Cervical Radiculopathy: Diagnosis and Management
Likely Diagnosis
This clinical presentation of arm pain radiating down the arm with passive neck stretch (positive Spurling-type maneuver) is classic for cervical radiculopathy, caused by compression or irritation of a cervical nerve root. 1, 2
The key diagnostic features are:
- Radiating arm pain in a dermatomal distribution triggered by neck movement or positioning 1, 2
- Positive provocation with passive neck stretch (similar to Spurling test) reproduces the radicular symptoms 3
- Pain typically follows C5-C6 or C7 nerve root distributions, the most commonly affected levels 2, 4
Initial Management Approach
Start with conservative nonoperative management, as 75-90% of cervical radiculopathy cases resolve spontaneously or with conservative treatment. 1, 5, 6
First-Line Conservative Treatment (4-6 weeks):
- Short-term cervical collar immobilization for symptom relief (avoid prolonged use to prevent deconditioning) 5
- NSAIDs for pain and inflammation control 5, 3
- Physical therapy with strengthening and stretching exercises once acute pain subsides 5, 3
- Activity modification avoiding positions that provoke symptoms 3
- Consider cervical traction for temporary nerve decompression 5
- Muscle relaxants if significant muscle spasm is present 3
Imaging Decision Algorithm:
Do NOT order imaging initially unless red flags are present. 1, 7
Order MRI cervical spine without contrast only if:
- Symptoms persist beyond 4-6 weeks despite conservative management 1, 3
- Progressive motor weakness develops 1, 8
- Red flag symptoms appear (see below) 1, 7
- Surgical intervention is being considered 1, 6
MRI is the preferred imaging modality when indicated, providing superior soft tissue visualization for detecting disc herniations and nerve root compression. 1, 8
Red Flags Requiring Urgent Evaluation
Immediately escalate care if any of these develop:
- Progressive or severe motor weakness 1, 8
- Bilateral upper extremity symptoms (suggests myelopathy) 8, 9
- New bladder or bowel dysfunction 8, 9
- Loss of perineal sensation 8
- Constitutional symptoms (fever, weight loss, night sweats suggesting infection or malignancy) 9
- Symptoms affecting both upper and lower extremities (suggests cord compression) 8
Surgical Referral Criteria
Refer for surgical evaluation if:
- Persistent or intractable pain after 4-6 weeks of adequate conservative management 1, 6, 3
- Clinically significant or progressive motor deficits 2, 4
- Severe neurological dysfunction 2, 6
Surgical outcomes for arm pain relief range from 80-90% with either anterior or posterior decompression approaches. 1, 6
Common Pitfalls to Avoid
- Do not order MRI in the first 4-6 weeks without red flags – degenerative changes are common in asymptomatic individuals over age 30 and correlate poorly with symptoms, leading to unnecessary interventions. 1, 7, 9
- Do not miss myelopathy – always assess for bilateral symptoms, lower extremity involvement, gait disturbance, or bowel/bladder changes, as these require urgent evaluation. 8, 9
- Do not assume all radiating arm pain is radiculopathy – consider peripheral nerve entrapment (carpal tunnel, cubital tunnel) or brachial plexopathy if the distribution doesn't follow a clear dermatomal pattern. 8, 3
- Do not continue conservative management indefinitely with progressive motor weakness – this requires prompt MRI and surgical consultation. 1, 2, 6
Prognosis
Reassure the patient that the overall prognosis is favorable, with most cases improving over time with focused nonoperative treatment. 5, 6 Acute cervical radiculopathy generally has a self-limited clinical course with up to 75-90% spontaneous improvement rate. 1, 6