Cervical Radiculopathy

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Radiculopathy occurs when nerve root compression at the neck or spine results in pain, tingling, and numbness, with or without loss of function in the area supplied by the affected nerve. Common causes of cervical radiculopathy are neural foramen narrowing, usually caused by cervical arthritis in older adults, and cervical disk lesion caused by disk degeneration or herniation. Disk degeneration results in loss of disk space, with closer approximation of the vertebrae on either side of the involved disk space and subsequent impingement on the neural foramen (Fig. 31-7). The decrease in size of the neural foramen results in nerve root compression. The C5-C6 and C6-C7 disk spaces are more often affected. Disk herniation also occurs more often in these disks (Fig. 31-8). Some of the gelatinous pulp protrudes through the annulus fibrosus at the weakest point, usually where the posterolateral longitudinal ligament crosses the disk. In a smaller disk herniation, mild local pain may be caused by pressure on the posterior ligament. A larger disk herniation may impinge on the nerve and may be posterolateral or central herniation with resultant radicular symptoms.

The patient has a history of pain radiating to the shoulder or down the upper extremity, which may be aggravated by coughing, sneezing, or straining; paresthesias of the fingers; and less often, weakness in the extremity. There may be a history of prior trauma. Cervical radiculopathy on examination may reveal tenderness on the neck, limitation in certain movements of the neck, focal neurologic findings such as sensory loss in the dermatome pattern corresponding to the distribution of the affected nerve root, and asymmetric tendon reflexes in the upper extremities (Fig. 31-9).

Degenerate disc

Osteophytes

Narrowed foramen

Osteophytes

Figure 31-7 Osteoarthritis of cervical spine. A, Initial degeneration and narrowing of intervertebral disk, with formation of osteophytes anteriorly. B, Later, posterior or facet joints are affected; articular cartilage is worn away, and marginal osteophytes may encroach on the intervertebral foramen. (Redrawn from Adam JC, Hamblen DL. Outline of Orthopedics, 13th ed. New York, Churchill Livingstone, 2001, p 159; and Anderson BC. Office Orthopedics for Primary Care: Diagnosis and Treatment, 2nd ed. Philadelphia, Saunders, 1999, p 266.)

Degenerate disc

Osteophytes

Narrowed foramen

Osteophytes

Spinal cord

Nerve

Disc

Nerve

Disc

Figure 31-8 Prolapsed cervical disk. A, Posterolateral prolapse, with compression of the issuing nerve. B, Much less common central prolapse, with impingement on the spinal cord. (Redrawn from Adam JC, Hamblen DL. Outline of Orthopedics, 13th ed. New York, Churchill Livingstone, 2001, p 163.)

Figure 31-8 Prolapsed cervical disk. A, Posterolateral prolapse, with compression of the issuing nerve. B, Much less common central prolapse, with impingement on the spinal cord. (Redrawn from Adam JC, Hamblen DL. Outline of Orthopedics, 13th ed. New York, Churchill Livingstone, 2001, p 163.)

Figure 31-9 Volar and dorsal dermatome patterns of the forearm and hand. Pain and paresthesias may radiate into these areas when the affected nerve root is compressed. Note that extremity symptoms as a result of disk disease are almost always unilateral. (Redrawn from Mercier R. Practical Orthopedics, 5th ed. St Louis, Mosby 2000, p 29.)

Figure 31-9 Volar and dorsal dermatome patterns of the forearm and hand. Pain and paresthesias may radiate into these areas when the affected nerve root is compressed. Note that extremity symptoms as a result of disk disease are almost always unilateral. (Redrawn from Mercier R. Practical Orthopedics, 5th ed. St Louis, Mosby 2000, p 29.)

General examination should include the lower extremities and gait. Axial compression testing may reproduce the pain.

Diagnostic tests include radiographs of the cervical spine, which may appear normal or may show loss of normal cervical lordosis, narrowing of the disk space, and bone spurs with foramen encroachment. If the patient has neurologic symptoms, MRI identifies soft tissue structures and may show displacement of the disk. CT may also be performed.

Treatment relieves pressure on the affected nerve and is mainly conservative, including rest, pain relief, stress reduction, and short-term muscle relaxants. Patients with persistent symptoms may need structured physical therapy and referral for specialist evaluation. Neurologic signs and symptoms and loss of strength are also indications for referral to neurosurgery. A few patients require surgical intervention.

KEY TREATMENT

Whiplash is usually managed conservatively (Binder, 2007) (SOR: C). Uncomplicated pain in cervical strains and sprains is managed conservatively (Binder, 2007) (SOR: C).

Range of motion exercises may be beneficial for uncomplicated cervical strain or sprain (Cochrane Review, 2005) (SOR: A). Treatment of cervical radiculopathy is usually conservative (Binder, 2007) (SOR: C).

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