Cervical Radiculopathy

aka “pinched nerve”

Benjamin J. Sloop
Family Medicine Rotation
7/27/2009
 Case Presentation
 54 y.o. Caucasian Male
 CC: Back pain and numbness along L arm
 HPI: Felt a pop in his upper back 1.5 weeks ago
while the performing a reeling motion at work.
 3 days later he noticed tingling and numbness
along the medial aspect of his entire L arm
extending to the fourth and fifth digits.
 Case Presentation
 6/10 constant pain in the upper
thoracic/lower cervical regions
 Advil takes the edge off (6-7 per day)
 Reports some swelling around his L elbow
 C/o difficulty using his left hand
 Case Presentation
 PMHx: Hypertension
 Current Medications: Quinapril, Norvasc,
HCTZ
 Surgical History: None
 Allergies: NKDA
 SHx: Single, works as a longshoreman,
denies drugs, alcohol, or tobacco use
 FHx: Noncontributory
 Case Presentation
 General: Well developed and nourished, A&Ox3,
appears uncomfortable
 Cardio: No MRG, No S3 or S4, S1 and S2
present, RRR, radial pulses +2 bilaterally
 Resp: CTAB with diminished lung expansion on
the L side
 Spine: Tenderness to palpation at C7/T1
interface, decreased cervical ROM and strength
 Case Presentation
 Upper Extremity: Swelling and tenderness
at the L elbow, unable to abduct L arm
beyond horizontal, decreased strength,
sensation, and ROM in L hand
 Referred to the Spine Center for further
evaluation.
 Cervical Radiculopathy
107.3/100,000 in men

63.5/100,000 in women

Peak incidence 50-54

y.o.

Preceeded by trauma in
15% of cases

70-75% due to foraminal

encroachment

20-25% due to
herniation

N Engl J Med 2005 July 28;353 (4):392

 Diagnosis
 Pain in the neck and one arm with a combination of
sensory, motor, or reflex changes in the area of the
affected nerve root distribution
 Sensory symptoms are usually dermatomal in
distribution whereas pain is myotomal in distribution.
 Turning the head toward the affected side usually
increases the pain whereas turning the head away from
the lesion or down decreases the amount of pain
 Placing the affected arm on top of the head also
decrease the amount of pain.
 Diagnosis

N Engl J Med 2005 July 28;353 (4):392

 Differential
 Be suspicious of tumors, infections, and
myelopathies
 Ask about history of fevers, chills, weight
loss and previous cancer
 Immunosuppression, IV drug use
 Night pain, diffuse hand numbness and
clumsiness, difficulty with balance, and
urinary urgency or frequency.
N Engl J Med 2005 July 28;353 (4):392
 Confirmatory Testing
 Lab studies: not recommended although sed
rate and C-reactive protein are elevated in spinal
infections or cancer
 Imaging: X-Ray – limited sensitivity
 MRI – Test of choice
 CT with contrast has accuracy similar to MRI but
is more invasive
 EMG – when H&P does not rule out other causes
of neck and arm pain
 Treatment
 Non-surgical treatment goals are for pain relief,
improving neurological function, and preventing
recurrences
 Recommendations are from case series and
anecdotal experience
 Analgesics (NSAIDS and opioids are first line)
 Short term immobilization using a C collar
 Cervical traction
 Exercise therapy
 Steroids
 Treatment
 Prednisone may be given short term in
patients with acute pain
 Transforminal epidural steroid injections:
insufficient evidence to support or refute
the recommendation for cervical
radiculopathy (Neurology 2007 March
6;68(10):723)
 Surgical Recommendations
 Surgery is recommended when myelopathy is
present in conjunction with the following:
 Definite nerve root compression
 Symptoms and signs of cervical root
dysfunction and/or pain
 Persistence of pain despite non-surgical
intervention for 6-12 weeks
 Presence of functionally important motor
deficit.
 Surgical Recommendations
 Also recommended when
imaging shows cervical
compression of the spinal
cord and clinical evidence
of moderate to severe
myelopathy
 75% show substantial
relief of radicular
symptoms
 Complications are
uncommon
N Engl J Med 2005 July 28;353 (4):392
 To Cut or Not to Cut…
 One study compared surgical intervention,
immobilization, and physiotherapy
 At one year there was no difference among the
three treatment groups in any of the measured
outcomes (including pain, function, and mood)
 In another study of patients not meeting criteria
for surgery, there were no differences in
neurological outcomes between the patients
treated medically and surgically.
 Summary
 No test can replace a good H&P
 If no red flags treat with analgesics
 After 4-6 weeks get an MRI if there is still
significant pain present or progressive deficits
 Surgery should be reserved for patients who
have persistent pain after 6-12 weeks,
progression of deficits, or moderate to mild
myelopathy
 Back to the Case
 C-spine X-ray series was done. Vertebra are
normal height and alignment. The disc spaces
are preserved. The neural foramina are patent.
Prevertebral soft tissues are normal. No
evidence of fracture or dislocation.
 An EMG was ordered
 Results were positive for ulnar neuropathy at the
elbow and minimal carpal tunnel syndrome. No
evidence of neck injury was indicated.