Cervical Radiculopathy

Author: Derek Moore

Topic updated on 03/29/14 3:12pm

Introduction
A clinical symptom caused by nerve root compression in the cervical
spine
o characterized by sensory or motor symptoms in the upper
extremity
Pathophysiology
o causes
degenerative cervical spondylosis
discosteophyte complex and loss of disc height
chondrosseous spurs of facet and uncovertebral
joints
disc herniation ("soft disc")
usually posterolateral
between posterior edge of uncinate and
lateral edge of PLL
o neural compression
nerve root irritation caused by
direct compression
irritation by chemical pain mediators including
IL-1
IL-6
substance P
bradykinin
TNF alpha
prostaglandins
affects the nerve root below
C6/7 disease will affect the C7 nerve root

Anatomy

Nerve root anatomy

o key differences between cervical and lumbar spine is
pedicle/nerve root mismatch
cervical spine C6 nerve root travels above C6 pedicle
(mismatch)
lumbar spine L5 nerve root travels under L5 pedicle
(match)
extra C8 nerve root (no C8 pedicle) allows transition
horizontal (cervical) vs. vertical (lumbar) anatomy of nerve
root
because of vertical anatomy of lumbar nerve root a

paracentral and foraminal disc will affect different nerve

roots
because of horizontal anatomy of cervical nerve root a
central and foraminal disc will affect the same nerve
root

Symptoms
Symptoms
o occipital headache (common)
o trapezial or interscapular pain
o neck pain
may present with insidious onset of neck pain that is
worse with vertebral motion
origin may be discogenic or mechanical due to facet
arthrosis
pain may radiate to shoulders
o unilateral arm pain
aching pain radiating down arm
often global and nondermatomal
o unilateral dermatomal numbness & tingling
numbness/tingling in thumb (C6)
numbness/tingling in middle finger (C7)
o unilateral weakness
difficulty with overhead activities (C7)
difficulty with grip strength (C7)
Physical exam
o common and testable exam findings
C5 radiculopathy
deltoid and biceps weakness
diminished biceps reflex
C6 radiculopathy
brachioradialis and wrist extension weakness
diminished brachioradialis reflex
paresthesias in thumb
C7 radiculopathy
triceps and wrist flexion weakness
diminished triceps reflex
paresthesia in the index,middle, ring
C8 radiculopathy
weakness to distal phalanx flexion of middle and
index finger (difficulty with fine motor function)
paresthesias in little finger
o provocative tests

Spurling Test positive

simultaneous extension, rotation to affected side,

lateral bend, and vertical compression reproduces
symptoms in ipsilateral arm

shoulder abduction test

shoulder abduction relieves symptoms
shoulder abduction (lifting arm above head)
often relieves symptoms
valuable physical exam test to differentiate
cervical pathology for other causes of
shoulder/arm pain
myelopathy
check for findings of myelopathy in large central disc
herniations

Imaging
Radiographs
o recommended views
AP, lateral, oblique views of cervical spine
obtain flexion and extension views if suspicion for
instability
o findings
general
degenerative changes of uncovertebral and facet
joints
osteophyte formation
disc space narrowing & endplate sclerosis
lateral radiograph
important to look for sagittal alignment and spinal
canal diameter
oblique radiograph
best view to identitfy foraminal stenosis caused by
osteophytes
flexion and extension views
important to look for angular or translational
instability
look for compensatory subluxation above or below
the spondylotic/stiff segment
o sensitivity & specificity
changes often do not correlate with symptoms
70% of patients by 70 yrs of age will have
degenerative changes seen on plain xrays
MRI
o views
T2 axial imaging is the modality of choice and gives

needed information on the status of the soft tissues.

findings
disc degeneration and herniation
foraminal stenosis with nerve root compression (loss of
perineural fat)
central compression with CSF effacement
sensitivity & specificity
has high rate of false positive (28% greater than 40 will
have findings of HNP or foraminal stenosis)

CT
indications
gives useful information on bony anatomy including
osteophyte formation that is compression the neural
elements
useful as a preoperative planning tool to plan
instrumentation
study of choice to evaluate for postoperative
pseudoarthosis
CT myelography
o indications
largely replaced by MRI
useful in patients who can not have an MRI due to
pacemaker etc
useful in patients with prior surgery and hardware
causing artifact on MRI
o technique
intrathecal injection of contrast given via C1-C2 puncture
and allowed to diffuse caudally
lumbar puncture and allowed to diffuse proximally by
putting patient in trendelenburg position.
Discography
o indications
controversial and rarely indicated in cervical spondylosis
o techniques
approach is similar to that used with ACDF
o risks include esophageal puncture and disc infection
o

Studies

Nerve conduction studies

o high false negative rate
o may be useful to distinguish peripheral from central process (ALS)
Selective nerve root corticosteroid injections
o may help confirm level of radiculopathy in patients with multiple
level disease and physical exam findings and EMG fail to localize

level

Differential
Carpal tunnel syndrome
Cubital tunnel syndrome
Parsonage-Turner Syndrome
Treatment
Nonoperative
o rest, medications, and rehabilitation
indications
75% of patients with radiculopathy improve with
nonoperative management
improvement via resorbption of soft discs and
decreased inflammation around irritated nerve
roots
techniques (very few substantiated by evidence)
immobilization
immobilization for short period of time (< 1-2
weeks) may help by decreasing inflamation
and muscles spasm
medications
NSAIDS / COX-2 inhibitors
oral corticosteroids
GABA inhibitors (neurontin)
narcotics
muscle relaxants
rehabilitation
moist heat
cervical isometric exercises
traction/manipulation
avoid in myelopathic patients
o selective nerve root corticosteroid injections
indicaitons
may be considered as therapeutic or diagnostic
option
outcomes
increased risk when compared to lumbar selective
nerve root injections with the following rare but
possible complications including
dural puncture
meningitis
epidural abscess

nerve root injury

Operative
o anterior cervical discectomy and fusion
indications
persistent and disabling pain that has failed
nonoperative modalities
progressive and significant neurologic deficits
outcomes
remains gold standard in surgical treatment of
cervical radiculopathy
single level ACDF is not a contraindication for
return to play for athletes
o

posterior foraminotomy
indications
foraminal soft disc herniation causing single level
radiculopathy ideal
may be used in osteophytic foraminal narrowing
outcomes
91% success rate
reduces the risk of itrogenic injury with anterior
approaches

cervical total disc replacement

indications (controversial)
single level disease with minimal arthrosis of the
facets
outcomes
studies show equivalence to ACDF
effect on adjacent level disease remains unclear
some studies show 3% per year for all
approaches

Techniques
Anterior Cervical Discectomy and Fusion (ACDF)
o approach
uses Smith-Robinson anterior approach
o techniques
decompression
placement of bone graft increases disk height and
decompresses the neural foramen through indirect
decompression
corpectomy and strut graft may be required for
multilevel spondylosis
fixation

anterior plating functions to increase fusion rates

and preserve position of interbody cage or strut
graft
o pros and cons
complications of anterior surgery including persistent
swallowng problems
Posterior foraminotomy
o approach
posterior approach
o technique
if anterior disc herniation is to be removed then superior
portion of inferior pedicle should be removed
o pros & cons
advantages
avoids need for fusion
avoids problems associated with anterior
procedure
disadvantages
more difficult to remove discosteophyte complex
disc height can not be restored
Total disc replacement
o approach
uses Smith-Robinson anterior approach
o pros & cons
avoids nonunions

Complications

Pseudoarthrosis
o incidence
5 to 10% for single level fusions, 30% for multilevel fusions
risk factors
smoking
diabetes
multi-level fusions
o treatment
if asymptomatic observe
if symptomatic treat with either posterior cervical
fusion or repeat anterior decompression and plating if patient
has symptoms of radiculopathy
improved fusion rates seen with posterior fusion
Recurrent laryngeal nerve injury (1%)
o laryngeal nerve follows aberrant pathway on the right
although theoretically the nerve is at greater risk of injury with

a right sided approach, there is no evidence to support a greater

incidence of nerve injury with a right sided approach.
treatment
initial treatment is observation
if not improved over 6 weeks than ENT consult to scope
patient and inject teflon

Hypoglossal nerve injury

o a recognized complication after surgery in the upper cervical spine
with an anterior approach
o tongue will deviate to side of injury
Vascular injury
o vertebral artery injury (can be fatal)
Dysphagia
o higher risk at higher levels (C3-4)
Horner's syndrome
o characterized by ptosis, anhydrosis, miosis, enophthalmos and loss of
ciliospinal reflex on the affected side of the face
o caused by injury to sympathetic chain, which sits on the lateral border
of the logus colli muscle at C6
Adjacent segment disease