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What is Cervical Radiculopathy?

Neck Pain

Are you having neck pain that is also running down your shoulder or arm? If so, you could potentially be suffering from a common condition we see here in the clinic called cervical radiculopathy. Cervical radiculopathy is a condition that results from compression of the nerves in your neck. The causes of this compression include disc herniation and spondylosis, which is degenerative changes within the cervical spine. Spondylosis can lead to bone spurs or narrowing of the intervertebral foramen, which is the opening that the nerves pass through.

With this condition, you could have symptoms such as neck pain, arm pain, scapular pain, numbness and tingling, muscle weakness, headache, and impairment of the reflexes. Symptoms usually occur on one side, but in rare cases, you can experience symptoms on both sides of your body. The weakness, nerve symptoms, and radiating pain will usually follow a specific pattern of the cervical nerve root that is affected. Cervical radiculopathy is commonly seen among the 40-49 years old age group.


Anatomy

The cervical spine consists of 7 cervical vertebrae and 8 cervical nerves. This may seem odd, but the 8th cervical nerve comes out between the C8 and T1 cervical vertebras. Each cervical nerve supplies a different part of the upper extremity and the muscles and each cervical nerve corresponds to a different movement.

  • C1/C2- Neck flexion/extension
  • C3- Neck lateral flexion
  • C4- Shoulder elevation
  • C5- Shoulder abduction
  • C6- Elbow flexion/wrist extension
  • C7- Elbow extension/wrist flexion
  • C8- Thumb extension
  • T1- Finger abduction

During a physical therapy examination, a clinician will ask you to perform these movements and will note what is weak in order to figure out what nerve level is affected. They will also examine dermatomes, which is a part of the skin that corresponds to a nerve level. If there is a sensory deficit in any of these dermatomes, that can also give us a clue about which cervical nerve is affected.


Red Flag Conditions

If you suffer from any of the following symptoms related to these conditions, it is highly recommended to seek professional help from a physician.


Cervical Myelopathy

  • Sensory disturbance of hands
  • Muscle wasting of hands
  • Unsteady gait
  • Change in bowel and bladder
  • Increased reflexes
  • Positive Babinksi and/or Hoffman’s reflex
  • Multi-segmental weakness and sensory changes

Neoplastic Condition

  • Age > 50 years old and previous history of cancer
  • Unexplained weight loss
  • Constant pain that is not relieved with bed rest
  • Night pain

Upper Cervical Ligamentous Instability

  • Headache and numbness in the back of the head
  • Significant decrease of neck range of motion in all directions
  • Signs of cervical myelopathy
  • Trauma
  • Rheumatoid Arthritis
  • Down Syndrome

Vertebral Artery Insufficiency

  • 5D’s
  • Drop attacks – spontaneous fall while standing or sitting without warning
  • Dizziness
  • Dysphasia – Disturbance of your ability to speak and produce language
  • Dysarthria – Weakness in the muscles of speed, leading to slowed or slurred speech
  • Diplopia or double vision
  • Positive cranial nerve signs
  • Ataxia
  • Nausea

Inflammatory or Systemic Disease

  • Fever > 100 degrees
  • Blood pressure > 160/95
  • Resting pulse > 100 bpm
  • Respiration rate > 25 at rest
  • Fatigue

Cervical Fracture

  • Canadian C-Spine Rules – Used to clear cervical spine fracture and see if patient is appropriate for radiography to check for fracture.

Diagnosis

Cervical radiculopathy can be diagnosed via MRI, EMG, and nerve conduction studies. However, it can also be easily diagnosed in the clinic through detailed clinical examination. We have 4 specific clinical tests that we use and if all 4 tests are positive, there is a 90% probability that you have cervical radiculopathy. These tests include the Spurlings Test, Upper limb tension test I, Distraction test, and cervical rotation range of motion.

For the Spurlings Test, you will be in the seated position and the clinician will extend and side bend your neck and apply a force at the top of your head. The test is positive if that reproduces the numbness and tingling that you experience with your neck pain.

The median nerve is the most likely nerve to be affected in cervical radiculopathy, so the Upper Limb Tension Test I is used to examine this nerve. During this test, you will be laying on your back and the clinician will put your arm in a position to stretch the median nerve. The test is positive if the nerve symptoms are reproduced. This can also be used as a treatment to help relieve the symptoms and it is known as nerve gliding.

The Distraction test involves the clinician giving a traction force onto your neck while you are laying down on the table. If this test relieves the symptoms, then that is considered a positive test.

The final test involves the clinician checking your ability to rotate your neck to both sides. A positive test if you cannot rotate your neck > 60 degrees to the side that is affected.


What Other Conditions Could Mimic the Signs of Cervical Radiculopathy?

Spinal Tumor

Cervical Myelopathy

  • Serious condition that involves compression of the spinal cord due to disc herniation’s, spondylosis, ossified posterior longitudinal ligament, or stenosis.
  • Symptoms include weakness and numbness in a non-specific pattern, decreased coordination or ataxia, exaggerated tendon reflexes, and even loss of bowel and bladder.

Thoracic Outlet Syndrome

  • TOS is usually a diagnosis of exclusion.
  • This is a syndrome due to compression of the neurovascular structures that exit through the thoracic outlet.
  • Symptoms differs from patient to patient and depends on the structures that are compressed.
  • These include: Pain and numbness in the neck, face, chest, or shoulder and upper extremity.
  • These symptoms are worse when the arm is moved overhead.

Parsonage-Turner Syndrome

  • Rare disorder that involves the inflammation of the nerves in the brachial plexus.
  • Symptoms include sudden, constant, severe shoulder pain and can radiate to the upper arm, forearm, and hand.
  • You can also experience muscle weakness, sensory deficits, and muscle atrophy.

Systemic Disease

Ligamentous Instability

Shoulder injury

Peripheral nerve disorders

Brachial plexus injury

  • Brachial plexus is a network of nerves that run through the neck and into the upper limb and supply these areas with sensory and motor signals.
  • An injury to this area can cause similar symptoms to cervical radiculopathy such as muscle weakness and sensory deficits.

Physical Therapy Assessment

A physical therapy assessment here at Apex Orthopedic Rehabilitation involves a conversation with you about your neck pain, your past medical history, your daily activities, and the goals you want achieve in physical therapy. Through this conversation, we get to know you more and your specific needs, so we can best tailor the treatment to you. After this conversation, we like to use the assessment structure of the McKenzie Method to assess your pain.

With the McKenzie Method, we will take you through different neck movements and assess the symptoms that comes with those movements. We will usually ask you to perform these movements for 5-10 repetitions and it’s important to let us know how the symptoms are developing during and after these movements. The McKenzie Method is super safe in this way because your response to each movement will dictate our treatment for your neck pain.

Two common terms you will hear with the McKenzie Method is peripheralization and centralization. Peripherialization is when your symptoms become more spread out through your body after performing a movement several times. You could see the pain symptoms in your neck spread to your shoulder, arm, and hand. This is not a good sign and likely means this is not the movement appropriate for you.

Centralization is when your symptoms becomes more focal to the source of the pain. For example, if you are having neck and arm symptoms and you perform a neck movement for say 5 repetitions or more, then the symptoms in the arm decreases and you only feel pain in the neck. This is a positive sign and this means that the movement you are performing is the appropriate one for you.

Keep in mind that the pain symptoms in the neck can worsen, but as long as the symptoms in the upper extremity improves or even disappears, you are still on the right track. It just may take a longer time for the neck pain to decrease. Another good sign to look out for is an improvement in range of motion of your neck. This will also tell you that this movement is the right one for you.

In addition, we will take baseline measurements of your neck and assess the range of motion of each movement. We will also look at your overall strength, especially in the upper extremity and see what needs to be addressed.


Treatment

Cervical radiculopathy is usually treated conservatively mainly with physical therapy as there is very strong evidence to support that it helps patients with this condition. Medications can be prescribed to you by your doctor for temporarily relief of symptoms. Surgery can be an option as well, but there are questionable long-term benefits as 25% patients continue to experience pain after surgery.

In treating cervical radiculopathy, a physical therapist can utilize therapeutic exercise, manual therapy and modalities (heat, ice, electric stimulation).

Therapeutic exercise is the bread and butter of treating this condition as there is a lot of evidence to support its effectiveness. The initial goal with exercise is to regain the range of motion in was lost in the neck and help the neck move better. This involves stretching the neck musculature to help open up the intervertebral foramen to relieve the compression of the nerves.

Once range of motion in the neck is regained, strengthening exercises is then utilized in order to help stabilize the area and prevent future episodes of cervical radiculopathy. We will typically prescribe exercises that will strengthen muscles around the neck as well as the scapular musculature. A few examples of these exercises include neck stabilization exercises, rows, prone push-ups with a plus, and I’s, T’s, and Y’s. A physical therapist can also potentially prescribe nerve gliding exercises to help the nerve move better within the joints.

In addition, a physical therapist, who specializes in the McKenzie Method, will prescribe the movement that showed to improve your symptoms in the assessment. A common movement you will see is the cervical retraction. With this movement, you usually perform this in sitting and while maintaining a good posture, you should draw your neck straight back as far as you can. You must reach end range of this movement in order to get the full benefit of this exercise. A common prescription of this exercise includes performing this exercise for 10 repetitions every 2 hours. Remember, if the symptoms spread out into your arms and hands, you must stop this movement immediately. However, if the symptoms stay focal to the neck, you are on the right track.

Manual therapy can also be used in combination of therapeutic exercise to help relieve your symptoms. One common technique that is commonly used to treat cervical radiculopathy was mentioned earlier as a test to diagnose the condition. Since patients with cervical radiculopathy find relief with distraction of the cervical spine, physical therapists will commonly utilize this technique as a treatment. We can do it manually or with a traction machine. Patients usually find relief with this technique because the distraction force helps open up the cervical joint and provide temporarily relief of the nerve compression.

Cervical and thoracic manipulations can also be an option to provide symptom relief. However, evidence is conflicted on how effective these treatments are for cervical radiculopathy, especially in the long-term. A physical therapist should screen whether you are appropriate for this treatment as there are potential rare complications.


Prognosis

The prognosis is great for most patients with cervical radiculopathy. 85% of patients who suffer from an acute bout of cervical radiculopathy find relief within 8-12 weeks without specific treatment.

However, if you continue to suffer from symptoms beyond that time frame, physical therapy is an excellent option to help find symptom relief.


Tom Willemann

Tom Willemann

Tom Willemann is a premier physical therapist based out of Bergen County, New Jersey. He holds an MS in physical therapy from the University of Miami, is credentialed in the world-renowned McKenzie Method of Mechanical Diagnosis and Therapy (MDT), and holds an OCS (Orthopedic Clinical Specialist) certification. As of 2018, there are approximately 14,000 ABPTS certified specialists in the nation and less than 400 of them are located in the state of New Jersey. Tom is the owner and director of Apex Orthopedic Rehabilitation in Paramus. He opened the clinic, which specializes in spine and sports injury prevention, in 2004 after many years of experience in the field. Tom’s caring interest in others and his strong belief in continuity of care, combined with his clinic’s ability to find solutions for the most difficult orthopedic problems, have earned Apex Orthopedic Rehabilitation its excellent reputation with patients and medical professionals in northeastern New Jersey and beyond. A true “family man,” Tom takes pride in his clinic’s warm and welcoming environment.
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