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Cervical Radiculopathy Workup

  • Author: Gerard A Malanga, MD; Chief Editor: Sherwin SW Ho, MD  more...
 
Updated: Oct 08, 2015
 

Imaging Studies

See the list below:

  • Plain radiography
    • Radiography of the cervical spine is usually the first diagnostic test ordered in patients who present with neck and limb symptoms, and more often than not, this study is diagnostic of cervical disc disease as the cause of the radiculopathy. The American College of Radiology recommends plain radiographs as the most appropriate initial study in all patients with chronic neck pain.[24] Lateral, anteroposterior, and oblique views should be ordered.
    • On the lateral view, look for disc-space narrowing, comparing the level above and below. Typically, the cervical disc spaces get larger from C2-C6, with C5-C6 being the widest disc space in normal necks, and C6-C7 slightly narrower. Besides narrowing, look for subchondral sclerosis and osteophyte formation.
    • On oblique views, look for foraminal stenosis at the level of the suspected radiculopathy, comparing it with the opposite foramina, if uninvolved. For example, in a patient with pain or sensory changes along the right C6 nerve distribution, look for narrowing of the right C5-C6 neural foramina as compared with the left side.
    • An open-mouth view should be ordered only to rule out injury to the atlantoaxial joint when significant acute trauma has occurred. Visualizing all 7 cervical vertebrae is very important. If C7 can not be properly seen, then a "swimmer's view" (supine oblique view, in which the patient's arm is extended over the head) or a computed tomography (CT) scan should be obtained for better visualization of the C7 and T1 segments.
    • The atlantodens interval (ADI) is the distance from the posterior aspect of the anterior C1 arch and the odontoid process. This interval should be less than 3 mm in adults and less than 4 mm in children. An increase in the ADI suggests atlantoaxial instability, such as from trauma or rheumatoid arthritis. Flexion and extension views can be helpful in assessing spinal mobility and stability in these patients.
    • The clinician should be aware of the limitations of plain radiographs. Problems with both specificity and sensitivity exist. Correlations of findings on plain radiographs and cadaver dissections have found a 67% correlation between disc-space narrowing and anatomic findings of disc degeneration. However, radiographs identified only 57% of large posterior osteophytes and only 32% of abnormalities of the apophyseal joints that were found on dissection.
  • CT scanning
    • CT scanning provides good visualization of bony elements and can be helpful in the assessment of acute fractures. It can also be helpful when C6 and C7 cannot be clearly seen on traditional lateral radiographic views. The accuracy of CT imaging of the cervical spine ranges from 72-91% in the diagnosis of disc herniation.
    • CT scanning with myelography has an accuracy approaching 96% for diagnosis of cervical disc herniation. Furthermore, the addition of contrast material allows for the visualization of the subarachnoid space and assessment of the spinal cord and nerve roots. CT scanning with myelography is preferable to plain CT for assessment and localization of spinal cord compression and any underlying atrophy. This study can also determine the functional reserve of the spinal canal in evaluating athletes with possible cervical stenosis.
    • Even with myelography, however, soft-tissue visualization with CT is inferior to that provided by magnetic resonance imaging (MRI). For that reason, MRI is replacing CT scanning for imaging of most cervical spine disorders.
  • MRI
    • MRI has become the method of choice for imaging the neck to detect significant soft-tissue pathology, such as disc herniation. The American College of Radiology recommends routine MRI as the most appropriate imaging study in patients with chronic neck pain who have neurologic signs or symptoms but normal radiographs.[24] MRI can detect ligament and disc disruption, which cannot be demonstrated by other imaging studies. The entire spinal cord, nerve roots, and axial skeleton can be visualized. This study is usually performed in the axial and sagittal planes.
    • MRI has been found to be quite useful in evaluating the amount of cerebrospinal fluid (CSF) surrounding the cord in the evaluation of patients with cervical canal stenosis, although the T2-weighted images tend to exaggerate the degree of stenosis. Cantu reviewed the use of MRI in the evaluation of athletes with possible cervical stenosis and noted that it can be quite helpful in determining the functional reserve of the spinal canal.[25]
    • Although MRI is considered the imaging method of choice for the evaluation of cervical radiculopathy, abnormalities have also been found in asymptomatic subjects. In one study, 10% of subjects younger than 40 years were noted to have disc herniations; of subjects older than 40 years, 20% had evidence of foraminal stenosis and 8% had disc protrusion or herniation.[26] Therefore, as with all imaging studies, the MRI findings must be used in conjunction with the patient's history and physical examination findings.
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Other Tests

See the list below:

  • Electromyography (EMG)
    • Electrodiagnostic studies are important in identifying physiologic abnormalities of the nerve root and in ruling out other neurologic causes for the athlete's complaints. EMG has been shown to be useful in the diagnosis of radiculopathy and has correlated well with findings on myelography and surgery.
    • EMG has 2 parts: (1) nerve conduction studies and (2) a needle-electrode examination. The nerve conduction studies are performed by placing surface electrodes over a muscle belly or sensory area and stimulating the nerve that supplies either the muscle or sensory area from fixed points along the nerve. From this, the amplitude, distal latency, and conduction velocity can be measured. The amplitude reflects the number of intact axons, whereas the distal latency and conduction velocity is more indicative of the degree of myelination.
    • The needle EMG portion of the electrodiagnostic examination involves inserting a fine-needle electrode into a muscle. Electrical activity is generated by the needle insertion into the muscle, voluntary muscle contraction, and the spontaneous firing of motor units. The activity is observed on an oscilloscope screen and quantified; an audible sound is also generated.
      • Denervated muscle produces spontaneous electrical activity while the muscle is at rest. These potentials are called fibrillations or positive sharp waves based on their characteristic shape and sound. Changes can be also seen in the configuration of the individual motor unit, as well as an increase in the firing rate of the individual motor units.
      • The timing of the EMG evaluation is important because positive sharp waves and fibrillation potentials first occur 18-21 days after the onset of a radiculopathy; therefore, it is best to delay this study until 3 weeks after an injury, to ensure that the results are as accurate as possible.
    • The primary use of EMG is to confirm nerve root dysfunction when the diagnosis is uncertain or to distinguish a cervical radiculopathy from other lesions when the physical examination findings are unclear. Although electrodiagnostic studies are very sensitive and specific, normal EMG results in a patient with signs and symptoms consistent with a cervical radiculopathy do not exclude the diagnosis of cervical radiculopathy.
  • Selective diagnostic nerve root block (SNRB)
    • In an SNRB, a small aliquot of local anesthetic is used to anesthetize the nerve root and dorsal root ganglion to determine if the patient’s pain is coming from the specific nerve root. SNRB has been shown to be useful in the diagnosis of radiculopathy, and the results correlate well with surgical findings. It is both sensitive and specific.
    • SNRB is best indicated when MRI findings are equivocal, show abnormalities at several cervical levels, and/or do not correlate with the patient’s symptoms. In these situations, a negative result on an SNRB is a superior indication of the absence of an offending lesion and may deter surgeons from operating on a patient with a suspicious, but clinically innocuous, lesion.
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Contributor Information and Disclosures
Author

Gerard A Malanga, MD Founder and Partner, New Jersey Sports Medicine, LLC and New Jersey Regenerative Institute; Director of Research, Atlantic Health; Clinical Professor, Department of Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey-New Jersey Medical School; Fellow, American College of Sports Medicine

Gerard A Malanga, MD is a member of the following medical societies: Alpha Omega Alpha, American Institute of Ultrasound in Medicine, North American Spine Society, International Spine Intervention Society, American Academy of Physical Medicine and Rehabilitation, American College of Sports Medicine

Disclosure: Received honoraria from Cephalon for speaking and teaching; Received honoraria from Endo for speaking and teaching; Received honoraria from Genzyme for speaking and teaching; Received honoraria from Prostakan for speaking and teaching; Received consulting fee from Pfizer for speaking and teaching.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Sherwin SW Ho, MD Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago Division of the Biological Sciences, The Pritzker School of Medicine

Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Arthroscopy Association of North America, Herodicus Society, American Orthopaedic Society for Sports Medicine

Disclosure: Received consulting fee from Biomet, Inc. for speaking and teaching; Received grant/research funds from Smith and Nephew for fellowship funding; Received grant/research funds from DJ Ortho for course funding; Received grant/research funds from Athletico Physical Therapy for course, research funding; Received royalty from Biomet, Inc. for consulting.

Additional Contributors

Janos P Ertl, MD Assistant Professor, Department of Orthopedic Surgery, Indiana University School of Medicine; Chief of Orthopedic Surgery, Wishard Hospital; Chief, Sports Medicine and Arthroscopy, Indiana University School of Medicine

Janos P Ertl, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, Hungarian Medical Association of America, Sierra Sacramento Valley Medical Society

Disclosure: Nothing to disclose.

Acknowledgements

Michael A Romello, MD Staff Physician, Department of Physical Medicine and Rehabilitation, Kessler Institute for Rehabilitation, University of Medicine and Dentistry of New Jersey, New Jersey Medical School

Disclosure: Nothing to disclose.

References
  1. Bogduk N, Twomey LT. Clinical Anatomy of the Lumbar Spine. 2nd ed. Edinburgh, UK: Churchill Livingstone Inc; 1991.

  2. Ellenberg MR, Honet JC, Treanor WJ. Cervical radiculopathy. Arch Phys Med Rehabil. 1994 Mar. 75(3):342-52. [Medline].

  3. Malanga GA. The diagnosis and treatment of cervical radiculopathy. Med Sci Sports Exerc. 1997 Jul. 29(7 suppl):S236-45. [Medline].

  4. Radhakrishnan K, Litchy WJ, O'Fallon WM, Kurland LT. Epidemiology of cervical radiculopathy. A population-based study from Rochester, Minnesota, 1976 through 1990. Brain. 1994 Apr. 117(pt 2):325-35. [Medline].

  5. van Gijn J, Reiners K, Toyka KV, Braakman R. Management of cervical radiculopathy. Eur Neurol. 1995. 35(6):309-20. [Medline].

  6. White AA, Panjabi MM. Clinical Biomechanics of the Spine. 2nd ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 1990. 102.

  7. Parminder SP. Management of cervical pain. Delisa JA, Gans BM, eds. Rehabilitation Medicine: Principles and Practice. 3rd ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 1988. 753.

  8. Murphey F, Simmons JC, Brunson B. Chapter 2. Ruptured cervical discs, 1939 to 1972. Clin Neurosurg. 1973. 20:9-17. [Medline].

  9. Shelerud RA, Paynter KS. Rarer causes of radiculopathy: spinal tumors, infections, and other unusual causes. Phys Med Rehabil Clin N Am. 2002 Aug. 13(3):645-96. [Medline].

  10. Soubrier M, Dubost JJ, Tournadre A, et al. Cervical radiculopathy as a manifestation of giant cell arteritis. Joint Bone Spine. 2002 May. 69(3):316-8. [Medline].

  11. Tong HC, Haig AJ, Yamakawa K. The Spurling test and cervical radiculopathy. Spine. 2002 Jan 15. 27(2):156-9. [Medline].

  12. Fryholm R. Cervical nerve root compression resulting from disc degeneration and root-sleeve fibrosis. Acta Chiru. Scand. 1951. 160(suppl):1-149.

  13. Letchuman R, Gay RE, Shelerud RA, VanOstrand LA. Are tender points associated with cervical radiculopathy?. Arch Phys Med Rehabil. 2005 Jul. 86(7):1333-7. [Medline].

  14. Nordin M, Carragee EJ, Hogg-Johnson S, et al for the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Assessment of neck pain and its associated disorders: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine. 2008 Feb 15. 33(4 suppl):S101-22. [Medline].

  15. Furusawa N, Baba H, Miyoshi N, et al. Herniation of cervical intervertebral disc: immunohistochemical examination and measurement of nitric oxide production. Spine. 2001 May 15. 26(10):1110-6. [Medline].

  16. Kang JD, Stefanovic-Racic M, McIntyre LA, Georgescu HI, Evans CH. Toward a biochemical understanding of human intervertebral disc degeneration and herniation. Contributions of nitric oxide, interleukins, prostaglandin E2, and matrix metalloproteinases. Spine. 1997 May 15. 22(10):1065-73. [Medline].

  17. Viikari-Juntura E, Porras M, Laasonen EM. Validity of clinical tests in the diagnosis of root compression in cervical disc disease. Spine. 1989 Mar. 14(3):253-7. [Medline].

  18. Anderberg L, Annertz M, Rydholm U, Brandt L, Säveland H. Selective diagnostic nerve root block for the evaluation of radicular pain in the multilevel degenerated cervical spine. Eur Spine J. 2006 Jun. 15(6):794-801. [Medline].

  19. Sasso RC, Macadaeg K, Nordmann D, Smith M. Selective nerve root injections can predict surgical outcome for lumbar and cervical radiculopathy: comparison to magnetic resonance imaging. J Spinal Disord Tech. 2005 Dec. 18(6):471-8. [Medline].

  20. Anderberg L, Annertz M, Brandt L, Säveland H. Selective diagnostic cervical nerve root block--correlation with clinical symptoms and MRI-pathology. Acta Neurochir (Wien). 2004 Jun. 146(6):559-65; discussion 565. [Medline].

  21. Huston CW, Slipman CW. Diagnostic selective nerve root blocks: indications and usefulness. Phys Med Rehabil Clin N Am. 2002 Aug. 13(3):545-65. [Medline].

  22. Chesnut RM, Abitbol JJ, Garfin SR. Surgical management of cervical radiculopathy. Indication, techniques, and results. Orthop Clin North Am. 1992 Jul. 23(3):461-74. [Medline].

  23. Johnson EW, ed. Practical Electromyography. 2nd ed. Baltimore, Md: Lippincott Williams & Wilkins; 1979. 229-45.

  24. American College of Radiology. ACR Appropriateness Criteria: chronic neck pain. National Guideline Clearinghouse. Available at http://guideline.gov/summary/summary.aspx?doc_id=8297. Accessed: March 24, 2009.

  25. Cantu RC. Cervical spine injuries in the athlete. Semin Neurol. 2000. 20(2):173-8. [Medline].

  26. Boden SD, McCowin PR, Davis DO, Dina TS, Mark AS, Wiesel S. Abnormal magnetic-resonance scans of the cervical spine in asymptomatic subjects. A prospective investigation. J Bone Joint Surg Am. 1990 Sep. 72(8):1178-84. [Medline]. [Full Text].

  27. Kuijper B, Tans JT, Beelen A, Nollet F, de Visser M. Cervical collar or physiotherapy versus wait and see policy for recent onset cervical radiculopathy: randomised trial. BMJ. 2009 Oct 7. 339:b3883. [Medline]. [Full Text].

  28. Cohen SP, Gupta A, Strassels SA, Christo PJ, Erdek MA, Griffith SR, et al. Effect of MRI on Treatment Results or Decision Making in Patients With Lumbosacral Radiculopathy Referred for Epidural Steroid Injections: A Multicenter, Randomized Controlled Trial. Arch Intern Med. 2011 Dec 12. [Medline].

  29. Friedly J, Deyo RA. Imaging and Uncertainty in the Use of Lumbar Epidural Steroid Injections: Comment on "Effect of MRI on Treatment Results or Decision Making in Patients With Lumbosacral Radiculopathy Referred for Epidural Steroid Injections". Arch Intern Med. 2011 Dec 12. [Medline].

  30. American Society of Interventional Pain Physicians. Interventional techniques: evidence-based practice guidelines in the management of chronic spinal pain. National Guideline Clearinghouse. Available at http://guideline.gov/summary/summary.aspx?doc_id=10531. Accessed: March 25, 2009.

  31. Pobiel RS, Schellhas KP, Eklund JA, Golden MJ, Johnson BA, Chopra S, et al. Selective cervical nerve root blockade: prospective study of immediate and longer term complications. AJNR Am J Neuroradiol. 2009 Mar. 30(3):507-11. [Medline].

  32. Engel A, King W, MacVicar J. The effectiveness and risks of fluoroscopically guided cervical transforaminal injections of steroids: a systematic review with comprehensive analysis of the published data. Pain Med. 2014 Mar. 15(3):386-402. [Medline].

  33. Council of Acupuncture and Oriental Medicine Associations. Acupuncture and electroacupuncture: evidence-based treatment guidelines. National Guideline Clearinghouse. Available at http://guideline.gov/summary/summary.aspx?doc_id=9343. Accessed: March 24, 2009.

  34. Van Zundert J, Patijn J, Kessels A, Lamé I, van Suijlekom H, van Kleef M. Pulsed radiofrequency adjacent to the cervical dorsal root ganglion in chronic cervical radicular pain: a double blind sham controlled randomized clinical trial. Pain. 2007 Jan. 127(1-2):173-82. [Medline].

  35. Griffiths C, Dziedzic K, Waterfield J, Sim J. Effectiveness of specific neck stabilization exercises or a general neck exercise program for chronic neck disorders: a randomized controlled trial. J Rheumatol. 2009 Feb. 36(2):390-7. [Medline].

  36. Skeppholm M, Lindgren L, Henriques T, Vavruch L, Löfgren H, Olerud C. The Discover artificial disc replacement versus fusion in cervical radiculopathy--a randomized controlled outcome trial with 2-year follow-up. Spine J. 2015 Jun 1. 15 (6):1284-94. [Medline].

  37. Ahlgren BD, Garfin SR. Cervical radiculopathy. Orthop Clin North Am. 1996 Apr. 27(2):253-63. [Medline].

  38. Carragee EJ, Hurwitz EL, Cheng I, et al, and the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Treatment of neck pain: injections and surgical interventions: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine. 2008 Feb 15. 33(4 suppl):S153-69. [Medline].

  39. Chiba S, Koge N, Oda M, et al. Synovial chondromatosis presenting with cervical radiculopathy: a case report. Spine. 2003 Oct 1. 28(19):E396-400. [Medline].

  40. Dreyfus P. The cervical spine: non-surgical care. Presented at: The Tom Landry Sports Medicine and Research Center. April 8, 1993; Dallas, Tex.

  41. Friedenberg ZB, Edeiken J, Spencer HN, Tolentino SC. Degenerative changes in the cervical spine. J Bone Joint Surg Am. 1959 Jan. 41-A(1):61-70 passim. [Medline]. [Full Text].

  42. Leblhuber F, Reisecker F, Boehm-Jurkovic H, Witzmann A, Deisenhammer E. Diagnostic value of different electrophysiologic tests in cervical disk prolapse. Neurology. 1988 Dec. 38(12):1879-81. [Medline].

  43. Lipetz JS, Malanga GA. Oral medications in the treatment of acute low back pain. Occup Med. 1998 Jan-Mar. 13(1):151-66. [Medline].

  44. Lo YL, Chan LL, Leoh T, et al. Diagnostic utility of F waves in cervical radiculopathy: electrophysiological and magnetic resonance imaging correlation. Clin Neurol Neurosurg. 2008 Jan. 110(1):58-61. [Medline].

  45. Malanga GA, Campagnolo DI. Clarification of the pronator reflex. Am J Phys Med Rehabil. 1994 Sep-Oct. 73(5):338-40. [Medline].

  46. Marks MR, Bell GR, Boumphrey FR. Cervical spine injuries and their neurologic implications. Clin Sports Med. 1990 Apr. 9(2):263-78. [Medline].

  47. Miwa M, Doita M, Takayama H, et al. An expanding cervical synovial cyst causing acute cervical radiculopathy. J Spinal Disord Tech. 2004 Aug. 17(4):331-3. [Medline].

  48. Thomas M, Bell GB. Radiologic evaluation and imaging of the spine. Nicholas JA, Hershman EB, eds. The Lower Extremity and Spine in Sports Medicine. 2nd ed. 1995. 1096-7.

  49. Wilbourn AJ, Aminoff MJ. AAEE minimonograph #32: the electrophysiologic examination in patients with radiculopathies. Muscle Nerve. 1988 Nov. 11(11):1099-114. [Medline].

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Sagittal magnetic resonance image of the cervical spine. This image reveals a C6-C7 herniated nucleus pulposus.
Axial magnetic resonance image of the cervical spine. This image reveals a C6-C7 herniated nucleus pulposus.
 
 
 
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