radicular pain

[123rich]

hi i am a student and i am finding it hard to diagnose a pt who has pain in his neck and pain radiating down his arm from his biceps to his forearm and hand. he also has pins and needles. his pain is a mechanical pain as movement brings it on. i feel that he has a facet joint problem with radicular pain in a dermatomal pattern due to compression of the c5, c6 cervical spine nerve. his symptoms are related however i want to know if i am on the right track with my clinical reasoning. any help would be great

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[Dr Damien]

Dear 123Rich

Not knowing your patient, I think you might be on the right track. The question to ask is, does his radiating pain get worse with certain neck movements?

radiating pain as far as the hand strongly suggest neck issues, why do you feel it is a facet joint problem specifically?

What you can do is post how you reasoned up to the point of this diagnosis, i mean what your assessments were, what special questions you asked, what tests you did and what was drawing you towards that conclusion...myself and other physios on this forum will be more than delighted to help you reason out this one and perhaps give you a better understanding of what you are doing...I dont think you are far from it though, but I need to hear your thoughts first through this process...

Cheers

[123rich]

the pt slipped and fell onto an outstretched hand. felt pain in the neck first.then complained of pain in the arm with paresthesia which made the pain in his neck worse. now his pain is intermittent.gets pain in the arm and paresthesia when he reaches forward, returns to neutral eases pain. gets pain in the neck in extension and rotation. return to neutral eases pain. 5ds 3 ns and all special questions are ok. pmh is ok.

[Dr Damien]

Dear 123rich

I dont see what you need help with in diagnosing this problem...I think you might be on the mark with your diagnosis

some amount of neck rotation will occur with reaching forward... extension rotation will close the facet joints likely compressing a nerve root, the distribution of the pain suggests C5-C6 (if pain is radiating down the hand to fingers, then maybe lower brachial plexus)
Neural signs such as parasthesia also agrees...the fact that his pain is intermittent is a good thing....

I just have a few suggestions to make to the good reasoning you have done so far

My questions are extension and rotation? what sides preciptates the symptoms...same side or other side?
same side would suggest a facet joint pathology from compression, other rotation will suggest a herniated disc problem or perhaps traction injury to the brachial plexus

What happens with just pure extension and flexion?

it might be unneccessary to do any upperlimb tension tests if the symptoms are pointing to a facet joint pathology primarily because they are uncomfortable for the client and why put them through uneccessary discomfort if the clinical picture is clear...

A few pointers might make it easier to rule out any of the above of include any of the above differentials ive suggested

Traction injuries are unlikely going to give intermittent pain, the pain will most likely always be there and movements that seperate theneck from the shoulder will aggravate even more...id be wary of a distribution that covers serveral dermatomal areas i.e C6, C7,T1 etc...extending to fingers inner side of arm...because this might suggest a herniated disc that is large or several discs out of place at once. In this instance I would refer to a specialist, especially if the client is also having some muscle weakness that is progressive...

If its a cervical disc as would be the case if flexion aggravates or if rotation or rotation/extension aggravates away from the side of the problem, however it can present like a facet joint issue if the disc herniated is large and its pinched by the movement of extension rotation to the same side...again if there is a progressive muscle weakness/numbness...I would refer to a specialist

My experience with facet joint syndromes are that they are more likely in the middleaged to older clients (not exclusively except that in this client, arthritic changes already makes them susceptible)...is your client young? indirect trauma from below as in the outstretched arm can transmit forces to the neck causing the cervical vertebrae to be mal aligned predisposing to narrowing of the facet joints...

I would not conclude yet that it is a facet joint problem until i have explored the other differentials...

Cheers

[123rich]

thanks for the reply. mov to the same side precipitates the symptoms. he is 45 yrs old. however i feel that he may have somatic referred pain from facet joint that causes the pain in his neck with compression of the c5/6 nerve root that causes pain in the c,5,6 dermatome pattern with paresthesia affecting the median nerve. the problem with radicular pain is that it usually is described as a shrap, shooting pain not a deep ache

[Dr Damien]

Dear 123rich

I dont think you have a problem with your reasoning, I think what you are hoping for is some confirmation to your diagnosis. Are you working with a senior colleague?

Just to point out, avoid specifying nerve entrapments at the neck to a specific nerve, leave it at the roots because these nerves do not become what they are until lower...
technically it could be the musculocutaneous nerve as well...or any other nerve that has C5/C6 root fibers...and you are right, radicular pain is often described as sharp pain, when it involves the nerve root...

If you have a senior colleague you are working with seek his advice about a management plan, but I dont see any issues with your diagnosis, it was good in my own opinion...

cheers

[jordanloughlin]

Radicular pain will have changes in hard neuro (Dural Signs) loss of reflexes, particularly biceps, dermatome changes and myotome changes. Sometimes good to test bilaterally.
Facet joints can refer pain. Radicular = nerve root, referred = facet joint.

[yelufem]

Hi 123rich.It sound to me that your assessment of the pt in question has not been adequate.So your diagnosis may be questionable.Little is known whether the pain in the neck which later radiated to the forearm is due to trauma or the case is insidious. Either way, a plain x-ray is vital to rule in or out some problems.Traumatic neck pain without # rarely produce pain with character discribed by u.Mechanical neck pain would likely be insidious,with xray revaeling, reduced intradiskal space and narrowing of intervertebral foramen.provocative test +,mvt in ipsi pain +, rotation could trigger a radiating pain to d forearm +fingers.I cannot really cordinate your mention of facet jt to a cervical problem.Hope i have not caused more confusion. Yelufem.