Background
The patient is 42 years old. Married, with two adult children. Works in a kindergarten and has experienced a lot of stress at work in the position as a pedagogical leader. Previously healthy, but has some stress headaches. There is high sick leave in the kindergarten, which is currently understaffed.
The patient presents due to headache (VAS 4) and neck pain (VAS 5) radiating to the right shoulder and arm down to the thumb. The symptoms have lasted for a few months. The pain started in the neck, and in the past month, it has spread to the shoulder and arm. The neck pain began suddenly without any particular cause. The pain has worsened over the past two to three weeks, also with paresthesia and numbness in the right arm. Painkillers have had no effect, and the patient has scheduled an appointment to get something stronger than Paracetamol and Ibuprofen.
Consultation video
Medical history
- Doctor
What can I help you with?
- Patient
I have gotten quite a lot of pain in my neck… and now it goes down into my arm as well.
- Doctor
Where did it start?
- Patient
It started in the neck a few months ago… but in the past month it has begun to go down the right arm.
- Doctor
Where in the arm do you feel it?
- Patient
Down towards the thumb… like on the outside.
- Doctor
How would you describe the pain?
- Patient
It is quite sharp… and sometimes it tingles.
- Doctor
Have you felt numbness?
- Patient
Yes, it feels a bit dull in the hand too.
- Doctor
Have you noticed any weakness?
- Patient
A little… it is harder to use the hand than before.
- Doctor
Is there anything that makes it worse?
- Patient
When I move my neck… especially to the right.
- Doctor
Have you tried any treatment?
- Patient
Yes, Paracetamol and Ibuprofen, but it doesn't help… That's why I thought maybe I need something stronger.
Standard examination
Perform standard examination:
- 1 Inspection
- 2 Active movements
- 3 Passive movements
- 4 Isometric movements
- 5 Palpation
Tentative diagnosis
based on medical history and standard examination- nerve root involvement of the right C6 nerve root.
Examination
Special tests to strengthen or weaken the likelihood of the tentative diagnosis.
-
1. Active neck movement
Doctor
Can you rotate your head to the right?
Patient
Starts rotation, but stops before full movement with noticeable pain reaction.
Ouch… it shoots down the arm.
Findings
- Pain VAS 7.
- Radiating to the right shoulder and arm.
- Refuses full movement.
-
2. Extension and side bending to the right
Doctor
Performs combined movement in the neck.
Patient
There you go! It goes straight down the arm.
Findings
- Reproduces radicular pain.
-
3. Palpation
Doctor
Palpates m. trapezius.
Patient
Yes, it is tender there.
Findings
- Tenderness in right m. trapezius.
-
4. Spurling test
Doctor
I apply a little pressure on the head. Let me know if it hurts.
Patient
Light compression causes an immediate reaction.
Yes! It goes down the arm, same pain!
Findings
- Positive Spurling test.
- Reproduces radiation (VAS 7).
-
5. Sensation
Doctor
Tests pinprick and touch over the thumb.
Patient
It feels weaker there than on the other side.
Findings
- Decreased sensation in the C6 area at the thumb.
-
6. Strength in wrist extension
Doctor
Tests wrist extension.
Patient
Can hold a little, but gives way on the right side.
It is weaker there.
Findings
- Reduced strength in wrist extension (C6).
-
7. Brachioradialis reflex
Doctor
Taps the reflex.
Patient
There is no reaction when you tap with the reflex hammer.
Findings
- Reduced or absent reflex.
Learning points
- 1 Reduced sensation in dermatome C6, with the thumb as the key point.
- 2 Reduced strength in myotome during wrist extension.
- 3 Positive Spurling test suggests root irritation.
- 4 The findings indicate that this is not just muscular or diffuse pain.