Cervical Radiculopathy

Author(s): Christopher Plastaras, MD, Marzena Buzanowska MD,

Originally published:11/15/2011

Last updated:05/05/2016



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.


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. 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. Lower cervical roots, particularly C7 are more commonly affected than higher cervical roots. In a series of 100 patients with surgically verified radiculopathy at 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 cases4.


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 sequelae 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)

New onset/acute presentation:
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.

Chronic/stable presentation:
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.

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 up5.

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.



History taking is an important component of evaluation of cervical radiculopathy as this is still 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 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)1,2,11. While history taking it is of utmost importance to evaluate for symptoms of myelopathy, such as subtle loss of hand dexterity, balance dysfunction, 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 it is degenerative cervical spondylosis (which again would prompt an assessment of spinal cord dysfunction). Other causes are spinal cord tumors (ependymoma, leptomeningeal metastases, etc), inflammatory disorders (such as cervical radiculoplexus neuropathy, Lyme disease, etc) or root avulsion (in the setting of trauma).

Physical examination

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 would point towards 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 (upgoing toes, positive Hoffman’s sign, hyperactive reflexes). The pattern of dermatomal and myotomal changes based on the root level is 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 has shown that the pain referral patterns are highly variable from person to person6.

The most common special test used in 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%7. 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.

Functional assessment

The Neck Disability Index8 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)9.

The Patient Specific Functional Scale10 asks for five activities with which the patient has difficulty due to the radiculopathy, and evaluates those activities9.

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.


Conventional radiographs: low sensitivity, with limited usefulness due to the inability to detect disc herniation and nerve-root or cord compression. Obtaining oblique views are critical to identify spondylitic foraminal stenosis. Flexion/extension films are useful when cervical instability is suspected based on clinical history, including any history of trauma (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 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. 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 ligament1,2,3.

Supplemental assessment tools

Electrodiagnostics can be a useful tool in some cases of radiculopathy, especially when the diagnosis is not clear. 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 needle electromyography, which shows abnormal spontaneous potentials with relatively low sensitivity (50-95%) but very high specificity in cervical radiculopathy11. 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 6 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)12.

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 injury1,2,3. Electrodiagnostics has several significant limitations in assessing radiculopathy that can result in false negative studies. Purely sensory or purely demyelinating radiculopoathy will yield a normal study. In acute radiculopathy (first 10-14 days), electromyographic examination of limb musculature will be normal or might show 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 poses when more than one pathology exists.

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. Patients that are not on high dose opioids preoperatively have better post-surgical outcomes than their cohorts on high dose opioids before surgery13. One randomized controlled trial of 468 patients reported the following 5 factors to have a statistically significant adverse effect on outcome at 6 months: history of recurrent cervical radiculopathy for more than 5 years, more than 3 cervical radiculopathy episodes, bilateral paresthesia, women over 50 years of age, and symptoms that were worsening at the time of initial presentation14 A major limitation of this study was a significant loss to follow up.


Heavy lifting, neck trauma (sports, motor vehicle accidents, etc.), and smoking have been associated with an increased risk for cervical radiculopathy1,2,3. Adopting good sleep postures, good sleep habits, stress reduction skills as well as good ergonomic postures are paramount in treating active symptoms and reducing chance of recurrent 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.

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, brachial plexopathy etc. Additionally, myelopathic symptoms or signs that may suggest compression of the spinal cord, which require an urgent surgical referral to avoid progression of neurologic deficit.


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 paramount15.

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 of treatment includes avoidance of provocative activities, and 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 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 steroids7. A randomized, double blind, placebo controlled study of 59 patients with neck pain for at least one month and no alarm symptoms found that received 5 days of oral prednisolone with a 5 day taper, had 75% improvement in neck pain, compared to 30% improvement in the placebo group16. A randomized clinical trial of oral steroids in treatment of acute lumbosacral radiculopathy however, did not show any improvement in pain but did show a small improvement in function. 27 Prior to issuing a steroid prescription, physician must ensure that there’s no contraindications (no ongoing infection/immunosuppression, peptic ulcer disease, liver disease, history of steroid psychosis/suicidality, anaphylactoid reaction, etc).

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 pain17 . 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 injections18,19. Other interventions include manual therapy, neural mobilization, correction of the forward flexed neck posture, etc. 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 6 months compared to the group with physical therapy alone20. 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, interventional management can play an important role. Lee et al conducted a study where they took 98 patients with cervical radiculopathy without neurologic deficits who were surgical candidates and treated them conservatively with cervical epidural steroid injections. A series of 1-3 injections was administered at 1-2 week time intervals using either the interlaminar or transforaminal technique depending on the imaging findings. They found that 80% of patients avoided surgery21. 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 28.There are two administration routes: interlaminar and transforaminal. A systematic review of cervical interlaminar epidural steroid injections8 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 procedures.29 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. It is therefore likely more effective in a single level pathology. It may also be used as a diagnostic procedure to selectively block a single cervical level to determine the pain generator. This method of injection has been implicated however with case reports of serious complications, such as stroke, spinal cord injury, paralysis and death22. 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 30 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 a surgery sparing effects. There are a few studies with long term follow up of up to 2 and even 5 years. The Spine Intervention Society published Safeguards to Prevent Neurologic Complications after Epidural Steroid Injections: Consensus Opinions from Multidisciplinary Working Groups 31, 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. Kennedy et al published a randomized, double blind trial where they compared the effectiveness of dexamethasone with a particulate steroid and concluded that the effectiveness in lumbosacral radicular pain from herniated disc is similar. 32Similarly, Dreyfuss found no significant difference with particulate and nonparticulate corticosteroid preparations for cervical radicular pain in a comparative effectiveness trial.33Complications of radiculopathy, such as chronic pain, loss of motor strength and function, or potential progression to cervical myelopathy should be prevented and promptly managed23. 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 management.3 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 up24. 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 surgery25.

Neuromodulation (spinal cord stimulators) 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-surgery26.

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 measures include Numeric Pain Rating Scale (NPRS) and Visual Analogue Scales (VAS) for pain ratings9.

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, shoulder 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 and clinical correlation.
  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.


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

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.

Author Disclosures:

Christopher Plastaras, MD

Affiliation/Company/Institution What Was Received? Type For What Role?
TLG Associates for Family owned business which performs legal opinions/summaries and has $75,000 annual contract with the State of Pennsylvania and questionnaire to assess access to medical care for injured workers. < $1,000 annual income
-pays for professional licensure/membership and CME activity (fees/travel/meals/lodging)
Senior Medical Consultant
Elite Rehabilitation Solutions, LLC – 2010, 2011, 2012, 2013 (online), 2014 (online) “Medical Management and Non-Operative Management of the cervical and lumbar spine” honorarium <$300 Speaker
Oakstone Publishing/CMEInfo
2010 & 2013 “Lumbar Spine Update” on DVD
honorarium $1000 Speaker
North American Spine Society
2010, 2011, 2012, 2013, 2014
honorarium <= $500; meal/travel/lodging expenses Co-Chair of course
Injection Course Instruction
18th European congress of Physical & Rehabilitation Medicine: Science & Art in Physical & Rehabilitation Medicine 2012 travel/lodging expenses to Thessaloniki, Greece Lecturer
Excel Physical Therapy
2012 “Non Operative Management of the Low Back Pain” ; Arcadia University, Glenside, PA.
<=$500 honorarium Invited Speaker Inservice
Ownership of copyright of the RICPLAS (© 2006) computer software pertaining to outpatient musculoskeletal pain practice; a database that tracks clinical and research information, generates clinical forms & documentation, tracks clinical and research outcomes, suggests charges. Offered at no cost to academic institutions and research collaborators. There have been no financial gains from Intellectual Property from 2006 to present. copyright

Marzena Buzanowska MD
Nothing to Disclose

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