Anatomy & Background
The neck or cervical spine is composed of seven vertebral levels C1-C7. In the spine, there are areas where the intervertebral disc and facet joints, join two cervical vertebral bodies. Where this occurs, it forms two canals on either side of the spine, called intervertebral foramina. At each level, the cervical spinal nerves exit the spinal cord through the intervertebral foramen. The spinal nerves are the electrical wires of the body. The size or diameter of the spinal foramina varies from person to person. Any compromise or encroachment of the canal may put pressure on the exiting nerve, producing symptoms varying from pain, tingling, numbness and weakness.
Nerves exiting the area of the cervical spine provide sensation and motor control to the neck, shoulder, arm, and down to the hand. Damage or interference with the conduction of these nerves can cause neurological problems including pain, weakness, abnormal sensations, numbness and changes in spinal reflexes.
“Radiculopathy” is a term used to describe chronic conditions that injure the spinal nerves by compression or irritation. This irritation or compression results in radicular – or radiating – symptoms distally from their origin, in this case the cervical neck or cervical spine.
The greatest amount of movement occurs at cervical vertebra C5-C6, but the levels C4-C5, and C6-C7 are responsible for almost as much movement. Movement produces more stress on these areas of the spine, thus the greatest amount of degeneration of the cervical spine occurs at these locations. Degeneration of these areas can be manifested in different ways, from disc degeneration to bony spur or osteophyte formation resulting in possible nerve encroachment or pinching. The most common nerves affected are at the C5, C6 and C7 levels.
Anything that encroaches on, or presses on a nerve disrupting its function can be considered a cause of radiculopathy.
- Herniated discs can place pressure on the nerve in addition to inflammation that irritates the nerve.
- Degenerative joint disease resulting in the formation of bony spurs on the facet joints can narrow the intervertebral space placing pressure on the exiting nerve.
- Trauma or muscle spasms can put pressure on the peripheral nerve, producing symptoms along that nerve’s distribution.
- Degenerative disc disease often results in wear-and-tear on the intervertebral disc, and a reduction in disc height may result in loss of space at the intervertebral foramen compressing the exiting nerve.
The symptoms experienced as a result of radiculopathy will be located along the same path that the nerve travels.
- Pain, that starts in the neck and travels to the shoulder and runs down to the arm and can as far as the hand.
- Impaired normal reflexes in the upper extremity
- Numbness or paraesthesia (tingling) may be experienced from the neck to the hand, depending on the distribution of the affected nerve.
- Muscle weakness may occur on any muscle that is innervated by the pinched nerve. Long term pressure on the nerve can produce atrophy or wasting of that particular muscle.
- Pain in the neck or radicular to the shoulder blade and arm.
- Pain and tenderness localized at the level of the involved nerve.
- Muscle spasm and changes in posture in response to the injury.
- Loss of motion like the inability to bend backward, move sideways to the effected side, or turn the head.
- A poor tolerance for sitting.
- Loss of the normal cervical curvature (lordosis).
- A desire to want to hold the arm bent at the elbow, or over the head to keep tension off the nerve.
- Pain experienced with excess activity and relief with rest.
Common Pain Patterns
- Posterior occipital, back of the head, headaches – C2
- Occipital, behind the eye, behind the ear pain – C3
- Base of neck, upper shoulder pain – C4
- Upper arm pain – C5
- Thumb, side of forearm, and index finger pain – C6
- Middle finger pain – C7
- Pain in the ring and little finger – C8
- Little finger, side of forearm pain -T1
Treating Cervical Radiculopathy
Treatment of cervical radiculopathy will depend on the severity of the condition. When treating acute back problems:
- Rest: avoid the activities that produce the pain (bending, lifting, twisting, turning or bending backwards).
- Anti-inflammatory drugs and pain medication.
- Ice in acute cases: apply ice to the neck or cervical spine to help reduce pain and associated muscle spasm. Apply it right away and then at intervals for about 20 minutes at a time. Do not apply directly to the skin.
- An exercise regiment that is designed specifically to address the cause of the symptoms associated with the radiculopathy and improve joint mobility, spinal alignment, posture, and range of motion.
- A neck collar may be necessary to reduce stress on the nerves, facet joints, muscles and cervical spine.
- Steroidal medication to reduce inflammation in moderate to severe conditions.
- Cervical nerve or epidural injections
- Physical therapy to reduce inflammation, restore joint function, improve motion, and help the return of full function.
In mild cases many patients find that rest, ice and medication may be enough to reduce the pain. Physical therapy is recommended to develop a series of postural, stretching and strengthening exercises to prevent re-occurrence of the injury. Return to activity should be gradual to prevent a return of symptoms.
Moderate to Severe Cases
If the problem persists, consult with your health care provider. Your physician will perform a thorough evaluation to determine the possible cause of your symptoms, the structures involved, the severity of the condition, and the best course of treatment.
In addition to performing a thorough examination your physician may order the following tests to make a more concise diagnosis:
- X-ray to determine if there is any joint degeneration, fractures, bony malformations, arthritis, tumors or infection present.
- MRI to determine any soft tissue involvement, including visualization of the discs, spinal cord and nerve roots.
- CT scans, which can give a cross section view of the spinal structures.
Medications to consider
Your physician may recommend several medication options individually or in combination to reduce the pain, inflammation and muscle spasms that may be associated with facet joint injuries.
- Over the counter medications for mild to moderate pain.
- If over the counter medications are not effective, your physician may prescribe stronger pain medication.
- Anti-inflammatory drugs or prescription NSAIDS (non-steroidal anti-inflammatory drugs) to reduce inflammation following acute injury.
- Muscle relaxers to reduce acute muscle spasm.
- Injections (explained below).
Severe or Non-responsive Conditions
In the case of conditions that do not respond to conservative care surgery may be needed, if you continue to experience some of the following symptoms:
- An increase in radiating or radicular pain
- Pain or nerve irritation that gets worse over time
- Weakness (muscle atrophy)
- Associated disc involvement
Injections like facet injections, nerve blocks or an epidural. These may involve the injection of corticosteroids to a specific structure to reduce local inflammation caused that is irritating the nerve as it exits the foramen.
- Caudal Epidural Injections
- Interlaminar Caudal Epidural Steroid Injections
- Transforaminal Epidural Injections
- Selective Nerve Root Blocks
Surgical Procedures to address the structures that contribute to the compression on the nerve as it exits the intervertebral foramen.
- Endoscopic Decompression
- Endoscopic Foraminotomy
- Percutaneous Decompression
- IDET Intradiscal Eletrothermal Therapy
- Selective Endoscopic Discectomy
- Spinal Cord Stimulator
- Epidural Lysis of Adhesions
- Laser Facet Arthrotomy