What is the diagnostic approach and treatment for cervical radiculopathy?

Diagnostic Approach and Treatment for Cervical Radiculopathy

MRI cervical spine without contrast is the recommended imaging modality for diagnosing cervical radiculopathy, but it must always be interpreted in combination with clinical findings due to frequent false-positive and false-negative results. 1

Clinical Presentation and Diagnosis

Clinical Features

• Characterized by upper limb pain or sensorimotor deficit due to cervical nerve root impingement/irritation 2
• Presents with neck and/or upper limb pain with or without sensory/motor deficits 1
• Annual incidence: 83 per 100,000 persons 1
• Self-limiting in 75-90% of patients with conservative therapy 1

Diagnostic Algorithm

1. Document specific nerve root involvement:

   Nerve Root	Pain Distribution	Sensory Changes	Motor Weakness	Reflex Changes
   C5	Lateral arm, shoulder	Lateral arm	Deltoid, biceps	Biceps reflex ↓
   C6	Lateral forearm, thumb, index finger	Thumb, index finger	Biceps, wrist extensors	Brachioradialis reflex ↓
   C7	Middle finger, posterior forearm	Middle finger	Triceps, wrist flexors	Triceps reflex ↓
   C8	Medial forearm, ring and little fingers	Ring and little fingers	Hand intrinsics, finger flexors	None specific

2. Assess for red flags that warrant immediate imaging 1:

   • Trauma
   • Malignancy
   • Prior neck surgery
   • Spinal cord injury
   • Systemic diseases (ankylosing spondylitis, inflammatory arthritis)
   • Suspected infection
   • History of intravenous drug use
   • Intractable pain despite therapy
   • Tenderness over vertebral body
   • Abnormal labs (ESR, CRP, WBC)
   • Neurological deficits

3. Imaging selection:

   • First-line (without red flags): No imaging initially, as spondylotic changes correlate poorly with neck pain 1
   • First-line (with red flags or persistent symptoms): MRI cervical spine without contrast 1
   • Alternative (if MRI contraindicated): CT myelography 1
   • Not recommended: Plain radiography (65% of asymptomatic patients 50-59 years show degeneration) 1

Important Diagnostic Considerations

• Physical examination alone has limited diagnostic accuracy for cervical radiculopathy 1
• MRI has superior soft tissue contrast but shows frequent false-positive/negative findings 1
• CT provides better definition of bony elements but is less sensitive than MRI for nerve root compression 1

Treatment Approach

Conservative Management (First-Line)

Most cases of acute cervical radiculopathy with radicular symptoms resolve spontaneously or with conservative treatment 1:

1. Medications:

   • NSAIDs/COXIBs at maximum tolerated dosage 2
   • Muscle relaxants for associated spasm
   • Short-term oral steroids for severe symptoms

2. Physical Interventions:

   • Physical therapy focusing on neck strengthening and posture 2
   • Cervical collar immobilization for short periods (2-3 weeks maximum) 2
   • Cervical traction for appropriate patients 3

3. Interventional Procedures:

   • Epidural steroid injections for persistent radicular pain 2, 3
   • Selective nerve root blocks for diagnostic confirmation and therapeutic benefit 4

Surgical Management

Indicated for patients with 1, 3:

• Clinically significant motor deficits
• Debilitating pain resistant to conservative treatment for at least 6 weeks
• Instability in the setting of disabling radiculopathy

Surgical options:

1. Anterior approach:

   • Anterior cervical decompression and fusion (ACDF) - gold standard 1, 5
   • Cervical disc arthroplasty - evolving role 3, 5

2. Posterior approach:

   • Posterior laminoforaminotomy - effective for lateral soft disc displacement or foraminal stenosis 1
   • Microendoscopic foraminotomies 5

Treatment Algorithm

1. Initial phase (0-6 weeks): Conservative management for all patients without myelopathy or significant muscle weakness
2. Persistent symptoms (6-12 weeks): Consider interventional procedures (injections)
3. Refractory symptoms (>12 weeks): Surgical evaluation if symptoms persist despite adequate conservative management

Important Clinical Considerations

• Surgery provides faster relief of pain and sensory dysfunction at 3-4 months compared to conservative treatment, but these effects may diminish by 12 months 1
• Surgical complications include pseudoarthrosis, adjacent segment disease, and hardware complications 1
• Recurrent symptoms have been reported in up to 30% of patients after anterior cervical foraminotomy 1
• CT is the most sensitive modality for assessing spinal fusion after surgery 1

Remember that diagnosis requires correlation between clinical symptoms and imaging findings, as degenerative changes are common in asymptomatic individuals 3.