Jennifer Werely, MD
David S. Younger, MD
DESCRIPTION 
Cervical radiculopathy refers to dysfunction of a cervical nerve root, usually due to compression and usually caused by degenerative spine disease or acute disc herniation. Typical clinical picture includes neck and arm pain with or without alterations in strength, sensation, and reflexes.
EPIDEMIOLOGY
- Incidence
- Annual incidence rate 83.2/100,000 population.
- Age
- Incidence of herniation of the nucleus pulposus (HNP) is highest at ages 50–54, mean age 47 and most often due to cervical spondylosis and spinal stenosis with root compression due to osteophytes rather than disc material, or both. Approximately 50% of compressive radiculopathy affects the C7 root, 30% C6, 10% C5, and 10% C8. Isolated T1 radiculopathy is rare.
- Sex
RISK FACTORS
The only major risk factor is trauma.
ETIOLOGY
Degenerative spine disease (spondylosis) has two elements: Degenerative disc and joint disease (DJD). Primarily due to aging; superimposed macro- or microtrauma may aggravate the process. Degenerative disc disease predisposes to HNP (“soft disc”) whereas DJD causes osteophytic narrowing of the neural foramina (“hard disc”). Either process may cause compressive radiculopathy. More advanced spondylosis may also lead to spinal stenosis and cord compression.
COMMONLY ASSOCIATED CONDITIONS
The commonly associated conditions comprise osteoarthritis.
[Outline]
- Features favoring radiculopathy as opposed to other etiologies of neck and/or arm pain are as follows:
- Age 35–60
- Acute/subacute onset
- Past history of cervical or lumbosacral radiculopathy
- Cervicobrachial pain radiating to shoulder, periscapular region, pectoral region, or arm
- Paresthesias in arm or hand
- Pain on neck movement—especially extension or ipsilateral bending
- Positive root compression signs
- Radiating pain with cough, sneeze, or bowel movement
- Myotomal weakness
- Decreased reflexes
- Dermatomal sensory loss
- Pain relief with hand on top of head
- Pain relief with manual upward traction
- Onset acute in half, subacute in a quarter, insidious in a quarter; many patients awake with pain in neck and rhomboid region. Majority of patients symptomatic for about 2 weeks prior to diagnosis. Pain in pectoral region occurs in about 20%. Neck, periscapular, and pectoral region pain may be referred from disc itself; arm pain more likely due to nerve root compression. Only 56% of the patients have neck or shoulder pain, but 99% have pain in the upper arm, often poorly localized. Pain in forearm in 88%, usually poorly localized.
- Cervical range-of-motion maneuvers affect size of intervertebral foramen. Pains produced by movements that close the foramen suggest radiculopathy. Pain on symptomatic side on putting ipsilateral ear to shoulder suggests radiculopathy; increased pain on leaning or turning away from the symptomatic side suggests myofascial pain. Radiating pain with neck extended and tilted slightly to the symptomatic side suggests radiculopathy; brief breath holding in this position sometimes elicits radicular pain. Axial compression (Spurling maneuver) adds little. Light digital compression of the external jugular veins until the face is flushed sometimes elicits radicular symptoms: Unilateral shoulder, arm, pectoral or periscapular pain, or radiating paresthesias into the arm or hand (Naffziger's sign), a highly specific but insensitive finding.
- Findings that suggest a lesion at a given level are as follows:
- C5—pain only in neck and shoulder, no pain below elbow, depressed biceps and brachioradialis reflexes, weakness of spinati or deltoid
- C6—weakness of deltoid or biceps, paresthesias limited to the thumb, sensory loss over thumb only, depressed biceps and brachioradialis reflexes
- C7—presence of scapular/interscapular pain, pain involving the posterior upper arm, pain involving the medial upper arm, paresthesias limited to index and middle fingers, whole hand paresthesias, depressed triceps reflex, weakness of triceps, sensory loss involving middle finger
- C8—presence of scapular/interscapular pain, pain involving the medial upper arm, depressed triceps reflex, paresthesias limited to ring and small fingers, weakness of hand intrinsics, sensory loss involving small finger
- T1—disproportionate weakness of abductor pollicis brevis
DIAGNOSTIC TESTS AND INTERPRETATION
Lab
C-reactive protein, ESR, ANA, and rheumatoid factor support an acquired inflammatory process, whereas HLA B27 seropositivity suggests genetically mediated spondyloarthropathy.
Imaging
Plain cervical spine films with oblique views assess for osteoarthritis changes and osteophytes. Non-contrast MRI assesses disc herniation and evidence of root compression. Abnormalities on MRI are common in asymptomatic individuals.
Diagnostic Procedures/Other
EMG and nerve conduction studies including F-responses are essential in the diagnosis of cervical radiculopathy, but may be normal for up to 3 weeks after the acute insult while the root lesion matures. “Double crush injury” often seen in the setting of cervical radiculopathy refers to concomitant peripheral lesions noted on electrodiagnostic studies, such as carpal tunnel syndrome and ulnar entrapment that overlaps clinically with lower cervical root compression.
DIFFERENTIAL DIAGNOSIS
- Brachial plexopathy
- Entrapment neuropathy
- Nerve root tumors (neurofibroma, schwannoma)
- Infection [herpes zoster, Lyme disease, cytomegalovirus, epidural abscess]
- Meningeal carcinomatosis/lymphomatosis
- Multiple sclerosis (causing radiculopathy)
- Giant cell arteritis
- Non-neuropathic mimickers
- Cervical myofascial pain
- Shoulder pathology (bursitis, tendinitis, impingement syndrome)
- Lateral epicondylitis
- De Quervain tenosynovitis
- Facet arthropathy
- Referred pain from heart, lungs, esophagus, or upper abdomen
[Outline]
MEDICATION
Empiric non-steroidal anti-inflammatory medications may be taken to avert abdominal upset decreases radicular inflammatory component and relieves pain; and should be combined with a muscle relaxant such as cyclobenzaprine 5–10 mg PO at bed time. Baclofen 10 mg PO t.i.d. can be substituted for cyclobenzaprine if muscle spasm is severe.
- Contraindications
- Known hypersensitivity for mediations.
- Precautions
- Standard precautions for the drug employed.
- Alternative drugs
- When there is radiographic and electrodiagnostic evidence of acute disc herniation and root compression, a course of oral methylprednisolone taken as a “6 day pack” affords effective anti-inflammatory benefit but should be taken with meals to avoid abdominal upset, and may be repeated if necessary. In selected circumstances of severe pain or focal deficit, consideration may be given to epidural injection of a depot corticosteroid mixed with a long-acting anesthetic under fluoroscopic guidance, typically in a hospital setting by a physician experienced in this procedure.
ADDITIONAL TREATMENT
General Measures
Treatment relies on three approaches: Mechanical, medical, and surgical. Nerve roots lying in the foramen normally enjoy freedom of movement through a small range. The size of the intervertebral foramen and the lateral recess changes dynamically with neck movement. When neck is extended or tilted or turned ipsilaterally, foramen is narrowest; with flexion or contraversive movement, foramen is wider. When caliber of foramen or lateral recess is narrowed because of osteophyte or disc herniation, neck movement may cause microtrauma, which induces inflammation and edema. With HNP, intradiscal inflammatory mediators may spill onto the root, exacerbating the process. Mainstay of treatment is to reduce neck movement and increase the size of the foramen.
- Soft cervical collar is usually helpful. For compressive cervical radiculopathy, the collar should be worn “backward,” with high side posterior, to maintain neck in slight flexion and open foramina. Hard collars cannot be turned around in this fashion and are not as useful for a radiculopathy syndrome. Soft collar should be worn at night if tolerated; if not, use cervical pillow. Prolonged use of collar may weaken neck muscles.
- Gentle manual cervical traction administered by a licensed physical therapist or chiropractor may be helpful.
COMPLEMENTARY AND ALTERNATIVE THERAPIES
- Symptomatic treatment
- Modality physical therapy, or local heat or ice, may provide some relief of axial pain component, but the effects seldom persist much beyond the individual treatment session. Cervical range of motion exercises are of no benefit and possibly harmful.
- Adjunctive treatment
- Acupuncture may be helpful in reducing pain but does not change the natural course of the disorder.
SURGERY/OTHER PROCEDURES
Cervical root decompression should be considered when conservative medical treatments fail to diminish severe pain and ameliorate focal muscle weakness, and neuroimaging and electrodiagnostic concur in the causative underlying root or roots involved.
IN-PATIENT CONSIDERATIONS
Admission Criteria
Hospital admission not required for medically treated patients.
[Outline]
FOLLOW-UP RECOMMENDATIONS
Patient Monitoring
Follow especially strength and reflexes of involved segment; worsening strength or loss of reflex may prompt more aggressive treatment.
PROGNOSIS
The typical patient is significantly improved by 2–3 months. Generally favorable long-term prognosis; 90% have minimal to no symptoms on prolonged follow-up. When due to HNP, cervical radiculopathy has a tendency to recur: 31% have previous history of CR, 32% have recurrence during follow-up.
[Outline]
