Cervical Radiculopathy May Cause A Pain In The Neck & Arm Symptoms
Cervical radiculopathy gets its name from the neck (cervical) and compression of the root of a nerve (radiculopathy). This is caused by a disc herniation and/or the formation of bone spurs resulting from degenerative disc disease or cervical spondylosis. As a nerve is pinched (compression or impingement) from these disease processes, it can produce pain directly in the neck along with radiating pain, numbness or tingling into the arm and even the hand. The numbness/tingling are called “sensory deficits” or “sensory disturbances”. Another symptom caused by cervical radiculopathy is when muscles are affected due to the nerve compression and this can cause the muscles to not function correctly, leading to weakness or loss of control of motion or strength called “motor disturbances” of “motor deficits”.
Causes of Cervical Radiculopathy
As stated, cervical radiculopathy often causes neck pain as well as radiation of this pain and/or numbness/tingling into the arm and/or hand. This occurs following the path of a nerve root (part of the nerve that is being pinched). The pain of cervical radiculopathy can go beyond the neck (radiating) into the shoulder, arm and hand affecting muscle function and/or numbness/tingling (motor and/or sensory disturbance). Causes of cervical radiculopathy are usually due to disc herniation, cervical spondylosis (degenerative changes), which lead to a closing or narrowing of the space which the nerve will exit the cervical spine and this narrowing of the space is called “foraminal encroachment”, leading to compression or “pinching” along with resulting irritation and inflammation of the nerve.
Therefore, foramina are the openings for the nerve and these openings can be narrowed or encroached upon by the means described above. Foraminal encroachment of the spinal nerve from degenerative changes in the uncovertebral (in the body of the vertebra) and zygapophyseal (in the back of the vertebra) joints, as well as disc herniation, where the inner, soft part of the disc pushes outside and presses against the nerve, are the two most common causes regarding cervical radiculopathy.
There are specifc levels where the nerve is being pinched and this can be used to determine which disc is causing the problem. The fifth cervical nerve root comes through the disc space between the disc that sits in between the fourth and fifth cervical bones (vertebrae), so a disc herniation at C4/5 will cause cervical radiculopathy of the fifth nerve root (C5 nerve root). Similarly, a disc herniation at the C5/6 level will lead to C6 nerve pinching or radiculopathy. The cervical spine consists of 7 bones or vertebrae along with 8 nerves or nerve roots.
Cervical radiculopathy is a neurologic condition characterized by dysfunction of a cervical spinal nerve, the roots of the nerve, or both. It usually presents with pain in the neck and one arm, with a combination of sensory loss, loss of motor function, or reflex changes in the affected nerve-root distribution.
The most common cause of cervical radiculopathy (in 70 to 75 percent of cases) is foraminal encroachment of the spinal nerve due to a combination of factors, including decreased disc height and degenerative changes of the uncovertebral joints anteriorly (front) and zygapophyseal joints posteriorly (back) as we have discussed with degenerative changes and cervical spondylosis. This condition also is seen in the lower back, however, herniation of the nucleus pulposus of the disc is responsible for only 20 to 25 percent of cases for the neck. Other causes, including tumors of the spine and spinal infections, which are infrequent.
There are no universally accepted criteria for the diagnosis of cervical radiculopathy. In most cases, the patient’s history and physical examination are sufficient to make the diagnosis. Typically, patients present with severe neck and arm pain. Although the sensory symptoms (including burning, tingling, or both) typically follow a dermatomal distribution as seen in the diagram, the pain is more commonly referred in a myotomal pattern. For example, radicular pain from C7 is usually perceived deeply through the shoulder girdle with extension to the arm and forearm, whereas numbness and paresthesias are more commonly restricted to the central portion of the hand, the third digit, and occasionally the forearm.
Weakness of the arm or hand is reported less frequently. Holding the affected arm on top of the head or moving the head to look down and away from the symptomatic side often improves the pain, whereas rotation of the head or bending it toward the symptomatic side increases the pain.
When the nerve root is pinched or has compression on it from a herniated disc, it is usualy called a “soft disc herniation” due to the nature of the material pushing outside the disc, while compressing of a nerve by degenerative changes which result in excessive bone growth (hypertrophy), it is called a “hard disc” pathology, again due to the nature of the material that is causing the nerve to be compressed. In this case it is not really the disc, but the formation of bone in the joints, however, it is often called a “hard disc”. Regardless of the cause, soft or hard disc, it produces inflammation (swelling or edema) and blood vessel formation which all factor into the developing radicular (nerve root) pain.
Pain due to soft disc type herniation usually have an acute/recent incident, which may or may not present with radiation of pain/numbness/tingling in the arm/hand. Chronic (long lasting), bilateral (both sides) neck as well as radiation of pain in the arm/hand is most often caused as a result from spondylosis degeneration related to different causes, including degenerative disease of the disc as well as a facet joint syndrome.
So, chronic neck pain in assiciation with cervical spondylosis is usually bilateral (both sides), where the neck pain of cervical radiculopathy is usually unilateral (one sided). The radiating pain will depend on which nerve is compressed, however, it is not always clear because there can be overlapping of the areas, confusing the clinical picture. A lack of pain that radiated into the arm/hand doesn’t mean there is no compression of the nerve root. It is possible that pain is confined only to the shoulder area. It is also possible that numbness/tingling (sensory) or muscle weakness (motor) dysfunctioning may occur with no major pain findings. The symptoms of cervical radiulopathy frequently can be worsened with neck movements such as backward bending (extension) while at the same time turning (rotation). This motion will cause a decrease in size regarding the opening for the nerve root (neural foramen) and is called “Spurling’s Test”. The doctor may press downward on the head to further compress the nerve. This is a maneuver that a doctor would perform in attempts to diagnose cervical radiculopathy. Another test is placing the affected arm up and above the head, which may open the space where the nerve exits (decompress) and provide relief of pain or other symptoms, and this is called “Shoulder Abduction Test”.
Findings on physical examination vary depending on the level of radiculopathy and on whether there is myelopathy. In most cases, the nerve root that is most frequently affected is the C7, followed by the C6. There is sometimes confusion between C4 Radiculopathy and mechanical neck pain.
Treatment for Cervical Radiculopathy
When neck pain is significant due to radiculopathy, a brief period of immobility can help relieve the pain due to inflammation. This is often accomplished by using a comfortable neck collar. The collar should not be too rigid, nor too soft. Some have advocated the use of short-term immobilization with either hard or a soft neck collars (either continuously or only at night) to aid in pain control. Use of a neck pillow during sleep has also been recommended.
Home neck traction devices can provide relief of radiculopathy pain by separating the vertebral bones, thus opening the space that the nerve is being compressed, offering decompression. Neck traction consists of administering a distracting force to the neck in order to separate the cervical segments and relieve compression of nerve roots by intervertebral discs. Various techniques and durations – minutes vs. up to an hour have been recommended. Recent advances in traction have made this form of treatment less expensive, easier, more comfortable and portable.
In a recent January 2014 study published the Journal of Orthopaedic & Sports Physical Therapy, it was shown that the addition of traction with exercises for those with cervical radiculopathy provided relief of pain and lowered disability, especially in the long term.
There is a use for neck pain medications in cervical radiculopathy, especially early when there is inflammation. Antiinflammatory medications are useful for similar conditions in the lower back, therefore, an initial prescription of non-steroid or steroid medication for the neck pain as well as the radiation of pain into the arm/hand can be quite effective. There may also be a beneficial response to analgesic medications, muscle relaxers, as well as anti-depressants or anti-convulsants. Cervical radiculopathy may also respond to opioid medications for nerve pain up to 8 weeks in duration. There is not enough research to support these medications greater than 2 months. Muscle relaxers may relieve neck pain due to spasm or an increase of tensioning of tendons, where muscles attach to bones. For long lasting or chronic nerve pain from cervical radiculopathy, medications can be beneficial for those who do not undergo or continue to have pain after surgical procedures. Some anti-depressants offer a fair amount of pain relief for those suffering chronic nerve (neuropathic) pain. Tramadol may also offer relief regarding this chronic nerve pain. Oral Steroids like medrol dose pack, may not have an effect on the overall course of radiculopathy, they can provide significant relief when used early in the inflammatory stage of the disease. Due to complication, long-term steroid use is not warranted and the effectiveness can decrease with subsequent use.
Gradual progression of physical therapy may help with restoration of motion as well as improving neck muscle strength. During the initial 6 weeks, mild motion along with stretching type exercising with massage therapy and therapeutic agents like moist heat, ice applications, ultrasound and electrical stimulation are often employed. With improvement in pain levels, gradually implemented strength exercises can be started, progressing to more active motion and resistance exercises.
Manipulation can also be helpful. This requires care in selection of technique, however, carefully implemented adjustments can help remove pressure on the nerve root and assist in healing, especially in the latter stages where residual affects from healing like scar tissue can limit motion and cause onging pain. Initially, techniques like flexion/distraction manipulation provides careful and controlled manually applied traction using special tables. This is usually employed in conjunction with therapeutic agents described previously.
Injections of steroids are often utilized for pain of cervical radiculopathy. These injections need to be administered via radiographic guiding for CT/MRI confirmed radiculopathy. The injections, sometimes called nerve blocks, directly surround the nerve root with steroid medication. It is possible to obtain pain relief within fourteen days and at 6 months following a routine of injections. It is possible that these nerve block steroid injections can reduce nerve pain and decrease the necessity for surgery. It is also possible that injections may fail to produce any results. Side effects asociated with injections are not common, with minor complications in about 1.5% and a major complications less that 1%. Major complications, although rare, can be very problematic like damage to the spinal cord or possibly the brain-stem. Steroid injections can have a short term, improvement in the symptoms associated with cervical radiculopathy.
About 33% of cervical radiculopathy sufferers who undergo treatment without surgery will experience ongoing symptoms. A basic rule is those who are not afforded pain relief within 6 weeks of conservative therapy and continue to have decreasing nerve function along with any signs of myelopathy or instability, require surgical consultation.
Cervical Radiculopathy Conclusion
Combined neck and arm pain are much more disabling than either symptom alone. Younger patients (younger than 40 or 40-60) are more affected by these symptoms than patients older than 60 years. In addition, as symptom duration increases, a negative impact on mental health is observed. Patients with a significant component of neck pain in conjunction with cervical radiculopathy should be considered the most affected of all patients with cervical spondylosis. Given the evidence that the treatment methods at the disposal of physicians are effective, prompt treatment of these patients may help avoid the harmful effects of chronic symptoms on mental functioning, especially among younger patients who were found to be more impacted by the symptoms. There is a positive correlation between intensity of neck pain and difficulty during work, leisure time, and sleep.