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13
CHAPTER PREVIEW
Chapter Synopsis
Important Points
Neural compression resulting in radiculopathy can result from a variety of sources, the
most common being cervical spondylosis and herniated nucleus pulposus.
Consensus statements from a review of available evidence indicate that cervical radiculopathy from degenerative processes has a favorable prognosis and tends to be selflimiting.
Symptoms of cervical radiculopathy frequently mimic those of other diseases; therefore, careful history, examination, and imaging are required to confirm the diagnosis.
Careful correlation of history and examination with imaging studies is necessary because asymptomatic degenerative changes in the cervical spine are very common findings in advanced imaging, in particular magnetic resonance imaging.
Epidemiology
A population-based study from Rochester, Minnesota,
revealed an incidence of cervical radiculopathy of 107.3
Natural History
The natural history of cervical radiculopathy was initially studied by Lees and Turner in 1963.4 These investigators followed two groups of patients: one group with
myelopathy and the other with radiculopathy. Fifty-seven
patients with cervical radiculopathy were followed for
up to 19 years. No patients with radiculopathy became
myelopathic, but 25% suffered from persistent or worsening radicular pain.
Gore and associates followed 205 patients with neck
pain and no neurologic deficit for a minimum of 10
years.5 At the final follow-up, one third of these patients
had moderate to severe pain that limited their lifestyle.
Unfortunately, it is difficult to determine how many of
these patients had primarily radicular pain, as opposed to
isolated neck pain, despite tabular notation in the article
of shoulder, arm, forearm, and hand pain in some of the
patients.
131
A more recent article from the Degenerative Disorders Work Group of the North American Spine Society
Evidence-Based Clinical Guideline Development Committee noted methodologic problems with all reviewed
studies pertaining to the natural history of cervical radiculopathy.6 This work group proposed the following consensus statement: It is likely that for most patients with
cervical radiculopathy from degenerative disorders signs
and symptoms will be self-limited and will resolve spontaneously over a variable length of time without specific
treatment.
C5
C5
C6
C6
C7
C7
C8
T1
Pathophysiology
Most patients with cervical radiculopathy patients pre
sent to their physician with symptoms caused by cervical
spondylosis and the resultant neuroforaminal stenosis or
hard disk. Cervical spondylosis starts with disk desiccation.7 The avascular disk loses water because of a decrease
in the proteoglycan content in the nucleus pulposus that
leads to a reduction of water content from 90% at birth to
74% during the eighth decade of life.8 This change results
in a loss of disk height, microinstability and subsequent
osteophyte formation, facet hypertrophy, and ligamentum flavum buckling and hypertrophy. Degeneration of
the spine, or spondylosis, may result in neuroforaminal
stenosis and potentially, spinal canal stenosis.
The other main cause of cervical radiculopathy is a
soft disk or herniated nucleus pulposus. This disorder
is seen more often than a hard disk in younger patients.
Roughly 75% of cervical radiculopathies occur between
the ages of 40 and 59 years. Patients in their 40s tend to
have more soft disks, and those in their 50s tend to have
more hard disks.
Double crush phenomenon occurs less than 1% of the
time on the same nerve, according to Morgan and Wilbourn; it is observed when a cervical nerve root is compressed and is accompanied by additional peripheral
compression.9 These investigators found that 3.4% of the
time, a patient had either carpal tunnel syndrome or ulnar
neuropathy combined with a cervical root lesion. The
double crush phenomenon was first reported by Upton
and McComas, who hypothesized that it originated from
impaired axoplasmic flow that made the distal portion of
the nerve more susceptible to compression injury.10
T1
Sensory
C7
C6
C5
C8
T1
Motor
Finger
flexors
C8
Deltoid
C5
Biceps
C5, C6
Triceps
C6
Finger
extensors C5
Interossei C8-T1
FIGURE 13-1 Cervical root motor and sensory findings by level. (From
Benzel EC, editor: Spine surgery: techniques, complication avoidance, and management, ed 2, Philadelphia, 2005, Churchill Livingstone, as modified in Shen
FH, Shaffrey CI, editors: Arthritis and arthroplasty: the Spine, Philadelphia, 2010,
Saunders.)
Diagnostic Clues
C4-5
C5-6
C5
C6
C6-7
C7
C7-T1
C8
T1-2
T1
Shoulder abduction/deltoid
Elbow flexion/biceps
Radial wrist extension/extensor
carpi radialis longus
Elbow extension/triceps
Finger extension/extensor
digitorum communis
Finger flexion/flexor digitorum
superficialis and profundus
Hand intrinsics/interossei (<T1)
Hand intrinsics/interossei
Modified from Benzel EC, editor: Spine surgery: techniques, complication avoidance, and management, ed 2, Philadelphia, 2005, Churchill Livingstone.
Differential Diagnosis
The differential diagnosis of cervical radiculopathies
often includes peripheral neuropathies. Carpal tunnel
syndrome, cubital tunnel syndrome, and anterior and
posterior interosseous nerve compression can have similar presentations. Table 13-2 may help differentiate one
diagnosis from another.
Imaging Studies
Radiography
Radiographs provide information regarding sagittal alignment, fractures, dislocations, and congenital anomalies. Overt or occult instability may be demonstrated by
dynamic imaging.12 Oblique radiographs may be useful
for demonstrating neuroforaminal stenosis (Fig. 13-2).
C6 or C7 versus carpal
tunnel syndrome
C7 versus posterior
interosseous nerve
compression
C8 versus anterior
interosseous nerve
compression
C8 versus ulnar
entrapment
Modified from Abbed KM. Coumans JV: Cervical radiculopathy: pathophysiology, presentation, and clinical evaluation. Neurosurgery 60(Suppl 1):S28-S34,
2007.
Adjunct Studies
Electrodiagnostic Studies
Electromyography and nerve conduction velocity studies
can supplement imaging data when history and physical
examination findings do not seem to correlate with the
imaging or when peripheral neuropathy is suspected.
Treatment Options
According to the North American Spine Society clinical
guideline, cervical radiculopathy is a disorder that can be
treated with conservative management a majority of the
time and will resolve. Conservative management options
include corticosteroids, nonsteroidal anti-inflammatory
drugs, muscle relaxants, cervical traction, cervical isometric exercises, cervical collars, and judicious use of narcotics.
The use of cervical injections may be an option in selected
patients. However, careful consideration of the associated
risks should be considered and discussed with the patient.
B
history, pathogenesis, and differential diagnosis of the
disease. It also discusses specific examination findings
and the rationale for selecting imaging modalities related
to the diagnosis. Once a diagnosis is achieved, the discussion touches on treatment options; however, examination, imaging, and surgical treatment options are covered
in greater depth in other chapters of this text.
REFERENCES
Conclusion
Cervical radiculopathy is a disorder with a favorable natural history. This chapter reviews the epidemiology, natural
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2. Brain WR , Knight GC , Bull JWD: Discussion on rupture of the
intervertebral disc in the cervical region, Proc R Soc Med 41:509516,
1948.
3. Brain WR , Northfield D, Wilkinson M : The neurological manifestations of cervical spondylosis, Brain 75:187225, 1952.
4. L ees F, Turner JW: Natural history and prognosis of cervical spondylosis, Br Med J 2:16071610, 1963.
5. G ore D R , Sepic S B , Gardner G M , Murray M P: Neck pain: a longterm follow-up of 205 patients, Spine (Phila Pa 1976) 12:15, 1987.
6. Bono C M , Ghisellli G , Gilbert TJ , etal.: An evidence-based clinical guideline for the diagnosis and treatment of cervical radiculopathy from degenerative disorders, Spine J 11:6472, 2011.
7.
Ferguson R J , Caplan L R : Cervical spondylitic myelopathy, Neurol
Clin 3:373382, 1985.
8. K raemer I , Kolditz D, Cowin R : Water and electrolyte content of
human intervertebral discs under variable load, Spine (Phila Pa
1976) 10:6971, 1985.
9.
Morgan G , Wilbourn A : Cervical radiculopathy and coexisting distal entrapment neuropathies: double-crush syndromes? Neurology
50:7883, 1998.
10. Upton A R , McComas A J : The double crush in nerve entrapment
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and pathophysiology, Neurosurgery 60(Suppl 1):S14S20, 2007.
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60(Suppl 1):S28S34, 2007.
13. Matz PG , Holly L T, Groff MW, etal.: Indications for anterior cervical decompression for the treatment of cervical degenerative
radiculopathy, J Neurosurg Spine 11:174182, 2009.