AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

Background

Cervical radiculopathy is a dysfunction of a nerve root of the cervical spine. The seventh (C7; 60%) and sixth (C6; 25%) cervical nerve roots are the most commonly affected.^{1, 2, 3, 4, 5, 6, 7}

In the younger population, cervical radiculopathy is a result of a disc herniation or an acute injury causing foraminal impingement of an exiting nerve.⁸ Disc herniation accounts for 20-25% of the cases of cervical radiculopathy. In the older patient, cervical radiculopathy is often a result of foraminal narrowing from osteophyte formation, decreased disc height, degenerative changes of the uncovertebral joints anteriorly and of the facet joints posteriorly.

Factors associated with increased risk include heavy manual labor requiring the lifting of more than 25 pounds, smoking, and driving or operating vibrating equipment. Other, less frequent causes include tumors of the spine, an expanding cervical synovial cyst, synovial chondromatosis in the cervical facet joint, giant cell arteritis of the cervical radicular vessels, and spinal infections.^{9, 10} The purpose of this article is to provide information on the presentation, evaluation, differential diagnosis, and treatment of cervical radiculopathy.

For excellent patient education resources, visit eMedicine's Back, Ribs, Neck, and Head Center. Also, see eMedicine's patient education articles Shoulder and Neck Pain and Neck Strain.

Frequency

United States

Cervical radiculopathy occurs with much less frequency than radiculopathy of the lumbar spine. The annual incidence rate is approximately 85 per 100,000.

Functional Anatomy

Seven cervical vertebrae and 8 cervical nerve roots exist. The C1-2 (atlantoaxial) joint forms the upper cervical segment.^{1, 3, 11, 12} This joint allows for 50% of all cervical rotation motion. The occipitoatlantal joint is responsible for 50% of flexion and extension. Below the C2-C3 level, lateral bending of the cervical spine is coupled with rotation in the same direction. This is due to the 45° inclination of the cervical facet joints.

The vertebral bodies of C3-C7 are similar in appearance and function. They articulate via the zygapophyseal or facet joints posteriorly. On the lateral aspect of the vertebral bodies are sharply defined margins, which articulate with the facet above. These articulations are called uncovertebral joints, or the joints of Luschka. These joints can develop osteophytic spurs, which can narrow the intervertebral foramina.

Intervertebral discs are located between the vertebral bodies of C2-C7. The discs are composed of an outer annular fibrosis and an inner nucleus pulposus and serve as force dissipators, transmitting compressive loads throughout a range of motion (ROM). The intervertebral discs are thicker anteriorly and therefore contribute to normal cervical lordosis. The foramina are largest at C2-C3 and progressively decrease in size to the C6-C7 level.

The nerve root occupies 25-33% of the foraminal space. The neural foramen is bordered anteromedially by the uncovertebral joints, posterolaterally by facet joints, superiorly by the pedicle of the vertebra above, and inferiorly by the pedicle of the lower vertebra. Medially, the foramina are formed by the edge of the end plates and the intervertebral discs. The nerve roots exit above their correspondingly numbered vertebral body from C2-C7. C1 exits between the occiput and atlas, and C8 exits below the C7 vertebral body. Degenerative changes of the structures that form the foramina can cause nerve root compression. This compression can occur from osteophyte formation, disc herniation, or a combination of the 2.

Related eMedicine topics:
Herniated Nucleus Pulposus
Nerve Entrapment Syndromes

Related Medscape topic:
Resource Center Spinal Disorders

Sport-Specific Biomechanics

Cervical radiculopathy in athletes can occur from several mechanisms. These injuries can occur from an extension, lateral bending, or rotation mechanism, which closes the neural foramen and results in ipsilateral nerve root injury. Conversely, a traction injury can occur with a sudden flexion or extension, coupled with lateral bending away from the affected nerve root.

Additionally, cervical disc herniations can occur with a sudden load with the neck in either flexion or extension. In elderly persons with osteophyte formation, repetitive neck extension and rotation in certain sports, such as swimming or tennis, may result in a more insidious injury.

Related eMedicine topics:
Cervical Discogenic Pain Syndrome
Cervical Facet Syndrome
Spinal Cord Trauma and Related Diseases
Torticollis

Related Medscape topics:
Resource Center Spinal Disorders
Resource Center Trauma

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

History

Obtaining a detailed history is important to establish a diagnosis of cervical radiculopathy.

• The examiner should first determine the main complaint (eg, pain, numbness, weakness, location of symptoms).
• • A visual analog scale from 0-10 can be used to determine the patient's perceived level of pain.
• • Anatomic pain drawings can also be helpful in giving the physician a quick review of the patient's pain pattern.
• Activities and head positions that increase or decrease symptoms are also helpful in making the diagnosis, as well as in guiding treatment.
• When did the injury occur, what was the mechanism of injury, and what was done are all important inquiries for the patient. Previous episodes of similar symptoms or localized neck pain are important for the diagnosis and ultimate treatment.
• Symptoms suggestive of a cervical myelopathy, such as changes in gait, bowel or bladder dysfunction, or lower-extremity sensory changes or weakness should also be obtained.
• The examiner should ask what previous treatments have been tried, including the use of ice and/or heat and medications (eg, acetaminophen, aspirin, nonsteroidal anti-inflammatory drugs [NSAIDs]).
• Questions regarding previous medical treatment should include physical therapy, traction, manipulation, previous injections, or surgical treatments. A social history should include the patient's sport and position, occupation, and the use of nicotine and/or alcohol.
• The typical patient with cervical radiculopathy presents with an insidious onset of neck and arm discomfort. The discomfort can range from a dull ache to a severe burning pain. Typically, pain is referred to the medial border of the scapula, and the patient's chief complaint is shoulder pain. As the radiculopathy progresses, the pain radiates to the upper or lower arm and into the hand, along the sensory distribution of the nerve root that is involved.
• The older patient may have had previous episodes of neck pain or give a history of having arthritis of the cervical spine.
• Acute disc herniations and sudden narrowing of the neural foramen may also occur in injuries involving cervical extension, lateral bending, or rotation and axial loading. These patients complain of increased pain with neck positions that cause foraminal narrowing (eg, extension, lateral bending, or rotating toward the symptomatic side).
• Many patients report a reduction in their radicular symptoms by abducting their shoulder and placing their hand behind their head. This relief in symptoms is thought to occur by decreasing tension at the nerve root.
• Patients may complain of sensory changes along the involved nerve root dermatome, which can include tingling, numbness, or loss of sensation.
• Some patients may complain of motor weakness. A small percentage of patients will present only with weakness, without significant pain or sensory complaints.

Physical

• Observation
• • The physical examination begins with observation of the patient during the history portion of the evaluation. This includes head and neck posture and movement during normal conversation. Typically, the patient exhibits a head tilt away from the side of injury and holds his or her neck stiffly.
  • Active ROM is usually reduced, particularly in extension, rotation, and lateral bending, either toward or away from the affected nerve root.
  • Increased pain with lateral bending away from the affected side can cause increased displacement of a disc herniation upon a nerve root, whereas ipsilateral pain would suggest an impingement of a nerve root at the site of the neural foramen. 
• Palpation
• • On palpation, tenderness is usually noted along the cervical paraspinal muscles, and it is usually more pronounced along the ipsilateral side of the affected nerve root.
  • Muscle tenderness may be present along the muscles where the symptoms are referred (eg, medial scapula, proximal arm, lateral epicondyle).
  • Associated hypertonicity or spasm on palpation in these painful muscles may occur.
  • Letchuman et al showed that cervical radiculopathy is associated with increased tender spots (both trigger and tender points) on the side of the radiculopathy, with a predilection toward the muscles innervated by the involved nerve root.¹³ This study revealed that not only pain, but also tenderness may be referred in radiculopathy.
• Motor
• • Manual muscle testing is an important aspect of determining an affected nerve root level on physical examination. Perform manual muscle testing to detect subtle weakness in a myotomal distribution.
  • Place the limb of the affected side in the antigravity position; the force is applied just proximal to the next distal joint. For example, the extensor carpi ulnaris muscle should be tested with the forearm in full pronation and resting on a table or supported and then resisted against the dorsum of the fifth metacarpal bone in the direction of flexion toward the radial side. Muscle strength is then graded on a scale of 0 to 5 as follows:
  • • 0 – No muscle contraction
    • 1 – Muscle contracts but is not able to move the joint/limb
    • 2 – Muscle is able to move the joint/limb, but not against gravity
    • 3 – Muscle is able to move the joint/limb against gravity, but not through a full ROM
    • 4 – Muscle is able to move the joint/limb through a full ROM, but the strength against resistance is not equal to the opposite limb (if normal)
    • 5 – Muscle strength is normal (equal to the opposite, normal limb)
  • Radiculopathies by nerve level
  • • C5 radiculopathy: shoulder abduction weakness
    • • Test: Have the patients hold their shoulders in abduction, against downward force by the examiner. 
    • C6 radiculopathy: elbow flexion, wrist extension weakness
    • • Test: Have the patients lift their arm against resistance by the examiner.
    • C7 radiculopathy: elbow extension, wrist flexion weakness
    • • Test: Have the patients push with their arm away from their chest against resistance by the examiner.
    • C8:  thumb extension, wrist ulnar deviation weakness
    • • Test: Have the patients hold their extended fingers together against the examiner's attempts to open the fingers.
• Sensory
• • On sensory examination, a dermatomal decrease or loss of sensation should be noted in patients with clear-cut radiculopathy.
  • In addition, patients with radiculopathy may have hyperesthesia to light touch and pin-prick examination. However, the sensory examination can be quite subjective because it requires a response by the patient.
• Deep tendon reflexes
• • The deep tendon reflexes—or, more properly, muscle stretch reflexes because the reflex occurs after a muscle stretch is obtained (most commonly by tapping the distal tendon of a muscle)—are helpful in the evaluation of patients who present with limb symptoms that are suggestive of a radiculopathy. The examiner must position the limb properly when obtaining these reflexes, and the patient needs to be as relaxed as possible. Any grade of reflex can be normal, so it is the asymmetry of the reflexes which is most helpful.
  • The biceps brachii reflex is obtained by tapping the distal tendon in the antecubital fossa. This reflex occurs at the C5-C6 level.
  • The brachioradialis reflex is another C5-C6 reflex that can be obtained by tapping the radial aspect of the wrist.
  • The triceps reflex can be obtained by tapping the distal tendon at the posterior aspect of the elbow, with the elbow relaxed at about 90° of flexion. This tests the C7-C8 nerve roots.
  • The pronator reflex can be helpful in differentiating C6 and C7 nerve root problems. If this reflex is abnormal in conjunction with an abnormal triceps reflex, then the level of involvement is more likely to be C7. The pronator reflex is performed by tapping the volar aspect of the distal radius with the forearm in a neutral position and the elbow flexed. This results in a stretch of the pronator teres, resulting in a reflex pronation.
  • In patients that demonstrate concern about possible myelopathy, the lower-extremity reflexes and Hoffman and Babinski reflexes should also be assessed. Diffuse hyperreflexia and/or positive Hoffman and abnormal Babinski reflexes would indicate that the patient has a cervical myelopathy.  
• Provocative tests
• • The foraminal compression test or Spurling test is probably the best test for confirming the diagnosis of cervical radiculopathy. It is performed by extending the neck and rotating the head and then applying downward pressure on the head. The test is considered positive if pain radiates into the limb ipsilateral to the side to which the head is rotated. The Spurling test has been found to be very specific (93%), but not sensitive (30%), in diagnosing acute radiculopathy.¹¹ Therefore, it is not useful as a screening test, but it is clinically useful in helping to confirm cervical radiculopathy.
  • Manual cervical distraction can be used as a physical examination test. With the patient in a supine position, gentle manual distraction often greatly reduces the neck and limb symptoms in patients with radiculopathy.
  • Lhermitte sign is performed by flexing the neck and asking the patient about symptoms of an electric shocklike sensation radiating down the spine, and in some patients, into the extremities. This sign has been found in patients with cervical cord involvement, cervical spondylosis, and also in patients with tumor and multiple sclerosis (MS); however, the Lhermitte sign should be negative in those with cervical radiculopathy. Manual distraction may reduce the neck and limb symptoms in patients with cervical radiculopathy.

Related eMedicine topics:
Cervical Spondylosis
Multiple Sclerosis

Related Medscape topic:
Resource Center Spinal Disorders

Causes

Little is known about the natural history of cervical radiculopathy. The pathogenesis of radiculopathy occurs from the inflammatory process initiated by nerve root compression. Evidence exists that inflammatory mediators, including nitric oxide, prostaglandin E2, interleukin-6, and matrix metalloproteinases, are released by herniated intervertebral discs.^{14, 15} This results in nerve root swelling. The compression may be from a disc herniation, degenerative changes about the neural foramen, or a combination of the 2.

A study regarding patients under local anesthesia found that compression of a nerve root produced limb pain, whereas pressure on the disc produced pain in the neck and medial border of the scapula.¹⁶ Results from intradiscal injection and electrical stimulation of the disc have also suggested that neck pain is referred by a damaged outer annulus.^{17, 18, 19, 20, 21, 22, 23} Muscle spasms of the neck have also been found after electrical stimulation of the disc.

Related eMedicine topics:
Degenerative Lumbar Disc Disease in the Mature Athlete
Lumbar (Intervertebral) Disk Disorders
Nerve Entrapment Syndromes

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

Other Problems to Be Considered

Acute brachial neuritis (Parsonage Turner syndrome)
Inflammatory arthropathy
Infection (including tuberculosis)
Tumor of the vertebral/neural elements

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

Imaging Studies

• Plain radiography
• • Radiography of the cervical spine is usually the first diagnostic test ordered in patients who present with neck and limb symptoms, and more often than not, this study is diagnostic of cervical disc disease as the cause of the radiculopathy. On the lateral view, look for disc-space narrowing, comparing the level above and below. Typically, the cervical disc spaces get larger from C2-C6, with C5-C6 being the widest disc space in normal necks, and C6-C7 slightly narrower. Besides narrowing, look for subchondral sclerosis and osteophyte formation.

    On oblique views, look for foraminal stenosis at the level of the suspected radiculopathy, comparing it with the opposite foramina, if uninvolved. For example, in a patient with pain or sensory changes along the right C6 nerve distribution, look for narrowing of the right C5-C6 neural foramina as compared with the left side.

  • Lateral, anteroposterior, and oblique views should be ordered. An open-mouth view should only be ordered to rule out injury to the atlantoaxial joint when significant acute trauma has occurred. Visualizing all 7 cervical vertebrae is very important. If C7 can not be properly seen, then a "swimmer's view" (supine oblique view, in which the patient's arm is extended over the head) or a computed tomography (CT) scan should be obtained for better visualization of the C7 and T1 segments.
  • The atlantodens interval (ADI) is the distance from the posterior aspect of the anterior C1 arch and the odontoid process. This interval should be less than 3 mm in adults and less than 4 mm in children. An increase in the ADI suggests atlantoaxial instability, such as in cases of trauma or rheumatoid arthritis. Flexion and extension views can be helpful in assessing spinal mobility and stability in these patients.
  • The clinician should be aware of the limitations of plain radiographs. Problems with both specificity and sensitivity exist. Correlations of findings on plain radiographs and cadaver dissections have found a 67% correlation between disc-space narrowing and anatomic findings of disc degeneration. However, radiographs identified only 57% of large posterior osteophytes and only 32% of abnormalities of the apophyseal joints that were found on dissection.
• CT scanning
• • CT scanning provides good visualization of bony elements and can be helpful in the assessment of acute fractures. It can also be helpful when C6 and C7 cannot be clearly seen on traditional lateral radiographic views. The accuracy of CT imaging of the cervical spine ranges from 72-91% in the diagnosis of disc herniation. The accuracy has approached 96% when combining CT scanning with myelography. The addition of contrast material allows for the visualization of the subarachnoid space and assessment of the spinal cord and nerve roots.
  • CT scanning with myelography is thought to best assess and localize spinal cord compression and any underlying atrophy. This study can also determine the functional reserve of the spinal canal in evaluating athletes with possible cervical stenosis. Because of the improved soft-tissue visualization provided by magnetic resonance imaging (MRI), CT scanning is being replaced by MRI for most cervical spine disorders. 
• MRI
• • MRI has become the method of choice for imaging the neck to detect significant soft-tissue pathology, such as disc herniation. MRI can detect ligament and disc disruption, which cannot be demonstrated by other imaging studies. The entire spinal cord, nerve roots, and axial skeleton can be visualized. This study is usually performed in the axial and sagittal planes.
  • MRI has been found to be quite useful in evaluating the amount of cerebrospinal fluid (CSF) surrounding the cord in the evaluation of patients with cervical canal stenosis, although the T2-weighted images tend to exaggerate the degree of stenosis. Cantu reviewed the use of MRI in the evaluation of athletes with possible cervical stenosis and noted that it can be quite helpful in determining the functional reserve of the spinal canal.²⁴
  • Although MRI is believed to be the imaging method of choice in the evaluation of cervical radiculopathy, abnormalities have also been found in asymptomatic subjects. Ten percent of subjects younger than 40 years were noted to have disc herniations in one study.²⁵ Of subjects older than 40 years, 20% had evidence of foraminal stenosis and 8% had disc protrusion or herniation. Therefore, as with all imaging studies, the MRI findings must be used in conjunction with the patient's history and physical examination findings.

Related eMedicine topics:
Atlantoaxial Injury and Dysfunction
Herniated Nucleus Pulposus
Os Odontoideum

Related Medscape topics:
Resource Center Arthritis
Resource Center Osteoporosis
Resource Center Spinal Disorders

Other Tests

• Electromyography (EMG)
• • Electrodiagnostic studies are important in identifying physiologic abnormalities of the nerve root and in ruling out other neurologic causes for the athlete's complaints. Electromyography has been shown to be a useful diagnostic test in the diagnosis of radiculopathy and has correlated well with findings on myelography and surgery.
  • EMG has 2 parts: (1) nerve conduction studies and (2) a needle-electrode examination. The nerve conduction studies are performed by placing surface electrodes over a muscle belly or sensory area and stimulating the nerve that supplies either the muscle or sensory area from fixed points along the nerve. From this, the amplitude, distal latency, and conduction velocity can be measured. The amplitude reflects the number of intact axons, whereas the distal latency and conduction velocity is more of a reflection of the degree of myelination.
  • The needle EMG portion of the electrodiagnostic examination involves inserting a fine-needle electrode into a muscle. Electrical activity is generated by the needle insertion into the muscle, voluntary muscle contraction, and the spontaneous firing of motor units. The activity is observed on an oscilloscope screen and quantified; an audible sound is also generated.

    Denervated muscle produces spontaneous electrical activity while the muscle is at rest. These potentials are called fibrillations or positive sharp waves based on their characteristic shape and sound. Changes can be also seen in the configuration of the individual motor unit, as well as an increase in the firing rate of the individual motor units.

    The timing of the EMG evaluation is important because positive sharp waves and fibrillation potentials first occur 18-21 days after the onset of a radiculopathy; therefore, it is best to delay this study until 3 weeks after an injury, so that it can be as precise a study as possible.

  • The primary use of EMG is to diagnose nerve root dysfunction when the diagnosis is uncertain or to distinguish a cervical radiculopathy from other lesions, which are unclear on physical examination. Although electrodiagnostic studies are very sensitive and specific, a "normal" EMG in the face of signs and symptoms that are consistent with a cervical radiculopathy does not exclude the diagnosis of cervical radiculopathy.
• Selective diagnostic nerve root block (SNRB)
• • In an SNRB, a small aliquot of local anesthetic is used to anesthetize the nerve root and dorsal root ganglion to determine if the patient’s pain is coming from the specific nerve root. SNRB has been shown to be a useful diagnostic test in the diagnosis of radiculopathy and has correlated well with surgical findings. It is both a sensitive and specific test.
  • SNRB is best indicated when MRI findings are equivocal, multilevel, and/or do not correlate with the patient’s symptoms. In these situations, the result of a negative diagnostic SNRB becomes superior in predicting the absence of an offending lesion and may persuade surgeons from operating on an initially suspicious, but incorrect, level of radiculopathy.

Related eMedicine topics:
Electrophysiology
Motor Unit Recruitment in EMG
Single-Fiber EMG

Related Medscape topic:
Resource Center Spinal Disorders

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

Acute Phase

Rehabilitation Program

Physical Therapy

Little is known about the natural history of cervical radiculopathy or about controlled randomized studies comparing operative versus nonoperative treatment for this condition. The initial treatment should be directed at reducing pain and inflammation. The treatment can begin with local icing, NSAIDs, and with reducing the forces compressing the nerve root by relative rest, avoiding positions that increase arm and/or neck symptoms, manual traction, and if necessary, mechanical traction.

In addition, a cervical collar can also be used for patient comfort and some support. A cervical pillow at night can be helpful in maintaining the neck in a neutral position and limiting head positions that cause narrowing of the neural foramen. Manual and, if necessary, mechanical traction can be used to reduce radicular symptoms by decreasing foraminal compression and intradiscal pressures. Modalities such as electrical stimulation have also been found to be helpful in uncontrolled studies. These modalities appear to be helpful in reducing the associated muscle pain and spasm that are often found with cervical problems, but they should be limited to the initial pain control phase of treatment.

Related eMedicine topics:
Electrophysiology
Nerve Entrapment Syndromes
Transcutaneous Electrical Nerve Stimulation

Related Medscape topics:
Resource Center Pain Management: Advanced Approaches to Chronic Pain Management
Resource Center Pain Management: Pharmacologic Approaches

Other Treatment

Cervical epidural steroids have been used in patients whose conditions have not had satisfactory responses to medications, traction, and a well-designed physical therapy program. When properly performed by experienced physicians under fluoroscopic guidance, a significant number of patients' cervical radiculopathies respond to cervical epidural steroids when other treatments have not helped.

Studies have reported favorable results with translaminar and transforaminal epidural corticosteroid injections. These studies have shown up to 60% long-term relief of radicular pain and neck pain and a return of the patients to their usual activities. Complications from these procedures are rare, but some case studies show that complications can be catastrophic and include severe sequelae from spinal cord or brainstem infarction. SNRBs can be helpful in patients with electrodiagnostically demonstrated single-root lesions. This has rarely been necessary in the author's experience.

Acupuncture has been used to treat radicular pain with some success. This treatment can be considered if pain control is not achieved with physical therapy and medications or in conjunction with these treatments. In addition, acupuncture can be tried instead of cervical epidural injection in patients who are hesitant or who do not wish to proceed with this procedure.

Recovery Phase

Rehabilitation Program

Physical Therapy

Once pain and inflammation are controlled, the patient's therapy should be progressed to the restoration of full ROM and flexibility of the neck and shoulder girdle muscles. Various soft-tissue mobilization techniques can be helpful to stretch the noncontractile elements of the soft tissues. Instruct patients on the proper stretching techniques, which they can complete 1-2 times per day. Gentle prolonged stretching is recommended. Stretching is best completed after a warm-up activity (eg, using an exercise bike or brisk walking).

As ROM and flexibility improve, cervical muscle strengthening should begin with isometric strengthening in a single plane and include flexion, extension, lateral bending, and rotation. In addition, the scapular stabilizing muscles, including the trapezius, rhomboids, serratus anterior, and latissimus dorsi, should be strengthened with progressive isotonic activity. Strength training can progress to manual resistive cervical stabilization exercises in various planes. All exercises should be performed without pain, although some degree of postexercise soreness can be expected.

Isokinetic exercises of the neck and upper extremities are not functional and are not recommended as a strengthening tool. Isolated strengthening of the weakened muscle secondary to the radiculopathy is important before beginning more complex activities involving multiple muscles. In the initial phases of treatment, strengthening should be limited to isometric exercises in the involved extremity. Once all radicular symptoms have resolved, then progressive isotonic strengthening may begin. This should initially stress low weight and high repetitions (15-20 repetitions). Closed kinetic chain activities can be very helpful in rehabilitating weak shoulder girdle muscles.

Patients should be encouraged to maintain their level of cardiovascular fitness as much as possible throughout the rehabilitation process. This is completed by alternative conditioning that does not increase patients' symptoms as they progress through the rehabilitation process. Cardiovascular conditioning should be started as soon as possible to prevent deconditioning. These exercises also serve as a great warm-up before a stretching program. Finally, the patient should be told that these exercises (stretches and strengthening) should be continued indefinitely with the goal of preventing recurrences.

Related Medscape topics:
Resource Center Exercise and Sports Medicine
Resource Center Spinal Disorders

Surgical Intervention

Early surgical intervention is recommended in any athlete found to have cervical instability. In addition, refer patients with a progressive neurologic deficit or long tract signs to a spine surgeon.

Other Treatment (Injection, manipulation, etc.)

Spinal manipulation is not indicated in patients with frank radiculopathy. An application for manual therapy only may exist in patients with radicular symptoms.

Maintenance Phase

Rehabilitation Program

Physical Therapy

Patients should be independent in a stretching and strengthening program and continue with these exercises under the supervision of an athletic trainer initially and then completely on their own. Emphasis is placed on stretching the anterior neck and shoulder muscle groups and strengthening the neck and scapular muscles. If completed correctly, proper head and neck positioning is then maintained in everyday activity and sports.

Surgical Intervention

Patients whose condition fails to improve with a comprehensive rehabilitation program and selective injections should be offered a surgical evaluation. Generally, patients should show progressive improvement over the first 6-8 weeks with conservative treatment. If there is no significant improvement in this time frame, consider a surgical evaluation.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

NSAIDs are commonly prescribed for their effects on pain and inflammation. In cervical radiculopathy, a great deal of the pain is secondary to inflammation of the nerve root, usually due to a mechanical irritation of the nerve.

Oral steroids have been used to reduce the associated inflammation from compression. No controlled study exists to support the use of oral steroids in the treatment of cervical radiculopathy; however, these agents have been found to be clinically useful. Doses as high as 60 mg daily for 7 days and continuing for 5 days have been recommended without evidence of adrenal suppression. Tricyclic antidepressants can be a useful adjunct in controlling radicular pain. Opioid medications are generally not necessary for pain relief, but these drugs can be used when other medications fail to provide adequate relief or if other agents are contraindicated. When opioid medications are prescribed, adequate doses and appropriate dosing schedules should be used.

Related eMedicine topics:
Toxicity, Narcotics
Toxicity, Nonsteroidal Anti-inflammatory Agents
Toxicity, Tricyclic Antidepressant

Related Medscape topics:
Resource Center Pain Management: Advanced Approaches to Chronic Pain Management
Resource Center Pain Management: Pharmacologic Approaches

Drug Category: Nonsteroidal anti-inflammatory drugs

Various NSAIDs are available either over the counter or by prescription. Proper doses should be used in the acute phase around the clock for approximately 7-10 days.

Drug Category: Tricyclic antidepressants

Tricyclic antidepressants are a complex group of drugs that have central and peripheral anticholinergic effects, as well as sedative effects. These agents have central effects on pain transmission and block the active reuptake of norepinephrine and serotonin.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

Return to Play

Return-to-play criteria require the athlete to have no pain, a full pain-free ROM, a negative Spurling test, and a normal neurologic examination. A neck roll should be properly fitted and used in athletes at risk for a repeat injury (eg, a middle linebacker in football).

Complications

Complications include incomplete neurologic recovery, loss of full cervical ROM, and radiographic changes that indicate disc-space narrowing, persistent loss of normal cervical lordosis, and/or osteophyte formation.

Prevention

Some injuries can be prevented by using good technique (eg, when tackling an opponent in football, breathing properly when swimming). Proper head positioning may also be of benefit by stretching the anterior muscles of the neck and chest (ie, the anterior scalenes, pectoralis muscles) and strengthening the scapular muscles. Neck strengthening, including some eccentric strengthening exercises, may be helpful in providing muscular control of the neck.

Prognosis

The prognosis for patients with cervical radiculopathy is excellent with the proper treatment, in which 80-90% of patients can be treated nonoperatively. Surgery is indicated when nonoperative treatment has failed. The time frame for this decision depends on the ability of the patient to progress through the various phases of rehabilitation (see Treatment, Acute Phase, Recovery Phase, and Maintenance Phase).

Education

Proper sport technique is usually of great importance in the prevention and rehabilitation of many cervical radiculopathies. This includes a proper ball toss in tennis, a proper body turn in swimming, and proper head positioning when tackling in football.

Related Medscape topic:
Resource Center Exercise and Sports Medicine

MULTIMEDIA

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

Media file 1:  Sagittal magnetic resonance image of the cervical spine. This image reveals a C6-C7 herniated nucleus pulposus.
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Media type:  MRI

Media file 2:  Axial magnetic resonance image of the cervical spine. This image reveals a C6-C7 herniated nucleus pulposus.
	View Full Size Image
Media type:  MRI

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

1. Bogduk N, Twomey LT. Clinical Anatomy of the Lumbar Spine. 2^nd ed. Edinburgh, UK: Churchill Livingstone Inc; 1991.
2. Ellenberg MR, Honet JC, Treanor WJ. Cervical radiculopathy. Arch Phys Med Rehabil. Mar 1994;75(3):342-52. [Medline].
3. Malanga GA. The diagnosis and treatment of cervical radiculopathy. Med Sci Sports Exerc. Jul 1997;29(7 suppl):S236-45. [Medline].
4. Radhakrishnan K, Litchy WJ, O'Fallon WM, Kurland LT. Epidemiology of cervical radiculopathy. A population-based study from Rochester, Minnesota, 1976 through 1990. Brain. Apr 1994;117(pt 2):325-35. [Medline].
5. van Gijn J, Reiners K, Toyka KV, Braakman R. Management of cervical radiculopathy. Eur Neurol. 1995;35(6):309-20. [Medline].
6. White AA, Panjabi MM. Clinical Biomechanics of the Spine. 2^nd ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 1990:102.
7. Parminder SP. Management of cervical pain. In: Delisa JA, Gans BM, eds. Rehabilitation Medicine: Principles and Practice. 3^rd ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 1988:753.
8. Murphey F, Simmons JC, Brunson B. Chapter 2. Ruptured cervical discs, 1939 to 1972. Clin Neurosurg. 1973;20:9-17. [Medline].
9. Shelerud RA, Paynter KS. Rarer causes of radiculopathy: spinal tumors, infections, and other unusual causes. Phys Med Rehabil Clin N Am. Aug 2002;13(3):645-96. [Medline].
10. Soubrier M, Dubost JJ, Tournadre A, et al. Cervical radiculopathy as a manifestation of giant cell arteritis. Joint Bone Spine. May 2002;69(3):316-8. [Medline].
11. Tong HC, Haig AJ, Yamakawa K. The Spurling test and cervical radiculopathy. Spine. Jan 15 2002;27(2):156-9. [Medline].
12. Fryholm R. Cervical nerve root compression resulting from disc degeneration and root-sleeve fibrosis. Acta Chiru. Scand. 1951;160(suppl):1-149.
13. Letchuman R, Gay RE, Shelerud RA, VanOstrand LA. Are tender points associated with cervical radiculopathy?. Arch Phys Med Rehabil. Jul 2005;86(7):1333-7. [Medline].
14. Furusawa N, Baba H, Miyoshi N, et al. Herniation of cervical intervertebral disc: immunohistochemical examination and measurement of nitric oxide production. Spine. May 15 2001;26(10):1110-6. [Medline].
15. Kang JD, Stefanovic-Racic M, McIntyre LA, Georgescu HI, Evans CH. Toward a biochemical understanding of human intervertebral disc degeneration and herniation. Contributions of nitric oxide, interleukins, prostaglandin E2, and matrix metalloproteinases. Spine. May 15 1997;22(10):1065-73. [Medline].
16. Viikari-Juntura E, Porras M, Laasonen EM. Validity of clinical tests in the diagnosis of root compression in cervical disc disease. Spine. Mar 1989;14(3):253-7. [Medline].
17. Carragee EJ, Hurwitz EL, Cheng I, et al, and the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Treatment of neck pain: injections and surgical interventions: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine. Feb 15 2008;33(4 suppl):S153-69. [Medline].
18. Anderberg L, Annertz M, Rydholm U, Brandt L, Säveland H. Selective diagnostic nerve root block for the evaluation of radicular pain in the multilevel degenerated cervical spine. Eur Spine J. Jun 2006;15(6):794-801. [Medline].
19. Sasso RC, Macadaeg K, Nordmann D, Smith M. Selective nerve root injections can predict surgical outcome for lumbar and cervical radiculopathy: comparison to magnetic resonance imaging. J Spinal Disord Tech. Dec 2005;18(6):471-8. [Medline].
20. Anderberg L, Annertz M, Brandt L, Säveland H. Selective diagnostic cervical nerve root block--correlation with clinical symptoms and MRI-pathology. Acta Neurochir (Wien). Jun 2004;146(6):559-65; discussion 565. [Medline].
21. Huston CW, Slipman CW. Diagnostic selective nerve root blocks: indications and usefulness. Phys Med Rehabil Clin N Am. Aug 2002;13(3):545-65. [Medline].
22. Chesnut RM, Abitbol JJ, Garfin SR. Surgical management of cervical radiculopathy. Indication, techniques, and results. Orthop Clin North Am. Jul 1992;23(3):461-74. [Medline].
23. Johnson EW, ed. Practical Electromyography. 2^nd ed. Baltimore, Md: Lippincott Williams & Wilkins; 1979:229-45.
24. Cantu RC. Cervical spine injuries in the athlete. Semin Neurol. 2000;20(2):173-8. [Medline].
25. Boden SD, McCowin PR, Davis DO, et al. Abnormal magnetic-resonance scans of the cervical spine in asymptomatic subjects. A prospective investigation. J Bone Joint Surg Am. Sep 1990;72(8):1178-84. [Medline]. [Full Text].
26. Ahlgren BD, Garfin SR. Cervical radiculopathy. Orthop Clin North Am. Apr 1996;27(2):253-63. [Medline].
27. Chiba S, Koge N, Oda M, et al. Synovial chondromatosis presenting with cervical radiculopathy: a case report. Spine. Oct 1 2003;28(19):E396-400. [Medline].
28. Dreyfus P. The cervical spine: non-surgical care. Presented at: The Tom Landry Sports Medicine and Research Center. April 8, 1993; Dallas, Tex.
29. Friedenberg ZB, Edeiken J, Spencer HN, Tolentino SC. Degenerative changes in the cervical spine. J Bone Joint Surg Am. Jan 1959;41-A(1):61-70 passim. [Medline]. [Full Text].
30. Leblhuber F, Reisecker F, Boehm-Jurkovic H, Witzmann A, Deisenhammer E. Diagnostic value of different electrophysiologic tests in cervical disk prolapse. Neurology. Dec 1988;38(12):1879-81. [Medline].
31. Lipetz JS, Malanga GA. Oral medications in the treatment of acute low back pain. Occup Med. Jan-Mar 1998;13(1):151-66. [Medline].
32. Lo YL, Chan LL, Leoh T, et al. Diagnostic utility of F waves in cervical radiculopathy: electrophysiological and magnetic resonance imaging correlation. Clin Neurol Neurosurg. Jan 2008;110(1):58-61. [Medline].
33. Malanga GA, Campagnolo DI. Clarification of the pronator reflex. Am J Phys Med Rehabil. Sep-Oct 1994;73(5):338-40. [Medline].
34. Marks MR, Bell GR, Boumphrey FR. Cervical spine injuries and their neurologic implications. Clin Sports Med. Apr 1990;9(2):263-78. [Medline].
35. Miwa M, Doita M, Takayama H, et al. An expanding cervical synovial cyst causing acute cervical radiculopathy. J Spinal Disord Tech. Aug 2004;17(4):331-3. [Medline].
36. Nordin M, Carragee EJ, Hogg-Johnson S, et al for the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Assessment of neck pain and its associated disorders: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine. Feb 15 2008;33(4 suppl):S101-22. [Medline].
37. Thomas M, Bell GB. Radiologic evaluation and imaging of the spine. In: Nicholas JA, Hershman EB, eds. The Lower Extremity and Spine in Sports Medicine. 2^nd ed. 1995:1096-7.
38. Wilbourn AJ, Aminoff MJ. AAEE minimonograph #32: the electrophysiologic examination in patients with radiculopathies. Muscle Nerve. Nov 1988;11(11):1099-114. [Medline].

Article Last Updated: Mar 31, 2008