C6 Nerve Root Compression or Carpal Tunnel Syndrome? | OEP349

In this episode I will talk about...
-Overlapping signs and symptoms of C6 NRC and CTS

-Tips and special tests to tease these diagnoses out and so much more!

(Video) C6 NRC after surgery.
(Video) Scratch collapse test
(Video) Marquis Maneuver explanation
(Video) Marquis Maneuver positive with patient

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Transcript

Speaker 1: 0:02

<silence> Hello and welcome to episode 349 of the Ortho Eval Pal podcast. I'm your host, Paul Marque , and today we're gonna be talking about C six nerve root compression or carpal tunnel syndrome. We're gonna talk about some of the overlapping signs and symptoms of a C six nerve root compression and carpal tunnel syndrome. We're gonna talk about some tips and some special tests to help tease out these diagnosis. Um, but before we get started, I just want to talk about our sponsor, range Master , um, range Master carries a number of different products including overhead, pulleys, shoulder wands, resisted bands, wall anchors, finger ladders, and their latest product is the Sling Thing adapter. Now, this thing is great. Um, I, I love it because when patients come in, they have a sling on, they're having a lot of pressure where that sling strap goes over the shoulder. Um, we basically put this , um, s lengthening adapter around the proximal humerus of the good arm and then take a small strap and put it underneath the , um, the sling strap near the patient's neck, and we just pull that strap away from their neck. Um, and it velcros right there. It's easy to do, not easy to do on yourself, but if somebody else can put it on for you, it's super, super simple. Takes me about 20 seconds to put it on the patient , um, and they get immediate relief. So it makes a huge difference. So if you are a medical professional , um, and you work with shoulder patients, you know, get a free sample by clicking on the link in the show notes or email jim@myrangemaster.com. Just put ortho eval pal in the subject line. Um, and they will send you one right away and just start trying it with your patients. They're gonna love it. Um, again, I am not , uh, uh, getting any affiliate , um, compensation for this. They're just a sponsor to the podcast. Um, so , uh, be sure to get yours for free. Now onto today's topic, we're gonna be talking about , um, our lookalike series. Again, just just a con continuation of this, today we're gonna be talking about how C six nerve root compression can look like a carpal tunnel syndrome. Now, let's just talk about some of the most common, you know, signs and symptoms that correlate to both of them. Okay? So it's very common for both folks to have paresthesias in the thumb and index finger. Um, there could be weakness in the hand, and , um, the reason this is with a C six, now people think, well, C six is really a loss of, you know, biceps and wrist extension, number one, wrist extension, and then biceps secondary. Uh, I've seen this with experience after seeing hundreds of C six nerve root compressions. The C six um, affects the wrist extension the most and then a little bit of biceps. Now, the reason people have weakness in the hand with their grip when they have a C six nerve root compression is because they lose that ability to keep the wrist in that tenodesis position. Um, and so therefore , uh, the wrist drops and then you end up with this, you know, active insufficiency because

Speaker 2: 2:58

The, the wrist is flexed, the fingers are shortened , uh, the flexor tendons are shortened and therefore you have less grip. So if you can maintain better wrist extension, that can help give you better strength. Okay? So that is something that you need to recognize. They both can have weakness there. They both can have pain in the hand and fingers. They both can offer you nighttime pain. Okay? Now, the people with carpal tunnel issues will get discomfort if their wrist is in an excessive amount of flexion. You know, they might sleep on it and put under their head or their neck or tuck it right in there, and they HyperFlex the wrist and fingers that will give 'em some , uh, compression in the carpal tunnel. Give them some pain into the , uh, the wrist and fingers. And then if you are having a C six nerve root compression problem and the disc is quite large, you have a lot of emeral compromise there. Your neck could , uh, if you're laterally flexing to that side, could cause an increase Pinch of that C six nerve root caused you a lot of discomfort down the arm and into the hand. Um, so that's why these two can kind of look alike. Now, with carpal tunnel syndrome, it's usually , um, the default when somebody has pain in the wrist, thumb and index fingers. But we should not forget what's happening upstream. You should, you know, palpate that median nerve as it goes up the forearm where you can have other entrapment areas, such as in the sublimate archer near the , uh, the , the flex digitorum musculature where that nerve travels right under there. So right in that , uh, anterior forearm. So, you know, palpate up there, check that out. And don't forget the , uh, cervical spine. So teasing these out can be quite easy. I always start with a cervical spine screen. Um, you know, if you're doing deep tender reflexes, C six will be the brachial radialis . And so what you're doing is you're comparing one side to the other. So if they don't have a reflex, no big deal. We're gonna be doing a full podcast in , uh, episode 350, which will be next week. And we'll be talking about deep tender reflexes, but C six is brachial radis . And , um, if you don't have it on the affected side, but you have it on the other side, that is something to be concerned about. You then wanna do some manual muscle testing. Wrist extension is the , uh, number one , uh, muscle group affected by a C six nerve root. And , um, I, I know that the biceps are also affected here, but nothing like wrist extension . Um, now there might be a little loss of sensation in the thumb , uh, and somewhat in the index finger and also half of the middle finger if , um, which , which will be affected mostly by somebody who has carpal tunnel syndrome. But if you have loss of sensation in the thumb and the lateral forearm, that is more likely to be coming from the um, C six nerve root area. Alright , next thing I might do with somebody is , uh, lay them on their back. Uh, put them in the supine position. I don't give them a pillow because if they go into extension that reproduces their common symptoms or their concordant signs , um, then that tells me it's coming from their neck. I simply will flex

Speaker 3: 5:57

Their neck a little bit. And if the pain in the arm and the hand go away, or the paresthesias go away, I know it's coming from the neck in this , um, position, I'll then do some cervical distraction or traction manually. I pull about, you know, 18 to 20 pounds, I'll flex that neck about 15 degrees. The laterally flex 'em to the contralateral side where they're not having the radicular type symptoms and see what happens there. Um, while I'm tractioning them, I may have a therapist come in and retest their strength. So if they came in with weakness of wrist extension and I traction their neck and they have a significant improvement , um, then you have to consider that as a cervical spine issue. That would not change if you had carpal tunnel syndrome. Alright , that's called the marque maneuver. Um, a test I developed. I will , uh, include a video in today's show notes so that you can take a look at how we use that. I use it on a weekly basis to help identify what level a cervical spine disc , um, is, is herniating, which nerve root is being compressed. And it's actually become a bigger predictor on how patients will do after cervical spine fusion or decompression type surgeries , uh, of the cervical spine. So , um, then I will , uh, proceed to a Spurlings test of the neck and just do a little extension, lateral flexion and rotation to the affected side. I'm not big on pushing down hard with these, okay? A lot of, a lot of people wanna bear down really hard when they do that. That can be super painful. You can make their symptoms worse. Uh, they'll hate you if they have , um, some significant emeral encroachment, they'll know it just by getting into that position. Sometimes you don't even get halfway through that position. You don't even need to put a downward pressure. Um, and , uh, their symptoms will be reproduced. So let's migrate now over to carpal tunnel syndrome. I will start with a Tinels at the wrist, and that should reproduce, you know, a , a tingling shocking sensation , um, throughout the thumb index finger and , um, half of the middle finger. You , uh, I then will jump into a LANs where I have them , uh, passively flex the wrist. Now, I'm careful with this one. I don't like to put the arms out in front of them with the elbows up in the air. I will just keep that arm by their side and I will passively flex their wrist and ask them what they feel. I don't tell them, you know, what they should feel. Um, the reason I don't want 'em to put the backs of their hands together is that some people just can't figure out how to let go and let them let their wrists flex. A lot of people don't have a lot of wrist flexion to be able to do that. And then getting those arms up in the air in front of them can cause a little bit of thoracic outlet compression and contribute to this. So I try to keep the arm by their side. I might put their elbow at 90 degrees and I'll passively flex the wrist and see if they have an increase in , uh, those carpal tunnel symptoms. You can also , uh, perform the scratch collapse test. I will have a video , uh, in the show notes. So you can take a look at this. I think we had a gentleman with a cubital tunnel syndrome who had a positive test. Check that out. Any , uh, time you have an area where you can get some nerve root compression or I mean nerve , um, compression in the upper extremity. This is an interesting test. Give it a try sometime. And then if I'm really confused, or maybe somebody comes in and they're just like, on a whim, you know, Paul, I'm going on vacation. I've been getting this tingling in my hand and wrist. Um, what do I do? And if I don't have a time to completely evaluate them, but I'm suspecting a carpal tunnel , um, syndrome, I may say, go grab yourself a cheap wrist cockup splint where that at night, if they do and they get immediate relief , uh, it , it's as simple as that. It's very diagnostic for carpal tunnel syndrome. And , uh, they sleep the night, it's better, they have less paresthesias, less pain. So , um, that is something I might try with them. It's, it's like I said, you know , buy a $10 brace , uh, put it on, the wrist up, don't let them get into flex at night. Um, you could do some neurodynamic testing of the median nerve, but this could reproduce symptoms in both the carpal tunnel and with somebody who has nerve root compression. Now, it is a good treatment option. So nerve gliding is gonna be important for both. Um, so make sure you incorporate that into your treatment along with your soft tissue modalities or whatever manual therapies you are doing with your patient. Nerve gliding , um, should be, you know, a part of your program. Um, and that needs to be done very gently. I can even throw some videos in on how to do those. If you want to check those out. Just look at the links in the show notes. Yes. Now I have seen people who have had pain that migrates, you know, from the carpal tunnel and it goes up the arm toward the cervical spine, generally not to the cervical spine, but toward it. Um, sometimes , uh, you know, up to the brachial region, up near the bicep area, it's, it's really unusual. You don't see this very often, but I have had , um, some patients who have had this arm pain. Uh, you know, you , you , you treat them, you think of a cervical spine 'cause it's, it's going up the arm or it's in the arm. Um, and you can rule out all the other orthopedic issues. They go and have a carpal tunnel release and boom, all of a sudden, not only is their hand and, and wrist and fingers feeling better, but the whole arm is feeling better. So, contrary to what you might've learned in school, you can sometimes see this , um, in, in patients. So , um, remember now patients can have both. They could have , uh, what we call a double crush injury, which could be carpal tunnel , uh, you know, nerve root or nerve compression, and a C six nerve root compression. So there'll be a less neuro mobility in these people. So remember, if you do nerve gliding or nerve flossing exercises, they are going to like flare up right away. So you have to be super light. Maybe you just attack one side, you just have the arm down by the side and you're extending the wrist

Speaker 4: 11:52

Only. Maybe you're just laterally tilting the head and neck to the opposite side and not doing anything in combination to start with, but just very, very gentle. Okay? So if you're having a hard time identifying these two and teasing them out, because maybe they have both, or you're just not quite sure where this compression or nerve , uh, root irritation is coming from , um, and EMG can be very helpful in determining this. Um, so , um, that would be something that you could certainly recommend and send people , um, to have. Uh, so unfortunately, you know, I, I've been at this for 32 years. I've seen a ton of people with all of the above. I don't see as many carpal tunnel syndromes as I used to, only because we have occupational therapists who , um, oftentimes will see these patients. Um, but I used to see a ton of them. I see C six nerve root compressions on a weekly basis. It's something we see a lot of. Um, and I have unfortunately seen patients who have had carpal tunnel surgery and they've had no improvements because the issue is coming from C six. So be diligent with your exam, you know, and, and you'll be able to focus on your treatment just a little bit better and fine tune that. Um, now folks, I have a request for you. My podcast is now on YouTube and I wanna know, would you like to , uh, see this podcast in video format, just watching me do the podcast? Or do you just want to stick with listening to the audio version of the, for , you know, the podcast? Now we have this new fan mail feature , uh, in buzzsprout, which is the platform that I utilize for my podcast. And , um, they're now able to add a , a small link in the description. So if you go into, let's say it's Apple Podcast or Spotify or whatever platform you're using , um, just go to the top of the description. You're gonna see where it says, send us a text message. You can send me questions to the show, comments about the topic I just talked about, maybe requests or information that you would like, whatever it might be. I cannot text you back, but if it's something that I can put on the show or maybe answer on the show, I will do that. All right . So certainly send me , um, your message. I'll do my very best to address it. Um, thank you so much for listening to , uh, this podcast today. I hope you have a great day. Be kind to each other and take care.