Radiculopathy: Definition and Clinical Implications
Radiculopathy is a syndrome of pain or sensorimotor deficits due to compression or irritation of a spinal nerve root, characterized by pain radiating in a dermatomal distribution with possible accompanying sensory loss, motor weakness, or reflex changes. 1
Clinical Presentation
Radiculopathy manifests with several key features:
- Pain pattern: Radiating pain from the spine into the distribution of the affected nerve root
- Sensory changes: Numbness, tingling, or paresthesias in the affected dermatome
- Motor deficits: Weakness in muscles innervated by the affected nerve root
- Reflex changes: Diminished deep tendon reflexes, particularly notable in cervical radiculopathy
Cervical Radiculopathy Specifics
Cervical radiculopathy specifically presents as:
- Neck pain with radiating arm pain
- Sensory loss or paresthesias in the affected dermatome
- Motor dysfunction corresponding to the compressed nerve root
- Reflex changes (particularly diminished triceps reflex) 2
Pathophysiology
The most common causes of radiculopathy include:
- Disc herniation: Protrusion of intervertebral disc material compressing the nerve root
- Degenerative spondylosis: Including facet joint hypertrophy and uncovertebral joint changes
- Foraminal stenosis: Narrowing of the neural foramen through which the nerve root exits 1, 3
Diagnostic Approach
Physical Examination
Key diagnostic tests include:
- Spurling test: Extension and lateral rotation of the neck toward the affected side reproduces symptoms
- Shoulder abduction test: Relief of symptoms when placing hand on top of head
- Upper limb tension test: Reproduction of symptoms with specific arm positioning
Imaging
- Initial approach: Imaging may not be required at initial presentation in the absence of "red flags" 1
- MRI: Most sensitive test for detecting nerve root compression, but has high rates of both false-positive and false-negative findings 1
- CT: Provides good definition of bony elements but is less sensitive than MRI for nerve root compression 1
- Radiographs: May show degenerative changes but often correlate poorly with symptoms 1
Red Flags Requiring Immediate Imaging
- Trauma
- Malignancy history
- Progressive neurological deficits
- Suspected infection
- Intractable pain despite therapy 1
Distinguishing Radiculopathy from Plexopathy
It's important to differentiate radiculopathy from plexopathy:
- Radiculopathy: Pain and deficits in a dermatomal distribution (single nerve root)
- Plexopathy: Pain and deficits occurring in multiple peripheral nerve distributions 1
When clinical uncertainty exists between radiculopathy and plexopathy, MRI of both the spine and the relevant plexus may be complementary 1.
Treatment Approach
Most cases of radiculopathy (up to 75%) improve spontaneously with conservative management 4. Treatment options include:
Conservative Management (First-line)
- Physical therapy with strengthening and stretching exercises
- NSAIDs for pain control
- Muscle relaxants for associated spasm
- Possible cervical traction
Interventional Options
- Epidural steroid injections for persistent symptoms
- Selective nerve root blocks
Surgical Indications
Surgery should be considered for:
- Significant motor deficits
- Debilitating pain resistant to conservative treatment
- Persistent symptoms after 4-6 weeks of conservative management 3
Prognosis
The natural history of radiculopathy is generally favorable, with most patients experiencing significant improvement regardless of treatment approach. Surgical outcomes for relief of arm pain range from 80% to 90% when indicated 4.
Common Pitfalls in Management
- Overreliance on imaging: MRI findings often exist in asymptomatic individuals and may not correlate with symptoms
- Premature surgical intervention: Most cases resolve with conservative management
- Failure to identify red flags: Missing signs of serious pathology requiring urgent intervention
- Inadequate differential diagnosis: Failing to consider other conditions that may mimic radiculopathy, such as peripheral neuropathy or plexopathy