Reply To: Weekend 2 Case

[Michael McMurray]

1. C8 Nerve Root/Radiculopathy, Upper Cervical Joint Dysfunction, myofascial pain

2. Upper Cervical Joint Dysfunction potentially causing cervicogenic headache. Reasoning: C2/3 PAIVM increased complaint of left ear pain, Cluster of tests for radiculopthy didn’t reproduce her CC, protraction pain (upper cervical closing joints), retraction diminishes pain (opening joints), prolonged sitting aggravates symptoms

3. I would tell my patient she’s been a student since these symptoms came on and likely spends a ton of time reading with poor posture. We were partially able to reproduce symptoms with poor cervical posture (forward head/protraction) and her symptoms were relieved with good posture/retraction. I would explain facet referral pain for the upper cervical vertebrae and how this irritation can easily cause cervicogenic headaches which is another complaint of hers. I’m not fully able to explain the C8 distribution of symptoms but she may also have lower cervical facet irritation and with a 14 year history of chronic pain I would explain the longer you’re in pain the more pain tends to refer elsewhere and cause secondary symptoms.

4. Cervical flexion strengthening, I personally also tell my patients to set an alarm on their phone as a “posture check”, self myofascial release to suboccipitals and upper traps/levator, stretching to same muscles

5. I was unsure about what the statement regarding spurlings, distraction, and ULTT being painful meant and if that means a positive finding than I would likely be leaning more towards radiculopathy but if they’re negative I’m sticking to joint. I’d like to know how often her C8 type symptoms are present and whether or not spurling created a local neck pain or more of a “pins and needles” pain as this would also be crucial information. I’d like to know her thoracic and shoulder mobility because with limited thoracic extension she may be extending more through her cervical spine causing more of a C8 compression or facet irritation throughout the cervical spine. I would ask the patient if her arm symptoms seam related to her neck pain and whether there is a pattern between the two.

Overall there’s still some uncertainty as to whether or not this is all coming from one issue or whether she potentially has multiple issues. It’s possible she has upper cervical dysfunction causing cervicogenic type headaches and corresponding myofascial impairments and at the same time has C8 irritation from lower cervical dysfunciton. I don’t want to hang my hat on one set of special tests but knowing in more detail the findings of the ULTT and spurlings would give me better insight as to whether this is more radiculopathy or joint related.