Cervical Radiculopathy: Nonoperative Management of Neck Pain and Radicular Symptoms
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Cervical Radiculopathy:
Nonoperative Management
of Neck Pain and Radicular Symptoms
JASON DAVID EUBANKS, MD, Case Western Reserve University School of Medicine, Cleveland, Ohio
Cervical radiculopathy is a disease process marked by nerve com-
pression from herniated disk material or arthritic bone spurs. This
impingement typically produces neck and radiating arm pain or
numbness, sensory deficits, or motor dysfunction in the neck and
upper extremities. Magnetic resonance imaging or computed tomo-
graphic myelography can confirm neurologic compression. The
overall prognosis of persons with cervical radiculopathy is favor-
able. Most patients improve over time with a focused, nonoperative
treatment course. There is little high-quality evidence on the best
nonoperative therapy for cervical radiculopathy. Cervical collars
may be used for a short period of immobilization, and traction may
temporarily decompress nerve impingement. Medications may help
alleviate pain and neuropathic symptoms. Physical therapy and
ILLUSTRATION BY john w. karapelou
manipulation may improve neck discomfort, and selective nerve
blocks target nerve root pain. Although the effectiveness of individ-
ual treatments is controversial, a multimodal approach may benefit
patients with cervical radiculopathy and associated neck pain. (Am
Fam Physician. 2010;81(1):33-40. Copyright © 2010 American Acad-
emy of Family Physicians.)
C
ervical radiculopathy leads to disk protrusion on imaging. Spondylosis, disk
neck and radiating arm pain or protrusion, or both caused nearly 70 percent
numbness in the distribution of of cases.
a specific nerve root. Often, this
radicular pain is accompanied by motor or Pathoanatomy
sensory disturbances. Although the causes A variety of conditions can lead to nerve
of radiculopathy are varied (e.g., acute disk root compression in the cervical spine. Each
herniations, cervical spondylosis, foraminal motion segment in the subaxial spine (C3
narrowing), they all lead to compression and through C7) consists of five articulations,
irritation of an exiting cervical nerve root. including the intervertebral disk, two facet
joints, and two neurocentral (uncovertebral)
Epidemiology joints. Bounded by these elements, the nerve
An epidemiologic survey showed the annual roots exit laterally.
age-adjusted incidence of radiculopathy to be Unlike the lumbar spine, the cervical
83 per 100,000 persons.1 Persons reporting spine has cervical nerve roots that exit above
radiculopathy were between 13 and 91 years the level of the corresponding pedicle. For
of age, and men were affected slightly more instance, the C5 nerve root exits at the C4-
than women. In this study, 14.8 percent of C5 disk space, and a C4-C5 disk herniation
persons with radiculopathy reported ante- typically leads to C5 radiculopathy. There are
cedent physical exertion or trauma, and only seven cervical vertebrae and eight cervical
21.9 percent had an accompanying objective nerve roots. In the lumbar spine, the nerve
January 1, 2010 ◆ Volume 81, Number 1 www.aafp.org/afp American Family Physician 33
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SORT: KEY RECOMMENDATIONS FOR PRACTICE
Evidence
Clinical recommendation rating References
Acute radicular pain
A short period (one week) of immobilization in a cervical collar may relieve C 9
radicular pain.
Home cervical traction units may provide temporary relief of radicular pain. C 10, 11
Opioids may help alleviate neuropathic pain of up to eight weeks duration. A 13, 14
In patients with cervical radiculopathy, exercises and manipulation should C 17-19
focus on stretching and strengthening after the acute pain has subsided.
Selective nerve root blocks may relieve radicular pain, but rare serious B 20-24
complications may occur.
Chronic radicular pain
Antidepressants (tricyclic antidepressants, and venlafaxine [Effexor]) and A 15, 16
tramadol (Ultram) may alleviate chronic neuropathic pain.
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evi-
dence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information
about the SORT evidence rating system, go to http://www.aafp.org/afpsort.xml.
exits below the corresponding pedicle. There- decompresses the exiting nerve root. Table 1
fore, an analogous lumbar disk herniation presents the classic patterns of cervical radic-
(L4-L5) would compress the traversing nerve ulopathy based on the affected nerve root.3,4
root (L5), not the exiting root (L4). Whether Before diagnosing cervical radiculopathy,
in the cervical spine or the lumbar spine, physicians should consider other potential
the nerve impingement typically occurs in causes of pain and dysfunction (Table 2).2,4
the nerve numerically corresponding to the Myelopathic symptoms or signs (e.g., dif-
lower of the two vertebral levels. ficulty with manual dexterity; gait distur-
The exiting nerve root can be compressed bance; objective, upper motor neuron signs
by herniated disk material (soft disk her- such as Hoffman sign, Babinski sign, hyper-
niation) or through encroachment by sur-
rounding degenerative or hypertrophic
bony elements (hard disk pathology). In
either case, a combination of factors, such
as inflammatory mediators (e.g., substance
P), changes in vascular response, and intra
neural edema, contribute to the development
of radicular pain.2
Clinical Presentation
Chronic neck pain associated with spondy-
losis is typically bilateral, whereas neck pain
associated with radiculopathy is more often
unilateral.3 Pain radiation varies depending
ILLUSTRATION BY marcia hartsock
on the involved nerve root, although some
distributional overlap may exist. Absence of
radiating extremity pain does not preclude
nerve root compression. At times, pain may
be isolated to the shoulder girdle.3 Similarly,
sensory or motor dysfunction may be present
without significant pain. Symptoms are often Figure 1. Spurling sign. Axial compression of
exacerbated by extension and rotation of the the spine and rotation to the ipsilateral side
of symptoms reproduces or worsens cervical
neck (Spurling sign; Figure 1), which decreases radiculopathy. Pain on the side of rotation is
the size of the neural foramen. Holding the usually indicative of foraminal stenosis and
arm above the head (shoulder abduction sign) nerve root irritation.
34 American Family Physician www.aafp.org/afp Volume 81, Number 1 ◆ January 1, 2010Table 1. Classic Patterns of Cervical Radiculopathy
Abnormalities
Nerve
root Interspace Pain distribution Motor Sensory Reflex
C4 C3-C4 Lower neck, trapezius NA Cape distribution NA
(i.e., lower
neck and upper
shoulder girdle)
C5 C4-C5 Neck, shoulder, lateral Deltoid, elbow Lateral arm Biceps
arm flexion
C6 C5-C6 Neck, dorsal lateral Biceps, wrist Lateral forearm, Brachioradialis
(radial) arm, thumb extension thumb
C7 C6-C7 Neck, dorsal lateral Triceps, wrist Dorsal forearm, Triceps
forearm, middle flexion long finger
finger
C8 C7-C8 Neck, medial forearm, Finger flexors Medial forearm, NA
ulnar digits ulnar digits
T1 C8-T1 Ulnar forearm Finger intrinsics Ulnar forearm NA
NA = not applicable.
Information from references 3 and 4.
reflexia, and clonus) may suggest compres- or symptoms of systemic disease; unrelent-
sion of the spinal cord rather than nerve root. ing pain at rest; constant or progressive
Spinal cord compression typically requires signs or symptoms; neck rigidity without
surgical decompression because myelopa- trauma; dysphasia; impaired consciousness;
thy is progressive and does not improve with central nervous system signs and symp-
nonoperative measures. The following fac- toms; increased risk of ligament laxity or
tors may also indicate an alternate diagno- atlantoaxial instability, such as in patients
sis: age younger than 20 years or older than with Down syndrome or heritable connec-
50 years, especially if the patient has signs tive tissue disorders; sudden onset of acute
Table 2. Differential Diagnosis of Cervical Radiculopathy
Condition Characteristics
Cardiac pain Radiating upper extremity pain, particularly in the left shoulder and arm, that has possible cardiac origin
Cervical spondylotic Changes in gait, frequent falls, bowel or bladder dysfunction, difficulty using the hands, stiffness of the
myelopathy extremities, sexual dysfunction accompanied by upper motor neuron findings
Complex regional pain Pain and tenderness of the extremity, often out of proportion with examination findings, accompanied by
syndrome (reflex skin changes, vasomotor fluctuations, or dysthermia; symptoms often occur after a precipitating event
sympathetic dystrophy)
Entrapment syndromes For example, carpal tunnel syndrome (median nerve) and cubital tunnel syndrome (ulnar nerve)
Herpes zoster (shingles) Acute inflammation of dorsal root ganglion creates a painful, dermatomal radiculopathy
Intra- and extraspinal tumors Schwannomas, osteochondromas, Pancoast tumors, thyroid or esophageal tumors, lymphomas,
carcinomatous meningitis
Parsonage-Turner syndrome Acute onset of proximal upper extremity pain, usually followed by weakness and sensory disturbances;
(neuralgic amyotrophy) typically involves upper brachial plexus
Postmedian sternotomy lesion Occurs after cardiac surgery; C8 radiculopathy may develop secondary to an occult fracture of the first
thoracic rib
Rotator cuff pathology Shoulder and lateral arm pain
Thoracic outlet syndrome Median and ulnar nerve (lower brachial plexus nerve roots, C8 and T1) dysfunction from compression
by vascular or neurogenic causes, often a tight band of tissue extending from first thoracic rib to C7
transverse process
Information from references 2 and 4.
January 1, 2010 ◆ Volume 81, Number 1 www.aafp.org/afp American Family Physician 35Cervical Radiculopathy
and unusual neck pain or headache with or Natural History
without neurologic symptoms; suspected Most patients with cervical radiculopathy
cervical artery dissection; transient ischemic have a favorable prognosis.1,6 A large epide-
attack, which may indicate vertebrobasilar miologic study demonstrated that over a five-
insufficiency or carotid artery ischemia or year follow-up period, 31.7 percent of patients
stroke; suspected neoplasia; suspected infec- with symptomatic cervical radiculopathy
tion, such as diskitis, osteomyelitis, or tuber- had symptom recurrence and 26 percent
culosis; failed surgical fusion; progressive needed surgical intervention for intractable
or painful structural deformity; abnormal pain, sensory deficit, or objective weakness.1
laboratory examination results.5 At final follow-up, however, nearly 90 percent
of patients were asymptomatic or only mildly
Diagnostic Evaluation incapacitated by the pain.
Adults who have persistent neck pain and The classic study of the natural history of
radicular symptoms should receive antero- cervical radiculopathy followed 51 patients
posterior open-mouth, anteroposterior lower over two to 19 years.6 In the study, 43 per-
cervical, and neutral lateral radiography.5 If cent of patients had no further symptoms
a period of nonoperative management fails after a few months, 29 percent had mild or
in patients with suspected cervical radicu- intermittent symptoms, and 27 percent had
lopathy and normal radiography findings, more disabling pain. No patient with radicu-
further diagnostic studies may be needed to lar pain progressed to myelopathy.
direct treatment. If it is unclear whether the
patient has cervical radiculopathy or entrap- Nonoperative Management Strategies
ment syndrome in the upper extremity, elec- In most patients with cervical radiculopathy,
tromyography may be helpful. In the presence nonoperative treatment (Figure 32,5) is effective.
of normal radiography findings and contin- In a one-year cohort study of 26 patients with
ued symptoms, magnetic resonance imaging documented herniated nucleus pulposus and
(MRI) should be performed to evaluate for a symptomatic radiculopathy, a focused, non-
disk herniation with or without compressive, operative treatment program was successful
spondylotic osteophytes (Figure 2). Com- in 92 percent of patients.7 Little high-quality
puted tomographic myelography may be used evidence supports the use of an individual
instead of MRI in patients with a pacemaker nonoperative treatment; however, a multi-
or stainless steel cervical hardware. modal approach may alleviate symptoms.
A B
Figure 2. T2-weighted magnetic resonance imaging in a patient with right-sided C6 radiculopathy. (A) Sagittal view
showing spondylosis at C5-C6 and C6-C7 disk levels (arrows). (B) Axial view showing a right-sided disk-osteophyte
complex at C5-C6 disk level (arrow) that is putting pressure on the C6 nerve root.
36 American Family Physician www.aafp.org/afp Volume 81, Number 1 ◆ January 1, 2010Cervical Radiculopathy
Nonoperative Treatment of Acute Cervical Radiculopathy
Acute radicular pain
Nonprogressive neurologic Red flag symptoms, progressive
deficit or no neurologic deficit neurologic deficit, or signs of myelopathy
Anteroposterior open-mouth, Anteroposterior, lateral, and
anteroposterior lower cervical, flexion-extension cervical
and neutral lateral radiography spine radiography; MRI
Refer to spine subspecialist
Osseous destruction Normal radiography findings
or signs of instability
MRI, medical
workup, referral to Nonoperative management
spine subspecialist for two weeks
Resolving symptoms: continue No improvement
nonoperative management
Unchanged symptoms Questionable diagnosis Progressive deficit
Continue nonoperative Electromyography Refer to spine subspecialist
management for four weeks
Reevaluation
Improvement No improvement
Counsel patient on the MRI
natural history of the disease
Positive findings consistent with Negative findings
clinical symptoms and signs
Refer to a rheumatologist or
Refer to spine subspecialist pain subspecialist as needed
Figure 3. Algorithm for nonoperative treatment of acute cervical radiculopathy. (MRI = mag-
netic resonance imaging.)
Adapted with permission from Levine MJ, Albert TJ, Smith MD. Cervical radiculopathy: diagnosis and nonoperative manage-
ment. J Am Acad Orthop Surg. 1996;4(6):312, with additional information from reference 5.
January 1, 2010 ◆ Volume 81, Number 1 www.aafp.org/afp American Family Physician 37Cervical Radiculopathy
When approaching the nonoperative radiculopathy. Although medications have
management of neck and radicular pain, it no proven benefit for cervical radiculopathy,
is important to distinguish the acuity of the positive results with their use in the treat-
process. Pain emanating from nerve com- ment of lumbar radiculopathy and low back
pression by a soft disk herniation typically pain suggest a potential role. Nonsteroidal
has a more acute presentation, with or with- anti-inflammatory drugs have been shown
out radiating extremity symptoms. Chronic, to be effective in treating acute low back
bilateral axial neck and radiating arm pain pain,3,12 and many physicians consider them
is usually caused by cervical spondylosis first-line agents in the treatment of neck
and may emanate from a variety of sources, and radiating arm pain. Some patients may
including the degenerative disk or the facet benefit from the addition of narcotic anal-
joints. Although education about these and gesics, muscle relaxants, antidepressants, or
other components of cervical radiculopa- anticonvulsants. Although not specific to
thy may benefit some patients, a systematic cervical radiculopathy, a systematic review
review did not show that patient education and a meta-analysis suggest that opioids may
(i.e., advice focusing on activation and cop- be effective in the treatment of neuropathic
ing skills, and traditional neck school) is pain of up to eight weeks duration.13,14 Insuf-
beneficial in the treatment of neck pain and ficient evidence exists to recommend treat-
radicular arm pain.8 ment beyond two months. Muscle relaxants
(e.g., cyclobenzaprine [Flexeril]) may allevi-
IMMOBILIZATION ate acute neck pain from increased tension at
For patients with acute neck pain secondary muscle insertion sites.2
to radiculopathy, a short course (one week) of Medications may be effective for patients
neck immobilization may reduce symptoms with chronic radicular pain who decline sur-
in the inflammatory phase.2 Although the gery or have continued pain after surgery.
effectiveness of immobilization with a cer- A systematic review suggests that tricyclic
vical collar has not been proven to alter the antidepressants and venlafaxine (Effexor)
course or intensity of the disease process,2,3,9 may produce at least moderate relief in
it may be beneficial in some patients. patients with chronic neuropathic pain.15
Similarly, another systematic review sug-
TRACTION gests that tramadol (Ultram) may provide
Home cervical traction units may decrease significant relief of neuropathic pain.16
radicular symptoms.2,3,10 In theory, traction Although oral steroids are widely used to
distracts the neural foramen and decom- treat acute radicular pain via dose packs,
presses the affected nerve root. Typically, no high-quality evidence has shown that
eight to 12 lb of traction is applied at an angle oral steroids alter the disease course.3 Long-
of approximately 24 degrees of flexion for term use of steroids should be avoided
15- to 20-minute intervals.2 Traction is most because of the potential for rare, but serious,
beneficial when acute muscular pain has complications.3,12
subsided and should not be used in patients
PHYSICAL THERAPY AND MANIPULATION
who have signs of myelopathy.2 A recent sys-
tematic review of mechanical traction for A graduated physical therapy program may
neck pain of more than three months dura- be beneficial in restoring range of motion
tion, with or without radicular symptoms, and overall conditioning of the neck mus-
found insufficient evidence to recommend culature. In the first six weeks after onset of
for or against its use in the management of pain, gentle range-of-motion and stretch-
chronic symptoms.11 ing exercises supplemented by massage and
modalities such as heat, ice, and electri-
PHARMACOTHERAPY cal stimulation may be used, although this
Pharmacotherapy may be beneficial in alle- approach has no proven long-term benefit.
viating acute pain associated with cervical As the pain improves, a gradual, isometric
38 American Family Physician www.aafp.org/afp Volume 81, Number 1 ◆ January 1, 2010Cervical Radiculopathy
strengthening program may be initiated Referral
with progression to active range-of-motion Approximately one third of patients with cer-
and resistive exercises as tolerated.3 vical radiculopathy who are treated nonop-
No high-quality evidence has proved the eratively have persistent symptoms.6 Patients
effectiveness of manipulative therapy in the should be referred to a spine subspecialist for
treatment of cervical radiculopathy. How- consideration of surgical intervention if there
ever, limited evidence suggests that manipu- is intractable radicular symptoms unrespon-
lation may provide short-term benefit in the sive to nonoperative management over a six-
treatment of neck pain, cervicogenic head- week period, motor weakness
aches,3,17 and radicular symptoms.18 Rare persisting for more than six Little high-quality
complications, such as worsening radicu- weeks, progressive neurologic
evidence supports the use
lopathy, myelopathy, and spinal cord injury, deficit at any point after symp-
of individual nonopera-
may occur.3,19 Because of these risks and the tom onset, signs or symptoms
tive treatments for cervical
lack of high-quality evidence to support its of myelopathy, or instability or
radiculopathy; however, a
effectiveness, manipulative therapy cannot deformity of the spine. The25
multimodal approach may
be recommended for the treatment of cervi- Washington State Department
cal radiculopathy. of Labor and Industries’ criteria alleviate symptoms.
for initiating surgical manage-
STEROID INJECTIONS ment are six to eight weeks of conservative
Cervical steroid injections may be consid- care (i.e., physical therapy, medications, or
ered in the treatment of radicular pain. traction); subjective sensory symptoms or
Cervical perineural injections (e.g., trans- Spurling sign, objective motor, reflex, or elec-
laminar and transforaminal epidurals, selec- tromyography findings; and abnormal imag-
tive nerve root blocks) should be performed ing findings that correlate with the patient’s
under radiographic guidance and only after symptoms.26 Alternatively, in the rare patient
confirmation of pathology via MRI or com- who has radicular pain without objective
puted tomography. These blocks attempt to physical examination or electromyography
bathe the affected nerve root in steroids. One findings, a selective nerve root block may be
study demonstrated significant pain relief at used. If the nerve block is “positive,” or effec-
14 days and six months after a series of selec- tive in partially alleviating symptoms, then
tive nerve root blocks.20 In another prospec- surgery may be considered.
tive cohort series of 21 patients awaiting
surgery for symptomatic radiculopathy, cer- The Author
vical injections improved pain and reduced JASON DAVID EUBANKS, MD, is an assistant professor in
the need for operative intervention.21 More the Department of Orthopaedic Surgery, Division of Spine
recently, however, a prospective, random- Surgery, at Case Western Reserve University School of
ized study of 40 patients showed no differ- Medicine in Cleveland, Ohio. At the time this manuscript
was written, Dr. Eubanks was a spine fellow at the Univer-
ence after three weeks between patients who sity of Pittsburgh (Pa.) Medical Center.
received a steroid injection and those who
Address correspondence to Jason David Eubanks, MD,
were in the control groups.22 Complications Dept. of Orthopaedics, University Hospitals Case Medi-
associated with cervical injections are rare. cal Center, 11100 Euclid Ave., Cleveland, OH 44106.
One study of a series of more than 1,000 Reprints are not available from the author.
blocks showed a minor complication rate of Author disclosure: Nothing to disclose.
1.66 percent and a major adverse events rate
of less than 1 percent.23 However, patients REFERENCES
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