1. Cervical Nerve Root Impingement By: Michael Cox

2. Overview Anatomy of cervical spine and nerve roots
Reasons for impingement
Signs and symptoms associated with nerve root impingement
Acute treatment of injury
Rehabilitation
Return to play criteria

3. Anatomy
Primary Function: Mobility, support, and protection of spinal canal and neural structures
7 cervical vertebrae
8 nerve roots
6 intervertebral discs
Foramina
Nerve root occupies 25-33%
over the foramina space
Lordotic curve
most of lordosis occurs at C1-C2
Some Biomechanics:
50% of flexion and extension occurs at occipitoatlantal joint
50% of rotation occurs at C1-C2

4. Anatomy

5. Anatomy Vertebral Disc Located between C2-C7
Composed of annulus fibrosis, which is the outer layer made up of thick fibrous cartilage
Nucleus pulposus is the inner layer which is a water gelatin
Discs serve as shock absorbers
and allow the spine to bend

6. Anatomy Nerve roots Myotomes Dermatomes C1: Cervical flexion
C3: Cervical lateral bending
C4: Shoulder elevation
C5: Shoulder Abduction
C6: Elbow Flexion/wrist extension
C7:Elbow extension/wrist flexion
C8: Ulnar deviation/thumb extension
T1: Finger abduction/adduction
Dermatomes
C1: Top of head
C2: Side of face
C3: Down mandible
C4: Lateral neck
C5: lateral upper arm
C6: Lateral forearm to thumb
C7: Middle forearm to 3rd
C8: 5th to medial forearm
T1: Medial upper arm

7. Anatomy Muscles SCM Splenius muscles Levator scapula Scalenes
Upper trapezius

8. Mechanism for Impingement
This injury can occur from an extension, lateral bending, or rotation mechanism, which causes a narrowing of the neural
foramen and results in ipsilateral nerve root injury
Disc herniation can cause the nucleus
pulposus to leak into the foramen and cause
impingement on the nerve

9. Signs and Symptoms
Neck and shoulder pain and discomfort that can radiate down the arm
Tingling or numbness along the nerve root involved
Motor weakness in affected nerve root (manual muscle testing)
Depending on reason for impingement certain motions (AROM) can cause pain
Point tenderness is usually located along the lateral and posterior cervical muscles on the affected side
Muscle tenderness and spasm on affected side is usually present

10. Special Test’s Deep Tendon Reflexes Foraminal Compression Test
Biceps Brachii reflex: C5-C6
Brachioradialis reflex- C5-C6
Triceps reflex: C7-C8
Foraminal Compression Test
Manuel Distraction
Shoulder Abduction Test

11. Acute Treatment
“A best-evidence synthesis by the Bone and Joint Decade Task Force on Neck Pain and its Associated Disorders concluded that there is not clear evidence that surgical treatment of cervical radiculopathy provides better long-term outcomes than nonoperative measures.”
Icing
NSAIDS
Rest
Take measures that reduce force compressing the nerve root
Avoiding positions that increase symptoms

12. Rehabilitation Early Phase
Main goal is reducing symptoms: controlling pain and inflammation
Cervical collar
Restricts motions that cause pain
Patient comfort
Cervical pillow at night can help can help maintain the neck in a neutral position and limit head positions that cause narrowing of the neural foramen
Ice- help reduce muscle spasm and pain
NSAIDS

13. Rehabilitation Early Phase
Traction- Decreases pressure caused by axial loading
Manuel traction
Mechanical traction
Positional traction
Self administered, body positioning
Disc Protrusion- Intermittent traction
Force pulposus back in
Impingement- Sustained traction
Removes mechanical pressure on nerve root and allows for inflammation of nerve root to decrease
Reducing adhesions within Dural sleeve by elongating the surrounding structure
Restoring normal slack in the neuromeningeal structures

14. Rehabilitation Moderate Phase
Goals:
Restoring ROM
Maintaining pain free symptoms
Light strengthening
Criteria for progression
Pain and inflammation have been controlled

15. Rehabilitation Moderate Phase
Continued Traction
Stretching:
Sustained stretching in all directions
Flexion, extension, lateral bending, rotation
Home stretching exercises
Soft Tissue Mobilizations
Spleni muscles, posterior cervical muscles, scalenes, upper trap, levator scapulae, SCM
AROM exercises
Go until pain then return to neutral
All directions

16. Rehabilitation Moderate Phase
Joint Mobilizations
Cervical lateral glides in upper
limb neurodynamics position
Upper and Midthoracic spine
manipulation in supine:
“an association exists between mobility
in the thoracic spine
and neck/shoulder pain.”
“thoracic manipulation can help
increase cervical ROM”
Central PA’s

17. Rehabilitation Moderate Phase
Strengthening
At this time rehab should focus on isometric strengthening only until full ROM is achieved
Flexion
Extension
Lateral bending
Rotation
Deep flexor strengthening
Scapular muscle strengthening
Rhomboids: rows
Serratus anterior: push up plus
Middle and upper trap: fly’s

18. Rehabilitation Progressive Phase
Goals:
Maintain ROM
Maintain pain free symptoms
Cervical muscle strengthening
Cervical Stabilization
Nerve root strengthening
Functional Activity
Criteria for progression
Pain free ROM
Diminished inflammation

19. Rehabilitation Progressive Phase
Strengthening:
Isotonic cervical strengthening
All directions: can be done using a cervical machine, pulley system, or Thera-band
Involved nerve root strengthening
Isotonic motions
Can use either dumbbells, Thera-band, tubing, mechanically

20. Rehabilitation Progressive Phase
Cervical stabilization
All directions
Hold for 30 sec
3 sets
PNF Patterns
Functional Activity

21. Return to Play Criteria
Full pain-free ROM
Full strength and stabilization
No tingling or numbness with ROM
Full cardiovascular endurance

22. Summary
Cervical nerve root impingement can occur from a herniated disc or from narrowing of the neural foramen
Patient may complain of neck pain and tingling or numbness radiating down the arm
Progression is based on patient symptoms
Pain management is important