Cervical radiculopathy

What is it?

Cervical radiculopathy is when the nerve leaving the neck is irritated or compressed, possibly resulting in several different signs and symptoms. The cause for this compression and/or irritation is thought to be due to mechanical or chemical mechanisms(1).Cervical Radiculopathy is different from radicular pain. Where radicular pain is pain that originates from the neck but does not include any deficits in sensation or power.

Signs and symptoms

All of the following are possible signs and symptoms that people may experience(1-3):

• Neck pain and/or arm pain (usually one side).

• Reduced sensation

• Weakness

• Diminished reflexes

Diagnosis

A physiotherapist, doctor, or other qualified health professional with experience in this area can reach a good level of certainty that a cervical radiculopathy is present(2). Both CT and MRI scans can further increase the level of certainty(1). Other investigations such as electrodiagnostic studies could also be useful in raising the certainty and differentiating it from other possible causes(1-2).

Recovery time

Research has shown that up to 90% of cervical radiculopathy resolves on its own over time(1,4). For the majority of cases improvement in symptoms are seen in the initial 6 months(1-2,4-5). This will be different for each individual. For example, recovery times are usually significantly longer for people with workers compensation injuries(1,5).

Another important and reassuring finding from research is that from the onset of symptoms, majority of the time it does not progress further(5). Recurrence rates are also relatively low(5).

Treatment

A study(6) in 2022 highlighted that there is a lack of high-quality research and studies for the treatment of cervical radiculopathy. They pointed out that this may be due to a lack of consensus on the diagnostic criteria(6).The aim of conservative treatment (non-surgical) is to reduce pain, symptoms and maintain and/or improve physical function while healing occurs.

Exercise therapy

The role of exercise in cervical radiculopathy is mainly to maintain, possibly improve, or slow down the loss of physical function. The effect on cervical radiculopathy itself and its symptoms are limited, overall showing a small positive effect especially with neck strengthening and mobility exercises(7). Additionally, nerve glider/tensioner/slider exercises could also provide benefits(8). Importantly, exercise is considered very safe and side effects are usually positive (improved cardio-metabolic health, improved general health, decrease systemic inflammation, improved mood, etc.). It can, however, increase pain in the short-term especially initially.

Pain can lead to disability in fact it is the leading cause of disability worldwide9. Physical disability can also be an indirect result of pain mainly when people start avoiding physical activity and movement.

Manual therapy

Studies have shown that manipulations and mobilization may be able to provide a slight short-term pain reduction(1,10). However, this is based on low quality research(1). Manipulations are however, not without risk. Although the risk of adverse effects is low, they can be very serious (e.g., stroke) and can occur(1). Overall, they are not recommended(2).

Massage therapy could be another option to reduce pain levels with minimal risk(2). Another therapy that could provide possible benefits are TENS. TENS can be self-administered (so no need for appointments), are generally safe, and have shown an effect for neuropathic pain(11-12)

Other conservative measures & lifestyle changes

Immobilization using collars may be useful in the short term immediately post onset of symptoms(1).

As described above, during painful conditions people often tend to avoid painful movements and general physical activity to avoid pain or because they fear pain. This can lead to deconditioning, and eventually disability and worsening of pain(13). Therefore, it is important to stay active! Physiotherapists and/or exercise physiologists can assist in helping to plan and guide you through any uncertainties.

Smoking is well-known to have a negative effect on general health and creates a sub-optimal environment for the body to recover.

Sleep is also an important factor in pain, you can read more on our blog: Link to blog

Diet plays another important role in recovering from injury and/or pain. We have discussed this further on our ACL blog: Link to blog

Surgery

There are instances where immediate surgery is needed. Some possible scenarios are if the spinal cord is injured, an instability or fracture is suspected, tumour, or another mass is present(1).

If this is not the case, then a trial of conservative treatment is recommended(1). On occasions, surgery can still be an appropriate and an effective option. This will depend on several individual factors. Usually, the following factors can be good reasons to get a surgical opinion:

• There is a clear structural cause for the compression that is correlated with the symptoms.

• A decent amount of time (usually 6-12 weeks(2)) and effort has been spent on conservative

• Worsening of symptoms(1-2).

Overall, for the majority of cases (90%) surgery is not required to fully recover(1).

Medication

Pain medications could be used to make the pain more manageable and to allow people to continue living their life(3).There are limited to no trials looking into the effects of analgesia on cervical radiculopathy. Therefore, we need to look at the broader picture. Symptomatic cervical

radiculopathy includes a neuropathic pain component and a possible inflammatory component.

Therefore, NSAIDs (non-steroidal anti-inflammatories), pregabalin, gabapentin, SNIRs (particularly

Duloxetine) or amitriptyline may be possible options(14). To determine the best option, dosage for you and your circumstances (other medication interactions, allergies, comorbidities, etc.) it is best to

discuss this with your GP or a pain specialist.

Injections

Corticosteroid injections is another optional treatment for cervical radiculopathy(1). It is usually only recommended after 4-6 weeks of other conservative therapies(2). These injections are used as a pain modulator (reduce pain) however, will not address the underlying mechanism of pain(2). It can however, make pain more manageable and allow people to continue with normal life.

It is still important to remember that even though these injections are commonly used and generally considered safe(2). They are not completely risk free and can result in mild to more serious adverse effects(1-2).

Psychotherapy

If you have read our other blogs or social media posts, you will now know that psychosocial factors play a significant (and underestimated) role in pain itself and pain-related disability. There are numerous psychosocial factors that can exacerbate pain directly and/or how pain affects the person. These include but are not limited to Anxiety, Depression, previous trauma, excessive worry, hypervigilance, stress, heightened emotions, excessive fear of pain and several others. If these factors are present psychotherapy may be an option to address these factors.

Prevention

There are several risk factors for the development of cervical radiculopathy some non-modifiable (race, previous cervical or lumbar radiculopathy, genetics)(1) and some modifiable ones such as:

• Smoking(1,15)

• Alcohol(15)

• Psychological factors(15)

However, we can only reduce the risk and not prevent it completely. In fact, the occurrence of cervical radiculopathy does not only occur during trauma or certain activities(1). 30% of cases occur during sitting, standing, or lying positions(1).

References

1.       Iyer, S., & Kim, H. J. (2016). Cervical radiculopathy. Current reviews in musculoskeletal medicine, 9(3), 272–280. https://doi.org/10.1007/s12178-016-9349-4 

2.       Kang, K. C., Lee, H. S., & Lee, J. H. (2020). Cervical Radiculopathy Focus on Characteristics and Differential Diagnosis. Asian spine journal, 14(6), 921–930. https://doi.org/10.31616/asj.2020.0647 

3.       McCartney, S., Baskerville, R., Blagg, S., & McCartney, D. (2018). Cervical radiculopathy and cervical myelopathy: diagnosis and management in primary care. The British journal of general practice : the journal of the Royal College of General Practitioners, 68(666), 44–46. https://doi.org/10.3399/bjgp17X694361 

4.       Luyao, H., Xiaoxiao, Y., Tianxiao, F., Yuandong, L., & Ping Wang (2022). Management of Cervical Spondylotic Radiculopathy: A Systematic review. Global spine journal, 12(8), 1912–1924. https://doi.org/10.1177/21925682221075290 

5.       Wong, J. J., Côté, P., Quesnele, J. J., Stern, P. J., & Mior, S. A. (2014). The course and prognostic factors of symptomatic cervical disc herniation with radiculopathy: a systematic review of the literature. The spine journal : official journal of the North American Spine Society, 14(8), 1781–1789. https://doi.org/10.1016/j.spinee.2014.02.032 

6.       Lam, K. N., Heneghan, N. R., Mistry, J., Ojoawo, A. O., Peolsson, A., Verhagen, A. P., Tampin, B., Thoomes, E., Jull, G., Scholten-Peeters, G. G. M., Slater, H., Moloney, N., Hall, T., Dedering, Å., Rushton, A., & Falla, D. (2022). Classification criteria for cervical radiculopathy: An international e-Delphi study. Musculoskeletal science & practice, 61, 102596. https://doi.org/10.1016/j.msksp.2022.102596 

7.       Zhang, Y. H., Hu, H. Y., Xiong, Y. C., Peng, C., Hu, L., Kong, Y. Z., Wang, Y. L., Guo, J. B., Bi, S., Li, T. S., Ao, L. J., Wang, C. H., Bai, Y. L., Fang, L., Ma, C., Liao, L. R., Liu, H., Zhu, Y., Zhang, Z. J., Liu, C. L., … Wang, X. Q. (2021). Exercise for Neuropathic Pain: A Systematic Review and Expert Consensus. Frontiers in medicine, 8, 756940. https://doi.org/10.3389/fmed.2021.756940

8.       Papacharalambous, C., Savva, C., Karagiannis, C., & Giannakou, K. (2022). The effectiveness of slider and tensioner neural mobilization techniques in the management of upper quadrant pain: A systematic review of randomized controlled trials. Journal of bodywork and movement therapies, 31, 102–112. https://doi.org/10.1016/j.jbmt.2022.03.002 

9.       Blyth, F. M., Briggs, A. M., Schneider, C. H., Hoy, D. G., & March, L. M. (2019). The Global Burden of Musculoskeletal Pain-Where to From Here?. American journal of public health, 109(1), 35–40. https://doi.org/10.2105/AJPH.2018.304747 

10.   Thoomes E. J. (2016). Effectiveness of manual therapy for cervical radiculopathy, a review. Chiropractic & manual therapies, 24, 45. https://doi.org/10.1186/s12998-016-0126-7 

11.   Akyuz, G., & Kenis, O. (2014). Physical therapy modalities and rehabilitation techniques in the management of neuropathic pain. American journal of physical medicine & rehabilitation, 93(3), 253–259. https://doi.org/10.1097/PHM.0000000000000037 

12.   Bernetti, A., Agostini, F., de Sire, A., Mangone, M., Tognolo, L., Di Cesare, A., Ruiu, P., Paolucci, T., Invernizzi, M., & Paoloni, M. (2021). Neuropathic Pain and Rehabilitation: A Systematic Review of International Guidelines. Diagnostics (Basel, Switzerland), 11(1), 74. https://doi.org/10.3390/diagnostics11010074 

13.   Zale, E. L., & Ditre, J. W. (2015). Pain-Related Fear, Disability, and the Fear-Avoidance Model of Chronic Pain. Current opinion in psychology, 5, 24–30. https://doi.org/10.1016/j.copsyc.2015.03.014 

14.   Gebke, K. B., McCarberg, B., Shaw, E., Turk, D. C., Wright, W. L., & Semel, D. (2023). A practical guide to recognize, assess, treat and evaluate (RATE) primary care patients with chronic pain. Postgraduate medicine, 135(3), 244–253. https://doi.org/10.1080/00325481.2021.2017201 

15. Smith, B. H., Hébert, H. L., & Veluchamy, A. (2020). Neuropathic pain in the community: prevalence, impact, and risk factors. Pain, 161 Suppl 1, S127–S137. https://doi.org/10.1097/j.pain.0000000000001824 

This blog was written by Samuel Bulten