Neck pain - cervical radiculopathy
Exam Tips
- In OSCEs, map pain/sensory change to a single dermatome and confirm with matching myotome/reflex changes (C6 thumb/biceps-supinator, C7 middle finger/triceps, C8 little finger/finger flexion).
- Use test clusters rather than a single maneuver: positive Spurling plus traction/arm squeeze increases diagnostic confidence; negative ULNT cluster helps exclude.
- Do not perform Spurling if possible cervical instability/serious pathology is suspected (for example trauma, infection, malignancy, inflammatory destructive disease).
- Always screen for myelopathy red flags (gait change, hyperreflexia, Babinski, clumsy hands, bladder/bowel symptoms) and escalate urgently.
- Image reference for revision: see a cervical dermatome/myotome map figure in your neuroanatomy text (commonly C5-T1 upper-limb chart) and a sagittal MRI foraminal stenosis example in spinal surgery chapters.
Definition
Cervical radiculopathy is a clinical syndrome caused by dysfunction of one or more cervical nerve roots, producing neck pain with radiating arm pain in a dermatomal pattern. It commonly coexists with sensory disturbance (for example numbness or paraesthesia), and may include motor or reflex deficits when root conduction is impaired by compression or inflammatory irritation.
Pathophysiology
Most cases arise from cervical spondylotic change (disc height loss, osteophytes at uncovertebral/facet joints, and foraminal narrowing) or disc herniation, classically at C6-7 or C5-6, which affects C7 and C6 roots respectively. Mechanical compression plus local inflammatory mediators (for example cytokine-driven neuritis) cause intraneural oedema, ischaemia, and impaired saltatory conduction, leading to neuropathic radicular pain and possible weakness/reflex change. Symptoms can occur even without clear structural compression on imaging, supporting a combined mechanical-inflammatory mechanism.
Risk Factors
- Middle age (peak around 50-54 years)
- Male sex
- White ethnicity (epidemiological association)
- Smoking
- Occupations with heavy lifting or vibrating equipment
- Sports or activities loading the cervical spine
- Previous neck trauma or spinal nerve injury
- History of lumbar radiculopathy
Clinical Features
Symptoms
- Unilateral neck pain radiating to shoulder/arm in a dermatomal distribution (can be bilateral)
- Neuropathic arm pain (shooting, burning, electric-shock quality), sometimes waking the patient at night
- Paraesthesia, numbness, hyperaesthesia (sensory symptoms are more common than motor symptoms)
- Myotomal weakness (for example reduced elbow extension in C7 involvement)
- Less typical presentations: chest/anterior breast pain, temporal or retro-orbital pain from upper cervical referral
Signs
- Reduced cervical range of movement; pain reproduced on extension/ipsilateral rotation
- Positive Spurling test reproducing typical radicular arm pain
- Positive arm squeeze test (mid-arm compression pain at least 3/10 higher than comparator sites)
- Dermatomal sensory loss, myotomal weakness, and reduced deep tendon reflexes (for example triceps reflex in C7)
- Antalgic posture with head held flexed or tilted away from painful side
- Red flags for alternative serious disease: fever/weight loss/night sweats, severe unremitting night pain, myelopathic signs (hyperreflexia, Babinski, clumsy hands, gait disturbance, bladder/bowel dysfunction)
Investigations
Management
Lifestyle Modifications
- Reassure that prognosis is usually good; encourage early return to usual activity and avoidance of prolonged immobilization
- Short-term physiotherapy/exercise therapy focusing on cervical mobility, posture, and scapular stabilizers
- Ergonomic modification at work (reduce heavy lifting/vibration exposure), smoking cessation, and sleep-position advice
- Urgent same-day referral if red flags (myelopathy, infection, malignancy suspicion, significant or progressive neurological deficit)
Pharmacological Treatment
Simple analgesia
- Paracetamol 1 g orally up to 4 times daily (max 4 g/day)
First-line for pain if no contraindication; reduce maximum dose in low body weight, frailty, or liver impairment.
NSAIDs (if inflammatory/mechanical pain prominent)
- Ibuprofen 400 mg orally three times daily
- Naproxen 250-500 mg orally twice daily
Use lowest effective dose for shortest duration; co-prescribe gastroprotection (for example omeprazole 20 mg once daily) if GI risk. Avoid/caution in CKD, heart failure, peptic ulcer disease, anticoagulation, pregnancy (especially 3rd trimester), and uncontrolled hypertension.
Neuropathic pain agents (when radicular neuropathic pain persists)
- Amitriptyline 10 mg at night, titrate gradually (commonly 25-75 mg at night as tolerated)
- Gabapentin 300 mg at night then titrate (for example to 300 mg three times daily, up to max 3.6 g/day in divided doses)
- Pregabalin 75 mg twice daily, titrate to 150 mg twice daily then up to 300 mg twice daily if needed
Adjust gabapentinoids for renal function; warn about sedation, dizziness, falls risk, dependence/misuse potential, and driving impairment. Amitriptyline causes anticholinergic effects and can prolong QT interval; avoid in significant recent MI/arrhythmia risk and use caution in older adults.
Opioids (short rescue only if severe acute pain)
- Codeine 30-60 mg every 4-6 hours as required (max 240 mg/day)
Use brief courses only; discuss constipation, sedation, nausea, dependence risk, and impaired driving; avoid combination with other CNS depressants where possible.
Surgical / Interventional
- Consider spinal surgical referral for persistent disabling radicular pain despite adequate conservative treatment (typically >= 6-12 weeks) or progressive objective neurological deficit
- Typical procedures: anterior cervical discectomy and fusion (ACDF), cervical disc arthroplasty in selected patients, or posterior cervical foraminotomy depending on pathology and level
Complications
- Persistent motor, sensory, or reflex deficit due to incomplete neurological recovery
- Chronic neuropathic pain with reduced function and impaired activities of daily living
- Work disability and socioeconomic impact
- Comorbid depression/anxiety in chronic cases
- Progression to cervical myelopathy if cord compression is present (less common but serious)
Prognosis
Overall prognosis is favorable: most patients improve with non-operative treatment, and around 88% improve within about 4 weeks. Recovery may be slower in those with severe baseline pain, persistent neurological deficits, smoking exposure, or ongoing occupational cervical strain.
Sources & References
✅NICE Guidelines(1)
- Neck pain - cervical radiculopathy[overview]