Cervical radiculopathy

Background

• Cervical radiculopathy (CR) is commonly seen in the ED
  • Incidence of 107.3/100,000 men and 63.5/100,000 women
  • Peak incidence at age 50-54
• Risk factors
  • White race
  • Female gender
  • Cigarette smoking
  • Prior lumbar radiculopathy
• Neck pain radiating to the upper extremities
  • can have associated weakness or numbness
• Compression and inflammation of the spinal nerve
• Most commonly affects C5-C6 or C6-C7

Clinical Features

• Follows a dermatome or myotome distribution
  • Diminished muscle tendon reflexes
  • Sensory changes
  • Motor weakness
• If C6 is affected: diminished brachioradialis reflex, bicep muscle weakness, paresthesias in the arms to the thumb/index finger
• If C7 is affected: diminished triceps reflex, tricep muscle weakness, paresthesias radiating in the arms to the middle finger
• Spurling maneuver (neck compression test)
  • With patients head extended and rotated to affected side, apply pressure to top of head
  • Positive if it produces pain or parasthesias beyond the shoulder
  • High specificity (0.89-1.00) with variable sensitivity (0.38-0.97)

Cervical Exam by Level

Radiculopathy	Motor Deficit	Sensory Deficit	Diminished Reflex
C4	Levator Scapulae & Shoulder elevation
C5	Deltoid & Biceps		Biceps
C6	Brachioradialis & Wrist extension	Thumb Paresthesia	Brachioradialis
C7	Triceps & Wrist flexion	Index/Middle/Ring Paresthesia	Triceps
C8	Index/Middle distal phlnx flexion	Small Finger Paresthesia

Differential Diagnosis

Neck pain

• Musculoskeletal
• Torticollis
• Dystonic reaction
• Cervical spondylosis
• Cervical stenosis
• Cancer
• Epidural abscess
• Vertebral osteomyelitis
• Transverse myelitis
• Temporal arteritis
• Epidural hematoma (anticoagulation, hemophilia)
• Cervical disk herniation
• Blunt neck trauma
• Anterior horn disease
• Cervical fractures and dislocations
• Cervical radiculopathy

• Lateral disc herniation
• brachial plexitis, Brachial plexus injury
• Shoulder pathology
  • Adhesive capsulitis
  • Recurrent anterior subluxation
  • Impingement syndrome
• Entrapment neuropathy
  • Carpal tunnel syndrome
  • Thoracic outlet syndrome

Evaluation

• Full neuro exam
  • motor weakness → early surgical referral
• Imaging
  • Cervical xray
    • can be obtained to exclude frank instability
  • MRI
    • Performed non-urgently
    • spondylararthrosis
    • Herniated disc

Management

• Primary treatment typically utilizes NSAIDS
  • 6 weeks of nonsurgical treatment with pain control
  • May consider steroids, gabapentin, nortriptyline, SNRIs (e.g. venlafaxine, duloxetine) and muscle relaxers (e.g. cyclobenzaprine)
• Short term immobilization and rest may calm symptoms of CR
  • Recent literature review showed that exercise is beneficial for improving function and activity levels
  • Outpatient physical therapy evaluation may be beneficial but home exercises should be recommended to patients in the interim

Disposition

• Outpatient follow up with primary care/orthopedics
• Majority of patients approx 75% in one study reported pain relief in 4 weeks
• pain control with NSAIDS

External Links

• http://www.bmj.com/content/bmj/339/bmj.b3883.full.pdf
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3116771/