Special Test:
Compression Test Distraction Test Spurling Test

Compression test
Procedure: Axial compression is applied to the cervical spine in the neutral (0) position. Assessment: Compression of the intervertebral disks and exiting nerve roots, the facet joints, and/or the intervertebral foramina increases a radicular, strictly segmental pattern of symptoms. The presence of diffuse symptoms that are not clearly specific to any one segment may be regarded as a sign of ligamentous or articular functional impairment (facet joint pathology).

Distraction test
Differentiates between radicular pain in the back of the neck, shoulder,and arm and ligamentous or muscular pain in these regions. Procedure: The patient is seated. The examiner grasps the patients head about the jaw and the back of the head and applies superior axial traction.

Spurling test
Procedure: The patient is seated with the head rotated and tilted to one side. The patient bends or laterally flexes the head to the unaffected side first, then to the affected side. With the other hand, the examiner lightly taps (compresses) the hand resting on the patients head Assessment: If pain radiates from the cervical spine down the patients arm the test is considered to be positive.

Supporting examination:

X-ray Cervical AP / L / Oblique MRI Cervical

Differential diagnosis:

1. Thoracic Outlet Syndrome 2. Carpal Tunnel Syndrome

Management :
1. Medical
NSAIDs Muscle relaxan Neurotropic

2. Rehabilitation Program
Modalities : SWD / MWD / or USD TENS Cervical Traction OP : Soft Cervical Collar : remainding Home Exercise Program Neck Cailliet Exercise Posture Correction

3. Surgical

cervical root syndrom

43

Neck Calliet exercises

Flexion. Have the patient place both hands on the forehead and press the forehead into the palms in a nodding fashion while not moving Side bending. Have the patient press one hand against the side of the head and attempt to side-bend, as if trying to bring the ear toward the shoulder but not allowing motion. Axial extension. Have the patient press the back of the head into both hands, which are placed in the back, near the top of the head Rotation. Have the patient press one hand against the region just superior and lateral to the eye and attempt to turn the head to look over the shoulder but not allowing motion. cervical root syndrom 44

MANUVER ADSON
Tes ini dilakukan dengan mempalpasi pulsasi arteri radialis setelah lengan pasien diletakkan pada posisi anatomis (abduksi 15o dan supinasi), leher dirotasikan secara aktif ke sisi yang diperiksa. Dinyatakan positif jika pulsasi arteri radialis mengalami obliterasi pada saat inspirasi dalam.

Manuver Halstead (costoclavicular) atau tes posisi militer

Dilakukan dengan retraksi scapula dan depresi bahu. Tes ini dinyatakan positif jika ditemukan obliterasi pulsasi arteri radialis atau ada reproduksi dari gejala.

Manuver Allen . Tes ini untuk mengetahui

adanya kompresi pada thoracic outlet. Pasien dalam posisi duduk. Lengan yang sakit ditahan pada posisi fleksi siku 90o. Pemeriksa mempalpasi arteri radialis, tangan pemeriksa lainnya menahan punggung pasien. Kemudian pemeriksa mendorong lengan pasien sehingga bahu ke arah hiperekstensi dan rotasi internal. Kemudian pasien diminta menolehkan kepala ke arah kontralateral dari sisi yang diperiksa. Dinyatakan positif jika terjadi obliterasi arteri radialis, nyeri pada bahu dan lengan, iskemia, dan parestesi.

Stabilisasi
Tujuan :

Membatasi nyeri
Memaksimalkan fungsi Mencegah cedera lebih lanjut Stabilisasi termasuk : Fleksibilitas spina servikal

Reedukasi postur
Penguatan

Outer annulus fibrosus

Nucleus pulposus

Inner annulus fibrosus

STRUCTURES OF IVD :
1.Outer Annulus: Fibroblast cells Collagen I 2.Inner Annulus : Chondrocyte-like cells Collagen II 3.Central Nucleus Pulposus 4.Vertebral endplate : hyaline calcified cartilage