Cervical radiculopathy is a condition resulting from cervical spine nerve root dysfunction. This condition is most often associated with disc herniation. Radiculopathy is a very wide, but non-specific term, which some authors use to refer to pain, weakness, or numbness in a specific radicular (or nerve root distribution) pattern.
Dysfunction of the nerve root can be secondary to: internal, non-compressive, causes, such as inflammation, nerve tumors like schwannomas or neurofibromas; or 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 supply1,2.
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, with a prevalence of 3.5 cases per 1,000 population2,3. 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, and the majority of patients do not present with a specific injury or inciting event4. Lower cervical roots, particularly C7, are more commonly affected than higher cervical roots. 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 approximately 20% of patients and C5, C8 and T1 levels accounted for the remainder of the cases5.
One common cause of radicular symptoms is compression. Once the external pressure exceeds the intraneuronal pressure, deformation and malfunctioning of the nerve begins. The effects of the direct mechanical compression are: conduction block, interruption of axonal flow, vascular sequelae like hypoxia and metabolic byproduct accumulation1. The volume of the intervertebral foramen increases in flexion, decreasing the impact of nerve root compression; however, extension decreases the cervical foraminal dimensions, thus increasing the degree of nerve root compression. 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)
New onset/acute presentation:
Disc herniations are associated with acute presentation of the symptoms, not always from a direct mechanical compression of the nerve root, but also due to chemical injury. This type of presentation is more common in young people1,2,3.
A more insidious presentation has been associated with spondylosis, where a gradual 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 in this case, with chronic neck discomfort 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.
Natural history of the disease is largely unknown. An epidemiological study at Mayo evaluated charts of 561 patients who were diagnosed with cervical radiculopathy and found that during the median follow up of 4.9 years, there was a 31.7% recurrence rate, 26% underwent surgery and 90% were asymptomatic at last follow up6.
Specific secondary or associated conditions and complications
Common complications include incomplete neurologic recovery, loss of full cervical range of motion (ROM), chronic neck pain, and headaches. Common 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.2,3 In addition, a close relationship between cervical spine and shoulder pathology has been noted7, though a causal relationship is not well-established.
ESSENTIALS OF ASSESSMENT
History taking is a critical component of cervical radiculopathy evaluation, as it remains largely a clinical diagnosis. Information regarding characteristics of the pain – its distribution, aggravating and relieving factors – are important in addition to ruling out less common causes of radiculopathy. The symptoms may have a specific pattern depending on the nerve root(s) compromised. However, sometimes the pain is 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) 1,2,14. History taking is of the utmost importance to evaluate for symptoms of myelopathy, such as subtle loss of hand dexterity, balance deficit, bowel or bladder incontinence or sensory/motor deficits in upper and/or lower extremities. Should history (and then physical examination) indicate involvement of more than one root level, cervical polyradiculopathy should be suspected. The most common cause of this is degenerative cervical spondylosis (which again should prompt an assessment of spinal cord function). 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).
Physical examination involves evaluation of cervical range of motion, neurological exam and special testing. Neurological exam includes strength testing, sensory exam and reflex testing including evaluation of upper motor neuron signs. Red flags that indicate myelopathy include sensory and motor deficits in multiple root levels, bilateral upper extremity or upper and lower extremity involvement, as well as positive upper motor neuron signs (positive Hoffman’s, and Babinski signs, hyperactive reflexes). 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 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 fifth finger2,3. While this distribution of findings is generally accurate, Slipman et al and McAnany et al ha ve 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 8,9.
The most common special test used in the evaluation of cervical radiculopathy is the Spurling’s maneuver, which includes end range neck extension, rotation, side bending, and axial compression. Wainner et al found that with the cluster of involved cervical rotation less than 60 degrees, positive distraction test, positive Spurling’s test and positive upper limb tension test (ULTT), the post-test probability of cervical radiculopathy is 90%10. ULTT 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. While not applicable to testing for cervical radiculopathy, it is important to keep in mind that by changing the positions of the shoulder, elbow and wrist, the ulnar and radial nerves can also be assessed. A note should be made that if sensory examination reveals allodynia, hyperalgesia or sensory after effects in the setting of chronic radicular pain, a component of central and peripheral sensitization should be considered.
The Neck Disability Index11 evaluates how much the pain affects patient’s ability to manage her/his everyday activities (personal care, lifting, reading, concentration, work, driving, sleeping, recreation, pain intensity and headaches).12
The Patient Specific Functional Scale13 asks for five activities with which the patient has difficulty due to the radiculopathy, and evaluates those activities12.
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 a C-reactive protein levels can be considered1,2,3.
Conventional radiographs: low sensitivity, with limited usefulness due to the inability to detect disc herniation and nerve-root or cord compression. Oblique views can help to identify spondylitic 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 and surgical consultation must be obtained instead. 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 presence of symptoms or signs of myelopathy, red flags suggestive of tumor or infection, or the presence of progressive neurologic deficits1,2,3.Contrast study may be useful when evaluating for infection, cancer or post surgically in differentiating between scar tissue vs new disc herniation.
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 ligament 1,2,3.
Supplemental assessment tools
Electrodiagnostic testing 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. Sensory nerve conduction studies are usually normal (unless there is a co-existent distal pathology). Motor nerve-conduction studies may show reduced response amplitude or normal responses. More diagnostic is the needle electromyography, which shows abnormal spontaneous potentials with relatively low sensitivity (50-95%) but very high specificity in cervical radiculopathy14. Electromyographically, radiculopathy is diagnosed when needle study of two muscles that receive innervation from the same nerve root, preferably via different peripheral nerves are abnormal. When feasible, six muscles should be electromyographically examined including paraspinals (for example, a muscle screen that included paraspinals, deltoid, triceps, pronator teres, abductor pollicis brevis, and extensor digitorum communis yielded a 83% sensitivity with emphasis on spontaneous activity alone, but when adding recruitment changes, reached 99% sensitivity in this study) 15.
Additionally, one may see neuropathic recruitment in the very early stages, then abnormal spontaneous activity 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 injury 1,2,3. Electrodiagnostic testing has several significant limitations in assessing radiculopathy that can result in false negative studies. Purely sensory or purely demyelinating radiculopathy will yield a normal electromyography study. 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. 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. 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 overall pain, functional status, and neurologic outcomes. Cervical disc surgery is most likely2,3. Patients that are not on high dose opioids preoperatively have better post-surgical outcomes than their cohorts on high dose opioids before surgery16. One randomized controlled trial of 468 patients reported the following five factors to have a statistically significant adverse effect on outcome 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 presentation17. A major limitation of this study was a significant loss to follow up of study subjects.
Heavy lifting, neck trauma (sports, motor vehicle accidents, etc.), and smoking have been associated with an increased risk for cervical radiculopathy1,2,3. Adding and using stress reduction skills and pursuing good ergonomic postures are paramount in treating active symptoms and reducing chance of recurrent symptoms. Changes in sleep position may be helpful in improving symptoms.
Social role and social support system
When pain persists beyond the expected or fails both medical and surgical management, a chronic state of pain exists. Chronic pain is a disease in and of itself, mostly irrespective of the specific pathology that initiated the process. This chronic state can lead to loss of vocation, leisure activity, and status within society and the family and needs interdisciplinary treatment including addressing sleep and associated mental health issues.
It is important to consider other potential causes of cervical spine pathology and neurologic dysfunction, such as: vertebrobasilar insufficiency, carotid artery ischemia or stroke; neoplasia; discitis; osteomyelitis, brachial plexopathy etc. Additionally, myelopathic symptoms, or signs that may suggest compression of the spinal cord, require an urgent surgical referral to avoid progression of a neurologic deficit.
REHABILITATION MANAGEMENT AND TREATMENTS
Available or current treatment guidelines
Commonly recommended rehabilitation 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 relapses. Often reducing kyphosis and providing balance is paramount18.
At different disease stages
Acute cervical radiculopathy without evidence of major neurological deficit (progressive weakness or signs of myelopathy) should be treated conservatively. First-line treatment includes avoidance of provocative activities, and usage of analgesic agents such as NSAIDs or muscle relaxants such as cyclobenzaprine. 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. Some physicians advocate a seven day course of oral steroids10. A randomized, double-blind, placebo-controlled study of 59 patients with neck and shoulder pain for at least one month and a diagnosis of cervical radiculopathy confirmed by electrodiagnosis found that five days of oral prednisolone via a taper resulted in 75% improvement in pain, compared to 30% improvement in the placebo group19. A randomized clinical trial of oral steroids in treatment for acute lumbosacral radiculopathy, however, did not show any improvement in pain but did show a small improvement in function20. Prior to issuing a steroid prescription, physician 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. Rehabilitation interventions depend on the extent and type of deficits. These include: physical modalities, activity modifications (this might include workplace / environmental / ergonomic modifications), mobilization techniques, kinetic chain analysis, and addressing flexibility and weakness. There should be a progression to normalizing spine mechanics, followed by incorporation of dynamic functional strengthening with the goal to restore range of motion, strength and function. One trial of 205 adults with acute cervical radiculopathy diagnosed by a neurologist found that treatment with either physical therapy and home exercises for six weeks or a cervical collar and rest for three to six weeks was superior to no treatment (control) for reduction in neck and arm pain21. While there is a lack of evidence for specific therapy interventions for the treatment of cervical radiculopathy, there have emerged case reports where upon identification of patient’s directional preference, the McKenzie mechanical diagnosis and therapy evaluation can be very beneficial in lowering long term healthcare utilization, especially when combined with epidural steroid injections22,23. Other therapeutic interventions might include manual therapy, neural mobilization and correction of the forward flexed neck posture.
Among modalities, cervical traction is a popular option. It is defined as application of distracting forces to the neck in order to relieve compression. Its effectiveness has been debated, with some studies showing benefit of intermittent traction. In one randomized study of 86 patients, the traction group had 13% lower scores in Neck Disability Index at six months compared to the group with physical therapy alone24. 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 can play an important role. 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 time intervals using either the interlaminar or transforaminal technique depending on the imaging findings. They found that 80% of patients were able to avoid surgery25. 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 26. There are two common epidural injection approaches:interlaminar and transforaminal. A systematic review of cervical interlaminar epidural steroid injections 11 concluded that the injection showed significant effect in relieving chronic intractable pain of cervical origin. 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. 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 procedures27. Cervical transforaminal epidural steroid injections have the benefit of a more accurate administration of the active product at the level of the affected nerve root. The transforaminal approach is therefore likely more effective in treating single level nerve root pathology. It may also be used as a diagnostic procedure to more selectively block a single cervical level to determine the pain generator. Both the cervical interlaminar and transforaminal epidural injection approach have been associated with case reports of serious complications, such as stroke, spinal cord injury, paralysis and death28,29. Anatomic investigation with ultrasound prior to a cervical nerve root block in 104 cases demonstrated a substantial prevalence of vulnerable vessels in the region of the needle target 30. 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 28 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 injection and the injection may have surgery-sparing effects. 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 Groups31, 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. Mehta et al. came to a similar conclusion in a 2017 study regarding particulate and nonparticulate steroid efficacy32. Similarly, Dreyfuss found no significant difference with particulate and nonparticulate corticosteroid preparations for cervical radicular pain in a comparative effectiveness trial33.
Complications of radiculopathy, such as chronic pain, loss of motor strength and function, or potential progression to cervical myelopathy should be prevented and promptly managed34. In the absence of such findings, surgery is generally recommended when the patient has persistent and severe disabling pain after at least 6 to 12 weeks of nonsurgical management3. Though a benefit from surgery for cervical radiculopathy was noted across all time points in a recent study, a symptom duration of more than two years was a predictor of worse outcomes after surgery34. 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 duration of symptoms35. Surgical options include anterior cervical decompression and fusion (ACDF), cervical disk arthroplasty, and posterior foraminotomy. Patient selection is essential to optimize outcome. A randomized prospective study of 60 patients with cervical radiculopathy found that patients who underwent surgery had 87% reduction in neck pain intensity vs 62% in nonsurgical group at 12 months but this effect was statistically insignificant at 24 months follow up36. 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 outcome from surgery 37.
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-surgery38. Pulsed radiofrequency treatments for the cervical nerve root have been postulated with some efficacy noted in a small patient analysis39.
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. 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 involves input from the patient in the decision making process as well.
Patient & family education
Patients should be well informed of the nature, purpose, potential risks, alternatives, benefits, and limitations of the various available surgical and medical/rehabilitative and interventional treatment options.
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 with increasing frequency, particularly for one- and two-level disc surgeries. There are some level 1 studies suggesting that a disc replacement or disc arthroplasty is equivalent to an anterior cervical discectomy and fusion for one- and two-level disc surgeries 41,42,43. 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 disease44.
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 pain, along with symptoms of numbness and paresthesias.
- 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 and clinical correlation.
- If the cervical radiculopathy follows a non-classical dermatomal distribution, often it can go undiagnosed.
- 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.
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.
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.
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Original Version of the Topic:
Jose Mena, MD, German Ojeda Correal, MD. Cervical Radiculopathy. Publication Date: 2011/11/15.
Previous Revision(s) of the Topic
Christopher Plastaras, MD, Marzena Buzanowska MD. Cervical Radiculopathy. 05/05/2016.
Michael J. Mehnert
Nothing to disclose