Background & Etiology
Spinal Nerves and Intervetebral Foramen
In the spine, there are areas where the intervertebral disc and facet joints join two cervical vertebral bodies. Where this occurs, it forms two canals on either side of the spine. These canals are called intervertebral foramina. The spinal nerves leave the spinal cord, and travel through the foramina, exiting the spinal column, where they travel to the rest of the body.
The size or diameter of the spinal foramina can vary from person to person. If anything compromises or encroaches on the canal, it may put pressure on the exiting nerve. This produces symptoms that may include pain, tingling, numbness or even weakness. Degenerative disc disease, degenerative joint disease, disc herniation, bony spurs and osteophyte formation are conditions that can narrow the intervetebral foramen and compress the exiting nerves. This produces symptoms in the neck and arms.
The spinal nerves are the electrical wires of the body. They originate at the spinal cord and exit the spinal column through the intervetebral foramen. Once out in the body, the spinal nerves are considered peripheral nerves. They provide both sensation (afferent) and motor or muscle (myotomal) innervations to the body.
Nerves exiting the area of the cervical spine provide sensation and motor control to the neck, shoulder, arm, and down to the hand. Damage or interference with the conduction of these nerves can cause neurological problems including pain, weakness, abnormal sensations, numbness and changes in spinal reflexes.
Anything that encroaches, decreases or narrows the space where the nerves exit the foramen can produce what is commonly known as a pinched nerve. Common causes of pinched nerve include:
- Degenerative disc disease that results in wear on the intervertebral disc, and a reduction in disc height may result in loss of space at the intervertebral foramen.
- Herniated discs can place pressure on the nerve in addition to inflammation that irritates the nerve.
- Degenerative joint disease resulting in the formation of bony spurs on the facet joints can narrow the intervertebral space placing pressure on the exiting nerve.
- Trauma or muscle spasm can put pressure on the peripheral nerve, producing symptoms along that nerve’s distribution.
The symptoms experienced as a result of a pinched nerve will be located along the same path that the nerve travels.
- Pain, which can start in the neck and travel to the shoulder and run down to the arm as far as the hand.
- Impairment of normal reflexes in the upper extremity
- Numbness or paraesthesia (tingling) may be experienced from the neck to the hand, depending on the distribution of the affected nerve.
- Muscle weakness may occur on any muscle that is innervated by the pinched nerve. Long term pressure on the nerve can produce atrophy or wasting of that particular muscle.
- Pain in the neck or radicular to the shoulder blade and arm.
- Pain and tenderness localized at the level of the involved nerve.
- Muscle spasm and changes in posture in response to the injury.
- Loss of motion like the inability to bend backward, move sideways to the effected side, or turn the head; in addition to poor tolerance for sitting.
- Loss of the normal cervical curvature or lordosis.
- The tendency to want to hold the arm bent at the elbow, or over the head to keep tension off the nerve.
- Pain with excess activity and relief with rest.
The greatest amount of movement occurs at cervical vertebra C5-C6, but the levels C4-C5, and C6-C7 are responsible for nearly as much movement. This movement produces more stress on these areas of the spine, thus the greatest amount of degeneration of the cervical spine occurs at these locations. Degeneration of this area can be manifested in different ways, from disc degeneration to bony spur or osteophyte formation resulting in possible nerve encroachment or pinching. The most common nerves affected are at the C5, C6 and C7 levels.
Common Pain Patterns
- C2- Posterior occipital, back of the head, headaches
- C3- Occipital, behind the eye, behind the ear pain
- C4- Base of neck, upper shoulder pain
- C5- Upper arm pain
- C6- Thumb, side of forearm, and index finger pain
- C7- Middle finger pain
- C8- Pain in the ring and little finger
- T1- Little finger, side of forearm pain
Treatment of a pinched nerve or injury will depend on the severity of the condition. When treating acute back problems:
- Rest: avoid the activities that produce the pain (bending, lifting, twisting, turning or bending backwards).
- Medication to reduce inflammation (anti-inflammatory drugs and pain medication).
- Ice in acute cases: apply ice to the neck or cervical spine to help reduce pain and associated muscle spasm. Apply it right away and then at intervals for about 20 minutes at a time. Do not apply directly to the skin.
- An exercise regiment designed specifically to address the cause of the symptoms associated with the pinched nerve and improve joint mobility, spinal alignment, posture, and range of motion.
- A neck collar may be necessary to reduce stress on the nerves, facet joints, muscles and cervical spine.
- Steroidal medication to reduce inflammation in moderate to severe conditions.
- Cervical nerve or epidural injections
- Physical therapy to reduce inflammation, restore joint function, improve motion, and help the return of full function.
In mild cases rest, ice and medication may be enough to reduce the pain. Many patients will do well with this regiment. Physical therapy is recommended to develop a series of postural, stretching and strengthening exercises to prevent reoccurrence of the injury. Return to activity should be gradual to prevent a return of symptoms.
Moderate to Severe
If the problem persists, consulting with your health care provider should be the next step. Your physician will perform a thorough evaluation to determine the possible cause of your symptoms, the structures involved, the severity of the condition, and the best course of treatment.
In addition to performing a thorough examination your physician may order the following tests to make a more concise diagnosis:
- X-ray to determine if there is any joint degeneration, fractures, bony malformations, arthritis, tumors or infection present.
- MRI to determine any soft tissue involvement, including visualization of the discs, spinal cord and nerve roots.
- CT scans, which can give a cross section view of the spinal structures.
Your physician may recommend several medication options individually or in combination to reduce the pain, inflammation and muscle spasms that may be associated with facet joint injuries.
- Over the counter medications for mild to moderate pain.
- If over the counter medications are not effective, your physician may prescribe stronger pain medication.
- Anti-inflammatory drugs or prescription NSAIDS (non-steroidal anti-inflammatory drugs) to reduce inflammation following acute injury.
- Muscle relaxers to reduce acute muscle spasm.
- Injections like facet injections, nerve blocks or an epidural. These may involve the injection of corticosteroids to a specific structure to reduce local inflammation.
Severe or Non-responsive Condition
In the case of conditions that do not respond to conservative care surgery may be indicated. If you continue to experience some of the following symptoms:
- Increase in radiating or radicular pain
- Pain or nerve irritation that gets worse
- Weakness with muscle atrophy
- Associated disc involvement
If symptoms continue to get worse, surgery may be indicated to release entrapment and remove the degenerative changes that are compromising the nerve. One such procedure is called a Foraminotomy.
Physical Therapists are professionals, educated and trained to administer interventions. As defined by The Guide to Physical Therapist Practice, interventions are the skilled and purposeful use of physical therapy methods and techniques to produce changes consistent with the diagnosis, prognosis and the patient or client’s goals.
Your physical therapist will perform a thorough evaluation to assess and determine the following:
- Spinal Examination: where the patient is put through a series of movements and tests to determine the most probable cause of the condition.
- Strength: resisted testing is performed to determine if there is associated weakness or strength imbalances.
- Flexibility: tight muscles can contribute to poor mechanics and weakness creating imbalances and making one more susceptible to disc and back injuries.
- Posture Analysis, ADL’s and technique: discuss and observe the activity that may have started the problem. An examination of the dynamic and static postures that may have caused or contributed to the back problem. A review of your current activities at home and work that may or may not be causing or prolonging your present condition.
Physical therapy for cervical degenerative joint disease must remain conservative at the onset to avoid aggravating the condition. Emphasis will be on rest, reducing the inflammation, load, and stress on the affected area. Once the initial inflammation has been reduced, a program of stretching and strengthening will be initiated to restore flexibility to the joints and muscles involved, while improving strength and stability to the spine. Your program design will be based on the structure and cause of your symptoms. A program not tailored to your problem could aggravate your symptoms.
Common Physical Therapy interventions in the treatment of a cervical pinched nerve include:
- Manual Therapeutic Technique (MTT): hands on care including soft tissue massage, stretching and joint mobilization by a physical therapist to improve alignment, mobility and range of motion of the cervical spine. Use of mobilization techniques also helps to modulate pain.
- Therapeutic Exercises (TE) including stretching and strengthening exercises to restore joint mobility, range of motion, and strengthen muscles of the back and abdominals to support, stabilize and decrease the stresses place on the spinal joints, discs, and neck.
- Neuromuscular Re-education (NMR) to improve posture, restore stability, retrain the patient in proper sleeping, sitting and body mechanics to protect the injured spine.
- Modalities including the use of ultrasound, electrical stimulation, ice, cold laser, traction and others to decrease pain and inflammation of spinal structures.
- Home programs including strengthening, stretching and stabilization exercises and instructions to help the person perform daily tasks and advance to the next functional level.
Most pinched nerves or entrapment problems can be managed conservatively without surgery and return to normal function. Duration of treatment can range from 4 to 12 weeks depending on the severity of the symptoms. Patients need to continue with a regiment of postural, stretching, strengthening and stabilization exercises. Use of proper mechanics, proper posture, body mechanics and awareness of the do’s and don’ts for a healthy back is necessary for a good long-term prognosis. The attitude of, “once you have a back problem, you have a back problem” goes a long way to preventing further injury. Staying on a regimented home program to treat the condition that caused the entrapment is important.