Cervical radiculopathy: localization and management

Localize the root by its muscle, reflex and dermatome, expect most degenerative cervical radiculopathy to improve without surgery, and reserve early surgery for progressive deficit, myelopathy or instability.

1. Map root to examination. C7 supplies the triceps, triceps reflex, and posterior forearm and middle finger; C6 maps to elbow flexion, the radial forearm and thumb; C8 to thumb extension, the ulnar forearm and little finger ¹. C5 weakens the deltoid; T1 the hand intrinsics ².
2. C7 is the most common root. C7 (C6–7 disc) is most often affected, followed by C6 (C5–6) and C8 (C7–T1) ².
3. Provocative tests rule in better than out. Spurling's test, traction/neck distraction and Valsalva show low to moderate sensitivity and high specificity; the upper limb tension test is sensitive but not specific ³.
4. The natural history is favorable. NASS concludes by work-group consensus that for most patients symptoms are self-limited and resolve spontaneously over a variable time without specific treatment ⁴.
5. Know when to operate early. Progressive neurologic deficit, myelopathy, fracture or instability, and osseous lesions merit early surgical consideration; otherwise a trial of nonoperative care is typical ².
6. Transforaminal cervical steroid must be nonparticulate. Catastrophic cord and brain infarctions have been linked to particulate steroid in vertebral or radicular arteries; the FDA-convened working group favored dexamethasone ⁵. Reported major complications also include high spinal anesthesia, seizures and bleeding ².

Signs of myelopathy, progressive neurologic deficit, instability or a destructive bony lesion shift management away from a trial of observation toward early surgical evaluation ².

• Reflex loss correlated best with surgical findings (82%), ahead of motor weakness (77%) and sensory loss (65%) ².
• The largest Spurling study found 30% sensitivity and 94% specificity; the purely axial-loading variant performs worst ².
• The shoulder abduction test, which relieves symptoms by taking tension off the nerve, has 17–78% sensitivity and 75–92% specificity ².
• MRI shows soft disc herniation and myelomalacia; CT better delineates bony, "hard" disc impingement ².
• Workers' compensation claims correlated with more invasive treatment and a poorer prognosis ².
• The provocative-test review found only six eligible studies of five tests, too heterogeneous for meta-analysis ³.
• A negative upper limb tension test may help rule radiculopathy out ³.
• Most patients improve substantially within 4–6 months, generally maintained over 2–3 years, without progression to myelopathy ².

• Attributing triceps weakness to C6 ¹.
• Assuming most patients progress to myelopathy without surgery ².
• Using a negative Spurling test to exclude radiculopathy ³.
• Recommending surgery at a fixed early time point without red flags ²⁴.