A 35-year-old woman presented at the clinic with what she described as a “crick” in her neck on arising from bed a few mornings ago. The patient described experiencing pain in the lower part of the neck, which radiated into the right shoulder and arm, and anteriorly and posteriorly over the upper right chest area. The patient also reported a tingling sensation over the radial aspect of the right forearm, the hand, and the fingers. The pain was reported to be aggravated by coughing, sneezing, and straining, and was disturbing her sleep. The pain was lessened by maintaining the head in an upright position and when ambulating.
The patient’s past medical and surgical history was unremarkable, and she reported being in good general health.
What is your working hypothesis at this time?
Although further confirmation is needed, the initial presentation seems to suggest the classic presentation of an idiopathic cervical disk herniation.
Does this presentation/history warrant a Cyriax upper quarter scanning examination? Why or why not?
Given the reports of neurologic symptoms, the insidious onset and the distribution of symptoms, this patient would warrant an upper quarter screening examination. In addition, the scan can be used to confirm the hypothesis while ruling out the more serious causes for these symptoms. It is always important to rule out other possible causes of neck and limb symptoms, including brachial plexus lesions, space-occupying lesions (benign or malignant tumors, cysts), thoracic outlet syndrome, nerve compression from facet or osteophyte impingement, rotator cuff tendonitis or tears, subacromial bursitis, bicipital tendonitis, and lateral epicondylitis. These disorders are distinguished by positive provocative maneuvers specific to them, in the absence of the other previously mentioned neurologic findings.
What is the significance of pain that is aggravated by coughing, sneezing, and straining?
Coughing, sneezing, and straining are all activities that produce an increase in intradiscal pressure.
The scanning examination revealed the following:
- Observation of the patient revealed that the cervical lordosis was reduced and that her head was held in neutral flexion and deviation to the left.
- Marked limitation of active and passive cervical motion was noted, with a spasmodic end-feel on right rotation, right side bending, and extension.
- Gentle compression through the patient’s head reproduced the pain, and general distraction relieved it slightly. Performance of Spurling test is unnecessary in this case.
- Palpable tenderness was elicited over the right aspect of the C6 to C7 segment.
- Hypoesthesia was present in the C7 dermatome.
- Triceps deep tendon reflex was hyporeflexive.
- Weakness of the C7 key muscles (elbow extensors and wrist flexors) was noted.
- Special testing revealed negative thoracic outlet testing and positive neurodynamic mobility testing in the radial and median tests.
- Negative vertebral artery involvement was found.