Radicular Pain

Definition

Pain evoked by ectopic discharges emanating from a dorsal root or its ganglion (Bogduk, 2009).

Cause

Herniation of a disc is the most common cause, with inflammation of the affected nerve (Bogduk, 2009).

Presentation

Lancinating, electric shock like pain travelling along the length of the upper limb (Bogduk, 2009).

Radiculopathy

Definition

Radiculopathy is a neurological state in which conduction is blocked along a spinal nerve or its roots. When sensory fibres are blocked, numbness is the symptom and sign. When motor fibres are blocked weakness ensues.

Diminished reflexes occur as a result of either sensory or motor block. The numbness is dermatomal in distribution and the weakness is myotomal.
Radiculopathy can occur in the absence of pain and radicular pain can occur in the absence of radiculopathy (Bogduk, 2009) therefore radiculopathy is not defined by pain. It is defined by objective neurological signs.

Cause

Usually due to compression or injury to a nerve root within the cervical spine. The axons of these nerves are either compressed directly or are rendered ischaemic by compression of their blood supply.

The 3 most common ways that compress or irritate an exiting nerve root include

• Herniation of a disc posterolaterally
• Degeneration of disc causing decreased height causing narrowing of neural foramen
• Both formation of osteophytes and hypertrophied joints, known collectively as cervical spondylosis, can contribute to narrowing of the neural foramen (Yoon, 2011)

The exact pathogenesis of cervical radiculopathy is unclear.

Prevalence

Annual incidence 83 per 100,000, most often in middle age (Eubanks, 2010; Yoon, 2011). C7 nerve root is most commonly affected followed by C6 and C5 (Yoon, 2011).

Presentation

Neck pain associated with radiculopathy is often unilateral. Pain radiation depends on the involved nerve root, although some distributional overlap may exist.

At times pain may be isolated to the shoulder girdle. Sensory or motor dysfunction may be present without significant pain (Eubanks, 2010; Yoon, 2011).

Signs of cervical radiculopathy may include postural changes (e.g. antalgic posture, torticollis fixed flexion or loss of normal lordosis) restricted and painful neck movements, muscle wasting and neurological signs (CKS NICE).

Frequent signs and symptoms include varying degrees of sensory loss, reduction of muscle power with or without evidence of muscle wasting and reduction or absence of reflexes as well as anaesthesias, dysesthesias and paraesthesias related to nerve roots without evidence of spinal cord dysfunction (Myelopathy) (NASS).

In subjects with confirmed radiculopathy (from nerve conduction studies), as many as 31% will have no weakness and as many as 45% will have no sensory abnormalities detected on physical examination. This is due to significant overlap of dermatomes which results in each segment of skin receiving sensory information from more than one spinal nerve.

Weakness requires degeneration or conduction block of a relatively large proportion of axons contributing to a particular muscle. Nearly all muscles receive innervations from more than one spinal nerve (Luigi, 2011).

Cervical x-ray and other imaging studies and investigations are not routinely required to diagnose or assess neck pain with or without radiculopathy (CKS NICE, 2015).
MRI is the diagnostic choice if further investigation is required to determine the presence of cervical radiculopathy (Yoon, 2011).

Consider conservative treatment.

Progressing as expected (up to 3 Rxs) then before discharge or onward referral.

Consider general progression and escalation advice.

Most cases seem to be self limiting and symptoms resolve over the course of weeks to months without specific treatment.  Most will improve within 3 months.

Approximately one third of patients with cervical radiculopathy who are treated non-operatively have persistent symptoms. After 3 months refer to a specialist if persistent debilitating arm pain +/- loss of power and/or sensation.

Patients should be referred to a spinal specialist if there are intractable radicular symptoms unresponsive to non-operative management over a 6 week period, motor weakness persisting for more than 6 weeks, progressive neurologic deficit at any point after symptom onset, signs or symptoms of myelopathy, instability or deformity of the spine (Eubanks, 2010).

BOGDUK, N., 2009. On the definitions and physiology of back pain, referred pain, and radicular pain. Pain, 147(1-3), pp. 17-19. (Link here - link correct as at 12/8/21)

De Luigi AJ, Fitzpatrick KF. Physical examination in radiculopathy. Phys Med Rehabil Clin N Am 2011 Feb;22(1):7-40 (link here - link correct as at 12/8/21)

EUBANKS, J.D., 2010. Cervical radiculopathy: nonoperative management of neck pain and radicular symptoms. American Family Physician, 81(1), pp. 33-40. (Link here - link correct as at 12/8/21)

NATIONAL INSTITUTE FOR HEALTH AND CARE EXCELLENCE, 2015. Neck pain - cervical radiculopathy. NICE. (Link here - link correct as at 12/8/21)

NORTH AMERICAN SPINE SOCIETY, 2010. Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders. NASS. (Link here - link correct as at 12/8/21)

YOON, S.H., 2011. Cervical radiculopathy. Physical Medicine and Rehabilitation Clinics of North America, 22(3), pp. 439-46, viii. (Link here - link correct as at 12/8/21)