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REVIEW ARTICLE Cervical

Maury R. Ellenberg, MD, Joseph C. Honet, MD, Walter J. Treanor, MD

ABSTRACT. Ellenberg M, Honet JC, Treanor WJ. Cervical radiculopathy. Arch Phys Med Rehabil 1994;75: 342-52. l The history, pathoanatomy and pathophysiology, clinical picture, differential diagnosis, diagnostic evaluation, and treatment of cervical radiculopathy are reviewed. The review is based on a lo-year Medline literature search, review of bibliographies in textbooks, and bibliographies in articles obtained through the search. Cervical radiculopathy, although recognized early in the 20th century, was first associated with disc pathology in the mid- 1930s. It is most commonly caused by disc herniation or cervical spondylosis. History and physical examination using location, manual muscle testing, and specialized testing (Spurling’s maneuver) will usually suffice to diagnose the radiculopathy and determine the root level involved. Diagnostic imaging such as magnetic resonance imaging, computed tomography, or myelography should be used as presurgical evaluative tools or when tumor or other etiology besides disc hemiation or spondylosis is suspected. Electromyography is of benefit in distinguish- ing various entities that clinically present similar to cervical radiculopathy and can also help to “date” the lesion. Treatment of this disorder has not been systematically studied in a controlled fashion. However, using a variety of different treatments, the radiculopathy usually improves without the need for . Indications for surgery are unremitting pain despite a full trial of non-surgical management, progressive weakness, or new or progressive cervical myelopathy. Prospective studies evaluating the various treatment options would be of great benefit in guiding practitioners toward optimum cost-effective evaluation and care of the patient with cervical radiculopathy. 0 1994 by the American Congress of Rehabilitation and the American Academy of Physical Medicine and Rehabilitation

Cervical radicular syndrome is a general term describing Medline search. Articles were selected based on historical, a set of symptoms. This symptom complex may arise from clinical, or research data they contained. several causes, including nerve root irritation, myofascial pain syndromes, and soft tissue . This review will HISTORICAL PERSPECTIVE concentrate on cervical syndromes that are caused by radicu- Cervical radiculopathy or “radiculitis” particularly asso- lopathy. ciated with intervertebral disc rupture as a cause of “brachial Cervical radiculopathy is a pathologic process involving pain” was not distinguished from other causes of upper the nerve root, arising from cervical disc herniation, cervical extremity pain attributed to “neuritis,” ‘ ‘fibrositis,” and spondylosis, tumor (benign or malignant), or trauma causing “myalgia” in the early 20th century.’ As early as 1936, nerve root avulsion. Cervical radiculopathy may also occur however, there were descriptions of shoulder girdle, arm, and in a setting in which no definite cause can be determined. precordial pain attributed to “cervical arthritis” resulting in Historical, physical examination, and laboratory features “irritation or inflammation of the cervical spinal roots.“’ seen in cervical radiculopathy of any cause are addressed. Cervical disc hemiation resulting in cord compression and This review will also delineate the clinical, physical, and myelopathy was recognized as a syndrome in the early 20th laboratory features, highlight similarities, emphasize ways century, but was initially attributed to spinal cord tumors to distinguish the various etiologies, discuss differential di- termed ‘ ‘chondromas. ’ ‘3s4This syndrome of cord compres- agnosis, outline certain laboratory and testing procedures, sion was defined as a ruptured disc by Mixter and Aye? in particularly computed tomography (CT) scan, magnetic res- 1935, shortly after the report by Mixter and Barr in 1934’j onance imaging (MRI) and electrodiagnostic testing, and of disc herniation as the etiology of “sciatica” in the lumbar address treatment and prognosis. region. We review the clinical aspects of cervical radiculopathy It was not, however, until the early 1940s that Semmes and cite research performed, but this review does not repre- and Murphey’ and shortly thereafter Spurling and Scoville,8 sent a meta analysis of all research on this topic. Articles and Michelsen and Mixter’ directly related “cervical radicu- were obtained through a Medline search of the literature of litis,” in the absence of cervical myelopathy, to ruptured the past 10 years, a review of bibliographies in text books, cervical intervertebral discs. At that time, Spurling and Sco- and a review of bibliographies in the articles found in the ville also described the “neck compression test,” which has since become known as Spurling’s test. Subsequent articles From the Department of Rehabilitation Medicine, Sinai Hospital, Detroit, MI published at the end of that decade defined the relationship 482352899. between cervical radiculopathy, upper extremity pain, and Submitted for publication June 29, 1993. Accepted in revised form August 4, 1993. No commercial party having a direct financial interest in the results of the research protruded cervical intervertebral discs.‘0-12 supporting this article has or will confer a benefit upon the authors or upon any organization with which the authors are associated. ANATOMY Reprint requests to Maury R. Ellenberg, MD, Department of Rehabilitation Medi- cine, Sinai Hospital, 6767 West Outer Drive, Detroit, MI 48235-2899. There are seven cervical vertebra that articulate via the 0 1994 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation zygoapophyseal (facet) joints located at the posterior portion 0003-9993/94/7503-0100$3.00/0 of the vertebrae. The uncovertebral joints, or joints of

Arch Phys Med Rehabil Vol75, March 1994 CERVICAL RADICULOPATHY, Ellenberg

Luschka, are located on the lateral aspect of the vertebral The precise mechanism whereby disc herniation or spon- body and composed of the sharply defined bony margins dylosis causes radicular pain is still unclear. Experimentally, about the superior rim of each vertebra articulating with the referred pain can be generated from several structures in the facet of the vertebra above it. This area is often the site of cervical spine probably including the disc’-? (shown to have abnormal bony overgrowth that can compromise the verte- innervation to the outer third of the annulus), from the perios- bral canal or neural foramen. The eight cervical nerve roots teum, ligaments, fascia,23 or the nerve root.6.24 Direct pres- exit via intervertebral foramina, which are bordered ante- sure on the root, however, does not necessarily cause pain,” romedially by the vertebral disc, and posterolaterally by the and pure motor deficit may occur.26 Proposed mechanisms facet joints. The foramina are largest at C2-3 and progres- for pain in radiculopathy include increased discharge of dor- sively decrease in size to C6-7. The nerve root occupies sal root ganglia whose have undergone , about l-4 to l-3 of the space in the foramina, accompanied mechano-sensitivity or chemo-sensitivity of the nerve root by spinal radicular arteries and intervertebral veins.13 The itself, or direct pressure on chronically injured axons or nor- first cervical nerve root exits between the occiput and atlas mal dorsal root ganglia.25,27Causes of cervical radiculopathy (Cl vertebra) and all subsequent roots exist above their cor- other than disc herniation or cervical spondylosis include respondingly numbered cervical vertebrate except the C8 tumor,‘8 trauma,29 sarcoidosis,30 arteritis,“’ and athetoid and root, which exits below C7 and above Tl. Therefore, C5-6 dystonic cerebral palsy.32 disc herniation or foraminal narrowing will affect the C6 root, and a similar C6-7 lesion will affect the C7 root. Due CLINICAL PICTURE to differential growth of the vertebra and spinal cord, the The most commonly involved nerve roots in cervical lower cervical vertebra are at the same level as the next lower radiculopathy are the sixth and seventh cervical roots, which spinal segment. The C5-6 interspace is therefore opposite the are caused by C5-6 or C6-7 disc herniation, or spondylosis. C7 spinal level where the C7 nerve root arises and the C6 Which of these is the most commonly involved nerve seems root exits. The C7 root then descends from this level to exit to depend on the case series. 0dom,18 in a series of 246 between the C6 and C7 vertebrae. Myotomal and dermato- cases, found C7 root with C6-7 disc involvement in 70% of ma1 distributions of the cervical nerve roots are depicted in cases, the C6 root with C5-6 disc in 24% of cases, whereas table 1 (myotomes) and the figure (dermatomes). Lundsford,‘” in a series of 334 patients, found 48% C6 root PATHOANATOMY AND PATHOPHYSIOLOGY with C5-6 herniation, and 37% C7 root with C6-7 herniation. The nerve root is vulnerable to compression in the inter- The series of 846 patients by Henderson and colleagues33 vertebral foramen by three structures: the facet joint, the demonstrated some of the difficulty in determining the level uncovertebral joints, and the disc. The most common cause of the radiculopathy. Triceps weakness (C7) was present in of cervical radiculopathy is a herniated cervical disc,14 fol- 37% of the patients, and biceps (C6) weakness in 28%. Surgery based on sensory findings and myelographic abnor- lowed by cervical spondylosisL5.16 with or without myelopa- malities was performed on 449 cases (53.1%) at C5-6 (C6 thy. Hypertrophic facet and uncovertebral joints can en- root) and only 45.6% at C6-7 (C7 root). Most studies de- croach on the nerve root, and the disc may rupture or become termining radiculopathy on a clinical basis however found calcified. The effect of these processes may be enhanced a preponderance of C7 (table 2).‘7,‘“,34,3s when there is congenital narrowing of the spinal cana1.17The disc herniations have been divided into “soft” and “hard,” the former being ruptured nucleus pulposus, the latter refer- Symptoms and History ring to an intraforaminal spur from the uncovertebral or facet The symptoms of cervical radiculopathy are pain, pares- joint or to disc hardening, thickening, or calcification causing thesia or weakness, or a combination of these symptoms. a median ridge and potential root and cord pressure.‘8-20 Evaluation for radiculopathy should include a careful history Recent literature refers to the “hard disc” as cervical spon- to delineate the precipitating cause, the distribution, duration, dylosis either with or without myelopathy or radiculopathy.” and frequency of pain, paresthesia or weakness, occurrence

Table 1: Myotomes

Rhomboids 5 Latissimus Dorsi 6 I 8 Supraspinatus 5 6 Flex. Car. Radialis 7 8 Infraspinatus 5 6 Triceps Brachii 6 2 8 Deltoid 5 6 Ext. Carp. Uln. z 8 Brachialis 5 ; Ext. Dig. Comm. 7 8 Biceps Brachii -s 6 Ext. Pollicis Longus 1! T-l Brachioradialis 5 6 Flex. Digit. Super 7 8 T-l Supinator 5 6 Flex. Digit. Profundus 7 8 T-l Ext. C. Rad. Longus 6 J Flexor Pollicis Longus J 8 T-l Ext. C. Rad. Brevis 6 7 Flex. Carpi Ulnaris 8 T-l Pronator Teres 6 7 Abd. Poll. Brevis s T-l Serratus Anterior 5 6 z Opponens Pollicis 8 T-l Pectoralis Major Upper 5 6 7 1st Dorsal Interosseous Pectoralis Major Lowern 4 7 8 -T-l 8 -T-l Abd. Digiti Quinti 8 -T-l Myotomal root innervation based on a series of 255 operated patients (Treanor personal communication); Mayo Clinic’s Clinical Examinations in .‘“’ See Hollinshead for a full discussion of individual variation.rsO Underscores represent the primary root innervation most used.

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and physical examination. The presence of atrophy may help in “dating” the radiculopathy. Areas to observe carefully for atrophy include for C5 or C6 root the suprascapular and infrascapular areas (supraspinatus and infraspinatus) and upper lateral arm (deltoid); for C7 root the posterior arm (triceps); for C8 root the thenar eminence; and for Tl root between the thumb and index finger (first dorsal interosse- ous). The patient should also be observed and tested for scapular “winging,” which may occur with C6 or C7 radicu- lopathy.4’ At times, palpation of the above-mentioned mus- cles may allow the examiner to detect abnormalities before atrophy can be visually detected. Manual muscle testing is of prime importance and has been shown by Yes? to have greater specificity than either reflex or sensory examination. There may be overlap in the myotomes, although this is less likely to be variable than dermatomal overlap. ‘9.34,35Some of this variation may be due to intradural connections between nerve roots described to occur at the level of posterior (sensory) and anterior (mo- tor) rootlets. Despite the variations in clinical findings, single root level involvement can be diagnosed by clinical means 75% to 80% of the time.‘4’35Manual muscle testing should be performed in the antigravity position using the techniques described by the Medical Research Council (MRC)45 to detect minimal weakness. Attempts should be made to detect weakness in the myotomal distribution of the nerve root involving at least two or three peripheral nerves in order to exclude a peripheral nerve lesion as the etiology of the weakness. For example, C6 root entrapment causes weakness in shoulder abduction and external rotation (axil- lary and suprascapular nerve) and elbow flexion (musculocu- taneous nerve). The distribution of motor weakness present Arrangement of the dermatomes on the anterior (a) and poste- with various root involvement is listed in table 3. To detect rior (b) aspects of the upper extremity. (Note: According to minimal weakness, test external shoulder rotation for C5 or ASIA Standards, the forefinger is C6 and ring finger is CS C6 nerve root; finger extension or elbow extension with dermatome. Other differences are not substantive). (Reprinted the elbow in 90” of flexion for the C7 nerve root. Sensory with permission.“‘) examination for cervical radiculopathy is much less reliable than motor because of the considerable overlap of derma- with activity and presence of night pain. Eighty to 100% of tomes.35 The most common patterns of sensory and reflex patients will present with neck and arm pain with or without changes are outlined in table 3 and normal sensory distribu- motor weakness or paresthesia, generally not preceded by tion is depicted in the figure. Gait and lower extremity re- trauma or other determinable precipitating cause.‘8.34.36The flexes, motor and sensory function must be examined to pain and paresthesia that occur in cervical radiculopathy are detect cord compression. This may occur (albeit rarely) with not well localized anatomically, because a number of roots soft disc hemiation (eg, central) but is more frequently may cause a similar distribution of pain or even paresthesia. caused by cervical spondylosis.” The most common patterns are depicted in table 3.‘8.34The The neck compression test, first described by Spurling in pain is usually in the cervical region, the upper limb, shoulder 1944’ helps to localize the symptom to the cervical spine. or interscapular region. The pain may at times be atypical It is extremely helpful in the diagnosis of cervical radiculop- and present as chest pain (pseudo-angina),37^39or breast pain,@ athy when present because of its high specificity,46 although or pain in the facial region. In most studies, the pain is present its sensitivity is low and thus its absence does not preclude in the upper limb more frequently;? in the neck, although it is usually present in both areas. 2 When cervical myelopa- thy is resent, pain has been described in the back and Table 2: Frequency of Cervical Radiculopathy legs. 33,4P,42 Other important aspects of the history include prior by Root Level in Several Series episodes of cervical radiculopathy, current or past treatment Root Level Odoml* Lundsford” Yoss”S HonetJ4* course, history, difficulty walking, lower extremity pain or paresthesia, and/or bowel or bladder complaints. c5 ? 10% 2% 0 C6 27% 48% 19% 15.8% Physical Examination c7 65% 37% 69% 75.6% Physical examination should begin with careful observa- C8 ? 2% 10% 14.6% tion of the neck position and movement during the history * Five patients with 2 level root involvement.

Arch Phys Med Rehabil Vol75, March 1994 CERVICAL RADICULOPATHY, Ellenberg 345

Table 3: Most Common Patterns of Reflex, Sensory, and Motor Abnormalities in Cervical Radiculopathy Primary Motor Pathology Site Root Reflexes Pain Sensorv Weakness Comment

Foramen magnum Incr. upper & lower Neck (head) Variable X-rays of atlanto-axial extremities joint C.?-4 (silent zone) Incr. upper & lower Interscapular, Ear to neck Shoulder elevation and X-rays for foraminal extremities neck, retraction, neck enlargement shoulder Hcxion and rotation C.4-5 C.5 Deer. biceps. Neck, shoulder, Axillary Shoulder abduction. (brachioradialis) interscapular “patch.” external rotation. proximal arm (elbow Hexion) c.s-6 C.6 Drcr. Brachioradialis Shoulder, radial Thumb and index Elbow Hexion. forearm Ulnar wrist extensors (biceps) forearm. Hnger supination. radial spared. Look for interscapular wrist extension reHex inversion to (scapular winging) tinger Hexors (2.6-7 C.7 Deer. triceps Interscapular Long and ring Elbow extension, wrist Check for scapular forearm. fingers and finger extension, “winging,” check chest. ulnar pronation, scapular for reflex hand “winging,” (radial “inversion” to wrist Hexion) elbow Aexion C.7-T. I C.8 Normal or deer. (triceps, Medial forearm Little tinger, Finger and wrist Hexion. Distinguish from finger flexors) hypothenar thumb opposition. peripheral area. medial finger abduction. neuropathy forearm extension t ) = less prominent loss. the diagnosis. “~4h It is performed by extending the neck and Local disorders that can result in upper limb pain include rotating to the side of the pain and then applying downward subacromial bursitis, bicipital tendinitis, rotator cuff tears. pressure on the head.” This maneuver may cause or accentu- and lateral epicondylitis. These can usually be distinguished ate limb pain or paresthesia because neck extension causes from cervical radiculopathy on clinical grounds. Absence of posterior disc bulging, whereas lateral flexion and rotation weakness. reproduction of pain with local maneuvers (Yer- narrow the ipsilateral neural foramina.“7 It is wisest to per- gason’s sign,“.” painful arc5”) and local tenderness help dis- form this maneuver by having the patient actively extend tinguish these disorders. If initial treatment does not resolve the neck then laterally flex and rotate toward the side of the problem, electrodiagnostic studies and further radiologic the pain, and only then to use careful compression. When studies should be performed. radiating pain or extremity numbness is produced, the ma- Upper limb nerve entrapments (median. ulnar. and radial) neuver should be stopped. L’Hermitte’s sign, initially de- are characterized by pain, paresthesia, and weakness in the scribed in 1932,” is performed by flexing the neck with the distribution of a single peripheral nerve in contrast with patient in the seated position. This may produce an electric- the multiple nerve pattern of cervical radiculopathy. Median like sensation down the spine and occasionally the extremi- neuropathy at the wrist, however. may present with proximal ties, and has been reported in patients with cervical cord symptoms as high as the neck. Tinel’s sign. tapping with a involvement secondary to tumor, cervical spondylosis, and finger or instrument over a peripheral nerve. results in radiat- multiple sclerosis.‘” ing pain or paresthesia in the distribution of the nerve, and DIFFERENTIAL DIAGNOSIS is often present with peripheral nerve entrapment. These entrapments may coexist with cervical radiculopathy as re- There are a number of disorders that must be distinguished ported in the “double crush” phenomenon.‘” EMG. by de- from cervical radiculopathy or cervical radiculopathy with fining the distribution of abnormalities, helps to differentiate myelopathy. between an entrapment syndrome and a monoradicu- Idiopathic brachial plexopathy (IBP) or neuralgic amyot- lopathy.57.‘x rophy is a disorder of undetermined etiology that may affect any combination of nerves in the upper limb, cranial nerves, When cervical radiculopathy occurs with myelopathy, sy- or less commonly. a single upper limb nerve.5”.5’ IBP usually ringomyelia and motor neuron disease-particularly amyo- presents with severe pain later followed by weakness and trophic lateral sclerosis (ALS)-should be excluded. These eventually by atrophy. At its onset, it may be difficult to disorders may pose some of the most difficult diagnostic distinguish from cervical radiculopathy, particularly when challenges. The diagnosis of syringomyelia has been greatly the upper trunk of the brachial plexus is involved, mimicking facilitated by MR.‘” Clinically, a band of paresthesia, espe- a C5 or C6 cervical radiculopathy. Distinguishing features cially involving the upper thorax, may be present with cervi- of IBP are the high intensity of the pain followed by weak- cal syringomyelia. ness after which the pain usually recedes,sO,s’ the absence of ALS is characterized by the absence of sensory abnormal- Spurling’s sign,“” negative cervical paraspinal electromyo- ity and presence of motor neuron abnormalities in the lower graphic examination, and imaging studies that do not demon- limb(s). The latter may be detected only with careful electro- strate a lesion sufficient to result in such a severe neurologic myographic examination. If ALS is suspected, careful elec- deficit. IBP may be bilateral 25% of the time.” trodiagnostic examination of the tongue. facial muscles, and

Arch Phys Med Rehabil Vol75, March 1994 346 CERVICAL RADICULOPATHY, Ellenberg sternocleidomastoid or trapezius to detect bulbar disease The performance of imaging studies beyond the plain cer- may be the key to making the proper diagnosis if bulbar vical spine radiograph is usually not initially indicated. Im- motor neuron disease is present. aging studies should be reserved for patients when symptoms Multiple sclerosis has also been described in association and findings are not classic and lead to suspicion of one of with radiculopathy, particular cervical radiculopathy. It the disorders outlined in the differential diagnosis; cervical should be suspected if symptoms or signs such as diplopia myelopathy is present, especially acutely or subacutely; the or dysarthria suggest abnormalities above the foramen patient is not improving with treatment as expected; progres- magnum.60 sion of the neurologic deficit is occurring; or surgical treat- ment is contemplated. DIAGNOSTIC STUDIES The preferred imaging method has been much discussed in the literature, and several studies have compared CT, Diagnostic studies are used to evaluate structural (eg, x- myelography, and MR.77-79Initial studies found a close cor- ray, CT, MR) or functional abnormalities (eg, EMG, nerve relation between the three techniques. Later investigations conduction, SSEP). These areas will be briefly addressed. demonstrated a higher correlation of MR findings with oper- ative findings than either myelogram” or CT.‘l This was Imaging Techniques particularly true if plain cervical spine x-rays were used to The diagnosis of radiculopathy cannot be based only on supplement the MR scan.8o Current radiologic opinion is that spinal imaging. Brain in 195261 first determined that radio- MR is the technique of choice in cervical radiculopathy.82 logic evidence of disc degeneration did not necessarily imply The clinician should be aware of several caveats: (1) MR disc herniation. Although comparative radiologic studies results are technique-specific and dependent on the quality such as those by Tapiovaara in 195262 and Friedenberg in of the magnet used and the expertise of the neuroradiologist 196363 found a statistically greater amount of disc degenera- interpreting the image; (2) If MR is unavailable and CT tion, foraminal narrowing, or uncovertebral joint abnormali- is used for cervical spine imaging, contrast enhancement ties in patients with cervico-brachial pain, the difference significantly improves sensitivity in identifying disc hemia- was not great enough to permit clinical decision making in tion83; (3) If the imaging is performed presurgically, the individual cases.62’63This is particularly true because 70% surgeon may feel most comfortable with a certain technique of asymptomatic women and 95% of asymptomatic men and should be consulted prior to ordering the study; (4) Each between the ages of 60 and 65 have been shown to have practitioner should become familiar with interpreting these degenerative changes of the cervical spine on x-ray.64 Simi- scans since they are valuable only when they are correlated larly, cervical myelograms have been shown to be abnormal with clinical findings.68 in 21% of asymptomatic individuals in a classic study by Hitselberger in 1968.65 More recently, these findings, albeit Electrodiagnosis in the lumbar spine, have been extended to e6 and MR.67 Electrodiagnostic studies are an important adjunct in the Imaging techniques can be a valuable adjunct to the diag- diagnosis of cervical radiculopathy because they identify the nosis and treatment of patients with cervical radiculopathy physiologic abnormality in the nerve root and help determine by defining the structural abnormality leading to the radicu- if a visualized anatomic defect is causing axonal pathology, lopathy, but there is wide agreement that they must be used or if axonal pathology is present in the absence of an ana- only with proper clinical correlation.68,69 There is also tomic defect. The electrophysiologic diagnosis of radic- agreement that further study is needed to define precise algo- ulopathy has been the subject of two recent thorough re- rithms for the most appropriate sequence of performing these views.84,85 imaging studies.68-70 Even when algorithms are proposed, Electromyography is a well proven technique in the evalu- they usually address which technique to use next rather than ation of radiculopathys4 and shows a close correlation with when the study is indicated based on ongoing or changing myelography and operative findings.86 This has been investi- clinical findings. ” The following, therefore, represents the gated more thoroughly in lumbar radiculopathy where EMG authors’ viewpoint using whatever support the literature of- has been found to correlate with surgical or clinical findings fers. as well, or better, than CT or myelography.87-89 EMG in the The cervical spine radiograph can be used as an initial cervical region has been studied by Marinaccig6 who studied screening tool, but need not be performed until treatment is 161 patients in 1966. In this series, the correlation between attempted.72-74An AP and lateral film, including flexion and surgical findings, EMG, or myelogram approached 90%. Ne- extension views, should be performed and are of particular grin and colleaguesW found a concurrence of approximately value in determining spine stability after trauma or in cases 77% between the EMG root abnormality and the level shown of rheumatoid arthritis or ankylosing spondylitis. They may on myelography. Partanen and coworkers” studied 360 pa- detect unsuspected fractures or tumors. The cost effective- tients retrospectively. In 77 of 360 patients who underwent ness of multiple views has been questioned in relation to the both EMG and myelography with subsequent surgery, 26 lumbar spine,69 and cervical spine.75 The value of spinal patients had sensory impairment, and only 34 had motor radiographs in nontraumatic disorders has also been ques- weakness or atrophy. They found an “accurate diagnosis” tioned,73,74*76however, the studies regarding the cervical by EMG in 57% of the patients. Only 36% of their patients spine were performed outside of the United States, and each with a negative EMG showed improvement after surgery. individual practitioner must evaluate the standard of practice However, Partanen’s group did not correlate the EMG abnor- in his or her community. malities with motor weakness. This points out the difficulty

Arch Phys Med Rehabil Vol75, March 1994 CERVICAL RADICULOPATHY, Ellenberg 347 in some of these studies, particularly in view of studies by of a patient with cervical radiculopathy is a clinical decision Hitselberger6’ and Boden67 indicating that large percentages and has not been well studied. of normal individuals may have abnormalities on myelogram The major use of electromyography is to diagnose radicu- or MR of the cervical spine. lopathy in cases where it is uncertain whether the patient The EMG will provide the anatomic distribution of the has any neurologic lesion, or in distinguishing cervical ra- abnormalities thereby facilitating diagnosis and differentiat- diculopathy from other lesions where they cannot be distin- ing cervical radiculopathy from some of the syndromes in the guished clinically. EMG can also be used when it is unclear Differential Diagnosis Section. Careful electromyographic whether the anatomic lesion seen on imaging techniques is examination can help “date” the lesion. The age of the resulting in nerve root pathology. The authors have also used lesion can be roughly approximated using needle electromy- EMG in the industrial setting to distinguish musculoskeletal ography. The first abnormality, which may be seen immedi- from neurologic pain, and in circumstances when the patient ately after motor root compromise, is decreased recruit- appears to be improving clinically, but continues to complain ment.92 Positive waves and fibrillation potentials will first of symptoms. In general, the authors find this an important occur 18 to 21 days after the onset of the radiculopathy.“” test to correlate with the clinical picture and physical find- The fibrillation potentials are larger in early, and smaller in ings, and to substantiate the presence of a radiculopathy. In long-standing peripheral nerve lesions, but within the first 6 patients with less severe clinical findings, performance of months post lesion there is a variability in the amplitude.94 the EMG should be delayed for at least 3 to 4 weeks after The clinical usefulness of this method in cervical radiculopa- symptom onset to permit detection of the positive waves and thy remains unproven. The motor units will increase in size, fibrillation potentials, which would be the hallmark of the duration, and number of phases in radiculopathies where diagnosis in these instances.84 collateral sprouting occurs.84 Some of these changes, particu- larly polyphasia, may occur as early as 3 to 4 weeks after TREATMENT the onset of the lesion.85 In “old” radiculopathies, large motor unit action potentials may be the only abnormal find- There are no medically related outcome studies that have ing.84 The amplitude of the evoked motor response in motor compared operative to nonoperative treatment of cervical conduction studies can help differentiate between axonal loss radiculopathy. One prospective study evaluating various and neuropraxia thereby aiding in determining prognosis.‘7 nonsurgical treatments is The British Association of Physical In the presence of severe motor involvement, sensory con- Medicine Study,“’ which also discussed some of the diffi- duction studies can be useful in distinguishing cervical ra- culties in evaluating treatment of this disorder. The authors diculopathy from a more distal source of paresis. In cervical stated how little is known of the natural history of this com- radiculopathy or root avulsion, the sensory evoked potential mon syndrome, that the patients in their study were a highly will be normal because the root lesion is proximal to the select group, were followed for a maximum of 6 months, dorsal root ganglia,95 whereas with a peripheral lesion (eg, that only certain forms of treatment were investigated, and plexopathy) there may be severe reduction or absence of the only outpatient therapy was used. Consequently, the treat- sensory evoked potential. ment is based on individual experience with various inter- Electrodiagnostic techniques other than standard EMG ventions that have been applied with the description of the and nerve conduction studies are much less useful in the results. evaluation of cervical radiculopathy and need be used only The major objectives of treatment are the reduction or under special circumstances. The H-reflex is consistently resolution of pain, improvement, or resolution of the neuro- obtainable only from the tibia1 nerve, although a number of logical deficit and avoidance of spinal cord complications. studies have convincingly demonstrated that it can be ob- The treatment indicated depends on the patient’s symptoms tained from the median nerve96.y7by placing the active elec- and physical findings. The treatment, including physical trode over the flexor carpi radialis. These have not found therapy prescription, must be specific and is dependent on their way into general electrodiagnostic practice.84 the severity of the symptoms and on the underlying etiology The F-wave, although initially believed to be of value in of the radiculopathy. evaluating cervical radiculopathy,‘” has since been shown to be of limited value.9YZ’00Its usefulness is limited because Activity Limitation there are at least two roots innervating almost every muscle, and the F-response may be traveling along the uninvolved Specific studies comparing outcome with and without lim- root. With mild lesions, even the involved root may have itation on activities or work have not been performed, but sufficient unaffected fibers such that the F-response will still individual patient tolerance in response to treatment should be normal because only between .l% and 20% of axons guide the practitioner. produce the F-response.“’ The usefulness of somatosensory Heavy or moderately heavy activities, and occupations evoked potential (SSEP) testing in the diagnosis of radicu- that require use of the neck in vulnerable positions, such lopathy remains controversial, although theoretically it as extension and ipsilateral flexion and rotation, should be should be of added benefit, especially with pure sensory avoided during the acute stage. Depending on the occupa- lesions.‘02 For a thorough discussion, the reader is referred tion, some patients can continue to work and, on rare occa- to Weichersn5 who outlines all of the issues and cites the sions, can continue with noncontact sporting activities. Pa- numerous studies addressing this technique. tients with severe radiculopathy are usually unable to work Precisely when to use electrodiagnosis in the evaluation and may even require bed rest.

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Neck Positioning and there was no difference in separation at 7, 30, and 60 It has been suggested that the patient must be instructed seconds of tractive force.l17 When a 30-pound tractive force in proper neck position to avoid further irritation of the was used for a period of 7 seconds, with a rest period of 5 involved nerve root. The telephone user must avoid ipsilat- seconds, it was found that the maximum mean vertebral era1 neck flexion. A headset can help eliminate this mo- separation occurred at 25 minutes, and that there was only tion.lo4 The bifocal eyeglass wearers should be instructed minimal anterior cervical separation 20 minutes after traction in proper position of the head to avoid neck extension. In ceased.l18 Although the efficacy of cervical traction has not occupations where close work is necessary at eye level or been proven,‘03 and has even been reported to cause temporo- above, placement of the reading segment at the top of the mandibular joint problems,“’ nevertheless it is commonly lens can result in symptom relief.lo5 When watching theatri- used’20-‘23and is believed by some to be of benefit.lz4 For cal or sporting events, the patient must be instructed in home use, over the door traction may be tried when properly proper positioning, depending on the seating location and, used, for example, with the patient facing the door and with specifically while following a sporting activity, be told not the head flexed at 20 to 30°.‘25 A water bag with 10 pounds to rotate the neck ipsilaterally to the involved side. Sleeping can be used initially with the weight increasing to 20 pounds in a sitting position, either in a lounge chair or in bed with as tolerated. Ten pounds of cervical traction in the seated a bolster for the upper back and with the knees flexed or position counterbalances the weight of the head and 20 with two pillows will suffice to position the head in the pounds is usually an effective distracting force. A home partially flexed position, thereby relieving pain. None of pneumatic traction device may be useful as an alternative to these suggestions have been studied to determine their value. using weight.lz6 Recumbent traction is also useful and may There are many collars that have been studied regarding be more comfortable but is more difficult to set up and apply. the motion restrictions they afford.106-108More rigid collars, The patient must be adequately instructed in the use of home particularly with chin extensions, can provide greater restric- traction because of possible errors in weight and head posi- tion of cervical motion than soft collars, which do not sig- tioning.’ l9 Traction reportedly is contraindicated in patients nificantly restrict flexion and extension.‘09.‘10 The issue of with significant or severe spondylosis who have myelopathy, patient compliance and outcomes with the use of collars that a positive L’Hermittes sign, or rheumatoid arthritis with at- restrict motions have received little attention in the literature. lanto-axial subluxation.“8~‘23 Traction can be used at home In a series of 22 patients comparing two different types of two to three times a day for 15 minutes each time. It can relatively hard collars, there was only a 68% to 72% compli- be continued fewer times per day, for 4 to 6 weeks, even ance rate in the use of the collars.“’ A soft cervical collar after the patient is improved from the point of view of pain can increase patient comfort,“* although it has not been and/or neurologic deficit. In the authors’ experience, some shown to change long-term outcome.‘03Z113The authors pre- patients are benefited by using traction on a long-term basis. scribe soft cervical collars which, together with patient edu- Range of motion exercises of the cervical spine should not cation, can serve to maintain relative flexion of the neck. be used during the acute stage of cervical radiculopathy.‘*’ In Except in rare instances such as the patient with a positive the authors’ opinion, range of motion exercises, particularly L’Hermittes sign, or a person with rheumatoid arthritis and those that mimic Spurling’s maneuver or prolonged neck atlanto-axial subluxation, the attachment, which is usually extension, should be avoided even when the pain abates. the narrower part of the collar, is worn in front, thus main- Exercises that precipitate arm pain should also be avoided taining the neck in a neutral or slightly flexed position. The because there are no controlled studies showing that exercise soft collar should be worn for as long as possible during the will improve outcome or prevent recurrence’ 2 and there is day, using comfort as a guide. As symptoms improve, it can potential for increasing symptomatology or neurologic defi- be worn only while engaged in strenuous activities and while cit. This is particularly true when forceful cervical manipula- driving, and can be discontinued completely when appro- tion is used.‘27 Isometric strengthening neck exercises may priate. It is difficult to judge the exact time to decrease or be used when the pain abates.l*’ Manipulation should not discontinue collar use, but improvement in extremity pain, be used in patients with this problem.128 disappearance of Spurling’s sign, and improvement in motor deficit can be used as guides. In the authors’ opinion, medications should be used spar- ingly. They are indicated for pain relief or presumably to Modalities decrease “inflammation” around the nerve root, although a Thermotherapy may be used for pain relief.114,115It may true inflammatory response at the level of the nerve root or also be used prior to or at the time of cervical traction for disc has not been demonstrated. In patients who are in- muscle relaxation. Cold may be applied for 15 to 30 minutes, structed in proper neck positioning and who use a cervical one to four times a day, or heat for 30 minutes, two to three collar, adequate pain relief is usually achieved with aspirin times a day if the cold is not effective. The decision regard- or other nonsteroidal anti-inflammatory agents.‘03’129Other ing which modality to use is pragmatic, and is often based medications of clinical benefit include diazepam (Valium) 2 on the patient’s perception of pain relief.l16 to 5mg at bedtime, especially in very anxious patients, low Cervical traction is frequently used in patients with cervi- dose tricyclic antidepressants (eg, amitriptyline [Elavil] 10 cal radiculopathy. Intermittent cervical traction can produce to 25mg at bedtime), and narcotic only if needed. a greater separation of the vertebra at a 50-pound than at a It is speculative that in some patients with severe radiculopa- 30-pound force. It has been studied at a 24” angle of pull, thy, of less than 10 days duration, high-dose oral steroids

Arch Phys Med Rehabil Vol75, March 1994 CERVICAL RADICULOPATHY, Ellenberg 349 will rapidly decrease the pain and shorten the course of the therapy.144 Patient progress, depending on severity of the disease; eg, prednisone 60mg daily for 7 days and then taper- problems, should be evaluated every 1 to 3 weeks. As men- ing doses for the 5 following days. The effectiveness of tioned earlier, pain, by careful characterization, and neuro- steroids, as with most interventions in radiculopathy, re- logic deficit using manual muscle and reflex testing are used mains controversial,‘“*-‘“” and has not been thoroughly stud- as guides for patient progress. ied in cervical radiculopathy. Early treatment can include activity modification, cervical collar, medication, thermotherapy, and traction. The patient Epidural Steroids should be strongly advised to avoid any activities (even ther- Instillation of steroids into the cervical epidural space re- apeutic ones) that accentuate the extremity pain, and a well- portedly is of benefit in patients with pain who do not im- informed patient should be part of the decision making pro- prove with the above therapy.134 It must be performed by a cess to help decide the proper sequence of treatment. physician who is well trained and facile in the technique. If symptoms improve with treatment, then activities can Shulman found that 64% of the 25 patients who received no progressively be increased and treatment discontinued or relief from “conservative therapy” underwent 45 e idural decreased. If there is no improvement or worsening of pain steroid injections with good to excellent response.13P War- with a stable neurologic deficit, cervical epidural steroids field and associates’36 treated 16 patients with epidural injec- may be considered. At this point, in the authors’ opinion, tions and noted improvement in pain in 12, and in 6 of these, complete evaluation including MRI and EMG is warranted. improvement in their neurological deficit. The architecture In the 10% to 20% of patients in whom symptoms persist of the cervical spine makes its contents vulnerable to damage despite treatment, surgical intervention should be consid- and thus this procedure is used infrequently and with great ered. There are no guides for how long nonsurgical treatment care in experienced hands. should be continued prior to consideration of surgery, but if neurologic progression or myelopathy are not present, or Surgery neurologic improvement is occurring, patient comfort and ability to return to a normal lifestyle need be the only guides. For discussion of the various surgical approaches, the Neurologic deficit, even in the presence of large disc hernia- reader is referred to the surgical literature.‘7*19,33,42,137-143We tions, has been shown to improve with nonoperative manage- believe the decision to operate should be predicated on the ment in patients with lumbar radiculopathy,‘4”,‘46 and we patient having received appropriate nonsurgical treatment believe the same holds true for cervical radiculopathy. and/or fulfilling clinical requirements, as outlined later. When cervical radiculopathy is documented and accompa- nied by significant upper motor neuron findings in the lower Outcome and Sequence of Treatment limbs, treatment options in sequence are different than that Medically related outcome measures include: pain relief, described above. Treatment of the cervical syndrome with return of neurologic deficit to normal, return to previous myelopathy is beyond the scope of this article. occupation, leisure or sporting activities, and return to full Surgical outcomes vary between 64% and 96% good re- lifestyle. The ideal outcome is return to full pre-illness life- sults. 17,19,.13.‘39.140~141,147Many of the surgical studies, however, style without pain and complete reversal of the neurologic deal with patients who have spondolytic radiculopathy or deficit; a good outcome includes minimal residual neurologic myelopathy, and none clearly delineate the nonoperative deficit and ability to return to work. Martin and Corbin’“4 treatment USed..?3.139.14~).148 treated 61 ambulatory patients with cervical radicular symp- toms nonoperatively and obtained good to excellent results CONCLUSION in 49 (80.3%). Surgery was performed in the remaining 12 patients. Rubin12” reported that 90% of 84 patients with cer- Cervical radiculopathy may have various underlying etiol- vical radiculopathy responded well to nonoperative treat- ogies. Its most common causes are cervical disc herniation ment. Nonoperative treatment was also helpful in providing and cervical spondylosis. It can usually be diagnosed by temporary or more long lasting relief in a majority of patients history and physical examination, and most diagnostic stud- who had pain in the neck and arm.lo3 Sixty-six of 82 patients ies are needed only when the clinical presentation is unusual, (80%) treated by Honet and Puri34 had good to excellent there is poor response to initial treatment, or surgery is con- results with nonoperative treatment. One to two year follow- templated. up on their patients revealed that 71% of the patients with The large majority of patients with single root involve- excellent results continued to do well. None of these studies ment improve with nonsurgical treatment, although which were controlled regarding types of treatment, so no conclu- precise treatment hastens or affords resolution of the disorder sions regarding individual nonoperative treatments can be is not yet determined by carefully controlled studies. Surgery made based on their results. Nevertheless, it may be con- should be considered in patients who have persistent pain cluded when groups of patients with proven cervical radicu- despite careful nonsurgical treatment, progressive weakness, lopathy are treated nonoperatively, ideal outcomes may oc- or new or progressive cervical myelopathy. cur in 80% to 90% of patients.34,‘04,‘29All of the authors analyzed their data retrospectively. References The sequence of treatment should be guided by individual 1. Elliott FA, Kremer M. Brachial pain for herniation of cervical interver- tebral disc. Lancet 1945;1:4-8. history, physical examination, patient needs and circum- 2. Hanflig SS. Pain in the shoulder girdle, arm and precordium due to stances, as well as the progress of disease and result of cervical arthritis. JAMA 1936:106:523-7.

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3. Adson AW. Diagnosis and treatment of lesions of tumors of the spinal 31. Sanchez MC, Arenillas JIC, Gutierrez DA, Alonso JLG, Alvarez JDP. cord. Northwest Med 1925;24:309-17. Cervical radiculopathy: a rare symptom of giant cell arteritis. Arthritis 4. Stookey B. Compression of the spinal cord due to ventral extradural Rheum 1983;26:207-9. cervical chondromas: diagnosis and surgical treatment. Arch Nemo1 32. Fuji T, Yonenobu K, Fujiwara K, et al. Cervical radiculopathy or Psychiatry 1928;20:276-91. myelopathy secondary to athetoid cerebral palsy. J Bone Joint Surg 5. Mixter WJ, Ayer JB. Herniation or rupture of the intervertebral disc 1987;69A:815-21. into the spinal canal. N Engl J Med 1935;9:386-93. 33. Henderson CM, Hennessy RG, Shuey HM, Shackelford EG. Posterior- 6. Mixter WJ, Barr JS. Rupture of the intervertebral disc with involve- lateral foraminotomy as an exclusive operative technique for cervical ment of the spinal canal. N Engl J Med 1934;211:210-5. radiculopathy: a review of 846 consecutively operated cases. Neuro- 7. Semmes RE, Murphey MF. The syndrome of unilateral rupture of the surgery 1983;13(5):504-12. sixth cervical intervertebral disk with compression of the seventh 34. Honet JC, Puri K. Cervical radiculitis: treatment and results in 82 cervical nerve root. A report of four cases with symptoms simulating uatients. Arch Phvs Med Rehabil 1976:57:12-6. coronary disease. JAMA 1943;121:1209-14. 35. koss RE, Corbin KB, McCarthy CS, Love JG. Significance of symp- 8. Spurling RG, Scoville WB. Lateral rupture of the cervical interverte- toms and signs in localization of involved root in cervical disc protru- bral discs. A common cause of shoulder and arm pain. Surg Gynecol sion. Neurology 1957;7:673-83. Obstet 1944;78:350-8. 36. Murphy F, Simmons JCH. Ruptured cervical disc: experience with 9. Michelsen JJ, Mixter WJ. Pain and disability of shoulder and arm due 250 cases. Am Surg 1966;32:83-8. to herniation of the nucleus pulposus of cervical intervertebral disks. 37. Nachlas IW. Pseudo-angina pectoris originating in the cervical spine. N Engl J Med 1944;8:279-87. JAMA 1934;103:323. 10. Frykholm R. Deformities of dural pouches and strictures of dural 38. Booth RE Jr, Rothman RH. Cervical angina. Spine 1976;1:28-32. sheaths in the cervical region producing nerve-root compression. A 39. Hanflig SS. Pain in the shoulder girdle, arm and precordium due to contribution to the etiology and operative treatment of brachial neural- foraminal compression of nerve roots. Arch Surg 1943;46:652-63. gia. J Neurosurg 1947;4:403-13. 40. LaBan MM, Meerschaert JR, Taylor RS. Breast pain: a symptom of 11. Eaton LM. Neurologic causes of pain in the upper extremities with cervical radiculopathy. Arch Phys Med Rehabil 1979;60:315-7. particular reference to syndromes of protruded intervertebral disk in 41. Langfitt TW, Elliott FA. Pain in the back and legs caused by cervical the cervical region and mechanical compression of the brachial plexus. spinal cord compression. JAMA 1967;200(5):112-5. Surg Clin North Am 1946;26:810-33. ^ 42. Bertalanffy H, Eggert HR. Clinical long-term results of anterior disc- 12. Brain WR. Knirrht GC. Bull JWD. Discussion on runture of the inter- ectomy without fusion for treatment of cervical radiculopathy and vertebral disc 1% the cervical region. In: Proceedings of the Royal myelopathy: a follow-up of 164 cases. Acta Neurochir 1988;90:127- Society of Medicine, Section of Neurology 1948;41:509-16. 35. 13. Bland JH. Disorders of the cervical spine. Philadelphia: Saunders, 43. Makin GJV. Brown WF, Ebers GC. C7 Radiculopathy: importance of 1987:9-63. scapular winging in clinical diagnosis. J Neurol Neurosurg Psychiatry 14. Hunt WE, Miller CA. Management of cervical radiculopathy. Clin 1986;49:640-4. Neurosurg 1986;33(29):485-502. 44. Marzo JM, Simmons EH, Kallen F. Intradural connections between 15. Yu YL, Woo E, Huang CY. Cervical spondylitic myelopathy and adjacent cervical spinal roots. Spine 1987;12:964-8. radiculopathy. Acta Neurol Stand 1987;75:367-73. 45. Medical Research Council (MRC). Aids to the investigation of periph- 16. Adams C. Cervical spondylitic radiculopathy and myelopathy. In: eral nerve injuries. 2nd ed, Rev. London: Her Majesty’s Stationery Vinken PJ, Bruyn GW, editors. Handbook of Clinical Neurology. Office, War Memorandum #7, 1943. Amsterdam: North-Holland, 1977:97-112. 46. Viikari-Juntura E, Porras M, Laasonen EM. Validity of clinical tests 17. Heiskari M. Comparative retrospective study of patients operated for in the diagnosis of root compression in cervical disc disease. Spine cervical disc herniation and spondylosis. Ann Clin Res 1989;14:253-7. 1986;18(47):57-63. 47. Ehni B, Ehni G, Patterson RH Jr. Extradural spinal cord and nerve root 18. Odom GL, Finney W, Woodhall B. Cervical disk lesions. JAMA compression from benign lesions of the cervical area. In: Youmans JR 1958;166:23-38. (ed): Neurologic Surgery. Philadelphia: Saunders, 1990:2878-916. 19. Lundsford LD, Bissonette DJ, Jannetta PJ, Sheptak PE, Zorub DS. 48. L’Hermitte J. Etude de la Commation de la Moele. Rev Neurol 1:210- Anterior surgery for cervical disc disease. Part 1: Treatment of lateral 39, 1932. cervical disc herniation in 253 cases. J Neurosurg 1980;53:1-11. 49. Parminder SP. Management of cervical pain. In: DeLisa JA, editor. 20. Scoville WB, Dohrmann GV, Corkill G. Late results of cervical disc Rehabilitation Medicine: Principles and Practice. Philadelphia: Lip- surgery. J Neurosurg 1976;45:203-10. pincott, 1988:753. 21. Herkowitz HN, Kurz LT, Overholt DP. Surgical management of cervi- 50. Favero KJ, Hawkins RH, Jones MW. Neuralgic amyotrophy. J Bone cal soft disc herniation: a comparison between the anterior and poste- Joint Surg 1987;69-B:195-8. rior approach. Spine 1990;15:1026-30. 51. England JD, Sumner AJ. Neuralgic amyotrophy: an increasingly di- 22. Bogduk N, Windsor M, Inglis A. The innervation of the cervical verse entity. Muscle Nerve 1987;10:60-8. intervertebral discs. Spine 198&13:2-S. 52. Dyck PJ, Thomas PK, Lambert EH, Bunge R, editors. Peripheral 23. Inman VT, Saunders JB. Referred pain from skeletal structures. J neuropathy. 2nd ed, Philadelphia: Saunders, 1984, pp 1392-3. Neur Ment Dis 1944;99:660-7. 53. Yergason RM. Supination sign. J Bone Joint Surg 1931;13:160. 24. Adrian ED. The effects of on mammalian nerve fibers. Proc 54. Post M, editor. The shoulder: surgical and non-surgical management. Royal Sot B 1930;106:596-618. Philadelphia: Lea & Febiger, 1978, ch 2, p 21. 25. Howe JF, Loeser JD, Calvin WH. Mechanosensitivity of dorsal root 55. Turek SL, editor. Orthopedics: principles and their applications. Phila- ganglia and chronically injured axons: a physiological basis for the delphia: Lippincott, 1984, ch 23, p 925. radicular pain of nerve root compression. Pain 1977;3:25-41. 56. Upton ARM, McConas AJ. The double crush in nerve entrapment 26. Liversedge LA, Hutchinson EC, Lyons JB. Cervical spondylosis simu- syndromes. Lancet 1973;2:359. lating motor neuron disease. Lancet 1953;2:652-9. 57. Johnson EW, editor. Practical electromyography. 2nd ed. Baltimore: 27. Rappaport ZH, Dever M. Experimental pathophysiological correlates Williams & Wilkins, 1988235. of clinical symptomatology in peripheral neuropathic pain syndromes. 58. Kimura J: Electrodiagnosis in diseases of nerve and muscle: principles Stereotact Funct Neurosurg 1990;54&55:90-95. and practice. 2nd ed. Philadelphia: Davis, 1989;495-516. 28. Vargo MM, Flood KM. Pancoast tumor presenting as cervical radicu- 59. Medic MT, Masaryk TJ, Ross JS. Magnetic resonance imaging of the lopathy. Arch Phys Med Rehabil 1990;71:606-9. spine. New York: Yearbook, 1989, pp 257-71. 29. Poindexter DP, Johnson EW. Football shoulder and neck injury: a 60. Ramirez-Lassepas M, Tulloch JW, Quinones MR, Snyder BD. Acute study of the “stinger.” Arch Phys Med Rehabil 1984;65:601-2. radicular pain as a presenting symptom in multiple sclerosis. Arch 30. Atkinson R, Ghelman B, Tsairis P, Warren RF, Jacobs B, Lavyne M. Neurol 1992;49(3):255-8. Sarcoidosis presenting as cervical radiculopathy. a case report and 61. Brain WR, Northfield D, Wilkinson M. The neurological manifesta- literature review. Spine 1982;7:412-6. tions of cervical spondylosis. Brain 1952;75:187-225.

Arch Phys Med Rehabil Vol75, March 1994 CERVICAL RADICULOPATHY, Ellenberg

62. Tapiovaara J, Heinivaara 0. Correlation of cervico-brachialgias and diagnosis, treatment and prognosis of cervical disc disease: a study roentgenological findings in the cervical spine. Ann Chic et Gynec of I 14 patients. Electromyogr Clin Neurophysiol 1991;3 1: 173-9. Fenniae Suppl 1954;43:436-44. 91. Partanen J, Partanen K, Oikarinen H. Niemitukia L, Hemesniemi J. 63. Friedenberg ZB, Miller WT. Degenerative disc disease of the cervical Preoperative electroneuromyography and myelography in cervical root spine. J Bone Joint Surg 1963;45A:l 17 1-8. compression. Electromyogr Clin Neurophysiol 1991;31:21-6. 64. Gore DR, Sepic SB, Gardner GM. Roentgenographic findings of the 92. Eisen H. Electrodiagnosis of radiculopathies. In: Aminoff MJ. editor. cervical spine in asymptomatic people. Spine 1986;11(6):521-4. Neurologic clinics: symposium on electrodiagnoses, 1985:3(3):495- 6.5. Hitselberger WE. Witten RM. Abnormal myelograms in asymptomatic 10. patients. J Neurosurg lY68;28:204-6. 93. Johnson EW, editor. Practical electromyography. 2nd rd. Baltimore: 66. Wrisel SE, Tsourmas N, Feffer H, Citrin CM. Patronas N. A study Williams & Wilkins. 1988:229-45. of computer-assisted tomography--I. The incidence of positive CAT 94 Kraft GH. Fibrillation potential amplitude and muscle atrophy follow- scans in an asymptomatic group of patients. Spine 1984;9:549-5 1. ing peripheral nerve injury. Muscle and Nerve 19YO:13(9):814-21. 67 Boden SD, McCowin PR, Davis DO, Dina TS, Mark AS, Wiesel S. 95 Goss CM, editor. Gray’s anatomy of the human body. 29th ed. Phila- Abnormal magnetic-resonance scans of the cervical spine in asymp- delphia: Lea and Febiger, 1973:1466. tomatic subjects. J Bone Joint Surg 19YO;72A: 1178-84. 96 Jabre JF. Surface recording of the H-reflex elf the Hexor carp, radialia. 68 Simon JE, Lukin RR. Diskogenic disease of the cervical spine. Semin Muscle Nerve I98 I ;4:435-4 I. Roentgen lY88;23(2): 118-24. 97 Schimsheimer RJ. Ongerboer BW. Visser DE, Kemp B. The Hexor 69 Bates D. Ruggieri P. Imaging modalities for evaluation of the spine. carpi rddialis H-reHex in lesions of the sixth and seventh cervical Radio1 Clin North Am lY91;29(4):675-90. nerve roots. J Neurol Neurosurg Psychiatry 1985:48:445-Y. 70 Deyo RA, Bigos SJ. Maravilla KR. Diagnostic imaging procedures 98 Fisher MA, Shidve AJ, Teixera C, et al. The F-response-a clinically for the lumbar spine. Ann Intern Med 1989; I1 I( I I ):865-7. useful physiological parameter for the evaluation of radicular injury 71 Hyman RA. Corey MT. Imaging strategies for MR of the spine. Radio1 Electromyogr Clin Neurophysiol 1979;19:65-75. Clin North Am lY88;16(3):505-33. YY Eisen A. Aminoff MJ. Somatosensory evoked potentials. In: Aminofi 72. Russell EJ. Cervical disc disease. Radiology 1990;177:313-25. MJ. editor. Electrodiagnosis in clinical neurology. 2nd ed. New York. 73 Heller CA, Stanley P, Lewis-Jones B. Heller RF. Value of x-ray Churchill Livingstone, 1986:535-73. examinations of the cervical spine. Br Med J 1983;287:1276-8. 100 Leblhuber F, Reisecker F. Boehm-Jurkovic H. et al. Diagnostic value 14 Page JE. Olliff JFC. Dundas DD. Value of anterior posterior radiogra- of different electrophysiologic tests in cervical disk prolapse. Neurol- phy in cervical pain of non-traumatic origin. Br Med J 1989;298: 129% ogy 1988:3X: 1879-E I. 4. 101 Stalberg E. Trontelj J. Single fiber electromyography. Woking. UK, 75. MacPherson P. MacPherson ELS. Cervical spondylosis-routine Mirvalle, 1979. oblique film\ are unnecessary. Health Bulletin of Edinburgh 102 Eisen A. Hoirch M. The electrodiagnostic evaluation of spinal root 1981;3’:89-Y I. lesions. Spine 1983:8:98-104. 76. Gehweiler JA. Jr. Daffner RH. Low back pain: the controversy of 103 British Association of Physical Medicine. Pain In the neck and arm radiologic evaluation. Am J Roentgen01 1983: 140: IO9- 12. a multicentre trial of the effects of physiotherapy. Br Med .I 17. Daniels DL. Grogan JP. Johansen JG. Meyer GA. Williams AL. 1966:1:253-8. Haughton VM. Cervical radiculopathy: computed tomography and 104. Martin GM, Corbin KB. Evaluation of conservative treatment for myelography compared. Radiology 1984;lS 1: 109-l 3. patients with cervical disc syndrome. Arch Phys Med Rehabil 78. Medic MT, Masaryk TJ. Mulopulos GP. Bundschuh C. Han JS, Bohl- 1954:35:87-92. man H. Cervical radiculopathy: prospective evaluation with surface 105 Johnson EW, Wolfe CV. Bifocal spectacles in the etiology of cervicai coil MR imaging, CT with metrizamide, and metrizamide myelogra- radiculopathy. Arch Phys Med Rehabil lY72;53:201-5. phy. Radiology 1986: 161:753-Y. 106 Hartman JT. Palumbo F. Hill BJ. Cineradiography of the braced nor 79. Larsson E-M, Holtas S, Cronqvist S. Brandt L. Comparison of my- ma1 cervical spine: comparative study of five commonly used cervical elography. CT myelography and magnetic resonance imaging in cervi- orthoses. Clinical Orlhop 1975: 109:97- 102. cal spondylosls and disk herniation. Pre- and postoperative findings. 107. Johnson RM. Hart DL. Simmons EF. Ramsby GR. Southwick WO Acta Radiologica 198Y:30:233-9. Cervical orthoses. a study comparing their effectiveness in restricting 80. Nakstad PH. Hald JK. Bakke SJ, Skalpe IO, Wiberg J. MRI in cervical cervical motion in normal subjects. J Bone Joint Surg 1977:59:332 disk hemiation. Neuroradiology 1989;31:382-5. Y. 81. Wilson DW, Pezzuti RT. Place JN. Magnetic resonance imaging in 108. Podolsky S, Baraff LJ, Simon RR. et al. Efficacy of cervical spinr, the preoperative evaluation of cervical radiculopathy. Neurosurgery immobilization methods. J Trauma 1983;23(6):461-4. I YYI ;28: 175.9. 109. Cola&s SC. Strohm BR, Ganter EL. Cervical spine motion in normal 81. Manelfe C. Imaging of the spine and spinal cord. Radiology 199 l:3:5- women: radiographic study of effect of cervical collar>. Arch Phy\ IS. Med Rehabil 1973;54: 161-9. 83. Russell EJ. D‘Angelo CM, Zimmerman RD. Czervionke LF, Huck- I IO. Hartman JT. Palumbo F. Hill JB. Cineradiography of the braced no, man MS. Cervical disk herniation: CT demonstration after contrast ma1 cervical spine. A comparative study of five commonly used cervi- enhancement. Radiology 1984;152:703-12. cal orthoses. Clin Orthop Rel Res 1975:109:97-102. 84. Wilbourn AJ, Aminoff MJ. The electrophysiologic examination in Ill. Marr J. Edmond V. Cervical orthoses: the issue of patient compliance. patients with radiculopathies. AAEE Minimonograph #32. Muscle & J Neuroscience Nursing 1990:22(2): 104.7. Nerve 1988:!1:1OYY-I 114. 112. Naylor JR. Mulley GP. Surgical collars: a survey of their prescription 85. Wiechers DO. Radiculopathies. In: Dumitm D, editor. Clinical electro- and use. Br J Rheumatol 1991;30:282-84. physiology: physical medicine and rehabilitation. State of the Art 113. Huston GJ. Collars and corsets. Br Med J 1988;296:276. Reviews. lYXY;3(4):713-24. 114. Lehmann JF. DeLateur BJ. Therapeutic heat. In: Lehmann JF. editor-. 86. Marinacci AA. A correlation between operative findings in cervical Therapeutic heat and cold. 3rd ed. Baltimore: William & Wilkim. herniated disc with electromyograms and opaque myelograms. Elec- 1983:313-4. tromyography 1966:6:5-20. 115. Michlovitz S. Cryotherapy: the use of cold as a therapeutic agent. 87. Brady LP. Parker B. Vaughen J. An evaluation of the electromyogram In: Michlovitz S, editor. Thermal agents in rehabilitation. 2nd ec!. in the diagnosis of the lumbar disc lesion. J Bone Joint Surg Philadelphia: Davis, 1990:88-108. I969;5 1(A):S39-47. 116. Lehmann JF. Brunner GD, Stow RW. Pain threshold measurements 88. Khatri BO. Baruah 3. McQuillen MP. Correlation of electromyography after therapeutic application of ultrasound, microwaves and infrared. with computed tomography in evaluation of lower back pain. Arch Arch Phys Med Rehabil 1958:39:560-S. Neurol 1984:41:594-7. 117. Colachis SC, Strohm BR. Cervical traction: relationship of traction 89. Schoedinger III GR. Correlation of standard diagnostic studies with time to varied tractive force with constant angle. Arch Phys Med surgically proven lumbar disk rupture. South Med J 1987;80:44-6. Rehabil 1965:46:8 15-9. 90. Negrin P. Leili S, Fardin P. Contribution of electromyography to the 118. Colachis SC. Strohm RR. Effect of duration of intermittent cervical

Arch Phys Med Rehabil Vol75, March 1994 352 CERVICAL RADICULOPATHY, Ellenberg

traction on vertebral separation. Arch Phys Med Rehabil 1966;47:353- 135. Shulman J. Treatment of neck pain with cervical epidural steroid 9. injection. Reg Anesth 1986;11:92-4. 119. Shore NA, Schaefer MG, Hoppenfeld S. Iatrogenic TMJ difficulty: 136. Watlield CA, Biber MP: Crews DA, Dwarakanath GK. Epidural ste- cervical traction may be the etiology. J Prosth Dentistry 1979;41:541- roid injection as a treatment for cervical radiculitis. Clin J Pain 2. 1988:4:201-4. 120. Tan JC, Nordin M. Role of physical therapy in the treatment of cervi- 137. Dillin W, Booth R, Cuckler J, Balderston R, Simeone F, Rothman R. cal disk disease. Orthop Clin North Am 1992;23(3):435-49. Cervical radiculopathy: a review. Spine 1986; 11:998- 1. 121. Caldwell JW, Krusen EM. Effectiveness of cervical traction in treat- 138. Cloward RB. Lesions of the intervertebral discs and their treatment ment of neck problems: evaluation of various methods. Arch Phys by interbody fusion methods. Clin Orthop 1963;27:51-7. Med Rehabil 1962;43:214-21. 139. DePalma AF. Subin DK. Study of cervical syndrome. Clin Orthop 122. Goldie I, Landquist A. Evaluation of the effects of different forms of 1965;38:135-42. physiotherapy in cervical pain. Stand J Rehabil Med 1970:2(2): I 17- 140. Murphey F, Simmons JCH. Btunson B. Surgical treatment of laterally 21. ruptured cervical disc: review of 648 cases, 1939 to 1972. J Neurosurg 123. Hinterbuchner C. Traction. In: Basmajian JV, editor. Manipulation, 1973;38:679-83. Bollati A, Galli G, Gandolfini M. Marini G, Gatta G. Microsurgical traction and massage. 3rd ed. Baltimore: Williams & Wilkins, 141. anterior cervical disc removal without interbody infusion. Surg Neurol 1985:175-95. 1983;19:329-33. 124. Rath W. Cervical traction: a clinical perspective. Orthop Rev 142. Bertalanffy H, Eggert HR. Complications of anterior cervical discec- 1984;13:430-49. tomy without fusion in 450 consecutive patients. Acta Neurochir 125. Colachis SC, Jr, Strohm BR. Study of tractive forces and angles of 1989;99:41-50. pull on vertebral interspaces in cervical spine. Arch Phys Med Rehabil 143. Manabe S. Tateishi A. Epidural migration of extruded cervical disc 1965;46:820-30. and its surgical treatment. Spine 1986;11:873-8. 126. Waylonis GW, Denhart C, Grattan MMP. Wapenski JA. Home cervi- 144. Garvey TA. Eismont FJ. Diagnosis and treatment of cervical radicu- cal traction: evaluation of alternate equipment. Arch Phys Med Reha- looathv and mvelooathv. Orthoo Rev 1991:20:595-603. bil 1982;63:388-91. 145. Eilenberg M. kein’a N: Ross M. Chodoroff G, Honet JC, Gross N. 121. Schmidley JW, Koch T. The noncerebrovascular complications of Regression of herniated nucleus pulposus: two patients with lumbar chiropractic manipulation. Neurology 1984;34:684-5. radiculopathy. Arch Phys Med Rehabil 1989;70:842-4. 128. Treanor WJ. Reviewer’s comments. Patient Care 1984;86:89-90. 146. Ellenberg MR, Ross ML, Honet JC, Schwartz M. Chodoroff G, 129. Rubin D. Cervical radiculitis: diagnosis and treatment. Arch Phys Enochs S. Prospective evaluation of the course of disc hemiations in Med Rehabil 1960;41:580-6. patients with proven radiculopathy. Arch Phys Med Rehabil 130. Haimovic IC. Beresford HR. Dexamethasone is not superior to pla- 1993;74:3-8. cebo for treating lumbosacral radicular pain. Neurology 1986; 147. Wiberg J. Effects of surgery on cervical spondylotic myelopathy. Acta 36:1593-4. Neurochir 1986;8 1: 113-7. 131. Green LN. Dexamethasone in the management of symptoms due to 148. Amasson 0, Carlsson CA, Pellettieri L. Surgical and conservative herniated lumbar disc. J Neural Neurosurg Psychiatry 1975;38: 1211- treatment of cervical spondylotic radiculopathy and myelopathy. Acta 7. Neurochir 1987:84:48-53. 132. Green LN. Steroids for lumbar radiculopathy [letter]. Neurology 149. Mayo Clinic and Mayo Foundation. Clinical examinations in neurol- 1987;37: 1689-90. ogy. 5th ed. Philadelphia: Saunders, 1981. 133. Longstreth Jr WT. Steroids for lumbar radiculopathy [letter]. Neurol- 150. Hollinshead WH. Anatomy for surgeons. the back and limbs. vol 3. ogy-1987:37:1690. 2nd ed. New York: Harper & Row. 1969. 134. Rowlingson JC, Kirschenbaum LP. Epidural techniques in 151 Williams PL, Warwick R, Dyson M. Bannister LH, editors. Gray’s the management of cervical pain. Anesth Analg 1986;65:938-42. anatomy. 37th ed. Edinburgh: Churchill Livingstone, 1989: 1151.

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