Cervical radiculopathy

In one minute

Cervical radiculopathy is the medical name for a pinched nerve in the neck: pain, tingling, numbness or weakness in the territory of one nerve root, caused by pressure or irritation where the root leaves the spine. In the Rochester, Minnesota population study the annual incidence was 83.2 per 100,000 people and peaked at ages 50 to 54. It feels like an ache in the neck with a sharp pain down one arm into particular fingers. The diagnosis is clinical, confirmed by MRI (magnetic resonance imaging) when the result would change treatment. Most cases settle over weeks to months. For those that do not, or where a muscle is weakening, the root is freed through a 7 mm endoscopic foraminotomy or, for central compression, from the front of the neck.

What it is

The NASS (North American Spine Society) guideline defines cervical radiculopathy from degenerative disorders as pain in a radicular pattern in one or both arms, related to compression or irritation of one or more cervical nerve roots, with varying sensory, motor and reflex change, and without evidence of spinal cord dysfunction. If the cord is involved, the condition is cervical myelopathy, which has its own page.

There are eight cervical roots, C1 to C8. Each leaves the canal through a side opening, the foramen, bounded by the disc in front and the facet joint behind. Two things narrow it: a soft disc herniation, and bony overgrowth from spondylosis (age-related wear). In the Rochester series a confirmed disc protrusion accounted for 21.9% of cases and spondylosis, a disc, or both for 68.4%; the C7 root was affected most often, then C6. Other names for the same thing: a pinched nerve, radiculitis, or, in Russian-language reports, cervical osteochondrosis with a radicular syndrome.

Causes and risk factors

Wear of the disc and the small joints is the main cause, and it accumulates with age; the peak in the sixth decade reflects that. Injury is a smaller part of the story than people expect. In the Rochester study only 14.8% of patients recalled exertion or trauma before their symptoms began, while 41% had had a lumbar nerve-root episode earlier in life, which suggests that some people's discs and joints simply wear faster. There are no reliable figures for occupation, smoking or heredity specific to the neck, and we do not quote numbers we cannot source.

How it develops

The root sits in a channel with little spare room. When disc material or a bone spur takes some of it, the root is squeezed and its blood supply disturbed; inflammatory chemicals from a torn disc add irritation. The result is pain and tingling in the strip of skin the root serves, weakness in the muscles it drives, and a dull reflex at the joint it controls. With time the fragment is often broken down and the inflammation settles; in a systematic review of the course, substantial improvement tended to occur within the first 4 to 6 months.

Symptoms

The NASS guideline lists the common findings: arm pain, neck pain, pain around the shoulder blade, tingling, numbness, weakness and abnormal reflexes in the arm. Which finger tingles points to the root. C6 sends pain to the thumb and index finger and weakens the biceps and wrist extension; C7 goes to the middle finger and weakens the triceps; C8 goes to the ring and little fingers and weakens the hand. The pain is typically worse with the head tilted back or turned toward the painful side, and better with the hand resting on top of the head. Three neighbours are easy to confuse with it. Shoulder problems hurt with shoulder movement and do not tingle. Carpal tunnel syndrome tingles in the thumb, index and middle fingers, often at night, without neck pain. Myelopathy affects both hands, makes walking unsteady, and can be painless.

Diagnosis

The examination is the diagnosis: the pattern of pain and tingling, the strength of each muscle group, the reflexes, and provocative tests such as the Spurling test, which the guideline says may be considered. Because the level cannot be pinned by arm pain alone, the guideline suggests MRI, CT (computed tomography) or CT myelography before any decompression. MRI is suggested to confirm the lesion in patients who have not improved with conservative care and may be candidates for an injection or an operation; CT myelography when the MRI does not match the symptoms or is contraindicated. EMG (electromyography) received an insufficient-evidence grade. When the MRI shows compression at more than one level, a selective nerve root block (a small injection at one root to see whether the pain stops) may be considered to identify the level that matters. Findings on MRI are common in people with no symptoms; the figures are on the cervical disc herniation page. A report that says foraminal stenosis at C5-C6 is only meaningful when your examination says C6. When you send a scan, photograph the side-view T2 images, the cross-sections at the level in the report, and the report itself, and tell us which fingers tingle and whether anything is weak.

Treatment without surgery

The NASS guideline's literature search found no studies adequate to define what drugs, physiotherapy, exercise or manipulation do for this condition, and its work group agreed by consensus that for most patients the symptoms are self-limited and resolve over a variable length of time without specific treatment. That is the baseline everything else is measured against.

Early care has been tested in a Dutch randomised trial. Among 205 patients with symptoms for less than one month, arm pain in the wait-and-see group fell by 19 mm on a 100 mm scale over six weeks on its own. A semi-hard collar with rest for three to six weeks, or twelve sessions of physiotherapy with home exercises over six weeks, produced an extra 12 mm of relief at six weeks. The first weeks can be made easier; by six months the groups were no different, so neither measure changes where you end up.

Medication means short courses of anti-inflammatory or neuropathic pain drugs, chosen and dosed by the doctor. For severe arm pain, the guideline says a transforaminal epidural steroid injection under X-ray or CT guidance may be considered, with due consideration of its complications; its review of small uncontrolled series found relief in around 60% of patients, and short-term relief that removed the need for surgery in about 25% of those referred with surgical indications. The guideline's search also found case reports of serious harm after neck manipulation, including disc herniation, myelopathy and vertebral artery compression, a reason to avoid thrust manipulation of a neck with a compressed root. How often is this enough? In the Rochester cohort 26% had surgery over a median of 4.9 years and 90% were symptom-free or only mildly limited at last follow-up.

When surgery is considered

Surgery is discussed when radicular pain persists after 6 to 12 weeks of proper conservative care (the window commonly used in spine practice; the NASS guideline does not fix a number of weeks) and the MRI lesion matches the examination; sooner when a muscle is weakening or the cord is involved; and occasionally for pain that is intractable despite everything. The evidence on timing is consistent. The NASS guideline suggests surgery for rapid relief when compared with medical and interventional treatment, a Grade B recommendation. The Cochrane review, from a trial of 81 patients, found surgical decompression superior to physiotherapy or a collar in the short term for pain, weakness and sensory loss, with no significant differences at one year, and rated the evidence low quality. Surgery buys time, not a different destination, for pain alone. Weakness that is getting worse is the reason not to wait. In the systematic review of prognosis, patients with a workers' compensation claim did worse whatever the treatment.

Surgical options

Endoscopic cervical foraminotomy

A posterior approach through a 7 mm incision that removes bone and disc fragment from the foramen and leaves the disc and the movement of the segment intact: the right tool for a one-sided compression in or near the foramen, from a soft herniation or a spur. A meta-analysis of 26 studies pooled a clinical success rate of 93.6% for the full-endoscopic technique, a complication rate of 6.1%, most often a transient nerve root palsy (a temporary weakness), and a reoperation rate of 4.8%. The same decompression can be done under a microscope through a larger opening: in the FACET trial across nine Dutch hospitals, 265 patients with single-level radiculopathy were randomised between posterior foraminotomy and ACDF (anterior cervical discectomy and fusion), and posterior surgery was noninferior at one year, with success in 88% versus 76%. See endoscopic cervical foraminotomy.

ACDF

Anterior cervical discectomy and fusion removes the disc from the front and fuses the two vertebrae with a cage. It is the choice for central compression, for several levels, for an unstable segment or when the cord is involved. The NASS guideline grades ACDF and posterior foraminotomy as comparable for a single-level foraminal soft disc herniation, suggests ACDF rather than foraminotomy for central and paracentral compression and spondylotic disease, and finds single-level outcomes similar with or without a plate.

Cervical disc replacement

An artificial disc is placed instead of a fusion after the anterior discectomy. The guideline grades cervical disc replacement as comparable with ACDF for single-level radiculopathy in the short term; it suits a mobile segment without advanced joint wear.

How we treat it at spine.uz

We are Tashkent's first endoscopic spine team: five surgeons operating as one team, trained in South Korea, Japan, Germany and the USA, with 27,600+ endoscopic and spine operations between us. The first step costs nothing. Send your MRI and a description of the arm pain on Telegram or WhatsApp, and a doctor from the team replies by voice within 48 hours. The in-person consultation and any operation are paid.

The team performs the posterior endoscopic foraminotomy through a 7 mm incision, with no screws or implants, as well as ACDF, cervical disc replacement and multilevel cervical operations; which one fits follows the logic set out under surgical options. Most of our endoscopic decompressions are done under local anaesthesia with sedation, the anaesthetist and surgeon deciding per patient. Most patients walk on the day of surgery and go home within 24 hours. Across the team's operations our complication rate is well below 1%. Every patient leaves with a written team conclusion.

Recovery and outcomes

After a foraminotomy, radicular pain usually eases within days; numbness and weakness recover more slowly, over weeks to months, and a root that was badly squeezed for a long time may not recover fully. In the FACET trial at two years, the predicted proportion with a successful outcome was 81% after posterior foraminotomy and 74% after ACDF. Serious surgery-related adverse events occurred in 9 patients (8%) after posterior surgery, including 9 reoperations, and in 11 patients (9%) after ACDF, including 7 reoperations. Return to desk work is often possible within a few weeks of an endoscopic foraminotomy and to physical work later, and a fusion adds time for the bone to knit; the timing depends on the job and is agreed with the surgeon. Without surgery, substantial improvement is usual by 4 to 6 months and about 83% recover completely by 24 to 36 months. Recurrence happens: 31.7% in the Rochester cohort over a median of 4.9 years, in a population in which about a quarter had surgery.

Living with it and prevention

Keep the neck and shoulder-blade muscles working; the exercise evidence is summarised on the cervical spondylosis page. Change position often at a screen, and treat a new episode early and calmly rather than with weeks of bed rest. A collar, if used, is for a few weeks at most, not months.