Cervical Radiculopathy
Cervical radiculopathy refers to compression, irritation or inflammation of a cervical spinal nerve root.
Updated UKMLA guide to cervical radiculopathy based on NICE CKS, which covers causes, risk factors, symptoms, red flags, diagnosis and management.
Causes and Risk Factors
Most commonly caused by degenerative cervical spine changes, including
- Cervical disc herniation
- Spondylosis
Other rare causes include trauma and spinal instability
Risk factors:
- Peak incidence: 50-54 y/o
- White ethnicity
- Males
- Smoking
- Taking part in sports
- Occupation involving lifting heavy objects and operating vibrating equipment
- Prior lumbosacral radiculopathy, neck trauma, or spinal nerve injury
Clinical Features
| Non-specific neurological features |
For nerve root-specific findings, see below. |
| Possible other features |
|
Nerve root-specific findings:
| Affected nerve root | Sensory changes | Motor weakness | Affected reflex |
|---|---|---|---|
| C5 | Lateral shoulder and upper arm (“regimental badge” area) |
|
Biceps |
| C6 | Lateral forearm, thumb, index finger |
|
Biceps + supinator |
| C7 | Middle finger |
|
Triceps |
| C8 | Ring and little finger, medial lower forearm |
|
Reflexes are often spared |
| T1 | Medial lower and upper forearm |
|
Note: Dermatomal maps and myotomal distributions vary between sources and may differ between individual patients in clinical practice.
The findings presented above represent typical patterns that can be useful for exams and as a guide in clinical assessment.
Red Flags
| Serious underlying condition to exclude | Key red flags |
|---|---|
| Malignancy / infection / inflammation |
|
| Cervical myelopathy |
|
Other red flags:
- New symptoms <20 y/o or >55 y/o
- Altered cognitive state
- Weakness involving more than one myotome or loss of sensation involving more than one dermatome
- Headaches, facial pain, ataxia, or vertigo
- History of inflammatory arthritis (e.g. RA), cancer, tuberculosis, immunosuppression, drug abuse, AIDS
- History of violent trauma (e.g. road traffic accident) or a fall from a height or minor trauma in a person at risk of osteoporosis (especially in post–menopausal women)
- History of neck surgery
- Risk factors for osteoporosis
Assessment and Management
First, exclude red flags that may suggest a serious underlying cause. If present → refer urgently or arrange an immediate assessment.
Cervical radiculopathy is primarily a clinical diagnosis
Cervical X-rays, other imaging studies and investigations are not routinely required to diagnose neck pain with radiculopathy.
The approach largely depends on 1) symptom duration and 2) whether there are objective neurological signs.
Symptoms Present for <4-6 Weeks PLUS No Neurological Signs
Offer conservative management
- Advise that most patients with cervical radiculopathy improve regardless of treatment modality
- Encourage activity (including home exercise)
- Advise to return to a normal lifestyle (including work) ASAP
- Advise that a firm pillow may provide comfort at night (but avoid using 2 pillows as this may force the head into an unnatural position)
- Offer analgesia
- 1st line: NSAIDs, paracetamol, or codeine (based on clinical judgement)
- Consider offering neuropathic pain medications (see the Neuropathic pain article for more information)
Consider referring to physiotherapy (may include strengthening and stretching exercises, and manual therapy)
Do not recommend cervical collars; discourage their use as they restrict mobility and may prolong symptoms.
Symptoms Present for >4-6 Weeks OR Presence of Neurological Signs
Refer the patient for MRI (definitive investigation) and to consider invasive procedures
Invasive procedure options include:
- Interlaminar cervical epidural injections
- Transforaminal injections
- Spinal surgery
Consider spinal surgery when there is persistent disabling radicular pain despite 6–12 weeks of conservative management, or if there is progressive motor weakness, particularly when MRI confirms nerve root compression.