Cervical radiculopathy: what it is, how it is diagnosed and when you need a specialist.

The typical symptom is pain running from the neck down the arm, often sharp or electric, with tingling or numbness in the fingers. It may worsen when the neck is extended or turned toward the affected side, and it commonly eases when the hand is rested on top of the head, because that position reduces tension on the root (Rhee et al., 2007; Eubanks, 2010). There may also be arm or hand weakness, a lost reflex, or pain between the shoulder blade and the spine.

Some patterns are not intuitive. For example, a compromised root can cause selective finger drop that mimics a peripheral nerve injury (Campbell et al., 1995). That is why a targeted examination matters more than intuition.

When not to wait. Progressive clumsiness of the hands (buttoning, writing), unsteady gait, stiffness or weakness in the legs, or loss of bladder control suggest spinal cord involvement and need prompt evaluation. So does rapidly worsening arm weakness.

The diagnosis is clinical: a detailed history and a neurological examination of strength, sensation and reflexes, together with a search for signs of spinal cord involvement. MRI confirms and localizes, but does not replace the examination (Woods & Hilibrand, 2015; Wainner et al., 2003).

A classic study evaluated the accuracy of four tests and showed that their value improves when they are combined (Wainner et al., 2003):

Spurling test. With the neck extended and turned toward the painful side, gentle compression is applied from above; it is positive if it reproduces arm pain. It is more specific than sensitive: a positive result is informative, a negative one does not rule it out.

Distraction test. When the head is gently lifted upward, relief of arm pain supports the diagnosis. It too is more specific than sensitive.

Upper limb tension test (ULTT A). The median nerve is put under tension through the arm; it has low specificity but high sensitivity, so a negative test helps rule the diagnosis out. Cervical rotation under 60° toward the affected side is the fourth element of the cluster (Wainner et al., 2003).

In parallel, signs of myelopathy are assessed: brisk reflexes, Hoffmann sign, clonus, gait disturbance. If present, they change the plan.

Many conditions mimic cervical radiculopathy and are treated differently. The most relevant ones:

Cervical myelopathy. Compression of the cord, not of a root. It can coexist with radiculopathy or appear alone, with clumsy hands and gait disturbance. It is the one that must not be missed (Woods & Hilibrand, 2015).

Peripheral entrapments. Carpal tunnel syndrome and ulnar nerve entrapment cause hand tingling and are confused with a C6–C8 radiculopathy. Hand tingling can also have occupational and postural origins, as described in workers who use display screens (Oh et al., 2013).

Myofascial and muscular pain. Scalene myofascial pain syndrome can mimic a cervical disc herniation (Nizar et al., 2010), and active trigger points are more frequent in patients with radiculopathy, so the two sometimes coexist (Sari et al., 2012).

Other causes include shoulder pathology (rotator cuff), thoracic outlet syndrome, brachial neuritis, peripheral neuropathy and, less often but more seriously, tumors or infection. Left arm pain can also have a cardiac origin and should not be attributed to the neck without ruling that out.

When the picture is recent, the examination is compatible and there are no warning signs, imaging is often not needed at the start, because most patients improve with non-surgical treatment (Childress & Becker, 2016; Woods & Hilibrand, 2015). Imaging is requested for progressive neurological deficit or signs of myelopathy, a history of trauma, suspicion of tumor or infection, or pain that does not improve and might lead to an intervention.

Magnetic resonance imaging (MRI). It is the study of choice to see disc, roots and cord. As in the lumbar spine, degenerative findings are common and must be read together with the symptoms: a herniation on imaging does not prove by itself that it is the cause of the pain.

Radiographs to evaluate alignment and instability (including dynamic views); CT when bony detail of osteophytes and foramina is needed; and electromyography with nerve conduction studies when the diagnosis is uncertain or when distinguishing a radiculopathy from a peripheral entrapment (Woods & Hilibrand, 2015; Rhee et al., 2007).

Most patients with cervical radiculopathy improve with non-surgical treatment, and that is the starting point unless there is myelopathy or a significant motor deficit (Woods & Hilibrand, 2015; Childress & Becker, 2016; Eubanks, 2010).

Medication for pain and inflammation over a short period, prescribed by a physician. Physical therapy with specific neck-muscle exercises (Dedering et al., 2018), with or without manual therapy and mobilization (Young et al., 2009; Thoomes, 2016). Randomized trials have also evaluated stabilization and neck-muscle function exercises (Akkan & Gelecek, 2018; Halvorsen et al., 2016), neural mobilization (Efstathiou et al., 2015; Kim et al., 2017), thoracic manipulation (Young et al., 2019) and comparisons of manual therapy and exercise protocols (Boyles et al., 2011; Langevin et al., 2015). The evidence on adding traction to physical therapy is mixed (Romeo et al., 2018; Jellad et al., 2009; Fritz et al., 2014; Savva et al., 2016). Epidural steroid injections, as part of a multimodal program, may help selected patients (Benditz et al., 2017).

As for cervical manipulation, the evidence in radiculopathy is limited and of low quality (Zhu et al., 2016; Leininger et al., 2011), and forceful neck maneuvers are not risk-free, so they should be considered only after a specialist has ruled out serious structural causes.

Surgery is considered when there is progressive or severe motor deficit, associated myelopathy, or disabling radicular pain that persists after a reasonable period of treatment with a cause confirmed on imaging (Woods & Hilibrand, 2015; Rhee et al., 2007). Techniques include anterior cervical discectomy with fusion or with a disc prosthesis, and posterior foraminotomy. The choice depends on the level, the cause and each patient’s characteristics. Structured rehabilitation after surgery is part of the process (Wibault et al., 2018).

The first evaluation is usually done by a general practitioner or internist, but when pain is severe, there is weakness, there are signs of spinal cord involvement, it does not improve within a few weeks or the diagnosis is in doubt, the recommendation is to see a spine specialist (a neurosurgeon or orthopedic spine surgeon). That is the physician who can integrate symptoms, examination and studies and distinguish a radiculopathy from a myelopathy or a mimic.

Management is often multidisciplinary: rehabilitation, pain medicine when injections are considered, neurophysiology for electrodiagnostic studies, and spine surgery when appropriate.

In general it is favorable. The natural history of cervical radiculopathy is improvement in most patients, and on imaging the herniation can shrink over time (Casey, 2011; Yamazaki et al., 2003; Woods & Hilibrand, 2015). That is why, without severe deficit or signs of myelopathy, treatment almost always starts without surgery. To track progress, scales such as the Neck Disability Index and the numeric pain rating scale are used, and their reliability has been evaluated in patients with cervical radiculopathy (Young et al., 2010; Bobos et al., 2018).

Among those who undergo surgery, surgery usually relieves arm pain well when the cause is clearly identified (Woods & Hilibrand, 2015). The prognosis is less predictable when the diagnosis was not clearly confirmed, when there is long-standing cord compression or when other pain sources coexist, such as myofascial trigger points (Sari et al., 2012).