Cervical Radiculopathy

Overview

Cervical radiculopathy is dysfunction of a cervical nerve root caused by irritation or compression as it leaves the spine. It commonly produces pain radiating from the neck into one arm, sometimes with paraesthesia, numbness, weakness or altered reflexes. A disc herniation or degenerative narrowing of the neural foramen is a common cause.

Diagnosis is primarily clinical. The pattern of symptoms and neurological findings helps identify the affected root, although dermatomes overlap and findings are not always textbook. Most patients improve with non-operative treatment. Progressive weakness or features of spinal cord involvement require prompt reassessment.

Aetiology & Risk Factors

• Disc herniation: Disc material can irritate or compress an adjacent nerve root, sometimes after an acute onset of symptoms.
• Degenerative change: Disc height loss and bony overgrowth can narrow the neural foramen.
• Increasing age: Degenerative causes become more common over time.
• Less common causes: Trauma, infection, malignancy or other structural lesions should be considered when the history or examination suggests them.

Clinical Manifestations

• Neck pain radiating into the shoulder, arm or hand, usually on one side.
• Shooting, burning or electric pain, with possible tingling or numbness.
• Symptoms that may be provoked by neck movement.
• Weakness in muscles supplied by the affected root or a reduced corresponding reflex.
• Symptoms may follow an approximate root distribution, but overlap is common.

Nerve root	Possible sensory pattern	Possible motor or reflex finding
C5	Lateral shoulder and upper arm	Shoulder abduction or elbow flexion weakness
C6	Lateral forearm and thumb	Elbow flexion or wrist extension weakness; reduced brachioradialis reflex
C7	Posterior forearm and middle finger	Elbow extension weakness; reduced triceps reflex
C8	Medial forearm and little-finger side of the hand	Finger flexion weakness

These are useful clinical patterns, not absolute rules. Compare the whole history and examination rather than assigning a root from one symptom alone.

Features Requiring Urgent Assessment

• Progressive or substantial motor weakness.
• Hand clumsiness, gait disturbance, bilateral limb symptoms or other signs suggesting cervical myelopathy.
• New bladder or bowel dysfunction in the context of possible spinal cord disease.
• Fever, suspected infection, cancer-related features, significant trauma or severe unremitting pain suggesting another serious cause.

Diagnosis

Take a history of the pain distribution, onset, aggravating movements, sensory symptoms and functional weakness. Examine cervical movement and perform a neurological assessment of upper-limb power, sensation and reflexes. Screen for signs of myelopathy and for alternative causes, including shoulder disease and peripheral nerve entrapment.

• Provocative examination: A Spurling manoeuvre may reproduce radicular arm symptoms when the neck is extended, rotated and gently compressed. A positive test supports the diagnosis but is not conclusive on its own.
• MRI: Consider when there is progressive neurological deficit, concern for myelopathy or serious pathology, or persistent symptoms for which an injection or surgical assessment is being considered. Interpret imaging alongside the clinical findings because degenerative changes may be present without causing symptoms.
• CT: May help assess bony narrowing or be used when MRI is unsuitable.
• Electrodiagnostic testing: May help when the diagnosis remains uncertain or a peripheral nerve disorder is a competing explanation.

Routine blood tests are not required for an uncomplicated presentation. Investigations for infection, malignancy or inflammatory disease should follow the clinical findings.

Treatment

Initial Non-operative Management

• Explain the expected course and encourage activity within tolerable limits. Temporarily modify movements or tasks that clearly aggravate symptoms.
• Use suitable analgesia; an NSAID may be considered when appropriate.
• Offer physiotherapy focused on maintaining movement and gradually improving neck and shoulder-girdle function. Selected patients may benefit from supervised traction.
• Review pain, function and neurological findings to ensure that weakness is not progressing.

Persistent Symptoms

• Reassess the diagnosis and consider cervical MRI if symptoms remain troublesome despite an adequate course of conservative care.
• Specialist assessment may be appropriate for persistent disabling arm pain, particularly when imaging identifies a corresponding nerve-root lesion. An epidural steroid injection may be considered in selected patients after discussion of its potential benefits and risks.
• Surgical assessment is appropriate when pain remains severe despite non-operative treatment or when there is progressive or significant neurological impairment. The procedure depends on the site and cause of nerve-root compression.

Suspected Myelopathy or Serious Pathology

Arrange urgent assessment rather than continuing routine conservative management when signs suggest spinal cord involvement, progressive neurological loss, infection, malignancy or another serious condition.

Complications & Prognosis

Complications

• Persistent pain, sleep disturbance or reduced ability to work and perform daily activities.
• Ongoing sensory disturbance or weakness in some patients.
• An alternative or coexisting diagnosis, particularly cervical myelopathy, may be missed if new neurological findings are not reassessed.

Prognosis

Most patients improve with non-operative care, although symptoms can recur or persist. Follow-up is important when pain remains disabling or neurological findings are present. Progressive weakness or newly developing signs of spinal cord dysfunction require prompt reassessment.

References

1. American Academy of Orthopaedic Surgeons. Cervical Radiculopathy (Pinched Nerve). OrthoInfo. AAOS.
2. NICE Clinical Knowledge Summaries. Neck pain – cervical radiculopathy. NICE CKS.
3. Childress MA, Becker BA. Nonoperative Management of Cervical Radiculopathy. Am Fam Physician. 2016;93(9):746–754. PubMed.