Cervical case vignette

SUBJECTIVE EXAMINATION INTERPRETATION

Be sure to complete part 1 on your own before reviewing this. This is where the cervical series will start so that everyone has an understanding of the foundational concepts.

C/C/O:

L UE descending from posterior arm to ulnar border of the forearm & to the 4th & 5th digit.

-at it’s worst she cannot use the arm without further increase of both the UE symptoms & the CS pain: indicates concern of high severity

-UE pain was formerly erratic but is happening more frequently, and has increased from 2/10 to 8/10: indicates concern of deteriorating stability

-She feels that she cannot fully extend her elbow in reaching activity without increasing the UE pain: again indication of severity because of loss of function

Secondary C/O:

Constant L sided neck pain localized at lower cervical segments. This is the most consistent complaint. Described as low-grade constant ache in the neck (1/10), episodic elevation to 5. When it worsens it will lead to L UE pain in posterior UE & ulnar border of forearm:

-Gives indication of the nature of the problem, the neck pain is always present & when it increases so too does the UE. Neck pain may be the secondary c/o but the primary etiology of the worst complaint, they are associated phenomenon consistent with discogenic pathology.

Agg-Ease Factors

UE:

Intermittent, when it presents it goes from 2-8 quickly, aggravated by pushing, pulling or lifting within minutes, she has to stop the activity immediately. -it takes very little activity with the UE to give a sudden increase in her worst complaint & she cannot continue. She is telling us that the worst problem is highly irritable

She gets the same response from looking directly up at the overhead monitors which brings on her UE pain within 1 minute. The symptoms settle over 4 hours with supine positioning, ice & OTC analgesics. She has stopped the activity. -with 1 minute of neck extension her UE symptoms can get so bad that it takes 4 hours of lying supine with medication to settle back to baseline

Neck pain:

Driving provokes neck pain after more than 1 hour from 1-4, if she stops it will cease climbing & settle back to near baseline in 15 minutes.
-her neck will tolerate a full hour of rotation in seated prior to aggravation of the local neck pain & this will settle back to baseline with in 15 minutes.

Working with UE at a desk longer than 1 hour increase the neck pain from 1- 5.

It settles to 2 within minutes of ceasing, & to 1 in 15 minutes.

- repeated use of the UE in a seated position can disturb the neck but this also will tolerate an hour of the activity and settle within 15 minutes

Lifting heavy objects (> 20 # ) gives immediate neck pain to 5/10, and UE pain at a 5-6. Setting the object to rest the neck begins to settle immediately, but the arm pain may require 15-20 minutes.
- she gives a clear indication that the UE is more irritable than the neck

PATIENT PRESENTATION

Severity:

Cervical Spine : moderate severity ( it may be classified as low but for the direct association with the more troublesome UE pain)

Upper Extremity: Severe

Irritability:

Cervical Spine : moderate

Upper Extremity: highly irritable

Nature:

Neck pain with associated upper extremity pain. Consistent with discogenic pathology creating UE radiculopathy.

Stage:

Acute: onset 4 weeks ago

Stability:

Worsening: Began with neck pain, evolved to include UE pain

Hypotheses:

Neck dysfunction: cervical disc disease, HNP, lower cervical facet dysfunction UE: peripheral entrapment of ulnar nerve, medial epycondalgia, radicular pain

Working Hypothesis:

C7 Disc dysfunction (bulge, herniation, degeneration) with encroachment on C8 nerve root

Comparable Functional Signs

Looking at overhead monitors Driving 1 hour
Working with UE at desk

IMPACT OF SUBJECTIVE EXAM ON OBJECTIVE PLAN

OE plan

This appears to be a common clinical syndrome, if it is radiculopathy from disc pathology then it should behave in a predictable manner. It would be imprudent to over examine this patient. We would like to consolidate our initial exam to focus on things that if our working hypothesis is correct would be alleviating.

It would be unwise to disturb the UE pain. It is severe & irritable with likelihood of neurological origin.

The neck ache has been associated with her UE pain when it worsens, if we can find a comparable finding for the neck pain, we are likely to have a sign for both.

She is intolerant of overhead extension so the use of OP, repeated extension, should be ruled out.

Traction with the allowance for reloading on the release will be far wiser than compression as a test. Spurlings should already be doubtful.

She has already told us that she must get supine when the UE symptoms are bad. This has as one of it’s components an unloading effect of the head on the neck, hence she does prefer unloaded to vertical loading.

A neurologic exam must be done however the use of maximal testing in myotomes is unwise. Low load sustained if at all