Cervical Radiculopathy
By Dale Comrie

Neck pain is one of the most prevalent and costly health problems in our western society. It is reported that in the US, 50-70% of the population will experience at least one significant episode of neck pain in their lives and 10% will suffer from neck pain at any given time¹.

The incidence of cervical radiculopathy has been found to range from 83.2 to 202.9 persons per 1,000,000, with the peak incidence in the 50-54 year age group². Common causes of radiculopathy included disc protrusion (21.9%) and combined spondylosis and disc bulging (68.4%)². The most common level for disc protrusion is C6-7 affecting the C7 nerve root².

Over the past few years, I have become increasingly aware that Cervical Radiculopathy does not always present as the classic textbook case we are taught. If a patent presented with neck and shoulder pain, with shooting pain and tingling in the hand etc… we would all (I hope) do a thorough neurological and orthopaedic work up, with a high degree of suspicion for a cervical radiculopathy.

For the sake of this discussion, I will only be considering a cervical disc protrusion and/or cervical degeneration, as the cause of the presenting signs and symptoms. There are several other significant causes of radicular arm pain that should be considered.

If a cervical radiculopathy is mis-diagnosed and inappropriate care is provided, the outcomes can be potentially serious and lead to litigation.

One text that all Chiropractic should have on their shelves is ‘Neurological Differential Diagnosis’ by John Patten. If we truly consider ourselves as experts in musculoskeletal and nervous system care, a Neurology text is essential.

Discussion
Disc injury occurs most commonly at C7, with C5 and C6 being affected less commonly³. Lesions affecting roots C2,3,4,8, and T1 are relatively rare and should raise suspicions of other diagnostic considerations.

Cervical disc injuries occur in two main ways⁴:

1. Acute trauma in a seemingly normal spine. These typically occur in sports accidents or MVA’s, whereby the patient develops severe acute neck pain with specific radicular arm pain and muscular weakness.
2. Injury to a neck with pre-existing degenerative changes. Simple overuse type activity, atypical activity, heavy labour or mild trauma may exacerbate or initiate lingering disc injury and root irritation. This type of patient needs careful examination because of the potential seriousness of the injury causing ‘Compressive Cervical Myelopathy’.

Degeneration in the cervical region may affect both the Spinal Cord and Nerve Roots. The cervical region is vulnerable due to the cervical spinal cord being expanded (due to the brachial plexus) and the canal is relatively narrowed. Therefore, in patients with even mild degeneration a slightly narrowed canal may cause symptoms.

The most mobile segments are most vulnerable to degeneration and therefore the C6, C7 and C5 nerve roots are most likely to be affected. Pain in the affected root territory is usually related to neck movement, usually worse on waking, and often provoked by known trauma or unusual activity⁴.

Assessment of the patient with arm radiculopathy depends mostly upon careful evaluation of the motor function of the arm, which are much more reliable than sensory findings⁴. Sensory findings are unreliable due to the complexity of the central mapping of the upper limb and the overlapping of the peripheral nerve territories⁴.

Although pain may be exceptionally severe it is unusual to be able to document any definitive sensory loss. Therefore, failure to demonstrate sensory loss in situations of arm pain should not be taken as precluding radiculopathy.

It is common that patients will present without the sensory deficits expected in the lower limb. The pain they present with, motor changes and a typical history, should alert the practitioner to the possibility of cervical radiculopathy.

Patten⁴ presents a table, which is extremely helpful in the diagnosis of cervical radiculopathy (Table 1.). In particular, the row ‘Area of pain’ provides an important clinical clue for suspecting a radicular pain syndrome.

Table 1. Signs and Symptoms of Nerve Root Compression

Roots	C5	C6	C7	C8	T1
Sensory Supply	Lateral border upper arm to elbow	Lateral forearm including thumb & index	Over triceps, mid-forearm & middle finger	Medial forearm to include little finger	Axilla to Olecranon
Sensory Loss	As above + over deltoid	As above + over thumb & radial border of hand	Middle fingers; front & back of hand	Little finger; heel of hand to above wrist	In axilla
Area of Pain	Over the shoulder & into lateral arm; not below elbow. Confirmatory clue is often aching pain down medial border of scapulae	Deep aching biceps pain, which spreads down the lateral forearm, involving thumb and index finger	Inherently diffuse as C7 supplies the periosteum of the bones of the arm. Usually deep aching in triceps, pain down front and back of central forearm, into middle fingers. Patients may complain the entire arm is painful	Root pain is uncommon. Radiates from below olecranon into medial 2 fingers	Deep aching in shoulder joint & axilla, down medial upper arm to olecranon
Reflex Arc	Biceps (C5)	Supinator (C6)	Triceps (C7)	Finger (C8)	None
Motor Deficit	Weakness entire 180 of shoulder abduction	Weakness of elbow flexion in both supine & ½ pronated positions	Weakness of shoulder abduction, elbow extension, wrist extension and wrist flexion	Weakness of long extensors and flexors of fingers	Wasting & weakness of all intrinsic hand muscles
Causative Lesion	Brachial neuritis Cervical spondylosis Upper plexus avulsion	Cervical spondylosis Acute disc lesion	Acute disc lesion Cervical spondylosis	Rarely disc lesion or spondylosis Usually same as T1	Cervical rib Altered 1st rib Pancoast tumour Mets. in deep cervical nodes Outlet syndromes

Obviously, a thorough history is imperative in alerting the practitioner to the possibility of a radiculopathy. Being aware that most patients will present with little or no history of recent trauma and most likely no sensory disturbance in the arm, knowing the pain patterns may be enough to set off the alarm bells.

The value of orthopaedic test in the diagnosis of root compression in disc injury has been questioned. Maximal Cervical Compression, Cervical Axial Distraction and Bakodies Tests have been found to be highly specific for cervical root compression in disc injury, but sensitivity was low⁵. Meaning that they were good at identifying a cervical root compression when significant neurological and radiographic signs were present, but poor at identifying the subtle cases.

Management
We all treat patients with clinical signs and symptoms that we may suspect is due to a cervical radiculopathy. But, what evidence is there for conservative management?

As most of us know the literature for conservative management of the cervical spine in general is very thin. Consequentially, even less has been written for cervical radiculopathy.

As a general rule manipulation and mobilization in the acute phase of cervical disc herniation is contra-indicated, due to the high risk of spinal cord compression from a massive disc prolapse⁶.

There has been some evidence for the management of cervical radiculopathy with a combination of mobilization, traction, cervical collars, ice, rest, and NSAIDs⁷. There is scant evidence for the use of High Velocity Low Amplitude (HVLA) manipulation in the treatment of cervical radiculopathy.

Hubka et al⁸ made the recommendation that when treating these patients it was important to monitor pain sensation, strength and reflexes during management to decide whether to continue treatment, modify treatment or refer. The authors also suggested that before HVLA manipulation, the pre-thrust position is held to assess whether the symptoms are provoked.

Overall, one should understand that extreme care needs to be exercised before considering manual care for a patient with cervical radiculopathy.

Complications
Every day with every patient we need to exercise clear clinical decision-making. No one begins with the intention of injuring a patient, but if we do not learn to recognise the subtle signs and symptoms of conditions like cervical radiculopathy, we leave ourselves open to scrutiny.

Kleynhans⁹ outlined a number of practitioner–related causes of adverse reactions. The ‘Three’ main factors were: lack of knowledge or diagnostic error, lack of technique skill, and lack of rational clinical attitude in case management.

The consequences of inappropriate treatment of a cervical radiculopathy can range from mild to extremely severe.

Mild could be considered aggravation of the patient’s pain. With Severe being from aggravation of the ‘silent’ disc prolapse and being accused of causing the prolapse, to causing Cervical Myelopathy.

Conclusion
The practitioner needs to be more aware of the early signs of cervical radiculopathy, exercise rational clinical protocols and extreme care in the management of these conditions.

References

1. Hurwitz EL, Morgenstern H, et al. A Randomized Trial of Chiropractic Manipulation and Mobilization for Patients with Neck pain: Clinical Outcomes from the UCLA Neck pain Study. Am Journal Pub Health. Oct 2002. Vol 92(10): 1634-1641.
2. Hurwitz EL, Morgenstern H, et al. A Randomized Trial of Chiropractic Manipulation and Mobilization for Patients with Neck pain: Clinical Outcomes from the UCLA Neck pain Study. Am Journal Pub Health. Oct 2002. Vol 92(10): 1634-1641.
3. Yochm TR, Rowe Lj. Essentials of skeletal radiology. Baltimore: Williams and Wilkins, 1991.
4. Patten J. Neurological Differential Diagnosis. 2nd ed. Springer, 2000.
5. Viikari-Juntura E, Porras M, Et al. Validity of clinical tests in the diagnosis of root compression in cervical disc disease. Spine 1989; 14(3): 253-257.
6. Halderman S. Principles and Practice of Chiropractic. 2nd ed. Appleton & Lange, 1992:560-561.
7. Saal JS, Sall JA, Yurth EF.Nonoperative management of herniated cervical intervertebral disc with radiculopathy. Spine 1996; 21(16):1877-1883.
8. Hubka MJ et al. Rotary manipulation for cervical radiculopathy: Observations on the importance of the direction of the thrust. JMPT 1997; 20(9):622-627.
9. Kleynhans AM. Complications and contraindications to spinal manipulative therapy. In: Halderman S, ed. Modern developments in the principles and practice of chiropractic. Norwalk: Appleton-Century-Crofts, 1980;359-384.