Here is an article by McAnany et al regarding sensory dermatomes and cervical radiculopathy. Often when a patient presents with radiating symptoms (involving pain, numbness, tingling, etc) we want to complete a neurological exam (Sensory check via dermatomes, manual muscle test via myotomes, and Deep tendon reflexes). Often, surgery is validated for cervical radciulopathy cases via the narrative a particular dermatome is correlated to cervical findings (example a disc). This evidence demonstrates cervical radiculopathy can follow a non-standard pattern that is contradictory to what is taught in textbooks.
Alright I’m finding paper hard to figure out, so I figure why not post a few questions.
The paper used >75% improvement in symptoms post surgery to suggest the right level had been operated on. However if 46% of patients had non-textbook dermatomal distributions, wouldn’t that mean the level to operate on would frequently be miscalculated?
If a patient presented with cervical/lumbar radiculopathy symptoms, should imaging be ordered? I’ve read patients have worse physical therapy outcomes after imaging, however it seems important to know if a nerve root is being squished? But then again would it matter if this can be seen in the asymptomatic population?
Should imaging only be ordered if the patient has red flags such as unexplained muscle weakness, bladder and bowel dysfunction and tingling around the groin? If other neural symptoms such as sensation or reflex reflex changes, pins, needles and numbness are present would imaging not be indicated?
How would non-surgical treatment of cervical radiculopathy look? Education that the symptoms will likely resolve over time and to try not let this limit your activity?
If anyone else has any takeaways from the article feel free to share!
Can you expand on this point? Not sure I’m following. Of the 239 patients included, 129 (54%)
cervical levels matched dermatome presentation and 100 (46%) didn’t match in presentation.
If I’m understanding your point correctly, yes the study would appear to support the notion that sensory symptomatic presentation doesn’t regularly match biological tissue “abnormalities”. It’s also possible that relief had little to do with the “right” level being intervened on.
In atraumatic radiculopathy cases, initial imaging is not well supported for most cases. Although, this isn’t black and white. Potentially in trauma cases and cases with progressively worsening symptoms imaging may be warranted. However, even then, case context matters. If alternative treatment such as surgery is not being considered then it is unlikely to alter prognosis. You are correct, that often imaging has a nocebo effect and does more harm than good long term and we do have evidence if these “issues” such as degenerative disc disease readily occurring in the asymptomatic population.
The overall takeaway, symptomatic presentation is complex and variable beyond what we are taught in textbooks. We also can take this a step further and question the validity of surgery for relieving symptoms if symptom presentation isn’t strongly correlated to expected biological level of involvement.
Yep, education and reassurance goes a LONG ways. Then I usually dose in exercise specific to their activities of daily living or desired extracurricular activities. Regarding sham surgery - that would be an awesome study to see conducted…whether it ever happens or not is a different story. Although, I’m optimistic given the recent trials for meniscus and subacromial impingement…