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Home , Nerve root, Radicular pain, Radiculopathy

This is a corrected version of the article that appeared in print.

Cervical : Nonoperative Management of and Radicular Symptoms JASON DAVID EUBANKS, MD, Case Western Reserve University School of Medicine, Cleveland, Ohio

Cervical radiculopathy is a disease process marked by com- pression from herniated disk material or arthritic bone spurs. This impingement typically produces neck and radiating arm pain or numbness, sensory deficits, or motor dysfunction in the neck and upper extremities. Magnetic resonance imaging or computed tomo- graphic myelography can confirm neurologic compression. The overall prognosis of persons with cervical radiculopathy is favor- able. Most patients improve over time with a focused, nonoperative treatment course. There is little high-quality evidence on the best nonoperative therapy for cervical radiculopathy. Cervical collars may be used for a short period of immobilization, and traction may temporarily decompress nerve impingement. Medications may help alleviate pain and neuropathic symptoms. and manipulation may improve neck discomfort, and selective nerve blocks target pain. Although the effectiveness of individ- ual treatments is controversial, a multimodal approach may benefit patients with cervical radiculopathy and associated . (Am Fam Physician. 2010;81(1):33-40. Copyright © 2010 American Acad-

emy of Family Physicians.) ILLUSTRATION JOHN BY KARAPELOU W.

ervical radiculopathy leads to disk protrusion on imaging. , disk neck and radiating arm pain or protrusion, or both caused nearly 70 percent numbness in the distribution of of cases. a specific nerve root. Often, this Cradicular pain is accompanied by motor or Pathoanatomy sensory disturbances. Although the causes A variety of conditions can lead to nerve of radiculopathy are varied (e.g., acute disk root compression in the cervical spine. Each herniations, cervical spondylosis, foraminal motion segment in the subaxial spine (C3 narrowing), they all lead to compression and through C7) consists of five articulations, irritation of an exiting cervical nerve root. including the intervertebral disk, two facet joints, and two neurocentral (uncovertebral) Epidemiology joints. Bounded by these elements, the nerve An epidemiologic survey showed the annual roots exit laterally. age-adjusted incidence of radiculopathy to be Unlike the spine, the cervical 83 per 100,000 persons.1 Persons reporting spine has cervical nerve roots that exit above radiculopathy were between 13 and 91 years the level of the corresponding pedicle. For of age, and men were affected slightly more instance, the C5 nerve root exits at the C4- than women. In this study, 14.8 percent of C5 disk space, and a C4-C5 disk herniation persons with radiculopathy reported ante- typically leads to C5 radiculopathy. There are cedent physical exertion or trauma, and only seven cervical vertebrae and eight cervical 21.9 percent had an accompanying objective nerve roots. In the lumbar spine, the nerve

JanuaryDownloaded 1, 2010 from the◆ Volume American 81, Family Number Physician 1 website at www.aafp.org/afp.www.aafp.org/afp Copyright © 2010 American Academy of FamilyAmerican Physicians. Family For the private,Physician noncom 33- mercial use of one individual user of the website. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. SORT: KEY RECOMMENDATIONS FOR PRACTICE

Evidence Clinical recommendation rating References

Acute A short period (one week) of immobilization in a cervical collar may relieve C 9 radicular pain. Home cervical traction units may provide temporary relief of radicular pain. C 10, 11 Opioids may help alleviate neuropathic pain of up to eight weeks duration. A 13, 14 In patients with cervical radiculopathy, exercises and manipulation should C 17-19 focus on stretching and strengthening after the acute pain has subsided. Selective nerve root blocks may relieve radicular pain, but rare serious B 20-24 complications may occur. Chronic radicular pain Antidepressants (tricyclic antidepressants, and venlafaxine [Effexor]) and A 15, 16 tramadol (Ultram) may alleviate chronic neuropathic pain.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evi- dence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.xml.

exits below the corresponding pedicle. There- decompresses the exiting nerve root. Table 1 fore, an analogous lumbar disk herniation presents the classic patterns of cervical radic- (L4-L5) would compress the traversing nerve ulopathy based on the affected nerve root.3,4 root (L5), not the exiting root (L4). Whether Before diagnosing cervical radiculopathy, in the cervical spine or the lumbar spine, physicians should consider other potential the nerve impingement typically occurs in causes of pain and dysfunction (Table 2).2,4 the nerve numerically corresponding to the Myelopathic symptoms or signs (e.g., dif- lower of the two vertebral levels. ficulty with manual dexterity; gait distur- The exiting nerve root can be compressed bance; objective, upper motor neuron signs by herniated disk material (soft disk her- such as Hoffman sign, Babinski sign, hyper- niation) or through encroachment by sur- rounding degenerative or hypertrophic bony elements (hard disk pathology). In either case, a combination of factors, such as inflammatory mediators (e.g., substance P), changes in vascular response, and intra­ neural edema, contribute to the development of radicular pain.2

Clinical Presentation Chronic neck pain associated with spondy- losis is typically bilateral, whereas neck pain associated with radiculopathy is more often unilateral.3 Pain radiation varies depending on the involved nerve root, although some distributional overlap may exist. Absence of radiating extremity pain does not preclude nerve root compression. At times, pain may be isolated to the .3 Similarly,

sensory or motor dysfunction may be present HARTSOCK MARCIA BY ILLUSTRATION without significant pain. Symptoms are often Figure 1. Spurling sign. Axial compression of exacerbated by extension and rotation of the the spine and rotation to the ipsilateral side of symptoms reproduces or worsens cervical neck (Spurling sign; Figure 1), which decreases radiculopathy. Pain on the side of rotation is the size of the neural foramen. Holding the usually indicative of foraminal stenosis and arm above the head (shoulder abduction sign) nerve root irritation.

34 American Family Physician www.aafp.org/afp Volume 81, Number 1 ◆ January 1, 2010 Table 1. Classic Patterns of Cervical Radiculopathy

Abnormalities Nerve root Interspace Pain distribution Motor Sensory Reflex

C4 C3-C4 Lower neck, trapezius NA Cape distribution NA (i.e., lower neck and upper shoulder girdle) C5 C4-C5 Neck, shoulder, lateral Deltoid, elbow Lateral arm Biceps arm flexion C6 C5-C6 Neck, dorsal lateral Biceps, wrist Lateral forearm, Brachioradialis (radial) arm, thumb extension thumb C7 C6-C7 Neck, dorsal lateral Triceps, wrist Dorsal forearm, Triceps forearm, middle flexion long finger finger C8 C7-T1 Neck, medial forearm, Finger flexors Medial forearm, NA ulnar digits ulnar digits T1 T1-T2 Ulnar forearm Finger intrinsics Ulnar forearm NA

NA = not applicable. Information from references 3 and 4. reflexia, and clonus) may suggest compres- or symptoms of systemic disease; unrelent- sion of the rather than nerve root. ing pain at rest; constant or progressive Spinal cord compression typically requires signs or symptoms; neck rigidity without surgical decompression because myelopa- trauma; dysphasia; impaired consciousness; thy is progressive and does not improve with signs and symp- nonoperative measures. The following fac- toms; increased risk of ligament laxity or tors may also indicate an alternate diagno- atlantoaxial instability, such as in patients sis: age younger than 20 years or older than with Down syndrome or heritable connec- 50 years, especially if the patient has signs tive tissue disorders; sudden onset of acute

Table 2. Differential Diagnosis of Cervical Radiculopathy

Condition Characteristics

Cardiac pain Radiating upper extremity pain, particularly in the left shoulder and arm, that has possible cardiac origin Cervical spondylotic Changes in gait, frequent falls, bowel or bladder dysfunction, difficulty using the hands, stiffness of the myelopathy extremities, sexual dysfunction accompanied by upper motor neuron findings Complex regional pain Pain and tenderness of the extremity, often out of proportion with examination findings, accompanied by syndrome (reflex skin changes, vasomotor fluctuations, or dysthermia; symptoms often occur after a precipitating event sympathetic dystrophy) Entrapment syndromes For example, () and cubital tunnel syndrome () Herpes zoster () Acute inflammation of creates a painful, dermatomal radiculopathy Intra- and extraspinal tumors Schwannomas, osteochondromas, Pancoast tumors, thyroid or esophageal tumors, lymphomas, carcinomatous meningitis Parsonage-Turner syndrome Acute onset of proximal upper extremity pain, usually followed by weakness and sensory disturbances; (neuralgic amyotrophy) typically involves upper Postmedian sternotomy lesion Occurs after cardiac ; C8 radiculopathy may develop secondary to an occult fracture of the first thoracic rib Rotator cuff pathology Shoulder and lateral arm pain Median and ulnar nerve (lower brachial plexus nerve roots, C8 and T1) dysfunction from compression by vascular or neurogenic causes, often a tight band of tissue extending from first thoracic rib to C7 transverse process

Information from references 2 and 4.

January 1, 2010 ◆ Volume 81, Number 1 www.aafp.org/afp American Family Physician 35 Cervical Radiculopathy

and unusual neck pain or headache with or Natural History without neurologic symptoms; suspected Most patients with cervical radiculopathy cervical artery dissection; transient ischemic have a favorable prognosis.1,6 A large epide- attack, which may indicate vertebrobasilar miologic study demonstrated that over a five- insufficiency or carotid artery ischemia or year follow-up period, 31.7 percent of patients stroke; suspected neoplasia; suspected infec- with symptomatic cervical radiculopathy tion, such as diskitis, osteomyelitis, or tuber- had symptom recurrence and 26 percent culosis; failed surgical fusion; progressive needed surgical intervention for intractable or painful structural deformity; abnormal pain, sensory deficit, or objective weakness.1 laboratory examination results.5 At final follow-up, however, nearly 90 percent of patients were asymptomatic or only mildly Diagnostic Evaluation incapacitated by the pain. Adults who have persistent neck pain and The classic study of the natural history of radicular symptoms should receive antero- cervical radiculopathy followed 51 patients posterior open-mouth, anteroposterior lower over two to 19 years.6 In the study, 43 per- cervical, and neutral lateral radiography.5 If cent of patients had no further symptoms a period of nonoperative management fails after a few months, 29 percent had mild or in patients with suspected cervical radicu- intermittent symptoms, and 27 percent had lopathy and normal radiography findings, more disabling pain. No patient with radicu- further diagnostic studies may be needed to lar pain progressed to myelopathy. direct treatment. If it is unclear whether the patient has cervical radiculopathy or entrap- Nonoperative Management Strategies ment syndrome in the upper extremity, elec- In most patients with cervical radiculopathy, tromyography may be helpful. In the presence nonoperative treatment (Figure 32,5) is effective. of normal radiography findings and contin- In a one-year cohort study of 26 patients with ued symptoms, magnetic resonance imaging documented herniated nucleus pulposus and (MRI) should be performed to evaluate for a symptomatic radiculopathy, a focused, non- disk herniation with or without compressive, operative treatment program was successful spondylotic (Figure 2). Com- in 92 percent of patients.7 Little high-quality puted tomographic myelography may be used evidence supports the use of an individual instead of MRI in patients with a pacemaker nonoperative treatment; however, a multi- or stainless steel cervical hardware. modal approach may alleviate symptoms.

A B

Figure 2. T2-weighted magnetic resonance imaging in a patient with right-sided C6 radiculopathy. (A) Sagittal view showing spondylosis at C5-C6 and C6-C7 disk levels (arrows). (B) Axial view showing a right-sided disk- complex at C5-C6 disk level (arrow) that is putting pressure on the C6 nerve root.

36 American Family Physician www.aafp.org/afp Volume 81, Number 1 ◆ January 1, 2010 Cervical Radiculopathy

Nonoperative Treatment of Acute Cervical Radiculopathy

Acute radicular pain

Nonprogressive neurologic Red flag symptoms, progressive deficit or no neurologic deficit neurologic deficit, or signs of myelopathy

Anteroposterior open-mouth, Anteroposterior, lateral, and anteroposterior lower cervical, flexion-extension cervical and neutral lateral radiography spine radiography; MRI

Refer to spine subspecialist

Osseous destruction Normal radiography findings or signs of instability

MRI, medical workup, referral to Nonoperative management spine subspecialist for two weeks

Resolving symptoms: continue No improvement nonoperative management

Unchanged symptoms Questionable diagnosis Progressive deficit

Continue nonoperative Refer to spine subspecialist management for four weeks

Reevaluation

Improvement No improvement

Counsel patient on the MRI natural history of the disease

Positive findings consistent with Negative findings clinical symptoms and signs

Refer to a rheumatologist or Refer to spine subspecialist pain subspecialist as needed

Figure 3. Algorithm for nonoperative treatment of acute cervical radiculopathy. (MRI = mag- netic resonance imaging.) Adapted with permission from Levine MJ, Albert TJ, Smith MD. Cervical radiculopathy: diagnosis and nonoperative manage- ment. J Am Acad Orthop Surg. 1996;4(6):312, with additional information from reference 5.

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When approaching the nonoperative radiculopathy. Although medications have management of neck and radicular pain, it no proven benefit for cervical radiculopathy, is important to distinguish the acuity of the positive results with their use in the treat- process. Pain emanating from nerve com- ment of lumbar radiculopathy and low back pression by a soft disk herniation typically pain suggest a potential role. Nonsteroidal has a more acute presentation, with or with- anti-inflammatory drugs have been shown out radiating extremity symptoms. Chronic, to be effective in treating acute low back bilateral axial neck and radiating arm pain pain,3,12 and many physicians consider them is usually caused by cervical spondylosis first-line agents in the treatment of neck and may emanate from a variety of sources, and radiating arm pain. Some patients may including the degenerative disk or the facet benefit from the addition of narcotic anal- joints. Although education about these and gesics, muscle relaxants, antidepressants, or other components of cervical radiculopa- anticonvulsants. Although not specific to thy may benefit some patients, a systematic cervical radiculopathy, a systematic review review did not show that patient education and a meta-analysis suggest that opioids may (i.e., advice focusing on activation and cop- be effective in the treatment of neuropathic ing skills, and traditional neck school) is pain of up to eight weeks duration.13,14 Insuf- beneficial in the treatment of neck pain and ficient evidence exists to recommend treat- radicular arm pain.8 ment beyond two months. Muscle relaxants (e.g., cyclobenzaprine [Flexeril]) may allevi- IMMOBILIZATION ate acute neck pain from increased tension at For patients with acute neck pain secondary muscle insertion sites.2 to radiculopathy, a short course (one week) of Medications may be effective for patients neck immobilization may reduce symptoms with chronic radicular pain who decline sur- in the inflammatory phase.2 Although the gery or have continued pain after surgery. effectiveness of immobilization with a cer- A systematic review suggests that tricyclic vical collar has not been proven to alter the antidepressants and venlafaxine (Effexor) course or intensity of the disease process,2,3,9 may produce at least moderate relief in it may be beneficial in some patients. patients with chronic neuropathic pain.15 Similarly, another systematic review sug- TRACTION gests that tramadol (Ultram) may provide Home cervical traction units may decrease significant relief of neuropathic pain.16 radicular symptoms.2,3,10 In theory, traction Although oral steroids are widely used to distracts the neural foramen and decom- treat acute radicular pain via dose packs, presses the affected nerve root. Typically, no high-quality evidence has shown that eight to 12 lb of traction is applied at an angle oral steroids alter the disease course.3 Long- of approximately 24 degrees of flexion for term use of steroids should be avoided 15- to 20-minute intervals.2 Traction is most because of the potential for rare, but serious, beneficial when acute muscular pain has complications.3,12 subsided and should not be used in patients who have signs of myelopathy.2 A recent sys- PHYSICAL THERAPY AND MANIPULATION tematic review of mechanical traction for A graduated physical therapy program may neck pain of more than three months dura- be beneficial in restoring range of motion tion, with or without radicular symptoms, and overall conditioning of the neck mus- found insufficient evidence to recommend culature. In the first six weeks after onset of for or against its use in the management of pain, gentle range-of-motion and stretch- chronic symptoms.11 ing exercises supplemented by massage and modalities such as heat, ice, and electri- PHARMACOTHERAPY cal stimulation may be used, although this Pharmacotherapy may be beneficial in alle- approach has no proven long-term benefit. viating acute pain associated with cervical As the pain improves, a gradual, isometric

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strengthening program may be initiated Referral with progression to active range-of-motion Approximately one third of patients with cer- and resistive exercises as tolerated.3 vical radiculopathy who are treated nonop- No high-quality evidence has proved the eratively have persistent symptoms.6 Patients effectiveness of manipulative therapy in the should be referred to a spine subspecialist for treatment of cervical radiculopathy. How- consideration of surgical intervention if there ever, limited evidence suggests that manipu- is intractable radicular symptoms unrespon- lation may provide short-term benefit in the sive to nonoperative management over a six- treatment of neck pain, cervicogenic head- week period, motor weakness aches,3,17 and radicular symptoms.18 Rare persisting for more than six Little high-quality complications, such as worsening radicu- weeks, progressive neurologic evidence supports the use lopathy, myelopathy, and spinal cord injury, deficit at any point after symp- of individual nonopera- may occur.3,19 Because of these risks and the tom onset, signs or symptoms tive treatments for cervical lack of high-quality evidence to support its of myelopathy, or instability or effectiveness, manipulative therapy cannot deformity of the spine.25 The radiculopathy; however, a be recommended for the treatment of cervi- Washington State Department multimodal approach may cal radiculopathy. of Labor and Industries’ criteria alleviate symptoms. for initiating surgical manage- STEROID INJECTIONS ment are six to eight weeks of conservative Cervical steroid injections may be consid- care (i.e., physical therapy, medications, or ered in the treatment of radicular pain. traction); subjective sensory symptoms or Cervical perineural injections (e.g., trans- Spurling sign, objective motor, reflex, or elec- laminar and transforaminal epidurals, selec- tromyography findings; and abnormal imag- tive nerve root blocks) should be performed ing findings that correlate with the patient’s under radiographic guidance and only after symptoms.26 Alternatively, in the rare patient confirmation of pathology via MRI or com- who has radicular pain without objective puted tomography. These blocks attempt to or electromyography bathe the affected nerve root in steroids. One findings, a selective nerve root block may be study demonstrated significant pain relief at used. If the nerve block is “positive,” or effec- 14 days and six months after a series of selec- tive in partially alleviating symptoms, then tive nerve root blocks.20 In another prospec- surgery may be considered. tive cohort series of 21 patients awaiting surgery for symptomatic radiculopathy, cer- The Author vical injections improved pain and reduced JASON DAVID EUBANKS, MD, is an assistant professor in 21 the need for operative intervention. More the Department of Orthopaedic Surgery, Division of Spine recently, however, a prospective, random- Surgery, at Case Western Reserve University School of ized study of 40 patients showed no differ- Medicine in Cleveland, Ohio. At the time this manuscript was written, Dr. Eubanks was a spine fellow at the Univer- ence after three weeks between patients who sity of Pittsburgh (Pa.) Medical Center. received a steroid injection and those who were in the control groups.22 Complications Address correspondence to Jason David Eubanks, MD, Dept. of Orthopaedics, University Hospitals Case Medi- associated with cervical injections are rare. cal Center, 11100 Euclid Ave., Cleveland, OH 44106. One study of a series of more than 1,000 Reprints are not available from the author. blocks showed a minor complication rate of Author disclosure: Nothing to disclose. 1.66 percent and a major adverse events rate 23 of less than 1 percent. However, patients REFERENCES should be advised that these rare events 1. Radhakrishnan K, Litchy WJ, O’Fallon WM, Kurland LT. may be severe (e.g., spinal cord or Epidemiology of cervical radiculopathy. A population- damage). A recent review of the literature based study from Rochester, Minnesota, 1976 through suggests that epidural corticosteroids may 1990. Brain. 1994;117(pt 2):325-335. 2. Levine MJ, Albert TJ, Smith MD. Cervical radiculopathy: lead to short-term, symptomatic improve- diagnosis and nonoperative management. J Am Acad ment of radicular symptoms.24 Orthop Surg. 1996;4(6):305-316.

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3. Rhee JM, Yoon T, Riew KD. Cervical radiculopathy. J Am 17. Hurwitz EL, Aker PD, Adams AH, Meeker WC, Shek- Acad Orthop Surg. 2007;15(8):486-494. elle PG. Manipulation and mobilization of the cervical 4. Polston DW. Cervical radiculopathy. Neurol Clin. 2007; spine. A systematic review of the literature. Spine. 25(2):373-385. 1996;21(15):1746-1759. 5. Bussières AE, Taylor JA, Peterson C. Diagnostic imaging 18. Haneline M. manipulation in the presence practice guidelines for musculoskeletal complaints in of acute cervical herniation. Dynamic adults—an evidence-based approach—part 3: spinal dis- Chiropractic. 1999;17(25). orders. J Manipulative Physiol Ther. 2008;31(1):33-88. 19. Malone DG, Baldwin NG, Tomecek FJ, et al. Compli- 6. Lees F, Turner JW. Natural history and prognosis of cer- cations of cervical spine manipulation therapy: 5-year vical spondylosis. Br Med J. 1963;2(5373):1607-1610. retrospective study in a single-group practice. Neuro- surg Focus. 2002;13 (6):ecp1. 7. Saal JS, Saal JA, Yurth EF. Nonoperative management of herniated cervical intervertebral disc with radiculopa- 20. Vallée JN, Feydy A, Carlier RY, Mutschler C, Mompoint D, thy. Spine. 1996;21(16):1877-1883. Vallée CA. Chronic cervical radiculopathy: lateral- approach periradicular corticosteroid injection. Radiol- 8. Haines T, Gross A, Burnie SJ, Goldsmith CH, Perry ogy. 2001;218(3):886-892. L. Patient education for neck pain with or without radiculopathy. Cochrane Database Syst Rev. 2009(1): 21. Kolstad F, Leivseth G, Nygaard OP. Transforaminal CD005106. steroid injections in the treatment of cervical radicu- lopathy. A prospective outcome study. Acta Neurochir 9. Naylor JR, Mulley GP. Surgical collars: a survey of their (Wien). 2005;147(10):1065-1070. prescription and use. Br J Rheumatol. 1991;30(4): 282-284. 22. Anderberg L, Annertz M, Persson L, Brandt L, Säveland H. Transforaminal steroid injections for the treatment of 10. Swezey RL, Swezey AM, Warner K. Efficacy of home cervical radiculopathy: a prospective and randomised cervical traction therapy. Am J Phys Med Rehabil. 1999; study. Eur Spine J. 2007;16(3):321-328. 78(1):30-32. 23. Ma DJ, Gilula LA, Riew KD. Complications of fluoro- 11. Graham N, Gross A, Goldsmith CH, et al. Mechanical scopically guided extraforaminal cervical nerve blocks. traction for neck pain with or without radiculopathy. An analysis of 1036 injections. J Bone Joint Surg Am. Cochrane Database Sys Rev. 2008;(3):CD006408. 2005;87(5):1025-1030. 12. Deyo RA. Drug therapy for . Which drugs help 24. Carragee EJ, Hurwitz EL, Cheng I, et al. Treatment of which patients? Spine. 1996;21(24):2840-2849. neck pain: injections and surgical interventions: results 13. Eisenberg E, McNicol E, Carr DB. Opioids for neuropathic of the Bone and Joint Decade 2000-2010 Task Force on pain. Cochrane Database Sys Rev. 2006;(3):CD006146. Neck Pain and Its Associated Disorders. Spine. 2008; 14. Eisenberg E, McNicol ED, Carr DB. Efficacy and safety 33(4 suppl):S153-169. of opioid agonists in the treatment of neuropathic 25. Albert TJ, Murrell SE. Surgical management of cervi- pain of nonmalignant origin: systematic review and cal radiculopathy. J Am Acad Orthop Surg. 1999;7(6): meta-analysis of randomized controlled trials. JAMA. 368-376. 2005;293(24):3043-3052. 26. Washington State Department of Labor and Industries. 15. Saarto T, Wiffen PJ. Antidepressants for neuropathic Medical treatment guidelines. Review criteria for cervical pain. Cochrane Database Sys Rev. 2007;(4):CD005454. surgery for entrapment of a single nerve root. June 2004. 16. Hollingshead J, Dühmke RM, Cornblath DR. Trama- http://www.lni.wa.gov/ClaimsIns/Files/OMD/Med dol for neuropathic pain. Cochrane Database Sys Rev. Treat/SingleCervicalNerveRoot.pdf. Accessed August 2006;(3):CD003726. 26, 2009.

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