Clinical Intelligence

Sarah McCartney, Richard Baskerville, Stuart Blagg and David McCartney

Cervical radiculopathy and cervical myelopathy: diagnosis and management in primary care

INTRODUCTION by narrowing of the spinal canal. It is important in primary care to be able to Common causes include disc herniation, differentiate between cervical spine disease spondylosis, and congenital stenosis, often that can be managed conservatively and in combination. The compression causes that associated with neurological symptoms upper and lower motor and sensory suggestive of more serious disease, which neurone symptoms of the arms and legs, may require urgent surgery. This article will and the onset is often insidious. cover key points in the history, examination, and management of patients with neck RED FLAGS and neurological symptoms, with particular Given the high prevalence of benign non- reference to cervical myelopathy and specific neck pain, it is essential to first radiculopathy. highlight the red flags that have been The prevalence of neck pain in the developed to aid clinicians in identifying general population is high: it has been serious spinal pathology requiring urgent estimated that 30–50% of adults will treatment. In addition to cord compression experience neck pain in any given year,1 such as cervical myelopathy, it is important with the average GP estimated to consult to recognise cancer, infection, or trauma- with seven people per week for neck or related presentations. upper extremity symptoms.2 Neck pain A serious underlying cause is more likely with abnormal neurology (usually cervical in people presenting with new symptoms radiculopathy) is much less common: it before the age of 20 years or after the age has been estimated to affect around 100 of 55 years, weakness involving more than per 100 000 males and 60 per 100 000 one myotome, or loss of sensation involving females.3 Cervical myelopathy is even rarer more than one dermatome. but is worthy of discussion given that it Red flags particularly suggestive of requires urgent management and needs to cancer, infection, or inflammation are be identified from among the many cases malaise, fever, unexplained weight loss, pain of neck and neurological symptoms that a that is increasing, is unremitting, or disturbs GP sees on a regular basis — the incidence sleep, a history of inflammatory arthritis, of cervical myelopathy is poorly quantified cancer, tuberculosis, immunosuppression, S McCartney, MRCS, specialty trainee in but studies have estimated it to be around drug abuse, AIDS, or other infection. trauma and orthopaedics; S Blagg, FRCS, 4 per 100 000.4 On examination the presence of consultant spinal surgeon, Stoke Mandeville lymphadenopathy or exquisite localised Hospital, Aylesbury, and president, British Association of Spine Surgeons. R Baskerville, DEFINITIONS tenderness over a vertebral body should FRCS, MRCGP, academic GP; D McCartney, Cervical radiculopathy is due to raise suspicion that there could be a serious MRCP, MRCGP, clinical research fellow, compression or irritation of either or underlying cause for the pain. Nuffield Department of Primary Care Health both of the dorsal (sensory) and ventral Sciences, University of Oxford, Oxford. CERVICAL MYELOPATHY Address for correspondence (motor) roots of a cervical nerve at one or Sarah McCartney, Department of Trauma more vertebral levels. Compression can Although the least common, this article and Orthopaedics, Great Western Hospital, result from intervertebral disc herniation, addresses this condition first given Marlborough Road, Swindon, SN3 6BB, UK. osteophyte formation, or other mass the potential consequences of failure of E-mail: [email protected] effects near the exit foramen of the cervical recognition. The presenting features of Submitted: 6 June 2017; Editor’s response: spine. This results in lower motor neurone cervical myelopathy (cord compression) 1 July 2017; final acceptance: 1 September symptoms and often presents with arm are often non-specific — symptoms such 2017. ©British Journal of General Practice 2018; pain, weakness, and/or sensory loss, with as clumsiness of hands and feet, decreased 68: 44–46. or without associated neck pain. manual dexterity, and an unsteady gait. https://doi.org/10.3399/bjgp17X694361 Cervical myelopathy is spinal cord Cervical pain may be present but its absence dysfunction due to compression caused does not exclude this diagnosis. Patients

44 British Journal of General Practice, January 2018 will often describe difficulty undertaking A focused musculoskeletal and common everyday tasks such as holding a neurological examination is necessary to Box 1. Key abnormal findings cup or climbing the stairs. These difficulties differentiate between radiculopathy and 1 in radiculopathy can be associated with symptoms such myelopathy. Additional examination of the C5: deltoid and biceps weakness, reduced as numbness and tingling in the hands shoulder will help to exclude a primary biceps reflex. and feet. Asking about urinary and bowel shoulder problem from referred pain from C6: brachioradialis and wrist extensor function is essential as alterations of cervical radiculopathy.7 In those presenting weakness, reduced brachioradialis reflex, these may be an indication of severe cord with radicular symptoms, the myotomes thumb paraesthesia. compression. and dermatomes of the upper limb can be C7: triceps and wrist flexion weakness, Examination is important in cervical assessed as described in Box 1. diminished triceps relex, paraesthesia in index, middle, and ring fingers. myelopathy and is key to suspecting the MANAGEMENT AND WHEN TO REFER C8: weakness of distal phalanx flexion (keep diagnosis. Both the upper and lower your fingers curled), little finger paraesthesia. limbs should be examined as cervical For cervical myelopathy, any positive myelopathy causes upper motor neurone signs or symptoms warrant an immediate signs, particularly in the legs (brisk reflexes referral as this condition often requires and Babinski reflex). The Babinski reflex is urgent surgical decompression to prevent Box 2. What to tell my patient positive when the big toe is up-going. Other further neurological deterioration. This is about radiculopathy? eponymous upper motor neurone signs most appropriately referred by telephoning The British Association of Spinal Surgeons such as Hoffmann’s test have been reported the on-call orthopaedic or spinal registrar. (BASS) patient information leaflet on nerve to have a low sensitivity.5 Weakness can be Decompression is achieved using an root pain says that 75% of patients get better difficult to detect but clonus (more than anterior cervical decompression and in 28 days but low-grade symptoms may 3 beats) is highly suggestive of cervical fusion (ACDF) or posterior laminectomy or sometimes persist for several months. It gives the encouragement that there is a 90% myelopathy. Romberg’s test may be laminoplasty. chance that radiculopathy will not recur within positive, especially in more severe cases: Many cases of cervical radiculopathy, 10 years.8 the patient become unbalanced when even with neurological symptoms, will standing with arms stretched forward and resolve spontaneously and can initially eyes closed. Toe-heel walking is difficult in be managed conservatively, as with non- cervical myelopathy. specific neck pain (Box 2). Early distinction There is, though, a wide differential for between the two is therefore not essential these symptoms and signs and patients and patients often accept this clinical suspected to have cervical myelopathy uncertainty, although for some a descriptive may later be diagnosed with a primary label provides reassurance and for the neurological condition such as multiple clinician a management framework. sclerosis, motor neurone disease, or Physiotherapy in combination with home Parkinson’s disease. exercises for 6 weeks substantially reduces neck and arm pain compared with a wait- CERVICAL RADICULOPATHY and-see approach in the early phase.9 Although in practice it may be difficult to The National Institute for Health and distinguish between non-specific neck Care Excellence (NICE)6 suggests simple pain and cervical radiculopathy (without analgesia (ibuprofen, paracetamol, or objective signs), the distinction between codeine) and a trial of a neuropathic agent the two is worthy of discussion given that (amitriptyline, pregabalin, or gabapentin) guidelines6 recommend earlier referral, for those with neurological signs or imaging, and use of neuropathic agents for symptoms lasting over a month. However, cervical radiculopathy (see below). the guideline acknowledges that there is Pain is a common presenting symptom little specific evidence supporting the use for cervical radiculopathy and is classically of any of the agents in neck pain and its sited in the neck with radiation down recommendation is based on extrapolation the shoulder and arm in a dermatomal from other non-neck pain studies. distribution. A more generalised non- If symptoms of cervical radiculopathy dermatomal arm ache, occipital headache, persist for longer than 4 to 6 weeks, or or inter-scapular pain are other common there is earlier evidence of abnormal presentations. neurology, referral for imaging or specialist Asking about associated motor or assessment should be considered.6 sensory symptoms can help discriminate Cervical spine radiographs are unlikely non-specific neck pain from cervical to be useful in making a diagnosis and are radiculopathy. The sensory symptoms are not recommended.6 Magnetic resonance most usually unilateral with dermatomal imaging (MRI) is the investigation of numbness or tingling (C5–C7 levels are choice, although the prevalence of most commonly affected). Motor symptoms, asymptomatic degenerative disease in although less common, are also usually people >30 years old is high, so findings unilateral and in a myotomal distribution. must always be correlated with the clinical

British Journal of General Practice, January 2018 45 picture to avoid overdiagnosis. Therefore, a non-urgent referral to a spinal clinic (or Box 3. Take home message open-access MRI if local guidelines allow) The physician should ask about lower-limb is appropriate even in the presence of lower symptoms when patients have neck pain and/ motor neurone signs. It is recommended or upper-limb neurology. Identifying signs or that non-specific neck pain lasting longer symptoms of abnormal neurology in the legs will help the physician not to miss a problem than 3 months is referred to a pain clinic such as cervical myelopathy, which could with or without a trial of neuropathic agents. require urgent surgery. When considering a referral to a spinal clinic, it is important to remember that there is not clear evidence of surgical treatment REFERENCES presenting with bilateral neurology, gait for cervical radiculopathy providing better 1. Carroll LJ, Hogg-Johnson S, van der Velde G, disturbance, or bowel or bladder problems et al. Course and prognostic factors for long-term outcomes than non-operative (with or without neck pain), should be neck pain in the general population: results measures,10 but it may provide some benefit of the Bone and Joint Decade 2000–2010 discussed urgently with the on-call spinal in a very carefully selected population. In a Task Force on Neck Pain and Its Associated or orthopaedic team. These conditions small prospective randomised control trial Disorders. J Manipulative Physiol Ther 2009; highlight the importance of meticulous 32(2 Suppl): S87–S96. comparing ACDF and physiotherapy with clinical assessment to discern red-flag 2. Bot SD, Van der Waal JM, Terwee CB, et al. physiotherapy alone in patients referred to diagnoses from much more commonly Incidence and prevalence of complaints of the a secondary care clinic, over 90% of patients neck and upper extremity in general practice. occurring muscular and positional causes treated with ACDF and physiotherapy rated Ann Rheum Dis 2005; 64(1): 118–123. of simple neck pain. their symptoms as at least ‘better’ over 3. Radhakrishnan K, Litchy WJ, O’Fallon WM, Kurland LT. Epidemiology of cervical long-term follow-up compared with around 11 radiculopathy. A population-based study from 60% of patients in the non-surgical group, Funding Rochester, Minnesota, 1976 through 1990. suggesting some benefit of surgical Brain 1994; 117(Pt 2): 325–335. David McCartney is funded by a National intervention. 4. Nouri A, Tetreault L, Singh A, et al. Institute for Health Research In-Practice Degenerative cervical myelopathy: Fellowship. epidemiology, genetics, and pathogenesis. CONCLUSION Spine 2015; 40(12): E675–E693. Non-specific neck pain is common and Provenance 5. Grijalva RA, Hsu FP, Wycliffe ND, et al. can be managed conservatively. Although Freely submitted; externally peer reviewed. Hoffmann sign: clinical correlation of less common, those with an isolated Competing interests neurological imaging findings in the cervical radiculopathy can be initially managed in a spine and brain. Spine 2015; 40(7): 475–479. The authors have declared no competing similar manner to those with non-specific 6. National Institute for Health and Care interests. Excellence. Neck pain — cervical neck pain with referral to a routine outpatient radiculopathy. 2015. https://cks.nice.org.uk/ spinal clinic (or for MRI) if conservative Discuss this article neck-pain-cervical-radiculopathy#!scenario measures fail. However, patients with Contribute and read comments about this (accessed 30 Nov 2017). much rarer cervical myelopathy (Box 3), article: bjgp.org/letters 7. Artus M, Holt TA, Rees J. The painful shoulder: an update on assessment, treatment, and referral. Br J Gen Pract 2014; DOI: https://doi.org/10.3399/bjgp14X681577. 8. Sell P, Longworth S, Haynes J. Nerve root pain and some of the treatment options. British Association of Spine Surgeons, 2012. http://www.spinesurgeons.ac.uk/patients/ patient-information/nerve-root-pain-and- some-of-the-treatment-options (accessed 30 Nov 2017). 9. Kuijper B, Tans JT, Beelen A, et al. Cervical collar or physiotherapy versus wait and see policy for recent onset cervical radiculopathy: randomised trial. BMJ 2009; 339: b3883. 10. 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 2008; 33(4 Suppl): S101–S122. 11. Engquist M, Löfgren H, Öberg B, et al. A 5- to 8-year randomized study on the treatment of cervical radiculopathy: anterior cervical decompression and fusion plus physiotherapy versus physiotherapy alone. J Neurosurg Spine 2017; 26(1): 19–27.

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