What are the symptoms and treatment options for radiculopathy?

Symptoms and Treatment of Radiculopathy

Cervical radiculopathy presents with a combination of arm pain, sensory dysfunction, motor function loss, and often associated neck pain, resulting from compression or irritation of cervical nerve roots. 1

Clinical Presentation

Primary Symptoms

• Pain:

  • Neck pain radiating to the arm in the affected nerve root distribution
  • Pain may worsen with neck movements or Valsalva maneuvers
  • Can be sharp, burning, or electric in quality

• Sensory Disturbances:

  • Numbness, tingling, or paresthesias in the dermatomal distribution of the affected nerve root
  • Sensory loss in specific patterns depending on the affected level

• Motor Dysfunction:

  • Weakness in specific muscle groups corresponding to the affected nerve root
  • Decreased grip strength or difficulty with fine motor tasks
  • Muscle atrophy in chronic cases

• Reflex Changes:

  • Diminished or absent deep tendon reflexes in the affected distribution
  • Biceps (C5-C6), triceps (C7), or brachioradialis (C5-C6) reflexes may be affected

Diagnostic Approach

Imaging

• MRI Cervical Spine: Most sensitive test for detecting soft tissue abnormalities associated with radiculopathy, but has high rate of abnormalities in asymptomatic individuals 1

• Radiography: Useful initial assessment for spondylosis, degenerative disc disease, malalignment, or spinal canal stenosis 1

• CT Scan: Superior for visualizing bone structures such as osteophytes, uncovertebral joints, and facet joints that may compress nerve roots 1

Electrodiagnostic Studies

• EMG and nerve conduction studies can help confirm the diagnosis and rule out other conditions that may mimic radiculopathy

Treatment Options

Non-operative Management

Most cases (75-90%) of cervical radiculopathy improve with conservative treatment 1, 2. Initial management includes:

1. Immobilization:

   • Short-term use of cervical collar for acute symptoms
   • Temporary relief through immobilization

2. Medications:

   • NSAIDs for pain and inflammation
   • Muscle relaxants for associated muscle spasms
   • Neuropathic pain medications (gabapentin, pregabalin) for radicular symptoms

3. Physical Therapy:

   • Cervical traction
   • Stretching and strengthening exercises
   • Postural education and ergonomic modifications

4. Injections:

   • Epidural steroid injections
   • Selective nerve root blocks

Surgical Management

Surgery is indicated for patients with:

• Clinically significant motor deficits
• Debilitating pain resistant to conservative treatment
• Instability with disabling radiculopathy 3

Surgical options include:

1. Anterior Approach:

   • Anterior cervical discectomy with or without fusion (ACD/ACDF)
   • Recommended for rapid relief (within 3-4 months) of arm/neck pain, weakness, and sensory loss 1
   • Success rates of 90% in properly selected patients 4

2. Posterior Approach:

   • Posterior cervical foraminotomy
   • Preserves motion segments but has variable success rates (52-99%) 1
   • Recurrent symptoms reported in up to 30% of patients 1

Treatment Algorithm

1. Initial Presentation (0-6 weeks):

   • Conservative management with medications, short-term immobilization, and activity modification
   • Physical therapy focusing on gentle exercises and posture correction

2. Persistent Symptoms (6-12 weeks):

   • Continue physical therapy with more active interventions
   • Consider epidural steroid injections or selective nerve blocks
   • Obtain MRI if not already performed

3. Refractory Symptoms (>12 weeks):

   • Surgical consultation if:
     • Persistent pain despite adequate conservative treatment
     • Progressive neurological deficits
     • Significant functional limitations

Clinical Pearls and Pitfalls

• Differential Diagnosis: Important to distinguish cervical radiculopathy from other conditions that may present similarly, such as peripheral entrapment neuropathies, brachial plexopathy, or shoulder pathology 5

• Natural History: The overall prognosis is favorable, with most patients improving over time with focused non-operative treatment 6

• Surgical Outcomes: While surgery provides more rapid relief of symptoms, at 12-month follow-up, comparable clinical improvements may be seen with physical therapy or cervical immobilization 1

• Red Flags: Immediate imaging and specialist referral are warranted for patients with red flags such as trauma, malignancy history, progressive neurological deficits, or signs of myelopathy 1

• Imaging Correlation: MRI findings must correlate with clinical symptoms, as degenerative changes are common in asymptomatic individuals 1, 2