Cervical Radiculopathy


Article Author:
Warren Magnus


Article Editor:
Fassil Mesfin


Editors In Chief:
Laurie Graham
Andrew Wilt
Mary Cataletto


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Trevor Nezwek
Radia Jamil
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes


Updated:
3/19/2019 12:41:02 AM

Introduction

Neck pain is widespread and causes significant pain and disability. Workers with a history of neck pain account for up to 40% of work absenteeism.[1][2][3] In the setting of cervical radiculopathy, because the nerve root of a spinal nerve is compressed or otherwise impaired the pain and symptomatology can spread far from the neck and radiates to arm, neck, chest, upper back and/or shoulders. Often muscle weakness and impaired deep tendon reflexes are noted along the course of the spinal nerve.

Etiology

Any condition that causes compression or irritation of a spinal nerve root can result in radicular symptoms. In younger patients, typically in the third and fourth decade, disc trauma and herniation are the most frequent causes of impingement. [4]With increasing age, the causation becomes largely degenerative. In the fifth and sixth decades, disc degeneration becomes the most common cause. In the seventh decade, causation tends to stem from foraminal narrowing as a result of the arthritic change.

Epidemiology

Less frequent than lumbar radiculopathies, cervical radiculopathies occur at an incidence rate of approximately 85 persons per 100,000. Most frequently impacted is the C7 nerve root with greater than half of all cases affecting this level. Approximately a quarter of cases affect the C6 nerve root. Other levels are impacted at a much lower rate. Risk factors for developing radicular disease include manual labor involving heavy lifting, driving, or operation of vibrating equipment. A history of chronic smoking increases the risk of developing radiculopathies.

Pathophysiology

In nearly all cases of cervical radiculopathy, the key pathophysiologic feature is inflammation. That inflammation can result from acute herniation of an adjacent cervical disc that subsequently impinges on the nerve root. The inflammation also can exacerbate degenerative changes to such a degree that osteophytes or changes associated with disc dehydration can impinge on the nerve root. It is the direct compression of the nerve root that creates the symptomatology. 

History and Physical

History collections in patients with complaints of radicular pain or muscle weakness should include inquiring after occupational risk factors, history of trauma and pain pattern. Cervical radiculopathy is almost always unilateral, although, in rare cases, both nerves at a given level may be impacted. Those rare presentations can confound physical diagnosis and require acceleration to advanced imaging especially in cases of trauma.

On physical examination, positioning the patient to isolate individual reflex arcs is key. Given the individual variation in deep tendon reflexes comparing side to side is more important that overall magnitude. If there is nerve impingement, the affected side will be reduced relative to the unaffected side. Reduction in strength of muscles innervated by the affected nerve is also significant physical finding.

A Spurling test which compresses the foramina is useful in diagnosing likely radiculopathy. With the head extended, the head should then be rotated. The test is positive if pain radiates down the upper limb of the ipsilateral side of the rotation.

In some cases, cervical traction can provide relief of radicular pain.

Evaluation

Three-view plain x-ray studies of the cervical spine are the most common studies ordered for evaluation of neck and upper extremity pain. Lateral views may show disc space narrowing. Oblique views may show foraminal narrowing at the level of radicular symptoms. Open mouth views are only necessary if disruption of the atlantoaxial joint is suspected.[5][6][7][8]

CT scanning may be useful in the acute setting for diagnosis of traumatic injuries resulting in radicular symptoms. Poor visualization of soft tissue makes CT less effective outside of this setting.

MRI is the imaging method of choice for evaluating radiculopathies. MRI provides excellent visualization of soft tissue abnormalities including disc herniations and nerve compressions. There is a risk of falsely positive MRI studies as disc herniations and foraminal narrowing, while strongly correlated with radicular symptoms, may not be causative in any individual case.

Electromyelography can be useful in confirming the dysfunction of the affected nerve root.

Selective nerve root blocks can be used not only as a treatment adjunct to provide short-term pain relief to patients with radicular pain but also can be effective in confirming nerve root origins of radiated pain. 

Treatment / Management

Treatment of cervical radiculopathy should be approached in a stepwise fashion. Also, while surgery can provide significant relief, there is little evidence that surgery provides a clear advantage over non-surgical treatment in an acute setting. Over 85% of acute cervical radiculopathy resolves without any specific treatments within 8-12 weeks. [9][10][11] 

Over 85% of acute cervical radiculopathy resolves without any specific treatments within 8-12 weeks.  However, in order to facilitate reduce inflammation of the nerve root (s) and improve radiculopathy, it is important to implement non-surgical treatments including oral anti-inflammatory drugs,  physical therapy, and translaminar epidural steroid injections. 

An aggressive, well-designed physical therapy program can provide significant relief. In the setting of surgical intervention physical therapy can speed recovery.

Medical durable goods and appliances can provide significant symptom relief. Nighttime use of a cervical pillow can provide symptom relief and make sleeping easier during recovery. Short term use of a soft cervical collar can provide some support and relief. 

Since the main cause of pain in cervical radiculopathy is inflammation use of NSAIDs for 1 to 2 weeks can provide not only symptom relief but also treat the proximate cause. Use of oral steroids is controversial, and dosing should be short term if at all. Tricyclic antidepressants and drugs such as gabapentin can be useful adjuncts in the treatment of cervical radiculopathy. Opioid pain medications are not recommended but can have utility in the management of radicular pain. It should be noted that use of opioid medications is a risk factor for the slow recovery and delayed return to work for patients where surgical intervention becomes clinically necessary.[12][13]

Studies have shown that epidural steroids can provide significant relief and speed return to normal functioning for many patients. Relief from a single treatment can be significant and long-lasting. Half of the patients treated have reported relief of at least 50% for weeks following injection.

Using acupuncture as an adjunctive therapy also has shown to provide significant relief of symptoms. A direct physical manipulative technique such as chiropractic or direct osteopathic manipulation can worsen radicular symptoms. Indirect osteopathic techniques conversely can facilitate relief of symptoms. 

Surgical management of radicular pain can provide relief in patients that are failed non-surgical treatments. Surgical techniques can be done utilizing anterior or posterior approaches.  Usually, the anterior approach requires complete discectomies filled by fusion or disc replacements.  The posterior approach involved laminectomy, partial discectomy, and foraminotomy with or without fusion. Both approaches are found to be effective.  As always, surgical treatments are reserved for failed non-surgical treatments and patients have acute deterioration of their neurological function.   No matter the approach surgery complications can occur including complications caused by anesthesia or complications from the procedure itself including nerve palsies, vascular impairment, and laryngeal nerve damage.

Enhancing Healthcare Team Outcomes

The management of patients with cervical radiculopathy is best done with a multidisciplinary team that includes a neurologist, orthopedic surgeon, physical therapist,  nurse practitioner and the primary care provider. The treatment of cervical radiculopathy should be approached in a stepwise fashion. Also, while surgery can provide significant relief, there is little evidence that surgery provides a clear advantage over non-surgical treatment in an acute setting. Over 85% of acute cervical radiculopathy resolves without any specific treatments within 8-12 weeks.  

Over 85% of acute cervical radiculopathy resolves without any specific treatments within 8-12 weeks.  However, in order to facilitate reduce inflammation of the nerve root (s) and improve radiculopathy, it is important to implement non-surgical treatments including oral anti-inflammatory drugs,  physical therapy, and translaminar epidural steroid injections. 

Surgery should be last choice treatment in patients who do not improve. While many surgical procedures are available. they all have the potential to cause serious complications. Plus, a number of patients fail to improve with surgery and remain chronically disabled.[14][15]

 


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Cervical Radiculopathy - Questions

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What is the most appropriate study for a patient who presents with cervical radiculopathy with normal plain films that does not respond to conservative therapy?



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Which of the following is NOT a sign or symptom of cervical radiculopathy?



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A positive Spurling test or provocation maneuver of the neck is indicative of which of the following disorders?



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Which is NOT a sign or symptom of cervical radiculopathy?



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Which of the following is not a finding that occurs with a cervical radiculopathy?



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A patient has been having a great deal of arm pain and numbness. The provider examines him and finds a hypoactive bicep reflex and weak biceps muscle that can occur with either a C5 or C6 nerve root. Which of the following would permit the offending nerve root to be identified?



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Which of the following would be appropriate initial treatment for a herniated cervical disc of the spine with cervical nerve root compression?



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A patient complains of neck pain with radiation down the left upper arm. The pain is increased with reaching for items on high shelves. The pain decreases when the patient sits and puts her hands on her head. What is the most likely cause of the pain?



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A patient presents to his provider with acute onset neck pain with radiation to his shoulder. The patient reports problems when laterally rotating his shoulder. An inflamed nerve is diagnosed. Which segment is least likely involved?



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Cervical Radiculopathy - References

References

Peolsson A,Peterson G,Hermansen A,Ludvigsson ML,Dedering Å,Löfgren H, Physiotherapy after anterior cervical spine surgery for cervical disc disease: study protocol of a prospective randomised study to compare internet-based neck-specific exercise with prescribed physical activity. BMJ open. 2019 Feb 19;     [PubMed]
Hassan KZ,Sherman Al, Epidural Steroids 2019 Jan;     [PubMed]
Doughty CT,Bowley MP, Entrapment Neuropathies of the Upper Extremity. The Medical clinics of North America. 2019 Mar;     [PubMed]
Ament JD,Karnati T,Kulubya E,Kim KD,Johnson JP, Treatment of cervical radiculopathy: A review of the evolution and economics. Surgical neurology international. 2018;     [PubMed]
Lukies MW,Teoh WW,Clements W, Safety of CT-guided cervical nerve root corticosteroid injections. Journal of medical imaging and radiation oncology. 2019 Mar 12;     [PubMed]
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Bise S,Pesquer L,Feldis M,Bou Antoun M,Silvestre A,Hocquelet A,Dallaudière B, Comparison of three CT-guided epidural steroid injection approaches in 104 patients with cervical radicular pain: transforaminal anterolateral, posterolateral, and transfacet indirect. Skeletal radiology. 2018 Dec;     [PubMed]
Nordin M,Randhawa K,Torres P,Yu H,Haldeman S,Brady O,Côté P,Torres C,Modic M,Mullerpatan R,Cedraschi C,Chou R,Acaroğlu E,Hurwitz EL,Lemeunier N,Dudler J,Taylor-Vaisey A,Sönmez E, The Global Spine Care Initiative: a systematic review for the assessment of spine-related complaints in populations with limited resources and in low- and middle-income communities. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society. 2018 Sep;     [PubMed]
Fehlings MG,Tetreault LA,Riew KD,Middleton JW,Aarabi B,Arnold PM,Brodke DS,Burns AS,Carette S,Chen R,Chiba K,Dettori JR,Furlan JC,Harrop JS,Holly LT,Kalsi-Ryan S,Kotter M,Kwon BK,Martin AR,Milligan J,Nakashima H,Nagoshi N,Rhee J,Singh A,Skelly AC,Sodhi S,Wilson JR,Yee A,Wang JC, A Clinical Practice Guideline for the Management of Patients With Degenerative Cervical Myelopathy: Recommendations for Patients With Mild, Moderate, and Severe Disease and Nonmyelopathic Patients With Evidence of Cord Compression. Global spine journal. 2017 Sep;     [PubMed]
Guan Q,Xing F,Long Y,Xiang Z, Cervical intradural disc herniation: A systematic review. Journal of clinical neuroscience : official journal of the Neurosurgical Society of Australasia. 2018 Feb;     [PubMed]
Mattozzi I, [Conservative treatment of cervical radiculopathy with 5% lidocaine medicated plaster]. Minerva medica. 2015 Feb;     [PubMed]
Carlesso LC,Macdermid JC,Gross AR,Walton DM,Santaguida PL, Treatment preferences amongst physical therapists and chiropractors for the management of neck pain: results of an international survey. Chiropractic     [PubMed]
Ramirez MM,Brennan GP, Using the value-based care paradigm to compare physical therapy access to care models in cervical spine radiculopathy: a case report. Physiotherapy theory and practice. 2019 Feb 18;     [PubMed]
Cerier E,Jain N,Lenobel S,Niedermeier SR,Stammen K,Yu E, Smoking is Associated With 1-year Suboptimal Patient-reported Outcomes After 2-level Anterior Cervical Fusion. Clinical spine surgery. 2019 Jan 2;     [PubMed]

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