Continuing Education Activity
Neck pain is widespread and causes significant pain and disability. Workers with a history of neck pain account for up to 40% of work absenteeism. In the setting of cervical radiculopathy, because the nerve root of a spinal nerve is compressed or otherwise impaired the pain and symptomatology can spread far from the neck and radiates to arm, neck, chest, upper back and/or shoulders. Often muscle weakness and impaired deep tendon reflexes are noted along the course of the spinal nerve. This activity reviews the etiology, presentation, evaluation, and management of cervical spine radiculopathy and reviews the role of the interprofessional team in evaluating, diagnosing, and managing the condition.
Objectives:
Describe the pathophysiology of the various types of cervical spine radiculopathy.
Summarize the relevant steps in performing an examination and evaluation of cervical radiculopathy, including any indicated diagnostic imaging.
Review treatment options for cervical radiculopathy based on the specific etiology.
Explain the importance of interprofessional team strategies for improving care coordination and communication to aid in the diagnosis of cervical radiculopathy and improving outcomes in patients diagnosed with the condition.
Access free multiple choice questions on this topic.
Introduction
Neck pain is widespread and causes significant pain and disability. Workers with a history of neck pain account for up to 40% of work absenteeism.[1][2][3] In the setting of cervical radiculopathy, because the nerve root of a spinal nerve is compressed or otherwise impaired, the pain and symptomatology can spread far from the neck and radiates to arm, neck, chest, upper back and/or shoulders. Often muscle weakness and impaired deep tendon reflexes are noted along the course of the spinal nerve.
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 becomes largely degenerative. In the fifth and sixth decades, disc degeneration becomes the most common cause. In the seventh decade, causation tends to stem from foraminal narrowing as a result of arthritic change.
Epidemiology
Less frequent than lumbar radiculopathies, cervical radiculopathies occur at an incidence rate of approximately 85 persons per 100,000. Most frequently impacted is the C7 nerve root with greater than half of all cases affecting this level. Approximately a quarter of cases affect the C6 nerve root. Other levels are impacted at a much lower rate. Risk factors for developing the radicular disease include manual labor involving heavy lifting, driving, or operation of vibrating equipment. History of chronic smoking increases the risk of developing 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 that subsequently impinges on the nerve root. The inflammation also can exacerbate degenerative changes to such a degree that osteophytes or changes associated with disc dehydration can impinge on the nerve root. It is the direct compression of the nerve root that creates the symptomatology.
History and Physical
The history in patients with a complaint of radicular pain or muscle weakness should include inquiring about occupational risk factors, history of trauma and pain pattern. 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.
On physical examination, positioning the patient to isolate individual reflex arcs is key. Given the individual variation in deep tendon reflexes comparing side to side is more important than overall magnitude. If there is nerve impingement, the affected side will be reduced relative to the unaffected side. Reduction in strength of muscles innervated by the affected nerve is also significant physical finding.
Spurling test, which compresses the foramina, is useful in diagnosing 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
Three-view plain x-ray studies of the cervical spine are the most common studies ordered for evaluation of neck and upper extremity pain. 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 useful in the acute setting for the diagnosis of 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 imaging method of choice for evaluating radiculopathies. MRI provides excellent visualization of soft tissue abnormalities including disc herniations and nerve compressions. There is a risk of falsely positive MRI studies as disc herniations and foraminal narrowing, while strongly correlated with radicular symptoms, may not be causative in any individual case.
Electromyography can be useful in confirming the dysfunction of the affected nerve root.
Selective nerve root blocks can be used not only as a treatment adjunct to provide short-term pain relief to patients with radicular pain but also can be effective in confirming nerve root origins of radiated 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 8-12 weeks. [9][10][11]
Over 85% of acute cervical radiculopathy resolves without any specific treatments within 8-12 weeks. However, in order to facilitate reduced inflammation of the nerve root(s) 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 provide symptom relief and make sleeping easier during recovery. Short term use of a soft cervical collar can provide some support and relief.
Since the main cause of pain in cervical radiculopathy is inflammation use of non-steroidal anti-inflammatory drugs (NSAIDs) for 1 to 2 weeks can provide not only symptom relief but also treat the proximate cause. The use of oral steroids is controversial, and dosing should be short term if at all. Tricyclic antidepressants and drugs such as gabapentin can be useful adjuncts in the treatment of cervical radiculopathy. Opioid pain medications are not recommended but can have utility in the management of radicular pain. It should be noted that the use of opioid medications is a risk factor for the slow recovery and delayed return to work for patients where surgical intervention becomes clinically necessary.[12][13]
Studies have shown that epidural steroids can provide significant relief and speed return to normal functioning for many patients. Relief from a single treatment can be significant and long-lasting. Half of the patients treated have reported relief of at least 50% for weeks following injection.
Using acupuncture as an adjunctive therapy also has shown to provide significant relief of symptoms. A direct physical manipulative technique such as chiropractic or direct osteopathic manipulation can worsen radicular symptoms. Indirect osteopathic techniques conversely can facilitate relief of symptoms.
Surgical management of radicular pain can provide relief in patients that are failed non-surgical treatments. Surgical techniques can be done utilizing anterior or 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 are found to be 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
Brachial plexus injury in sports medicine
Cervical disc injuries
Cervical discogenic pain syndrome
Cervical facet syndrome
Cervical spine sprain
Rotator cuff injuries
Strain injuries
Enhancing Healthcare Team Outcomes
The management of patients with cervical radiculopathy is best done with an interprofessional team that includes a neurologist, neuro/orthopedic surgeon, physical therapist, nurse practitioner, and the primary care provider. The 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 8-12 weeks.
Over 85% of acute cervical radiculopathy resolves without any specific treatments within 8-12 weeks. However, in order to facilitate reduce inflammation of the nerve root (s) and improve radiculopathy, it is important to implement non-surgical treatments including oral anti-inflammatory drugs, physical therapy, and translaminar epidural steroid injections.
Surgery should be the last choice treatment in patients who do not improve. While many surgical procedures are available. they all have the potential to cause serious complications. Plus, a number of patients fail to improve with surgery and remain chronically disabled.[14][15]
Review Questions
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): Jan 2, 2022. 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.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]
15.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]