Non-Operative Treatment of Cervical Radiculopathy: A Three Part Article from the Approach of a Physiatrist, Chiropractor, and Physical Therapist

Cervical radiculopathy refers to a pinching or inflammation of a cervical nerve at its exit point in the spine, called the neuroforamen. It is caused by lesions that narrow the space in the neuroforamen, including cervical disk herniations, but more commonly occurs with cervical spondylosis.^1,2 This latter condition refers to a gradual wear and tear or age-related degenerative changes.³ Many of these changes can be diagnosed or identified on conventional X-rays and MRI’s and may include narrowing of the disc space, bulging of the contour of the disc, herniation of the disc, calcification of the disc, and vertebral margins that result in spurs. (See Figure 1.) When the spurring significantly narrows around the nerve root exit passage or foramen it is referred to as neuroforaminal stenosis. These degenerative changes can lead to constant or episodic waves of pain. The symptoms of cervical radiculopathy typically include severe neck pain with radiation of the pain to the back of shoulder blade, shoulders, arm, or hand. Numbness or weakness in the arm can also be present.

Cervical radiculopathy is a neurologic condition characterized by dysfunction of a certain spinal nerve, the roots of the nerve, or both. Cervical radiculopathy usually presents with pain in the neck or one arm, with a combination of sensory loss, loss of motor function, or reflex changes in the affected nerve-root distribution.⁴ Cervical radiculopathy can also cause headaches,⁵ head pain,⁶ and facial pain or dysfunction. Population-based data from Rochester, Minnesota, indicates that cervical radiculopathy has an annual incidence rate of 107.3 per 100,000 for men and 63.5 per 100,000 for women, with a peak at 50 to 54 years of age.⁷ The most common cause of cervical radiculopathy (70 to 75 percent of cases) is from foraminal encroachment of the spinal nerves due to a combination of factors, including decreased disc height and degenerative changes of the uncovertebral joints anteriorly and zygapophyseal joints posteriorly. Disc herniation of the nucleus pulposus is responsible for 20 to 25 percent of cases.⁸ Cervical radiculopathy can be multifactorial in etiology, with onset also initiated from zygapophyseal (facet) joint syndrome, ligament laxity or injury, tumors, infections, inflammatory mediators, and/ or trauma.

ANATOMY AND PHYSIOLOGY

The anatomy of the cervical spine consists of seven cervical vertebra, six cervical discs, eight pairs of cervical nerve roots, ligaments, muscles, and the spinal cord. Eight pairs of cervical nerve roots are formed directly from multiple tiny rootlets that originate directly from the spinal cord. These tiny rootlets coalesce immediately within the intraspinal canal and form the dorsal (sensory) and the ventral (motor) roots. These join together just before passing through the intervertebral foramen and form the spinal nerve root. On exiting the foramen, the nerve root splits into the small posterior ramus and the larger anterior ramus. In contrast to the roots, there are only seven cervical vertebra whereas the eight root exits below the seventh cervical vertebra and above the first thoracic vertebra.⁹ It is as the cervical nerve roots enter the neuroforamina that they are most susceptible to injury. The neuroforamen are bordered anteromedially by the uncovertebral joint, posterolaterally by the facet joint, superiorly by the pedicle of the vertebral body immediately above, and inferiorly by the pedicle of the vertebral body immediately below. The medial section of the foramen is derived from the intervertebral discs and the vertebral endplates. The roots originate in close proximity to the level at which they exit the intraspinal canal. Consequently, the cervical roots generally pass through the canal and in a somewhat more horizontal fashion. This arrangement causes the neuroforamen to originate more medially and the cervical root and the cervical spinal cord to be in close proximity, thereby susceptible to abnormalities of these medial structures such as osteophytes or disc herniations, leading to the symptoms of cervical radiculopathy.^10,11

A majority of patients who have cervical radiculopathy improve within 1-2 months with appropriate medical treatment, which can consist of rest, cervical immobilization, analgesics, anti-inflammatory agents, muscle relaxants, physical therapy, as well as chiropractic or osteopathic manipulation.^12-14 There are several case series reports suggesting that even patients with severe neurological deficits and severe pain can be managed quite successfully using a nonoperative approach.^15-17 Generally the patient is to refrain from repetitive movements of the neck and forceful or heavy lifting. Sometimes a soft cervical collar is prescribed to limit neck motion and provide splinting and rest in a position of comfort. Physicians will often prescribe anti-inflammatory medications or short courses of oral corticosteroid medications to provide pain relief and hopefully decrease nerve inflammation. Physical therapy is used to provide techniques such as intermittent traction and McKenzie exercises to try and decrease nerve tension by opening up the neural foraminal spaces. Chiropractors may utilize mobilization techniques such as manipulation when vertebral rotations are involved in the disease process. For those who do not respond to these conservative measures or for those whose pain is excruciating, cervical epidural steroid, periradicular steroid, or Prolotherapy injections may be given. For some, surgery will be recommended. This article will look at a variety of conservative nonoperative approaches including Prolotherapy, chiropractic, and physical therapy available to patients who are suffering from cervical radiculopathy. Some patients will need just one of these techniques, but others require some or all of the therapies to resolve their cervical radiculopathy.