Cervical Radicular Pain and Radiculopathy

Written by: Dr Jeremy Steinberg – created: 20 August 2020; last modified: 11 March 2023

This page is probably complete!

It is awaiting peer review

MRI T2 axial image showing right paramedian C6/7 disc protrusion compressing the right C7 nerve root
Cervical Radicular Pain and Radiculopathy
Definition	Cervical radicular pain: Pain perceived as arising in a limb or the trunk wall caused by ectopic activation of nociceptive afferent fibers in a spinal nerve or its roots or other neuropathic mechanisms. Cervical Radiculopathy: Objective loss of sensory and/or motor function as a result of conduction block in axons of a spinal nerve or its roots.
Epidemiology	Peak incidence 50-54 years old
Causes	"Hard" and "Soft" processes. C6 and C7 nerve roots most commonly involved.
Pathophysiology	Radiculopathy: Nerve root compression Radicular pain: Nerve root inflammation or dorsal ganglion compression
Risk Factors	Diving, coughing, heavy lifting
Clinical Features	Pain in dynatomal distribution; numbness in dermatomal distribution, weakness in myotomal distribution, hyporeflexia; positive special tests.
Tests	MRI cervical spine
Treatment	Conservative, physiotherapy, analegisa, epidural corticosteroid, decompression and fusion.
Prognosis	Generally good

Cervical radicular pain is pain perceived as arising in a limb or the trunk wall caused by ectopic activation of nociceptive afferent fibres in a spinal nerve or its roots or other neuropathic mechanisms. Cervical radiculopathy is the objective loss of function in some combination of sensory loss, motor loss, or impaired reflexes, in a segmental distribution. Pain is not a component of radiculopathy, and so it can be helpful to distinguish it from cervical radicular pain. (See also Cervical Spine Pain Definitions and Radicular Pain and Radiculopathy to be clear on taxonomy)

Pathophysiology

Less is known about the causes and mechanisms of cervical radicular pain compared to lumbar radicular pain.

Mechanism of Pain and Radiculopathy

See also: Radicular Pain and Radiculopathy, Cervical Discs

The literature often uses the term cervical radiculopathy, but radiculopathy and radicular pain are not synonymous.

Most of what we know about these entities comes from research in the lumbar spine. Less is known about the causes and mechanisms of cervical radicular pain compared to lumbar radicular pain with there being no equivalent experimental data. Therefore most of what we know is through extrapolation.

Radiculopathy arises from either direct compression of a cervical spinal nerve or root, or by ischaemia from vascular injury to their blood supply. There is a conduction block along the affected axons which results in sensory or motor loss. Compression of axons, including those of the lumbar nerve roots, does not cause activity in nociceptive afferent fibres. Meanwhile, compression of a dorsal root ganglion does cause pain through activation of Aβ, Aδ, and C fibres. The causes of cervical radicular pain cannot therefore be attributed to the same causes as those of radiculopathy.

It is thought that inflammation of the cervical nerve roots is the underlying mechanism through which radicular pain occurs secondary to disc herniation. Pro-inflammatory molecules have been found in herniated disc material (nitric oxide, metalloproteinases, interleukin-6, and prostaglandin E2) however unlike with lumbar radicular pain it hasn't been explicitly shown that cervical radicular pain is inflammatory in origin.

Meanwhile, inflammation cannot be the cause of pain in other causes of radicular pain when due to tumours, cysts, and osteophytes. In these conditions it must be through dorsal root ganglion compression that pain occurs, as these conditions are non-inflammatory in nature.

Disc protrusions can be "soft" or "hard."

Soft Protrusions

Soft protrusions refer to nucleus pulposus being extruded into the vertebral canal. The extrusion can be medial or lateral.

With medial protrusions the effect is primarily on the spinal cord and myelopathy may occur, while pain is uncommon or inconspicuous.

With lateral protrusions there is impingement on the spinal nerve and its roots in the intervertebral foramen, and this is regularly associated with pain.

Hard Protrusions

This is when disc material protrudes posteriorly transversely as a fibrocartilaginous transverse bar or ridge, ossified protrusion, or are covered by osteophytes extending from the vertebral endplate margins. These usually occur as part of spondylosis. There may be additional mass effect from osteophytosis of the zygapophysial joints.

Hard protrusions can narrow the vertebral canal and/or the intervertebral foramina.

Mixed Picture

The term "disc-osteophyte complex" (DOC) is sometimes used for mixed processes of the cervical spine (never used for the lumbar spine). This is because it is very difficult to distinguish between disc and osteophyte on T2 weighted images as they both appear dark. However this is a controversial term.

Those that dislike the term argue that knowing whether it is disc (that may resorb) or osteophyte (that won't resorb) can change prognosis and surgical decision making. Disc and osteophyte can be differentiated with gradient-echo (GRE) low flip-angle thin-section axial scans or CT, where osteophytes are dark and discs are relatively bright.

Those that advocate for the term argue that it is often impossible to say for sure what the microscopic pathology is,  that it is better to be open that one is unsure, management decision making varies widely, and if it is truly important to decision making then a CT should be requested.

Aetiology

Possible causes of cervical radiculopathy (different to radicular pain)

• Disc
  • Protrusion
  • Herniation
  • Osteophytes
• Facet joint
  • Osteophytes
  • Ganglion
  • Tumor
  • Rheumatoid arthritis
  • Gout
  • Ankylosing spondylitis
  • Fracture
• Vertebral body
  • Tumor
  • Paget’s disease
  • Fracture
  • Osteomyelitis
  • Hydatid
  • Hyperparathyroidism
• Meninges
  • Cysts
  • Meningioma
  • Dermoid cyst
  • Epidermoid cyst
  • Epidural abscess
  • Epidural hematoma
• Blood vessels
  • Angioma
  • Arteritis, vasculitis with nerve root infarction
• Nerve sheath
  • Neurofibroma
  • Schwannoma
• Nerve
  • Neuroblastoma
  • Ganglioneuroma
  • Nerve root avulsion
• Infectious or granulomatous
  • Herpes zoster
  • Tuberculosis
  • Syphilis
  • Brucelosis
  • CMV
  • Histiocytosis
  • Sarcoid
  • Lyme disease
• Infiltration
  • Lymphoma
  • Carcinomatous meningitis
• Acute demyelination
  • Early Guillain-Barré syndrome
• Diabetes Mellitus

The most common cause of cervical radiculopathy is intervertebral disc herniation. It is not completely clear why some people with disc herniation develop radiculopathy while others don't but it appears that an inflammatory response can lead to neurophysiologic dysfunction.

The second most common cause is degenerative change. This includes ligamentous hypertrophy, hyperostosis, disc degeneration, facet joint hypertrophy, and uncovertebral joint hypertrophy. Hypertrophy of the latter two structures can lead to foraminal stenosis and nerve root compression. Osteophytosis can also be involved in compression.

Other causes are less common such as facet joint cysts, trauma, haematomas, fibroproliferation, and various tumours.

Nondegenerative causes or cervical radiculopathy or polyradiculopathy includes diabetes mellitus, infection (especially herpes zoster) nerve root infarction, root avulsion, tumour or granulomatous tissue infiltration, and demyelination.

Epidemiology

The most commonly affected nerve roots are C6 and C7, with C7 being slightly more common. The pre-test probability of C7 is 54%. C4 and C8 are rare. C5 is variable.

Using a broad definition of definite, probable, and possible cases, the average annual age-adjusted incidence was reported to be 83.2 per 100,000 per year in a study of 561 patients. For definite cases the incidence was 38.4 per 100,000 per year. The peak incidence is 50-54 years old, where it reaches 202.9 per 100,000, and declines rapidly after age 60. It is more common in males than females at 107.3 vs 63.5 per 100,000 respectively

Trauma is alleged as the cause in less than 20% of cases. It is unclear whether the rates of trauma are higher in New Zealand due to the medico-legal context leading to patients paying higher attention to mechanical factors.

Cervical radiculopathy due to "hard" processes (68.4% due to spondylosis, disc, or both) is higher than due to "soft processes" (21.9% due to disc protrusion).

Risk factors associated with cervical disc prolapse are diving, coughing and heavy lifting. There is a trend with golfing, smoking, manual labour, driving, and using vibrating tools. There is no evidence for an association with psychosocial factors.

There is a past history of lumbar radiculopathy in 41%.

Clinical Features

Radicular pain is strongly associated with neurological signs, such as numbness, weakness and hyporeflexia. Neck pain alone, or pain in the shoulder girdle or proximal regions of the upper arm is more likely to be somatic referred pain (see Acute Neck Pain and Chronic Neck Pain)

Summary of clinical symptoms in cervical radiculopathy.

Symptom	Proportion (%)
Arm pain	97–99
Sensory deficit	85–91
Reflex deficit	71–84
Neck pain	56–80
Motor deficit	64–70
Periscapular pain	37–52
Anterior chest pain	18
Headaches	10

Pain Pattern

Figure 1. Dynatomal pain patterns in cervical radicular pain.

Figure 2. Referred scapula pain. (a)C5 and C8 cutaneous nerves traverse up and down the spine of the scapula, respectively, whereas the courses of C6 and C7 cutaneous nerves are not found.
(b) The site of radicular pain involving the C6 root overlaps with that of the C5 root, and also involves the posterior deltoid.

The pattern of cervical radicular pain is not dermatomal, but rather dynatomal (figure 1). The pain is typically in the neck (89% in one surgical series) and arm , but can also be felt in the head, shoulder girdle, and the anterior chest.

• With dorsal root pain the quality is described as lightning or electric-shocks, with radiation along the entire length of the upper arm. Proximally the pain is diffuse, but peripherally it is distinct where it typically involves the hand.
• With ventral root pain the pain is never felt distally. It is deep and boring, and perceived over the scapula and/or dorsal arm.

Proximal pain in the scapula and shoulder girdle usually precedes pain in the arm and/or fingers (figure 2). This is analogous to the common finding of buttock pain with lumbar radicular syndrome. The reason it is not dermatomal is likely due to the pain not being restricted to cutaneous fibres, but there is also a deeper pain arising from the muscles and joints.

The segmental innervation of the skin (dermatomes) is different to that of the deeper tissues. The muscles of the shoulder girdle are supplied by C6 and C7, very different to their dermatomes. See C6 and C7 columns in the complete myotome chart, and note how for example latissimus dorsi receives innervation from C6-C8. As such, the segmental innervation of the muscles is more closely related to the radicular pain patterns than the segmental innervation of the skin (dermatomes). Dermatomes are more helpful for patterns of sensory loss in radiculopathy.

The site of scapula pain may be a helpful data point in determining the affected level in cervical radicular pain (table 1). Mizutamari et al suspect that scapula pain occurs through the medial branches of the dorsal rami of the cervical nerves. They found that there was no cutaneous course of C6 and C7 and that these patients complained of deep scapula pain only. This is compared to patients with C5 and C8 lesions having both superficial and deep pain.

Table 1. Mizutamari et al found the following pain referral pattern:

Nerve root	Shoulder Girdle Region	Deep or superficial
C5	Suprascapular region	Superficial and deep pain
C6	Suprascapular to posterior deltoid region	Deep pain
C7	Interscapular region	Deep pain
C8	Interscapular and scapular regions	Superficial and deep pain

Slipman and colleagues coined the term dynatomal pain to describe radicular pain patterns. They purposefully stimulated the nerve roots of patients with cervical radicular syndromes and diligently recorded the pain patterns (figure 1). They found that while there was overlap with dermatomes, symptoms frequently were perceived outside of dermatomal regions.

• Pain in the lateral or posterior upper arm is most likely to be C7 radiculopathy, although C6 can also present with lateral limb posterior arm pain.
• Pain or paraesthesia in lateral forearm is typically C6 or C7 (most likely C7), NOT C5 C8.
• Pain or paraesthesia in medial or posterior forearm C7 or C8 (most likely C7), NOT C5 C6
• Forearm pain or paraesthesia is most likely C7

Neurological Examination

Figure 3. Sensory impairment in C6 and C7 radiculopathy. The asterix indicates the only area where there is a statistical difference, with impaired in the distal radial aspect of the dorsal forearm more common in C6 than C7 radiculopathy. Based off data from Rainville et al.

Patients with cervical radicular pain often have a concomitant radiculopathy and so warrant a neurological examination. The neurological examination is used to determine the severity of the condition, identify signs of myelopathy, and potentially determine the location of the lesion.

Cervical radiculopathy is typically characterised by negative objective signs: sensory loss, motor loss, or impaired reflexes, which occur in a segmental distribution. It may be possible to determine the affected level based on the neurological examination.

Sensory loss in surgically proven disc prolapse was present in 25% in one study (method of exam not defined), and and 85% in another (pin prick). The sensory loss occurs in the upper limbs, and classically has been described to be dermatomal in distribution. The likelihood ratios can be calculated from Yoss's study: thumb sensory loss has a +LR of 8.5 for C6, middle finger loss is not significant for C7, and little finger sensory loss has a +LR of 41.4 for C8. However a more recent study with better methodology found that C6 and C7 could not be differentiated based on dermatomes alone (figure 3).

The reliability of sensory loss has a Kappa score of 0.45-0.64.

If a patient only has sensory signs then the weight of the evidence suggests that the segmental level can't be determined with any level of accuracy, perhaps with the exception of sensory loss of the little finger for C8. (See also Dermatomes).

Paraesthesias are present with or without pain in 90% of surgically proven radiculopathy due to disc prolapse. None of the patterns of paraesthesias are pathognomonic. 45% of patients are unable to localise the paraesthesias with diffuse and/or non-dermatomal symptoms. Some of these patients may have combined C6 and C7 radiculopathy further complicating matters.

The classic distribution of paraesthesias is as follows:

• C5: Generally no hand paraesthesias, however the lack of hand paraesthesias can also occur with C6 and C7.
• C6: Thumb or index finger is C6. However C7 is also possible.
• C7: Middle finger is generally C7 with or without the thumb, index, and middle fingers. Index finger alone is generally C7.
• C8: Ring, little finger +/- the middle finger is generally C8. However C7 is also possible.

Weakness can be subjective or objective and occurs in a myotomal pattern. In patients with surgically proven radiculopathy, in one study subjective weakness was present in 34% and objective weakness in 75%, while another study found objective weakness in 68%.

• Weakness of elbow flexion is suggestive of C5 radiculopathy with a +LR of 5.3
• Weakness of the wrist extension and/or elbow flexion is suggestive of C6 radiculopathy with a +LR of 2.3
• Weakness of the elbow extension is suggestive of C7 radiculopathy with a positive LR of 4.0
• Weakness of finger flexion is suggestive of C8 radiculopathy with a positive LR of 3.8

The myotomal pattern of innervation is different to the dermatomal pattern of innervation. Because of the myotomes also supply proximal shoulder girdle muscles this can be used to differentiate between a proximal lesion (spinal nerve or root) versus a lesion in a peripheral nerve (radial, ulnar, median, etc). A peripheral nerve lesion is not going to cause proximal motor weakness. So patients with cervical motor radiculopathy may have scapular winging in addition to distal weakness.

Hyporeflexia can occur with lateral protrusions, while hyperreflexia can occur with medial protrusions. Reflex loss is present in approximately three quarters of patients with surgically proven radiculopathy. Reflex loss can aid in distinguishing the spinal level. (See also Reflex Testing).

• A loss of biceps or brachioradialis reflex has a +LR of 14.2 for C6 radiculopathy (but can also occur in C5),
• A loss of triceps reflex has a +LR of 3 for a C7 radiculopathy (but can also occur in C8).

Myelopathy: It is important to examine for and document the presence or absence of any long tract signs suggesting cervical myelopathy, including gait, Hoffman's, Babinski, clonus, hyperreflexia, and spasticity. Enquiry should also be made as to bowel and bladder functoin.

Special Tests

Spurling's test (compression test) is a special test used to reproduce the patients radicular pain (see video). Cervical extension tends to cause posterior disc bulging, while lateral flexion and rotation tends to cause narrowing of the ipsilateral neural foramina.

It has good reliability with Kappa score of 0.4-0.77, and good validity if a positive test is taken as the reproduction of the arm pain not only the neck pain. It is highly specific but has poor sensitivity and so it isn't useful as a screening test. Many patients with significant and symptomatic radiological changes do not have a positive compression test.

Shoulder abduction relief test is performed by asking the patient to lift their symptomatic arm above their head and rest the head on the top of their head. The test is positive with the reduction or elimination of radicular symptoms. Similar to Spurling's test it has good specificity but limited sensitivity.

Sensitivity and specificity of special tests in cervical radiculopathy.

Variable	Sensitivity (%)	Specificity (%)
Spurling	30–50	74–93
Shoulder abduction	17–78	75–92
Valsalva	22	94
Distraction	44	90–97
Upper limb tension test	72–97	11–33

Red Flags

Serious causes of radiculopathy are rare.

Red Flags

• Spinal infection – fever – history of risk factor (body penetration).
• Metastatic disease – history of cancer
• Primary tumours of spinal nerves – may present with radicular pain, but normally profound sensory loss
• Arteritis – fever and malaise (patient sicker than disc protrusion)
• Sarcoidosis – profound sensory and motor loss
• Apical tumours of the lung (Pancoast tumour) – involvement of C8 or T1 spinal nerves
• Intracranial tumour – no valid alerting features if presenting features restricted to neck and upper limb – rapid progression of symptoms only feature

Differential Diagnosis

Differential Diagnosis of Neuropathic Arm Pain

• Spinal cord injury
• Cervical Radicular Pain
• Median Nerve
  • Carpal Tunnel Syndrome
  • Pronator Teres Syndrome
  • Anterior Interosseous Nerve Syndrome
  • Supracondylar Process Syndrome
• Ulnar Nerve
  • Cubital Tunnel Syndrome (Ulnar neuropathy at the elbow)
  • Guyon's Canal Syndrome
• Radial Nerve
  • Radial Neuropathy at the Spiral Groove (Saturday Night Palsy)
  • Posterior Interosseous Nerve Entrapment (at arcade of Frohse)
  • Wartenberg Syndrome (superficial radial nerve at the distal forearm)
  • Humeral Shaft Fracture
• Other Peripheral Nerve Lesions
  • Suprascapular Nerve Entrapment (at suprascapular notch or spinoglenoid notch)
  • Shoulder Dislocation (Axillary nerve)
  • Long Thoracic Nerve Injury
  • Lateral Antebrachial Cutaneous Nerve Entrapment
• Brachial Plexus Lesions
  • Neuralgic Amyotrophy (Parsonage-Turner syndrome)
  • Neurogenic Thoracic Outlet Syndrome
  • Erb-Duchenne Palsy
  • Klumpke's Palsy
  • Burner or stinger
  • Backpacker's palsy
  • Traumatic nerve root avulsion
  • Hereditary Neuralgic Amyotrophy
  • Neoplasms
  • Radiation-induced brachial plexopathy
  • Iatrogenic plexopathies (e.g. medial brachial fascial compartment syndrome)
  • Diabetic-related brachial plexopathy
• Systemic
  • Thalamic Pain Syndrome
  • Hemiplegic migraine
  • Focal sensory seizures
  • Multiple sclerosis
  • Axillary vein thrombosis or Paget-Schroetter disease
  • Fibromyalgia or Myofascial Pain Syndrome
  • Herpes Zoster
  • Mononeuritis Multiplex
  • Multifocal Motor Neuropathy

The history and neurological examination can help to differentiate between radiculopathy, myelopathy, brachial plexopathy, and peripheral nerve lesions.

Brachial Plexus Lesions

Neuralgic Amyotrophy: In acute brachial-plexus neuritis, also known as Parsonage-Turner syndrome, or neuralgic amyotrophy, there is simultaneous weakness of muscles from two or more adjacent spinal segments and from two or more peripheral nerves. They typically affect either the upper plexus (C5 and C6) as a group which causes weakness of the shoulder and upper arm but spares the hand, or the lower plexus (C7 to T1) as a group which causes weakness of the hand but spares the shoulder and the upper arm.

There is an acute onset of pain in the neck, shoulder, and arm, followed by marked anaesthesia and weakness of the arm within a few days to week as the pain eases. In cervical radiculopathy usually the pain and neurologic deficits occur simultaneously.

Pancoast Syndrome: There is paraesthesias and weakness involving the intrinsic hand muscles, along with ipsilateral pstosis, miosis, and anhidrosis (i.e. Horner's syndrome)

Stinger: In sportspeople, traction injury to the upper trunk of the brachial plexus. Need to exclude C6 radiculopathy

Peripheral Nerve Lesions

In peripheral nerve lesions there is weakness of two or more muscles from a single peripheral nerve (which may belong to different spinal segments) and sparing of muscles from other nerves. The pattern of weakness varies depending on the location of injury. Finding hyporeflexia argues against a peripheral neuropathy. Importantly, it argues against both median and ulnar neuropathies as a cause for their symptoms because the median and ulnar nerves lack reflexes.

Nerve conduction studies can also help to discriminate between radiculopathy and peripheral nerve lesions. In radiculopathy they are normal, in peripheral neuropathy they are abnormal

Radial nerve injury: A complete radial nerve injury causes weakness of the brachioradialis muscle, elbow extension, wrist extension, and finger extension (C5-C8). However a radial nerve lesion at the elbow after the branch to brachioradialis will only weaken the wrist and finger extensors. In severe peripheral nerve lesions there may be a classic appearance in the position of the hand such as the wrist drop of radial neuropathy and claw-hand of ulnar neuropathy.

There is sparing of the brachioradialis and triceps reflexes because the nerve branches to these muscles diverge from the main trunk proximally in the axilla, and most radial nerve injuries occur distal to this point.

Carpal tunnel syndrome: Carpal tunnel syndrome can mimic C6 radiculopathy. In C6 radiculopathy there may be pain or numbness that runs from the neck to the radial side of the arm, forearm, and dorsal web space of the hand between the 1st and 2nd digits. There may be weakness of the wrist extensors and biceps, and hyporeflexia of the biceps or brachioradialis. In Carpal tunnel syndrome there may be pain and numbness affecting the radial three and a half digits, along with thenar muscle atrophy, positive Tinel's, positive Phalens, or positive Durkan's tests.

Figure 4. Motor actions of the adductor pollicis (A), abductor pollicis brevis (B), lumbricals (C), flexor pollicis brevis (D), and opponens pollicis (E). Metacarpophalangeal joints are indicated by yellow circles in A and B. Copyrighted image.

Cubital tunnel syndrome: C8-T1 radiculopathies can be differentiated from cubital tunnel syndrome through detailed examination of the motor function of the hand (figure 4). All but five intrinsic hand muscles are innervated by the ulnar nerve. The five remaining muscles are innervated by C8-T1 via the median nerve. The mnemonic AbOF can be used to remember which muscles are above the law in that they aren't innervated by the ulnar nerve: the abductor (Ab) and flexor (F) pollicis brevis, opponens pollicis (O), and lateral lumbricals (Law). In cubital tunnel syndrome the motor function of these muscles are intact, while in C8-T1 radiculopathies they may be weak. In cubital tunnel syndrome there should also only be sensory change to the lateral hand, not the forearm.

Posterior interosseous nerve entrapment: This lesion can mimic C7 radiculopathy. In PIN entrapment there is weakness of triceps, wrist flexors, and flexor extensors. However there is no loss of sensation and triceps and wrist flexors have normal power.

Myelopathy

Myelopathy is a rare condition that can occur with a central disc protrusion. Symptoms and signs of myelopathy occur in the upper limbs, trunk, and lower limbs. The examination is used to determine whether long tract signs are present such as hyperreflexia, spasticity, and a positive Hoffman's sign. Patients may present with signs only in the upper limbs. There is the absence of lower motor neurone signs

Somatic Lesions

C5 radiculopathy can mimic shoulder pathology such as a rotator cuff tear where both can result in weak shoulder abduction. However C5 radiculopathy shouldn't cause pain during passive motion and impingement tests should be negative and reflexes may be impaired.

Investigations

Imaging

Plain films are routinely unhelpful diagnostically as a sole diagnostic test.

Previously myelography and CT were used but this has been replaced by MRI due to its technical superiority and better safety profile. MRI is slightly inferior for detection of bony impingement of nerve roots but this can be aided by also doing plain radiographs. Also newer MRI small slice sequence techniques can be used which are much better at showing bone.

Electrodiagnostic Studies

These are only potentially helpful if clinically a peripheral neuropathy is suspected.

Prognosis

The prognosis is generally good, although not as good as neck pain alone. One study found that recurrences were common at 31.7%, and 90.5% had minimal or no pain at a mean follow up of 5.9 years.

A 2014 systematic review of 8 articles found that the overall quality of the literature on the course of prognostic factors of this condition is poor.  They found that most patients initially present with intense pain and moderate disability, however there are substantial improvements in the first 4 to 6 months. Complete recovery occurred in 83% with a range of 24 to 36 months. There were no cases of progressive neurologic deficits or myelopathy.

A 2021 review of 60 patients found that a pain score of 2 or less out of ten occurred at 12 months in 85% of those with soft protrusions and 77% of those with hard protrusions, with overlapping confidence intervals. Surgery was done in 7% of those with soft herniations versus 11% with hard herniations.

This recovery has radiographic correlation as half of cervical disc herniations decrease within the first six months, and 75% decrease by more than 50% within two years. Studies using CT and MRI over 1-30 months show cervical disc protrusions decrease as a rule

There is preliminary evidence that having an ongoing worker's compensation claim increases the risk of poor prognosis, but the magnitude of the effect is unknown. Patients with approved claims require more invasive treatment (injections and/or surgery) and more time off work. It's not clear how this would relate to ACC in New Zealand.

Treatment

Conservative

Conservative therapy includes measures such as oral medication, physiotherapy, traction, collar, bed rest, exercise, and TENS. Much of the comparative research on conservative therapy is quite old (?external validity), all of it showing no benefit for any particular conservative passive intervention, and that conservative therapy is effectively equal to sham therapy. A 1966 study found no difference between traction, sham traction, collar, heat, and placebo tablets. A 1970 study found no difference between exercise, traction, and no treatment. A 1990 study found no clinically important difference between traction and placebo traction. A 2009 study found that a wait and see approach was inferior to both a semi-hard collar with rest and physiotherapy with home exercises.

Generally patients with cervical radicular pain should be offered some form of therapy, because no treatment results in a greater proportion of patients feeling that they haven't improved. However no specific therapy can be recommended as being superior to one another.

Medication can be considered such as TCAs, SNRIs, and gabapentinoids but there is limited evidence. Pregabalin is ineffective in lumbar radicular pain.

A short course of oral prednisone can be considered for severe cervical radicular pain. An Iranian RCT found that prednisone was superior to placebo but strangely the study did not report on what the time points were for outcome assessment. The authors used 50mg of prednisolone once daily for 5 days and then tapered over a further 5 days. The long-term outcome data following a course of oral corticosteroids is unknown.

Injections

This refers to transforaminal or interlaminar epidural corticosteroid injections.

Some clinicians have a preference for an interlaminar approach due to possible less risk of a black swan catastrophic event that can occur with the transforaminal approach. The interlaminar approach is typically done at at C7/T1 level regardless of the site of the disc protrusion because the epidural space is largest at this level. In some cases it can be done at C6/7 but no more cranial than that. If there is minimal epidural space seen on MRI then the procedure should not be attempted.

The Pain Physician Epidural Guidelines found that there is level I evidence for cervical interlaminar epidural injections with strong recommendation for long-term effectiveness.

Surgery

Surgery includes discectomy or foraminal decompression. There are two main approaches: anterior cervical discectomy and fusion and posterior laminoforaminotomy. Artificial disc replacement (cervical disc arthroplasty) is an emerging treatment that is currently controversial.

Surgical approaches for cervical radiculopathy. Modified from Kang et al.

Approach	Application	Advantages	Disadvantages
ACDF	Lateral and midline disc herniation and osteophytes	Direct removal of anterior pathology; bone graft or cages; maintain cervical disc height and prevent kyphosis, less manipulation of the spinal cord and nerve roots.	Pseudarthrosis; hardware failure; adjacent segment disease; small risk of damage to recurrent laryngeal nerve, carotid artery, trachea, oesophagus.
PCF	Single lateral disc herniation	Minimal invasiveness; no alteration of architecture of the spine; avoidance of fusion; preservation of neck motion and ASD; no risk of damage to anterior structures; cost effectiveness	Incomplete decompression; deterioration of pathology at index level; facet violation
CDA	?	Motion preservation; avoidance of non-union; prevention of adjacent segmental degeneration	Ectopic ossification; progressive decrease of neck motion; no long-term follow-up

A randomised controlled trial using an active control found some improvement at 3-4 months over conservative therapy, but none at 12 months. Only 8% had complete relief, 19% improved, 42% unchanged and 31% worse.

Surgery might be considered for chronic symptoms, progressive motor weakness, or cervical myelopathy, but it shouldn't be promoted as a cure for the majority of cases.

See Also

• Lumbar Radicular Pain
• Radicular Pain and Radiculopathy
• Neuropathic Pain
• Acute Neck Pain
• Chronic Neck Pain

Literature Review

Literature Review

Reviews from the last 7 years: review articles, free review articles, systematic reviews, meta-analyses, NCBI Bookshelf

Articles from all years: PubMed search, Google Scholar search.

TRIP Database: clinical publications about evidence-based medicine.

Other Wikis: Radiopaedia, Wikipedia Search, Wikipedia I Feel Lucky, Orthobullets,