Author(s): Adele Meron, MD, Andrea Wakim, MD, Louis Nikolis, MD
Originally published: November 15, 2011 Last updated: March 27, 2024
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Disease/Disorder

Definition

Cervical radiculopathy is an objective loss of sensory and/or motor function from the compromise of a cervical spinal nerve or nerve root. This can occur in the presence or absence of pain. This condition is most often associated with degenerative spine conditions causing neuroforaminal stenosis.1

Etiology

Dysfunction of the spinal nerve or nerve root can be secondary to external causes, such as 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. Internal, non-compressive causes, such as inflammation, nerve tumors like schwannomas or neurofibromas can also cause cervical radiculopathy.2,3

Epidemiology, including risk factors and primary prevention

The incidence of cervical radiculopathy has been estimated by population-based research. The most renowned data is from a 14-year study conducted in Rochester, Minnesota, from 1976 to 1990, which described an annual incidence rate of cervical radiculopathy of 107.3 per 100,000 for men and 63.5 per 100,000 for women.4  More recently, a systematic review from 2020 found that the prevalence of cervical radiculopathy per 1000 subjects varied from 1.21 to 5.8.1 The highest incidence is in the age group between 50 and 54 years.4,5 Common risk factors include age, female sex, white race.6 Other risk factors include military involvement, heavy manual labor requiring lifting of more than 25 pounds, cigarette smoking, driving, operating vibrating equipment, and previous cervical or lumbar radiculopathy.6,7,8 Antecedent of physical exertion or trauma was reported in 15 percent of persons with radiculopathy,5 and the majority of patients do not present with a specific injury or inciting event.9 Lower cervical roots, particularly C6 and C7, are more commonly affected than higher cervical roots.7 In a series of 100 patients with surgically verified radiculopathy at the Mayo Clinic, it was found that C7 radiculopathy was diagnosed in 69% of patients, C6 was diagnosed in 19% of patients, C8 in 10% of patients, and C5 in 2% of patients.10

Patho-anatomy/physiology

Cervical radiculopathy results from compression and inflammation of the cervical nerve root.2,11,12 The most common cause is cervical spondylosis, which causes osteophytes at the disc margins, uncovertebral joints, and facet joints. Although less frequent, cervical disc herniation can also cause nerve root compression.11,12 Uncommon causes of nerve root compression include tumors, synovial/meningeal cysts, and arterial/venous malformations.12

Compression of the nerve root causes deformation and malfunctioning of the nerve when the external pressure exceeds the intraneuronal pressure. The effects of direct mechanical compression are localized ischemia and axonal damage.11

In some cases, cervical radiculopathy is due to an increase in inflammatory substances (phospholipase A2, prostaglandin E2, leukotrienes, nitric oxide, proinflammatory cytokines, tumor necrosis factors, and metalloproteinases) coming from a degenerated or herniated nucleus pulposus.2,5,11

Disease progression, including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)

New onset/acute presentation
Disc herniations are associated with acute presentation of radicular symptoms, not always from direct mechanical compression of the nerve root, but also due to chemical injury. This type of presentation is more common in young people.2,3,5

The prognosis for acute cervical radiculopathy is usually good, with 90% of patients improving with medical/rehabilitative treatment.7 The natural history of radiculopathy in the setting of cervical disc herniations is particularly favorable.13 Studies support that clinical improvements are observed within 4-6 months of onset, and full recovery can occur over the course of two to three years. However, there may be long-standing residual impairments in a small subset of these patients.3

Chronic/stable presentation
A more insidious presentation has been associated with spondylosis, where a gradual narrowing of the neuroforamen from the narrowing of discs or generation of osteophytes over time produces a progressive compression or inflammation/irritation of the nerve. In this case, the symptoms will be subacute, with chronic neck discomfort plus 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 patients.2,3,5

In the 14-year Rochester study, which looked at patients with cervical radiculopathy from all causes, there was a 31.7% recurrence rate, and 26% underwent surgery. However, 90% of patients were asymptomatic or had mild symptoms by the final follow-up.The median follow-up time in this study was 4.9 years.4 The literature lacks strong evidence regarding which patients will fail conservative treatment and require more invasive interventions.7

Specific secondary or associated conditions and complications

Common complications include incomplete neurologic recovery and chronic pain. Loss of full cervical range of motion (ROM) and headaches may also occur in patients with concomitant cervical spondylosis. Commonly associated conditions are 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 centrally.3,5 In addition, a close relationship between cervical spine and shoulder pathology has been noted, though a causal relationship is not well-established.14

Essentials of Assessment

History

History taking is a critical component of cervical radiculopathy evaluation, as it remains largely a clinical diagnosis. It is essential to ask if a patient is experiencing weakness, numbness, and/or pain. Additionally, it is important to ask about the distribution of their symptoms. It is important to ask about the duration of symptoms and if any specific events resulted in the symptoms. Inquiring about aggravating and relieving factors is also key. It is important to assess functional status, including the ability to perform activities of daily living and independent activities of daily living.

Symptoms may have a specific pattern depending on the nerve root(s) compromised. However, sometimes the symptoms are not limited to just the innervated skin (dermatome) and can be perceived in other innervated structures, including muscles, joints, ligaments (sclerotome) as well as the affected nerve root (dynatome).2,3,15 Should history (and physical examination) indicate involvement of more than one root level, cervical polyradiculopathy should be considered. The most common cause of this is degenerative cervical spondylosis. Other causes are spinal cord tumors (ependymoma, leptomeningeal metastases, etc.), inflammatory disorders (such as cervical radiculoplexus neuropathy, Lyme disease, etc.), or nerve root avulsion (in the setting of trauma). Therefore, in these cases, it is important to take a thorough medical history and family history, inquiring about autoimmune conditions, cancer history, and history of trauma.

When taking a history in a patient with suspected cervical radiculopathy, it is also important to rule out concomitant cervical myelopathy by asking questions regarding loss of hand dexterity, balance deficit, bowel or bladder incontinence, or sensory/motor deficits in upper and/or lower extremities. This is important, as cervical spondylosis is a common cause of both cervical radiculopathy and cervical myopathy.

Physical examination

Physical examination involves evaluation of cervical range of motion, neurological exam, and special testing. The neurological exam includes strength testing, sensory exam, and deep tendon reflex testing, including evaluation of upper motor neuron signs. Red flags that indicate myelopathy include sensory loss and/or motor loss associated with hyperreflexia or upper motor neuron signs (positive Hoffman’s or Babinski signs) downstream or contralaterally. The pattern of dermatomal and myotomal changes based on the root level is generally as follows:

  • 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, brachioradialis, infraspinatus, and wrist extensors; sensory loss of the thumb and index finger; and changes in the biceps and/or brachioradialis reflex.
  • C7 Radiculopathy: pain in the medial scapula, posterior arm, dorsum of the forearm, and third finger; weakness of the triceps, wrist flexors/extensors, 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 the fifth finger.2,5 While this distribution of findings is generally accurate, Slipman et al. and McAnany et al. have shown that the pain referral patterns are highly variable from person to person and may follow an expected symptom referral pattern in as little as 54% of cases.16,17 

A common special test used in the evaluation of cervical radiculopathy is Spurling’s maneuver, which includes end-range neck extension, ipsilateral rotation, ipsilateral side bending, and axial compression. A systematic review identified three studies evaluating the diagnostic accuracy of Spurling’s maneuver and describes a specificity ranging from 89%-100% and a sensitivity of 38%-97%, suggesting high specificity and variable sensitivity.18 Another commonly used test for cervical radiculopathy is the upper limb neural tension test (ULNT), which is performed with the patient supine and the examiner introducing scapular depression, shoulder abduction, forearm supination, wrist and finger extension, shoulder lateral rotation, elbow extension, and contralateral then ipsilateral cervical side bending. This is also known as the Brachial Plexus Tension or Elvey test with median nerve bias. A systematic review of physical tests in cervical radiculopathy identified one study that evaluated the concordance of multiple separate ULNTs (with a bias for the median, radial (using two techniques), and ulnar nerve, respectively) and the combined results. This study indicated that the combined use of four ULNTs had a sensitivity of 97% and a specificity of 69%. Individually, the ULNT with a bias for the ulnar nerve had the highest specificity of 88%, and the ULNT with a bias for the median nerve showed the highest sensitivity of 83%.18 Wainner et al. found that the combination of cervical rotation less than 60 degrees, positive cervical distraction test, positive Spurling’s test, and positive ULTT, the post-test probability of cervical radiculopathy is 90%.19 A systematic review assessed classification criteria for cervical radiculopathy warranting evaluation and found nine components of good quality: muscle weakness, decreased reflexes, sensory change in a dermatomal distribution, positive Spurling’s test, positive ULTT, positive cervical distraction test, pain nature, pain location, and radiation or span of symptoms. This study further found the Childs et al. (2008) classification system was the most reliable and clinically useful of all classification systems evaluated in regard to assessing cervical radiculopathy.20

Of note, if sensory examination reveals allodynia, hyperalgesia, or sensory aftereffects in the setting of chronic radicular pain, a component of central and peripheral sensitization should be considered.

Functional assessment

The Numerical Pain Rating Scale (NPRS) is a widely used outcome measure to assess pain intensity on an 11-point scale of zero to 10 (where zero represents no pain, and 10 represents the most severe pain.21 However, more in-depth assessments are available with high-quality evidence for neck pain and cervical radiculopathy. A systematic review of outcome measures for neck pain found that the Neck Disability Index (NDI) had excellent reliability and consistency.22 The NDI evaluates the degree that pain affects a patient’s ability to manage everyday activities (personal care, lifting, reading, concentration, work, driving, sleeping, recreation, pain intensity, and headaches).20,23 Another commonly used outcome measure is the Neck Pain and Disability Scale (NPAD), which includes 20 items assessing neck pain and intensity and its interference with range of motion, function, emotion, cognition, and activities of daily living. The NPAD has similarly been found to have good reliability, validity, and consistency.24 25 Additionally, the Patient Specific Functional Scale (PSFS) is a valid and reliable tool that asks patients to identify five activities with which they have difficulty and rate the pain before and following intervention from zero to ten.20,26 When used for assessing cervical radiculopathy, the reliability of the PSFS is high.27 

Laboratory studies

Laboratory studies are not recommended as a routine exam. However, if a coexisting rheumatologic condition is suspected or an infectious process needs to be ruled out, a complete blood count with differential, erythrocyte sedimentation rate, and C-reactive protein levels can be considered.2,3,5 

Imaging

Conventional radiographs have low sensitivity and specificity due to the inability to detect disc herniation and nerve root or cord compression. However, radiographs can help determine bony abnormalities, like fractures, or spondylotic causes, like spondylotic foraminal stenosis. Flexion/extension films are useful when cervical instability is suspected based on clinical history, including any history of trauma. However, if gross instability is suspected after high-velocity trauma, flexion/extension films are contraindicated. Computed tomography (CT) can be useful in imaging of patients with acute trauma. It can also be useful in distinguishing the extent of osteophyte, foraminal encroachment, or the presence of ossification of the posterior longitudinal ligament. It can also be useful in cases where there are contraindications to MRI, such as MRI-incompatible pacemaker. 2,3,5 

Magnetic resonance imaging (MRI) is the gold standard cervical spine imaging modality of choice. It is indicated in patients with persistent signs and symptoms after four to six weeks of non-interventional treatment, or with the presence of symptoms or signs of myelopathy, red flags suggestive of tumor or infection, or the presence of progressive neurologic deficits.2,3,5 Contrast study may be useful when evaluating for infection, cancer, or post surgically in differentiating between scar tissue vs new disc herniation.

Supplemental assessment tools

Electrodiagnostic testing (EDX) can be a useful tool in some cases of radiculopathy, especially when the diagnosis is not clear, and ruling out another etiology of symptoms is important. However, EDX may be normal in early or more mild cases of radiculopathy as abnormalities on EDX do not occur until there is more severe nerve damage, or axonal loss. During nerve conduction testing, both sensory and motor nerve conduction studies (NCS) are normal in early or mild cervical radiculopathy and motor NCS may only be abnormal in severe or advanced radiculopathy with axonal damage.28 More diagnostic is needle electromyography (EMG), which evaluates for axonal damage. Similarly, EMG may be normal in early or mild cases of cervical radiculopathy with minimal axonal damage, as denervation potentials take weeks to appear on EMG and reinnervation potentials occur over months. Specifically, abnormal spontaneous activity, such as positive sharp waves and fibrillation potentials, may occur as early as 10 days after injury in paraspinal muscles but take at least three weeks to show abnormalities in more distal muscles.2,3,5 To diagnose cervical radiculopathy on EMG, there must be abnormal findings in two or more muscles that receive innervation from the same nerve root via different peripheral nerves and different portions of the brachial plexus (such as different trunks, cords, etc.). While cervical paraspinals are often studied on EMG, abnormal findings are non-specific to a single nerve root level as there is significant overlap in innervation from varying nerve roots for each paraspinal level.

When feasible, six muscles should be electromyographically examined, including cervical paraspinals, to increase study sensitivity. For example, a muscle screen that included paraspinals, deltoid, triceps, pronator teres, abductor pollicis brevis, and extensor digitorum communis yielded an 83% sensitivity with emphasis on spontaneous activity alone, but when adding recruitment changes, reached 99% sensitivity in this study).29

Electrodiagnostic testing has several significant limitations in assessing cervical radiculopathy . Purely sensory or purely demyelinating radiculopathy will yield a normal EDX. In acute radiculopathy (the first 10-14 days), electromyographic examination of limb musculature may be normal or might show only a mild decrease in recruitment. Because of the time course for axonal damage to occur and create changes that would be seen on EMG, EMG has a low sensitivity for cervical radiculopathy (50-95%) and may result in false negative studies. However, EMG does have a very high specificity in diagnosing cervical radiculopathy, when EMG reveals abnormal findings.15 In addition, it might be difficult to localize the lesion to a single root level as most muscles are innervated by more than one myotome and different nerve fascicles may be preferentially affected or spared. A particular challenge occurs when more than one pathology exists, and this can confound test results as well.

Early predictions of outcomes

The prognosis is usually good, with 90% of patients improving with medical/rehabilitative treatment.3 The Rochester study reports that 26% of the patients with cervical radiculopathy not responsive to non-operative management underwent surgery within three months of the diagnosis.4 Surgery is often reserved for patients with severe or progressive neurologic deficits or significant pain that does not respond to conservative management for at least 6 to 12 weeks. More strict indications for surgery include signs and symptoms of cervical radiculopathy, evidence of cervical nerve root compression by MRI at a level and side that is concordant with the patient’s symptoms, and the presence of progressive motor weakness.5

Both medical treatment and surgical treatment have the potential to improve overall pain, functional status, and neurologic outcomes. Commonly performed surgeries include anterior cervical discectomy with or without spinal fusion, posterior cervical laminoforaminotomy, and cervical arthroplasty.3,5 Patients who are not on high-dose opioids preoperatively have better post-surgical outcomes than their cohorts on high-dose opioids before surgery.30 One randomized controlled trial of 468 patients reported the following five factors to have a statistically significant adverse effect on outcomes at six months: history of recurrent cervical radiculopathy for more than five years, more than three cervical radiculopathy episodes, bilateral paresthesia, women over 50 years of age, and symptoms that were worsening at the time of initial presentation.31 A major limitation of this study was a significant loss to follow-up of study subjects.

Environmental

Heavy lifting, previous cervical or lumbar radiculopathy, neck trauma (sports, motor vehicle accidents, etc.), and smoking have been associated with an increased risk for cervical radiculopathy.2,3

Social role and social support system

In concordance with the biopsychosocial model of pain, several psychosocial factors can contribute to persistent pain in cases of cervical radiculopathy. This can include factors such as pre-existing anxiety, cognitive beliefs, coping skills, emotional stress, financial status, isolation, social withdrawal, and dysfunctional relationships. Patients with cervical radiculopathy, particularly those with poor response to medical management, should be screened for psychosocial prognostic factors. These should be addressed individually but may require behavioral therapy or counseling.32,33

Professional issues

In the workplace, it is essential to consider the functional implications of cervical radiculopathy. An emphasis on workplace ergonomics and posture can help with symptom management. This can include ergonomic seating and computer screen height adjustment to avoid kyphotic posturing. Further, patients should avoid activities that work or exacerbate symptoms. Workplace precautions should be considered on a case-by-case basis depending on a patient’s work duties and pain pattern.

Rehabilitation Management and Treatments

Available or current treatment guidelines

In the United States, there are no published guidelines for assessing and managing cervical radiculopathy. Recommendations are based on existing research, including systematic reviews.5 The main objectives of treatment are to relieve pain, improve or return to baseline neurological function, and prevent recurrences or relapses. Often, reducing kyphosis and providing balance is paramount.34 

At different disease stages

Acute cervical radiculopathy without evidence of major neurological deficit (progressive weakness or signs of concomitant cervical myelopathy) should be treated conservatively.Most patients with acute cervical radiculopathy in the setting of cervical disc herniation improve over time.13 However, there is no consensus regarding the treatment or time course. First-line treatment includes activity modification and avoidance of provocative activities. Usage of analgesic agents such as acetaminophen and non-steroidal anti-inflammatory drugs are often used as first-line agents. Muscle relaxants may play a role in symptom relief as well.3 Judicious use of medications with consideration of co-morbidities, side effects, and risk/benefit ratio is critical, especially in the elderly population. The use of opioid agents should generally be avoided but may be necessary for symptom relief in early, severe stages of cervical radiculopathy.2 A recent systematic review on cervical radicular pain denotes that there may be a role for oral steroids. However, in this review, only one high-quality RCT supports this. Otherwise, the evidence in the literature is limited.35 Before prescribing oral steroids, physicians must ensure that there are no contraindications, such as ongoing infection/immunosuppression, peptic ulcer disease, liver disease, history of steroid psychosis/suicidality, anaphylactoid reaction, or others.

An essential part of conservative management is exercise therapy. A recent systematic review and meta-analysis support this.36 It is important to note that 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, followed by the incorporation of dynamic functional strengthening to restore range of motion, strength, and function.

Other therapeutic interventions might include manual therapy, neural mobilization, and forward-flexed neck posture correction.37 In a systematic review published in 2021 by Borella-Andres et al., it was demonstrated that the use of manual therapy reduces chronic cervical pain and the index of cervical disability in cervical radiculopathy, regardless of the type of manual therapy technique applied. Neural mobilization can also improve the quality of life in patients with cervical radiculopathy when combined with cervical isometric exercises.38

Among modalities, cervical traction is a popular option. It is the application of distracting forces to the neck to relieve compression. A recent systematic review supports the use of traction therapy in conjunction with physical therapy for pain relief. There is not sufficient evidence to support that this intervention can improve overall function and reduce disability.39 It is also important to note that traction is not recommended in the presence of dynamic spondylolisthesis/instability or spinal cord compression.

In the setting of cervical radiculopathy not responding to medical/rehabilitative management, fluoroscopically guided interventional treatments, including cervical epidural steroid injections, can play an important role. The principle of epidural administration of corticosteroids relies on eliciting the anti-inflammatory response from the inhibition of the phospholipase A2-initiated arachidonic acid cascade. Other mechanisms include blocking nociceptive C fiber transmission, hyperpolarizing spinal neurons, and inhibiting ectopic impulses by stabilizing nerve membranes.40 Lee et al. conducted a study where 98 patients with cervical radiculopathy without neurologic deficits who were surgical candidates were treated conservatively with cervical epidural steroid injections. One to three spine injections were administered at one-to-two-week intervals using the interlaminar or transforaminal technique, depending on the imaging findings. They found that 80% of patients were able to avoid surgery.41

There are two common epidural injection approaches: interlaminar and transforaminal. The interlaminar approach may be useful in multilevel pathology and bilateral symptoms as the medication spreads bilaterally from the posterior central or parasagittal epidural space where it is injected. A systematic review of cervical interlaminar epidural steroid injections concluded that the injection showed a significant effect in relieving chronic intractable pain of cervical origin.23 The potential risks associated with this route of injection include epidural hematoma, spinal cord injury, dural puncture, and headache. Stojanovic et al. evaluated 38 epidurograms of interlaminar epidural steroid injection and noted that the loss of resistance technique alone resulted in 53% false entry into the epidural space, highlighting the importance of fluoroscopic guidance while performing these procedures.42

Cervical transforaminal epidural steroid injections may benefit from a more accurate administration of the active product at the level of the affected nerve root. The transforaminal approach may be more effective in treating single-level nerve root pathology. It may also be used as a diagnostic procedure to selectively block a single cervical level to determine the pain generator. A recent systematic review published in 2021 on cervical transforaminal epidural steroid injections supports the use of this procedure in cases of cervical radiculopathy.43 Further, Andrew Engel et al., on behalf of the Standards Division of the Spine Intervention Society, published a systematic review of the effectiveness and risks of cervical transforaminal epidural steroid injections and concluded that while the evidence is based mostly on observational studies, approximately 50% of patients experience 50% of relief of radicular pain for at least four weeks after cervical transforaminal epidural steroid injections and the injection may have surgery-sparing effects. However, this review also discussed the potential risks of cervical transforaminal epidural steroid injections and identified several articles with reports of serious complications, including 13 deaths and catastrophic neurologic injuries.44

There are a few studies with long term follow up of up to two and even five years. The Spine Intervention Society published Safeguards to Prevent Neurologic Complications after Epidural Steroid Injections: Consensus Opinions from Multidisciplinary Working Groups, in which it was proposed, among other recommendations, that for therapeutic cervical transforaminal steroid injections, only dexamethasone should be used to decrease the risk of neurologic injury. (safeguards) Mehta et al. came to a similar conclusion in a 2017 study regarding particulate and nonparticulate steroid efficacy.45 In a comparative effectiveness trial, Dreyfuss et al. found no significant difference in subjective pain scores with particulate and nonparticulate corticosteroid preparations for cervical radicular pain.46    

In summary, both cervical interlaminar epidural steroid injections and cervical transforaminal epidural steroid injections under fluoroscopic guidance have evidence to support their utility in patients with cervical radiculopathy but have been associated with case reports of serious complications, such as stroke, spinal cord injury, paralysis, and death.44,47

Recently, more studies have been investigating the use of ultrasound-guided epidural steroids. A recent randomized trial published in 2022 by Ziohong Cui et al. demonstrated that ultrasound-guided transforaminal epidural steroid injections may be non-inferior to fluoroscopically guided epidural steroid injections. This claim was based on similar accuracy ratings when comparing contrast dispersion into the epidural or intervertebral foraminal space under ultrasound and fluoroscopic guidance. Ultrasound-guided procedures in the cervical spine may be an alternative to the conventional fluoroscopic method as it can provide the ability to visualize vascular structures, avoid vascular puncture, and decrease radiation exposure.48 More literature is required in this realm.

Surgery is often reserved for patients with severe or progressive neurologic deficits or significant pain that does not respond to conservative management for at least 6 to 12 weeks.5 Though a benefit from surgery for cervical radiculopathy was noted across all time points in a recent study, symptom duration of more than two years was a predictor of worse outcomes after surgery.49 These findings were not reproduced in a study by Basques et al. in 2019, who noted no significant difference in final outcomes for surgical patients despite the duration of symptoms.50 Surgical options include anterior cervical decompression and fusion (ACDF), cervical disk arthroplasty, and posterior foraminotomy. Patient selection is essential to optimize outcomes. A randomized prospective study of 60 patients with cervical radiculopathy found that patients who underwent surgery had an 87% reduction in neck pain intensity vs 62% in the nonsurgical group at 12 months. Still, this effect was statistically insignificant at 24 months follow-up.51 In a follow-up study, patients were randomized to surgery (ACDF), followed by physical therapy vs. physical therapy alone. In this study, shorter duration of pain (less than 12 months), female sex, low health quality, high level of anxiety, and low self-efficacy before treatment were associated with better outcomes from surgery.52 A meta-analysis from 2020 of 21 trials found that efficacy, outcomes, and safety profiles were similar among surgical procedures.

Neuromodulation (spinal cord stimulation) has been shown to be effective in patients who fail conservative management and undergo spinal surgery but continue to have radicular pain symptoms even after surgery (cervical post-laminectomy syndrome). It might also be recommended for patients who do not meet the criteria for anticipated good outcomes post-surgery.53 Pulsed radiofrequency treatments for the cervical nerve root have been postulated with some efficacy noted in a small patient analysis.54

Coordination of care

The etiology of cervical radiculopathy can be multifactorial. Treatment varies according to the clinical presentation. The physiatrist must coordinate medications, functional rehabilitation programs (physical therapy and/or ergonomic assessment), interventional procedures, and/or surgery consultations. Motor vehicle injuries involving litigation will often require the treating physicians to interact 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 also involves input from the patient in the decision-making process.

Patient & family education

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

Emerging/unique interventions

As noted above, cervical arthroplasty or cervical disc replacement is an option for surgical treatment of radiculopathy caused by disc pathology. It is being utilized increasingly frequently, particularly for one- and two-level disc surgeries. Some level 1 studies suggest that disc replacement or disc arthroplasty is equivalent to an anterior cervical discectomy and fusion for one- and two-level disc surgeries.55–57 As opposed to anterior cervical discectomy and fusion, there is evidence that a disc replacement or disc arthroplasty may allow for less stress on the adjacent spinal levels and the need for less surgery in the future for adjacent segment disc disease.58 Further, minimally invasive posterior cervical foraminotomy is an emerging alternative to ACDF in select patients. This minimally invasive surgical procedure has been shown to improve pain scores and reduce hospital length of stay.57,59

Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills

  • Cervical radiculopathy should be considered in the differential diagnosis of neck, shoulder, and arm numbness, paresthesias, and weakness in the presence or absence of pain.
  • In patients presenting with these symptoms, along with radiological evidence, a complete, comprehensive evaluation and clinical correlation should be performed before making the diagnosis of cervical radiculopathy.
  • If cervical radiculopathy follows a non-classical dermatomal distribution, it may go undiagnosed.
  • Cervical radiculopathy should be considered in the differential diagnosis in someone presenting with scapular or periscapular pain out of proportion to neck pain, with or without the presence of arm pain.
  • A significant portion of patients with cervical radiculopathy improve over time with conservative management.
  • Patients who do not respond to conservative treatment such as activity modification, physical therapy, and medications may benefit from an epidural steroid injection. The benefits of an epidural steroid injection should be weighed against the risks, which can include stroke, spinal cord injury, and death.
  • Approximately 90% of patients improve with conservative care.
  • Surgery should be considered for patients with severe or progressive neurologic decline or severe, disabling pain that is not responsive to more conservative management over 6 to 12 weeks.

Cutting Edge/Emerging and Unique Concepts and Practice

Advances in neuroimaging techniques may play a key future role in assessment and management. Newer minimally invasive techniques, as described above, might provide better outcomes in treatment.

Gaps in the Evidence-Based Knowledge

The natural history of cervical radiculopathy remains largely uncertain. Well-designed, randomized, controlled trials are needed to guide the creation of clinical practice guidelines.

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Original Version of the Topic

Jose Mena, MD, German Ojeda Correal, MD. Cervical Radiculopathy. 11/15/2011.

Previous Revision(s) of the Topic

Christopher Plastaras, MD, Marzena Buzanowska MD. Cervical Radiculopathy. 5/5/2016.

Michael J. Mehnert. Cervical Radiculopathy. 7/24/2020

Author Disclosures

Adele Meron, MD
Nothing to Disclose

Andrea Wakim, MD
Nothing to Disclose

Louis Nikolis, MD
Nothing to Disclose