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Cervical Radiculopathy

  1. Disease/Disorder:
    Definition

    Cervical radiculopathy is any dysfunction of a nerve root emerging at the level of the cervical spine, most often but not always associated with disc herniation. Radiculopathy is a very wide term, non-specific, but some authors use this term to talk about pain, weakness, or numbness in a specific radicular pattern. 

    Etiology

    Dysfunction of the nerve root can be secondary to: internal (non-compressive) causes (inflammation, nerve tumors like schwannomas or neurofibromas); or external causes (compression due to a herniated disc, neuroforaminal narrowing, tumors, fibroproliferation, hematomas, trauma; irritation due to inflammatory mediators such as substance P, bradykinin, potassium, histamine; or changes in vascular supply)1,2.

    Epidemiology including risk factors and primary prevention

    Cervical radiculopathy has an annual incidence rate of 107.3 per 100,000 for men and 63.5 per 100,000 for women; the prevalence is 3.5 cases per 1,000 population2,3. Men are affected slightly more than women. The highest incidence is in the age group between 50 and 54 years. Risk factors include heavy manual labor requiring lifting of more than 25 pounds, smoking, driving, operating vibrating equipment, and previous cervical or lumbar radiculopathy. Antecedent of physical exertion or trauma was reported in 15 percent of persons with radiculopathy3.

    Patho-anatomy/physiology

    One cause of radicular symptoms is compression. Once the external pressure exceeds the intraneuronal pressure, deformation and malfunctioning of the nerve starts. The effects of the direct mechanical compression are: conduction block, interruption of axonal flow, vascular sequelas like hypoxia and metabolic byproduct accumulation1. The volume of the intervertebral foramen increases in flexion, however extension decreases the cervical foraminal dimensions. Sometimes there is no mechanical compression, and the symptoms are due to inflammatory substances (phospholipase A2, prostaglandin E2, leukotrienes, nitric oxide, proinflammatory cytokines, tumor necrosis factors, and metallo-proteinases) coming from a degenerated or herniated nucleus pulposus1,3.

    Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)
    1. New onset/acute

      Disc herniations are associated with acute presentation of the symptoms, not always a direct mechanical compression of the nerve root, but also chemical injury. This type of presentation is more common in young people1,2,3.
    2. Chronic/stable

      A more insidious presentation has been associated with spondylosis, where a narrowing of the neuroforamen from narrowing of discs or generation of bone spurs over time produce a progressive compression or inflammation/irritation of the nerve. The symptoms will be subacute or chronic neck pain plus a progressive radicular pain associated with numbness, and weakness in the dermatome or myotome. This type of presentation is more common in middle-aged and elderly patients1,2,3.
    Specific secondary or associated conditions and complications

    Common complications include incomplete neurologic recovery, loss of full cervical range of motion (ROM), chronic neck pain, headaches. Common associated conditions are radiographic changes that indicate disc-space narrowing, persistent loss of normal cervical lordosis, and/or osteophyte formation. Large herniations or advanced spondylosis may result in myelopathy from compression of the spinal cord centrally2,3.

  2. Essentials of Assessment
    History

    Information regarding characteristics of the pain, its distribution, aggravating and relieving factors, are important,  in addition to ruling out less common casues of radiculopathy. The symptoms may have a specific pattern depending on the nerve root compromised. However, sometimes the pain is not limited to just the dermatome and can be perceived in all the innervated structures (muscles, joints, ligaments, skin) by the affected nerve root1,2.

    Physical examination

    Cervical vertebra 5 (C5) radiculopathy: pain in the medial scapular border and lateral upper arm; weakness of the deltoid, supraspinatus and infraspinatus; sensory loss in the lateral upper arm; and changes in the supinator reflex. C6 radiculopathy:  pain in the lateral forearm, thumb and index finger; weakness of the biceps, brachioradilis and wrist extensors; sensory loss of the thumb and index finger; and changes in the biceps reflex. C7 radiculopathy: pain in the medial scapula, posterior arm, dorsum of forearm and third finger; weakness of the triceps, wrist flexors and finger extensors; sensory loss in the posterior forearm and third finger; and changes in the triceps reflex. C8 radiculopathy: pain in the ulnar side of the forearm and fifth finger; weakness of thumb flexors, abductors and hand intrinsics; and sensory loss in fifth finger. Upper motor neuron signs suggests the need to rule out myelopathy2,3.

    Functional assessment

    The Neck Disability Index4 evaluates how much the pain affects patient’s ability to manage his everyday activities (personal care, lifting, reading, concentration, work, driving, sleeping, recreation, pain intensity and headaches)5.

    The Patient Specific Functional Scale6 asks for five activities with which the patient has difficulty due to the radiculopathy, and evaluates those activities5.

    Laboratory studies

    Laboratory studies are not recommended as a routine exam.  However if an infectious process needs to be ruled out, a complete blood count with differential, erythrocyte sedimentation rate, and a C-reactive protein levels are indicated1,2,3.

    Imaging

    Conventional radiographs: low sensitivity, with limited usefulness due to the inability to detect disc herniation and nerve-root or cord compression.

    Magnetic resonance imaging (MRI) is the imaging of choice. It is indicated in patients with persistent signs and symptoms after four to six weeks of non-interventional treatment; or with presence of symptoms or signs of myelopathy, red flags suggestive of tumor or infection, or the presence of progressive neurologic deficits1,2,3.

    Computed tomography (CT) alone is of limited value in assessing cervical radiculopathy; however, it can be useful in distinguishing the extent of bony spurs, foraminal encroachment, or the presence of ossification of the posterior longitudinal ligament1,2,3.

    Supplemental assessment tools

    Nerve-conduction studies may show reduced response amplitude or normal responses. More diagnostic is needle electromyography, which shows spontaneous potentials with relatively low sensitivity but very high specificity in cervical radiculopathy. Additionally, one may see neuropathic recruitment, then abnormal spontaneous, including positive sharp-wave potentials and fibrillation potentials around three weeks after the onset of nerve compression in the muscles innervated by the nerve root.  However, abnormal activity might be seen in the paraspinal muscles as early as 10 days after the nerve injury1,2,3.

    Early predictions of outcomes

    The prognosis is usually good, with 90% of patients improving with medical/rehabilitative treatment. When the pain persists, and especially when associated with progression of neurological deficits, surgical treatment may be considered. Both medical treatment and surgical treatment will improve significantly overall pain, functional status, and neurologic outcomes. The best results of cervical disc surgery occur with relief of radicular pain2,3.

    Environmental

    Environmental factors associated with cervical radiculopathy are physical activities with heavy lifting, neck trauma (sports, motor vehicle accidents, etc.), smoking. All of them have been associated with an increased risk for cervical radiculopathy1,2,3.

    Social role and social support system

    When pain persits beyond the expected or fails both medical and surgical management, a chronic state of pain exists. This chronic state can lead to loss of vocation, leisure activity, and status within society and the family.

    Professional Issues

    It is important to consider other potential causes of neck pain and dysfunction, such as: vertebrobasilar insufficiency, carotid artery ischemia or stroke; neoplasia; discitis; osteomyelitis, etc . Additionally, myelopathic symptoms or signs that may suggest compression of the spinal cord which may need appropriate surgical referral to aviod further neurologic loss.

  3. Rehabilitation Management and Treatments
    Available or current treatment guidelines

    Commonly recommended rehabiliation therapies for cervical radiculopathy have not been tested well enough in randomized, placebo-controlled trials. Recommendations are based primarily from case series or physician/physical therapist anecdotal experiences3. The main objectives of treatment are to relieve pain, improve or return back to baseline neurological function, and prevent recurrences or relapses7. Often reducing kyphosis and providing balance is paramount7.

    At different disease stages
    1. In an acute cervical radiculopathy without evidence of major neurological deficit, analgesic agents, including opioids and NSAID, are often used as first-line therapy. Many physicians advocate a short course of oral steroids for 7 days7.
    2. In the setting of subacute cervical radiculopathy not responding to medical/rehabilitative management, interventional management can play a role. The principle of epidural administration of corticosteroids relies on the anti-inflammatory response from the inhibition of the phospholipase A2-initiated arachidonic acid cascade. There are two administration routes:
      1. Cervical Interlaminar Epidural Steroid Injections:  A systematic review8 on the effectiveness of this procedure in the management of chronic neck pain included 3 randomized control trials: The global conclusion was a positive pain releiving effect on cervical radicular pain.
        1. Pros: May be useful in multiple level pathology and bilateral symptoms.
        2. Cons: Lacks specificity.
      2. Cervical Transforaminal Epidural Steroid Injections: This gained in popularity because of the more accurate administration of the active product at the level of the affected nerve root.
        1. Pros: Specifically deposits medication closest to the site of pathology. May give diagnostic information to determine the primary pain generator in cervical pathology.
        2. Cons: Reports of serious and/or even fatal complications including stroke, spinal cord injury, and death have been reported due to close proximity to vertebral artery, other vascular structures.
    3. In the setting of a Sub-Acute to Chronic cervical radiculopathies, a surgical consultation is recommended when the patient still has persistent and severe disabling pain after at least 6 to 12 weeks of nonsurgical management, and progression of neurologic deficits3.

    Rehabilitation interventions depend on the extent and type of deficits. These include: physical modalities, activity modifications, mobilization techniques, kinetic chain analysis, and addressing flexibility and weakness. There should be a progression to normalizing spine mechanics and incorporating a dynamic functional strengthening finalizing in restoring pre-injury range of motion and strength.

    Neuromodulation has been shown to be effective in patients who fail conservative management and undergo spinal surgery, but continue to have pain symptoms even after surgery (cervical post-laminectomy syndrome). It might also be recommended for patients who do not meet the criteria for good outcomes post-surgery.

    Complications of radiculopathy, such as chronic pain, loss of motor strength and function, or potential progression to cervical myelopathy should be prevented and promptly managed9.

    Coordination of care

    The etiology of cervical radiculopathy can be multifactorial. Treatment varies according to the clinical presentation.  The physiatrist must coordinate the use of  medications, functional rehabilitation programs (physical therapy and/or ergonomic assessment), interventional procedures, and/or surgery consultations.  Car injuries involving litigation will require the treating physicians to interface with lawyers and the judicial system. Injured workers will require that the physiatrist coordinate care with case managers and employers. An interdisciplinary approach to care involves the patient in the decision making process as well.

    Patient & family education

    Patients should be well informed of the potential risks, benefits, and limitations of the various available surgical and medical/rehabilitative and interventional treatment options.

    Emerging/unique Interventions

    Functional assessments include the Neck Disability Index (NDI), the Patient-Specific Functional Scale (PSFS), and the Oswestry Disability Scale (ODS).  Other meaures include Numeric Pain Rating Scale (NPRS) and Visual Analogue Scales (VAS) for pain ratings5. ​

    Translation into practice: practice "pearls"/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills
    1. Cervical radiculopathy should be considered in the differential diagnosis of neck and arm pain, along with symptoms of numbness and paresthesias.
    2. Do not assume that cervical radiculopathy is the diagnosis in anyone presenting with neck and arm pain along with radiological evidence, without a full comprehensive evaluation.
    3. If the cervical radiculopathy follows a non-classical dermatomal distribution, often it can go undiagnosed.
    4. Keep cervical radiculopathy in the differential diagnosis in someone presenting with scapular or periscapular pain out of proportion to neck pain, with or without having arm pain.​
  4. Cutting edge/emerging and unique concepts and practice
    Cutting edge concepts and practice

    Advances in neuroimaging techniques may play a key future role in assessment and management. Newer minimally-invasive techniques under investigation might provide better outcomes in treatment.

  5. Gaps in the evidence-based knowledge
    Gaps in the evidence-based knowledge

    The natural history of cervical radiculopathy still remains uncertain. Well designed, randomized, controlled trials are needed to guide nonsurgical management and decisions regarding whether and when to perform surgery.

    References
    1. Rhee JM, Yoon T, Riew KD. Cervical Radiculopathy. J Am Acad Orthop Surg. 2007 Aug; 15(8):486-94
    2. Polston, D. Cervical radiculopathy. Neurol Clin. 2007; 25(2): 373-85.
    3. Carette S, Fehlings M. Cervical radiculopathy. N Engl J Med. 2005; 353:392-399.
    4. Zundert J, Huntoon J, Lataster A. Cervical radicular pain. Pain Practice. 2010; 10(1); 1-17.
    5. Delito A, Dyriw G. Neck pain: clinical practical guidelines linked to the International Classification of Functional Disability, and Health, from the Orthopedic section of the American Physical Therapy Assocation. J Orthop Sports Phys Ther. 2008; 38(9): A1-A34.
    6. Young IA, Cleland JA, Michener LA, Brown C. Reliability, construct validity, and responsiveness of the neck disability index, patient-specific functional scale, and numeric pain rating scale in patients with cervical radiculopathy. Am J Phys Med Rehabil. 2010 Oct;89(10):831-9.
    7. Wolff MW, Levine LA. Cervical radiculopathies: conservative approaches to management. Phys Med Rehabil Clin N Am 2002;13:589-608
    8. Benyamin RM, Singh V, Parr AT, Conn A, Diwan S, Abdi S. Systematic review of the effectiveness of cervical epidurals in the management of chronic neck pain. Pain Physician. 2009;12:137
    9. Abbasi A, Malhotra G, Malanga G, Elovic EP, Kahn S. Complications of interlaminar cervical epidural steroid injections: a review of the literature. Spine. 2007;32:2144–2151.