Cervical radiculopathy

Cervical radiculopathy (CR) is a clinical syndrome caused by compression or irritation of a cervical nerve root, resulting in pain, sensory disturbance, and/or motor deficit in a dermatomal or myotomal distribution in the upper limb. It is one of the most common causes of neck and arm pain in adults, with an estimated annual incidence of 83 per 100,000 in the general population, peaking in the fifth and sixth decades of life.

The most common aetiology is disc herniation (acute onset, typically younger patients) or spondylotic foraminal stenosis from osteophyte formation and disc height loss (chronic or subacute, older patients). The C6 and C7 nerve roots are most frequently affected, accounting for approximately 70% of all cases. Cervical radiculopathy must be distinguished from cervical myelopathy, peripheral nerve entrapments, and referred pain from shoulder or thoracic pathology.

The natural history of cervical radiculopathy is generally favourable — the majority of patients improve with conservative management within 6–12 weeks. Surgery is reserved for those with persistent disabling pain despite adequate conservative treatment, or who have progressive or severe neurological deficit. This guideline outlines the Australian primary care approach to diagnosis, investigation, and management of CR.

Cervical nerve roots exit the spinal cord through the intervertebral foramina, which are bounded anteriorly by the disc and uncovertebral joints, and posteriorly by the facet joint. Compression at any of these boundaries results in radiculopathy.

Disc herniation is the most common cause in younger patients. Posterolateral disc herniation compresses the exiting nerve root in the lateral recess or foramen. Herniated nucleus pulposus also causes a chemical inflammatory response — inflammatory cytokines (TNF-α, IL-6) directly sensitise and injure the nerve root, contributing to pain independent of mechanical compression. This explains why radicular pain can resolve without the disc reabsorbing.

Spondylotic foraminal stenosis is more common in older patients. Progressive disc height loss, end-plate osteophyte formation, uncovertebral joint hypertrophy, and facet joint enlargement combine to narrow the neuroforamen and compress the nerve root chronically. This tends to produce a more insidious onset with less inflammatory character.

The cervical dermatomes and myotomes follow predictable patterns: C5 — deltoid, lateral arm; C6 — thumb/index finger, wrist extensors, brachioradialis reflex; C7 — middle finger, triceps, triceps reflex; C8 — ring/little finger, finger flexors; T1 — medial forearm, intrinsic hand muscles. Knowledge of these patterns allows clinical localisation of the affected level.

Cervical radiculopathy classically presents with neck pain radiating into the arm in a dermatomal pattern, associated with paraesthesia, numbness, or weakness in the affected nerve root territory. The onset may be acute (disc herniation) or gradual (spondylosis).

Spurling’s test: Lateral flexion and axial compression toward the symptomatic side reproducing radicular arm pain. Sensitivity 40–60%, specificity 90–95% — highly specific when positive. Shoulder abduction relief sign: symptom relief with arm resting on head — suggests nerve root compression. Distraction test: upward traction of head reduces radicular pain — supports radiculopathy diagnosis.

Investigations confirm the clinical diagnosis, identify the level of pathology, and guide management decisions — particularly surgical planning.

Severity assessment in cervical radiculopathy guides management intensity and surgical referral decisions. Key factors are pain severity, functional impact, presence and degree of neurological deficit, and duration of symptoms.

The majority of cervical radiculopathy resolves spontaneously or with conservative management within 6–12 weeks. Treatment is directed at pain control, maintaining function, and facilitating natural recovery. Surgery is reserved for failure of conservative treatment or progressive neurological deficit.

• Reassurance: Explain the favourable natural history. The majority of disc herniations resorb over time and radicular symptoms improve. Reassurance reduces fear-avoidance and catastrophising.
• Activity modification: Maintain activity within tolerable limits. Avoid positions and movements that reproduce arm symptoms. Short-term cervical collar use (maximum 1–2 weeks) may provide temporary relief but should not be prolonged.
• Physiotherapy: Cervical mobilisation, traction (manual or mechanical), and nerve root gliding exercises have evidence for symptom relief. Neural mobilisation techniques may reduce radicular symptoms. Avoid aggressive manipulation.
• Cervical traction: Mechanical or manual intermittent traction may provide short-term relief for foraminal radiculopathy by increasing foraminal diameter and reducing nerve root compression.
• Cervical epidural corticosteroid injection: Transforaminal or interlaminar epidural steroid injection (specialist-administered) may provide short-to-medium term relief. Useful as a bridge to allow conservative treatment or to defer surgery. Refer to pain medicine or spinal surgery for injection.
• Surgery: ACDF (anterior cervical discectomy and fusion) or posterior foraminotomy. Indicated for failure of conservative management at 6–12 weeks with persistent disabling pain or progressive neurological deficit.

Pharmacotherapy targets the nociceptive and neuropathic components of cervical radiculopathy. A stepwise approach is recommended, starting with simple analgesics and adding neuropathic agents if required.

Acute cervical radiculopathy (onset <6 weeks) from disc herniation often has an excellent prognosis with appropriate early management. The priority is pain control, reassurance, and maintaining function while awaiting natural resolution.

• Confirm clinical diagnosis; exclude red flags; assess neurological deficit baseline (grip strength, reflexes, sensation).
• Commence analgesia: paracetamol first-line; add NSAIDs if inflammatory component (acute disc herniation); add pregabalin or gabapentin if neuropathic symptoms prominent.
• Short-course oral prednisolone (5–14 days) for severe acute radiculopathy unresponsive to simple analgesia — evidence modest but may reduce acute inflammatory phase.
• Physiotherapy referral: cervical mobilisation, traction, neural mobilisation; postural advice; avoid provocative positions.
• Short-term cervical collar (maximum 1–2 weeks) for severe pain — do not prolong; promotes deconditioning.
• Review at 6 weeks: if not improving or deficit is worsening, arrange MRI and consider surgical referral or pain medicine for epidural injection.
• Immediate surgical referral if: rapidly progressive weakness; significant functional loss (e.g., cannot lift arm); bilateral arm involvement.

Monitoring focuses on symptom trajectory, neurological status, and treatment response. Regular GP review is important to detect those not responding to conservative management who require escalation.

Modified management considerations for specific population groups with cervical radiculopathy.

Aboriginal and Torres Strait Islander peoples may face barriers to timely access to physiotherapy, imaging, and specialist services for cervical radiculopathy, particularly in regional and remote settings.

Stewardship principles in cervical radiculopathy focus on appropriate analgesic use, avoiding opioids, and preventing over-medicalisation of a condition with a generally favourable natural history.

• Opioids: Not recommended for cervical radiculopathy. No evidence of long-term benefit; high risk of dependence, opioid-induced hyperalgesia, and cognitive impairment. If already prescribed, initiate structured tapering plan.
• Pregabalin/gabapentin: Prescribe for neuropathic symptoms only; reassess at 3 months; avoid indefinite prescribing; taper to discontinue; PBS Authority required — document indication clearly.
• NSAIDs: Limit to 2 weeks; reassess at each prescription; monitor renal function, blood pressure; avoid in high-risk patients.
• Oral corticosteroids: Short course only (5–14 days); document clinical indication; screen for contraindications; do not repeat courses without specialist review.
• Avoid imaging for uncomplicated acute CR: MRI at 6 weeks if not improving, not at initial presentation. Incidental findings (disc bulges, degenerative changes) on early imaging may increase patient anxiety and medicalisation.
• Avoid prolonged passive treatment: Cervical collar >2 weeks, prolonged physiotherapy without active rehabilitation component, or repeat injection without improvement reassessment.

The prognosis for cervical radiculopathy is generally excellent. Most patients recover well with conservative management. Early active management, reassurance, and timely escalation for those not responding are the key follow-up priorities.

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