Cervical Radiculopathy

Normal Anatomy Cervical spinal nerves exit via the intervertebral foramen Intervertebral foramen is the gap between the facet joint and vertebral body Cervical nerves are named corresponding to the vertebral body below, up to C8 nerve root which exits between C7 and T1

Pathophysiology Cervical radiculopathy is a syndrome of radiating pain and sensory and/or motor deficit due to compression or injury of a cervical nerve root Injury or compression of the nerve root can be caused by anything that occupies the intervertebral foraminal space Radiculopathy – state of neurological loss i.e sensation, reflex, motor due to blocked axon conduction in the nerve Radicular pain – pain that arises due to irritation of the spinal nerve or nerve root

Mechanism Of Injury Insidious – Degenerative Disc Disease/Spondylosis – Intervertebral Disc Herniation – Osteophytes – Ossification of longitudinal ligament – Instability – Tumor Traumatic – Road Traffic Accident – Direct impact or compression

Subjective Paraesthesia, numbness or motor changes in a nerve root pattern +/- arm pain Neck and/or scapular pain Coughing and sneezing may worsen the pain or tingling in the arm Aggravated by long static position, first thing in the morning or ipsilateral rotation Pain may be unrelenting causing restlessness and loss of sleep May find short term relief by raising the arm above the head

Objective Pain and/or aggravation of neurological symptoms with movements that close down intervertebral foramen (Extension, ipsilateral rotation, ipsilateral side flexion) Reduced sensation, power and reflex’s in a nerve root pattern Abnormal upper limb tension testing Rarely movements towards the side of pain relieve symptoms Antalgic postures that correspond to unloading of sensitive neural tissues

Special Tests Spurling’s test Valsalva Maneuver Shoulder abduction sign Upper limb tension test Neck distraction

Clinical prediction rule Positive findings on 3 of the following: Positive Spurlings test Positive distraction test Ipsilateral cervical spine rotation less than 60 degrees. Positive upper limb tension test-median nerve bias.

Further Investigation MRI CT myelography Electromyography or nerve conduction studies

General Management Conservative management usually effective in Education on cause of pain very important in these cases Priority to improve neurological or peripheral symptoms

Conservative Management Reduce Inflammation – Ice, NSAID’s, Massage Restore Normal ROM – Cervical, Thoracic and Shoulder – Soft Tissue Techniques – Joint mobilisations, manipulations, tractions – Neurodynamic mobilisations – Cervical and Thoracic Stretches Restore Normal Muscle Activation – Cervical, Thoracic and Shoulder/Scapular – Deep Cervical flexors and extensors, scapular stabilisers Restore Dynamic Stability and Proprioception Global shoulder girdle strengthening

Surgical Management Indications of surgery – Failure of conservative management after at least weeks trial – Progressive neurological deficit Epidural Steroid injection Anterior decompression and fusion Discectomy with or without fusion Posterior laminoforaminotomy Facetectomy