Cervical Radiculopathy
CERVICAL RADICULOPATHY - NERVE ROOT COMPRESSION
Arm pain from cervical nerve root compression - C7 most common, 75-90% respond to conservative treatment
Classification by Etiology and Severity
Critical Must-Knows
- C7 root most commonly affected (C6-7 disc) - triceps weakness, middle finger numbness
- Arm pain greater than neck pain is hallmark - if neck pain predominates, consider other diagnosis
- Spurling test: axial compression + rotation reproduces radicular symptoms
- 75-90% improve with conservative management - trial 6-12 weeks before surgery
- ACDF gold standard surgical treatment with 90-95% success rate
Examiner's Pearls
- "Know dermatomal and myotomal patterns for each root cold
- "C5: deltoid/biceps, C6: wrist extensors/brachioradialis, C7: triceps/wrist flexors
- "Progressive motor weakness or myelopathy are surgical indications
- "MRI is gold standard imaging - correlate with clinical findings
Clinical Imaging
Imaging Gallery
Clinical Imaging
Imaging Gallery
Exam Warning
The Hallmark Symptom
Arm Pain > Neck Pain: If neck pain predominates, question the diagnosis (think facet/muscular).
The 'Exit' Rule
Cervical Spine: Root exits above pedicle (C6 disc hits C6 root). Lumbar Spine: Traversing root hit (L4 disc hits L5 root).
Most Common
C7 Root: Most frequently affected (C6-7 disc). Triceps weakness, middle finger numbness.
Viva Trap
Painless Weakness?: Think neurological (ALS) or tendon rupture. Radiculopathy usually HURTS.
At a Glance
| Aspect | Key Information |
|---|---|
| Definition | Nerve root dysfunction from compression/inflammation |
| Peak age | 40-50 years |
| Most common root | C7 (60%), then C6 (25%), then C5/C8 |
| Most common level | C5-6 and C6-7 discs |
| Classic pattern | Arm pain greater than neck pain |
| Key test | Spurling test (93% specific) |
| First-line imaging | X-ray then MRI if neurological symptoms |
| Conservative success | 75-90% |
| Surgery if | Progressive weakness, refractory to 6-12 weeks conservative care |
C5678Cervical Root Patterns
Memory Hook:Count backwards for muscle strength!
Overview and Epidemiology
Overview and Epidemiology
Cervical radiculopathy results from compression or inflammation of a cervical nerve root, producing a characteristic pattern of pain, sensory changes, and/or motor weakness in the distribution of that nerve root.
Epidemiology
Incidence and Prevalence
| Parameter | Value |
|---|---|
| Annual incidence | 83 per 100,000 (US data) |
| Peak age | 40-50 years |
| Gender | Slight male predominance |
| Most common root | C7 (60%), C6 (25%), C5 (10%), C8 (5%) |
| Most common level | C5-6 and C6-7 (90% of cases) |
Risk Factors
- Occupational: Heavy manual labor, vibration exposure
- History of cervical trauma
- Smoking (disc degeneration)
- Diabetes mellitus (peripheral nerve vulnerability)
- Genetics (disc degeneration patterns)
Pathophysiology
Pathophysiology
Cervical Nerve Root Anatomy
Key Anatomical Points
| Feature | Description |
|---|---|
| Nerve root exit | C1-C7 exit ABOVE corresponding vertebra; C8 exits between C7-T1 |
| Foramen boundaries | Anterior: uncovertebral joint, posterior: facet, superior/inferior: pedicles |
| Foramen size | 9-10mm height, 4-6mm width |
| Root position | Occupies one-third of foramen, remainder is fat and vessels |
| Stenosis threshold | Under 4mm foraminal diameter = high radiculopathy risk |
Which Root is Affected?
- C5-6 disc affects C6 nerve root (exits BELOW the disc)
- C6-7 disc affects C7 nerve root
- This differs from lumbar spine where L4-5 disc affects L5 (traversing root)
Exam Pearl
Critical Exam Point: In the cervical spine, the nerve root that exits AT the level of the disc is the root that is compressed. C5-6 disc = C6 root. This is opposite to the lumbar spine convention where the TRAVERSING root (one below) is usually affected.
Pathophysiology Mechanisms
Mechanisms of Radiculopathy
| Type | Mechanism | Features |
|---|---|---|
| Soft disc | Acute nucleus pulposus herniation | Young patients, sudden onset, often central/centrolateral |
| Hard disc | Disc-osteophyte complex | Older patients, insidious, foraminal stenosis |
| Combined | Soft + hard components | Most common presentation |
| Chemical | Inflammatory mediators (phospholipase A2, TNF-alpha) | Can cause pain without significant compression |
Compression Types
- Posterolateral herniation: Compresses exiting nerve root (most common)
- Central herniation: May cause myelopathy
- Foraminal stenosis: Chronic compression from osteophytes
Classification
Classification
Etiological Classification
| Type | Cause | Age Group | Features |
|---|---|---|---|
| Soft disc | Acute herniation | 20-40 years | Sudden onset, may resolve spontaneously |
| Hard disc | Spondylotic stenosis | Over 40 years | Insidious, progressive, associated cervical spondylosis |
| Inflammatory | Chemical radiculitis | Any age | Pain disproportionate to compression |
| Traumatic | Fracture, dislocation | Any age | Associated with injury |
Clinical Presentation
Clinical Presentation
History
Cardinal Symptoms
| Symptom | Characteristics |
|---|---|
| Arm pain | Radiates from neck to shoulder, arm, forearm, hand - follows dermatomal pattern |
| Paresthesias | Numbness, tingling in specific digits |
| Weakness | Difficulty with specific motor tasks (grip, lifting) |
| Neck pain | Usually less prominent than arm pain |
Key History Questions
- Onset: Sudden (soft disc) vs gradual (spondylosis)
- Distribution: Specific dermatome or vague/non-anatomic
- Aggravating factors: Extension/rotation (foraminal narrowing)
- Relieving factors: Arm elevation (shoulder abduction sign)
- Red flags: Myelopathy symptoms, trauma, weight loss
Physical Examination
Dermatomal Patterns
| Root | Sensory Distribution | Motor Weakness | Reflex |
|---|---|---|---|
| C5 | Lateral arm (deltoid patch) | Deltoid, biceps | Biceps |
| C6 | Lateral forearm, thumb, index finger | Wrist extensors, biceps | Brachioradialis |
| C7 | Middle finger, posterior forearm | Triceps, wrist flexors, finger extensors | Triceps |
| C8 | Ring and small fingers, medial forearm | Hand intrinsics, finger flexors | Finger flexor reflex |
| T1 | Medial arm | Hand intrinsics (abductor pollicis) | None reliable |
Special Tests
| Test | Technique | Positive Finding | Interpretation |
|---|---|---|---|
| Spurling test | Extend, rotate, axially compress neck | Reproduction of radicular arm pain | 93% specific, 50% sensitive |
| Shoulder abduction test | Patient places hand on head | Relief of arm pain | Suggests radiculopathy (opens foramen) |
| Neck distraction test | Axial traction on head | Relief of symptoms | Suggests foraminal compression |
| Valsalva | Bear down/cough | Increased radicular pain | Suggests disc herniation |
SPURLINGSPURLING Test
Memory Hook:Spurling is SPURRING on the nerve!
Myelopathy Red Flags
Always check for myelopathy signs:
- Hoffman sign (finger flicking causes thumb flexion)
- Clonus at ankles
- Hyperreflexia in legs
- Babinski sign
- Gait disturbance
- Hand clumsiness (fine motor dysfunction)
Investigations
Investigations
Imaging Algorithm
Standard Approach
| Step | Investigation | Indication |
|---|---|---|
| 1 | Plain X-rays | First-line, exclude instability, assess alignment |
| 2 | MRI | Neurological symptoms, radiculopathy suspected |
| 3 | CT | Osseous detail, surgical planning, MRI contraindicated |
| 4 | CT myelogram | MRI contraindicated, dynamic assessment |
Plain Radiographs
Key Findings
- Disc space narrowing
- Foraminal stenosis on oblique views
- Uncovertebral joint hypertrophy
- Facet arthropathy
- Alignment (loss of lordosis, kyphosis)
Measurements
| Parameter | Normal | Abnormal |
|---|---|---|
| Foraminal height | 9-10mm | Under 4mm = stenosis |
| Disc height | 4-6mm | Under 3mm = degeneration |
| Canal diameter | 17-18mm | Under 13mm = stenosis |
MRI Findings
| Finding | Description | Significance |
|---|---|---|
| Disc bulge | Concentric expansion beyond margins | Common, often asymptomatic |
| Disc protrusion | Focal bulge, base wider than apex | May cause compression |
| Disc extrusion | Apex wider than base | Usually symptomatic |
| Sequestered disc | Fragment separated from parent disc | May migrate, often needs surgery |
| Foraminal stenosis | Loss of perineural fat on T1 | Direct nerve compression |
| Cord signal | T2 hyperintensity | Myelomalacia if present |
Exam Pearl
MRI Interpretation: On T2-weighted sagittal images, look for "loss of CSF signal" around the cord (effacement). On axial images, assess foraminal fat signal loss on T1 and nerve root compression.
Electrodiagnostic Studies
Role in Cervical Radiculopathy
- EMG/NCS: May help localize root level
- Positive findings in denervated muscles 3+ weeks after onset
- Useful for differentiating from peripheral neuropathy
- Not routine but helpful in atypical presentations
Imaging Case Examples (Differentials)
While common radiculopathy is degenerative, be alert for other pathologies on MRI.
Management
Management
Complications
Complications
Conservative Treatment Complications
| Complication | Cause | Prevention/Management |
|---|---|---|
| Chronic pain | Inadequate treatment | Multimodal approach |
| NSAID gastropathy | Prolonged use | PPI cover, limit duration |
| Progression to weakness | Natural history | Monitor closely, early surgery if progressive |
| Nerve damage | ESI complication | Fluoroscopic guidance |
Surgical Complications
| Complication | Rate | Management |
|---|---|---|
| Dysphagia | 20-50% transient, 1-2% permanent | Usually resolves 2-4 weeks, soft diet |
| Recurrent laryngeal nerve injury | 1-2% | Speech therapy, may recover |
| Esophageal injury | Under 0.5% | Primary repair if recognized, NPO |
| CSF leak | 0.5-1% | Primary repair, fibrin glue, lumbar drain |
| Vertebral artery injury | Under 0.5% | Avoid lateral dissection, careful with burr |
| Pseudarthrosis | 3-10% | CT assessment, revision if symptomatic |
| Adjacent segment disease | 2.9% per year | Surveillance, may require extension of fusion |
| C5 palsy | 1-5% (higher posterior) | Usually transient, recovers 6 months |
ACDFACDF Complications
Memory Hook:The procedure name lists the complications!
Postoperative Care
ACDF Protocol
Immediate (Day 0-2)
- Airway monitoring (hematoma risk)
- Swallow assessment before diet
- Early mobilization
- Soft collar if needed (not mandatory)
- DVT prophylaxis
Early (Weeks 1-6)
- Wound check at 2 weeks
- Soft diet if dysphagia
- Cervical precautions (no heavy lifting, driving)
- Gentle ROM exercises from week 2
- Return to sedentary work 2-4 weeks
Intermediate (Weeks 6-12)
- X-rays at 6 weeks
- Begin physiotherapy
- Gradual return to activities
- Return to manual work typically 8-12 weeks
Late (3-12 months)
- Fusion assessment (CT if concern)
- Full activity by 3-6 months
- Monitor for adjacent segment disease
Expected Recovery
| Timeline | Milestone |
|---|---|
| Day 1-2 | Mobilizing, oral intake |
| Week 2 | Return to light activities |
| Week 6 | Driving resume |
| Week 8-12 | Return to work (most occupations) |
| 6 months | Full recovery expected |
Outcomes and Prognosis
Conservative Treatment Outcomes
Natural History of Cervical Radiculopathy
- Systematic review of conservative management outcomes
- 75-90% improve with conservative care
- Most improvement within first 6-12 weeks
- Recurrence rate 20-25% at long-term follow-up
- Motor weakness may predict poorer conservative outcome
Surgical Outcomes
ACDF Outcomes for Radiculopathy
- ACDF success rate 90-95% for radiculopathy
- NDI improvement averages 15-20 points
- Return to work 80% by 12 weeks
- Fusion rate greater than 95% with modern techniques
- Patient satisfaction over 90%
ACDF vs Posterior Foraminotomy
- Both procedures effective for lateral soft disc
- Similar pain and function outcomes
- Foraminotomy: No fusion, preserved motion
- ACDF: Better for central disc, kyphosis
- Foraminotomy faster recovery, less dysphagia
Evidence Base
Evidence Base
Cervical Disc Arthroplasty vs ACDF
- FDA IDE trial comparing CDA vs ACDF
- Similar clinical outcomes at 2 years
- CDA maintained motion at index level
- Lower adjacent segment degeneration with CDA
- CDA appropriate for select patients
Cervical Epidural Steroid Injections
- Moderate evidence for short-term benefit
- 70% report meaningful pain relief at 4 weeks
- Interlaminar safer than transforaminal in cervical spine
- May delay need for surgery
- Diagnostic value for surgical planning
Differential Diagnosis
Differential Diagnosis of Cervical Radiculopathy
| Condition | Distinguishing Features | Investigation |
|---|---|---|
| Cervical myelopathy | Long tract signs, gait disturbance, bilateral symptoms | MRI shows cord compression/signal |
| Brachial plexopathy | Multiple root pattern, may follow viral illness | EMG/NCS, MRI of plexus |
| Thoracic outlet syndrome | Vascular symptoms, provocation with arm positions | Doppler, nerve conduction studies |
| Peripheral nerve entrapment | Distal to root, Tinel positive at compression site | EMG/NCS localizes to peripheral nerve |
| Shoulder pathology | Shoulder ROM limited, rotator cuff signs | Shoulder X-ray, MRI, impingement tests |
| Cardiac referred pain | Exertional, risk factors, associated symptoms | ECG, cardiac enzymes |
| Pancoast tumor | Horner syndrome, severe pain, T1 involvement | CXR, CT chest |
| Fibromyalgia | Diffuse pain, tender points, no neurological deficit | Normal investigations, clinical diagnosis |
ROOTS vs CORDRadiculopathy vs Myelopathy
Memory Hook:ROOTS for radiculopathy, CORD for myelopathy!
Exam Viva Scenarios
Practice these scenarios to excel in your viva examination
Scenario 1: Classic C6 Radiculopathy
"A 45-year-old office worker presents with 4 weeks of right arm pain radiating from the neck to the thumb and index finger. He has numbness in these digits and weakness of wrist extension. Examination shows reduced brachioradialis reflex."
Diagnosis: C6 radiculopathy, likely from C5-6 disc pathology. The dermatomal pattern (thumb/index), myotomal weakness (wrist extensors), and reflex change (brachioradialis) are classic for C6 root involvement.
Investigations: Plain radiographs first (AP, lateral, obliques) to assess alignment and disc height. MRI cervical spine to confirm disc pathology and rule out myelopathy. Expected finding: C5-6 disc herniation or foraminal stenosis compressing C6 root.
Initial Management (6-12 weeks): NSAIDs (naproxen 500mg BD) with PPI cover. Neuropathic agent (gabapentin 300mg TDS titrated) for radicular pain. Physiotherapy for postural training, cervical traction if tolerated. Activity modification (ergonomic workstation). Consider cervical epidural steroid injection if symptoms persist at 4-6 weeks. Regular neurological monitoring.
Surgical Indications: Progressive motor weakness (currently has weakness - monitor closely). Failure of 6-12 weeks conservative care. Development of myelopathy signs. If surgery indicated, ACDF C5-6 is standard approach with over 90% success rate for radiculopathy.
Scenario 2: Progressive Weakness
"A 52-year-old presents with 3 weeks of left arm pain and progressive weakness. Initially had grip weakness but now cannot lift her arm against gravity. MRI shows large C6-7 disc extrusion with severe C7 root compression."
Severity Assessment: This is SEVERE cervical radiculopathy with progressive motor deficit. Cannot lift arm against gravity suggests deltoid weakness (C5) or triceps weakness (C7) at MRC grade 2/5 or less. Progressive weakness over 3 weeks is a red flag requiring urgent intervention.
Conservative Management: NOT appropriate in this case. Progressive motor deficit is an absolute indication for surgical decompression. Delayed surgery risks permanent nerve injury. This patient needs urgent surgical consultation and operative intervention within days.
Surgical Approach: ACDF C6-7 is the standard approach. Large disc extrusion with severe compression requires direct anterior decompression. Key steps: Complete discectomy, removal of extruded fragment, foraminotomy to decompress C7 root, interbody cage, anterior plate optional. Alternative: posterior foraminotomy only if purely lateral and no central compression.
Prognosis Counseling: Explain that surgery aims to halt progression and allow recovery. Motor function may take 3-6 months to improve. Some residual weakness possible if nerve significantly damaged. Early surgery (before severe/prolonged compression) has better outcomes. Success rate for pain relief is over 90%, but motor recovery is less predictable with severe weakness.
Scenario 3: Multi-level Disease
"A 60-year-old man has bilateral arm symptoms with C5-6 and C6-7 disc disease on MRI. He has C6 and C7 dermatomal symptoms, mild weakness of right triceps, and subtle hyperreflexia in the legs."
Concerns: Bilateral symptoms and leg hyperreflexia suggest MYELOPATHY in addition to radiculopathy. This is cervical spondylotic myeloradiculopathy. The multi-level disease and cord involvement change the urgency and surgical approach. Need to assess for other myelopathy signs.
Distinguishing Features: Radiculopathy: Arm pain greater than neck pain, dermatomal pattern, specific myotomal weakness, single reflex affected. Myelopathy: Bilateral symptoms, long tract signs (hyperreflexia in legs, clonus, Babinski), gait disturbance, hand clumsiness. This patient has elements of BOTH.
Additional Examination: Hoffman sign (finger flick test). Clonus at ankles. Babinski reflex. Gait assessment (broad-based, spastic). Hand coordination tests (finger tapping, nine-hole peg). Lhermitte sign. Bladder function inquiry. Check for inverted brachioradialis reflex (finger flexion on tapping - pathognomonic of cord compression).
Surgical Approach: Given 2-level disease with myelopathy, options include: (1) 2-level ACDF C5-6 and C6-7 - addresses both disc and alignment, or (2) Anterior corpectomy C6 with cage - removes both discs and vertebra. Posterior laminoplasty is less ideal for 2 levels only. Anterior approach preferred as it allows direct decompression and restoration of lordosis. Would obtain flexion-extension films to assess stability.
MCQ Practice Points
High-Yield Concepts
- C7 is most common root affected (60%), from C6-7 disc level
- Cervical roots exit ABOVE their corresponding vertebra (unlike lumbar)
- Spurling test: High specificity (93%), moderate sensitivity (50%)
- Arm pain greater than neck pain is classic radiculopathy pattern
- 75-90% improve with conservative management - trial for 6-12 weeks
- Progressive motor weakness is indication for urgent surgery
- ACDF vs foraminotomy: ACDF for central disc, foraminotomy for lateral soft disc
- Dysphagia is most common ACDF complication (transient)
Common Examination Pitfalls
- Missing myelopathy signs in a radiculopathy patient
- Attributing symptoms to wrong root level
- Not checking reflexes systematically
- Forgetting that C8 exits between C7 and T1
- Overlooking progressive weakness as surgical emergency
- Not differentiating from peripheral entrapment
Australian Context
MCQ Practice Points
C7 Root and Cervical Anatomy
Q: Which cervical nerve root is most commonly affected by radiculopathy and what is the typical disc level?
A: C7 root (60% of cases) from C6-7 disc herniation. Remember: Cervical roots exit ABOVE their corresponding vertebra (unlike lumbar spine). The C7 root exits between C6 and C7, so a C6-7 disc herniation affects C7.
Root Level Localisation
Q: How do you differentiate C6 vs C7 radiculopathy on clinical examination?
A: C6 radiculopathy: Weakness of biceps and wrist extension, diminished biceps and brachioradialis reflexes, sensory loss in thumb and lateral forearm. C7 radiculopathy: Weakness of triceps and wrist flexion, diminished triceps reflex, sensory loss in middle finger.
Spurling Test Interpretation
Q: What is the sensitivity and specificity of the Spurling test for cervical radiculopathy?
A: High specificity (93%) but moderate sensitivity (50%). A positive test (reproduction of radicular symptoms with extension, lateral flexion, and axial compression) strongly suggests radiculopathy, but a negative test does not rule it out.
Surgical Decision Making
Q: What are the surgical indications for cervical radiculopathy and what procedure is most appropriate?
A: Urgent surgery: Progressive motor weakness or myelopathy signs. Elective surgery: Failed 6-12 weeks conservative management with persistent symptoms. Procedure choice: ACDF for central/paracentral disc or with axial neck pain; Posterior foraminotomy for lateral soft disc without instability.
Australian Context
PBS-Subsidized Medications
NSAIDs: Available on general schedule (Celecoxib requires authority for chronic use). Neuropathic Agents: Gabapentin and Pregabalin are Restricted Benefits for neuropathic pain (requires TGA chronic pain criteria). Opioids: Restricted to short-term acute pain due to addiction risk.
eTG Recommendations
- First-line: Paracetamol, NSAIDs (short course)
- Neuropathic agents: Gabapentin or pregabalin for radicular pain
- Avoid opioids for chronic radiculopathy
- Physiotherapy as core management
Medicare Considerations
Diagnostic imaging including plain radiographs and MRI are available under Medicare, with MRI rebate eligibility often requiring specialist referral or specific indications for GP referral (such as trauma or radiculopathy). Surgical procedures including nerve root decompression and fusion are covered under standard spinal surgery schedules.
Australian Practice Points
- Public hospital wait times: 6-12 months for elective spine surgery
- Private practice: Typically 2-6 weeks to surgery
- Multidisciplinary teams increasingly common
- Workers compensation considerations for occupational cases
Exam Day Cheat Sheet
Cervical Radiculopathy
High-Yield Exam Summary
Key Diagnosis Facts
- •**Definition**: Nerve root dysfunction from compression/inflammation
- •**Most common root**: C7 (60%), then C6 (25%), from C6-7 and C5-6 levels
- •**Classic pattern**: Arm pain greater than neck pain in dermatomal distribution
Level Specifics
- •**C6 pattern**: Thumb/index numbness, wrist extension weakness, brachioradialis reflex
- •**C7 pattern**: Middle finger numbness, triceps weakness, triceps reflex
Management & Outcome
- •**Key test**: Spurling: Extension + rotation + axial load = 93% specific
- •**Conservative success**: 75-90% improve in 6-12 weeks
- •**Surgery indication**: Progressive weakness, refractory 6-12 weeks, severe deficit
- •**ACDF success**: 90-95% for radiculopathy
- •**Main complication**: Dysphagia (20-50% transient)
References
- Radhakrishnan K, et al. Epidemiology of cervical radiculopathy: a population-based study. Brain 1994;117:325-35.
- Wong JJ, et al. Clinical practice guidelines for the noninvasive management of cervical radiculopathy. Eur Spine J 2014;23:1-22.
- Heller JG, et al. Comparison of BRYAN cervical disc arthroplasty with anterior cervical decompression and fusion. Spine 2009;34:101-7.
- Ruetten S, et al. Endoscopic full-spectrum anterior cervical discectomy for the treatment of cervical disc herniations. Spine 2008;33:940-8.
- Manchikanti L, et al. An update of comprehensive evidence-based guidelines for interventional techniques in chronic spinal pain. Pain Physician 2012;15:E1-206.
- Mummaneni PV, et al. Cervical Spine Research Society evidence-based clinical guidelines. Spine 2007;32:S169-224.
- Gebremariam L, et al. Effectiveness of cervical disc surgery: a systematic review. Spine 2012;37:E30-E36.
- Albert TJ, Murrell SE. Surgical management of cervical radiculopathy. J Am Acad Orthop Surg 1999;7:368-76.