Continuing Education Activity

Neck pain is a prevalent issue that can cause significant pain and disability. Up to 40% of work absenteeism is due to individuals with a history of neck pain. Cervical radiculopathy occurs when a nerve root in the spine is compressed or impeded, leading to pain that can spread beyond the neck and into the arm, chest, shoulders, and upper back. Common signs of impingement include muscle weakness and impaired deep tendon reflexes. These deficits may worsen over time, leading to a decrease in quality of life and daily function. While most symptoms can be treated with supportive care, more severe signs of functional loss may require rehabilitation or surgery. This activity covers the causes, symptoms, evaluation, and management of cervical spine radiculopathy, emphasizing the importance of the interprofessional team in assessing, diagnosing, and treating the condition.

Objectives:

• Determine the pathophysiology of cervical spine radiculopathy that leads to common symptoms and signs.
• Select the relevant steps in examining and evaluating cervical radiculopathy, including any indicated diagnostic imaging.
• Identify treatment options for cervical radiculopathy based on the specific etiology.
• Implement interprofessional team strategies in diagnosing cervical radiculopathy and improving outcomes.

Introduction

Neck pain is a common condition that can cause significant discomfort and disability in patients of different ages. Workers who have experienced neck pain account for up to 40% of work absenteeism.[1][2][3] Cervical radiculopathy, on the other hand, is a condition where the nerve root of a spinal nerve is compressed or impaired, causing the pain and symptoms to spread beyond the neck and radiate to other areas of the body, such as the arms, neck, chest, upper back, and shoulders. Due to the nerve impingement, muscle weakness and impaired deep tendon reflexes are often observed.

Etiology

Any condition that causes compression or irritation of a spinal nerve root can result in radicular symptoms. In younger patients, typically in the third and fourth decade, disc trauma and herniation are the most frequent causes of impingement.[4] With increasing age, the causation is degenerative. Disc degeneration is the most common cause in the fifth and sixth decades. In the seventh decade, causation stems from foraminal narrowing due to arthritic change.

Epidemiology

Less frequent than lumbar radiculopathies, cervical radiculopathies occur at an incidence rate of approximately 85 persons per 100,000. The C7 nerve root is most frequently impacted, with more than half of all cases affecting this level. Roughly a quarter of cases involve the C6 nerve root. Nerve roots C1 to C5 and C8 are less impacted. Risk factors for developing radicular disease include manual labor with heavy lifting, driving, or operating vibrating equipment. Chronic smoking history can increase the risk of radiculopathies.

Pathophysiology

In nearly all cases of cervical radiculopathy, the key pathophysiologic feature is inflammation. That inflammation can result from acute herniation of an adjacent cervical disc impinging on the nerve root. The inflammation can also exacerbate degenerative changes so that osteophytes or changes associated with disc dehydration can affect the nerve root. The direct compression of the nerve root leads to pain, numbness, tingling, and weakness.

History and Physical

The history of patients with a complaint of radicular pain or muscle weakness should include inquiries about occupational risk factors, history of trauma, and pain patterns. Cervical radiculopathy is almost always unilateral, although, in rare cases, both nerves at a given level may be impacted. Those rare presentations can confound physical diagnosis and require acceleration to advanced imaging, especially in cases of trauma.

When performing a physical examination, it is crucial to position the patient in a way that allows for the isolation of individual reflex arcs. This helps accurately assess the patient's overall reflex response. Given the individual variation in deep tendon reflexes, comparing both sides of the neck is more important than overall magnitude. If there is nerve impingement, the affected side is reduced relative to the unaffected side. Reduced muscle strength, innervated by the affected nerve, is a significant physical sign.

The spurling test, which compresses the foramina, helps diagnose likely radiculopathy. With the head extended, the head should then be rotated. The test is positive if the pain radiates down the upper limb of the ipsilateral side of the rotation. In some cases, cervical traction can provide relief of radicular pain.

Evaluation

Plain x-ray studies of the cervical spine are commonly ordered for neck and upper extremity pain evaluation. Lateral views may show disc space narrowing. Oblique views may show foraminal narrowing at the level of radicular symptoms. Open mouth views are only necessary if disruption of the atlantoaxial joint is suspected.[5][6][7][8]

Computed tomogram (CT) scanning may be helpful in the acute setting for diagnosing traumatic injuries resulting in radicular symptoms. Poor visualization of soft tissue makes CT less effective outside of this setting.

Magnetic resonance imaging (MRI) is the preferred modality for evaluating radiculopathies. MRI provides excellent visualization of soft tissue abnormalities, including disc herniations and nerve compressions. While disc herniations and foraminal narrowing strongly correlate with radicular symptoms, they may not be causative in every case. False positives are a risk in MRI studies.

Electromyography is useful in confirming the dysfunction of the affected nerve root. Selective nerve root blocks can provide short-term pain relief and confirm the nerve root origins of radiating pain.

Treatment / Management

Treatment of cervical radiculopathy should be approached in a stepwise fashion. Also, while surgery can provide significant relief, there is little evidence that surgery provides a clear advantage over non-surgical treatment in an acute setting. Over 85% of acute cervical radiculopathy resolves without any specific treatments within 8 to 12 weeks.[9][10][11] 

However, to facilitate reduced nerve root inflammation and improve radiculopathy, it is important to implement non-surgical treatments, including oral anti-inflammatory drugs, physical therapy, and translaminar epidural steroid injections. An aggressive, well-designed physical therapy program can provide significant relief. In the setting of surgical intervention, physical therapy can speed recovery. Medical durable goods and appliances can provide significant symptom relief. Nighttime use of a cervical pillow can relieve symptoms and make sleeping easier during recovery. Short-term use of a soft cervical collar can provide some relief. 

Since the main cause of pain in cervical radiculopathy is inflammation, the use of non-steroidal anti-inflammatory drugs (NSAIDs) for 1 to 2 weeks can provide symptom relief and treat the proximate cause. The use of oral steroids should be limited to short-term due to controversies surrounding their use. Tricyclic antidepressants and drugs such as gabapentin are useful adjuncts in the treatment of cervical radiculopathy. Opioid pain medications are not recommended for routine use, but they can be useful in managing radicular pain. It should be noted that the use of opioid medications is a risk factor for slow recovery and delayed return to work for patients where surgical intervention is clinically necessary.[12][13]

Studies have shown that epidural steroids can provide significant pain relief and accelerate the return to normal function for many patients. Relief from a single treatment can be significant and long-lasting. Half the treated patients reported at least 50% relief for weeks following injection.

Using acupuncture as an adjunctive therapy has also been shown to provide significant symptomatic relief. Chiropractic or direct osteopathic manipulation can worsen radicular symptoms. Conversely, indirect osteopathic techniques can facilitate the relief of symptoms. 

Surgical management can provide relief to patients who have failed non-surgical approaches. Two main surgical techniques can be used: anterior and posterior approaches. Usually, the anterior approach requires complete discectomies filled by fusion or disc replacements. The posterior approach involves laminectomy, partial discectomy, and foraminotomy with or without fusion. Both approaches have proven effective. As always, surgical treatments are reserved for failed non-surgical treatments, and patients have acute deterioration of their neurological function. No matter the approach, surgery-related complications can occur, including complications caused by anesthesia or complications from the procedure itself, including nerve palsies, vascular impairment, and laryngeal nerve damage.

Differential Diagnosis

The following diagnoses should be considered in the differential:

1. Brachial plexus injury in sports medicine
2. Cervical disc injuries
3. Cervical discogenic pain syndrome
4. Cervical facet syndrome
5. Cervical spine sprain
6. Rotator cuff injuries
7. Strain injuries

Postoperative and Rehabilitation Care

Manual-based treatments, including traction, mobilization, and manipulation, are used for cervical radiculopathy rehabilitation. Traction is considered the main cornerstone based on available literature. In addition, manual therapy can include various forms of massage and exercises, including stretching, strengthening, and neurodynamic exercises.[14][15] Mechanical traction provides improved outcomes compared to manual traction based on the limited research comparing the two, though further research is needed.[16]

Therapeutic efforts are cited as having multiple benefits, including reducing pain, improving functional outcomes, and improving the timeliness of outcomes depending on the onset of treatment and how aggressive the treatment plan is. It is worth noting that the effectiveness of individual treatments has not been demonstrated in the literature. Combining these treatments has been shown to reduce radiculopathy symptoms. Further research is needed for a more comprehensive understanding.[14][15]

Enhancing Healthcare Team Outcomes

Managing patients with cervical radiculopathy is best accomplished with an interprofessional team that includes a neurologist, neuro or orthopedic surgeon, physical therapist, nurse practitioner, and primary care provider. The treatment of cervical radiculopathy should be approached in a stepwise fashion. Also, while surgery can provide significant relief, little evidence supports that surgery provides a clear advantage over non-surgical treatment in an acute setting. Over 85% of acute cervical radiculopathy resolves without any specific treatments within 8 to 12 weeks. Supportive care includes nonsurgical treatments such as anti-inflammatory drugs, physical therapy, and translaminar epidural steroid injections. 

While many surgical procedures are available, they all have the potential to cause serious complications. Additionally, cases where surgical procedures do not result in significant improvement are evident, and patients continue to suffer from chronic disabilities.[17][18] Patients who do not show improvement could be considered for surgery as a last resort.

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References

1.

Peolsson A, Peterson G, Hermansen A, Ludvigsson ML, Dedering Å, Löfgren H. Physiotherapy after anterior cervical spine surgery for cervical disc disease: study protocol of a prospective randomised study to compare internet-based neck-specific exercise with prescribed physical activity. BMJ Open. 2019 Feb 19;9(2):e027387. [PMC free article: PMC6377535] [PubMed: 30782952]

2.

Hassan KZ, Sherman AL. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Jul 17, 2023. Epidural Steroids. [PubMed: 30726005]

3.

Doughty CT, Bowley MP. Entrapment Neuropathies of the Upper Extremity. Med Clin North Am. 2019 Mar;103(2):357-370. [PubMed: 30704687]

4.

Ament JD, Karnati T, Kulubya E, Kim KD, Johnson JP. Treatment of cervical radiculopathy: A review of the evolution and economics. Surg Neurol Int. 2018;9:35. [PMC free article: PMC5838835] [PubMed: 29527393]

5.

Lukies MW, Teoh WW, Clements W. Safety of CT-guided cervical nerve root corticosteroid injections. J Med Imaging Radiat Oncol. 2019 Jun;63(3):300-306. [PubMed: 30859711]

6.

Miyoshi K. [Dissociation of Anatomical (Neurological) Diagnosis and Imaging Diagnosis]. Brain Nerve. 2019 Mar;71(3):249-256. [PubMed: 30827958]

7.

Jenkins HJ, Downie AS, Moore CS, French SD. Current evidence for spinal X-ray use in the chiropractic profession: a narrative review. Chiropr Man Therap. 2018;26:48. [PMC free article: PMC6247638] [PubMed: 30479744]

8.

Bise S, Pesquer L, Feldis M, Bou Antoun M, Silvestre A, Hocquelet A, Dallaudière B. Comparison of three CT-guided epidural steroid injection approaches in 104 patients with cervical radicular pain: transforaminal anterolateral, posterolateral, and transfacet indirect. Skeletal Radiol. 2018 Dec;47(12):1625-1633. [PubMed: 30032466]

9.

Nordin M, Randhawa K, Torres P, Yu H, Haldeman S, Brady O, Côté P, Torres C, Modic M, Mullerpatan R, Cedraschi C, Chou R, Acaroğlu E, Hurwitz EL, Lemeunier N, Dudler J, Taylor-Vaisey A, Sönmez E. The Global Spine Care Initiative: a systematic review for the assessment of spine-related complaints in populations with limited resources and in low- and middle-income communities. Eur Spine J. 2018 Sep;27(Suppl 6):816-827. [PubMed: 29492717]

10.

Fehlings MG, Tetreault LA, Riew KD, Middleton JW, Aarabi B, Arnold PM, Brodke DS, Burns AS, Carette S, Chen R, Chiba K, Dettori JR, Furlan JC, Harrop JS, Holly LT, Kalsi-Ryan S, Kotter M, Kwon BK, Martin AR, Milligan J, Nakashima H, Nagoshi N, Rhee J, Singh A, Skelly AC, Sodhi S, Wilson JR, Yee A, Wang JC. A Clinical Practice Guideline for the Management of Patients With Degenerative Cervical Myelopathy: Recommendations for Patients With Mild, Moderate, and Severe Disease and Nonmyelopathic Patients With Evidence of Cord Compression. Global Spine J. 2017 Sep;7(3 Suppl):70S-83S. [PMC free article: PMC5684840] [PubMed: 29164035]

11.

Guan Q, Xing F, Long Y, Xiang Z. Cervical intradural disc herniation: A systematic review. J Clin Neurosci. 2018 Feb;48:1-6. [PubMed: 29162303]

12.

Mattozzi I. [Conservative treatment of cervical radiculopathy with 5% lidocaine medicated plaster]. Minerva Med. 2015 Feb;106(1):1-7. [PubMed: 25582970]

13.

Carlesso LC, Macdermid JC, Gross AR, Walton DM, Santaguida PL. Treatment preferences amongst physical therapists and chiropractors for the management of neck pain: results of an international survey. Chiropr Man Therap. 2014 Mar 24;22(1):11. [PMC free article: PMC3987839] [PubMed: 24661461]

14.

Kuligowski T, Skrzek A, Cieślik B. Manual Therapy in Cervical and Lumbar Radiculopathy: A Systematic Review of the Literature. Int J Environ Res Public Health. 2021 Jun 07;18(11) [PMC free article: PMC8201115] [PubMed: 34200510]

15.

Caridi JM, Pumberger M, Hughes AP. Cervical radiculopathy: a review. HSS J. 2011 Oct;7(3):265-72. [PMC free article: PMC3192889] [PubMed: 23024624]

16.

Bukhari SR, Shakil-Ur-Rehman S, Ahmad S, Naeem A. Comparison between effectiveness of Mechanical and Manual Traction combined with mobilization and exercise therapy in Patients with Cervical Radiculopathy. Pak J Med Sci. 2016 Jan-Feb;32(1):31-4. [PMC free article: PMC4795884] [PubMed: 27022340]

17.

Ramirez MM, Brennan GP. Using the value-based care paradigm to compare physical therapy access to care models in cervical spine radiculopathy: a case report. Physiother Theory Pract. 2020 Dec;36(12):1476-1484. [PubMed: 30776939]

18.

Cerier E, Jain N, Lenobel S, Niedermeier SR, Stammen K, Yu E. Smoking is Associated With 1-year Suboptimal Patient-reported Outcomes After 2-level Anterior Cervical Fusion. Clin Spine Surg. 2019 May;32(4):175-178. [PubMed: 30608236]

Disclosure: Warren Magnus declares no relevant financial relationships with ineligible companies.

Disclosure: Omar Viswanath declares no relevant financial relationships with ineligible companies.

Disclosure: Vibhu Krishnan Viswanathan declares no relevant financial relationships with ineligible companies.

Disclosure: Fassil Mesfin declares no relevant financial relationships with ineligible companies.