Cervical Radiculopathy - Alaska Chiropractic Society

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342
REVIEW ARTICLE
Cervical Radiculopathy
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 mid1930s. It is most commonly caused by disc herniation or cervical spondylosis. History and physical examination
using pain 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 distinguishing 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 surgery. 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 Medicine and the American Academy of Physical Medicine and
Rehabilitation
Cervical radicular syndrome is a general term describing
a set of symptoms. This symptom complex may arise from
several causes, including nerve root irritation, myofascial
pain syndromes, and soft tissue injuries. This review will
concentrate on cervical syndromes that are caused by radiculopathy.
Cervical radiculopathy is a pathologic process involving
the nerve root, arising from cervical disc herniation, cervical
spondylosis, tumor (benign or malignant), or trauma causing
nerve root avulsion. Cervical radiculopathy may also occur
in a setting in which no definite cause can be determined.
Historical, physical examination, and laboratory features
seen in cervical radiculopathy of any cause are addressed.
This review will also delineate the clinical, physical, and
laboratory features, highlight similarities, emphasize ways
to distinguish the various etiologies, discuss differential diagnosis, outline certain laboratory and testing procedures,
particularly computed tomography (CT) scan, magnetic resonance imaging (MRI) and electrodiagnostic testing, and
address treatment and prognosis.
We review the clinical aspects of cervical radiculopathy
and cite research performed, but this review does not represent a meta analysis of all research on this topic. Articles
were obtained through a Medline search of the literature of
the past 10 years, a review of bibliographies in text books,
and a review of bibliographies in the articles found in the
From the Department of Rehabilitation
Medicine, Sinai Hospital, Detroit, MI
482352899.
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
supporting this article has or will confer a benefit upon the authors or upon any
organization with which the authors are associated.
Reprint requests to Maury R. Ellenberg, MD, Department of Rehabilitation Medicine, Sinai Hospital, 6767 West Outer Drive, Detroit, MI 48235-2899.
0 1994 by the American Congress of Rehabilitation
Medicine and the American
Academy of Physical Medicine and Rehabilitation
0003-9993/94/7503-0100$3.00/0
Arch Phys Med Rehabil Vol75, March 1994
Medline search. Articles were selected based on historical,
clinical, or research data they contained.
HISTORICAL
PERSPECTIVE
Cervical radiculopathy or “radiculitis” particularly associated with intervertebral disc rupture as a cause of “brachial
pain” was not distinguished from other causes of upper
extremity pain attributed to “neuritis,” ‘ ‘fibrositis,” and
“myalgia” in the early 20th century.’ As early as 1936,
however, there were descriptions of shoulder girdle, arm, and
precordial pain attributed to “cervical arthritis” resulting in
“irritation or inflammation of the cervical spinal roots.“’
Cervical disc hemiation resulting in cord compression and
myelopathy was recognized as a syndrome in the early 20th
century, but was initially attributed to spinal cord tumors
termed ‘ ‘chondromas. ’ ‘3s4This syndrome of cord compression was defined as a ruptured disc by Mixter and Aye? in
1935, shortly after the report by Mixter and Barr in 1934’j
of disc herniation as the etiology of “sciatica” in the lumbar
region.
It was not, however, until the early 1940s that Semmes
and Murphey’ and shortly thereafter Spurling and Scoville,8
and Michelsen and Mixter’ directly related “cervical radiculitis,” in the absence of cervical myelopathy, to ruptured
cervical intervertebral discs. At that time, Spurling and Scoville also described the “neck compression test,” which has
since become known as Spurling’s test. Subsequent articles
published at the end of that decade defined the relationship
between cervical radiculopathy, upper extremity pain, and
protruded cervical intervertebral discs.‘0-12
ANATOMY
There are seven cervical vertebra that articulate via the
zygoapophyseal (facet) joints located at the posterior portion
of the vertebrae. The uncovertebral joints, or joints of
CERVICAL
RADICULOPATHY,
Luschka, are located on the lateral aspect of the vertebral
body and composed of the sharply defined bony margins
about the superior rim of each vertebra articulating with the
facet of the vertebra above it. This area is often the site of
abnormal bony overgrowth that can compromise the vertebral canal or neural foramen. The eight cervical nerve roots
exit via intervertebral foramina, which are bordered anteromedially by the vertebral disc, and posterolaterally by the
facet joints. The foramina are largest at C2-3 and progressively decrease in size to C6-7. The nerve root occupies
about l-4 to l-3 of the space in the foramina, accompanied
by spinal radicular arteries and intervertebral veins.13 The
first cervical nerve root exits between the occiput and atlas
(Cl vertebra) and all subsequent roots exist above their correspondingly numbered cervical vertebrate except the C8
root, which exits below C7 and above Tl. Therefore, C5-6
disc herniation or foraminal narrowing will affect the C6
root, and a similar C6-7 lesion will affect the C7 root. Due
to differential growth of the vertebra and spinal cord, the
lower cervical vertebra are at the same level as the next lower
spinal segment. The C5-6 interspace is therefore opposite the
C7 spinal level where the C7 nerve root arises and the C6
root exits. The C7 root then descends from this level to exit
between the C6 and C7 vertebrae. Myotomal and dermatoma1 distributions of the cervical nerve roots are depicted in
table 1 (myotomes) and the figure (dermatomes).
PATHOANATOMY
AND PATHOPHYSIOLOGY
The nerve root is vulnerable to compression in the intervertebral foramen by three structures: the facet joint, the
uncovertebral joints, and the disc. The most common cause
of cervical radiculopathy is a herniated cervical disc,14 followed by cervical spondylosisL5.16with or without myelopathy. Hypertrophic facet and uncovertebral joints can encroach on the nerve root, and the disc may rupture or become
calcified. The effect of these processes may be enhanced
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 referring to an intraforaminal spur from the uncovertebral or facet
joint or to disc hardening, thickening, or calcification causing
a median ridge and potential root and cord pressure.‘8-20
Recent literature refers to the “hard disc” as cervical spondylosis either with or without myelopathy or radiculopathy.”
Ellenberg
The precise mechanism whereby disc herniation or spondylosis causes radicular pain is still unclear. Experimentally,
referred pain can be generated from several structures in the
cervical spine probably including the disc’-? (shown to have
innervation to the outer third of the annulus), from the periosteum, ligaments, fascia,23 or the nerve root.6.24Direct pressure on the root, however, does not necessarily cause pain,”
and pure motor deficit may occur.26 Proposed mechanisms
for pain in radiculopathy include increased discharge of dorsal root ganglia whose axons have undergone neurotmesis,
mechano-sensitivity or chemo-sensitivity of the nerve root
itself, or direct pressure on chronically injured axons or normal dorsal root ganglia.25,27Causes of cervical radiculopathy
other than disc herniation or cervical spondylosis include
tumor,‘8 trauma,29 sarcoidosis,30 arteritis,“’ and athetoid and
dystonic cerebral palsy.32
CLINICAL
PICTURE
The most commonly involved nerve roots in cervical
radiculopathy are the sixth and seventh cervical roots, which
are caused by C5-6 or C6-7 disc herniation, or spondylosis.
Which of these is the most commonly involved nerve seems
to depend on the case series. 0dom,18 in a series of 246
cases, found C7 root with C6-7 disc involvement in 70% of
cases, the C6 root with C5-6 disc in 24% of cases, whereas
Lundsford,‘” in a series of 334 patients, found 48% C6 root
with C5-6 herniation, and 37% C7 root with C6-7 herniation.
The series of 846 patients by Henderson and colleagues33
demonstrated some of the difficulty in determining the level
of the radiculopathy. Triceps weakness (C7) was present in
37% of the patients, and biceps (C6) weakness in 28%.
Surgery based on sensory findings and myelographic abnormalities was performed on 449 cases (53.1%) at C5-6 (C6
root) and only 45.6% at C6-7 (C7 root). Most studies determining radiculopathy on a clinical basis however found
a preponderance of C7 radiculopathies (table 2).‘7,‘“,34,3s
Symptoms and History
The symptoms of cervical radiculopathy are pain, paresthesia or weakness, or a combination of these symptoms.
Evaluation for radiculopathy should include a careful history
to delineate the precipitating cause, the distribution, duration,
and frequency of pain, paresthesia or weakness, occurrence
Table 1: Myotomes
Rhomboids
5
Supraspinatus
Infraspinatus
Deltoid
Brachialis
Biceps Brachii
Brachioradialis
5
5
5
5
-s
5
6
6
6
;
6
6
Supinator
Ext. C. Rad. Longus
Ext. C. Rad. Brevis
Pronator Teres
Serratus Anterior
Pectoralis Major Upper
Pectoralis Major Lowern
5
6
6
6
6
6
6
4
5
5
J
7
7
z
7
7
Myotomal root innervation
based on a series of 255 operated
Neurology.‘“’
See Hollinshead for a full discussion of individual
8
-T-l
Latissimus Dorsi
Flex. Car. Radialis
Triceps Brachii
Ext. Carp. Uln.
Ext. Dig. Comm.
Ext. Pollicis Longus
Flex. Digit. Super
Flex. Digit. Profundus
Flexor Pollicis Longus
Flex. Carpi Ulnaris
Abd. Poll. Brevis
Opponens Pollicis
1st Dorsal Interosseous
Abd. Digiti Quinti
6
6
I
7
2
z
7
7
7
J
8
8
8
8
8
1!
8
8
8
8
s
8
8
8
T-l
T-l
T-l
T-l
T-l
T-l
T-l
T-l
T-l
-
patients (Treanor personal communication);
Mayo Clinic’s Clinical Examinations
variation.rsO Underscores
represent the primary root innervation most used.
Arch Phys Med Rehabil Vol75,
in
March 1994
CERVICAL
344
RADICULOPATHY,
Ellenberg
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 interosseous). The patient should also be observed and tested for
scapular “winging,” which may occur with C6 or C7 radiculopathy.4’ At times, palpation of the above-mentioned muscles 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
Some of this variation may be
dermatomal overlap. ‘9.34,35
due to intradural connections between nerve roots described
to occur at the level of posterior (sensory) and anterior (moDespite the variations in clinical findings,
tor) rootlets.
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 (axillary and suprascapular nerve) and elbow flexion (musculocutaneous nerve). The distribution of motor weakness present
with various root involvement is listed in table 3. To detect
Arrangement of the dermatomes on the anterior (a) and posteminimal weakness, test external shoulder rotation for C5 or
rior (b) aspects of the upper extremity. (Note: According to
ASIA Standards, the forefinger is C6 and ring finger is CS C6 nerve root; finger extension or elbow extension with
the elbow in 90” of flexion for the C7 nerve root. Sensory
dermatome. Other differences are not substantive). (Reprinted
with permission.“‘)
examination for cervical radiculopathy is much less reliable
than motor because of the considerable overlap of dermawith 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 distribumotor weakness or paresthesia, generally not preceded by tion is depicted in the figure. Gait and lower extremity retrauma 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 radiculopand 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 myelopaTable 2: Frequency of Cervical Radiculopathy
thy is resent, pain has been described in the back and
P,42Other important aspects of the history include prior
by Root Level in Several Series
legs. 33,4
episodes of cervical radiculopathy, current or past treatment
Lundsford”
Yoss”S
HonetJ4*
Odoml*
Root Level
course, medication history, difficulty walking, lower extremity
0
?
10%
2%
c5
pain or paresthesia, and/or bowel or bladder complaints.
48%
15.8%
27%
19%
Physical Examination
Physical examination should begin with careful observation of the neck position and movement during the history
Arch Phys Med Rehabil Vol75,
March 1994
C6
c7
C8
* Five patients
65%
?
37%
2%
with 2 level root involvement.
69%
10%
75.6%
14.6%
CERVICAL
Table 3: Most Common
Pathology Site
Foramen
C.?-4
Root
Patterns
(silent zone)
Reflexes
Pain
Sensorv
Neck (head)
Variable
Interscapular,
neck,
shoulder
Neck, shoulder,
interscapular
Ear to neck
C.4-5
C.5
Deer. biceps.
(brachioradialis)
c.s-6
C.6
Drcr. Brachioradialis
(biceps)
Shoulder, radial
forearm.
interscapular
(2.6-7
C.7
Deer. triceps
Interscapular
forearm.
chest. ulnar
hand
Long and ring
fingers
C.7-T. I
C.8
Normal or deer. (triceps,
finger flexors)
Medial forearm
Little tinger,
hypothenar
area. medial
forearm
t
loss.
) = less prominent
345
Ellenberg
of Reflex, Sensory, and Motor Abnormalities
Incr. upper & lower
extremities
Incr. upper & lower
extremities
magnum
RADICULOPATHY,
the diagnosis. “~4hIt is performed by extending the neck and
rotating to the side of the pain and then applying downward
pressure on the head.” This maneuver may cause or accentuate limb pain or paresthesia because neck extension causes
posterior disc bulging, whereas lateral flexion and rotation
narrow the ipsilateral neural foramina.“7 It is wisest to perform this maneuver by having the patient actively extend
the neck then laterally flex and rotate toward the side of
the pain, and only then to use careful compression.
When
radiating pain or extremity numbness is produced, the maneuver should be stopped. L’Hermitte’s
sign, initially described in 1932,” is performed by flexing the neck with the
patient in the seated position. This may produce an electriclike sensation down the spine and occasionally
the extremities, and has been reported in patients with cervical cord
involvement
secondary to tumor, cervical spondylosis,
and
multiple sclerosis.‘”
DIFFERENTIAL
DIAGNOSIS
There are a number of disorders that must be distinguished
from cervical radiculopathy
or cervical radiculopathy
with
myelopathy.
Idiopathic brachial plexopathy (IBP) or neuralgic amyotrophy is a disorder of undetermined
etiology that may affect
any combination
of nerves in the upper limb, cranial nerves,
or less commonly. a single upper limb nerve.5”.5’ IBP usually
presents with severe pain later followed by weakness and
eventually
by atrophy. At its onset, it may be difficult to
distinguish
from cervical radiculopathy,
particularly
when
the upper trunk of the brachial plexus is involved, mimicking
a C5 or C6 cervical radiculopathy.
Distinguishing
features
of IBP are the high intensity of the pain followed by weakness after which the pain usually recedes,sO,s’ the absence of
Spurling’s sign,“” negative cervical paraspinal electromyographic examination,
and imaging studies that do not demonstrate a lesion sufficient to result in such a severe neurologic
deficit. IBP may be bilateral 25% of the time.”
Axillary
“patch.”
proximal arm
Thumb and index
Hnger
in Cervical Radiculopathy
Primary Motor
Weakness
Shoulder elevation and
retraction, neck
Hcxion and rotation
Shoulder abduction.
external rotation.
(elbow Hexion)
Elbow Hexion. forearm
supination. radial
wrist extension
(scapular winging)
Elbow extension, wrist
and finger extension,
pronation, scapular
“winging,”
(radial
wrist Hexion)
Finger and wrist Hexion.
thumb opposition.
finger abduction.
extension
Comment
X-rays of atlanto-axial
joint
X-rays for foraminal
enlargement
Ulnar wrist extensors
spared. Look for
reHex inversion to
tinger Hexors
Check for scapular
“winging,”
check
for reflex
“inversion”
to
elbow Aexion
Distinguish from
peripheral
neuropathy
Local disorders that can result in upper limb pain include
subacromial
bursitis, bicipital tendinitis,
rotator cuff tears.
and lateral epicondylitis.
These can usually be distinguished
from cervical radiculopathy
on clinical grounds. Absence of
weakness. reproduction of pain with local maneuvers (Yergason’s sign,“.” painful arc5”) and local tenderness help distinguish these disorders. If initial treatment does not resolve
the problem, electrodiagnostic
studies and further radiologic
studies should be performed.
Upper limb nerve entrapments (median. ulnar. and radial)
are characterized by pain, paresthesia, and weakness in the
distribution
of a single peripheral
nerve in contrast with
the multiple nerve pattern of cervical radiculopathy.
Median
neuropathy at the wrist, however. may present with proximal
symptoms as high as the neck. Tinel’s sign. tapping with a
finger or instrument over a peripheral nerve. results in radiating pain or paresthesia in the distribution
of the nerve, and
is often present with peripheral nerve entrapment.
These
entrapments
may coexist with cervical radiculopathy
as reported in the “double crush” phenomenon.‘”
EMG. by defining the distribution of abnormalities,
helps to differentiate
between
an entrapment
syndrome
and a monoradiculopathy.57.‘x
When cervical radiculopathy occurs with myelopathy, syringomyelia
and motor neuron disease-particularly
amyotrophic lateral sclerosis (ALS)-should
be excluded. These
disorders may pose some of the most difficult diagnostic
challenges. The diagnosis of syringomyelia
has been greatly
facilitated by MR.‘” Clinically, a band of paresthesia, especially involving the upper thorax, may be present with cervical syringomyelia.
ALS is characterized by the absence of sensory abnormality and presence of motor neuron abnormalities
in the lower
limb(s). The latter may be detected only with careful electromyographic examination.
If ALS is suspected, careful electrodiagnostic examination
of the tongue. facial muscles, and
Arch Phys Med Rehabil Vol75,
March 1994
CERVICAL RADICULOPATHY, Ellenberg
346
sternocleidomastoid or trapezius to detect bulbar disease
may be the key to making the proper diagnosis if bulbar
motor neuron disease is present.
Multiple sclerosis has also been described in association
with radiculopathy, particular cervical radiculopathy. It
should be suspected if symptoms or signs such as diplopia
or dysarthria suggest abnormalities above the foramen
magnum.60
DIAGNOSTIC
STUDIES
Diagnostic studies are used to evaluate structural (eg, xray, CT, MR) or functional abnormalities (eg, EMG, nerve
conduction, SSEP). These areas will be briefly addressed.
Imaging Techniques
The diagnosis of radiculopathy cannot be based only on
spinal imaging. Brain in 195261 first determined that radiologic evidence of disc degeneration did not necessarily imply
disc herniation. Although comparative radiologic studies
such as those by Tapiovaara in 195262 and Friedenberg in
196363 found a statistically greater amount of disc degeneration, foraminal narrowing, or uncovertebral joint abnormalities in patients with cervico-brachial pain, the difference
was not great enough to permit clinical decision making in
individual cases.62’63This is particularly true because 70%
of asymptomatic women and 95% of asymptomatic men
between the ages of 60 and 65 have been shown to have
degenerative changes of the cervical spine on x-ray.64 Similarly, cervical myelograms have been shown to be abnormal
in 21% of asymptomatic individuals in a classic study by
Hitselberger in 1968.65 More recently, these findings, albeit
in the lumbar spine, have been extended to e6 and MR.67
Imaging techniques can be a valuable adjunct to the diagnosis and treatment of patients with cervical radiculopathy
by defining the structural abnormality leading to the radiculopathy, but there is wide agreement that they must be used
only with proper clinical correlation.68,69 There is also
agreement that further study is needed to define precise algorithms for the most appropriate sequence of performing these
imaging studies.68-70Even when algorithms are proposed,
they usually address which technique to use next rather than
when the study is indicated based on ongoing or changing
clinical findings. ” The following, therefore, represents the
authors’ viewpoint using whatever support the literature offers.
The cervical spine radiograph can be used as an initial
screening tool, but need not be performed until treatment is
attempted.72-74An AP and lateral film, including flexion and
extension views, should be performed and are of particular
value in determining spine stability after trauma or in cases
of rheumatoid arthritis or ankylosing spondylitis. They may
detect unsuspected fractures or tumors. The cost effectiveness of multiple views has been questioned in relation to the
lumbar spine,69 and cervical spine.75 The value of spinal
radiographs in nontraumatic disorders has also been questioned,73,74*76however, the studies regarding the cervical
spine were performed outside of the United States, and each
individual practitioner must evaluate the standard of practice
in his or her community.
Arch Phys Med Rehabil Vol75,
March 1994
The performance of imaging studies beyond the plain cervical spine radiograph is usually not initially indicated. Imaging studies should be reserved for patients when symptoms
and findings are not classic and lead to suspicion of one of
the disorders outlined in the differential diagnosis; cervical
myelopathy is present, especially acutely or subacutely; the
patient is not improving with treatment as expected; progression of the neurologic deficit is occurring; or surgical treatment is contemplated.
The preferred imaging method has been much discussed
in the literature, and several studies have compared CT,
myelography, and MR.77-79Initial studies found a close correlation between the three techniques. Later investigations
demonstrated a higher correlation of MR findings with operative findings than either myelogram” or CT.‘l This was
particularly true if plain cervical spine x-rays were used to
supplement the MR scan.8o Current radiologic opinion is that
MR is the technique of choice in cervical radiculopathy.82
The clinician should be aware of several caveats: (1) MR
results are technique-specific and dependent on the quality
of the magnet used and the expertise of the neuroradiologist
interpreting the image; (2) If MR is unavailable and CT
is used for cervical spine imaging, contrast enhancement
significantly improves sensitivity in identifying disc hemiation83; (3) If the imaging is performed presurgically, the
surgeon may feel most comfortable with a certain technique
and should be consulted prior to ordering the study; (4) Each
practitioner should become familiar with interpreting these
scans since they are valuable only when they are correlated
with clinical findings.68
Electrodiagnosis
Electrodiagnostic studies are an important adjunct in the
diagnosis of cervical radiculopathy because they identify the
physiologic abnormality in the nerve root and help determine
if a visualized anatomic defect is causing axonal pathology,
or if axonal pathology is present in the absence of an anatomic defect. The electrophysiologic diagnosis of radiculopathy has been the subject of two recent thorough reviews.84,85
Electromyography is a well proven technique in the evaluation of radiculopathys4 and shows a close correlation with
myelography and operative findings.86 This has been investigated more thoroughly in lumbar radiculopathy where EMG
has been found to correlate with surgical or clinical findings
as well, or better, than CT or myelography.87-89 EMG in the
cervical region has been studied by Marinaccig6 who studied
161 patients in 1966. In this series, the correlation between
surgical findings, EMG, or myelogram approached 90%. Negrin and colleaguesW found a concurrence of approximately
77% between the EMG root abnormality and the level shown
on myelography. Partanen and coworkers” studied 360 patients retrospectively. In 77 of 360 patients who underwent
both EMG and myelography with subsequent surgery, 26
patients had sensory impairment, and only 34 had motor
weakness or atrophy. They found an “accurate diagnosis”
by EMG in 57% of the patients. Only 36% of their patients
with a negative EMG showed improvement after surgery.
However, Partanen’s group did not correlate the EMG abnormalities with motor weakness. This points out the difficulty
CERVICAL RADICULOPATHY, Ellenberg
in some of these studies, particularly in view of studies by
Hitselberger6’ and Boden67 indicating that large percentages
of normal individuals may have abnormalities on myelogram
or MR of the cervical spine.
The EMG will provide the anatomic distribution of the
abnormalities thereby facilitating diagnosis and differentiating cervical radiculopathy from some of the syndromes in the
Differential Diagnosis Section. Careful electromyographic
examination can help “date” the lesion. The age of the
lesion can be roughly approximated using needle electromyography. The first abnormality, which may be seen immediately after motor root compromise, is decreased recruitment.92 Positive waves and fibrillation potentials will first
occur 18 to 21 days after the onset of the radiculopathy.“”
The fibrillation potentials are larger in early, and smaller in
long-standing peripheral nerve lesions, but within the first 6
months post lesion there is a variability in the amplitude.94
The clinical usefulness of this method in cervical radiculopathy remains unproven. The motor units will increase in size,
duration, and number of phases in radiculopathies where
collateral sprouting occurs.84 Some of these changes, particularly polyphasia, may occur as early as 3 to 4 weeks after
the onset of the lesion.85 In “old” radiculopathies, large
motor unit action potentials may be the only abnormal finding.84 The amplitude of the evoked motor response in motor
conduction studies can help differentiate between axonal loss
and neuropraxia thereby aiding in determining prognosis.‘7
In the presence of severe motor involvement, sensory conduction studies can be useful in distinguishing cervical radiculopathy from a more distal source of paresis. In cervical
radiculopathy or root avulsion, the sensory evoked potential
will be normal because the root lesion is proximal to the
dorsal root ganglia,95 whereas with a peripheral lesion (eg,
plexopathy) there may be severe reduction or absence of the
sensory evoked potential.
Electrodiagnostic techniques other than standard EMG
and nerve conduction studies are much less useful in the
evaluation of cervical radiculopathy and need be used only
under special circumstances. The H-reflex is consistently
obtainable only from the tibia1 nerve, although a number of
studies have convincingly demonstrated that it can be obtained from the median nerve96.y7by placing the active electrode over the flexor carpi radialis. These have not found
their way into general electrodiagnostic practice.84
The F-wave, although initially believed to be of value in
evaluating cervical radiculopathy,‘” has since been shown to
be of limited value.9YZ’00
Its usefulness is limited because
there are at least two roots innervating almost every muscle,
and the F-response may be traveling along the uninvolved
root. With mild lesions, even the involved root may have
sufficient unaffected fibers such that the F-response will still
be normal because only between .l% and 20% of axons
produce the F-response.“’ The usefulness of somatosensory
evoked potential (SSEP) testing in the diagnosis of radiculopathy remains controversial, although theoretically it
should be of added benefit, especially with pure sensory
lesions.‘02 For a thorough discussion, the reader is referred
to Weichersn5 who outlines all of the issues and cites the
numerous studies addressing this technique.
Precisely when to use electrodiagnosis in the evaluation
347
of a patient with cervical radiculopathy is a clinical decision
and has not been well studied.
The major use of electromyography is to diagnose radiculopathy in cases where it is uncertain whether the patient
has any neurologic lesion, or in distinguishing cervical radiculopathy from other lesions where they cannot be distinguished clinically. EMG can also be used when it is unclear
whether the anatomic lesion seen on imaging techniques is
resulting in nerve root pathology. The authors have also used
EMG in the industrial setting to distinguish musculoskeletal
from neurologic pain, and in circumstances when the patient
appears to be improving clinically, but continues to complain
of symptoms. In general, the authors find this an important
test to correlate with the clinical picture and physical findings, and to substantiate the presence of a radiculopathy. In
patients with less severe clinical findings, performance of
the EMG should be delayed for at least 3 to 4 weeks after
symptom onset to permit detection of the positive waves and
fibrillation potentials, which would be the hallmark of the
diagnosis in these instances.84
TREATMENT
There are no medically related outcome studies that have
compared operative to nonoperative treatment of cervical
radiculopathy. One prospective study evaluating various
nonsurgical treatments is The British Association of Physical
Medicine Study,“’ which also discussed some of the difficulties in evaluating treatment of this disorder. The authors
stated how little is known of the natural history of this common syndrome, that the patients in their study were a highly
select group, were followed for a maximum of 6 months,
that only certain forms of treatment were investigated, and
only outpatient therapy was used. Consequently, the treatment is based on individual experience with various interventions that have been applied with the description of the
results.
The major objectives of treatment are the reduction or
resolution of pain, improvement, or resolution of the neurological deficit and avoidance of spinal cord complications.
The treatment indicated depends on the patient’s symptoms
and physical findings. The treatment, including physical
therapy prescription, must be specific and is dependent on
the severity of the symptoms and on the underlying etiology
of the radiculopathy.
Activity
Limitation
Specific studies comparing outcome with and without limitation on activities or work have not been performed, but
individual patient tolerance in response to treatment should
guide the practitioner.
Heavy or moderately heavy activities, and occupations
that require use of the neck in vulnerable positions, such
as extension and ipsilateral flexion and rotation, should be
avoided during the acute stage. Depending on the occupation, some patients can continue to work and, on rare occasions, can continue with noncontact sporting activities. Patients with severe radiculopathy are usually unable to work
and may even require bed rest.
Arch Phys Med Rehabil Vol75, March 1934
348
CERVICAL
RADICULOPATHY,
Neck Positioning
It has been suggested that the patient must be instructed
in proper neck position to avoid further irritation of the
involved nerve root. The telephone user must avoid ipsilatera1 neck flexion. A headset can help eliminate this motion.lo4 The bifocal eyeglass wearers should be instructed
in proper position of the head to avoid neck extension. In
occupations where close work is necessary at eye level or
above, placement of the reading segment at the top of the
lens can result in symptom relief.lo5 When watching theatrical or sporting events, the patient must be instructed in
proper positioning, depending on the seating location and,
specifically while following a sporting activity, be told not
to rotate the neck ipsilaterally to the involved side. Sleeping
in a sitting position, either in a lounge chair or in bed with
a bolster for the upper back and with the knees flexed or
with two pillows will suffice to position the head in the
partially flexed position, thereby relieving pain. None of
these suggestions have been studied to determine their value.
There are many collars that have been studied regarding
the motion restrictions they afford.106-108More rigid collars,
particularly with chin extensions, can provide greater restriction of cervical motion than soft collars, which do not significantly restrict flexion and extension.‘09.‘10 The issue of
patient compliance and outcomes with the use of collars that
restrict motions have received little attention in the literature.
In a series of 22 patients comparing two different types of
relatively hard collars, there was only a 68% to 72% compliance rate in the use of the collars.“’ A soft cervical collar
can increase patient comfort,“* although it has not been
shown to change long-term outcome.‘03Z113The authors prescribe soft cervical collars which, together with patient education, can serve to maintain relative flexion of the neck.
Except in rare instances such as the patient with a positive
L’Hermittes sign, or a person with rheumatoid arthritis and
atlanto-axial subluxation, the attachment, which is usually
the narrower part of the collar, is worn in front, thus maintaining the neck in a neutral or slightly flexed position. The
soft collar should be worn for as long as possible during the
day, using comfort as a guide. As symptoms improve, it can
be worn only while engaged in strenuous activities and while
driving, and can be discontinued completely when appropriate. It is difficult to judge the exact time to decrease or
discontinue collar use, but improvement in extremity pain,
disappearance of Spurling’s sign, and improvement in motor
deficit can be used as guides.
Modalities
Thermotherapy may be used for pain relief.114,115It may
also be used prior to or at the time of cervical traction for
muscle relaxation. Cold may be applied for 15 to 30 minutes,
one to four times a day, or heat for 30 minutes, two to three
times a day if the cold is not effective. The decision regarding which modality to use is pragmatic, and is often based
on the patient’s perception of pain relief.l16
Cervical traction is frequently used in patients with cervical radiculopathy. Intermittent cervical traction can produce
a greater separation of the vertebra at a 50-pound than at a
30-pound force. It has been studied at a 24” angle of pull,
Arch Phys Med Rehabil Vol75,
March 1994
Ellenberg
and there was no difference in separation at 7, 30, and 60
seconds of tractive force.l17 When a 30-pound tractive force
was used for a period of 7 seconds, with a rest period of 5
seconds, it was found that the maximum mean vertebral
separation occurred at 25 minutes, and that there was only
minimal anterior cervical separation 20 minutes after traction
ceased.l18 Although the efficacy of cervical traction has not
been proven,‘03 and has even been reported to cause temporomandibular joint problems,“’ nevertheless it is commonly
used’20-‘23and is believed by some to be of benefit.lz4 For
home use, over the door traction may be tried when properly
used, for example, with the patient facing the door and with
the head flexed at 20 to 30°.‘25 A water bag with 10 pounds
can be used initially with the weight increasing to 20 pounds
as tolerated. Ten pounds of cervical traction in the seated
position counterbalances the weight of the head and 20
pounds is usually an effective distracting force. A home
pneumatic traction device may be useful as an alternative to
using weight.lz6 Recumbent traction is also useful and may
be more comfortable but is more difficult to set up and apply.
The patient must be adequately instructed in the use of home
traction because of possible errors in weight and head positioning.’ l9 Traction reportedly is contraindicated in patients
with significant or severe spondylosis who have myelopathy,
a positive L’Hermittes sign, or rheumatoid arthritis with atlanto-axial subluxation.“8~‘23 Traction can be used at home
two to three times a day for 15 minutes each time. It can
be continued fewer times per day, for 4 to 6 weeks, even
after the patient is improved from the point of view of pain
and/or neurologic deficit. In the authors’ experience, some
patients are benefited by using traction on a long-term basis.
Range of motion exercises of the cervical spine should not
be used during the acute stage of cervical radiculopathy.‘*’ In
the authors’ opinion, range of motion exercises, particularly
those that mimic Spurling’s maneuver or prolonged neck
extension, should be avoided even when the pain abates.
Exercises that precipitate arm pain should also be avoided
because there are no controlled studies showing that exercise
will improve outcome or prevent recurrence’ 2 and there is
potential for increasing symptomatology or neurologic deficit. This is particularly true when forceful cervical manipulation is used.‘27 Isometric strengthening neck exercises may
be used when the pain abates.l*’ Manipulation should not
be used in patients with this problem.128
Medications
In the authors’ opinion, medications should be used sparingly. They are indicated for pain relief or presumably to
decrease “inflammation” around the nerve root, although a
true inflammatory response at the level of the nerve root or
disc has not been demonstrated. In patients who are instructed in proper neck positioning and who use a cervical
collar, adequate pain relief is usually achieved with aspirin
or other nonsteroidal anti-inflammatory agents.‘03’129Other
medications of clinical benefit include diazepam (Valium) 2
to 5mg at bedtime, especially in very anxious patients, low
dose tricyclic antidepressants (eg, amitriptyline [Elavil] 10
to 25mg at bedtime), and narcotic analgesics only if needed.
It is speculative that in some patients with severe radiculopathy, of less than 10 days duration, high-dose oral steroids
CERVICAL RADICULOPATHY, Ellenberg
349
therapy.144 Patient progress, depending on severity of the
problems, should be evaluated every 1 to 3 weeks. As mentioned earlier, pain, by careful characterization, and neurologic deficit using manual muscle and reflex testing are used
as guides for patient progress.
Early treatment can include activity modification, cervical
collar, medication, thermotherapy, and traction. The patient
should be strongly advised to avoid any activities (even therEpidural Steroids
Instillation of steroids into the cervical epidural space re- apeutic ones) that accentuate the extremity pain, and a wellportedly is of benefit in patients with pain who do not im- informed patient should be part of the decision making proprove with the above therapy.134 It must be performed by a cess to help decide the proper sequence of treatment.
If symptoms improve with treatment, then activities can
physician who is well trained and facile in the technique.
progressively
be increased and treatment discontinued or
Shulman found that 64% of the 25 patients who received no
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.
In the 10% to 20% of patients in whom symptoms persist
improvement in their neurological deficit. The architecture
despite treatment, surgical intervention should be considof the cervical spine makes its contents vulnerable to damage
and thus this procedure is used infrequently and with great ered. There are no guides for how long nonsurgical treatment
should be continued prior to consideration of surgery, but if
care in experienced hands.
neurologic progression or myelopathy are not present, or
neurologic improvement is occurring, patient comfort and
Surgery
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 herniareader is referred to the surgical literature.‘7*19,33,42,137-143
We tions, has been shown to improve with nonoperative managebelieve 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 accompanied 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 relifestyle. The ideal outcome is return to full pre-illness life- sults. 17,19,.13.‘39.140~141,147
Many 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 symptoms nonoperatively and obtained good to excellent results
CONCLUSION
in 49 (80.3%). Surgery was performed in the remaining 12
Cervical radiculopathy may have various underlying etiolpatients. Rubin12” reported that 90% of 84 patients with cervical radiculopathy responded well to nonoperative treat- ogies. Its most common causes are cervical disc herniation
and cervical spondylosis. It can usually be diagnosed by
ment. Nonoperative treatment was also helpful in providing
history
and physical examination, and most diagnostic studtemporary or more long lasting relief in a majority of patients
ies
are
needed
only when the clinical presentation is unusual,
who had pain in the neck and arm.lo3 Sixty-six of 82 patients
there
is
poor
response
to initial treatment, or surgery is con(80%) treated by Honet and Puri34 had good to excellent
templated.
results with nonoperative treatment. One to two year followThe large majority of patients with single root involveup on their patients revealed that 71% of the patients with
ment
improve with nonsurgical treatment, although which
excellent results continued to do well. None of these studies
precise
treatment hastens or affords resolution of the disorder
were controlled regarding types of treatment, so no conclusions 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
despite careful nonsurgical treatment, progressive weakness,
cluded when groups of patients with proven cervical radicuor
new or progressive cervical myelopathy.
lopathy are treated nonoperatively, ideal outcomes may occur in 80% to 90% of patients.34,‘04,‘29All of the authors
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