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Cervical Radiculopathy

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Other Names

  • Cervical Radiculopathy
  • Cervical Radiculitis
  • Radicular Neck Pain

Background

  • This page refers to cervical radiculopathy
    • Defined as a clinical condition resulting from compression of cervical nerve roots characterized by unilateral arm pain, numbness and tingling
  • Cervical Cord Neuropraxia is discussed separately
  • Cervical Myelopathy is discussed separately

Epidemiology

  • Incidence
    • US Population: 107.3 per 100,000 for men and 63.5 per 100,000 for women[1]
    • US military: incidence of 1.79 per 1000 person-years[2]
  • Peaks in 4th, 5th decade of life

Pathophysiology

  • Compression of a nerve as it travels from the spinal cord
    • Nerve roots most commonly pinched are C6 and C7 (C7 root), followed by the C6 (C5-6 herniation) and C8 (C7-T1 herniation) nerve roots[3]
    • 70% of cervical radiculopathy cases, the location of the impingement is at the foramen
    • Most commonly due to anterior degeneration of the uncovertebral joints and posteriorly of the zygapophyseal joints [4]
  • Impingement is due to both mechanical and chemical pathways
  • Disc degeneration
    • Leads to local inflammation and inflammatory cascade, increasing sensitization and pain[5]

Etiology

  • Degenerative
  • Not typically associated with trauma
  • Sports related
    • Due to extension, lateral bending, or rotation mechanism and closing of the neural foramen
    • Results in ipsilateral nerve injury
    • Can also have sidebending away from affected nerve leading to a traction injury

Pathoanatomy

  • 7 Cervical Vertebrae
  • Intervertebral discs between bodies of C2-C7

Associated Conditions


Risk Factors

  • White race
  • Cigarette smoking
  • History of lumbar radiculopathy
  • Additional proposed risk factors
    • Lifting heaving objects
    • Frequent diving from a board
    • Driving equipment that vibrates
    • Golf

Differential Diagnosis


Clinical Features

  • History
    • Diagnosis can often be made on history alone
    • Inquire about nature of onset, duration of symptoms, provocative and relieving factors, etc
    • Most commonly will report unilateral neck pain radiating down arm[6]
    • May also endorse weakness, numbness, tingling
    • These may follow a dermatome (sensation) or myotome (motor strength)
    • Headache which is occipital or tension in nature
  • Physical Exam: Physical Exam Neck
    • Yoss et al: diminished reflexes were most commonly correlated to the pathology identified at surgery (82 %), followed by motor weakness (77 %), and diminished sensation (65 %)[7]
    • C4: Winged Scapula
    • C5: Deltoid, biceps weakness
    • C6: Brachioradialis, wrist extension weakness
    • C7: Triceps, wrist flexion weakness
    • C8: Weakness of abduction and adduction fingers
  • Special Tests

Evaluation

Radiology

  • Standard Cervical Spine Radiographs
  • Findings
    • Degenerative changes of facet joints, osteophytes, disc space narrowing, sclerosis
    • Foraminal stenosis can be seen on oblique views
  • Findings do not necessarily correlate with symptoms
    • 70% of patients by age 70 will have degenerative changes, not all will be symptomatic (need citation)

CT

  • Useful to better evaluate bony anatomy
  • May be helpful for operative planning
  • Consider CT myelogram if unable to obtain MRI

MRI

  • Useful to evaluate soft tissues
  • Findings
    • Degenerative disc disease and herniation
    • Foraminal stenosis
    • Central compression

EMG/NCS

  • Can be helpful to distinguish radiculopathy from peripheral neuropathy
  • Unfortunately, significant false positive and false negative rate
  • Only 42% of EMG findings correlated to findings at the time of surgery (need citation)

Classification

  • N/A

Management

Prognosis

  • 75% of patients will improve with nonoperative management (need citation)
    • Occurs via resorption of disc, decreased inflammation

Nonoperative

  • Indications
    • Generally considered first line therapy
  • Soft Cervical Collar
    • Generally not recommended, little to no evidence supporting use[8]
    • May have unintended consequences such as pressure sores, deconditioning of cervical musculature
  • NSAIDS
  • Neuropathic analgesics
  • Muscle relaxants
  • Oral Corticosteroids
    • No evidence to support use, must weight against side effects of hyperglycemia, osteonecrosis and infection[9]
  • Physical therapy
    • Typically focused on strength training and stretching of the neck muscles
    • Should include postural, ergonomic training
    • Moderate short term benefit that dissipates at 6 months[10]
  • Corticosteroid Injection
    • Stav et al: 68% of patients reported relief compared to sham injections at 12 months[11]
    • Systematic review found CSI may lead to short-term improvement in patient symptoms[12]
  • Cervical Traction
    • Can be performed manually by physical therapist, massage therapist or with weights
    • No benefit is seen when compared to placebo using standardized, objective outcomes[13]
    • There may be a small benefit using non-standardized outcomes (need citation)
  • Cervical Manipulation
    • Overall paucity of literature
    • May provide immediate relief but no benefit in short- or long-term
    • No benefit when combined with physical therapy as an adjunct[14]
    • Complications include vertebral artery dissection and stroke with OR of 3-12[15]

Operative

  • Surgery is generally reserved for those with prolonged symptoms or progressive symptoms [16]
  • Indications
    • No clear consensus on hard indications
    • Failure of conservative management
    • Rapidly progressive neurological symptoms
    • Signs of myelopathy
    • Co-occuring pathology including fractures, instability
  • Technique
    • Anterior cervical decompression and fusion (ACDF)
    • Cervical disc arthroplasty (CDA)
    • Posterior cervical foraminotomy (PCF)
    • Cervical total disc replacement

Rehab and Return to Play

Rehabilitation

  • Needs to be updated

Return to Play

  • Can be allowed to return when symptoms resolve and no radiographic evidence of myelopathy
  • One study demonstrated expedited RTP After short course of oral corticosteroids (need citation)

Complications

  • Pseudoarthrosis
  • Recurrent laryngeal nerve injury
  • Hypoglossal nerve injury
  • Vascular injury
  • Dysphagia
  • Horner's syndrome

See Also


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):325–35.
  2. Schoenfeld AJ, George AA, Bader JO, et al. Incidence and epidemiology of cervical radiculopathy in the united states military: 2000 to 2009. J Spinal Disord Tech. 2012;25:17–22.
  3. Deanna Lynn Corey, D. C. (2014). Cervical radiculopathy. Medical Clinics of North America, 791-799
  4. Fehlings, S. C. (2005). Cervical Radiculopathy. The New England Journal of Medicine, 392-399.
  5. Van Boxem K, Huntoon M, Van Zundert J, et al. Pulsed radiofrequency: a review of the basic science as applied to the pathophysiology of radicular pain: a call for clinical translation. Reg Anesth Pain Med.
  6. Rhee JM, Yoon T, Riew KD. Cervical radiculopathy. J Am Acad Orthop Surg. 2007;15:486–94.
  7. YOSS RE, CORBIN KB, MACCARTY CS, et al. Significance of symptoms and signs in localization of involved root in cervical disk protrusion. Neurology. 1957;7:673–83. doi: 10.1212/WNL.7.10.673.
  8. Rhee JM, Yoon T, Riew KD. Cervical radiculopathy. J Am Acad Orthop Surg. 2007;15:486–94.
  9. Rhee JM, Yoon T, Riew KD. Cervical radiculopathy. J Am Acad Orthop Surg. 2007;15:486–94.
  10. Cheng CH, Tsai LC, Chung HC, et al. Exercise training for non-operative and post-operative patient with cervical radiculopathy: a literature review. J Phys Ther Sci. 2015;27:3011–8.
  11. Stav A, Ovadia L, Sternberg A, et al. Cervical epidural steroid injection for cervicobrachialgia. Acta Anaesthesiol Scand. 1993;37:562–6.
  12. Carragee EJ, Hurwitz EL, Cheng I, et al. Treatment of neck pain: injections and surgical interventions: results of the bone and joint decade 2000–2010 task force on neck pain and its associated disorders. J. Manip. Physiol. Ther. 2009;32:176
  13. Fritz JM, Thackeray A, Brennan GP, et al. Exercise only, exercise with mechanical traction, or exercise with over-door traction for patients with cervical radiculopathy, with or without consideration of status on a previously described subgrouping rule: a randomized clinical trial. J Orthop Sports Phys Ther. 2014;44:45–57
  14. Gross A, Langevin P, Burnie SJ, et al. Manipulation and mobilisation for neck pain contrasted against an inactive control or another active treatment. Cochrane Database Syst Rev. 2015;9
  15. Biller J, Sacco RL, Albuquerque FC, et al. Cervical arterial dissections and association with cervical manipulative therapy: a statement for healthcare professionals from the american heart association/american stroke association. Stroke. 2014;45:3155–74.
  16. Michael G. Kaiser, R. H. (2018). Degenerative Cervical Myelopathy and Radiculopathy. Switzerland: Springer.
Created by:
John Kiel on 17 June 2019 14:23:48
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Last edited:
10 April 2022 11:29:13
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