Cervical Radiculopathy

13

Jonathan Tuttle and Norman Chutkan

CHAPTER PREVIEW
Chapter Synopsis

Cervical radiculopathy is defined as pain with or without a motor, sensory, or reflex

deficit that is caused by cervical nerve root compression or irritation. Typically, cervical
radiculopathy has a favorable natural history. This chapter reviews the epidemiology,
natural history, pathogenesis, and differential diagnosis of the disease.

Important Points

Neural compression resulting in radiculopathy can result from a variety of sources, the
most common being cervical spondylosis and herniated nucleus pulposus.
Consensus statements from a review of available evidence indicate that cervical radiculopathy from degenerative processes has a favorable prognosis and tends to be selflimiting.
Symptoms of cervical radiculopathy frequently mimic those of other diseases; therefore, careful history, examination, and imaging are required to confirm the diagnosis.
Careful correlation of history and examination with imaging studies is necessary because asymptomatic degenerative changes in the cervical spine are very common findings in advanced imaging, in particular magnetic resonance imaging.

As a degenerative condition, cervical radiculopathy results

most commonly from spondylosis or herniated nucleus
pulposus. Cervical radiculopathy can also have other
causes, such as tumor, trauma, synovial cysts, meningeal
cysts, dural arteriovenous fistulas, or tortuous vertebral
arteries. This chapter focuses on spondylosis and herniated nucleus pulposus.
In 1817, Parkinson published the first clinical description of cervical radiculopathy but misunderstood the
etiology.1 In 1926, Elliott published his work describing
how neuroforaminal stenosis caused cervical radiculopathy. In 1948 and 1952, Brain published articles on the
intervertebral disk and cervical spondylosis.2,3
Cervical radiculopathy is defined as pain with or without a motor, sensory, or reflex deficit that is caused by
cervical nerve root compression or irritation. The irritation may result in one or more of the following signs and
symptoms: loss of strength, neck pain, arm pain, and
numbness or paresthesias in a dermatomal or myotomal
distribution.

Epidemiology
A population-based study from Rochester, Minnesota,
revealed an incidence of cervical radiculopathy of 107.3

per 100,000 men and 63.5 per 100,000 women.1 In this

study population, no cervical radiculopathy was seen is
persons who were more than 60 years old. The investigators also found that the C7 nerve root was most often
involved, followed by C6.

Natural History
The natural history of cervical radiculopathy was initially studied by Lees and Turner in 1963.4 These investigators followed two groups of patients: one group with
myelopathy and the other with radiculopathy. Fifty-seven
patients with cervical radiculopathy were followed for
up to 19 years. No patients with radiculopathy became
myelopathic, but 25% suffered from persistent or worsening radicular pain.
Gore and associates followed 205 patients with neck
pain and no neurologic deficit for a minimum of 10
years.5 At the final follow-up, one third of these patients
had moderate to severe pain that limited their lifestyle.
Unfortunately, it is difficult to determine how many of
these patients had primarily radicular pain, as opposed to
isolated neck pain, despite tabular notation in the article
of shoulder, arm, forearm, and hand pain in some of the
patients.
131

132SECTION 2 Degenerative Conditions

A more recent article from the Degenerative Disorders Work Group of the North American Spine Society
Evidence-Based Clinical Guideline Development Committee noted methodologic problems with all reviewed
studies pertaining to the natural history of cervical radiculopathy.6 This work group proposed the following consensus statement: It is likely that for most patients with
cervical radiculopathy from degenerative disorders signs
and symptoms will be self-limited and will resolve spontaneously over a variable length of time without specific
treatment.

C5

C5

C6

C6

C7

C7

C8
T1

Pathophysiology
Most patients with cervical radiculopathy patients pre
sent to their physician with symptoms caused by cervical
spondylosis and the resultant neuroforaminal stenosis or
hard disk. Cervical spondylosis starts with disk desiccation.7 The avascular disk loses water because of a decrease
in the proteoglycan content in the nucleus pulposus that
leads to a reduction of water content from 90% at birth to
74% during the eighth decade of life.8 This change results
in a loss of disk height, microinstability and subsequent
osteophyte formation, facet hypertrophy, and ligamentum flavum buckling and hypertrophy. Degeneration of
the spine, or spondylosis, may result in neuroforaminal
stenosis and potentially, spinal canal stenosis.
The other main cause of cervical radiculopathy is a
soft disk or herniated nucleus pulposus. This disorder
is seen more often than a hard disk in younger patients.
Roughly 75% of cervical radiculopathies occur between
the ages of 40 and 59 years. Patients in their 40s tend to
have more soft disks, and those in their 50s tend to have
more hard disks.
Double crush phenomenon occurs less than 1% of the
time on the same nerve, according to Morgan and Wilbourn; it is observed when a cervical nerve root is compressed and is accompanied by additional peripheral
compression.9 These investigators found that 3.4% of the
time, a patient had either carpal tunnel syndrome or ulnar
neuropathy combined with a cervical root lesion. The
double crush phenomenon was first reported by Upton
and McComas, who hypothesized that it originated from
impaired axoplasmic flow that made the distal portion of
the nerve more susceptible to compression injury.10

Pertinent Examination Findings

by Level
Cervical radiculopathies can result from any pathologic condition at the nerve root level.11 Above the level
of C5, diagnosis can be difficult to elucidate based on
history and physical examination because examination
findings are limited and nonspecific (Fig. 13-1). C2
radiculopathy is characterized by a history of occipital neuralgia in which the patient has suboccipital or
auricular pain. The C3 nerve root, which is the smallest
cervical root, exits through the largest foramen and is
usually not affected by spondylosis. Because C4 radiculopathy may manifest with pain to the posterior neck,

T1

Sensory
C7

C6

C5

C8

T1

Motor

Finger
flexors
C8

Deltoid
C5
Biceps
C5, C6
Triceps
C6

Finger
extensors C5
Interossei C8-T1
FIGURE 13-1 Cervical root motor and sensory findings by level. (From
Benzel EC, editor: Spine surgery: techniques, complication avoidance, and management, ed 2, Philadelphia, 2005, Churchill Livingstone, as modified in Shen
FH, Shaffrey CI, editors: Arthritis and arthroplasty: the Spine, Philadelphia, 2010,
Saunders.)

trapezius muscle, and anterior chest, this disorder can

sometimes be difficult to differentiate from axial neck
pain.
C5 radiculopathy typically causes pain that radiates
over the shoulder and into the proximal arm along the
lateral aspect of the deltoid muscle (Table 13-1). Examination findings can include deltoid weakness, as well as
some biceps muscle weakness. Biceps weakness can also
come from C6 radiculopathy because of dual innervation.
For C6 radiculopathy, pain, numbness, or tingling may
radiate to the thumb and index fingers. Wrist extension,
provided by the extensor carpi radialis muscle, is from C6
innervation, and this may be weak. The brachioradialis
reflex may be diminished or absent.
C7 radiculopathy may cause pain that radiates to
the middle finger or to the interscapular region. The triceps muscle is innervated by C7, and it may be weak.
An absent or diminished triceps reflex also indicates C7
radiculopathy.

CHAPTER 13 Cervical Radiculopathy 133

Table 13-1Cervical Motor and Sensory Findings by

Nerve Root Level

Table 13-2Differential Diagnosis

Diagnostic Concern

Diagnostic Clues

Disk Herniation Affected Root Motor Test/Muscle

C5 versus rotator cuff

tear

Intrinsic shoulder problems often are

associated with shoulder motion that
causes pain and decreased range of
motion
Carpal tunnel syndrome is associated
with nocturnal dysesthesias in the
palmar aspect of the index through
ring fingers, and may produce a positive Phalen test result and Tinel sign at
the wrist
The posterior interosseous nerve does
not have a sensory component; C7
radiculopathy can cause a diminished
or absent triceps reflex or weakness
Anterior interosseous nerve entrapment does not cause sensory changes
and may produce a positive pinch
test in which the terminal phalanges
of the thumb and index finger are
hyperextended.
Ulnar entrapment may produce a positive Phalen test result or Tinel sign at
the elbow.

C4-5
C5-6

C5
C6

C6-7

C7

C7-T1

C8

T1-2

T1

Shoulder abduction/deltoid
Elbow flexion/biceps
Radial wrist extension/extensor
carpi radialis longus
Elbow extension/triceps
Finger extension/extensor
digitorum communis
Finger flexion/flexor digitorum
superficialis and profundus
Hand intrinsics/interossei (<T1)
Hand intrinsics/interossei

Modified from Benzel EC, editor: Spine surgery: techniques, complication avoidance, and management, ed 2, Philadelphia, 2005, Churchill Livingstone.

C8 radiculopathy may cause pain radiating to the

medial arm and forearm, as well as the ring and little fingers. Hand intrinsic muscles may be weak, and the patient
may exhibit the benediction sign in which the ring and
little fingers do not fully extend. Rarely, T1 radiculopathy
may be present and may cause numbness on the ulnar
side of the forearm or atrophy of the dorsal interosseous
muscle.

Differential Diagnosis
The differential diagnosis of cervical radiculopathies
often includes peripheral neuropathies. Carpal tunnel
syndrome, cubital tunnel syndrome, and anterior and
posterior interosseous nerve compression can have similar presentations. Table 13-2 may help differentiate one
diagnosis from another.

Imaging Studies
Radiography
Radiographs provide information regarding sagittal alignment, fractures, dislocations, and congenital anomalies. Overt or occult instability may be demonstrated by
dynamic imaging.12 Oblique radiographs may be useful
for demonstrating neuroforaminal stenosis (Fig. 13-2).

Computed Tomography Myelography or

Plain Computed Tomography
This imaging modality provides excellent visualization of
previously instrumented levels in which magnetic resonance imaging (MRI) may have too much artifact. It is the
test of choice for patients with metal foreign bodies who
cannot undergo MRI studies and is excellent at showing
ossification of the posterior longitudinal ligament. Computed tomography myelography is invasive and therefore suboptimal for routine imaging in patients who can
undergo MRI. A computed tomography scan without
myelography is helpful to reveal fractures or dislocations
in great detail, as well as uncovertebral hypertrophy and
neuroforaminal stenosis (Fig. 13-3).

C6 or C7 versus carpal
tunnel syndrome

C7 versus posterior
interosseous nerve
compression
C8 versus anterior
interosseous nerve
compression

C8 versus ulnar
entrapment

Modified from Abbed KM. Coumans JV: Cervical radiculopathy: pathophysiology, presentation, and clinical evaluation. Neurosurgery 60(Suppl 1):S28-S34,
2007.

Magnetic Resonance Imaging

MRI is noninvasive and is the test of choice to evaluate
cervical spinal cord compression, tumors, syringomyelia, neuroforaminal stenosis, demyelinating disorders,
herniated nucleus pulposus, and myelomalacia. However, careful correlation of the history and examination
with imaging studies is necessary because asymptomatic
degenerative changes in the cervical spine are very common findings on advanced imaging, in particular MRI.

Adjunct Studies
Electrodiagnostic Studies
Electromyography and nerve conduction velocity studies
can supplement imaging data when history and physical
examination findings do not seem to correlate with the
imaging or when peripheral neuropathy is suspected.

Treatment Options
According to the North American Spine Society clinical
guideline, cervical radiculopathy is a disorder that can be
treated with conservative management a majority of the
time and will resolve. Conservative management options
include corticosteroids, nonsteroidal anti-inflammatory
drugs, muscle relaxants, cervical traction, cervical isometric exercises, cervical collars, and judicious use of narcotics.
The use of cervical injections may be an option in selected
patients. However, careful consideration of the associated
risks should be considered and discussed with the patient.

134SECTION 2 Degenerative Conditions

FIGURE 13-2 A and B, Oblique

radiographs showing neuroforaminal
stenosis.

B
history, pathogenesis, and differential diagnosis of the
disease. It also discusses specific examination findings
and the rationale for selecting imaging modalities related
to the diagnosis. Once a diagnosis is achieved, the discussion touches on treatment options; however, examination, imaging, and surgical treatment options are covered
in greater depth in other chapters of this text.
REFERENCES

FIGURE 13-3 Computed tomography myelogram depicting neuroforaminal stenosis.

Operative management is covered in depth in other

chapters but is usually reserved for patients who have
undergone a trial of conservative management that has
failed or who have progressively lost motor function or
have unbearable pain.13 The cervical spine can be treated
from anterior or posterior approaches, and treatment can
involve decompression or decompression and fusion.
Another available option is cervical disk arthroplasty.

Conclusion
Cervical radiculopathy is a disorder with a favorable natural history. This chapter reviews the epidemiology, natural

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