Hand and Wrist Surgery - part 3 pdf

18 Cervical Root Compression Bradley M. Thomas, John M. Olsewski, and Jerry G. Kaplan His tory and Clinical Presentation A 49-year-old right hand dominant electrician presented with complaints of pro- gressive weakness in his right arm. He also described having pain in his neck ex- tending down the front of his arm to his hand. He was having difficulty lifting objects with his right hand and performing repetitive-type motions, with weakness of his right shoulder and biceps. He reported occasional numbness in his thumb and index finger while at work. He did not recall any trauma to his neck or arm. He denied bowel or bladder dysfunction, and was not experiencing disturbances in his gait. On further ques- tioning he denied any history of smoking, diabetes, or hypertension. He also de- nied night pain. Phy sic al Ex ami nat ion Examination revealed a patient in no acute distress, with a full range of motion of the cervical spine. Reproduction of his right arm pain was elicited with ex- tension of the neck and rotation of his head to the right (Spurling’s maneuver). He appeared to have mild deltoid wasting on his right with prominence of his acromion. Motor testing was symmetric with 5/5 strength in bilateral deltoids, biceps, triceps, wrist flexors, wrist extensors, finger flexors, finger extensors, and hand intrinsics. His deep tendon reflexes were 2+ and symmetric, with the ex- ception of the biceps reflex, which was depressed on the right side compared with the left. He had a negative Hoffman’s sign and his gait was within normal limits. Tinel’s and Phalen’s testing of the median nerve at the wrist were not provocative. Dia gno stic Studies Radiographs taken included an anteroposterior, lateral, obliques, and flexion/exten- sion laterals of the cervical spine. There is evidence of multilevel degenerative changes, with principal changes at the C5-C6 level. These changes include loss of C5–6 disk height on the lateral and narrowing of the C6 neural foramen with en- croachment on the foramina by osteophyte on the oblique views (Fig. 18–1). Mag- netic resonance imaging (MRI) of the cervical spine showed evidence of multilevel mild cord impingement with disk herniation at C3–4, C4–5, C5–6, and C6–7, along with focal increased signal intensity within the cord at the C5–6 level on the T2-weighted images consistent with cord edema (Fig. 18–2). There is also bilateral foraminal narrowing on the axial images at the C5–6 level (not shown). A needle electromyogram (EMG) was performed, which showed membrane instability of the C6 innervated muscles on the right side. C5, C7, and C8 muscles were normal. The nerve conduction studies did not exhibit peripheral nerve slowing as evidence for peripheral nerve compression. C O M P R E S S I O N N E U R O P A T H Y 102 PEARLS • Spurling’s maneuver repro- duces a patient’s arm pain and paresthesias by turning the patient’s head toward the symptomatic side and ex- tending the neck. This position decreases the size of the neu- roforamina. • Use an EMG to differentiate first-degree shoulder problems from a C5 root problem. • Biceps weakness may be the first sign of rotator cuff disease, although a herniated C6 root can give similar findings. PITFALLS • Patients with sensory changes in the thumb and index fin- ger may have carpal tunnel syndrome and not a C6 radiculopathy. • Check for a local Tinel’s and Phalen’s sign. • An incomplete cervical spine exam in a patient with upper extremity problems often leads to an incorrect diagnosis. • A full cervical spine x-ray series should be used to see on oblique films encroachment on the foramina by osteophytes. 103 A B Figure 18–1. (A) Lateral radiograph of the cervical spine showing multilevel degenerative changes with narrowing at the C5–6 disk space. (B) Oblique radiograph showing narrowing and osteophyte (4) formation within the C5–6 neuroforamen. Figure 18–2. T2-weighted sagittal magnetic resonance imaging (MRI) of the cervical spine shows disk herniations at C3 lumen 4, C4–5, C5–6, and C6–7, along with focal increased signal intensity within the cord at the C5–6 level on the images consistent with cord edema. Dif feren tia l Diagnosis Carpal tunnel syndrome Rotator cuff tear C5 radiculopathy C6 radiculopathy Brachial neuritis Thoracic outlet syndrome Dia gno sis C6 Ra diculopathy Cervical radiculopathy represents impingement of an exiting cervical nerve root generally caused by herniated disk material or from degenerative cervical spon- dylosis, or commonly a combination of the two. In cases where the etiology is a herniated disk, the symptoms are more acute in onset and may be exacer- bated by coughing or other Valsalva-type maneuvers. Cervical spondylosis as a cause for radiculopathy has an insidious onset, with degenerative changes oc- curring at the disk and the zygapophyseal and neurocentral joints (Fig. 18–3). Other causes of cervical root irritation or compression include intraspinal tu- mors, infection, inflammatory arthritic changes, and chemical irritation from neurohumeral factors. The presentation of cervical radiculopathy begins with varying degrees of pain, paresthesias, and motor weakness in the neck and upper extremity. Significant neck pain is often associated with the radicular pain and sensory changes, which generally follow a dermatomal distribution. Breast pain and angina-like symptoms should also be considered as potential radicular complaints. Weakness and reflex changes are also root specific, but significant overlap exists in the muscular innervation of the upper extremity and may occasionally be confusing. Table 18–1 outlines the clinical symp- toms and findings seen with individual root involvement, and other potential causes for similar findings. C O M P R E S S I O N N E U R O P A T H Y 104 Cervical nerve root Cord Intervertebral foramina (neuroforamen) Uncinate process (joint of Luschka) Disk Vertebral body Articular process (facet joint) Figure 18–3. Axial anatomy of the cervical spine at the level of the disk and exiting nerve root at the interverte- bral foramina. Note the disk herniation on the left side impinging the nerve root. The physical exam should be focused on identifying a dermatomal distribution of radicular complaints and sensory changes. Specific muscle group weakness and reflex changes as compared with the opposite side should also be recorded. Special tests like the previously mentioned Spurling’s sign and the Valsalva maneuver can reproduce a patient’s radicular complaints by decreasing the size of the neuroforam- ina. Davidson’s shoulder abduction relief sign functions to relieve a patient’s radicu- lar complaints with abduction of the shoulder and presumably decreased tension on the cervical root. In this patient’s presentation a typical C6 radiculopathy is present with neck pain radiating down the biceps region of the arm to the lateral aspect of the forearm into the thumb and index fingers. Although he did not exhibit weakness on testing, he did report difficulty maintaining biceps strength with repetitive motion, and he had a de- pressed biceps reflex. Spurling’s maneuver was provocative for reproducing his radic- ular pain. The radiographs and MRI are significant for loss of C5–6 disk space, C6 neural foramen narrowing, encroachment on the foramina by osteophyte, and focal cord edema at the C5–6 level. The EMG confirmed denervation at the C6 level. Dif feren tia l Diagnosis Other conditions that may mimic C6 radiculopathy include other level radiculopa- thies, carpal tunnel syndrome, rotator cuff tendinopathies, brachial neuritis, and thoracic outlet syndrome. C E R V I C A L R O O T C O M P R E S S I O N 105 Table 18–1 Clinical Symptoms and Physical Findings Seen in Individuals with Cervical Root Involvement and Other Potential Causes for Similar Findings Pain or Root Level Sensory changes Motor Reflex Diagnosis with Similar Findings C3 C2–3 Back of the neck XX“Tension headache” Mastoid region Ear C4 C3–4 Back of the neck XXMyofascial pain Along the trapezius Anterior neck C5 C4–5 Side of the neck to Deltoid X Primary shoulder problem top of the shoulder Rotator cuff Over the deltoid C6 C5–6 Lateral side of the Biceps Biceps Carpal tunnel syndrome (CTS) arm and forearm Wrist extensors Brachioradialis Upper trunk BPN Thumb and index fingers C7 C6–7 Back of the forearm Triceps Triceps CTS to the middle finger Wrist flexors Pronator syndrome Finger extensors Radial tunnel synd. Posterior cord BPN C8 C7–T1 Ulnar side of the Finger flexors X Ulnar nerve entrapment at Guyon’s forearm to the Intrinsics canal or the cubital tunnel ring and small AIN palsy fingers Lower trunk BPN AIN, anterior interosseous nerve; BPN, brachial plexus neuropathy. Clinical neurophysiologic testing is very important for differentiating radiculopa- thy from peripheral neuropathies. Needle EMG has traditionally been the most use- ful electrophysiologic tool for diagnosing cervical radiculopathy. If compression produces axonal interruption in some fibers, the EMG reveals changes in muscles from decreases in motor unit action potentials to fibrillation potentials of muscles. In radiculopathy the nerve compression is proximal to the dorsal primary ramus, which should produce changes in the paraspinal muscles, differentiating this lesion from a brachial plexus injury or more distal nerve compression. The sensory changes involving the thumb and index finger seen in C6 radicu- lopathy are also present in carpal tunnel syndrome. The differences can be seen in the dorsal and volar distribution of sensory changes in the hand and the proximal findings associated with radiculopathy. Coexisting distal nerve entrapment and cervical radiculopathy can occur, known as the double crush phenomenon. EMG is useful for differentiation of proximal versus distal nerve entrapment, with nerve conduction velocities identifying periph- eral neuropathy. Pain that originates in the neck and extends to the shoulder and arm is very typical for radiculopathy, but patients with rotator cuff disease often have associated neck pain due to shoulder weakness and trapezium muscle spasm. In addition, biceps weakness may be a subjective complaint with rotator cuff disease due to an associated biceps tendinopathy causing pain and restricted motion. Specific testing of the rotator muscu- lature and an MRI of the shoulder are helpful in diagnosing a rotator cuff tear. Proximal arm pain and weakness may be present in brachial neuritis. In this con- dition of unknown etiology a patient might awaken with shoulder pain and arm weakness without an inciting event. The symptoms are usually self-limited and treated symptomatically. Again, electrodiagnostic testing along with a thorough his- tory and physical examination should differentiate this entity from radiculopathy. Thoracic outlet syndrome may involve nerves of the brachial plexus and may present with weakness and numbness of the hand. Physical findings of asymmetric pulses, vas- cular bruits, and a positive Adson’s test are tips to suspect thoracic outlet syndrome. Nonsurgical Ma nagement The majority of patients with first-time symptoms of radiculopathy may be man- aged nonoperatively. Initial management should include immobilization in a soft collar with the neck slightly flexed, antiinflammatory medications, and physical therapy. Narcotic medications may be used in conjunction with nonsteroidal anti- inflammatory drugs (NSAIDs) in the acute period in cases of severe pain. Physical therapy consists of heat and ultrasound modalities to make the patient more com- fortable, cervical traction, and stretching exercises when tolerated. Epidural or se- lective nerve root corticosteroid injections are also an option, but require accurate needle placement around an irritated nerve root. Improvement in symptoms should be seen within 2 weeks; if symptoms worsen or marked neurologic deficits are pres- ent, more aggressive management should be considered. Surgical Management Cases of cervical radiculopathy that require surgical intervention are those with unrelenting pain despite conservative management, progressive neurologic deficit, C O M P R E S S I O N N E U R O P A T H Y 106 upper extremity weakness, and nerve root compression that is proven diagnostically and correlates clinically. Surgical choices include anterior cervical diskectomy and fusion as described by Robinson, or posterior diskectomy involving a hemilaminectomy or foraminotomy. The anterior approach is considered the best option for the acute disk herniation to decompress the nerve root from impinging disk fragments in the intervertebral foramen, and for cases where the nerve root is compressed by osteophytes from the joints of Luschka (Fig. 18–3). This anterolateral approach in the neck takes ad- vantage of the fascial plane between the carotid sheath laterally and the trachea and esophagus medially, which affords visualization of the entire surgical spine. The posterior approach is useful for cases of chronic compression due to degenerative changes at the facet joints, and for cases where several levels need to be addressed. Both approaches produce excellent results for relieving radiculopathy, but the an- terior approach is more consistent for relieving axial neck pain. Postoperatively, the patients are immobilized in a hard collar in cases of fusion and a soft collar if a sim- ple diskectomy is performed. Suggested Readings An HS. Cervical root entrapment. Hand Clin 1996;12:719–730. Bohlman HH, Emery SE, Goodfellow DB, et al. Robinson anterior cervical dis- cectomy and arthrodesis for cervical radiculopathy. J Bone Joint Surg 1993;75A: 1298–1307. Dumitru D. Electrodiagnostic Medicine. Philadelphia: Hanley & Belfus; 1995. Levine MJ, Albert TJ, Smith MD. Cervical radiculopathy: diagnosis and nonopera- tive management. J Am Acad Orthop Surg 1996;4:305–316. Lomen-Hoerth C, Aminoff MJ. Clinical neurophysiologic studies: which test is useful and when? Neurol Clin 1999;17:65–74. Morgan G, Wilbourn AJ. Cervical radiculopathy and coexisting distal entrapment neuropathies: double-crush syndromes? Neurology 1998;50:78–83. Persson LC, Moritz U, Brandt L, Carlsson CA. Cervical radiculopathy: pain, muscle weakness and sensory loss in patients with cervical radiculopathy treated with surgery, physiotherapy, or cervical collar. A prospective, controlled study. Eur Spine J 1997;6:256–266. Saal JS, Saal JA, Yurth EF. Nonoperative management of herniated cervical inter- vertebral disc with radiculopathy. Spine 1996;21:1877–1883. Stewart JD. Focal Peripheral Neuropathies. 2nd ed. New York: Raven Press; 1993. C E R V I C A L R O O T C O M P R E S S I O N 107 19 Complex Regional Pain Syndrome Type 1 (Reflex Sympathetic Dystrophy) Carole W. Agin History and Clinical Presentation A 50-year-old woman was undergoing magnetic resonance imaging (MRI) with contrast. Intravenous access was started in her right antecubital fossa. As the infu- sion of gadolinium was started, the patient reported a burning pain in her arm from the antecubital fossa to her fingers. Her forearm and hand swelled. As the swelling increased, she reported numbness and cyanosis. Over the next few days the swelling resolved. Slowly sensation returned to her arm; however, the patient reported a con- stant burning pain. The patient also noted changes in the color of her hand and pain with movement of her wrist, elbow and shoulder. Diagnostic Studies There are no radiologic findings that are pathognomonic for complex regional pain syndrome (CRPS) type 1, reflex sympathetic dystrophy (RSD). Radiologic findings are often nonspecific, and many findings are a result of prolonged disuse, which is attributable to the pain associated with the syndrome. However, imaging studies can support a diagnosis of CRPS (RSD). Fine detail radiography may help to suggest the presence of CRPS. Early radiologic changes seen with sympathetic hyperdysfunction include patchy demineralization of the epiphyses and short bones of the hands and feet. Periarticular osteoporosis in long bones and diffuse osteoporosis in small bones may be seen on plain radiographs. Sub- periosteal resorption, striation, and tunneling of the cortex may occur. Comparison with the unaffected limb is always required. Unfortunately, these findings may be seen whenever there is disuse of a limb. As CRPS advances, patchy osteopenia may be seen. Triple-phase scintigraphy has also been used to help diagnosis CRPS (RSD). Three-phase bone scanning measures the uptake of a radionucleotide tracer at three different times: arterial phase, measured seconds after the injection of tracer; soft tissue phase, measured after several minutes have passed; and mineral phase, mea- sured hours after the tracer is given. The triple-phase bone scan pattern most consis- tently seen in a patient with CRPS (RSD) is that of increased flow to the involved extremity and delayed static images that show diffusely increased uptake activity throughout the involved extremity, usually in a periarticular distribution. MRI studies may show skin thickening and tissue edema. Nuclear bone density measurements have been used to follow the progression of the syndrome. Differential Diagnosis Peripheral neuropathy disease Inflammatory disease C O M P R E S S I O N N E U R O P A T H Y 108 PEARLS • When presented with a ques- tionable case of CRPS early after symptom development, a three-phase bone scan may be helpful. • CRPS (RSD) is often a diagnosis of exclusion. PITFALLS • Radiologic studies performed late in the disease process may show changes secondary to disuse atrophy, which may be caused by other medical conditions. • If the sympathetically main- tained pain is the result of a persistent but treatable condi- tion, the condition needs to be treated. Treating only the signs/symptoms of CRPS with- out addressing the underlying condition may prove futile. • If the patient has a diagnosed psychiatric illness (i.e., post- traumatic stress disorder, de- pression), this must be treated or it can adversely affect any potential improvements ob- tained from other treatment modalities. Infectious disease Vascular disease Connective tissue disorder Reflex sympathetic dystrophy CRPS (RSD) is often a diagnosis of exclusion. Other causes of similar pain com- plaints include peripheral neuropathies, which may also present with neuropathic pain. Traumatic injuries to nerves may present with dysesthesia and hyperpathia, but without the sympathetic component. Inflammatory and infectious causes for pain needed to be ruled out when autonomic dysfunction is the primary presenting symptom. Examples of this would include tenosynovitis and bursitis. Vasculitis and vascular disorders can also manifest with similar findings. In many instances vascu- lar diseases present with bilateral symptoms. Raynaud’s disease produces vasospasm that will lead to findings of pallor, cold skin, and potentially cyanosis. Connective tissue disorders also have to be ruled out. Myofascial pain may also present with a nondermatologic distribution of pain. These patients may report burning pain as a symptom and have tender trigger points in the affected muscles. Malingering and psychiatric disorders must also be ruled out as a cause of the patient’s unremitting pain, which presents out of proportion to the inciting event. Diagnosis Complex Regional Pain Syndrome, Type 1 (Reflex Sympath etic Dyst roph y) The Committee on Taxonomy of the International Association for the Study of Pain (IASP) recently renamed reflex sympathetic dystrophy as complex regional pain syndrome type 1. This new taxonomy was promulgated in an attempt to estab- lish uniform diagnostic criteria. This will aid in the development of treatment pro- tocols for the syndrome. Previously many symptom constellations were included within the category of RSD, making treatment pathways and outcome studies dif- ficult. A study done to evaluate the validity of the IASP’s CRPS diagnostic criteria to distinguish between CRPS and other neuropathies showed that the new classifi- cation did assist in improved accuracy of diagnosis. To meet criteria for CRPS type 1 a patient must present with regional pain out- side of the distribution of a single peripheral nerve and out of proportion to the in- citing event. CRPS has been reported to develop after compression/crush injuries, lacerations, fractures, sprains, burns, or surgery. Allodynia and hyperalgesia are typ- ically present. Abnormalities in skin blood flow (causing changes in skin tempera- ture and color), abnormal sudomotor activity, and edema are also present. Dystonia and weakness, although not necessary for the diagnosis, may also be present. Trophic changes and personality changes may develop as the disease progresses. CRPS type 2 has all of the same signs and symptoms; however, it follows injury of a major peripheral nerve. Methods of Management As the pathophysiology of CRPS type 1 (RSD) is not well understood, multiple treatment protocols have been described. The consensus is that these patients do best with a multidisciplinary treatment plan (Table 19–1). This includes regional blockade (Fig. 19–1), physical therapy, pharmacologic therapy, and psychological C O M P L E X R E G I O N A L P A I N S Y N D R O M E T Y P E 1 ( R E F L E X S Y M P A T H E T I C D Y S T R O P H Y ) 109 110 Table 19–1 Treatment Modalities Pharmacologic Interventional Techniq ue Physical Modalities Psychological Interventions Antidepressants, Sympathetic blockade Physical/occupational Psychiatric evaluation TCAs, SSRIs Stellate ganglion therapy Lumbar sympathetic IV regional Membrane stabilizers Spinal cord stimulator Contrast baths Cognitive behavior skills Anticonvulsants Local anesthesia Antiarrhythmic NSAIDs TENS Relaxation training Topical medications Heat/cold Imagery EMLA Capsaicin Opiates Massages Hypnosis Clonidine Calcitonin NSAID, nonsteroidal antiinflammatory drug; TCA, tricyclic antidepressant; TENS, transcutaneous electrical nerve stimulation; SSRI, selective serotonin reuptake inhibitor. Figure 19–1. Anatomy of the neck and placement of the needle for a stellate ganglion block. [...]... reduced side effects and an improved efficacy-to-toxicity ratio when compared with phenytoin and carbamazepine Lidocaine, mexiletine, and tocainide effect sodium channels Lidocaine has been used intravenously in the management of neuropathic pain Intravenous lidocaine therapy is often followed by oral treatment with mexiletine Topical medications have been tried for the hyperpathia and allodynia associated... mediators and a reduction in inflammation NSAIDs may be helpful in the early stages of CRPS type 1; however, the potential for gastrointestinal complications and renal failure must be considered if continued use is to be recommended Membrane stabilizing medications are also used This category includes anticonvulsants, local anesthetics, and antiarrhythmic agents Gabapentin, a selective voltage-gated Ca2+... associated with CRPS Topical application of local anesthetics, lidocaine, and prilocaine (eutectic mixture of local anesthetics, EMLA) has been tried recently in the treatment of neuropathic pain in patients with CRPS type 1 (RSD) Topical capsaicin causes a reversible depletion in substance P and calcitonin gene-related peptide from the C-fiber nerve terminals There are anecdotal reports of its use for localized... signs of a sympathetic block Blocks of the sympathetic nervous system interrupt nociceptor visceral and somatic afferents and vasomotor, sudomotor, and visceromotor fibers One would therefore look for signs of increased blood flow to the limb(s) involved As cutaneous blood flow affects skin temperature and this is controlled by the sympathetic nervous system, an increase in skin temperature should occur... patient’s pain utilizing all available means so that active physical therapy can be pursued and disuse atrophy avoided As is true whenever using opioids, constipation should be expected and treated prophylactically There have been anecdotal reports of the use of other medications for CRPS Medications that inhibit ␥-aminobutyric acid (GABA), such as baclofen, have been reported to be useful in neuropathic... starch-iodide A quantitative sudomotor axon reflex test (QSART) can also be used For CRPS affecting the upper limb a stellate ganglion block is usually performed Many patients develop Horner’s syndrome (enophthalmos, miosis, anhidrosis, and ptosis) after a stellate (cervicothoracic) ganglion block Block of the thoracic sympathetic chain is technically difficult, requiring radiologic guidance, and is... sympathetic blocks, which is very useful in giving patients the analgesia that they require to participate in a physical therapy regimen If a patient responds positively to a trial of sympathetic block, these blocks should be repeated as long as the patient continues to be afforded increasing duration of pain relief and symptom improvement with subsequent blocks In addition to assessing the level of pain... its application may cause increased pain This is secondary to the release of substance P that occurs The use of opioids in the treatment of neuropathic pain, and specifically in CRPS, has not been studied Opioids are useful in nociceptive pain, and their effect is related to interaction at the level of the spinal cord with the opioid receptors Although their use may be considered controversial in chronic,... administered epidurally and intrathecally in patients with CRPS These patients are at a much greater risk for hemodynamic complications when the drug is used transdermally Subcutaneous calcitonin has been shown to be effective in treatment of spontaneous pain Its use in CRPS has not yet been documented In the early stages of CRPS a patient may benefit from a trial of corticosteroids This is particularly true... limb to the ganglionic blocking agent In the United States this technique is typically performed with bretylium Bretylium accumulates in adrenergic nerves and blocks norepinephrine release These blocks have also been performed with guanethidine and reserpine Spinal Cord Stimulation Spinal cord stimulation is hypothesized to affect pain based on the gate control theory whereby stimulation of large myelinated . syndromes. New concepts. Hand Clin 1997; 13: 319 32 5. Zyluk A. The reasons for poor response to treatment of posttraumatic reflex sympa- thetic dystrophy. Acta Orthoped Belg 1998;64 :30 9 31 3. C O M P R E. ex- tending down the front of his arm to his hand. He was having difficulty lifting objects with his right hand and performing repetitive-type motions, with weakness of his right shoulder and. transection and repair. J Hand Surg 1982;7A :35 3 36 5. Chow JA, Van Beek AL, Meyer DL, Johnson MC. Surgical significance of the motor fascicular group of the ulnar nerve in the forearm. J Hand Surg