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Basics ⬇

Author: SaraNeal, MD, MA, CAQSM

Description

  • Cervical radiculopathy is a syndrome of pain and/or sensorimotor deficits resulting from compression and inflammation of a cervical nerve root at or near the neural foramen.
  • The most common causes of nerve root compression and irritation are herniated cervical discs and spondylosis.
  • Spondylosis describes the degenerative aging process of the intervertebral discs, ligaments, facet joints, and vertebral bodies.
  • Mechanical compression can be a result of facet and uncovertebral joint hypertrophy, vertebral body osteophytes, disc protrusion, or some combination of all three.

Epidemiology

  • Peak age for cervical radiculopathy is 50 to 54 yr.
  • Male > female with ratio 1.7:1

Incidence

Annual incidence rates of cervical radiculopathy:

  • 107.3 cases/100,000 men
  • 63.5 cases/100,000 women (1)

Etiology and Pathophysiology

  • Cervical radiculopathy occurs when the nerve root becomes dysfunctional from compression, stretch, and/or irritation.
  • Radiculopathy can also be a result of infection (herpes zoster, Lyme disease), granulomatous infiltration (sarcoid), vasculitis, or tumor.
  • Causes of nerve root dysfunction: spondylosis > disc herniation > infection > granulomatous > tumor
  • Pathophysiology of spondylosis:
    • As discs age, they undergo desiccation, loss of compressibility, and bulging with result of loss in disc height.
    • As the bony spine ages, osteophytes form at the uncovertebral and facet joints.
    • The ligamentum flavum undergoes hypertrophy.
    • These changes can cause narrowing of the neural foramen, impinging the nerve as it exits the cord.
  • Pathophysiology of disc herniation:
    • Disc herniation is more common in the older age group. It can occur in adults <45 yr, but more force generally is needed to cause herniation because the discs are more resilient in the younger population.
    • With progressive age, the annular fibers surrounding the nucleus pulposus degenerate.
    • Under certain conditions such as mechanical force, the nucleus pulposus can herniate through the annular fibers.
    • Herniated disc material impacts and compresses the nerve root.
    • Herniation also incites inflammatory cytokines causing irritation of the nerve.
  • Pathoanatomy:
    • Cervical nerve roots exit above their correspondingly numbered pedicles.
    • C6 nerve root exits between C5 and C6.
    • C7 nerve root exits between C6 and C7.
    • C8 nerve root exits between C7 and T1.
    • Most common level for the disc herniation is C6–C7 (70%), affecting the seventh cervical nerve.
    • C5–C6 is the next most common level (20%). Herniation here affects the sixth cervical nerve.
    • Disc herniations usually prolapse laterally into the neural foramen.
    • Occasionally, herniation disc material protrudes directed posteriorly, impacting the spinal cord; can cause myelopathy (cord compression); may have bilateral symptoms

Diagnosis ⬆ ⬇

History

  • If the radiculopathy is from a herniated disc, symptoms are usually acute; symptoms from spondylosis are typically more insidious.
  • Acute symptoms from herniation may be coincident with trauma such as axial loading and/or hyperflexion.
  • Symptoms are typically unilateral and can include neck, shoulder, or arm pain; paresthesias; numbness; muscle weakness; and/or diminished deep tendon reflexes.
  • Classically, pain in the limb is in the distribution of the cervical nerve myotome.
  • If present, numbness and paresthesia occur in a dermatomal distribution; however, due to overlap of dermatomes, this may not be clinically evident or follow the classic dermatomal pattern.
  • The patient may report relief of symptoms by abducting the upper limb because this maneuver decreases the amount of stretch on the nerve root.
  • Weakness can develop in the muscles supplied by the nerve.
  • Red flags:
    • Symptoms indicating a myelopathy (cord compression) rather than a radiculopathy include gait disturbance, bowel/bladder dysfunction, hand clumsiness or loss of manual dexterity, hyperreflexia, and/or clonus.
    • Fever, chills, unexplained weight loss
    • Constant and progressive symptoms
    • Bilateral symptoms
    • Unremitting night pain
    • Immunosuppression
    • History of cancer
    • Intravenous (IV) drug abuse

Physical Exam

  • Evaluate neck range of motion (ROM) with attention to any movement that worsens or alleviates symptoms.
  • Motor testing of shoulders, arms, forearm/wrist, hand, and finger; evaluating for weakness/asymmetry
  • Deep tendon reflexes should be symmetrical.
  • Test sensation of dermatomes evaluating for asymmetry or abnormality.
  • Spurling maneuver may be positive:
    • This position increases foraminal narrowing/compression and may reproduce symptoms.
    • To perform, extend the neck, rotate the head toward the side of symptoms, and apply downward pressure to the head. It is positive if symptoms are reproduced or increased.
    • Specificity of this test is moderate to high, whereas the sensitivity is moderate (2).
  • Red flags: physical exam findings that may suggest myelopathy rather than radiculopathy:
    • Hyperreflexia
    • Note that a classic pattern of myelopathy at the C5–C6 interspace is suggested by hyperreflexia at the tricep reflex (C7) with diminished bicep and supinator reflexes (C5 and C6).
    • Babinski sign
    • Ankle clonus
    • Lhermitte sign: shock-like sensation radiating down the spine with neck flexion
    • Lower extremity weakness
    • Muscle atrophy in bilateral hands
    • Gait disturbance

Differential Diagnosis

Diagnostic Tests & Interpretation

Initial Tests (lab, imaging)

  • X-rays:
    • Obtain on initial visit if red flags; otherwise, optional
    • Anteroposterior, lateral, and oblique views
    • Spondylosis is a common finding, not diagnostic of radiculopathy.
  • Magnetic resonance imaging (MRI; noncontrast): reveals good soft tissue detail of discs and nerves:
    • Indications:
      • Symptoms or signs of myelopathy
      • Red flags suggestive of tumor or infection (Get contrast MRI.)
      • Progressive or disabling neurologic deficit
      • Consider MRI if no improvement after 6 to 8 wk of conservative treatment.
    • Disc herniation seen best on T2 images
    • Caution should be used when interpreting MRIs because findings must correspond with symptoms to be clinically significant.
  • Computed tomography (CT) myelogram:
    • Useful if patient has metallic surgical hardware in the neck because there can be distortion of MRI images
    • May offer better analysis of bony impingement on foramina
    • Disadvantages: It is invasive and uses radiation.

Diagnostic Procedures/Other

Electrodiagnostic studies (nerve conduction study with electromyogram):

  • Obtain only if diagnosis is unclear.
  • Can help differentiate from peripheral nerve entrapment
  • False-negative results common if test performed too early in workup (must wait at least 3 wk minimum)

Treatment ⬆ ⬇

  • Optimal treatment is controversial. Most recognize conservative therapy as the initial treatment choice.
  • Subsequent options include physical therapy, epidural steroid injections, and surgical procedures. The data for each of these treatment options is limited to relatively small studies. No large well-controlled studies have shown clear evidence of improved outcome for any specific treatment versus conservative treatment alone (3)[C].
  • Because of a relatively high rate of spontaneous resolution, initial treatment is usually nonoperative. Exceptions that may require further workup and subspecialty consultation include:
    • Progressive neurologic deficit.
    • Disabling weakness.
    • Infection or tumor.
    • Vertebral fracture or subluxation from trauma (3)[C].
  • Traditionally, conservative therapy has included some combination of the following modalities: oral analgesics, avoidance of provocative activities, short-term neck immobilization with soft collar, cervical traction, a short course of oral steroids, and physical therapy. Recent guidelines call into question the appropriateness of oral glucocorticoids and benzodiazepines given their unfavorable risk/benefit ratio (4)[A].
  • Patients should be reevaluated at regular intervals during the treatment process so that worsening symptoms can be identified promptly.

Medication

First Line

  • Nonsteroidal anti-inflammatory drugs (NSAIDs):
    • Use at anti-inflammatory doses (e.g., ibuprofen 600 mg QID).
    • Block formation of inflammatory mediators at the site of the disc herniation.
    • Use cautiously if:
      • Risk factors for gastrointestinal (GI) bleeding
      • Risk factors for renal disease
      • In older patients (>65 yr)
  • Oral steroids:
    • More potent anti-inflammatory agents than NSAIDs, although greater potential side effects
    • May consider using if:
      • Not responding to NSAIDs
      • Severe pain
      • Weakness
      • Renal insufficiency
    • Avoid using with NSAIDs.
    • Dose:
      • Typical regimen: Start with 50 to 70 mg/day of prednisone; taper over next 10 days (3)[C].
    • Side effects: have not been shown to alter the natural history of cervical radiculopathy, and risk/benefit ratio is unfavorable (4)[A]

Second Line

  • Narcotics:
    • May be considered for short-term use if pain is severe and not controlled by other medications and modalities (5)[A].
    • Have additive effect with NSAIDs on pain relief.
    • Typical prescription: hydrocodone/acetaminophen—5/325 mg q4–6h PRN for pain
    • Potential side effects: drowsiness, vomiting, constipation, dependency
  • Antispasmodic agents (muscle relaxants):
    • Consider using if muscle spasm is prominent.
    • Additive effect on pain relief when used with a NSAID or narcotic; drowsiness when combined with a narcotic may be intolerable.
    • Typical prescription: cyclobenzaprine—10 mg TID
    • Avoid using for >2 to 3 wk.
    • Potential side effects: sedation, dependency

Additional Therapies

  • Rest and avoidance of provocative activities:
    • “Relative rest” is typically recommended. Patient is encouraged to be as active as the pain allows.
  • Cervical collar to limit motion:
    • Limited data on efficacy
    • May consider initially if severe pain when moving head
    • Limit use to <1 to 2 wk (to avoid weakness and stiffness).
    • Come out of the collar several times per day for ROM exercises within limits of pain.
  • Formal physical therapy or home exercise program:
    • Start ROM exercises as early as possible within limits of pain.
    • Heat/cold, active ROM, isometric strengthening as tolerated
    • Add resistive exercises as tolerated.
    • May add nonimpact aerobic exercise; gear toward an activity that allows the neck to remain in neutral position (e.g., walking, stationary bike)
    • Postural education
    • Ergonomic adjustments
  • Traction:
    • Limited reliable data
  • Spinal manipulation (chiropractic treatment):
    • No consistent data showing benefit. Possible complications include spinal cord and vertebral artery injury if done improperly.
  • Fluoroscopically guided epidural steroid injections:
    • May be effective in reducing pain and reducing need for surgery, but evidence of effectiveness is of low quality and serious complications are possible (6)[A]
    • Specific risks of procedure:
      • Dural puncture
      • Nerve damage
      • Spinal cord and brain stem infarction

Surgery/Other Procedures

  • Consider referring to spine surgeon if:
    • Progressive or severe neurologic deficit
    • Recalcitrant radicular pain or numbness despite nonoperative treatment for 6 to 12 wk; no data on the optimal timing
    • Instability of the spine with radicular symptoms
    • Moderate to severe myelopathy
    • Muscle atrophy
  • Surgical outcomes for relief of arm pain range from 80% to 90% (2)[C].
  • Typical procedure for cervical radiculopathy:
    • Anterior cervical discectomy and fusion (ACDF): allows removal of the disc and uncovertebral spur without neural retraction. Bone graft or plate is placed anteriorly to vertebral body.
    • Addition of physical therapy postoperatively may improve outcome (7)[A].
  • Total disc arthroplasty (experimental):
    • Diseased disc is removed, and an artificial disc is placed.
    • Allows preservation of motion, thereby theoretically decreasing the incidence of adjacent segment disease (5)[B].
    • Preliminary results have been equivocal compared with ACDF surgical procedures (8)[B].

Ongoing Care ⬆ ⬇

Patient Education

In attempts to decrease recurrence of symptoms:

  • Keep the neck and shoulder girdle muscles strong.
  • Use correct posture when sitting (head centered over shoulders).
  • Set up workstations ergonomically.
  • Avoid forcing the neck into extremes of motion.
  • Regular aerobic exercise

Prognosis

  • Resolution of all or most symptoms occurs within 6 to 12 wk in most patients.
  • Acute cervical radiculopathy has up to a 75% rate of spontaneous improvement (3).

Complications

Waiting too long to treat: If weakness is present for too long, patient may never regain full strength and function.

Additional Reading ⬆ ⬇

  • Brown S, Guthmann R, Hitchcock K, et al. Clinical inquiries. Which treatments are effective for cervical radiculopathy?J Fam Pract. 2009;58(2):97–99.
  • Caridi JM, Pumberger M, Hughes AP. Cervical radiculopathy: a review. HSS J. 2011;7(3):265–272.
  • Childs JD, Cleland JA, Elliott JM, et al. Neck pain: clinical practice guidelines linked to the International Classification of Functioning, Disability, and Health from the orthopedic section of the American Physical Therapy Association. J Orthop Sports Phys Ther. 2008;38(9):A1–A34.
  • Ellis JL, Gottlieb JE. Return-to-play decisions after cervical spine injuries. Curr Sports Med Rep. 2007;6(1):56–61.
  • Kelly JC, Groarke PJ, Butler JS, et al. The natural history and clinical syndromes of degenerative cervical spondylosis. Adv Orthop. 2012;2012:393642.
  • Nikolaidis I, Fouyas IP, Sandercock PA, et al. Surgery for cervical radiculopathy or myelopathy. Cochrane Database Syst Rev. 2010;(1):CD001466.
  • Nordin M, Carragee EJ, Hogg-Johnson S, et al; for Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Assessment of neck pain and its associated disorders: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine (Phila Pa 1976). 2008;33(Suppl 4):S101–S122.
  • Young IA, Michener LA, Cleland JA, et al. Manual therapy, exercise, and traction for patients with cervical radiculopathy: a randomized clinical trial. Phys Ther. 2009;89(7):632–642.

References ⬆ ⬇

  1. Radhakrishnan K, Litchy WJ, O’Fallon WM, et al. Epidemiology of cervical radiculopathy. A population-based study from Rochester, Minnesota, 1976 through 1990. Brain. 1994;117(Pt 2):325–335.
  2. Thoomes EJ, van Geest S, van der Windt D, et al. Value of physical tests in diagnosing cervical radiculopathy: a systematic review. Spine J. 2018;18(1):179–189.
  3. Rhee JM, Yoon T, Riew KD. Cervical radiculopathy. J Am Acad Orthop Surg. 2007;15(8):486–494.
  4. Chou R, Cote P, Randhawa K, et al. The Global Spine Care Initiative: applying evidence-based guidelines on the non-invasive management of back and neck pain to low- and middle-income communities [published online ahead of print February 19, 2018]. Eur Spine J. doi:10.1007/s00586-017-5433-8.
  5. Eisenberg E, McNicol E, Carr DB. Opioids for neuropathic pain. Cochrane Database Syst Rev. 2006;(3):CD006146.
  6. Engel A, King W, MacVicar J. The effectiveness and risks of fluoroscopically guided cervical transforaminal injections of steroids: a systematic review with comprehensive analysis of the published data. Pain Med. 2014;15(3):386–402.
  7. Engquist M, Löfgren H, Öberg B. A 5- to 8-year randomized study on the treatment of cervical radiculopathy: anterior cervical decompression and fusion plus physiotherapy versus physiotherapy alone. J Neurosurg Spine. 2017;26(1):19–27.
  8. Skeppholm M, Lindgren L, Henriques T, et al. The Discover artificial disc replacement versus fusion in cervical radiculopathy—a randomized controlled outcome trial with 2-year follow-up. Spine J. 2015;15(6):1284–1294.

Clinical Pearls ⬆

  • Distinguish radiculopathy from myelopathy.
  • Weakness is the most serious complication of cervical radiculopathy and should be followed closely.
  • MRI is the test of choice for imaging the discs and nerves.
  • Treatment in most patients is nonoperative.
  • The timing of surgical intervention for cervical radiculopathy has not been established, but surgery should be considered if there is significant weakness or symptoms that are refractory to nonoperative treatment.
  • Don’t miss the red flags: cervical myelopathy, tumor, and infection.