Cervical Radiculopathy Clinical Presentation

Obtaining a detailed history is important to establish a diagnosis of cervical radiculopathy. The examiner should ask the following questions:

• First, what is the patient's chief complaint (eg, pain, numbness, weakness, location of symptoms)?

  • A visual analogue scale from 0-10 can be used to determine the patient's perceived level of pain.

  • Anatomic pain drawings can also be helpful in giving the physician a quick review of the patient's pain pattern.

• What activities and head positions increase or decrease symptoms?

  • This information can be helpful for both diagnosis and treatment.

• When did the injury occur, what was the mechanism of injury, and what was done at that time?

• Has the patient experienced previous episodes of similar symptoms or localized neck pain?

• Does the patient have symptoms suggestive of a cervical myelopathy, such as changes in gait, bowel or bladder dysfunction, or lower-extremity sensory changes or weakness?

• What previous treatments (prescribed or self-selected) has the patient tried? These may include:

  • The use of ice and/or heat

  • Medications (eg, acetaminophen, aspirin, nonsteroidal anti-inflammatory drugs [NSAIDs])

  • Physical therapy, traction, or manipulation

  • Injections

  • Surgical treatments.

• A social history should include the patient's sport and position, occupation, and the use of nicotine and/or alcohol.

• The typical patient with cervical radiculopathy presents with neck and arm discomfort of insidious onset. The discomfort can range from a dull ache to a severe burning pain. Typically, pain is referred to the medial border of the scapula, and the patient's chief complaint is shoulder pain. As the radiculopathy progresses, the pain radiates to the upper or lower arm and into the hand, along the sensory distribution of the nerve root that is involved.

• The older patient may have had previous episodes of neck pain or give a history of having arthritis of the cervical spine.

• Acute disc herniations and sudden narrowing of the neural foramen may also occur in injuries involving cervical extension, lateral bending, or rotation and axial loading. These patients complain of increased pain with neck positions that cause foraminal narrowing (eg, extension, lateral bending, or rotation toward the symptomatic side).

• Many patients report that they can reduce their radicular symptoms by abducting their shoulder and placing their hand behind their head. This maneuver is thought to relieve symptoms by decreasing tension at the nerve root.

• Patients may complain of sensory changes along the involved nerve root dermatome, which can include tingling, numbness, or loss of sensation.

• Some patients may complain of motor weakness. A small percentage of patients will present with weakness only, without significant pain or sensory complaints.

See the list below:

• Observation

  • The physical examination begins with observation of the patient during the history portion of the evaluation. This includes head and neck posture and movement during normal conversation. Typically, patients tilt their head away from the side of injury and hold their neck stiffly.

  • Active ROM is usually reduced, particularly in extension, rotation, and lateral bending, either toward or away from the affected nerve root.

  • Increased pain with lateral bending away from the affected side can result from increased displacement of a herniated disc onto a nerve root, whereas ipsilateral pain suggests impingement of a nerve root at the site of the neural foramen.

• Palpation

  • On palpation, tenderness is usually noted along the cervical paraspinal muscles, and it is usually more pronounced along the ipsilateral side of the affected nerve root.

  • Muscle tenderness may be present along the muscles where the symptoms are referred (eg, medial scapula, proximal arm, lateral epicondyle).

  • Associated hypertonicity or spasm on palpation in these painful muscles may occur.

  • Letchuman et al showed that cervical radiculopathy is associated with increased tender spots (both trigger and tender points) on the side of the radiculopathy, with a predilection toward the muscles innervated by the involved nerve root. ^[13] This study revealed that not only pain, but also tenderness, may be referred in radiculopathy.

• Motor

  • Manual muscle testing is an important aspect of determining an affected nerve root level on physical examination. Perform manual muscle testing to detect subtle weakness in a myotomal distribution.

  • Place the limb of the affected side in the antigravity position and apply resistance proximal to the next distal joint. For example, to test the extensor carpi ulnaris muscle, have the patient's forearm in full pronation and resting on a table or supported. The patient is then instructed to extend the hand and deviate it toward the ulnar side, while the examiner applies resistance against the dorsum of the fifth metacarpal bone. Muscle strength is then graded on a scale of 0 to 5, as follows:

    • 0 – No muscle contraction

    • 1 – Muscle contracts but is not able to move the joint/limb

    • 2 – Muscle is able to move the joint/limb, but not against gravity

    • 3 – Muscle is able to move the joint/limb against gravity, but not through a full ROM

    • 4 – Muscle is able to move the joint/limb through a full ROM, but the strength against resistance is not equal to the opposite limb (if normal)

    • 5 – Muscle strength is normal (equal to the opposite, normal limb)

  • Radiculopathies by nerve level:

    • C5 radiculopathy

    • - Weakness: shoulder abduction
    • - Test: Have patients hold their shoulders in abduction, against downward force by the examiner.

    • C6 radiculopathy

    • - Weakness: elbow flexion, wrist extension
    • - Test: Have patients lift their arm against resistance by the examiner.

    • C7 radiculopathy

    • - Weakness: elbow extension, wrist flexion
    • - Test: Have patients push with their arm away from their chest against resistance by the examiner.

    • C8 radiculopathy

    • - Weakness: thumb extension, wrist ulnar deviation
    • - Test: Have the patients hold their extended fingers together against the examiner's attempts to open the fingers.

Sensory

• The sensory examination can be quite subjective because it requires a response by the patient.

• In addition, patients with radiculopathy may have hyperesthesia to light touch and pin-prick examination.

• On sensory examination, patients with a clear-cut radiculopathy should demonstrate a decrease in or loss of sensation in a dermatomal distribution.

• Deep tendon reflexes

  • The deep tendon reflexes—or, more properly, muscle stretch reflexes, because the reflex occurs after a muscle is stretched (most commonly by tapping its distal tendon)—are helpful in the evaluation of patients who present with limb symptoms that are suggestive of a radiculopathy. The examiner must position the limb properly when obtaining these reflexes, and the patient needs to be as relaxed as possible. Any grade of reflex can be normal, so asymmetry of the reflexes is most helpful finding.

  • The biceps brachii reflex is obtained by tapping the distal tendon in the antecubital fossa. This reflex occurs at the C5-C6 level.

  • The brachioradialis reflex is obtained by tapping the radial aspect of the wrist. It is also a C5-C6 reflex

  • The triceps reflex can be obtained by tapping the distal tendon at the posterior aspect of the elbow, with the elbow relaxed at about 90° of flexion. This tests the C7-C8 nerve roots.

  • The pronator reflex can be helpful in differentiating C6 and C7 nerve root problems. If this reflex is abnormal in conjunction with an abnormal triceps reflex, then the level of involvement is more likely to be C7. The pronator reflex is performed by tapping the volar aspect of the distal radius with the forearm in a neutral position and the elbow flexed. This results in a stretch of the pronator teres, resulting in a reflex pronation.

  • In patients whose clinical picture raises concern about possible myelopathy, the lower-extremity reflexes and Hoffman and Babinski reflexes should also be assessed. Diffuse hyperreflexia and/or positive Hoffman and abnormal Babinski reflexes would indicate that the patient has a cervical myelopathy.

• Provocative tests

  • The foraminal compression test, or Spurling test, is probably the best test for confirming the diagnosis of cervical radiculopathy. It is performed by positioning the patient with the neck extended and the head rotated, and then applying downward pressure on the head. The test is considered positive if pain radiates into the limb ipsilateral to the side to which the head is rotated. The Spurling test has been found to be very specific (93%), but not sensitive (30%), in diagnosing acute radiculopathy. ^[11] Therefore, it is not useful as a screening test, but it is clinically useful in helping to confirm cervical radiculopathy. ^[14]

  • Manual cervical distraction can be used as a physical examination test. With the patient in a supine position, gentle manual distraction often greatly reduces the neck and limb symptoms in patients with radiculopathy.

  • Lhermitte sign is an electric shock-like sensation radiating down the spine, and in some patients into the extremities, elicited by flexion of the neck. This sign has been found in patients with cervical cord involvement or cervical spondylosis, and also in patients with tumor and multiple sclerosis (MS); however, the Lhermitte sign should be negative in those with cervical radiculopathy. Manual distraction may reduce the neck and limb symptoms in patients with cervical radiculopathy.

Little is known about the natural history of cervical radiculopathy. The pathogenesis of radiculopathy involves an inflammatory process initiated by nerve root compression. Evidence exists that inflammatory mediators, including nitric oxide, prostaglandin E2, interleukin-6, and matrix metalloproteinases, are released by herniated intervertebral discs. ^{[15, 16]} This results in nerve root swelling. The compression may be from a disc herniation, degenerative changes about the neural foramen, or a combination of the 2.

A study in patients with cervical disc disease found that compression of a nerve root produced limb pain, whereas pressure on the disc produced pain in the neck and medial border of the scapula. ^[17] Results from intradiscal injection and electrical stimulation of the disc have also suggested that neck pain is referred by a damaged outer annulus. ^{[18, 19, 20, 21, 22, 23]} Muscle spasms of the neck have also been found after electrical stimulation of the disc.