Nonoperative Management of Neck Pain and Radicular ...

Cervical steroid injections may be considered in the treatment of radicular pain. Cervical perineural injections (e.g., trans-laminar and transforaminal epidurals, selective nerve root blocks) should be performed under radiographic guidance and only after confirmation of pathology via MRI or computed tomography. These blocks attempt to bathe the affected nerve root in steroids. One study demonstrated significant pain relief at 14 days and six months after a series of selective nerve root blocks.20 In another prospective cohort series of 21 patients awaiting surgery for symptomatic radiculopathy, cervical injections improved pain and reduced the need for operative intervention.21 More recently, however, a prospective, randomized study of 40 patients showed no difference after three weeks between patients who received a steroid injection and those who were in the control groups.22 Complications associated with cervical injections are rare. One study of a series of more than 1,000 blocks showed a minor complication rate of 1.66 percent and a major adverse events rate of less than 1 percent.23 However, patients should be advised that these rare events may be severe (e.g., spinal cord or brainstem damage). A recent review of the literature suggests that epidural corticosteroids may lead to short-term, symptomatic improvement of radicular symptoms.24

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Continuing Education Activity

Neck pain is a prevalent issue that can cause significant pain and disability. Up to 40% of work absenteeism is due to individuals with a history of neck pain. Cervical radiculopathy occurs when a nerve root in the spine is compressed or impeded, leading to pain that can spread beyond the neck and into the arm, chest, shoulders, and upper back. Common signs of impingement include muscle weakness and impaired deep tendon reflexes. These deficits may worsen over time, leading to a decrease in quality of life and daily function. While most symptoms can be treated with supportive care, more severe signs of functional loss may require rehabilitation or surgery. This activity covers the causes, symptoms, evaluation, and management of cervical spine radiculopathy, emphasizing the importance of the interprofessional team in assessing, diagnosing, and treating the condition.

Objectives:

• Determine the pathophysiology of cervical spine radiculopathy that leads to common symptoms and signs.

• Select the relevant steps in examining and evaluating cervical radiculopathy, including any indicated diagnostic imaging.

• Identify treatment options for cervical radiculopathy based on the specific etiology.

• Implement interprofessional team strategies in diagnosing cervical radiculopathy and improving outcomes.

Introduction

Neck pain is a common condition that can cause significant discomfort and disability in patients of different ages. Workers who have experienced neck pain account for up to 40% of work absenteeism.[1][2][3] Cervical radiculopathy, on the other hand, is a condition where the nerve root of a spinal nerve is compressed or impaired, causing the pain and symptoms to spread beyond the neck and radiate to other areas of the body, such as the arms, neck, chest, upper back, and shoulders. Due to the nerve impingement, muscle weakness and impaired deep tendon reflexes are often observed.

Etiology

Any condition that causes compression or irritation of a spinal nerve root can result in radicular symptoms. In younger patients, typically in the third and fourth decade, disc trauma and herniation are the most frequent causes of impingement.[4] With increasing age, the causation is degenerative. Disc degeneration is the most common cause in the fifth and sixth decades. In the seventh decade, causation stems from foraminal narrowing due to arthritic change.

Epidemiology

Less frequent than lumbar radiculopathies, cervical radiculopathies occur at an incidence rate of approximately 85 persons per 100,000. The C7 nerve root is most frequently impacted, with more than half of all cases affecting this level. Roughly a quarter of cases involve the C6 nerve root. Nerve roots C1 to C5 and C8 are less impacted. Risk factors for developing radicular disease include manual labor with heavy lifting, driving, or operating vibrating equipment. Chronic smoking history can increase the risk of radiculopathies.

Pathophysiology

In nearly all cases of cervical radiculopathy, the key pathophysiologic feature is inflammation. That inflammation can result from acute herniation of an adjacent cervical disc impinging on the nerve root. The inflammation can also exacerbate degenerative changes so that osteophytes or changes associated with disc dehydration can affect the nerve root. The direct compression of the nerve root leads to pain, numbness, tingling, and weakness.

History and Physical

The history of patients with a complaint of radicular pain or muscle weakness should include inquiries about occupational risk factors, history of trauma, and pain patterns. Cervical radiculopathy is almost always unilateral, although, in rare cases, both nerves at a given level may be impacted. Those rare presentations can confound physical diagnosis and require acceleration to advanced imaging, especially in cases of trauma.

When performing a physical examination, it is crucial to position the patient in a way that allows for the isolation of individual reflex arcs. This helps accurately assess the patient's overall reflex response. Given the individual variation in deep tendon reflexes, comparing both sides of the neck is more important than overall magnitude. If there is nerve impingement, the affected side is reduced relative to the unaffected side. Reduced muscle strength, innervated by the affected nerve, is a significant physical sign.

The spurling test, which compresses the foramina, helps diagnose likely radiculopathy. With the head extended, the head should then be rotated. The test is positive if the pain radiates down the upper limb of the ipsilateral side of the rotation. In some cases, cervical traction can provide relief of radicular pain.

Evaluation

Plain x-ray studies of the cervical spine are commonly ordered for neck and upper extremity pain evaluation. Lateral views may show disc space narrowing. Oblique views may show foraminal narrowing at the level of radicular symptoms. Open mouth views are only necessary if disruption of the atlantoaxial joint is suspected.[5][6][7][8]

Computed tomogram (CT) scanning may be helpful in the acute setting for diagnosing traumatic injuries resulting in radicular symptoms. Poor visualization of soft tissue makes CT less effective outside of this setting.

Magnetic resonance imaging (MRI) is the preferred modality for evaluating radiculopathies. MRI provides excellent visualization of soft tissue abnormalities, including disc herniations and nerve compressions. While disc herniations and foraminal narrowing strongly correlate with radicular symptoms, they may not be causative in every case. False positives are a risk in MRI studies.

Electromyography is useful in confirming the dysfunction of the affected nerve root. Selective nerve root blocks can provide short-term pain relief and confirm the nerve root origins of radiating pain.

Treatment / Management

Treatment of cervical radiculopathy should be approached in a stepwise fashion. Also, while surgery can provide significant relief, there is little evidence that surgery provides a clear advantage over non-surgical treatment in an acute setting. Over 85% of acute cervical radiculopathy resolves without any specific treatments within 8 to 12 weeks.[9][10][11] 

However, to facilitate reduced nerve root inflammation and improve radiculopathy, it is important to implement non-surgical treatments, including oral anti-inflammatory drugs, physical therapy, and translaminar epidural steroid injections. An aggressive, well-designed physical therapy program can provide significant relief. In the setting of surgical intervention, physical therapy can speed recovery. Medical durable goods and appliances can provide significant symptom relief. Nighttime use of a cervical pillow can relieve symptoms and make sleeping easier during recovery. Short-term use of a soft cervical collar can provide some relief. 

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Since the main cause of pain in cervical radiculopathy is inflammation, the use of non-steroidal anti-inflammatory drugs (NSAIDs) for 1 to 2 weeks can provide symptom relief and treat the proximate cause. The use of oral steroids should be limited to short-term due to controversies surrounding their use. Tricyclic antidepressants and drugs such as gabapentin are useful adjuncts in the treatment of cervical radiculopathy. Opioid pain medications are not recommended for routine use, but they can be useful in managing radicular pain. It should be noted that the use of opioid medications is a risk factor for slow recovery and delayed return to work for patients where surgical intervention is clinically necessary.[12][13]

Studies have shown that epidural steroids can provide significant pain relief and accelerate the return to normal function for many patients. Relief from a single treatment can be significant and long-lasting. Half the treated patients reported at least 50% relief for weeks following injection.

Using acupuncture as an adjunctive therapy has also been shown to provide significant symptomatic relief. Chiropractic or direct osteopathic manipulation can worsen radicular symptoms. Conversely, indirect osteopathic techniques can facilitate the relief of symptoms. 

Surgical management can provide relief to patients who have failed non-surgical approaches. Two main surgical techniques can be used: anterior and posterior approaches. Usually, the anterior approach requires complete discectomies filled by fusion or disc replacements. The posterior approach involves laminectomy, partial discectomy, and foraminotomy with or without fusion. Both approaches have proven effective. As always, surgical treatments are reserved for failed non-surgical treatments, and patients have acute deterioration of their neurological function. No matter the approach, surgery-related complications can occur, including complications caused by anesthesia or complications from the procedure itself, including nerve palsies, vascular impairment, and laryngeal nerve damage.

Differential Diagnosis

The following diagnoses should be considered in the differential:

1. Brachial plexus injury in sports medicine

2. Cervical disc injuries

3. Cervical discogenic pain syndrome

4. Cervical facet syndrome

5. Cervical spine sprain

6. Rotator cuff injuries

7. Strain injuries

Postoperative and Rehabilitation Care

Manual-based treatments, including traction, mobilization, and manipulation, are used for cervical radiculopathy rehabilitation. Traction is considered the main cornerstone based on available literature. In addition, manual therapy can include various forms of massage and exercises, including stretching, strengthening, and neurodynamic exercises.[14][15] Mechanical traction provides improved outcomes compared to manual traction based on the limited research comparing the two, though further research is needed.[16]

Therapeutic efforts are cited as having multiple benefits, including reducing pain, improving functional outcomes, and improving the timeliness of outcomes depending on the onset of treatment and how aggressive the treatment plan is. It is worth noting that the effectiveness of individual treatments has not been demonstrated in the literature. Combining these treatments has been shown to reduce radiculopathy symptoms. Further research is needed for a more comprehensive understanding.[14][15]

Enhancing Healthcare Team Outcomes

Managing patients with cervical radiculopathy is best accomplished with an interprofessional team that includes a neurologist, neuro or orthopedic surgeon, physical therapist, nurse practitioner, and primary care provider. The treatment of cervical radiculopathy should be approached in a stepwise fashion. Also, while surgery can provide significant relief, little evidence supports that surgery provides a clear advantage over non-surgical treatment in an acute setting. Over 85% of acute cervical radiculopathy resolves without any specific treatments within 8 to 12 weeks. Supportive care includes nonsurgical treatments such as anti-inflammatory drugs, physical therapy, and translaminar epidural steroid injections. 

While many surgical procedures are available, they all have the potential to cause serious complications. Additionally, cases where surgical procedures do not result in significant improvement are evident, and patients continue to suffer from chronic disabilities.[17][18] Patients who do not show improvement could be considered for surgery as a last resort.

Disclosure: Warren Magnus declares no relevant financial relationships with ineligible companies.

Disclosure: Omar Viswanath declares no relevant financial relationships with ineligible companies.

Disclosure: Vibhu Krishnan Viswanathan declares no relevant financial relationships with ineligible companies.

Disclosure: Fassil Mesfin declares no relevant financial relationships with ineligible companies.

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