Cervical Radiculopathy

Definition

Pain and neurological dysfunction in the distribution of a cervical nerve root, from mechanical compression or chemical irritation of the root. Distinct from myelopathy (cord compression) and from referred somatic neck pain (non-dermatomal).

Anatomy

  • 8 cervical roots, 7 cervical vertebrae.
  • Roots exit above their correspondingly numbered pedicle to C7; C8 exits between C7 and T1.
  • A C5-C6 lesion therefore affects the C6 root.
  • Root sits in the inferior foramen; vulnerable to uncovertebral osteophyte anteriorly and facet osteophyte posteriorly.
  • Foraminal area reduced by extension, ipsilateral side-bending and rotation. Increased by flexion and contralateral rotation.

Aetiology

  • Spondylotic foraminal stenosis – commonest overall; usual cause >50 years
  • Soft disc herniation – younger patients; usually posterolateral
  • Less common – tumour, infection, synovial cyst, OPLL, inflammatory arthropathy
  • Compression alone does not produce radicular pain; inflammatory mediators from the disc contribute

Epidemiology

  • Annual incidence of the order of 80 per 100,000.
  • Peak in the fifth and sixth decades.
  • C7 most commonly affected, then C6; together ~75% of cases.
  • Minority report preceding trauma or exertion.

Natural History

  • Majority improve substantially within 6–12 weeks.
  • Disc herniations frequently regress on follow-up imaging.
  • Non-operative treatment appropriate first line in the absence of myelopathy or significant motor deficit.
  • Minority follow a relapsing course or fail to settle.

History

  • Neck and periscapular pain, then radiating arm pain in a dermatomal distribution; often worse at night
  • Paraesthesia and numbness distally
  • Weakness less commonly the presenting complaint
  • Shoulder abduction relief sign – relief on placing the hand on the head
  • Screen for myelopathy: gait, balance, hand dexterity, sphincter function

Examination

By Root Level

  • C5 – deltoid, biceps; lateral arm; biceps reflex
  • C6 – wrist extension, biceps; thumb and index; brachioradialis reflex
  • C7 – triceps, wrist flexion, finger extension; middle finger; triceps reflex
  • C8 – finger flexors, interossei; ring and little finger; no reliable reflex
  • T1 – intrinsics; medial forearm

Provocative Tests

  • Spurling – extension, ipsilateral rotation, axial compression. Specific, not sensitive.
  • Upper limb tension test – sensitive; useful to rule out.
  • Cervical distraction – relieves symptoms.
  • Always examine for long tract signs.

Differential

Investigations

Prolapsed Cervical Disc, mri of a c6 to c7 cervical disc herniation
MRI of a C6 to C7 cervical disc herniation. Image by Anthonp, Wikimedia Commons, CC BY-SA 3.0.
  • MRI – investigation of choice. Degenerative change near-universal over 50; findings count only when they match the examined level.
  • CT myelogram – MRI contraindicated, or bony foraminal stenosis needing definition
  • Electrodiagnostic studies – equivocal cases; distinguishes radiculopathy from peripheral entrapment or plexopathy
  • Plain radiographs including obliques – alignment, instability, foraminal narrowing

Treatment

Non-operative

  • First line for all patients without myelopathy or progressive motor deficit
  • Relative rest, analgesia, short course NSAID
  • Structured physiotherapy including traction and manual therapy
  • Short reducing course of oral corticosteroid
  • Transforaminal or interlaminar epidural steroid injection for persistent radicular pain; recognised risks at cervical level

Indications for Surgery

  • Progressive or significant motor weakness
  • Radicular pain failing 6–12 weeks of appropriate non-operative treatment
  • Any evidence of myelopathy

Operative Options

  • ACDF – standard; addresses soft disc and uncovertebral osteophyte, corrects alignment. Costs the motion segment; adjacent segment degeneration.
  • Cervical disc arthroplasty – younger patient, soft disc, preserved motion, no significant facet arthrosis or instability
  • Posterior foraminotomy, open or endoscopic – motion preserving; posterolateral soft disc or foraminal stenosis. Does not address central disease or kyphosis.

Outcome

  • Relief of arm pain more reliable than relief of neck pain. State this at consent.

References

  1. Woods BI, Hilibrand AS. Cervical radiculopathy: epidemiology, etiology, diagnosis, and treatment. J Spinal Disord Tech 2015. PubMed 25985461
  2. Cervical spine radiculopathy epidemiology: a systematic review. Musculoskeletal Care 2020. PubMed 32710604
  3. Nonoperative management of cervical radiculopathy. Am Fam Physician 2016. PubMed 27175952
  4. The course and prognostic factors of symptomatic cervical disc herniation with radiculopathy. Spine J 2014. PubMed 24614255
  5. Neurological examination for cervical radiculopathy: a scoping review. BMC Musculoskelet Disord 2025. PubMed 40188056
  6. Musculoskeletal mimics of cervical radiculopathy. Muscle Nerve 2022. PubMed 35466429

Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 10 October 2026.