A Patient's Guide to Cervical Radiculopathy
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Degeneration of the cervical spine can result in several different conditions that cause problems. These are usually divided between problems that come from mechanical problems in the neck and problems which come from nerves being irritated or pinched. A cervical radiculopathy is a problem that results when a nerve in the neck is irritated as it leaves the spinal canal. This condition usually occurs when a nerve root is being pinched by a herniated disc or a bone spur.
The purpose of this information is to help you understand:
- The anatomy of the cervical radiculopathy
- The signs and symptoms of cervical radiculopathy
- How the condition is diagnosed
- The treatments available for treatment of the condition
In order to understand your symptoms and treatment choices, you should start with some understanding of the general anatomy of your neck. This includes becoming familiar with the various parts that make up the neck and how these parts work together.
Please review the document, entitled:
Cervical Radiculopathy ("Pinched Nerve")
When a nerve root leaves the spinal cord and the cervical spine it travels down into the arm. Along the way each nerve supplies sensation (feeling) to a part of the skin of the shoulder and arm. It also supplies electrical signals to certain muscles to move part of the arm or hand. When a nerve is irritated or pinched -- by either a bone spur or a part of the intervertebral disc -- it causes problems in the nerve and the nerve does not work quite right. This shows up as weakness in the muscles the nerve goes to, numbness in the skin that the nerve goes to and pain where the nerve travels. In the neck, this condition is called cervical radiculopathy. Let's look at the different causes of cervical radiculopathy.
Pinched nerve from a herniated disc
Bending the neck forward and backward, and twisting left and right, places many kinds of pressure on the vertebrae and disc. The disc responds to the pressure from the vertebrae by acting as a shock absorber. Bending the neck forward compresses the disc between the vertebrae. This increased pressure on the disc may cause the disc to bulge toward the spinal canal and the nerve roots.
Injury to the disc may occur when neck motion puts too much pressure on the disc. One of the most painful injuries that can occur is a herniated disc. In this injury, the tear in the annulus portion of the intervertebral disc is so bad that part of the nucleus pulposus squeezes out of the center of the disc. The annulus can tear or rupture anywhere around the disc. If it tears on the side next to the spinal canal, when the nucleus pulposus squeezes out, it can press against the spinal nerves. Pressure against the nerve root from a herniated disc can cause pain, numbness, and weakness along the nerve. There is also evidence that the chemicals released from the ruptured disc may irritate the nerve root, leading to some of the symptoms of a herniated disc -- especially pain.
Herniated discs are more common in early middle-aged adults. This condition may occur when too much force is exerted on an otherwise healthy intervertebral disc. An example would be a car accident where your head hit the windshield. The force on the neck is simply too much for even a healthy disc to absorb and injury is the result. A herniated disc may also occur in a disc that has been weakened by the degenerative process. Once weakened, less force is needed to cause the disc to tear or rupture. However, not everyone with a ruptured disc has degenerative disc disease. Likewise, not everyone with degenerative disc disease will suffer a ruptured disc.
Pinched nerve from degeneration and bone spurs
In middle aged and older people, the degenerative disc disease can cause bone spurs to form around the nerve roots. This usually occurs inside the foramen -- the opening in the cervical spine where the nerve root leaves the spine to travel into the arm. If these bone spurs get big enough they may begin to rub on the nerve root and irritate the nerve root. This causes the same symptoms as a herniated disc. The irritation causes pain to run down the arm, numbness to occur in the areas the nerve provides sensation to and weakness in the muscles that the nerve supplies.
A cervical radiculopathy causes symptoms that radiate out away from the neck. What this means is that although the problem is in the spine, the symptoms may be felt in the shoulder, the arm, or the hand. The symptoms will be felt in the area where the nerve that is irritated travels. By looking at where the symptoms are, the spine specialist can usually tell which nerve is involved. The symptoms include pain, numbness and weakness. The reflexes in the upper arm can be affected.
When you are suffering from a cervical radiculopathy, there is usually also neck pain and headaches in the back of your head. These are sometimes referred to as occipital headaches because the area just about the back of the neck is called the "occiput."
Finding the cause of neck pain begins with a complete history and physical examination. After the history and physical examination, your doctor will have a good idea of the cause of your pain. To make sure of the exact cause of your neck pain, your doctor can use several diagnostic tests. These tests are used to find the cause of your pain -- not make your pain better. Regular X-rays, taken in the doctor's office, are usually a first step in looking into any neck problem and will help determine if more tests will be needed.
A "complete history" is usually two parts. One part is written; a form that you fill out while you wait to see the doctor. While you fill out the form, take time to think about everything you can remember that relates to your neck pain and write it down. The more you can tell him, the faster he can diagnose the cause and help relieve your pain. The second part of your history will be answering questions. Your doctor will ask you to describe when your neck pain began and the type of pain you are having.
For example, he may ask:
- When did the pain first begin?
- Have you increased your activity level?
- Have you had an injury, or surgery, to your neck at any time?
- Does the pain go down into your arms or legs?
- What causes your neck to hurt more or less?
- Have you had any problems with your bowels or bladder?
Once most of the information is gathered, your doctor will give you a thorough physical exam. During the exam your doctor will look at your neck to find out how well your neck is functioning. This includes:
- How well you can bend your neck and roll your head in all directions
- How well you can twist your neck
- If there is tenderness around the neck
- If there are muscle spasms around the neck and shoulders
Tests that examine the nerves that leave the spine is also important. This includes:
- Testing for numbness in the arms and hands
- Testing the reflexes
- Testing the strength of the muscles in the arms, hands, and legs
- Testing for signs of nerve irritation
X-rays show the bones of the cervical spine. Most of the soft tissue structures of the spine, such as the nerves, discs, and muscles, do not show up on X-ray. X-rays can show problems that affect the bones, such as infection, fractures, or tumors of the bones. X-rays may also give some idea of how much degeneration has occurred in the spine. X-rays alone will not show a herniated disc. The X-rays will be useful in showing how much degeneration and arthritis are affecting the neck. Narrowing of the disc space between each vertebra and bone spurs do show up on X-rays.
Magnetic Resonance Imaging (MRI)
The MRI is the most commonly used test to evaluate the spine because it can show abnormal areas of the soft tissues around the spine. The MRI is better than X-ray because in addition to the bones, it can also show pictures of the nerves and discs. The MRI is done to find tumors, herniated discs, or other soft-tissue disorders. The MRI is painless and lasts about 90 minutes. During the MRI, very detailed computer images of sections of the spine are taken. Unlike most other tests, which use X-rays, the MRI uses magnetic fields and radio waves to see the structures of the neck. Pictures can also be taken in a cross section view. The MRI allows the doctor to clearly see the nerves and discs without using special dyes or needles. In many cases, the MRI scan is the only special test that needs to be done to find what is causing your neck pain.
Before the MRI, you will be asked to remove any metal objects, such as jewelry. You will also be asked if you have metal implants such as a pacemaker or joint replacement. Because of the strong magnetic field, people with certain types of metal implants cannot undergo MRI.
The MRI scanner is a very large machine with a tunnel-like area in the center. While you lay on a table, the table slides into the tunnel of the scanner. Once in position, you will be asked to remain very still for the rest of the test. During the test you will hear the clicking and thumping noises as the scanner moves. While the scanner is taking pictures, the technician can see the pictures on a monitor and record them.
Treatment for any spine condition should include two main goals:
- Relieve pain
- Reduce the risk of re-injury
The treatment of neck pain can range from the reassurance that nothing is wrong to very delicate surgery. Treatment is always based on the individual and his symptoms. In general, treatment for neck pain falls into two broad categories: conservative treatment, meaning things you can do short of surgery, and surgical treatment.
Medications are commonly used to control pain, inflammation, muscle spasm, and sleep disturbance.
Some general tips about treatment with medicines:
- Medicine should be used wisely! Take all medications exactly as prescribed by your doctor and report any side effects to him.
- Some pain medicines are highly addictive!
- No pain medicine will control chronic pain if used over a long period of time.
- No medicine will cure neck pain of degenerative origin.
Mild pain medications can reduce inflammation and pain when taken properly. Medications will not stop degeneration, but they will help with pain control.
For a more detailed description of the use of pain medications in back and neck pain, please refer to the document entitled:
A cervical collar is often used to provide support and limit motion while an injured neck is healing. It also helps keep the normal alignment. Cervical collars can be soft (made of foam) or hard (made of metal or plastic). Because these collars can restrict the movement of your head, you may need help eating and with other activities. The skin under the collar needs to be checked every day to prevent blisters or sores.
A special pillow may help your pain at night and allow you to sleep better. These cervical pillows are specially designed to place the right amount of curvature in the neck while you sleep and decrease the amount of irritation on the nerve roots. The pillows can be purchased from drug stores and from your therapist.
Epidural Steroid Injection (Nerve Block)
If other treatments do not relieve your back pain, you may be given an epidural steroid injection, or a cervical nerve block. An epidural steroid injection places a small amount of cortisone into the bony spinal canal. Cortisone is a very strong anti-inflammatory medicine that may control the inflammation surrounding the nerves and may ease the pain caused by irritated nerve roots. The epidural steroid injection is not always successful. This injection is often used when other conservative measures do not work, or in an effort to postpone surgery.
In some cases, the cervical radiculopathy will not improve with non surgical care. In these cases your surgeon may recommend surgery to treat your cervical radiculopathy. Your surgeon may also recommend surgery if you begin to show signs of:
- Unbearable pain
- Increasing weakness
- Increasing numbness
- Muscle wasting
- The problem begins to affect the legs also
One of the most common operations used to treat a cervical radiculopathy caused by pressure from bone spurs and a herniated disc is the Anterior Cervical Fusion.
For a complete description of the procedure to remove the disc and perform a fusion for neck pain, you may wish to review the document entitled:
After surgery you will probably be placed in some type of brace while healing occurs. Following an anterior cervical fusion it is not unusual to wear a brace for 6 to 12 weeks while the fusion occurs. For a complete understanding of different types of spine braces and to understand what types of braces are used, you may wish to review the document, entitled:
Whether you have surgery or not, your doctor may have a physical therapist work on an exercise program developed just for you. The physical therapist will teach you ways to prevent further injury to your neck. Many problems in the cervical spine can be improved greatly with a good exercise program and good education on neck mechanics.
For a complete description of the rehabilitation of neck pain, you may wish to review the document entitled:
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