Cervical Radiculopathy
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Direct answer
Cervical radiculopathy is dysfunction of a cervical nerve root, most often from a disc herniation or foraminal narrowing by spondylosis. It produces arm pain, a dermatomal sensory change and a myotomal weakness that matches the level of the root. The C7 root is the commonest one affected, and most patients improve with conservative care over several weeks before surgery is considered.
What you must remember
- Commonest root: C7, because the C6-7 disc is the most frequently herniated cervical level.
- Root map: C5 gives shoulder abduction and biceps weakness; C6 gives wrist extension and thumb sensation; C7 gives elbow extension and middle finger sensation; C8 gives finger flexion with ulnar sensation.
- Reflex clues: a reduced biceps reflex points to C5 or C6, a reduced brachioradialis reflex to C6, and a reduced triceps reflex to C7.
- Spurling test: neck extension, side flexion to the symptomatic side and axial loading reproduce the radicular arm pain; it is specific but insensitive.
- Distraction test: relief of arm pain when the examiner lifts the head supports foraminal compression.
- Investigation of choice: MRI shows the compressing disc or osteophyte at its level, while nerve conduction studies separate radiculopathy from peripheral entrapment.
- Surgical indications: progressive motor deficit, myelopathic signs or pain that persists after about six weeks of conservative care.
A right-arm pain assessment, step by step
A 48-year-old clerk has right arm pain running to the thumb for three weeks. The stepwise approach localises the root first, then decides whether the problem needs imaging, referral or surgery.
- Localise the root: match the sensory loss to a dermatome and the weakness to a myotome. Thumb numbness with weak wrist extension points to C6.
- Confirm with reflexes: a diminished brachioradialis reflex supports C6, and a diminished triceps reflex supports C7.
- Provoke the pain: perform the Spurling and distraction tests. A positive result supports a foraminal source, but a negative one does not exclude it.
- Image the level: MRI of the cervical spine shows the lesion at the affected level. Plain films show alignment and foraminal narrowing only.
- Separate the mimics: carpal tunnel syndrome, thoracic outlet syndrome and brachial plexus lesions can imitate radiculopathy. Nerve conduction studies differentiate them.
- Start conservative care: NSAIDs, short-term analgesia, physiotherapy and brief soft-collar use. Most patients improve within weeks.
- Escalate on failure: progressive weakness, myelopathic signs or persistent pain beyond roughly six weeks lead to anterior cervical discectomy and fusion or posterior foraminotomy.
Where the exam tries to catch you
Examiners test whether you can localise the root before you reach for an operation.
- Trap: choosing surgery for any arm pain. Correct: most patients recover with conservative care, and surgery is reserved for progressive deficit, myelopathy or failure after about six weeks.
- Trap: treating the Spurling test as a gold standard. Correct: it is specific but insensitive, so a negative result does not rule out radiculopathy.
- Trap: reading radicular signs as cord compression. Correct: myelopathy needs upper motor neuron signs such as hyperreflexia, Hoffmann sign or clonus, and needs MRI of the cord.
Frequently asked questions
Which cervical root is most commonly affected in radiculopathy?
C7 is the commonest root affected in cervical radiculopathy, because the C6-7 disc is the most frequently herniated cervical level. Triceps weakness with a diminished triceps reflex is therefore the classic examination picture of C7 radiculopathy.
What does a positive Spurling test indicate in cervical radiculopathy?
A positive Spurling test reproduces the patient's arm pain when the neck is extended, laterally flexed to the symptomatic side and loaded axially. It suggests foraminal narrowing compressing the cervical root, but a negative test does not exclude cervical radiculopathy.
How does cervical radiculopathy differ from carpal tunnel syndrome?
Cervical radiculopathy follows a dermatome extending up the arm, with reflex and myotomal changes at the root level. Carpal tunnel syndrome gives median nerve sensory loss in the thumb, index, middle and radial half of the ring finger, sparing the thenar skin, with thenar weakness, and nerve conduction studies distinguish the two.
When should surgery be considered for cervical radiculopathy?
Surgery is considered in cervical radiculopathy for progressive motor weakness, myelopathic signs or pain that persists despite roughly six weeks of conservative management. Anterior cervical discectomy with fusion or posterior foraminotomy are the commonly chosen procedures.
Which investigation is most useful in cervical radiculopathy?
MRI is the most useful investigation in cervical radiculopathy, because it shows the disc, osteophyte or foraminal lesion compressing the root at its level. Electromyography and nerve conduction studies help confirm the root level and exclude peripheral neuropathy.