Cervical Radiculopathy
What is Cervical Radiculopathy?
Cervical radiculopathy is a medical term meaning compression or irritation of the nerve roots in the neck from one cause or another eg disc prolapse. Degeneration of the intervertebral disk is a universal, age-related process; therefore, radiculopathy (irritation of the radicle or nerve root) secondary to cervical (the “neck” part of the spine) spondylosis (“wear and tear”) is a relatively common phenomenon.
Classically, radiculopathy refers to the clinical features associated with nerve root dysfunction including sensory disturbances, motor weakness, and deep tendon reflex changes. Although radicular signs and symptoms typically occur along the course of the nerve in a dermatomal or myotomal distribution, anatomic variations in branching patterns within the brachial plexus can make the clinical localization of nerve root dysfunction difficult. A careful history and thorough physical examination are the most valuable clinical tools.
How is Cervical Radiculopathy diagnosed?
The classic signs and symptoms of radiculopathy include sensory disturbances such as pain, paresthesia or numbness, motor weakness, and deep tendon reflex changes. The most commonly affected nerve roots in the cervical spine are the C6 and C7 roots as the result of degeneration at the C5-C6 and C6-C7 disks, respectively. It is important to recognize that although radicular pain is technically limited to a specific dermatome, in reality, patients with cervical radiculopathy more frequently complain of a diffuse, poorly localized pain.
Advanced imaging such as magnetic resonance imaging (MRI) and electrophysiologic testing can also be useful in the diagnosis. The natural history of cervical radiculopathy is favorable with nonoperative management, although in refractory cases, surgical management can result in excellent clinical outcomes.
How is Cervical Radiculopathy treated?
Descriptions of the natural history of cervical spondylotic radiculopathy are rare. Resolution of symptoms may be attributed to resorption of the compressive lesion (e.g., disk herniation), atrophy or plastic deformation of the nerve root, and the diminishment of the biochemical factors that may mediate pain.
An often-quoted 1963 study of patients with cervical spondylosis from Lees and Turner found that approximately half of patients improve or remain unchanged, one quarter of patients improve, and a quarter of patients deteriorate.
The initial treatment of cervical spondylotic radiculopathy is most frequently non-operative.
Nonsteroidal anti-inflammatory drugs (NSAIDs) are generally the first line of medication treatment. The use of cyclooxygenase-2 (COX-2) inhibitors, such as celecoxib and rofecoxib, has increased substantially in recent years, although questions have recently been raised regarding the superiority of these agents compared to regular COX-1 inhibitors. Oral steroids may be useful because of their potent anti-inflammatory properties but because of their significant side effects, they should rarely be administered in a short, tapered dosing regimen.
Low-dose tricyclic antidepressants such as amitriptyline may be useful for alleviating neuropathic pain secondary to nerve root impingement and may also improve sleeping patterns. The use of gabapentin, an anticonvulsant, is also useful for controlling neuropathic pain. Pregabalin is a similar drug with a similar action to gabapentin. Narcotic analgesics are generally not recommended and, if deemed necessary, should be used on a limited and temporary basis.
Physical therapy modalities are often recommended for patients with cervical radiculopathy. A number of studies have demonstrated favorable outcomes in patients treated with an aggressive nonsurgical approach which included various exercise protocols, although it is difficult to establish exactly what exercises are optimal for this disorder. Stretching, strengthening, isometric, and progressive-resistance exercises are potentially useful and should be initiated by a therapist with the goals of getting the patients to do the appropriate exercises at home on a regular basis. Postural training and education about correct body mechanics may be helpful in restoring the patient to an acceptable level of functioning.
Epidural steroid injections are commonly used as diagnostic and therapeutic measures for patients with radicular symptoms. Numerous studies have supported their use as a potential means of producing a favorable nonoperative clinical outcome. Fluoroscopic guidance is necessary to determine accurate placement of the injection. Although this improves the localization and safety, the clinician must be aware of the potential hazards; cases of iatrogenic spinal cord injury caused by such injections have been reported.
Patients who have persistent radicular symptoms and fail conservative, non-operative treatment are candidates for surgical intervention. What constitutes an adequate course of non-operative care in terms of time and content has not been clearly established and likely varies from institution to institution. It has been suggested that patients persist with conservative therapies for at least 6 weeks.
Motor weakness, particularly of the deltoid or wrist extensors, can be extremely disabling and may warrant surgical intervention. Also, a neurologic deficit that is increasing may need to be addressed surgically. The main options for surgically managing cervical radiculopathy include anterior cervical diskectomy and fusion and posterior laminoforaminotomy, with or without diskectomy. A newer technique is to remove the disc in its entirety and insert a mobile disc replacement.
With the good outcomes reported for both anterior and posterior procedures for cervical radiculopathy, there is some controversy surrounding the optimal surgical approach. The advantages of anterior cervical diskectomy and fusion include the ability to decompress central and lateral disk herniations or osteophytes, enlarge the neural foramen, and stabilize the motion segment without directly manipulating the neural elements. The posterior approach avoids fusing the motion segment and provides direct decompression of the nerve root. The option of a disc replacement allows full decompression of neurological structures while still maintaining mobility.