Cervical Radiculopathy: Diagnosis and Management

By G. Chris Stephens, MD

Cervical radiculopathy is a clinical syndrome involving pain radiating into the upper extremities in a dermatomal (nerve root) distribution. Any process in the cervical spine that produces compression of the exiting cervical nerve roots can lead to this radicular pain. This compression may be caused by acute changes such as a soft disc herniation or chronic degenerative changes known as cervical spondylosis, i.e., hard disc.

The mainstay of diagnosis for cervical radiculopathy is the history and physical examination. Complaints will vary greatly among individual patients and may include pain in the extremity, paresthesia, and motor weakness. Most often, patients will complain of pain beginning in the posterior aspect of the neck, radiating into the trapezial and periscapular areas and into the involved extremity. Approximately 60% to 70% of patients will have at least some motor deficit.

When examining these patients, the physician can perform certain provocative maneuvers to confirm compressive lesions in the neck. Extending the neck and tilting the head toward the affected limb will decrease the size of the neuroforamen, thus increasing compression on the nerve and exacerbating radicular pain. A thorough motor sensory and reflex examination of the upper extremities must be performed to document any dermatomal sensory changes or motor and reflex changes. Lower extremity neurologic evaluation must also be performed to rule out myelopathy and other long-tract signs.

Other disease processes that can mimic cervical radiculopathy include peripheral nerve entrapment syndromes and intrinsic shoulder pathology such as impingement syndrome. These conditions should be ruled out when evaluating a patient with a cervical radiculopathy.

Initial evaluation includes plain cervical x-rays after a short course of conservative treatment has failed. If symptoms persist, MRI scanning of the cervical spine and cervical myelogram followed by CT scanning are the diagnostic procedures of choice. In cases of polyradiculopathy or difficulty in clinical diagnosis, EMG may prove to be a useful tool as well, although it should not be routinely used in the work-up of patients with cervical radiculopathy.

Cervical radiculopathy is usually treated nonoperatively. Most patients will respond favorably to this treatment. Patients may be given a short course of immobilization in a soft collar. It is believed that the immobilization decreases the acute inflammatory response and thereby decreases pain as well. Patients may be given narcotic analgesics, skeletal muscle relaxants, and nonsteroidal anti-inflammatory drugs, although prolonged use of the first two classes should be avoided because of their depressive and addictive side effects. Cervical traction may also be helpful in treating cervical radiculopathy. Home devices are available that can apply from six to twelve pounds of force over short periods of time.

Patients with a progressive neurologic deficit or a massive radicular deficit should immediately undergo a work-up with the imaging studies previously mentioned. In this scenario, early surgical decompression should be considered.

If these nonoperative measures fail, surgical treatment can be considered. The decompression can be performed from either a posterior or an anterior approach. Most surgeons prefer the anterior approach because it is quite safe and because the pathologic changes are found in the anterior portion of the spinal column. When an anterior approach is used, a complete discectomy may be performed. Most surgeons prefer to perform a fusion after the discectomy to maintain the height of the disc space, thereby preventing collapse and the associated foramenal stenosis. Other surgeons, however, believe that the discectomy alone is adequate and that spontaneous fusion will occur after the procedure.

In summary, the mainstay of diagnosis of cervical radiculopathy is the history and physical examination. Once the diagnosis has been made, conservative management protocols should be begun as soon as possible. In most cases, these nonoperative measures will provide relief of symptoms. However, when nonoperative management is ineffective or when disabling or progressive weakness is present, surgical intervention has been shown to be safe and effective.

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Last Updated: 10/4/03