Radiculopathy (Arm Pain)

Overview

Cervical radiculopathy is the term used to describe radiating nerve pain that begins in the neck region and runs down the shoulder, arm, forearm, and into the hand, and is associated with a neurologic deficit such as numbness or weakness. The term radiculitis indicates that there is only pain, without associated numbness or weakness, shooting down the arm into the hand and fingers. Although radiculopathy and radiculitis can be used to describe the above-mentioned signs and symptoms in the arms or legs, many people often used the term sciatica when referring to lower extremity and back problems.

Causes

There are numerous conditions that can cause cervical radiculopathy, but the most common is a herniated disc (herniated nucleus pulposus). When an intervertebral disc is injured and protrudes into the spinal canal, it can impinge on the spinal cord and nerves and cause pain. The pain may be in the neck or arms(s), or both. If the pain radiates into the arms(s), it is called radiculopathy. Other conditions may also cause radiculopathy, such as a bone spur (osteophyte) pinching a spinal nerve, or more rarely a tumor or infection. Conditions affecting the brachial plexus and nerves in the shoulder or the median, ulnar, and radial nerves in the arm and wrist can also cause neurologic dysfunction similar to cervical radiculopathy.

Symptoms

Radiculopathy is typically present in one arm only, but occasionally occurs in both arms. The arm and hand symptoms may manifest as a shooting electricity pain down the shoulder, arm, forearm, hand, and into specific fingers. The radicular pain may also have a component of numbness, tingling (parasthesia), and/or weakness. Patients may have difficulty turning their head because of the pain. Shoulder pain that arises from within the shoulder joint, particularly with abduction and raising the arm and shoulder generally indicates a shoulder problem such as bursitis or a rotator cuff injury. This type of pain is called referred pain, when the pain of a nearby joint causes the entire region or extremity to be painful.

Physical Findings

Since the majority of patients with cervical radiculopathy have the underlying diagnosis of a herniated disc, the physical findings are usually the same. Patients with cervical radiculopathy may have decrease cervical (neck) range-of-motion, especially rotation (looking from side to side). There may be significant weakness in one or more muscle groups and numbness in a specific dermatomal distribution. Patients with longstanding nerve compression and muscle weakness may demonstrate atrophy (decreased size) of the affected muscle(s), and this may be quite noticeable when comparing it with the opposite arm. Deep tendon reflexes may be diminished or absent for the particular spinal nerve that is affected.

Imaging Studies

An MRI of the spine is most useful to evaluate a patient with cervical radiculopathy. An MRI utilizes a powerful magnet and computer system to generate images in three dimensions of all structures, including the intervertebral disc, spinal cord and nerves, muscles, bone, and other soft tissues. Regular x-rays are most useful to evaluate fractures, instability, or arthritis changes of the spine. However, x-rays do not allow one to visualize the soft tissues of the spine such as disc, nerves, or muscles, and usually will not identify the cause of sciatica symptoms.

Laboratory Tests

There are no laboratory tests used to diagnose a herniated disc or radiculopathy. Occasionally, specific tests are ordered to rule out infection or other causes or neck pain and/or arm pain, numbness, and weakness.

Special Tests

Electromyography and nerve conduction velocity (EMG/NCV) tests are useful to determine which nerve is affected, and how severely it is damaged or irritated. The test will often clarify where a nerve is actually being compressed - whether it is a spinal nerve in the neck or a peripheral nerve in the shoulder, elbow, forearm, or wrist.

Diagnosis

The diagnosis of radiculopathy is typically made by taking a detailed patient history alone. Physical examination can further clarify the diagnosis. However, an MRI of the cervical spine will often be required to confirm the actual cause of the radicular pain. It is important for the clinician to conduct a thorough history and clinical examination prior to formulating the final diagnosis so as not to misdiagnose this condition.

Treatment Options

The natural history of a cervical herniated disc and radiculopathy is favorable, meaning that the majority of patients improve with conservative treatments and do not require surgery. Quite often, patients with cervical radiculopathy will quickly improve with a few days of rest, use of a soft cervical collar, and oral anti-inflammatory medications and pain medications. Muscle relaxant medications can also be used for severe pain and muscle spasms. Cervical epidural steroid injections and/or nerve root blocks may also be utilized for severe pain or moderate pain that is no longer responding to other conservative measures. Surgical options, such as anterior cervical discectomy and fusion or microscopic posterior cervical foraminotomy may be recommended for patients who fail conservative treatments. These surgical treatments, when indicated, demonstrate a high rate of success in relieving pain and restoring function, and often a rapid return to normal activities.

Selected Bibliography

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Chesnut RM, Abitbol JJ, Garfin SR. Surgical management of cervical radiculopathy. indication, techniques, and results. Orthop Clin North Am 1992;23:461.

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