What Is Cervical Radiculopathy?
Cervical radiculopathy is characterized by pain, numbness, tingling, and/or weakness that occurs in the distribution of one of the nerves in the cervical spine (neck). This typically causes pain that radiates into the shoulder blade and pain that travels down the arm on one side. Rarely, a “high cervical radiculopathy” can cause radiating one-sided headaches behind the ear or behind the eye if one of the upper cervical nerves are involved.
The cervical spine begins at the base of the skull and is made up of the first 7 vertebrae of the neck and comprises of 8 pairs of cervical nerves. The cervical nerve roots are large nerves that branch from the cervical region of the spinal cord and leave the spinal column to travel into the arms, shoulders, upper back and hands. The cervical nerves control upper body motor and sensory activities. Therefore, cervical radiculopathy can affect hand movements and coordination or cause numbness or decreased sensation. Cervical radiculopathy occurs when a nerve in the neck (cervical region) is irritated or pinched while it leaves the spinal canal.
Nerve root compression may occur at 3 locations:
- Neuroforamen- natural passageways on either side of the
- Right or left of the neck and upper extremity
- Central canal (area surrounding the spinal cord)
Cervical Radiculopathy Causes
Cervical radiculopathy is caused most commonly by either a herniated disk in the neck or degenerative disc disease and aging-related changes of the spine (uncovertebral joint hypertrophy). Both of these conditions can cause narrowing of the nerve channels (foraminal stenosis) and result in inflammation of the nerves themselves which results in the characteristic pain behind the shoulder blade and traveling down the arm.
Cervical Radiculopathy Symptoms
Cervical radiculopathy symptoms can include pain, numbness, tingling, and/or weakness. This can be exacerbated by moving the head or neck into certain positions. Regardless of the level involved, pain behind the shoulder blade is common. The distribution of pain in cervical radiculopathy is otherwise dependent on the precise level involved:
C2-3: radiates behind the ear
C3-4: trapezius muscle and to the collarbone
C4-5: shoulder, deltoid region.
C5-6: side and front of the upper arm, and then into the thumb side of the forearm and into the thumb and index finger
C6-7: back of the upper arm, across the side of the elbow, into the top of the forearm, and into the top of the hand and middle finger
C7-T1: inside part of the upper arm and the pinky side of the forearm, into the ring and small fingers
The most common levels affected at C5-6 and C6-7. Symptoms involving C2-3 and C7-T1 are relatively rare. Numbness and tingling is also often present in the same distribution as the pain. Weakness can also occur and is usually subtle but sometimes can be profound. Patients with C5-6 level symptoms can have trouble lifting objects due to biceps weakness. Patients with C6-7 level symptoms can have difficulty pushing objects away or doing a push-up due to triceps weakness.
Cervical Radiculopathy Diagnosis
Cervical radiculopathy diagnosis begins with a proper history and physical exam. The description of pain traveling down an arm and into the shoulder blade, and exacerbated by movement of the neck is classic for the diagnosis of cervical radiculopathy. Physical exam can show exacerbation of pain with Spurling’s maneuver (tilting the head to the same side and extending the neck). The physical exam is also important to test for weakness and numbness as this can indicate the severity and urgency needed for cervical radiculopathy treatment. It is important to rule out a primary shoulder problem (such as shoulder bursitis or a rotator cuff tear). If shoulder range of motion reproduces the arm pain then the problem is likely in the shoulder and not in the cervical spine (neck). Other conditions such as carpal tunnel syndrome or cubital tunnel syndrome can also cause numbness and tingling into the hands and should be excluded.
X-rays of the cervical spine are also typically obtained for cervical radiculopathy diagnosis. This can show degenerative changes, disc collapse, and spine arthritis growing into the nerve channels causing narrowing of the space available for the nerves. X-rays are an important test as they are obtained in the upright position, showing the effect of gravity on the structure of the spine.
If symptoms have been present for more than 4-6 weeks or are associated with significant weakness or numbness, then an MRI of the cervical spine is typically obtained to directly visualize the nerves and spinal cord. An EMG / nerve conduction study is sometimes helpful to exclude other conditions such as carpal tunnel syndrome or cubital tunnel syndrome.
Cervical Radiculopathy Treatment
The treatment of cervical radiculopathy begins with initial conservative management consisting of:
Anti-inflammatory medications (NSAIDS)
Cervical radiculopathy physical therapy
Cervical traction (inflatable cervical traction or over the door cervical traction)
Regular low-impact aerobic exercise (brisk walking, stationary bike, elliptical machine, etc)
Most patients with cervical radiculopathy symptoms will get resolution of their symptoms within 6-12 weeks using the modalities listed above. If symptoms are persistent, then a image guided epidural injection in the cervical spine can often be helpful to alleviate symptoms. These injections are performed by physiatrists (non-operative spine physicians) or anesthesiologists trained in pain management and interventional spine techniques. They can be performed in two different ways (intralaminar or transforaminal), each with their own risks and benefits.
If symptoms are persistent more than 6-12 weeks, or are associated with significant weakness or dense, constant numbness, then cervical radiculopathy surgery is recommended. The most common surgical procedures used to treat cervical radiculopathy are anterior cervical discectomy and fusion, cervical disc replacement, or a posterior cervical foraminotomy. The best procedure for any given patient may be different based on their particular problem and anatomy, and is selected after a thorough discussion of the risks and benefits.
There are several surgical procedures for cervical radiculopathy, which involves removing parts of bone or soft tissue causing the compression. The aim of the surgery is to decompress nerves and relieve the pressure. Surgical techniques that may be used include:
Anterior cervical discectomy and fusion : A surgical procedure where the disc and bone compressing the nerves is removed from the spinal level involved and the two vertebrae are fused together with bone graft and instrumentation.
Anterior cervical disc replacement : A surgical procedure performed in younger patients, typically with radiculopathy from a soft disc herniation, where the disc pressing on the nerves is removed and in its place a replacement disc prosthesis is implanted
Posterior foraminotomy : A surgical procedure for widening the neuroforamen, to relieve the pressure over the compressed nerves.
All of these operations can be performed minimally invasively with minimal soft tissue disruption.
Your surgeon will discuss surgical options and the associated risks and benefits as well as recommend the most appropriate procedure for you.