What are the diagnosis and treatment options for C (cervical) nerve impingement?

Cervical Nerve Impingement: Diagnosis and Treatment

Diagnosis

Cervical radiculopathy is diagnosed through a combination of clinical history, physical examination, and MRI confirmation, though MRI alone should never be used to diagnose symptomatic cervical radiculopathy due to frequent false-positive and false-negative findings. 1

Clinical Presentation

• Upper limb pain with or without sensory deficits (paresthesias in specific dermatomal distributions) 1
• Motor weakness in muscle groups corresponding to the affected nerve root 2
• Neck pain radiating to the shoulder, arm, or hand 3
• Symptoms typically correspond to the side of nerve root compression 1

Diagnostic Imaging Algorithm

First-line imaging: MRI cervical spine without IV contrast 1

• MRI correctly predicts 88% of lesions causing cervical radiculopathy 1
• Provides superior visualization of soft tissue abnormalities including disc herniations and nerve root compression 1
• Critical caveat: MRI findings must always be correlated with clinical symptoms—abnormalities are frequently present in asymptomatic patients and do not always correspond to clinical examination levels 1

Complementary imaging: CT cervical spine without IV contrast 1

• Superior for visualizing osseous structures including osteophytes, uncovertebral joints, and facet joints 1
• Particularly useful for suspected ossification of the posterior longitudinal ligament (OPLL) 1
• Less sensitive than MRI for disc herniations and soft tissue nerve root compression 1

Alternative imaging: CT myelography 1

• Reserved for patients who cannot undergo MRI (claustrophobia, contraindications) 1
• Offers excellent depiction of the thecal sac and small nerve roots at higher spatial resolution than MRI 1
• 81% accuracy for predicting surgical lesions (compared to 88% for MRI) 1

Imaging NOT recommended: Contrast-enhanced studies, bone scans, CTA, or MRA are not useful for initial evaluation of cervical radiculopathy without "red flag" symptoms 1

Common Diagnostic Pitfalls

• Do not rely on imaging alone: Physical examination has limited accuracy for diagnosing cervical radiculopathy compared to imaging or surgical findings 1
• Beware of false positives: Degenerative changes are common in asymptomatic individuals and increase with age 1
• Ensure anatomic correlation: Verify that imaging findings match the clinical dermatomal and myotomal distribution of symptoms 2

---

Treatment

Non-operative conservative treatment is the appropriate initial approach for cervical radiculopathy, with 75-90% of patients achieving symptomatic improvement. 1, 2

Conservative Management (First-Line)

Duration: Minimum 6 weeks of structured conservative therapy before considering surgery 2

Treatment components (multimodal approach):

• Physical therapy: Achieves comparable clinical improvements to surgery at 12 months, though surgery provides more rapid relief 2, 3, 4
• Medications: NSAIDs and neuropathic pain medications to alleviate symptoms 3, 4
• Cervical collar immobilization: Short-term use only 4
• Cervical traction: May provide temporary decompression of nerve impingement 4
• Selective nerve root blocks: Target nerve root pain with guided corticosteroid injections 3, 4, 5

Success rate: 75-90% of patients improve with conservative management 1, 2

Surgical Intervention (Second-Line)

Indications for surgery:

• Persistent symptoms despite 6+ weeks of adequate conservative treatment 2
• Progressive neurological deficits 2
• Significant functional deficit impacting quality of life 2

Surgical options:

Anterior cervical decompression and fusion (ACDF) 2

• Primary indication: Provides rapid relief (within 3-4 months) of arm/neck pain, weakness, and sensory loss compared to continued conservative treatment 2
• Success rate: 80-90% for arm pain relief, with 90.9% functional improvement 2
• Outcomes: 74-90% improvement rates for radiculopathy 2
• Instrumentation: Anterior cervical plating reduces pseudarthrosis risk (from 4.8% to 0.7%) and improves fusion rates (from 72% to 91%) for multilevel disease 2

Posterior laminoforaminotomy 2

• Indications: Soft lateral disc herniation, cervical spondylosis with lateral recess narrowing, or patients preferring motion preservation 2
• Success rate: 78-93% (variable based on Worker's Compensation status) 2
• Advantages: Motion preservation and avoidance of anterior approach risks 2
• Recurrence: Up to 30% of patients report recurrent symptoms 2

Treatment Algorithm

1. Initial presentation: Begin conservative management with physical therapy, NSAIDs, and activity modification 3, 4
2. At 6 weeks: Reassess symptoms—if improved, continue conservative care 2
3. Persistent symptoms at 6+ weeks: Consider surgical consultation if significant functional impairment or progressive deficits 2
4. Surgical planning: Obtain MRI to confirm anatomic correlation with clinical symptoms 1
5. Surgical approach selection: ACDF for multilevel disease or central/foraminal stenosis; posterior laminoforaminotomy for lateral soft disc herniation 2

Critical Treatment Considerations

• Long-term outcomes: At 12 months, surgical and conservative treatments show comparable results, though surgery provides faster symptom relief 2
• Patient selection: Surgery should only be performed when imaging findings correlate with clinical symptoms and severity meets moderate-to-severe thresholds 2
• Documentation requirement: Formal documentation of conservative therapy duration, frequency, and response is required before surgical intervention 2