What is the appropriate workup for C5-6 (cervical spine level 5-6) radiculopathy?

From the Guidelines

The workup for C5-6 radiculopathy should begin with a thorough history and physical examination, focusing on neck pain, arm symptoms, and neurological deficits in the C5-6 distribution, and initial imaging may not be required in the absence of red flag symptoms, as suggested by the American College of Radiology 1.

Key Components of Workup

• A thorough history and physical examination to identify neck pain, arm symptoms, and neurological deficits in the C5-6 distribution
• Initial imaging may not be necessary without red flag symptoms, but when required, cervical spine X-rays can assess degenerative changes
• MRI of the cervical spine is the gold standard for visualizing nerve root compression, especially when symptoms persist or worsen

Diagnostic Considerations

• Electrodiagnostic studies (EMG/NCS) can confirm radiculopathy and rule out peripheral neuropathy or other conditions
• The presence of red flag symptoms such as trauma, malignancy, or systemic diseases necessitates immediate imaging, typically with MRI or CT scans, as these conditions can significantly impact morbidity, mortality, and quality of life 1

Treatment Approach

• Conservative management should be tried first, including NSAIDs like ibuprofen 400-800mg three times daily or naproxen 500mg twice daily for 2-3 weeks
• Physical therapy focusing on cervical strengthening and range of motion exercises is essential, typically 2-3 sessions weekly for 4-6 weeks
• For moderate pain, a short course of oral steroids like prednisone 20mg daily for 5-7 days may help reduce inflammation
• If symptoms persist, consider epidural steroid injections at the C5-6 level, and surgical consultation is warranted for patients with progressive neurological deficits, severe pain unresponsive to conservative measures, or evidence of spinal cord compression, as these interventions can significantly improve quality of life and reduce morbidity and mortality 1

From the Research

Diagnosis and Treatment of C5-6 Radiculopathy

• Cervical radiculopathy is characterized by neurological dysfunction caused by compression and inflammation of the spinal nerves or nerve roots of the cervical spine, presenting with neck and arm pain, sensory loss, motor dysfunction, and reflex changes according to the dermatomal distribution 2.
• The diagnosis is made by combining elements from the patient's history, physical examination, and supplementary tests, with the Spurling and shoulder abduction tests being the two most common examinations used to identify cervical radicular pain 3.
• Imaging techniques such as MRI without contrast, CT scanning, and plain radiography can be used to diagnose nontraumatic cervical radiculopathy, with MRI recommended prior to interventional treatments 3.

Non-Surgical Management

• Non-surgical treatments are recommended as an initial management for cervical radiculopathy, with exercise being beneficial, and medications such as paracetamol, nonsteroidal anti-inflammatory drugs, and neuropathic pain medications having limited evidence for use 3.
• Epidural corticosteroid administration may be considered for acute and subacute cervical radicular pain, while pulsed radiofrequency treatment adjacent to the dorsal root ganglion may be considered for chronic cervical radicular pain 3.

Surgical Management

• Surgery is applicable to patients with intractable or persistent pain despite sufficient conservative management or with severe or progressive neurological deficits, with the choice of surgical treatment individualized based on the patient's main pathophysiology, specific clinical symptoms, and radiographic findings 2.
• Cervical disc arthroplasty (CDA) has been compared to conservative management for patients with single-level cervical radiculopathy at C5/6, with CDA stabilizing the C5/6 vertebrae and increasing the cervical range of motion and horizontal displacement of the upper adjacent C4/5 vertebrae 4.

Timing of Surgical Intervention

• The optimal duration of conservative management prior to surgery for cervical radiculopathy is unclear, with natural history studies demonstrating improvement within 4 weeks following onset of symptoms, and outcomes and cost-effectiveness studies supporting surgical intervention within 8 weeks of symptom onset 5.
• Epidural steroid injections may be considered for cervical radiculopathy, although definitive evidence of efficacy is lacking, and non-interventional care is recommended before undertaking such treatments 6.