CERVICAL RADICULOPATHY

It is characterised by neck pain with pain radiating down the arm and many a times associated with tingling and numbness which can extend upto the fingers. Clinically cervical radiculopathy might present as pain with sensory disturbances, weakness in specific muscle groups of the upper limb and  altered reflexes or a combination of the above. Cervical radiculopathy ensues as wear and tear in the supporting discs alters it’s consistency and can lead to compromise of the cushioning effects of the discs.

ETIOPATHOGENESIS

Degenerative Cervical disc disease-There are six jelly like cervical discs which act as  natural shock absorbers present in the neck. Disc is structurally filled on the inside with a mucoprotein gel and is referred to as the nucleus pulposus. The nucleus pulposus is a thin yet flexible layer of woven cartilage strands known as the annulus fibrosus. The discs are essentially filled with water and as the age advances, the water content starts decreasing. In certain cases this dehydration of the discs is pretty rapid and this makes the annulus susceptible to cracks and tears. Due to absence of an indigenous blood supply, tears in the discs have a high chance to go unhealed or form structurally weak scar tissue which again is a potential site of tear in the future.

Traumatic Cervical Disc Migration- Road Traffic Accidents, sports injuries and falls are some of the causes of a traumatic cervical disc migration.

Cervical foraminal stenosis- Narrowing of a foramen(bony opening where a nerve root exits the spinal canal)  can cause the adjacent nerve root to get pinched. Osteophytes(bone spurs) resulting due to degenerative arthritic changes in the cervical spine, a bulging disc or thickened ligaments might cause compression of the nerve root. Foraminal Stenosis is the single most common cause for cervical radiculopathy.

CLINICAL PRESENTATION

• Radiating pain due to nerve compression can be experienced which tends to be a sharp, electric shock like pain radiating down from the neck, along the shoulder Travelling further into the arm, hand and fingers.
• Neurological symptoms such as pins, needles, tingling,numbness and weakness can accompany the pain in the upper limbs. These can interfere with routine activities such as typing, holding and getting dressed.
• Pain due to the disc (discogenic pain)is usually aggravated by movements of the neck and is relieved by rest.When the pain is primarily discogenic, there is a higher chance of resolution by itself but if there is disc migration or bone spur causing a pinched nerve root and associated symptoms, it would be advisable to initiate treatment for the same.

RADICULOPATHIES AT INDIVIDUAL LEVELS

• C5 radiculopathy. This might present as pain associated with tingling and numbness which might radiate down from the neck into the shoulder and going down  the arm upto the thumb. Patient might experience some weakness in the shoulder and upper arm.
• C6 radiculopathy.  Radiation of symptoms usually follows the arm into the index finger. Weakness might be elicited in the biceps or the wrist.
• C7 radiculopathy. Tingling, numbness, and/or pain may be felt down the arm and into the middle finger. Weakness might be experienced in the triceps.
• C8 radiculopathy.  Symptoms may radiate down the arm and into the little finger. Handgrip strength might be reduced.

DIAGNOSIS

A thorough history can be extremely informative in guiding our diagnosis towards Cervical Radiculopathy.[2] Patients suffering with radiculopathy usually present with unilateral pain.[1]

Next comes the clinical examination including relevant sensory and motor examination which helps us in localising the level of the lesion responsible for the radiculopathy.

Distribution of sensory and motor weaknesses typically seen with cervical radiculopathy
Level Muscle weakness Sensory deficits/location of pain Reflex

C5 Deltoid Lateral arm Biceps

C6 Biceps, wrist extension Radial forearm, radial two digits Brachioradialis

C7 Triceps, wrist flexion Middle finger Triceps

C8 Finger flexors Ulnar two digits

T1 Hand intrinsics Ulnar forearm
 

Popular provocative tests

Provocative tests  are carried out to aid in the diagnosis of cervical radiculopathy.The aim of these  tests is to bring about narrowing of the foramen which will most likely reproduce the symptoms of Cervical Radiculopathy. These are namely

• Spurling test- This involves axial loading of the cervical spine along with rotation.(with or without extension) This test has very high specificity(94%) as compared to the other provocative tests.[3]
• Shoulder Abduction test
• Neck distraction
• Elveys upper limb tension test

Differential Diagnosis

• Cervical Myelopathy- Patients present with signs such as altered gait pattern,hyperreflexia and find it difficult to accomplish fine motor tasks such as writing and buttoning shirts. These are essentially signs of Upper Motor Neuron lesions.
• Peripheral Nerve Compression- Median or Ulnar Nerve Entrapment might cause confusing overlapping symptoms. The clinician should also be mindful of a “double crush” phenomenon which involves cervical radiculopathy accompanied by a peripheral nerve entrapment.[1]
• Shoulder pathologies can also present with similar symptoms and should ne ruled out.
• Uncommon differential diagnosis include cardiac pain, herpes zoster(shingles), Parsonage Turner syndrome, postmedian sternotomy lesion, intra and extraspinal tumors, and thoracic outlet syndrome [4].

Imaging

X rays of the cervical spine with AP and Lateral projections are helpful to observe the disc height and presence of degenerative changes.

MRI remains the gold standard imaging modality to assess the soft tissue sources of impingement as well as any changes indicating myelopathy.

CT scans give clearer idea about  bony pathology and may be used to better delineate “hard” disc impingement.

Non-operative treatment

The conservative approach includes immobilisation, physical therapy , manipulation and medical management.

Immobilization

Immobilisation  carried out with a soft cervical collar has been tried [6,21][1,6] to limit inflammation and reduce the irritation of the nerve root but this kind of mobilisation has not received much evidential support over the years.[6,19][1,5]

Physical therapy

The physical therapy modalities which are commonly used in the management of cervical radiculopathy include Intermittent Cervical Traction[7], Local Ultrasound and Infrared application[8] and Stretching and strength training of the neck muscles.[7]. The intensity of the physical therapy program is started cautiously and slowly amped up. Postural and ergonomic training should also be included in the physical therapy program.[6]

Traction

Cervical Traction has been a popular modality over the years in the past,  [5,6]  but in the last decade many clinicians have abandoned the use of traction for treating cervical pathologies because many studies reaching a consensus that traction does very little in the management of cervical radiculopathy.

Manipulation

Benefits of manipulation in treating cervical radiculopathy is definitely uncertain. Gross et al in their Cochrane review in assessing the efficacy of manipulation in managing neck pain[9], concluded that there were no discernible differences in the outcomes of patients treated with manipulation in the immediate,shot-term and intermediate follow up period.

Medication

NSAIDS are used in the management of cervical radiculopathy owing to their anti inflammatory and analgesic actions.

Oral steroid medications are sometimes given in the acute phase to dampen the inflammatory cascade.

Narcotic medications are used in some cases but caution has to be exercised to prevent dependence.

Image guided Cervical Epidural Anti inflammatory Injection

Anti inflammatory corticosteroid injections delivered in the cervical epidural space are an excellent treatment option for a vast majority of patients. These provide relief by reduce inflammation at the nerve root,  decreasing  nociceptive input from somatic nerves,  stabilizing effect on  neural membranes  and by  blocking  the synthesis of pain-mediating neuropeptides. Corticosteroids are also known to break up adhesions at the site of injections and block C-fiber activity in the dorsal root ganglion [1].

AT ALLEVIATE,

We go a step further and after the inflammation settles down following the steroid injection, we couple it up with successive sessions of Platelet Rich Plasma with Prolotherapy to strengthen the integrity of the cervical spine and the associated soft tissue structures. This is coupled with a structured physical therapy program and inputs from Clinical Nutrition and Clinical Psychology as and when necessary.

Operative treatment

Patients not responding to sincere attempt at conservative management are considered for surgical interventions. The choices of surgical interventions are as follows

• Anterior Cervical Discectomy with decompression
• Cervical Disc Arthroplasty
• Posterior decompression

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