Cervical Radiculopathy

a, b,c,d
Deanna Lynn Corey, MD *, Douglas Comeau, DO, CAQSM

KEYWORDS
 Cervical radiculopathy  Neck pain  Shoulder pain  Spurling test

KEY POINTS
 Evaluation of shoulder pain should prompt examination of the cervical spine.
 Patient history and physical examination are often sufficient to make a diagnosis of
cervical radiculopathy.
 Always correlate radiologic findings with clinical findings.
 A multimodal treatment approach may help to alleviate symptoms.

INTRODUCTION

Neck and shoulder pain are common presenting complaints for primary care pro-
viders, sports medicine physicians, and orthopedists. Shoulder pain may be a referred
symptom of cervical pathology. The age-adjusted incidence of cervical radiculopathy
is 83 per 100,000 persons, making it less common than lumbar radiculopathy.1 In a
recent study of United States military personnel, female gender and white race were
implicated as potential risk factors.2 Cigarette smoking, axial load bearing, and prior
lumbar radiculopathy may also predispose patients to cervical radiculopathy.3
Nerve roots C6 and C7 are most commonly affected. Radicular pain develops as in-
flammatory mediators, changes in vascular response, and intraneural edema combine
in response to nerve compression. Spondylosis resulting in foraminal encroachment
causes 70% of cases. Decreased disk height or degenerative changes of the uncover-
tebral joints anteriorly or zygopophyseal joints posteriorly are common contributors.
Disk herniation is not seen as frequently in cervical radiculopathy compared with
lumbar radiculopathy.1 Compression alone does not necessarily lead to radicular
pain unless the dorsal root ganglion is affected.4

Disclosures: None.
a
Department of Family Medicine, Boston Medical Center, Boston University, 1 BMC Place,
Boston, MA 02118, USA; b Sports Medicine, Ryan Center for Sports Medicine, Boston Medical
Center, Boston University, 915 Commonwealth Avenue Rear, Boston, MA 02215, USA; c Family
Medicine, Boston University School of Medicine, Boston University, 1 BMC Place, Boston, MA
02118, USA; d Department of Sports Medicine, Boston College, 140 Commonwealth Avenue,
Chestnut Hill, MA 02467, USA
* Corresponding author.
E-mail address: [Link]@[Link]

Med Clin N Am 98 (2014) 791–799

[Link] [Link]
0025-7125/14/$ – see front matter Ó 2014 Elsevier Inc. All rights reserved.
792 Corey & Comeau

PATIENT PRESENTATION

Symptoms related to radiculopathy tend to be unilateral. This is particularly true of

neck pain relating to cervical radiculopathy. Bilateral symptoms are more consistent
with arthritis of the cervical spine. Radiation of pain depends on the involved nerve
root. The absence of radiating symptoms does not eliminate cervical radiculopathy
as a potential diagnosis. Presenting pain may be isolated to the shoulder. Pain is
not always the presenting complaint, because sensory or motor deficits may present
without pain.
Certain modifying factors are consistent in cervical radiculopathy. Activities that
decrease the size of the neural foramen, such as extension and rotation to the affected
side, exacerbate symptoms. Abducting the shoulder tends to alleviate symptoms.
Distribution of sensory and motor deficits may overlap with other neuropathic con-
ditions, including carpal tunnel syndrome or ulnar nerve entrapment. Although these
conditions may coexist in some patients, an appropriate physical examination can
help differentiate the level at which the nerve is affected.
History should include questions to determine if there are signs or symptoms of
myelopathy. Problems with manual dexterity (dropping objects and difficulty writing)
are symptoms of myelopathy. Examination findings consistent with myelopathy
include upper motor neuron signs, such as Hoffmann sign, Babinski sign, hyperre-
flexia, and clonus. Differentiation between radicular and myelopathic symptoms is crit-
ical, because the latter is caused by spinal cord compression, which is best relieved
with surgical decompression. Therefore, this is an important distinction to make.
Red flags should also be evaluated in the history, because they may suggest other
diagnoses. Symptoms, such as fevers, chills, unexplained weight loss, night pain, pre-
vious cancer, immunosuppression, and intravenous drug abuse, are not associated
with radiculopathy. The presence of these symptoms is more suggestive of malig-
nancy or infection. Other factors of the history that make a diagnosis of cervical rad-
iculopathy less likely include age younger than 20 or older than 50 years, constant and
progressive signs and symptoms, neck rigidity without trauma, dysphasia, altered
consciousness, and central nervous signs and symptoms.5
Systemic disorders should also be considered potential causes. Down syndrome is
associated with atlantoaxial instability. Heritable connective tissue disorders carry an
increased risk of ligament laxity.

PHYSICAL EXAMINATION

Findings vary depending on the level of nerve root involved. Evaluation should include
neck range of motion, with careful observation of movements that result in worsening
symptoms. Neurologic examination of the upper extremities should include motor
testing at the shoulders, elbows, wrists, and hands to assess for any weakness and
sensory testing of all dermatomes to assess for variations. Reflex testing should be
considered abnormal when there is asymmetry between the affected and unaffected
side. Any deficits noted can help to determine the compressed nerve root (Table 1).
Provocative testing must also be included. Spurling test is designed to exacerbate
encroachment of exiting nerve roots by decreasing the dimensions of the foramen.
The patient is asked to extend and laterally rotate the neck to the suspected side while
the provider applies an axial load. A positive test recreates radiating pain. Equivocal
tests are notable for discomfort only. Recent studies have shown this test to be highly
sensitive (95%) and specific (94%).6 Shoulder abduction sign, where the arm is raised
above the head, should alleviate or relieve symptoms of cervical radiculopathy. Cervi-
cal traction should produce similar effects.
 Cervical Radiculopathy 793

Table 1
Patterns of cervical radiculopathy

Root Pain Distribution Motor Abnormalities Sensory Deficits Reflexes

C4 Lower neck and N/A Cape distribution N/A
trapezius
C5 Neck, shoulder, lateral Deltoid, elbow flexion Lateral arm Biceps
arm
C6 Neck, radial arm, thumb Biceps, wrist extension Radial forearm, Brachioradialis
thumb
C7 Neck, dorsal forearm, Triceps, wrist flexion Dorsal forearm, Triceps
long finger long finger
C8 Neck, medial forearm, Finger flexors Medial forearm, N/A
ulnar digits ulnar digits

DIAGNOSTIC TESTS/IMAGING STUDY

History and physical examination are often enough to diagnose cervical radiculopathy.
Laboratory studies are expected to be normal in cervical radiculopathy. These studies
should be ordered if other etiologies are more clinically suspicious.
Radiography, to include anterioposterior lower cervical and neutral lateral views,
may be indicated for patients with suspected cervical radiculopathy. Loss of the
normal cervical lordosis, osteophyte formation, and neuroforaminal narrowing respon-
sible for symptoms can be observed (Fig. 1).

Fig. 1. Loss of the normal cervical lordosis, osteophyte formation, and neuroforaminal
narrowing responsible for symptoms can be observed in the radiography.
794 Corey & Comeau

For patients with normal radiography who fail a nonoperative course of treatment,
additional diagnostic studies should be considered. MRI is the preferred modality to
evaluate for disk herniations with or without nerve root compression (Fig. 2). MRI
findings should be correlated with clinical findings, because both false-positive and
false-negative rates are high.7 CT may be used in patients with contraindications to
MRI, such as pacemakers or stainless steel hardware. If nerve entrapment at the
carpal or cubital tunnel is suspected, electromyelography should be pursued.

DIFFERENTIAL DIAGNOSIS

The differential for neck and shoulder pain is broad, including diagnoses related to
neurologic, cardiac, infectious, and musculoskeletal causes. A summary of the differ-
ential diagnosis is provided in Table 2.
Malignancy that may result in presenting symptoms similar to cervical radiculopathy
include, but are not limited to, schwannoma, osteochondromas, Pancoast tumors,
thyroid tumors, esophageal tumors, lymphomas, and carcinomatous meningitis.8,9

TREATMENT

Pain relief, improvement of neurologic function, and prevention of recurrence are the
treatment objectives. Nonoperative treatment modalities for cervical radiculopathy
have not been compared in large-scale, randomized control trials. Recommendations
are based on current available evidence, including case series and anecdotal experi-
ence. Patient preference and potential compliance should be considered when
making treatment decisions.4

Fig. 2. MRI is the preferred modality to evaluate for disk herniations with or without nerve
root compression.
 Cervical Radiculopathy 795

Table 2
Differential diagnosis of cervical radiculopathy

Condition Characteristics
Cardiac pain Radiating upper extremity pain, typically to left shoulder
and arm
Cervical spondylotic Difficulties with manual dexterity, gait changes, bowel or
myelopathy bladder dysfunction, upper motor neuron findings
Complex regional pain Pain and tenderness of the extremity out of proportion
syndrome/reflex sympathetic with examination, skin changes, vasomotor fluctuations,
dystrophy dysthermia
Entrapment syndromes Weakness and sensory deficits consistent with median or
ulnar nerve distributions, direct stimulation of nerve
recreates symptoms
Herpes zoster (shingles) Dermatomal radicular pain associated with reactivation of
viral infection
Malignancy Consider with presence of red flag symptoms, intra- and
extraspinal tumors, presentations vary depending on
primary tumor
Parsonage-Turner syndrome Acute onset of upper extremity pain, usually followed by
weakness and sensory disturbances
Rotator cuff impingement Pain and weakness in the shoulder and lateral arm
Thoracic outlet syndrome Lower brachial plexus nerve root dysfunction due to
compression by vascular or neurogenic causes

PHARMACOLOGIC TREATMENT OPTIONS

Pharmacotherapy may be helpful in the management and relief of symptoms. The

effectiveness of medications is extrapolated from their effectiveness in the treatment
of lumbar radiculopathy and low back pain. As discussed previously, however, the
etiology behind radiculopathy is not typically the same in both locations.
Nonsteroidal anti-inflammatory drugs (NSAIDs) may help alleviate symptoms in the
acute setting. A 2-week trial at a therapeutic dose can be effective in relieving symp-
toms or reducing pain to a degree that other treatment modalities can be better toler-
ated. These medications make a good choice for first-line therapy, because they are
readily available and affordable. Appropriate considerations should be made when
suggesting NSAID treatment, including patient age, medication interactions, and other
comorbidities.10
Muscle relaxants, including cyclobenzaprine (Flexeril) and tizanidine (Zanaflex), may
help alleviate neck pain caused by increased muscle tension at insertion sites.8 These
medications are most effective in the acute setting. Their long-term use in treatment of
cervical radiculopathy is unclear.
Tramadol may provide significant relief of neuropathic pain based on systematic re-
view findings.11 This makes it useful in managing acute exacerbations of cervical
radiculopathy.
Oral steroids, in particular dose packs, are often used to manage acute episodes.
High-quality evidence to support this practice is, however, lacking.12 In addition,
recurrent use of oral steroids can lead to avascular necrosis, hyperglycemia, weight
gain, and mood swings. The degree to which oral steroids improve symptoms may
be an indicator for further treatment with corticosteroid injection. Another systematic
review suggests that tricyclic antidepressants and venlafaxine (Effexor) may provide
796 Corey & Comeau

moderate relief of radicular pain in patients who have declined surgery or continue to
have pain after surgical intervention.13
Studies on neuropathic pain suggest opioids may be an effective treatment course
for up to 8 weeks. These findings are not specific to cervical radiculopathy, and there
is insufficient evidence to support their use beyond a 2-month period.13,14

NONPHARMACOLOGIC TREATMENT OPTIONS

Many modalities beyond pharmacotherapy exist for the treatment of cervical radicul-
opathy. A short course of immobilization has been suggested to reduce symptoms in
the inflammatory phase, although this has not been proved beneficial.8,12,15,16
Traction may be performed at home or in conjunction with physical therapy and
manipulation. Distracting the neural foramen leads to decompression of the nerve
root and improvement in symptoms. This modality works best when acute muscular
pain has subsided. It should be avoided in patients with signs of myelopathy. Insuffi-
cient evidence exists to support the use of traction, especially in the home setting.17
Physical therapy helps restore range of motion and strengthen neck musculature.
Doing this alleviates pain and prevents recurrence. Early on in the treatment of cervical
radiculopathy, gentle range-of-motion and stretching exercises may be combined
with additional modalities, including heat, ice, and electrical stimulation. As pain im-
proves, isometric strengthening, active range-of-motion, and resistance exercises
may be added as tolerated.12,15
Manipulative therapy lacks high-quality evidence to support its use in the long-term
management of cervical radiculopathy. There is evidence, however, to suggest short-
term benefit.15,18 Manipulative therapy is not without risk. Rare complications include
worsening radiculopathy, myelopathy, and spinal cord injury.12
Cervical steroid injections may also be considered in the management of cervical
radiculopathy. These procedures should be performed under radiographic guidance.
Patients who are good candidates for this modality include those with confirmed
pathology by advanced imaging (MRI or CT) who had improvement while taking and
after completing an oral steroid dose pack. Injections may consist of translaminar or
transforaminal epidurals or selective nerve blocks. Evidence suggests that corticoste-
roid injection may lead to short-term, symptomatic improvement of radicular symp-
toms.12,19–23 Retrospective and prospective studies show up to 60% of patients
with relief of radicular symptoms and neck pain and return to usual activity.4,19

SURGICAL TREATMENT OPTIONS

Surgery may relieve intractable symptoms of cervical radiculopathy in appropriate pa-

tients. Evidence is lacking to guide optimal timing of surgical intervention.4 The pres-
ence of myelopathy, as discussed previously, is a sign of spinal cord compression and
an indication for surgery.
Emotional and cognitive factors should be considered when addressing treatment
decisions for cervical radiculopathy. Patient expectations, postoperative limitations,
and job satisfaction are areas that should be discussed prior to choosing an interven-
tion course.24–36
Surgical intervention should be reserved for patients with radiographic evidence of
nerve compression on MRI or CT with corresponding signs and symptoms, persis-
tence of symptoms despite 12 weeks of nonoperative management, or progressive
or functionally important motor deficit.4 Various techniques exist, including anterior
and posterior approaches, but evidence comparing them is lacking. A majority of
patients have substantial relief of their symptoms. Complications are uncommon
 Cervical Radiculopathy 797

but may include iatrogenic injury of the spinal cord, nerve root injury, recurrent nerve
palsy, esophageal perforation, and failure of instrumentation.4
There is a lack of high-quality evidence comparing nonoperative and surgical inter-
vention in the treatment of cervical radiculopathy.

SUMMARY

Cervical radiculopathy is a commonly seen condition across many patient popula-

tions. It results from the compression of a cervical nerve root as it exits the neural fo-
ramen. Presentation may include pain, weakness, and sensory deficits. This diagnosis
should be considered for all patients presenting with neck and shoulder pain. A thor-
ough history and physical examination are often sufficient for diagnosis. Radiologic
studies are often helpful to confirm cervical radiculopathy.
There is no high-quality evidence comparing medical and surgical interventions.
Nonoperative treatment is the first course, unless there are signs of myelopathy. If pa-
tients fail to improve with nonoperative treatment or exhibit progressively worsening
symptoms, surgical intervention should be considered.

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