Hand Surgery Source

CERVICAL RADICULOPATHY

Introduction

Cervical radiculopathy is defined as a syndrome of pain and/or sensorimotor deficits owing to compression of a cervical nerve root. The syndrome typically manifests as neck pain that radiates into the affected nerve root distribution, including the arm and hand. Common causes of nerve root compression include disc herniation, spondylosis, instability, trauma and, although rarely, from tumors.1 Differentiating a cervical radiculopathy from more commonly occurring peripheral nerve entrapment syndromes is critically important to provide effective treatment and the best chance of recovery.

Related Anatomy

  • Cervical spinal nerves (C1–C8)
  • Cervical nerve roots
  • Neural foramen
  • Intervertebral discs
  • Facet joints

Pathophysiology

  • Cervical root compression

Incidence and Related Conditions

  • The current annual US estimate is about 85 cases per 100,000 population.
  • In an epidemiological survey from 1976 to 1990, the annual age-adjusted incidence rate was 83.2 per 100,000 in Rochester, MN and reached a peak of 202.9 for the cohort aged 50–54 years.2
    • Median duration of symptoms before diagnosis was 15 days
    • Monoradiculopathy involving C7 nerve root was most frequent, followed by C6
    • Disc protrusion accounted for 21.9% of cases; 68.4% were related to spondylosis, disc protrusion or both
    • History of lumbar radiculopathy in 41%; history of physical exertion or trauma in 14.8% of cases
    • During 4.9 years of follow-up, recurrence occurred in 31.7% of cases; 26% had surgery; at last follow-up, 90% were asymptomatic or only mildly incapacitated

Differential Diagnosis

  • Carpal tunnel syndrome
  • Double-crush syndrome
  • Wartenberg’s syndrome
  • Cubital tunnel syndrome
ICD-10 Codes

CERVICAL RADICULOPATHY

Diagnostic Guide Name

CERVICAL RADICULOPATHY

ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

DIAGNOSIS SINGLE CODE ONLY LEFT RIGHT BILATERAL (If Available)
CERVICAL RADICULOPATHY M54.12      

ICD-10 Reference

Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Symptoms
Neck pain radiating to shoulder, upper back, chest and/or arm
Numbness and tingling in the forearm, hand and/or digits
Upper extremity muscle weakness
Decreased upper extremity coordination
Depending on the nerve root compressed: − C2: Occipital/eye and/or ear pain, headache - C3/C4: Neck/trapezius pain − C5: Shoulder pain, deltoid weakness − C6: Lateral forearm/first two fingers pain, biceps weakness, biceps reflex absent − C7: Posterior
Positive Tests, Exams or Signs
Work-up Options
Images (X-Ray, MRI, etc.)
  • Significant Cervical Osteoarthritis and Disc space narrowing. Note large posterior osteophytes(arrow).
    Significant Cervical Osteoarthritis and Disc space narrowing. Note large posterior osteophytes(arrow).
  • Cervical Osteoarthritis and disc space narrowing AP view
    Cervical Osteoarthritis and disc space narrowing AP view
  • Cervical Osteoarthritis and disc space narrowing on oblique view. Note foramen impingement at arrows. In this AP view the head is rotated 45 degrees to RIGHT so the LEFT cervical foramen are demonstrated.
    Cervical Osteoarthritis and disc space narrowing on oblique view. Note foramen impingement at arrows. In this AP view the head is rotated 45 degrees to RIGHT so the LEFT cervical foramen are demonstrated.
Treatment Options
Conservative
  • Conservative: passive (collar immobilization, rest) and active (range-of-motion exercises, TENS, cervical pillow, massage, acupuncture, ultrasound, traction, chiropractic manipulation) therapy. Epidural steroid injections improve symptoms, but no studies have demonstrated long-term benefit.
Operative
  • Operative: two major categories are anterior and posterior approaches to the spine
    • Anterior: anterior cervical discectomy with fusion (ACDF), cervical discectomy (ACD) without fusion, foramenotomy without complete discectomy; total disc arthroplasty
    • Posterior: cervical laminoforaminotomy
Complications
  • Epidural steroid injections: rates range from 3–35%; case reports of catastrophic complications include epidural hematomas and spinal cord infarction
  • Chiropractic manipulation: vertebral artery injury is commonly reported and can have catastrophic outcomes
  • Anterior operative approaches: neuroproxia, ischemia, dysphagia, odynophagia; recurrent laryngeal nerve injury in up to 25% of patients
  • Posterior operative approaches: neck pain, progressive degeneration and spinal deformity among older patients, those with cervical kyphosis and who have undergone previous surgery
Outcomes
  • Conservative: a combination of active and passive therapies aids in patient recovery; 75–90% of patients will improve with conservative management
  • Operative: ACDF and ACD provide immediate and long-term relief of symptoms (75%); positive outcome for 75–98% of patients after posterior approaches
Key Educational Points
  • Cervical nerve roots exit above their corresponding numbered pedicles (for example, C6 exits between C5 and C6).
  • Nonsurgical treatment should be attempted for most patients with cervical radiculpathy. Many forms of nonsurgical treatment relieve pain but may not alter the natural history of the disease.
  • Monoradiculopathy involving C7 nerve root was most frequent, followed by C6.
References

Cited

  1. Caridi JM, et al. Cervical radiculopathy: A review. HSS J 2011;7:265-272. PMID: 23024624
  2. Radhakrishnan K, et al. Epidemiology of cervical radiculopathy. A population-based study from Rochester, Minnesota, 1976 trough 1990. Brain 1994;117(Pt 2):325-35. PMID: 8186959

New Articles

  1. Grotle M, Hagen KB. Surgery for cervical radiculopathy followed by physiotherapy may resolve symptoms faster than physiotherapy alone, but with few differences at two years. J Physiother 2014;60(2):109. PMID: 24952840
  2. Terai H, et al. Tandem keyhole foraminotomy in the treatment of cervical radiculopathy: retrospective review of 35 cases. J Orthop Surg Res 2014 16;9:38. PMID: 24884935

Reviews

  1. Corey DL, Comeau D. Cervical radiculopathy. Med Clin North Am 2014;98(4):791-9. PMID: 24994052
  2. Onks CA, Billy G. Evaluation and treatment of cervical radiculopathy. Prim Care2013;40(4):837-48. PMID: 24209721
  3. Thoomes EJ, et al. The effectiveness of conservative treatment for patients with cervical radiculopathy: a systematic review. Clin J Pain 2013;29(12):1073-86. PMID: 23446070

Classics

  1. Herkowitz HN, Kurz LT, Overholt DP. Surgical management of cervical soft disc herniation. A comparison between the anterior and posterior approach. Spine 1990;15(10):1026-30.PMID: 2263967
  2. Henderson CM, et al. Posterior-lateral foraminotomy as an exclusive operative technique for cervical radiculopathy: a review of 846 consecutively operated cases. Neurosurgery 1983;13(5):504-12. PMID: 6316196