Can nerve compression in the cervical region cause symptoms in the legs?

Can Cervical Nerve Compression Cause Leg Symptoms?

Yes, cervical nerve compression can absolutely cause leg symptoms when the spinal cord itself is compressed, a condition called cervical myelopathy, which is distinct from simple nerve root compression (radiculopathy) that typically only affects the arms. 1, 2

Understanding the Mechanism

Cervical Myelopathy vs. Radiculopathy

• Cervical radiculopathy (nerve root compression) typically causes symptoms only in the upper extremities following a specific dermatomal distribution 2
• Cervical myelopathy (spinal cord compression) causes leg symptoms because the compressed spinal cord contains descending motor tracts and ascending sensory pathways that control lower extremity function 3, 4
• When both arm and leg symptoms occur together, this strongly suggests myelopathy rather than simple radiculopathy 2

Clinical Presentation of Cervical Myelopathy

The most common leg symptoms include:

• Progressive spastic paraparesis (leg weakness and stiffness) 5
• Gait disturbance and difficulty walking 4, 5
• Numbness and paresthesias in the feet 5
• Loss of coordination and balance 1

Upper extremity symptoms typically include:

• Hand numbness and clumsiness 6
• Arm pain 4
• Weakness in the hands 4

Atypical Presentations: A Critical Pitfall

Approximately 1-1.2% of cervical myelopathy patients present WITHOUT upper extremity symptoms, showing only leg weakness and gait difficulty 6. This is a crucial diagnostic pitfall that can lead to misdiagnosis:

• These patients may have numbness perceived from the upper trunk, waist, perineum, or legs 6
• All such cases had cervical cord compression at C5-6 or C6-7 levels 6
• Many (83%) had a history of lumbar degenerative disease, which can confuse the clinical picture 6

Diagnostic Approach

When to Suspect Cervical Myelopathy

Red flags requiring urgent evaluation include: 2

• Bilateral symptoms affecting both arms and/or legs
• Progressive neurological deficits
• New bladder or bowel dysfunction
• Loss of perineal sensation
• Gait impairment with upper extremity symptoms

Imaging Strategy

• MRI of the cervical spine is the preferred initial imaging modality for evaluating suspected myelopathy 1, 2
• MRI provides superior soft-tissue resolution for visualizing spinal cord compression, disc herniations, and intramedullary signal changes 1
• When leg symptoms predominate without clear upper extremity findings, consider MRI of both cervical AND lumbar spine to evaluate for multilevel pathology 2

Prognostic MRI Findings

Specific MRI findings predict worse surgical outcomes: 1

• T2 hyperintensity at multiple cervical levels (Class III evidence)
• Combined T1 hypointensity with T2 hyperintensity at the same level (Class III evidence)
• Spinal cord atrophy with transverse area <45 mm² (Class III evidence)
• Cervical spinal cord compression exceeding 30% (compression area ratio >0.295) correlates with more severe clinical symptoms 7

Treatment Decisions

Severity-Based Management

For mild cervical myelopathy (modified Japanese Orthopaedic Association score >12):

• Either surgical decompression OR conservative management (cervical collar immobilization, activity modification, anti-inflammatory medications) for the first 3 years 1, 2
• Both approaches show similar outcomes at 2 years (Class II evidence) 1

For severe cervical myelopathy (mJOA score ≤12):

• Surgical decompression is recommended, with benefits maintained for 5-15 years postoperatively (Class III evidence) 1
• Surgical outcomes for symptom relief range from 80-90% 2

When Conservative Management Fails

• Surgical intervention should be considered after 4-6 weeks of failed conservative treatment 2
• Progressive neurological deficits warrant more urgent surgical evaluation 2

Key Clinical Pearls

• The degree of spinal cord compression is the only independent risk factor for severe symptoms in cervical myelopathy patients 7
• Paravertebral muscle degeneration correlates with neck pain but NOT with limb weakness, neurological dysfunction, or gait impairment 7
• Electromyography has poor sensitivity for detecting cervical radiculopathy and mixed utility in predicting surgical outcomes 1
• Consider neurology consultation for atypical presentations with both arm and leg symptoms to exclude non-spinal causes like multiple sclerosis 2