Sixth Cervical Roots Research Articles

Itch, skin lesions—and a stiff neck

In January, 2007, a 36-year-old man presented to his derma tologist, with a 3-month history of constant itching of his head, neck, shoulders, and upper limbs. The itch had become so intense that it disturbed the patient’s sleep; it had a burning character, especially when the patient was wearing clothes. Treatment with topical cortico steroids and oral antihistamines produced no improve ment. The patient took no other regular medications, except occa sional nonsteroidal anti-infl ammatory drugs to relieve inter mittent neck pain: he had a 2-year history of neck pain and stiff ness. After 1 month, during which the itch contin ued to worsen, the patient was referred to us for further investigation. Physical examination showed slight redness of the aff ected skin, as well as excoriated fl at papules and erosions on the neck and forearms (fi gure). These signs were considered to be caused by rubbing and scratching. The results of blood tests, including a full blood count, plasma glucose, renal and liver function tests, and infl ammatory markers were all unremarkable. The association of neck pain, cervical stiff ness, and itch localised to areas supplied by the cervical spinal cord, pointed to a neurological cause for the itch. Neurological examination revealed abnormalities of both arms, particularly severe distally and in the right arm: hypoaesthesia, paraesthesia, muscle weakness, and reduced refl exes. Electromyography and nerve conduction tests showed an axonal injury, at the levels of the fi fth and sixth cervical roots. Further sensory testing revealed complete loss of heat sensation, and reduced vibration sense, in the index fi ngers of both hands, corresponding to the sixth cervical root. The symmetrical loss of motor and sensory function led us to suspect a lesion of the cervical spinal cord, aff ecting most or all of its width. Cervical MRI showed a lesion extending from the level of the fi rst to the seventh cervical vertebra, with prominent perifocal oedema. The lesion was excised by a decom pressive laminectomy, and was found to be an ependymoma on histopathological analysis. Irritation of the spinal cord, during the operation, caused weakness of all the patient’s limbs. This weakness decreased during residential rehabilitation; by April, 2007, the patient had regained most of his strength and coordination. The itch was no longer present. In May, 2007, the patient started to receive radiotherapy, to ensure that the tumour was eradicated. Sadly, he then developed a fi stula extending from the spinal cord to the skin—through which cerebrospinal fl uid leaked—and a subse quent infection of the fi stula and the surrounding tissue, though not of the spinal cord itself. The cord was seen on MRI to be oedematous. When last seen, in May, 2007, the patient had severe neurological defi cits—although, ironically, no itch. Itch can be classifi ed into four types: pruritoceptive, psychogenic, neurogenic, and neuropathic. 1

회전근개 파열과 유사한 양상을 보인 피부 대상 포진의 지연성 근육 마비 - 증례 보고 -

Herpes zoster presents clinically with cutaneous vesicular eruption and pain along the dermatome, but it can sometimes cause muscular paralysis. When the disease involves cervical root, it is included in the differential diagnosis of shoulder diseases. A sixty-six year old patient, complaining of severe pain and weakness of his left shoulder, was referred to the authors as having a partial tear of the supraspinatus tendon on MRI. However, the authors found out a paralysis of the sixth cervical root in the patient by electrophysiologic studies, noting that the patient had been affected with a herpes eruption in the neck and arm two months before. Zoster paresis has been reported to be associated with the cutaneous eruption within two weeks of its onset, making its diagnosis not so difficult. The authors report a case of delayed-onset muscular paralysis after cutaneous herpes zoster, which presented just like a rotator cuff tear.

Solitary plexiform neurofibroma presenting as purely motor axonal cervical plexopathy

A 27‐year‐old male presented with three years of progressive weakness and atrophy in his right arm. He did not have sensory complaints or pain but occasional proximal arm dysesthesias. Neurological examination showed severe right shoulder girdle atrophy and proximal limb weakness affecting muscles supplied by the fifth and sixth cervical roots. Strength was normal distally in the right arm and in the other limbs. Deep tendon reflexes were normal. Sensation was normal. Laboratory studies showed increased creatine kinase levels. Anti‐GM1 IgM antibodies were not found. Electrodiagnostic studies were consistent with either focal motor neuronopathy or right brachial plexopathy involving the upper trunk. Nerve conduction studies did not show conduction blocks or slow conduction velocity. The CMAP amplitude of the right median nerve was normal. EMG showed chronic denervation and fibrillation potentials in paraspinal and arm muscles innervated by right C5–C6. MRI studies revealed markedly increased signal intensity on T2‐weighted images of the fifth and sixth right cervical roots and upper trunk of right plexus with contrast‐enhanced T1‐weighted images. A provisional diagnosis of motor axonal inflammatory plexopathy was made based on the purely motor focal deficit, increased creatine kinase levels and enhancing focal hypertrophic roots on MRI, as described in CIDP and MMN. The patient was treated with high dose IVIg 2 g/Kg over four days with no improvement. Two months later a biopsy of enlarged cervical root revealed a plexiform neurofibroma. The patient did not have a family history or other typical abnormalities of neurofibromatosis (NF1), including cafè‐au‐lait spots, skin fold freckling, Lisch nodules in the iris and bone dysplasia. Solitary plexiform neurofibroma may occur in patients without other stigmata of NF1 and should be considered in the differential diagnosis of purely motor focal inflammatory radiculoplexopathy.

Neuroplastic Changes Related to Pain Occur at Multiple Levels of the Human Somatosensory System: A Somatosensory-Evoked Potentials Study in Patients with Cervical Radicular Pain

Studies suggest that pain may play a major role in determining cortical rearrangements in the adult human somatosensory system. Most studies, however, have been performed under conditions whereby pain coexists with massive deafferentation (e.g., amputations). Moreover, no information is available on whether spinal and brainstem changes contribute to pain-related reorganizational processes in humans. Here we assess the relationships between pain and plasticity by recording somatosensory-evoked potentials (SEPs) in patients who complained of pain to the right thumb after a right cervical monoradiculopathy caused by compression of the sixth cervical root, but did not present with clinical or neurophysiological signs of deafferentation. Subcortical and cortical potentials evoked by stimulation of digital nerves of the right thumb and middle finger were compared with those obtained after stimulation of the left thumb and middle finger and with those obtained in a control group tested in comparable conditions. Amplitudes of spinal N13, brainstem P14, parietal N20 and P27, and frontal N30 potentials after stimulation of the painful right thumb were greater than those of the nonpainful left thumb and showed a positive correlation with magnitude of pain. This right-left asymmetry was absent after stimulation of the patients' middle fingers and in control subjects. Results suggest that chronic cervical radicular pain is associated with changes in neural activity at multiple levels of the somatosensory system. The absence of correlation between the amplitude of spinal, brainstem, and cortical components of SEPs suggests that enhancement of cortical activity is not a simple amplification of subcortical enhancement.

The Frontotemporal Region Plays a Role in the Genesis of Migraine Without Aura

We have compared the migraine-inducing effect of nitroglycerin ointment applied to the frontotemporal region of the head, which is innervated by the ophthalmic and maxillary divisions of the trigeminal nerve, with that of nitroglycerin applied to the chin (innervated by the mandibular division), the posterolateral region of the neck (innervated by the second and third cervical roots), the lateral surface of the proximal third of the forearm (innervated by the sixth cervical root), and the medial surface of the upper-arm region (second dorsal root). One hundred patients suffering from migraine without aura were randomly divided into five equal groups. Each group received an application of 5 mg nitroglycerin in 2% ointment on a preselected body area for 2 hours. Frontotemporal nitroglycerin induced a significantly greater number of early onset migraine attacks with respect to the arm and forearm regions. In all cases, nitroglycerin applied to the frontotemporal region resulted in subsequent migraine, whereas there was a significant number of negative trials with nitroglycerin applied to the neck, arm, and forearm vs the frontotemporal area. It, therefore, appears that the trigeminal nerve endings in the affected frontotemporal region are particularly sensitive to the migraine-inducing effect of the nitrate. This suggests a peripheral neurogenic hypothesis of migraine genesis.

Dobutamine increases diaphragmatic contractility in dogs.

The effects of dobutamine on diaphragmatic contractility were studied in 24 dogs anaesthetized with secobarbital and receiving mechanical lung ventilation. The phrenic nerves were stimulated supramaximally for two seconds with electrodes placed around the fifth and sixth cervical roots when the airway was closed at the level of FRC. The stimulating frequency ranged from 10 to 100 Hz. Transdiaphragmatic pressure gradient (Pdi) generated by the electrophrenic stimulation was used as an index of diaphragmatic contractility. The electrical activity of the diaphragm during the stimulation (Edi) was also measured with needle electrodes inserted in the right hemidiaphragm percutaneously. During an infusion of dobutamine (10 micrograms.kg-1.min-1 for 20 min), Pdi increased by 15 +/- 2.1% of control value at 20 Hz stimulation (P less than 0.01), and by 13 +/- 1.2% at 100 Hz stimulation (P less than 0.01). The Edi was not altered by dobutamine infusion. This enhancement of Pdi by dobutamine was abolished by simultaneous infusion of nicardipine, a Ca-channel blocker, but was not affected by prostaglandin E1. These results suggest that dobutamine has a stimulating effect on canine diaphragmatic contraction, and this action may be related to the increased inward movement of extracellular calcium.

Cervical stability after foraminotomy. A biomechanical in vitro analysis.

Laminectomy or facetectomy of the cervical spine, or both, may be needed for decompression of the spinal cord or of the nerve-roots. Acute stability of the cervical spine was tested after laminectomy and progressive staged foraminotomies in an in vitro model. Twelve cervical spines from human cadavera were used in the experiment. Biomechanical testing included the application of an axial load, the application of a flexion and extension moment, and the application of a torsional moment. Each specimen was tested intact, after laminectomy of the fifth cervical vertebra, and after progressive foraminotomy of the sixth cervical root. Foraminotomy was performed by resection of 25, 50, 75, and 100 per cent of the facet joint and capsule. Torsional stiffness decreased dramatically when more than 50 per cent of the facet had been resected. Statistically equivalent subsets were the intact specimen, laminectomy, 25 per cent facetectomy, and 50 per cent facetectomy in one subset, and 75 and 100 per cent facetectomy in the least-stiff subset. Flexion-moment testing showed that the posterior strain did not differ among three groups: the intact specimens, those that had been treated with laminectomy, and those that had been treated with a 25 per cent facetectomy. The 50 per cent facetectomy resulted in a 2.5 per cent increase in posterior strain, and the 75 or 100 per cent facetectomy, in a 25 per cent increase in posterior strain compared with the intact specimen. Segmental hypermobility of the cervical spine results if a foraminotomy involves resection of more than 50 per cent of the facet.(ABSTRACT TRUNCATED AT 250 WORDS)

Tinel's Percussion Test

ABSTRACT To the Editor:— I wish to reply to Dr. Rentschler's comments (208: 2337, 1969) concerning my modification of Tinel's percussion test for evaluating intraspinal sensory nerve root involvement (208:152, 1969).I stated that the use of Tinel's percussion test for evaluating peripheral nerve lesions was well known, and that I was suggesting a modification of this test for diagnosing involvement of any spinal sensory nerve root which innervated a cutaneous dermatomere. I chose the sixth cervical root as an example because it is frequently compressed or irritated by cervical disks or osteophytes. However, my comments concerning the manner of doing the test and its interpretation were applicable to any sensory dermatomere in the body. For example, the eighth cervical dermatomere supplying the little finger, and the mesial surface of the ring finger; the fifth thoracic dermatomere which crosses the nipple line; or the fifth lumbar dermatomere which includes the

Tinel's Percussion Test For Intraspinal Sensory Nerve Root Involvement

To the Editor:— Although Tinel in 1915 introduced the percussion sign, known by his name, to evaluate interruption or regeneration of a peripheral nerve, a review of his original paper and recent texts on neurological diagnosis reveals no mention of this percussion test to diagnose or localize intraspinal sensory nerve root involvement.1-3 The purpose of this letter is to recommend the use of finger tapping or percussion along the course of a sensory dermatomere to elicit the sensation of tingling or pins and needles or paresthesias, as an additional or corroboratory sign, of irritation or involvement of a specific spinal sensory nerve root supplying the percussed dermatomere. For example, if the sixth cervical root in involved intraspinally by intrinsic nerve pathologic condition or by pressure from a disk, osteophyte, or tumor, the patient will often complain of pain referred to the sensory dermatomere supplied by this cervical root, namely

Roentgen Findings in Obstetrical Injuries to the Brachial Plexus

Injury to the brachial plexus with resulting paralysis occurring at birth is caused by stretching of the nerves when the head and shoulder of the infant are forcibly separated (5). This may occur in vertex presentations when traction and lateral flexion are exerted on the neck while the shoulder is fixed in the maternal pelvis. In breech presentations, forceful manipulation with abduction and elevation of an arm and shoulder may exert excessive traction against a fixed neck. Other possible causes are difficult labor, forceps delivery, marked relaxation of the muscles of the fetus from profound anesthesia, and the use of undue force. In mild cases, there may be only hemorrhage or edema of the nerve sheaths, and spontaneous recovery usually occurs within three to six months. In more severe cases, there may be nerve-sheath rupture, hemorrhage into the nerve trunks, separation of nerve fibers, or partial or complete division of nerve trunks. Avulsion of the nerve roots from the spinal cord may also occur. The condition is not attributable to rupture of the capsule of the shoulder joint or to separation of the epiphysis of the humeral head (5). The paralysis has been classified into upper-arm, lower-arm, and whole-arm types. In the upper-arm type, or Erb's paralysis, the fifth and sixth cervical roots are involved. The arm hangs at the side with the extremity internally rotated and the forearm pronated. The elbow and wrist are flexed. The attitude of the extremity has been referred to as the “waiter's tip” position. When the paralysis persists, the limb becomes atrophic, contractures result, and external rotation is impaired. In the uncommon lower-arm type, or Klumpke's paralysis, the seventh and eighth cervical and first thoracic roots are involved. Loss of function of the intrinsic hand muscles, the flexors of the wrist, and the long flexors of the fingers results in a clawhand. Horner's syndrome may be associated with this paralysis as a result of injury to the cervical sympathetic fibers which enter the cord through the first dorsal root and, in some instances, the eighth cervical root. In the whole-arm type, roots C5 through T1 are involved. The entire arm is flaccid with wrist drop and paralysis of the small muscles of the hand. Marked atrophy of the arm is present, and its growth is delayed. Roentgen Findings In the injured newborn, the metaphysis of the humerus is farther from the glenoid than normal (Fig. 1). Development of the epiphyses of the humeral head is retarded (Fig. 2), and atrophy of the soft tissues around the shoulder joint is present (Fig. 3). The scapula is elevated and rotated outward. Later, the ossification center for the humeral head may lie lateral to that of the greater tuberosity because of internal rotation of the humerus. If the phrenic nerve is involved, the diaphragm on the affected side is elevated (Fig. 4) (2).

The importance of cervical myelography in cervical and upper throacic nerve root avulsion.

Injury to the brachial plexus is not uncommon. In infants it is seen as a birth palsy, usually involving the fifth and sixth cervical roots (5). In adults it occurs most frequently following trauma to the shoulder region in which stress traction has been placed on the involved roots. The term avulsion is reserved for intraspinal separation of the nerve root from the cord. Separation elsewhere as the result of blunt or closed trauma constitutes extraspinal or peripheral rupture (1, 5). The mechanism of occurrence, clinical features, treatment, and myelographic findings in brachial plexus avulsion will be considered here and 3 cases will be reported. Mechanisms of Injury Barnes (2) gives an excellent discourse on the probable mechanism of brachial plexus injury. The head and shoulder are separated forcibly, the position of the arm determining the type of injury. When the arm is in adduction, the greater stress is placed on the upper roots (C-5 and C-6), resulting in an Erb type of paralysis. With the arm in...