Sensory symptoms of pain or dysesthesias are difficult to evaluate, particularly when motor signs are absent. This is all too often the case in cervical spinal radiculopathies. The discrete separation of the motor and sensory roots at the cervical neural foramina is the explanation for motor sparing despite severe sensory symptoms. Marked C7 root irritability without motor weakness of the triceps (radial nerve C7-C8) or the pronator teres (median nerve C6-C7) can present only with aching at the medial, middle scapular border, or aching in the myotome distribution to the chest, axilla, or triceps. Numbness or tingling in the C7 dermatome distribution to the middle finger may be the only symptom of spinal root irritation.
Early cervical spinal myelopathies can only be recognized if the examiner looks for them, so a full neurologic examination that includes the lower extremities is needed to evaluate neck pain. Common signs and symptoms include hyperreflexia, a positive Babinski sign, gait disturbance, lower extremity weakness, impaired fine hand movement, or upper and lower extremity spasticity.
The need for radiographs depends on the clinical condition suspected. If degenerative disease is suspected, oblique views of the cervical spine can identify foraminal narrowing. Both the dens and the lowest cervical and upper thoracic vertebrae should also be visualized. Flexion-extension films are useful if instability is suspected. Magnetic resonance imaging is now the preferred test to evaluate the cervical cord.
Electromyographic (EMG) studies can diagnose neural structural abnormality, assess the level and the degree of severity, and provide a prognostic baseline and an objective means of reassessment. Both eMg and nerve conduction velocity testing are needed if there is progressive motor impairment or when confusion exists as to the level of neural compromise. Unfortunately, EMG findings lag 2 weeks behind a patient's actual clinical state. EMG is a test of motor dysfunction. If the sensory root is solely compromised and the motor root spared, the EMG findings may be normal.
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