What is Radiculopathy?
Radiculopathy is a syndrome of pain and/or sensorimotor deficits caused by compression or irritation of a spinal nerve root, most commonly presenting with dermatomal pain radiating into an extremity, accompanied by varying degrees of sensory loss, motor weakness, and reflex changes. 1, 2
Pathophysiology
- Nerve root compression occurs most commonly from two mechanisms: herniated intervertebral disc material and degenerative spondylotic changes (facet joint hypertrophy, uncovertebral joint hypertrophy, or foraminal stenosis). 1, 2
- Inflammatory cytokines released from damaged discs contribute to symptoms beyond pure mechanical compression. 3
- In the cervical spine, C5-C6 and C6-C7 nerve roots are most frequently affected. 4
Clinical Presentation
Cervical Radiculopathy:
- Neck pain with unilateral arm pain in a specific dermatomal distribution is the hallmark presentation. 5, 1
- Sensory disturbances (numbness, paresthesias) follow dermatomal patterns. 1, 2
- Motor weakness may occur in muscles innervated by the affected nerve root. 2, 6
- Deep tendon reflex changes, particularly diminished triceps reflex, are the most common objective neurologic finding. 6
- Pain often has an "electric" or shooting quality characteristic of neuropathic pain. 4
Lumbosacral Radiculopathy:
- Lower extremity pain following dermatomal distribution with or without back pain. 5
- Similar sensory, motor, and reflex changes as cervical radiculopathy but in lower extremity distribution. 5
Distinguishing Radiculopathy from Other Conditions
Critical distinction from myelopathy:
- Bilateral symptoms affecting both upper AND lower extremities suggest cervical myelopathy (spinal cord compression) rather than radiculopathy. 4, 7
- Gait disturbance, difficulty with fine motor tasks, bladder/bowel dysfunction, or loss of perineal sensation indicate myelopathy requiring urgent evaluation. 7
Radiculopathy versus plexopathy:
- Clinical overlap exists between single nerve root compression (radiculopathy) and brachial/lumbosacral plexus involvement (plexopathy). 5
- When clinical localization is uncertain, imaging of both spine and plexus may be necessary. 5
Epidemiology
- Cervical radiculopathy has an average annual age-adjusted incidence of 83.2 per 100,000 people. 5
- Peak prevalence occurs in persons aged 50-54 years. 6
- Spondylotic changes are commonly identified on imaging in patients >30 years of age and correlate poorly with presence of symptoms. 5
Red Flag Symptoms Requiring Urgent Evaluation
- Progressive motor weakness demands immediate assessment. 7
- Bilateral radicular symptoms (bilateral radicular pain and/or bilateral sensory disturbance or motor weakness) suggest risk for cauda equina syndrome or myelopathy. 5, 7
- New bladder or bowel dysfunction requires emergency imaging. 5, 7
- Subjective or objective loss of perineal sensation is a true red flag. 5
- Urgency of micturition with preserved control (any new change in bladder function but with preserved control) warrants urgent evaluation. 5
- History of malignancy, prior spine surgery, trauma, suspected infection, or intravenous drug use. 5
- Intractable pain despite therapy or tenderness to palpation over a vertebral body. 5
Natural History and Prognosis
- Most cases of acute radiculopathy resolve spontaneously or with conservative treatment, with success rates averaging 75-90%. 5, 7, 3
- Resolution typically occurs within 6-12 weeks of symptom onset. 7, 6
- Approximately 30-50% of patients may experience residual or recurrent symptoms up to 1 year. 7
Diagnostic Approach
Clinical diagnosis:
- History and physical examination are the foundation of diagnosis. 1, 2
- Spurling test, shoulder abduction test, and upper limb tension test can confirm cervical radiculopathy. 6
- Physical examination tests have limited positive predictive value, with high rates of both false-positive and false-negative findings. 5
Imaging:
- MRI without contrast is the imaging modality of choice for evaluating radiculopathy, correctly predicting 88% of cervical radiculopathy lesions compared to 81% for CT myelography. 5, 4, 7
- Imaging is NOT required at initial presentation in the absence of red flag symptoms, as most cases resolve with conservative management. 5, 6
- MRI should be obtained if symptoms persist after 4-6 weeks of conservative treatment, if red flags are present, or if surgical intervention is being considered. 6, 3
- Contrast is unnecessary unless there is concern for infection, malignancy, or prior surgery. 5, 7
Critical imaging caveat:
- MRI demonstrates frequent false-negative and false-positive findings. 5
- Abnormalities are detected in high rates of asymptomatic individuals. 5
- Detected abnormalities are not always associated with acute symptoms, and abnormal levels on MRI do not always correspond to clinical examination levels. 5
Electrodiagnostic testing:
- Not needed if the diagnosis is clear clinically. 6
- Has clinical utility when peripheral neuropathy is a likely alternate diagnosis. 6
Treatment Approach
Conservative management (first-line for all patients without red flags):
- Reassurance that 75-90% of cases resolve with nonoperative therapy. 7, 3
- NSAIDs or acetaminophen for pain control. 7
- Short course of oral corticosteroids may be considered for acute severe radicular pain. 7
- Physical therapy involving strengthening, stretching, and potentially cervical traction. 7, 6, 3
- Cervical collar immobilization for short-term use. 4
- Muscle relaxants and massage as adjunctive therapies. 6
- Activity modification during acute phase. 7
Epidural steroid injections:
- May be helpful for persistent symptoms but carry higher risks of serious complications. 6
- Consider after failed conservative therapy or for severe pain. 3
Surgical indications:
- Progressive motor weakness. 7, 2
- Intractable pain despite 6-12 weeks of conservative therapy. 7, 2, 3
- Significant functional impairment or debilitating pain resistant to conservative modalities. 5, 1
- Patient preference after failed conservative management. 7
Surgical options:
- Anterior cervical decompression with fusion (most common). 5, 1, 3
- Cervical disk arthroplasty. 3
- Posterior cervical laminoforaminotomy. 1, 3
- Surgical outcomes for arm pain relief range from 80-90%. 4
Timing of surgical intervention: