Cervical radiculopathy

01OverviewDefinition, clinical context and the essential points that orientate the chapter.

A cervical root may be compressed by a posterolateral disc, uncovertebral osteophyte, facet change or loss of foraminal height. The resulting syndrome combines radiating arm pain with sensory change, weakness or altered reflexes. Because dermatomes overlap and individuals vary, localisation is probabilistic. A careful examination of several muscles, reflexes and sensory territories is more reliable than mapping pain alone.

Typical patterns are useful anchors. C5 can affect shoulder abduction and elbow flexion; C6 often affects wrist extension and sensation toward the thumb with biceps or brachioradialis reflex change. C7 commonly affects elbow extension, wrist flexion or finger extension and the middle finger, with reduced triceps reflex. C8 may affect finger flexion and the ulnar hand. T1 involvement may weaken intrinsic hand muscles. Shoulder pain, median or ulnar entrapment and brachial plexus disease can overlap, so test muscles supplied by the same root through different peripheral nerves.

The crucial safety distinction is radiculopathy versus myelopathy. Root disease produces lower-motor-neuron findings in one upper-limb pattern. Cord disease produces gait imbalance, hand clumsiness, leg stiffness, brisk reflexes, clonus, extensor plantars or pelvic-organ disturbance; segmental arm weakness can coexist. NICE NG127 lists specific myelopathic features that prevent routine non-referral after six weeks. Degenerative cervical myelopathy can deteriorate and requires a cord-focused specialist pathway, not repeated analgesic trials.

Many uncomplicated radicular episodes improve with non-operative management. Imaging is not a substitute for clinical localisation, because asymptomatic disc and foraminal change are common. When symptoms persist or deficit progresses, MRI identifies the cord, roots and foramina and guides specialist care. The ACR adult criteria rate non-contrast MRI as usually appropriate for chronic cervical pain with radiculopathy and no red flags; suspected infection or malignancy changes the protocol. NASS guidance remains the current society guideline in its catalog but was published in 2010, so its older evidence base must be stated rather than presented as new evidence.

Key points

Cervical radiculopathy causes arm pain or paraesthesia with root-pattern sensory, motor or reflex change, usually from foraminal disc or osteophyte disease; neck pain may coexist but does not localise a root.
C5 affects shoulder abduction/elbow flexion, C6 often thumb sensation and wrist extension with biceps/brachioradialis reflex change, C7 middle-finger sensation and elbow extension with triceps change, and C8 finger flexion or ulnar-hand sensation.
Always screen for myelopathy: gait disturbance, clumsy or weak hands or legs, brisk reflexes, extensor plantars and new bladder or bowel disturbance require specialist escalation under NICE NG127.
For chronic cervical pain with radiculopathy and no red flags, non-contrast cervical MRI is usually appropriate; contrast is reserved for questions such as infection, malignancy or postoperative complication.
Stable symptoms can begin with explanation, activity modification and supervised exercise while monitoring power and function. Avoid prolonged immobilisation and medication escalation without a defined benefit.
Persistent disabling pain, progressive objective weakness or concordant structural compression warrants spinal assessment; surgery is selected to decompress the responsible root, with approach determined by level, anatomy and stability.

02AetiologyUnderlying causes, associations and risk factors, with why each one matters.

Foraminal disc herniation

Soft-disc material can acutely narrow the foramen and provoke inflammatory as well as mechanical root injury.

Cervical spondylosis

Uncovertebral and facet osteophytes, disc-height loss and foraminal narrowing more often create a chronic or recurrent syndrome.

Non-degenerative root disease

Tumour, infection, inflammatory plexopathy and trauma require different imaging protocols, urgency decisions and cause-specific treatment pathways.

03PathophysiologyThe causal sequence from the underlying abnormality to symptoms and harm.

1
Root compression and inflammation
Pressure and inflammatory mediators impair root function, producing radiating pain with possible sensory, motor and reflex change.
2
Foraminal mechanics
Extension and ipsilateral rotation can further narrow an affected foramen, although provocation tests are not diagnostic alone.
3
Cord coexistence
Central canal narrowing at the same level can produce myelopathy, making lower-limb and gait examination essential.

04Clinical features and red flagsSymptoms, examination findings, patterns of presentation and time-critical warnings.

C5–C6 pattern

Assess shoulder abduction, elbow flexion, wrist extension, thumb-side sensation and biceps/brachioradialis reflexes. Shoulder pathology can mimic pain but does not usually reproduce a coherent reflex and myotomal pattern.

C7 pattern

Test elbow extension, wrist flexion and finger extension, middle-finger sensation and the triceps reflex. Pain can radiate toward the middle digit or posterior arm.

C8–T1 pattern

Assess finger flexion, finger abduction and ulnar-hand or medial-forearm sensation. Compare median and ulnar nerve distributions and look for plexus or lower-trunk signs.

Degenerative cervical myelopathyRed flag

Ask about gait, falls, loss of hand dexterity, leg stiffness and bladder or bowel change; examine lower limbs, reflexes and plantar responses. Any progressive cord pattern warrants specialist assessment.

Progressive root motor deficitRed flag

Document power in reproducible positions and distinguish pain inhibition from true weakness. Rapid or functionally important progression requires urgent spinal advice.

Peripheral and shoulder mimics

Shoulder disease is provoked by joint movement; median, ulnar or radial neuropathy follows a named peripheral nerve. Testing multiple nerve territories helps separate these from a cervical root.

Red flags requiring action

Gait disturbance, clumsy or weak hands or legs, brisk triceps or lower-limb reflexes, extensor plantar responses or new bladder or bowel dysfunction are NICE referral triggers in a person labelled with cervical radiculopathy.
Rapidly progressive motor weakness, multilevel deficit or respiratory compromise requires urgent assessment even without established long-tract signs.
Trauma, destructive bone pain, fever, immunosuppression, cancer history or unexplained weight loss raises fracture, infection or malignant compression.
Severe neck pain with thunderclap headache, Horner syndrome, cranial deficit or posterior-circulation symptoms raises vascular pathology rather than routine root compression.
Age under 20 with persistent cervical radicular symptoms is an explicit NICE reason not to leave the patient on the routine stable-adult pathway.
Bilateral hand numbness with gait change should not be labelled carpal tunnel syndrome until cervical cord disease has been assessed.

05InvestigationsWhat to request, why it matters and how to interpret it.

Investigation order

Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.

01
Full neurological examination including gait and lower limbsFirst step
Why
Localise a cervical root and, critically, detect cord involvement that changes urgency.
Interpretation and limitations
A coherent myotome, dermatome and reflex pattern supports radiculopathy. Brisk legs, extensor plantars, clonus or impaired tandem gait indicates possible myelopathy even if arm pain dominates.
02
Cervical MRI without intravenous contrast
Why
Assess discs, foramina, roots and spinal cord in chronic radiculopathy when imaging is management-changing.
Interpretation and limitations
ACR rates it usually appropriate for adult chronic cervical pain with radiculopathy and no red flags. Match the level and side to clinical findings; incidental degeneration is common.
03
Contrast-enhanced MRI
Why
Characterise suspected infection, malignancy, inflammatory disease or selected postoperative complications rather than routine degenerative radiculopathy.
Interpretation and limitations
Contrast choice follows the diagnostic question and renal/product safety. It should not be added automatically to every foraminal-disc study.
04
Cervical radiographs
Why
Assess alignment and selected bony or dynamic questions, especially when MRI is not the first required answer.
Interpretation and limitations
Radiographs do not visualise the cord or roots adequately and cannot exclude clinically important compression.
05
CT or CT myelography
Why
Define osseous foraminal anatomy or neural compression when MRI is contraindicated or degraded by metal under specialist direction.
Interpretation and limitations
CT myelography is invasive; use it only when the additional anatomical answer is necessary for treatment planning.
06
Electrodiagnostic studies
Why
Differentiate radiculopathy from peripheral nerve or plexus lesions in persistent clinically discordant cases.
Interpretation and limitations
A root lesion can be electrodiagnostically normal early or if predominantly sensory. Testing complements rather than replaces MRI or urgent myelopathy evaluation.

06Differential diagnosisRealistic alternatives and the features that help distinguish them.

Shoulder pathology

Local joint restriction, painful arc or rotator-cuff weakness may reproduce symptoms without a root reflex pattern.

Peripheral entrapment neuropathy

Median, ulnar or radial lesions follow named nerve territories and can be separated by testing muscles outside that nerve but within the suspected root.

Brachial plexopathy

Multiroot, multiperipheral-nerve abnormalities, severe pain, trauma or systemic context can indicate plexus disease rather than a single root.

Cardiac or vascular pain

Chest symptoms, exertional autonomic features, pulse difference or neurological posterior-circulation signs require urgent non-spinal cardiovascular or neurological assessment.

07ManagementImmediate care, first-line treatment, alternatives and escalation.

01Stable radiculopathy pathwayArm-predominant root symptoms without cord signsFirst stepAn adult has a stable cervical root syndrome without trauma, systemic red flags, progressive weakness or myelopathy.

1Explain the likely root syndrome, maintain tolerable activity and offer structured exercise or physiotherapy with ergonomic and functional advice; document baseline power, reflexes and gait.
2EscalationReview within a defined interval and escalate sooner for weakness or cord features; if symptoms remain disabling, obtain non-contrast cervical MRI when it will guide specialist treatment.
3Use symptom medicines cautiously and for a defined trial, considering adverse effects and avoiding prolonged collar dependence or passive treatment without functional goals.
4Refer for spinal assessment when pain remains uncontrolled or disabling, objective deficit progresses or concordant compression requires a procedural discussion.
5Choose injection or surgery only after confirming the responsible level, anatomy and risks; the surgical approach depends on anterior versus posterior disease, number of levels and stability.

02Cord-risk pathwayRadicular pain with myelopathic featuresGait disturbance, hand clumsiness, brisk reflexes, extensor plantar response or new bladder/bowel dysfunction accompanies neck or arm symptoms.

1Treat this as possible cervical cord compression and arrange urgent specialist assessment and appropriate MRI rather than continuing routine radiculopathy care.
2DefinitiveUse trauma immobilisation if relevant, document serial limb and sphincter findings, and expedite definitive decompression planning when clinically significant compression is confirmed.
3After treatment selection, monitor gait, dexterity, power and bladder or bowel function because neurological recovery may be incomplete.

03Discordant upper-limb pathwayPossible shoulder, peripheral nerve or plexus diseaseArm symptoms persist but the root examination and cervical imaging do not provide a coherent anatomical explanation.

1Repeat shoulder, cranial, peripheral nerve and multimyotomal examination and review systemic, cancer, inflammatory and vascular clues.
2AlternativeSelect electrodiagnostic testing, shoulder imaging, plexus imaging or laboratory studies only to answer the leading alternative question.
3Treat the demonstrated disorder and avoid cervical injection or surgery until the symptomatic structure and level are credibly established.

Key medicines and prescribing safety2 treatments · regimens, roles and cautions

May support sleep and movement during a conservative trial but does not reverse root compression.

Simple analgesic or oral NSAID

If used, follow the selected product and individual risk, aiming for the lowest effective exposure and a time-limited review.

For NSAIDs assess gastrointestinal, renal, hepatic and cardiovascular risk, pregnancy and interactions. Avoid allowing transient analgesia to mask progressive weakness or myelopathy.

May be considered for selected persistent neuropathic symptoms, but evidence and licensing differ by medicine and condition.

Neuropathic-pain medicine

Use only for a clear individual indication under applicable prescribing guidance, with planned benefit and harm review; no universal cervical-radiculopathy regimen is supplied here.

Sedation, falls, dependence and withdrawal may be important. Do not extrapolate NICE sciatica drug prohibitions mechanically to every cervical neuropathic condition, and do not delay structural assessment.

08ComplicationsImportant consequences, why they occur and why they matter clinically.

Persistent motor deficit

Prolonged axonal root injury may leave weakness, muscle wasting, impaired dexterity and lasting occupational or self-care limitations.

Degenerative cervical myelopathy

Unrecognised cord compression can progress to gait, hand and pelvic-organ disability with incomplete recovery after later treatment.

Chronic pain and medicine harm

Sleep loss, fear and reduced activity can coexist with adverse effects or dependence from poorly reviewed medication.

Procedural complications

Injection or surgery can cause neural, vascular, dural, infectious or swallowing/voice complications that require procedure-specific consent.

09Monitoring and follow-upTreatment response, safety checks and longer-term review.

Record arm pain, sensory change, sleep and function together with objective myotomal power and reflexes.
Repeat gait, hand dexterity, lower-limb reflexes and plantar responses; emerging myelopathy overrides the planned review interval.
Reassess shoulder and peripheral nerve mimics if imaging and examination do not agree.
Review medicine benefit, sedation, falls and dependence risk at a pre-agreed time rather than issuing indefinite repeats.
After surgery or injection, provide explicit urgent-return advice for new weakness, severe pain, fever, wound change, swallowing or breathing difficulty.

10Special situationsVariants, exceptions and circumstances that change the usual approach.

Test across peripheral nerves

Weakness in several muscles sharing a root but supplied by different named nerves supports radiculopathy over one peripheral entrapment.

Arm signs do not exclude cord disease

A patient can have root pain and segmental weakness together with lower-limb long-tract signs from the same degenerative level.

MRI protocol follows the question

Non-contrast MRI is usually appropriate for chronic uncomplicated radiculopathy; suspected tumour, infection or postoperative disease may require contrast.

Age boundary matters

NICE explicitly includes age under 20 among reasons not to leave persistent cervical radiculopathy on a routine non-referral pathway.

11Common pitfallsFrequent interpretation and management errors.

01
Examining only the painful arm and missing gait or lower-limb signs of myelopathy.
02
Equating a common cervical MRI abnormality with the symptomatic root without level and side concordance.
03
Using a normal early electrodiagnostic study to exclude a clinically important root syndrome.
04
Continuing conservative care despite progressive objective weakness or new cord features.
05
Adding contrast routinely rather than matching the MRI protocol to infection, malignancy or postoperative concerns.

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