Cervical Radiculopathy: Neck Pain with Radiating Symptoms
Dr. Jamie McLean, PT
Defined by degenerative changes such as a disk herniation and spondylosis (arthritis) causing bony hypertrophy that encroaches on the joint space that allows for nerve roots to exit the spinal cord. This results in pain, numbness, tingling, or weakness that travels down the arm or could even be felt only in fingers, wrist, forearm, upper arm, or shoulder. The incidence of cervical radiculopathy is as follows: 107 per 100,000 men, 64 per 100,000 women with 22% of nerve compression cases are related to disc herniation (Childress & Becker 2016).
Anatomically, each nerve from C1 to C7 exits above corresponding level; C8 nerve root exists below C7 vertebra. The uncovertebral joint is located anterior to nerve meaning bony spurs here affects anterior aspect of nerve root meaning more motor deficits. Facet joint arthritis affects posterior aspect of nerve root meaning more sensory symptoms such as pain, numbness, or tingling [Figure 1]. Degenerative loss of disk height and resulting arthritic bone spurs also contribute to symptoms (Childress & Becker 2016).
Figure 1: (Childress & Becker 2016). Areas of arthritis encroaching on nerve roots. Area of disk herniation encroaching on nerve roots.
Disk herniation can occur in 3 main types. The most common is intra-foraminal herniation that results in radiating sensory symptoms. The second most common is posterolateral herniation that results in weakness and muscle atrophy. The most rare herniation type is midline herniation that results in spinal cord compression and leads to symptoms of myelopathy. Symptoms of myelopathy include numbness, weakness, gait abnormality, impaired coordination, and urinary incontinence (Childress & Becker 2016).
Symptoms of cervical radiculopathy include radiating pain (most common), numbness and tingling (second most common), and weakness (15% ). Typically, diagnosis can be done via history and physical exam from your physical therapist or physician. The affected nerve root (most commonly C5-T1) can typically be identified rather clearly due to distribution of symptoms [Figure 2]. There are a cluster of special tests your physical therapist will perform combined with the results of a neurological screen that lead to diagnosis. One of the most well researched test is called the Spurlings test. Your physical therapist will move your neck into a side bend and extension and then apply downward pressure, constricting the space the nerve runs through thus reproducing symptoms if positive. Based upon your findings overall, your physical therapist will determine if your case can be treated without a physician script or if you need to see your physician based upon red flag findings. If you are seen via direct access to physical therapy, a referral to physician is warranted if red flags are present, if a differential diagnosis leads to a more likely diagnosis, if symptoms are not reproducible or eradicable and/or you have received 4-6 weeks of treatment from your physical therapist with no change in symptoms (Childress & Becker 2016).
Figure 2 (Childress & Becker 2016): Relevant cervical dermatomes in cervical radiculopathy. Sensory symptoms often correlate with specific dermatomes depending on the impinged nerve root.
Diagnostic testing may be performed if suspicion of more serious causes of nerve root compression is present such as tumor. A plain radiograph (XRay) will be ordered if history of trauma, suspicion of malignancy, or failure to improve in 4-6 weeks of treatment. An MRI will be indicated if there is high suspicion of myelopathy or abscess, persistent or progressive neurological findings, or failure to improve in 4-6 weeks. Keep in mind that MRI testing has high chance of false negative and false positives for cervical radiculopathy because about 57% of people greater than 64 years old who do not have symptoms of cervical radiculopathy have evidence of disk herniation and 26% have evidence of spinal cord impingement. Radiograph and MRI is mostly used to rule out red flags (Childress & Becker 2016).
Non-operative treatment of cervical radiculopathy includes manual therapy and therapeutic exercises. Randomized controlled trials indicate significant improvements in patients who receive twice weekly physical therapy versus control group in the first six weeks (Childress & Becker 2016). Systematic reviews that researched surgical versus conservative treatment of cervical radiculopathy report that at 1 and 2 year follow ups, there are no significant differences in outcomes in groups who received surgery and groups who were treated conservatively. Conservative treatment includes manual therapy such as soft tissue mobilization and trigger point therapy, nerve gliding, and joint mobilizations. Therapeutic exercise includes strengthening of neck and shoulder musculature to increase proprioception, endurance, and muscle balance around cervical spine potentially reducing pain and prevent recurrence. Cervical radiculopathy is frequently associated with inactivity and thus aerobic activity also shown to be beneficial. Neck stretches can maintain active range of motion of the neck and restore or maintain normal function, avoiding scarring, adhesions, and repetitive micro trauma of neck. Exercise improves body structure and function by reducing pain, improving forward head posture, increase neck endurance, improve manual dexterity, enhance grip strength (Cheng et al 2015).
Cheng, C. H., Tsai, L. C., Chung, H. C., Hsu, W. L., Wang, S. F., Wang, J. L., Lai, D. M., … Chien, A. (2015). Exercise training for non-operative and post-operative patient with cervical radiculopathy: a literature review. Journal of physical therapy science, 27(9), 3011-8.
Childress, M.A., & Becker, B.A. (2016). Nonoperative Management of Cervical Radiculopathy. American family physician, 93 (9), 746-54.