Cervical Radiculopathy

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Radiculopathy\: compression/irritation of spinal nerve root, causing pain, sensory changes (numbness, paraesthesia),
and/or motor changes (weakness, loss of dexterity).
Prevalence\: a
Common causes\: cervical spondylosis (facet joint degeneration), disc herniation, with most cases involving C6-C7 nerve
roots.
Risk factors\: smoking, strenuous lifting, vibrating machinery, older age, male, history of cervical or lumbar radiculopathy.
Symptoms\: radiating neck pain, sensory changes (pain, numbness, paraesthesia), motor changes (weak grip, dexterity loss);
worsens with movement, often unilateral.
Examination\: dermatomes (C4-T1), myotomes (C1-T1), re
reproduced).
studies if needed.
Investigations\: MRI for disc herniation; X-ray for suspected fractures or degenerative changes; EMG and nerve conduction
Management\: conservative approach preferred—physiotherapy, lifestyle modi
(amitriptyline, gabapentin); surgery (discectomy, disc replacement) if severe or intractable symptoms.
Complications\: chronic pain, muscle atrophy, progressive weakness, central sensitisation if unresolved.
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A comprehensive topic overview

Introduction

Radiculopathy refers to the compression or irritation of a spinal nerve root, causing pain with sensory changes (e.g.
numbness, paraesthesia) and/or motor changes (e.g. weakness, loss of dexterity).
1
Unlike radicular pain, which refers only to pain, radiculopathy encompasses any combined symptoms that stem from the
a
2
After lumbar radiculopathy, cervical radiculopathy is the most common form. It a
adult population, usually within the fourth and 3-4
In rare cases, the upper
cervical nerve roots can also become a
5

Aetiology

Anatomy
Each spinal nerve contains a ventral (anterior) and dorsal (posterior) nerve root, which pass through the intervertebral
foramina. The ventral root contains motor
Due to their anatomical position, either or both may become compressed or irritated due to trauma (e.g. herniation or
prolapse, which are more common in young adults) or a degenerative process (e.g. spondylosis and neuroforaminal
stenosis, which are more common in middle-aged and older adults), which can result in oedema, ischaemia, and
in
Radicular pain\: pain which spreads distally via the a
Radiculopathy\: pain which spreads distally via the a
changes, depending on whether the dorsal
Figure 1. A transverse section of the spinal cord, showing the
major anatomical landmarks used to identify the ventral and
dorsal surfaces
Causes
The most common causes of cervical radiculopathy are spondylosis of the facet joints (neuroforaminal stenosis) and disc
herniation. 1
It most often a
neck, shoulder, arm, hand and digits. 1
However, any condition that compresses or irritates a spinal nerve root can lead to
radiculopathy.
When a nerve root becomes compromised due to peripheral nervous system syndromes such as herpes zoster virus, it is
known as polyradiculopathy.
6-7
Cervical radiculopathy can also be caused by a serious pathology, such as vertebral artery dissection, cancer, infection, or
a spinal fracture.
8-9

Risk factors

There are several risks factors associated with cervical radiculopathy\:
5
Modi
Non-modi

Clinical features

History
The most common symptom is radiating pain (e.g.
‘sharp’
,
‘stabbing’
,
‘shooting’
,
‘dull’
,
‘throbbing’
, or ‘aching’) that spreads
distally from the cervical spine and can often be easily localised by the patient (e.g. lateral arm and digits).
Pain is usually unilateral but can also be bilateral (here, it is important to assess for myelopathy and malignant spinal cord
compression) and accompanied by sensory changes and/or motor changes. These tend to follow the course of
the a
Sensory changes\: pain, numbness, paraesthesia
Motor changes\: paresis (weakness), loss of dexterity (e.g. di
shoelaces)
Pain often worsens during movement, especially after long periods of inactivity (e.g. sudden cervical rotation).
Symptoms can develop suddenly (acute onset due to injury/trauma) or insidiously (which may also be due to
injury/trauma or a progressive condition) and can be intermittent, consistent, or worsening.
For more information, see the Geeky Medics OSCE guide to back pain history taking.
Past medical historyPast medical history may include\:
Cervical spondylosis
Neck pain
Disc herniation or prolapse
Trauma to the cervical spine
A history of lumbar radiculopathy
Social considerations include\:
Smoking
Occupation (operating machinery)
Strenuous physical lifting
Recent falls or any indicators of potential injury to the cervical spine
Medications
Some medications (e.g. amiodarone, docetaxel, carbamazepine) can cause side e
symptoms to radiculopathy. Adverse reactions to class A drugs such as cocaine may also mimic symptoms.
Clinical examination
All patients with neck pain should undergo a thorough spine examination.
If radiculopathy is suspected, an upper limb neurological examination, including an assessment of dermatomes,
myotomes, and re
Clinical signs can include muscle atrophy, diminished deep tendon re
gripping, depending on which nerve
compromised (e.g. severe muscle atrophy is indicative of chronic impairment).
Targeted clinical examination
Speci
Dermatomes\: C4-T1
Myotomes\: C1-T1 (grade using MRC scale)
Re
Special tests\: Spurling’s compression test, axial traction test, arm squeeze test, upper limb neural tension tests
Spurling's compression test involves applying downward (caudal) pressure to the top of the head to elicit increased
cervical compression. The test is positive when it reproduces radicular symptoms, suggesting a compromised nerve
root.
Dermatome and myotome maps are poor predictors of nerve root involvement, as they do not indicate precisely which
nerve root is a
variable between individuals.
10-13
Figure 2. Whole body dermatome mapDi
These include a broad spectrum of disorders, and it is important to consider those which can a
digits. Important conditions to consider include but are not limited to\:
Spinal tumour\: associated pain is typically described as a constant, dull ache unrelated to activity. Other symptoms,
such as loss of appetite and weight loss, may be present.
Spinal infection (e.g. osteomyelitis)\: pain may be aggravated by bending and twisting, systemic symptoms such as fever
may be present, and an acute onset would be expected
Myelopathy\: symptoms are usually bilateral and may include numbness, loss of dexterity, di
tasks (e.g. typing shoelaces or buttons), poor coordination (this may include both upper and lower limbs if the lumbar
spine is involved, causing di
14
Thoracic outlet syndrome\: clinical presentations vary, but include pain, numbness and weakness of the forearm, hand
and digits, discolouration of the upper limb, and a positive Adson’s test
15
Acute torticollis\: characterised by neck pain and spasm, with an asymmetric position of the cervical spine (usually in a
position of rotation and/or lateral
Other neuropathic conditions\: consider other sources of neuropathic pain, including carpal tunnel syndrome, cubital
tunnel syndrome, shoulder and brachial plexus injuries, and radial nerve palsy
Mechanical neck pain that spreads into the shoulder, arm, or temporal/occipital region does not necessarily indicate
radiculopathy, as pain can radiate without nerve root compression or irritation.

Investigations

The majority of cases are managed conservatively and do not need investigation. Further investigations are indicated if
likely to change management (e.g. to determine the need for surgery), when a serious pathology is suspected (e.g.
malignancy, infection, myelopathy), or if symptoms persist/worsen beyond the normal trajectory.
Imaging
In most cases, imaging may identify an aetiology and the level of nerve compression\:
Magnetic resonance imaging\: the gold-standard investigation to identify disc herniation
X-ray\: appropriate if a spinal injury is suspected (e.g. fracture, spondylolisthesis) or to assess for degenerative joint
changes (e.g. spinal stenosis, facet joint deterioration, bone spur formation)
Other investigations
Other relevant investigations may include\:
Electromyography (EMG) and nerve conduction studies\: to identify which nerve roots are a
or to exclude other neurological abnormalities

Management

Patients with cervical radiculopathy have a good prognosis, as symptoms usually signi
and completely resolve within 2-3 years in approximately 83% of cases. 16
Therefore, conservative management is usually
preferred.
Conservative management
Conservative management includes\:
Patient education\: advice about how to avoid pain triggers (such as strenuous lifting), information lea
self-management, and reassurance around prognosis
Lifestyle modi
warehouse workers may need modi
Referral to musculoskeletal physiotherapy for exercise guidance and lifestyle modi
Referral to psychological services (e.g. behavioural therapies) as part of a multi-disciplinary approach if indicated (e.g. if
radiculopathy is causing problems with mental health, impacting the ability to work or ful
Medical management
Amitriptyline, gabapentin, or pregabalin can be used for neuropathic pain
Surgical management
Surgical management may be indicated when\:
Conservative management fails beyond the normal trajectory
Symptoms are intractable
Radiculopathy is caused by a serious pathology
There are severe neurological de
Common procedures include\:
Anterior or posterior cervical discectomy (with or without fusion)
Arti

Complications

Typical complications of cervical radiculopathy include\:
Pain\: causes reduced functional mobility, loss of independence, the inability to ful
decreased health-related quality of life
Central sensitisation or nociplastic pain if clinical features persist
Muscle atrophy and deconditioning, exacerbating loss of function
Progressive limb weakness and major motor radiculopathy

References

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Image references
Figure 1. BruceBlaus. Adapted by Geeky Medics. License\: [CC BY-SA].

Reviewer

Dr Richard Armitage
General Practitioner

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Contents

Introduction
Aetiology
Risk factors
Clinical features
Di
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