Cervical Radiculopathy

Cervical radiculopathy is dysfunction of a cervical nerve root, causing neck and arm pain in the root's distribution with sensory loss, weakness or reflex change, usually from foraminal disc herniation in younger patients (acute) or degenerative foraminal narrowing from osteophytes and uncovertebral joint hypertrophy in older patients.

• Annual incidence about 85 per 100 000; peak age 40 to 60 years; C7 is the commonest root (about 45 to 60 percent), then C6 (about 20 to 25 percent), C8 and C5.
• Other causes: trauma, facet joint hypertrophy, tumour (Pancoast, schwannoma, metastasis), infection (discitis, epidural abscess), herpes zoster, sarcoid, and diabetic amyotrophy.
• Natural history is favourable: about 75 to 90 percent improve within 4 to 6 months without surgery.
• Cervical myelopathy, which is compression of the spinal cord rather than a root, is a different problem that needs surgical evaluation.

• Unilateral neck and arm pain, often burning or aching, with paraesthesia and numbness in a dermatomal distribution; worse on neck extension, rotation or lateral flexion to the affected side; relief from placing the hand on the head (shoulder abduction relief sign).
• C5: shoulder and lateral upper arm pain; deltoid and biceps weakness; reduced biceps reflex.
• C6: lateral forearm, thumb and index finger; weakness of biceps, wrist extension; reduced brachioradialis reflex.
• C7: posterior arm and middle finger; weakness of triceps, wrist flexion and finger extension; reduced triceps reflex.
• C8: medial forearm, ring and little finger; weakness of finger flexors and hand intrinsics; no reflex change.
• Signs: Spurling test (neck extension, rotation and axial compression reproducing arm pain), distraction test (relief with manual traction), upper limb tension test.
• Myelopathy signs requiring urgent referral: gait ataxia, clumsy hands, difficulty with buttons, bilateral paraesthesia, Hoffmann sign, hyperreflexia, clonus, extensor plantar response, Lhermitte sign, bladder dysfunction.

• Clinical diagnosis; imaging is not needed in the first 4 to 6 weeks if there are no red flags.
• MRI cervical spine for: progressive or severe motor deficit, myelopathic signs, persistent pain after 6 weeks of treatment, suspected infection or tumour, or before intervention.
• X-rays (including flexion extension) for trauma, instability or deformity; CT for bony detail.
• EMG and nerve conduction studies at 3 weeks or later to separate radiculopathy from brachial plexopathy, carpal tunnel syndrome, ulnar neuropathy and neuralgic amyotrophy.
• Blood tests (if indicated): FBC, ESR, CRP, HbA1c, vitamin B12.
• Differentials: rotator cuff disease, carpal tunnel syndrome, ulnar neuropathy at the elbow, thoracic outlet syndrome, brachial neuritis, Pancoast tumour, angina (left arm pain), myofascial pain, cervical myelopathy, herpes zoster.

Conservative (6 to 12 weeks)

• Explain the favourable course; remain active; avoid prolonged neck extension and heavy lifting.
• Physiotherapy: postural correction, deep neck flexor strengthening, scapular stabilisation and gentle mobilisation; intermittent mechanical traction may help. Avoid high velocity cervical manipulation.
• Short use of a soft collar (no more than 1 to 2 weeks, at night or when symptomatic) to settle severe acute pain.
• Analgesia: ibuprofen 400 mg three times daily or naproxen 500 mg twice daily with food for up to 2 to 3 weeks with omeprazole 20 mg daily; paracetamol 1 g up to four times daily.
• Neuropathic pain: amitriptyline 10 mg at night increasing to 50 mg; gabapentin 300 mg at night increasing to 300 to 600 mg three times daily; pregabalin 75 mg twice daily increasing to 150 mg twice daily (renal dose adjustment); duloxetine 30 mg daily to 60 mg.
• Oral prednisolone 30 to 40 mg once daily for 5 to 7 days may be used for severe acute radicular pain when NSAIDs are contraindicated (monitor glucose and blood pressure).
• Short course of muscle relaxant: diazepam 2 mg at night for no more than 5 days or tizanidine 2 mg at night.
• Opioids only for severe pain for 5 to 7 days.

Injection therapy

• Cervical epidural or selective nerve root steroid injection under imaging for radicular pain that persists at 4 to 6 weeks; serious complications are rare but include spinal cord or brainstem infarction (especially with transforaminal injections), so use by experienced operators with non-particulate steroid (dexamethasone 8 to 10 mg) and imaging.

Surgical indications

• Progressive or severe motor deficit; myelopathy; persistent disabling radicular pain beyond 6 to 12 weeks with concordant imaging.
• Procedures: anterior cervical discectomy and fusion (or disc arthroplasty), or posterior foraminotomy; outcomes are good in 80 to 90 percent for arm pain.

Follow up

• Review at 2 to 4 weeks and 3 months; re-examine for myelopathic signs at each review.
• Safety advice: seek urgent care for new weakness, hand clumsiness, gait disturbance, bladder or bowel symptoms.