Cervical Radiculopathy

Introduction

Cervical radiculopathy is a disease process characterized by compression of nerves by herniated disc material or arthritic bone spurs. This impingement usually results in radiating pain or numbness in the neck and arms, sensory deficits, or motor dysfunction in the neck and upper extremities. [1]

Cervical radiculopathy occurs in conditions that cause nerve root symptoms. [2] These may be compressive stimulus traction and nerve root injury, caused by herniated or narrowed foramina or degenerative spondylitis changes (osteoarthritic changes or degeneration) resulting in foraminal stenosis [2] [3].

Most of the time, cervical radiculopathy appears unilaterally, but if severe bone spurs impinge/irritate the nerve roots on both sides at one level, bilateral symptoms may occur. If there is painful weakness or peripheral radiation from pinpricks The location of pain will be traced to the associated nerve root affected[2]

Clinically Relevant Anatomy

There are 8 cervical nerve roots for the 7 cervical vertebrae in the human body, which may seem confusing at first glance. However, the nerve root emerges from the spine between C7 and T1, so C8 and T1 are already present [2]. Tanaka N. et al. [4] conducted an anatomical study of the cervical spine using a surgical microscope Foraminal nerve roots and intradural roots. The intervertebral foramen is funnel-shaped, with the narrowest entrance zone. This is thought to be where the nerve root is compressed in the foramen. compression Roots on the anterior side are attributed to herniated discs and osteophytes in the area of the uncinate vertebrae. Compression on the posterior side is caused by the superior articular process, ligamentum flavum, and periapical fibrous tissue.

Nerve roots and local vessels lack the perineurium, the epineurium is poorly developed, and they are more susceptible to mechanical damage than the periphery. The blood supply is also less secure and susceptible to ischemic injury [5]. These anatomical differences in peripheral nerves may Explain why low pressure to the nerve root causes drastic changes and the signs and symptoms. Nerve roots are vulnerable to pressure injury, which is why a small bump can cause signs and symptoms.

At 5-10mmHg (0.1psi), capillary stasis and ischemia were observed, with partial blockage of axonal transport. At 50mmHg, tissue permeability increases with edema inflow, above 75mmHg, if sustained for 2 hours, nerve conduction failure occurs. At 70 mmHg, neuroischemia is complete, and Conduction is not possible [5]. Rarely are pressures this high, but 5-10 mmHg is a lot of pressure and signs and symptoms occur [5]. If the stress is acute, the symptoms are severe, but if Chronic nervous tissue has time to adapt and evolve into surrounding structures, and symptoms are less severe.

Epidemiology / Etiology

Cervical radiculopathy, a dysfunction of the nerve roots in the cervical spine, is a widespread disease with multiple pathological mechanisms that can affect people of any age [6], being most prominent between the ages of 40-50 [2][7][8] .The reported prevalence is 83 per 100,000 [8]. yearly The reported incidence is 1073 per 100.000 in men and 635 per 100.000 in women [9][10].

Basic picture of cervical vertebrae

The two main mechanisms of nerve root irritation or impingement are:[9]

1. Spondylosis causing narrowing or bone spurs – more common in older patients
2. Herniated disc – more common in younger patients

Mechanical compression caused by spondylosis affects the nerve foramen from all directions, limiting nerve root excursion. Cytokines released by damaged discs can also contribute to the disease. [9]

There is increasing evidence that inflammation itself and/or inflammation associated with root compression is a major cause of symptoms and signs. The presence of interleukins and prostaglandins in herniated discs, as evidenced by the spontaneous recovery of most patients within weeks or months patient. [11]

Level Of Compression

• The most common root compression level is C7 (46.3–69% reported)
• Followed by C6 (19–17.6%)
• Compression of roots C8 (10– 6.2%)
• Compression of roots C5 (2–6.6%).

One possible explanation is that, with the exception of the C7-Th1 foramen (C8), the intervertebral foramina is largest in the upper cervical region and gradually narrows in the middle cervical region. [11][12]

Characteristics/Clinical Presentation

Typical dermatomyotype of upper extremities

Typical symptoms of cervical spondylotic radiculopathy are: radiating arm pain corresponding to dermatome type neck pain sarcomere type muscle weakness reflex/loss headache scapular pain sensory and motor dysfunction of upper extremity and neck[2][6] [3][13][14].

Upper limb movements that are affected:

• C1/C2- Neck flexion/extension
• C3- Neck lateral flexion
• C4- Shoulder elevation
• C5- Shoulder abduction
• C6- Elbow flexion/wrist extension
• C7- Elbow extension/wrist flexion
• C8- Thumb extension
• T1- Finger abduction

The absence of radiating pain does not exclude nerve root compression. The same is true for sensory and motor dysfunction, which may occur without significant pain [2].

Symptoms are usually exacerbated by unidirectional or multidirectional movements, reducing the space available for the nerve root to exit the foramen, resulting in impingement [2]. This often results in patients with neck stiffness and a secondary decrease in cervical ROM Musculoskeletal issues Reduced muscle length in cervical musculature (upper fibers of trapezius levator scapulae) Joint stiffness Capsular tightness and postural deficits can continue to affect movement mechanisms in other parts of the body.

Specifics

• The sites of sensory impairment associated with symptomatic C6 and C7 nerve root compression overlap, so extreme caution should be exercised when diagnosing C6 or C7 nerve root compression based on the location of sensory impairment.
• Impaired sensation in the distal forearm is more common in C6 radiculopathy. [15]

Differential Diagnosis

The identification of cervical spondylotic radiculopathy should be combined with the patient’s medical history, physical examination and radiological examination results. [16] Pathology that mimics the signs and symptoms of radiculopathy. [17]

• Spinal Tumor
• Systemic disorders known to cause peripheral neuropathy
• Cervical myelopathy
• Ligamentous Instability
• Vertebrobasilar Insufficiency (VBI)
• Shoulder Pathology
• Peripheral nerve disorders
• Thoracic outlet syndrome
• Brachial plexus pathology
• Systemic disease
• Parsonage-Turner syndrome
• Superior pulmonary sulcus tumour

Diagnostic Procedures

The most common diagnostic methods used to assess possible compression are radiographs MRI and electrophysiological studies (EMG nerve conduction studies) to examine nerve roots and nerve conduction velocity [18][2][6].

Root compression seen on MRI may confirm cervical radiculopathy, but detection of foraminal stenosis leading to bone compression on nerve spiral CT is described as the best method for detecting this condition. [11]

Whether traditional electromyography (EMG) has a strong diagnostic value for cervical spondylotic radiculopathy is still not a consensus. Several unblinded studies reported sensitivities ranging from 30-95%. [11]

The subjective history and mechanism of injury are integral to the accurate diagnosis and cause of radiating pain in the arm. More commonly, acute arm radiating pain is caused by a herniated disc, whereas chronic bilateral mid-jacketing and arm radiating pain is often caused by cervical spondylosis [2].

Outcome Measures

Neck Disability Index NDIP Patient Specific Functioning Scale PSFS

Numerical Pain Rating Scale NPRS

Neck Pain and Disability Scale (NPAD)

Examination

Provocation tests are performed to provoke or aggravate symptoms in the affected arm and are indicative of cervical radiculopathy. [11]

Wainner et al. [19] tested the accuracy of the clinical examination and developed a clinical prediction rule to aid in the diagnosis of cervical radiculopathy. Their study showed that these 4 clinical tests combined had a higher diagnostic accuracy than the EMG study:

1. Spurlings Test, 
2. Upper limb tension-1 
3. Distraction test 
4. The range of motion of the cervical spine on the affected side is less than 60 degrees.

When all 4 clinical features are present, the post-test probability of cervical radiculopathy is 90%, decreasing to 65% if only 3 of the 4 tests are positive [19][3][6][20 ]. A further tested combination with good reliability is the Spurlings test neck combination Distraction Valsalva and upper extremity tension test 1 2a and 2b [21].

Tong Huicong et al. [22]. A Spurling test was performed before imaging was complete. The test has a sensitivity of 30% and a specificity of 93%. They concluded that the Spurling test was insensitive but very specific for cervical radiculopathy. Therefore, it cannot be used as a screening test, but it Works well for confirming cervical radiculopathy.

A study by Gumina et al. [23] found that the Arm Squeeze test was helpful in differentiating cervical nerve root compression from shoulder disease. The test has a sensitivity and specificity of 96% for an between-observer value of 0.81 and an intra-observer value of 0.87. However, the test utilizes subjective Measures and needs to be verified.

The neurological examination had moderate intraobserver reliability, with kappa values between 0.4 and 0.64 Neuropathy. With C8 radiculopathy, the entire finger is affected. Motor examination may or may not reveal a grade of muscular weakness corresponding to pathological nerves. No sarcomere corresponds to the upper four cervical nerve roots. C5 radiculopathy may indicate deltoid weakness (assessed by shoulder abduction test); C6 will show biceps and flexor carpi ulnaris weakness (assessed by wrist extension test); C7 weakness in triceps and brachioradialis (assessed by elbow extension assessment); C8 Pathology causing weakness Assess the intrinsic muscles of the hand with finger abduction and grip. In the case of radiculopathy, the muscle stretch reflex also tends to be decreased. Weakened biceps reflexes are indicative of C6 radiculopathy, while decreased triceps and brachioradialis reflexes correspond to pathology C7. Nazura Viikari-Juntura (1989). [24][25]

Medical Management

There are several intervention strategies for treating cervical spondylotic radiculopathy, the most common of which are physical therapy and surgical intervention. Long-term benefit of surgical intervention is questionable, but 25% of patients continue to experience pain and disability at age 12 Monthly follow-up [26]. There is substantial evidence supporting the use of physical therapy interventions [27], and the benefits of physical therapy and manual techniques for patients with neck pain with and without radicular symptoms.

Surgery

Indications for single-segment surgery; [28]:

• Sensory symptoms (radicular pain and/or paresthesias) in a dermatome distribution relative to the level of the cervical spine involved
• Altered motor deficit reflexes or positive EMG relative to the level of the affected cervical spine
• Positive response to selective nerve root block (SNRB).
• MRI or myelography with a positive computed tomography (CT) scan.
• Conservative treatment for at least 6 weeks, such as physical therapy epidural injections of NSAID pain relievers.
• Conservative treatment for 6 weeks is not required if there is significant dyskinesia.

Criteria for a 2nd level surgery:

• All criteria previously described for single-level surgery excluding the SNRB were present at the primary stage.
• Radical pain or EMG changes associated with at least moderate foraminal stenosis or lateral recess hernia in adjacent segments Motor deficits or reflex changes associated with adjacent segments.

Surgical techniques frequently used to treat cervical spondylotic radiculopathy include:

• Anterior Cervical Discectomy (Decompression) (ACD)
• Anterior Cervical Dissection and Fusion (ACDF)
• Total Disc Arthroplasty (TDA),
• Laminotomy,
• Foraminotomy,
• Corpectomy. [29][28]

Engquist M et al. The combination of surgery and physical therapy was found to improve faster in the first postoperative year compared with physical therapy, with significant improvements in neck pain and patients’ global assessments. After 2, the difference between the groups decreased year. They recommend that structured physical therapy should be tried before opting for surgery. [30]

Persson et al. It was concluded that there was no long-term (1-year) difference between surgery and physical therapy in terms of intensity pain and sensation. [31] Several other studies have shown significant improvements in physical and social function and pain after surgery, although these improvements Keep for relatively short periods (up to 1 year) and decrease after longer periods (1 to 4 years). [29]

ACDF was associated with reduced ROM and strength compared to conservatively treated subjects. This can sometimes be associated with prolonged pain. [29]

Peolsson A et al. It was concluded that ACDF did not lead to additional improvements in neck range of motion, neck muscle endurance, or hand-related function compared with structured physical therapy alone in patients with cervical spondylotic radiculopathy. Article Suggestion Structured Physiotherapy planning should precede the decision to intervene with ACDF in patients with cervical spondylotic radiculopathy to reduce the need for surgery. [32]

Short duration of pain Low quality of health High anxiety due to neck/arm pain Low self-efficacy and high pre-treatment distress were associated with poor surgical outcomes. [30]

Injections

Epidural steroid injections may also be used to treat cervical spondylotic radiculopathy. Injections were performed under fluoroscopic or CT guidance. Limited evidence suggests that transforaminal epidural steroid injections provide relief in 60% of patients and about 25% of Clear surgical indications. Steroid injections are not a causal cure, nor are they a solution, although steroid injections may be considered when planning a medical/interventional treatment for patients with cervical radiculopathy caused by degenerative disease. Transforaminal injections are not without Before performing this procedure, the risks and possible complications, such as spinal cord injury and death, must be considered. [33][34]

Lee SH et al. studied the use of ESI (epidural steroid injections) in patients diagnosed with cervical floppy or hard discs causing nerve root compression and symptoms. In more than 80% of patients in CR, surgery candidates avoided surgery using ESI. Significant factor The triggers for ESI failure were symptom intensity and previous CR episodes. [35]

Physical Therapy Management

Although a definitive treatment progression for the treatment of cervical radiculopathy has not yet been established, there is general consensus in the literature that the use of manual therapy techniques combined with therapeutic exercises is effective in increasing function and range of motion Exercise focused on reducing pain and disability levels (AROM) is likely to be the patient’s main focus [36]. Positive outcomes of exercise therapy have been confirmed by recent high-level studies [27].

If the patient has chronic pain, an element of pain sensitivity may be present, and chronic pain presents differently than acute pain. Therefore, education about pain and reconceptualization may be necessary.

Treatment Options:

1. Education and advice
2. Manipulative Therapy – PAIVM (Passive Assessment of Intervertebral Motion) / PPIVM (Passive Physiological Intervertebral Movement) / NAG (Natural Apophysis Glide) / SNAG (Persistent Natural Apophysis Glide)
3. Exercise Therapy – AROM Stretching and Strengthening
4. Postural re-education

Education and Advice

Education is key to getting patients on their side and cooperating with physical therapy. Patients are more likely to adhere to any rehabilitation program if they understand what and why their neck and arm pain is.

In the case of a herniated disc, smoking causes the vascular network around the intervertebral disc (IVD) to constrict, thereby reducing the indirect exchange of nutrients and anabolic agents from the blood vessels to the disc. Nicotine downregulates proliferation rate and glycosaminoglycan (GAG) Biosynthesis in Intervertebral Disc Cells. Nicotine primarily affects GAG concentrations at the cartilage endplates, reducing them to 65% of the value achieved under normal physiological conditions. Tobacco primarily affects the nucleus pulposus, which reduces cell density and GAG levels to 50% of normal Physiological level. The effectiveness of smoking cessation on regeneration of degenerative IVDs shows limited benefit for intervertebral disc health. Combining cell-based therapy with smoking cessation should significantly improve disc health, suggesting that in addition to smoking cessation Additional treatments should be implemented to restore the health of IVDs regressed by smoking. [37]

Manual Therapy

There are some contradictions in the use of manual therapy techniques, and their efficacy has been questioned. Gross AR et al report that mobilization and/or manipulation combined with exercise can help relieve pain and improve function in persistent mechanical neck disease, with or without Headaches, but manipulation and/or mobilization are not beneficial as a stand-alone treatment. This is echoed in the current literature. Addition of manual treatment techniques (thought to increase the size of the foramina of the affected nerve root) in a multimodal treatment model There are no significant additional benefits [38][39][40] and no advantages over each other. [41] Even the best procedures provide only short-term pain relief [42]

In addition, cervical spine manipulation carries the risk of complications such as vertebral body dissection and spinal cord compression due to large disc herniations. Therefore, such intervention should be discouraged in cervical spondylotic radiculopathy, especially if spine imaging has not yet been performed. [11] It is also important to be aware of any potential risk factors such as arterial insufficiency, hypertension, craniospinal ligament insufficiency, and upper motor neurone disease [43].

Fritz JM et al examined the effect of cervical traction plus exercise in patients with cervical spondylotic radiculopathy. Adding mechanical traction to exercise in patients with cervical radiculopathy reduces disability and pain, especially in long-term follow-up. [44][45]

However, Boyles et al. (2011) [46] found that manual therapy consisting of thrust mobilization of the cervical or thoracic spine and non-thrust mobilization of the cervical spine (PA glide/lateral glide/rotation/retraction in ULTT1 position) was shown to be effective in Reduced pain levels improved Features and increased joint ROM. When combined with exercise therapy, it was more effective than a control group of manual therapy or exercise therapy, but both control groups were effective in reducing signs and symptoms [47].

Persson et al. [31] highlighted that there were no significant differences in outcome measures among patients who had undergone surgical physical therapy or cervical collars, explaining that physical therapy was at least as effective as surgery.

Muscle Energy Techniques

Cleland et al. [48] used muscle energy technique (MET) in 28 patients and achieved positive results in 46% of patients. However, the details of the techniques used are insufficient and a variety of techniques are used, as it is up to the practitioner to decide which technique to use.

The quality of studies relevant to testing the validity of MET was poor. Studies were generally small and at high risk of bias due to methodological flaws. [49]

Neurodynamics – sliding and sliding/tensioning

Ragonese (2009)[47] performed the neurodynamic sliding and tensioning technique outlined by Butler[50] while placing the patient in the upper extremity tensioning position described by Magee[51] in a slow and oscillatory manner. As symptoms improve, the technique has been developed to Butler also described the “nervous” technique. Positive results were again observed in terms of pain and function, although the duration of treatment was not recorded.

Exercise Therapy

Exercise therapy has the most positive and long-lasting effects on the condition. [27] Exercises aimed at opening the foramina are optimal for reducing the effects of radiculopathy. Exercises such as contralateral rotation and lateral flexion are the easiest forms of exercise Exercises to effectively counter the signs and symptoms given in the form of active ROM [38]. Stretching is also an effective form of treatment for restoring ROM due to the complex and intimate relationship of the foraminal muscles and the possible manifestations of ROM reduction [52]

Once the ROM increases, as long as it is not caused by a structure that physical therapy cannot affect, strengthening exercises can be done to improve stability and reduce the risk of future nerve root irritation. In the initial phase of treatment intensification Exercises should be limited to isometric contractions of the affected upper extremity. Once the underlying symptoms have resolved, progressive isotonic strengthening can begin. This should initially involve low weights and high reps (15-20 reps). Closed kinetic chain activities are very helpful Restores weak shoulder girdle muscles. However, Griffiths et al. found no significant difference between general neck advice and the addition of specific neck stabilization exercises to an exercise program [53].

Patients should be instructed to remain as active as possible and to exercise daily between treatments. Therefore, written instructions for the walkthrough should be provided. We recommend a 2-component procedure as suggested by Fritz JM et al. 2 components: scapula strengthening and Cervical strengthening.

Cervical strengthening exercises should include supine craniocervical flexion to induce contraction of the deep neck flexors without contracting the superficial neck muscles [54]. Feedback using inflation pressure sensors or haptic cues may be useful. Patients should perform three sets of 10 contractions for 10 seconds to properly activate the muscles. The patient was also administered craniocervical flexion contractions with a goal of 30 repetitions of 10-second contractions.

Scapular retraction against resistance using elastic bands or pulleys can be added. Scapula strengthening exercises include prone horizontal abduction, lateral forward flexion, prone extension for each shoulder, and push-ups that focus on shoulder extension. Goal is 3 sets Repeat 10 times, increasing resistance as tolerated.

Prognosis

Regarding a physical therapy intervention in 2007, Joshua Cleland and colleagues [48] examined predictors of positive short-term outcomes in people with a clinical diagnosis of cervical spondylotic radiculopathy. The following clinical features were found to best predict positive short-term result:

• Age <54
• Dominant arm not affected
• Looking down does not worsen symptoms
• At least 50% of visits include manual therapy cervical traction and deep neck flexor strengthening

If 3 of these features are present, the probability of success is 85%, increasing to 90% if all 4 are present [55]

Clinical Bottom Line

Cervical radiculopathy is defined as a disorder affecting the spinal nerve roots in the cervical spine (compression-traction-irritated disc herniation). Cervical spondylotic radiculopathy usually causes radiating pain, numbness, sensory disturbances, or motor dysfunction in the neck and arms in the neck and arms limbs. Knowledge of cervical spine anatomy is important as it is key to effective physiotherapy practice and treatment.

Because there are other conditions that share the same signs and symptoms as radiculopathy, a good examination is recommended. You can use imaging studies (MRI) or electrophysiological studies (EMG nerve conduction studies) [56][1][39]. Better yet use these 4 clinical trials: Spurlings Test upper extremity tension – 1 distraction test and cervical flexion-rotation test. When all 4 clinical trials are positive, the post-trial probability of cervical radiculopathy is 90%.

The main focus of physical therapy or medical management of cervical radiculopathy is to reduce pain and disability. Once treatment begins, it is important to choose the right tool to assess your patients. The Neck Disability Index is a good choice.