Summary

Cervical Radiculopathy is a neurological condition caused by compression of a nerve root in the cervical spine, typically due to Disc Herniation (soft) or Spondylotic Osteophytes (hard). The C7 root (C6/7 level) is most commonly affected (60%). The hallmark is Brachialgia—shooting pain from the neck into the arm, often relieved by placing the hand on the head (Shoulder Abduction Relief Sign). It must be distinguished from Cervical Myelopathy (Cord compression), which is a surgical priority. 90% of radiculopathy cases resolve with conservative care. Surgery (ACDF or Foraminotomy) is reserved for intractable pain or progressive weakness. [1,2,3]

Key Facts

• Most Common Level: C6/C7 (compressing C7 root) > C5/C6 (compressing C6 root).
• Safety vs Danger:
  • Radiculopathy: Painful, LMN signs, Usually safe to watch.
  • Myelopathy: Clumsy, UMN signs (Hyperreflexia/Hoffman's), Gait ataxia. Surgical Emergency.
• Root Numbering: In the Cervical spine, roots exit above the pedicle (e.g., C6 root exits at C5/6). (Unlike lumbar where they exit below).

Clinical Pearls

"The Hand on Head Sign": If a patient walks in with their hand resting on top of their head (Bakody's Sign), it is Cervical Radiculopathy. This position reduces tension on the nerve root.

"Look at the hands": Wasting of the intrinsic muscles (guttering) is a late sign of neural compromise (T1/C8).

"Don't miss the Pancoast": Apical lung tumours can compress the lower brachial plexus (C8/T1). Always ask about smoking/weight loss.

1. Provocative Tests

• Spurling's Test:
  • Extension + Lateral Flexion (to affected side) + Axial Compression.
  • Positive: Radiating arm pain. (High Specificity 95%).
  • Mechanism: Narrows the foramen further.
• Distraction Test:
  • Examiner lifts the patient's head (Traction).
  • Positive: Relief of arm pain.
  • Mechanism: Opens the foramen.
• Shoulder Abduction Test (Bakody's):
  • Patient puts hand on head.
  • Positive: Relief of pain.

2. Myelopathy Screen (Mandatory)

• Hoffman's Sign: Flick the middle finger nail. Positive if thumb/index flex. (UMN sign).
• Gait: Tandem walk.
• Hyperreflexia: In legs (Clonus).

                 NECK & ARM PAIN
                        ↓
             IS THERE MYELOPATHY?
           (Hoffman's / Unsteady Gait)
           ┌────────────┴─────────────┐
          YES                        NO
           ↓                          ↓
     URGENT MRI           CONSERVATIVE CARE (6 weeks)
    (Cord Risk)          (NSAIDs + Physio + Rest)
           ↓                          ↓
        SURGERY            RESOLVED? ─┬─> YES (Discharge)
    (Decompression)                   ↓
                                     NO
                                      ↓
                                     MRI
                                      ↓
                         PERSISTENT RADICULOPATHY
                         ┌────────────┴─────────────┐
                     INJECTION                  SURGERY
               (Root Block / Epidural)     (ACDF / Foraminotomy)

The Natural History

• 90% of radiculopathy resolves spontaneously in 6-12 weeks.
• Mechanism: The herniated fragment resorbs.

Treatment

1. Analgesia: NSAIDs (careful with stomach), Neuropathic agents (Amitriptyline).
2. Physiotherapy:
   • Deep Neck Flexor strengthening.
   • Posture correction (Chin tucks).
   • Traction (sometimes helpful).
3. Lifestyle: Ergonomic desk setup. Avoid flexion (looking down at phone - "Text Neck").

Nerve Root Block (Transforaminal)

• Target: The specific nerve root in the foramen.
• Guidance: CT or Fluoroscopy.
• Goal: Diagnostic (confirms level) and Therapeutic (steroid effect).
• Risk: Rare but disastrous risk of spinal cord infarction if vertebral artery injected. (Use non-particulate steroid).

Surgery: ACDF (Anterior Cervical Discectomy and Fusion)

• The Gold Standard.
• Approach: Anterior neck (via natural skin crease). Moves trachea/oesophagus aside.
• Technique: Remove the whole disc. Put a "Cage" (spacer) filled with bone graft in the space. Usually a plate is added.
• Outcome: 95% success for arm pain.
• Risk: Dysphagia (swallowing difficulty) - usually temporary. Hoarse voice (Recurrent Laryngeal Nerve palsy).

Surgery: Posterior Foraminotomy

• Indication: Lateral soft disc without central stenosis.
• Technique: Keyhole surgery from the back. Drill away a bit of facet joint to free the nerve.
• Pro: Preserves motion (No fusion).
• Con: Cannot address central compression.

Surgery: Disc Replacement (Arthroplasty)

• Concept: Replace disc with a moving ball-and-socket joint.
• Goal: Preserve motion to protect adjacent levels (reduce Adjacent Segment Disease).
• Evidence: Similar outcomes to ACDF. Best for young patients (<50) with soft discs.

CARE Trial (2013)

• Compared ACDF vs Disc Replacement.
• Result: Both excellent. Disc replacement had lower rate of re-operation at adjacent levels at 7 years.

Comparison to Lumbar

• Cervical surgery generally has better outcomes (95% satisfaction) than lumbar surgery (80%).
• Recovery is faster (usually home next day).

What is trapping the nerve?

A piece of the shock-absorber disc has popped out, or a bone spur has grown. It's pinching the nerve as it leaves your neck to go down your arm.

Why does my hand hurt when the problem is in my neck?

The nerve is like a telephone wire. The problem is at the exchange (neck), but the signal rings in the handset (fingers).

Is neck surgery dangerous?

It sounds scary going through the front of the neck, but it is actually one of the safest and most successful spine operations. We slide between the windpipe and the muscle—we don't cut them.

Will I lose movement if you fuse it?

You lose a tiny amount of movement at that one level, but you likely won't notice it because your other levels compensate.

Q1: What is Spurling's Test? A: A provocative test for cervical radiculopathy. Extension and Lateral Rotation to the affected side, followed by axial compression. A positive test reproduces the radicular arm pain (Specificity 95%).

Q2: Differentiate C6 and C7 radiculopathy. A: C6: Weakness of Wrist Extension/Biceps. Numbness of Thumb/Index. Diminished Brachioradialis reflex. C7: Weakness of Triceps/Wrist Flexion. Numbness of Middle finger. Diminished Triceps reflex.

Q3: What is the most common complication of ACDF? A: Dysphagia (Difficulty swallowing). Usually transient due to retraction of the oesophagus.

Q4: Why must Myelopathy be ruled out? A: Radiculopathy is often non-surgical. Myelopathy (cord compression) is progressive and can lead to permanent spastic quadriparesis if not decompressed. Look for UMN signs.

(End of Topic)