Cervical radiculopathy
Introduction
Introduction to nerve root type cervical spondylosis This type is also more common, due to stimulation or compression of unilateral or bilateral spinal nerve roots, which is characterized by sensory, motor and reflex disorders consistent with the distribution of spinal nerve roots, and the prognosis is mostly good. basic knowledge The proportion of the disease: the incidence of this disease in the middle-aged and elderly people over 50 years old is about 0.04%-0.08% Susceptible people: no special people Mode of infection: non-infectious Complications: muscle atrophy
Cause
Causes of cervical spondylotic radiculopathy
(1) Causes of the disease
Prominence or prolapse of the nucleus pulposus, bone hyperplasia or traumatic arthritis of the posterior small joint, spur formation of the hook joint, and loosening of the adjacent three joints (intervertebral joint, hook joint and posterior small joint) Both the displacement and the like can cause irritation and compression to the spinal nerve roots. In addition, the narrowing of the root canal, the adhesive arachnoiditis at the root sleeve, and the inflammation and tumors in the peripheral parts can also cause symptoms similar to the disease. .
(two) pathogenesis
Because the pathogenesis of this type is more, the pathological changes are more complicated. Therefore, the location and degree of the involvement of the spinal nerve root are different, and the symptoms and clinical signs are different. If the root is under the pressure, the muscle strength changes (including the muscle). Tension reduction and muscle atrophy, etc. are more obvious; after the root compression is the main symptom, the symptoms of the sensory disorder are heavier, but in the clinical two, most of them coexist, mainly due to the multiple tissues in the narrow root canal. Intensively together, it is difficult for everyone to have room for retreat. Therefore, when the anterior side of the spinal nerve root is compressed, compression is also occurring at the same time behind the root canal, and its mechanism occurs, except for the hedging effect of the force. It is also caused by the congestion and congestion of local blood vessels under pressure, and is affected by each other. Therefore, both sensory and motor dysfunction occur at the same time, but because the sensory nerve fibers are more sensitive, the symptoms of abnormal feeling will be Show it earlier.
There are three mechanisms for cervical spondylosis causing various clinical symptoms: First, various kinds of pressure-induced substances directly cause compression, traction and local secondary reactive edema, which are manifested as root symptoms; The sinus nerve endings on the wall of the dural wall of the sleeve show the symptoms of the neck; the third is the imbalance of the internal and external balance of the cervical vertebrae on the basis of the first two, so that the ligaments, muscles and joint capsules of the vertebrae are affected. Symptoms (eg, the affected part of the vertebral joint and the interdependent longissimus dorsi, anterior scalene muscle and sternocleidomastoid muscle are involved in the whole pathological process).
Prevention
Radiation prevention of cervical spondylosis
1. Establish a correct attitude, master scientific methods to prevent and treat diseases, and cooperate with doctors to reduce recurrence.
2. Strengthen the exercise of the neck and shoulder muscles. When the work is idle, the flexion, extension and rotation of the head and the upper limbs can relieve fatigue, strengthen the muscles and strengthen the toughness, thus facilitating the neck section. The stability of the spine enhances the ability of the neck and shoulder to conform to sudden changes in the neck.
3, correct bad posture and habits, avoid high sleep, do not shrug shoulders, talk, read a book when you should look positive. Keep the integrity of the spine.
4. Pay attention to the neck and shoulders to keep warm, avoid head and neck weights, avoid excessive fatigue, do not doze off while riding.
5. Thoroughly treat neck and shoulder and back soft tissue strain early to prevent the development of cervical spondylosis.
6. Avoid contusion when working or walking, avoid head and neck injuries during sudden braking, and avoid falling.
Complication
Cervical spondylotic complication Complications muscle atrophy
Generally there will be no complications. This type is also more common, due to stimulation or compression of unilateral or bilateral spinal nerve roots, which is characterized by sensory, motor and reflex disorders consistent with the distribution of spinal nerve roots, and the prognosis is mostly good.
Because the cervical intervertebral disc, cervical vertebrae joint or facet joint hyperplasia, hypertrophic spurs protrude laterally, stimulate or oppress the corresponding level of nerve roots, and a series of clinical manifestations of nerve root stimulation or dysfunction of corresponding segments, The clinical symptoms include neck and shoulder pain, radiation pain, numbness and weakness of the upper limbs and fingers.
Symptom
Symptoms of cervical spondylotic radiculopathy Common symptoms Sensory allergy Sleeping back pain Anterior scalene hypertrophy Cervical sympathetic chain Residual neck Ischemic jump pain Shoulder pain Muscle tenderness Brain back pain Forearm lateral and finger... Bone formation
1. The symptoms of neck may be different depending on the cause of root compression. It is mainly due to the prominent nucleus pulposus. Because the local sinus nerve is directly stimulated, it is accompanied by obvious neck pain and paravertebral muscle tenderness. And the neck is in formal position, the direct tenderness or pain in the cervical spine or spinous process is mostly positive, and these manifestations are especially obvious in the acute phase, such as simple hook joint degeneration and bone hyperplasia. The neck symptoms are mild, and there may be no special findings.
2. Root pain is the most common, and its range is consistent with the distribution of the spinal nerve roots of the affected vertebrae. At this time, it must be associated with dry pain (mainly sacral nerve trunk, ulnar nerve trunk and median nerve trunk) and plexus pain. (mainly refers to the cervical plexus, brachial plexus and sacral plexus), and the root pain is accompanied by other sensory disturbances in the nerve root distribution area, in which finger numbness, fingertip hypersensitivity and skin sensation are more common.
3. The root muscle disorder is obvious before the root is compressed, the early muscle tension is increased, but it is weakened and the muscle atrophy is soon, and the range of involvement is limited to the muscle group dominated by the spinal nerve root. Large, small intermuscular and interosseous muscles are obvious, and need to be distinguished from dry and plexus muscle atrophy, and should be distinguished from muscle strength changes caused by spinal cord lesions. EMG or cortical evoked potentials may be feasible if necessary. Wait for the check to identify.
4. The change of sputum reflex is the abnormality of the reflex arc involved in the affected spinal nerve root, which is active early, but decreases or disappears in the middle and late stages. Compared with the contralateral side, the simple root involvement should not have pathological reflex, such as If there is pathological reflex, it means that the spinal cord is involved at the same time.
5. Special trials Most of the traction test to increase the spinal nerve root tension is positive, especially in the acute phase and later root compression. The positive cervical spine test is more common in the nucleus pulposus, nucleus pulposus and vertebral segments. Stable cases; most of them are weakly positive due to hyperplasia of the hook; most of them are negative due to space-occupying lesions in the spinal canal.
Examine
Examination of nerve root type cervical spondylosis
Depending on the cause, X-ray plain films are different, generally manifested as one or several abnormalities such as vertebral instability (trapezoidal change), cervical curvature, disappearance of intervertebral foramen and hyperplasia of the hook. MRI examination can show disc degeneration and nucleus pulposus, nucleus pulposus can even protrude into the root canal, spinal canal, and mostly biased to the affected side, CT examination of soft tissue is not clear, generally not used.
Diagnosis
Diagnosis and diagnosis of cervical spondylotic radiculopathy
Diagnostic criteria
1. Has more typical root symptoms including numbness and pain, and its range is consistent with the area dominated by the cervical spinal nerve.
2. The neck test and the upper limb pull test are mostly positive, and the pain point closure is not effective, but the diagnosis is clear and need not be done.
3. Imaging examination X-ray plain film can show changes in cervical curvature, vertebral instability and spur formation, MRI examination can clearly show local pathological anatomy, including nucleus pulposus protrusion and prolapse, spinal nerve roots The location and extent of involvement.
4. Consistent clinical manifestations and imaging abnormalities were consistent on the segment.
5. Exclusion diagnosis should exclude cervical skeletal skeletal lesions (tuberculosis, tumors, etc.), thoracic outlet syndrome, carpal tunnel syndrome, ulnar nerve, radial nerve and median nerve injury, inflammation around the shoulder joint, tennis elbow and biceps tenosynovitis A disease such as upper limb pain.
Differential diagnosis
There are 8 pairs of cervical spinal nerves, and they control different parts. Therefore, when they are involved, the distribution and difference of symptoms are different depending on the affected parts. In clinical practice, the 5-8 spinal nerve roots are more involved, so this is the focus. Identification of confusing wounds.
Ulnar neuritis
(1) Overview: The ulnar nerve is composed of the neck 7,8 and the thoracic 1 spinal nerve. The disease is more common in the elderly and elbows, and the incidence of elbow valgus deformity is higher. It is easily confused with those with cervical 8 spinal nerve involvement (Fig. 4).
(2) Identification points:
After 1 elbow, the ulnar nerve groove tenderness: There is more obvious tenderness in the ulnar nerve groove located in the posterolateral aspect of the elbow joint, and the degenerated ulnar nerve can be touched.
2 Sensory disturbance: The distribution of sensory disturbance is smaller than that of the eighth cervical nerve distribution area, and the ulnar side of the forearm is not affected.
3 The influence of the inner muscles of the hand: When the ulnar nerve is severely affected, it is usually a typical "claw-shaped hand" (Fig. 5); the Tinel sign of the ulnar nerve tube is mostly positive, mainly because the interosseous muscle is involved, causing the palm The knuckle is overextended and the interphalangeal joint is flexed, especially the ring finger and the little finger.
4 imaging changes: can refer to X-ray film (neck X-ray films of patients with ulnar neuritis are mostly negative, but X-ray films of the elbow joint, especially those with deformity may have positive findings), history and past History and so on.
2. Median nerve damage
(1) Overview: The median nerve is composed of the neck 7 and the thoracic 1 spinal nerve. The damage is mostly caused by trauma or fiber tube compression. The former factor can be diagnosed at the time of trauma, no need to identify, while the latter It is easy to be confused with the 7th cervical spinal nerve root compression, and needs to be carefully identified.
(2) Identification points:
1 Sensory disorder: As shown in Fig. 7, the sensory disorder distribution area is mainly the dorsal fingertip and the thumb, the middle finger of the middle finger, and the forearm is not affected.
2 Muscle strength changes: the muscle strength of the hand is weakened, and the appearance is a "hand rubbing" deformity, mainly due to atrophy of the great fish muscle.
3 autonomic symptoms: due to a large number of sympathetic nerve fibers mixed in the median nerve, the blood vessels, hair follicles, etc. in the hand are mostly in an abnormal state, which is characterized by flushing, sweating, etc., and the pain often causes burning pain.
4 reflex: more no effect; but when the cervical 7 spinal nerve is involved, the triceps reflex can be weakened or disappeared.
3. Nerve nerve damage
(1) Overview: The sacral nerve system consists of the neck 5-7 and the thoracic 1 spinal nerve. It is located in the sacral nerve sulcus in the upper arm and is close to the bone surface. It is easily affected by the humeral shaft fracture. Nerve damage is easy to identify, such as fiber adhesion, local compression and other factors, it needs to be distinguished from the sixth cervical spinal nerve involvement.
(2) Identification points
1 wrist sign: the symptoms of sacral nerve damage, mainly due to the loss of the wrist extensor and extensor muscles, the high sacral nerve involvement, the elbow function is also affected.
2 sensory dysfunction: As shown in Figure 9, unlike the sixth cervical nerve involvement, the sensory dysfunction area is mainly the dorsal side of the hand (thumb, index finger, middle finger) and the dorsal side of the forearm except the fingertip, while the thumb and forefinger palm There should be no obstacles on the side.
3 reflex changes: no significant effect, while the neck 6 spinal nerve involvement of the biceps and triceps muscles are weakened or disappeared (early hyperthyroidism).
4 other: can still refer to medical history, local examination and X-ray film.
4. Thoracic outlet syndrome
(1) Overview: thoracic outlet syndrome (TOS), also known as thoracic outlet stenosis, is more common in clinical, can directly compress the brachial plexus, or due to anterior scalene contracture, inflammatory Stimulation causes the anterior branch of the cervical spinal nerve to be affected, resulting in upper limb symptoms, mostly caused by sensory disturbances, and can cause hand muscle atrophy and muscle weakness, etc. The disease mainly includes the following three types, namely anterior scalene syndrome. The neck rib (or the 7th cervical transverse process is too long) syndrome and the rib lock syndrome, although the three are different, but have similar characteristics, and thus differentiated from cervical spondylotic radiculopathy.
(2) Identification points:
1 brachial plexus involvement: mainly in the lower trunk of the brachial plexus, clinical manifestations: from the upper arm ulnar side down and the forearm and hand ulnar sensory disturbance, as well as ulnar wrist flexor, refers to superficial flexor and bone Intermuscular involvement.
2 Partial signs of thoracic outlet: the upper part of the supraclavicular fossa is full, and the anterior scalene or bony neck rib can be touched during the examination. When the thumb is pressed deep into the body (or let the patient do deep inhalation) Exercise) can induce or exacerbate symptoms.
3Adson sign: Most of them are positive, that is, let the patient sit up, the head is slightly tilted back, hold the breath after deep inhalation, turn the head to the affected side, the examiner touches the patient's lower jaw with one hand, slightly gives resistance, and the other hand touches the patient. The lateral radial artery, if the pulse is weakened or disappeared, is positive, which is a special test for this disease.
4 Others: including imaging changes, etc., in this disease, X-ray plain film has more positive findings, if necessary, do CT or MRI examination, etc., are helpful to the identification of the two, in addition, the disease neck test is negative, There are no tenderness and other signs in the spinous process and the cervical vertebrae. Therefore, the two are not difficult to identify.
5. Carpal Tunnel Syndrome
(1) Overview: Carpal tunnel syndrome is mainly caused by compression of the median nerve through the carpal tunnel. It is also common in clinical practice, especially in the elderly, and the elderly and wrist trauma are more common.
(2) Identification points:
1 wrist middle pressure test: the examiner presses with the hand or slams the middle of the patient's wrist (palm) with the middle finger, which is equivalent to the proximal end of the transverse ligament of the wrist. If there is a thumb, index finger, middle finger numbness or tingling, It is positive and has diagnostic significance (Figure 11).
2 wrist back extension test: that is, let the patient extend the affected wrist joint to the dorsal side for 0.5 to 1 min. If there is a thumb, indication, middle finger numbness or tingling symptoms, it is positive and has diagnostic significance.
3 closed test: 1% 2% procaine 1 ~ 2ml partial closure of the wrist pain points, if effective, it is positive.
4 Others: Symptoms of sensory disorder with distal median nerve endings (expressed as thumb, index finger, middle finger numbness, hypersensitivity or tingling), no corresponding changes in cervical X-ray films, cervical spondylotic radiculopathy All tests are negative, and if necessary, refer to MRI results.
6. Surgery around the shoulder joints and other shoulder disorders
(1) inflammation around the shoulder joint: not only needs to be differentiated from cervical cervical spondylosis, but also should be distinguished from cervical spondylotic radiculopathy. In addition to the characteristics described in the previous section, the disease does not have root symptoms of the spinal nerve, so it is easy to identify However, it should be noted that some cases of cervical spondylosis may be accompanied by symptoms of inflammation around the shoulder joint. After treatment (such as traction or surgical treatment), the shoulder symptoms may be accompanied by other symptoms of cervical spondylosis. Disappeared, this is mainly due to the involvement of the phrenic nerve and the shoulder after the 5~7 spinal nerves are involved.
(2) Other shoulder disorders: including shoulder joint impingement, rotator cuff lesions, shoulder joint degeneration and shoulder instability, should be differentiated from cervical spondylotic radiculopathy, mainly based on clinical examination and imaging results. Generally, it is not difficult to identify. For individuals with difficult diagnosis, it can be judged by closed therapy.
7. Tumors at the spinal canal and root canal
Any tumor that invades the roots of the spinal nerve and its vicinity, including the lateral side of the dural sac, and the root canal and its adjacent tissue (mainly bone tissue) can cause root pain, of which metastatic is more common. At the same time, it can affect the spinal nerve roots and the cervical plexus or brachial plexus, causing various root or plexus symptoms. Therefore, in addition to the routine examination and palpation examination of the supraclavicular fossa and neck and shoulder, the abnormal feeling should be The shoulder and neck are centrally X-ray, CT and MRI, to prevent missed diagnosis or misdiagnosis.
8. Other
In addition to the above injuries, attention should be paid to the differentiation of peripheral neuritis, syringomyelia, rheumatism, tennis elbow (external humeral epicondylitis), biceps tendonitis and angina pectoris.
