Changes

November 2023 — reviewed. A literature search was conducted in October 2023 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of this topic. Minor structural changes have been made to the topic to align with up-to-date evidence. Short sections detailing risk factors and complications which can arise due to cervical radiculopathy have been added.

Update

Goals

To support primary healthcare professionals to: 

• Make an accurate diagnosis and assessment of cervical radiculopathy.
• Provide appropriate treatment and advice in primary care.
• Identify red flags which may indicate a serious underlying pathology.
• Refer to secondary care or other specialist services where appropriate.

Outcome measures

No outcome measures were found during the review of this topic.

Audit criteria

No audit criteria were found during the review of this topic.

QOF indicators

No QOF indicators were found during the review of this topic.

QIPP - Options for local implementation

​​​​​​Non-steroidal anti-inflammatory drugs (NSAIDs):

• Regularly review the appropriateness of NSAID prescribing, particularly in older people and/or those at higher risk of gastrointestinal (GI), cardiovascular or renal morbidity and mortality.
• Consider switching to a lower-risk NSAID or stopping treatment where appropriate.
• Consider alternatives to oral NSAIDs, such as topical NSAIDs, physiotherapy or a different analgesic, such as paracetamol or an opioid, before prescribing NSAIDs.
• When prescribing NSAIDs, choose those with the lowest cardiovascular, renal and/or GI risk, depending upon the individual person's risk factors.
• If more than one product is suitable, choose the product with the lowest acquisition cost. 
• Do not prescribe NSAIDs when contraindicated, and only prescribe NSAIDs to people at risk of renal impairment or failure when use is unavoidable.
• Use the lowest effective dose and the shortest duration of treatment necessary to control symptoms.
• Ibuprofen (1,200 mg a day or less) or naproxen (1,000 mg a day or less) are generally preferred for safety reasons.
• Co-prescribe a proton pump inhibitor (PPI) with NSAIDs for people with osteoarthritis or rheumatoid arthritis, those who are elderly, those with lower back pain, axial spondyloarthritis, psoriatic arthritis or other peripheral spondyloarthritides, and those at moderate or high risk for GI adverse effects.

[PrescQIPP, 2020]

NICE quality standards

No NICE quality standards were found during the review of this topic.

What is it?

• Radiculopathy is a neurological state in which conduction is limited or blocked along a spinal nerve or its roots — it is differentiated from radicular pain, although they commonly occur together.
  • Radicular pain is usually caused by compression of the nerve root due to cervical disc herniation or degenerative spondylotic changes, but radicular symptoms can also occur without evident compression (for example, due to inflammation of the nerve).  
• Cervical radiculopathy is the term used to describe the pain in one or both of the upper extremities, which corresponds to the dermatome of the involved cervical nerve root.
  • It often occurs alongside neck pain which is secondary to compression, or irritation of nerve roots in the cervical spine.
  • Pain can also be experienced in the shoulders, upper back and chest.

[Childress, 2016; Thoomes, 2017; BMJ, 2021; BMJ Best Practice, 2022b]

How common is it?

• The annual incidence of cervical radiculopathy in:
  • Men is 107 in 100,000.
  • Women is 64 in 100,000.
• Estimates of prevalence range from 121–580 per 100,000 people.
• It is most prevalent in people aged 50–54 years.

[Childress, 2016; Mansfield, 2020]

What causes it?

• The most common causes of cervical radiculopathy are degenerative changes, including cervical disc herniation (22% of cases) and spondylosis.
  • Osteoarthritis causes bony hypertrophy, most commonly at the facet joints or uncovertebral joints.
• Other possible causes include spinal instability and trauma. 

[Childress, 2016]

What are the risk factors for cervical radiculopathy?

• Risk factors for cervical radiculopathy include:
  • Race — people of white ethnicity may be more likely to experience cervical radiculopathy.
  • Age — cervical radiculopathy is more prevalent in middle-aged people.
  • Sex — cervical radiculopathy is more prevalent in men.
  • Lifestyle — cigarette smoking and taking part in sports that put stress on the cervical spine.
  • Medical history — prior lumbar radiculopathy, neck trauma, or spinal nerve injury.
  • Occupation — lifting heaving objects and operating vibrating equipment.

[Childress, 2016; Iyer, 2016; AAPMR, 2023] 

What is the prognosis for people with cervical radiculopathy?

• Most people with cervical radiculopathy will improve regardless of the treatment.
• Around 88% of people improve within 4 weeks with non-operative management.

[Childress, 2016; NICE, 2023]

What are the complications?

• Incomplete recovery from cervical radiculopathy can lead to motor, sensory, or reflex deficits.
• Chronic cervical radiculopathy can impair activities of daily living, and may also cause substantial socio-economic problems where the condition limits a person's ability to work.
• Depression may occur as a comorbidity in people with chronic cervical radiculopathy. If identified, depression should be managed appropriately. See the CKS topics on Depression in children and Depression for more information.

[Childress, 2016; Kuligowski, 2021; Mansfield, 2023]

How should I assess someone with suspected cervical radiculopathy?

• Take a detailed medical history and conduct a physical examination to distinguish neuropathic pain from mechanical neck pain.
  • In many cases, the affected nerve root can be identified from the medical history and physical examination.
• Ask about:
  • Signs and symptoms. 
  • Occupational history.
  • Medical history.
  • Symptoms of anxiety or depression.
  • Previous injury or infection.
  • History of cancer — in these people, aetiology of pain should be assumed to be cancer, until it is excluded.
  • Presence of fever — in these people, neck pain should be assumed to be secondary to an infection until proven otherwise.
• Assess the appearance of the neck and the range of motion. 
• Palpate the neck for tenderness.
• Inspect the skin — for example, for papulovesicular rash, petechiae, or purpura.
• Consider examining for Kernig's sign (painful/resisted extension of leg bent at hip and knee) and Brudzinski's sign (reflective flexion of the knees when the person is on his/her back and the neck is bent forwards) to demonstrate nuchal rigidity if meningitis is suspected.
• Exclude other causes of neck pain.
• A combination of tests can be used to help identify cervical radiculopathy, including:
  • The Spurling test — flex the neck laterally, rotate and then press on top of the person's head. The test is positive if this pressure causes the typical radicular arm pain. Note: This test should not be performed in people with rheumatoid arthritis, cancer, infection, or possible neck injury.
  • Arm squeeze test — squeeze the middle third of the upper arm with simultaneous thumb and fingers compression (the thumb from posterior on the triceps muscle and the fingers from anterior on the biceps muscle). The test is positive when the pain score (on a 0-10 visual analogue scale) is 3 points or higher during pressure on the middle third of the upper arm compared with two other areas.
  • Axial traction — a combination of a positive Spurling test, axial traction test, and arm squeeze test increases the likelihood of cervical radiculopathy.
  • Upper limb neurodynamic tests — a combination of four neurodynamic tests and an arm squeeze test can rule out cervical radiculopathy.
• Cervical X-rays, and other imaging studies and investigations are not routinely required to diagnose neck pain with radiculopathy.
  • Magnetic resonance imaging (MRI) is indicated in people with complex cervical radiculopathy. For example, if there is a high suspicion of myelopathy or abscess, persistent or progressive objective neurologic findings, or failure to improve after four to six weeks of conservative treatment.
• Identify and urgently refer people with red flags indicative of a serious spinal pathology. 

What are the signs and symptoms of cervical radiculopathy?

• Symptoms of cervical radiculopathy include:
  • Pain in the neck, shoulder, and/or arm that approximates to that of a dermatome.
    • It is usually unilateral but may be bilateral.
    • The pain may be severe enough to wake the person at night.
  • Sensory symptoms, such as absent or altered sensation (for example shooting pains, numbness, and hyperaesthesia).
    • Sensory symptoms are more common than motor symptoms.
  • Motor symptoms, such as muscle weakness and spasm. 
  • Gradual onset, although it may be abrupt.
• The most common nerve root affected is C7, followed by C6.
  • Retro-orbital and temporal pain suggest referral from the upper cervical levels (C1 to C3) and can mimic giant cell arteritis.
• Signs of cervical radiculopathy include: 
  • Postural asymmetry — the head may be held to one side or flexed, as this decompresses the nerve root.
    • If the asymmetry is long-standing, muscle wasting may be present.
  • Neck movements — these may be restricted, or sharp pain may radiate into the arms (especially on extension or on bending or turning to the affected side).
  • Dural irritation — assess with the Spurling test.  
  • Neurological problems — for example, upper limb weakness, paraesthesia, dermatomal sensory or motor deficit, or diminished tendon reflexes at the appropriate level.
    • Nerve root symptoms should normally arise from a single nerve root — involvement of more than one nerve root suggests a more widespread neurological disorder.
    • See Table 1 for features of the common cervical radiculopathies.
  • Atypical signs of cervical radiculopathy include deltoid weakness, scapular winging, weakness of the intrinsic muscles of the hand, chest or deep breast pain, and headaches.

Table 1. Neurological features associated with cervical radiculopathy.

What else might it be?

• The differential diagnosis of neck pain is broad, but includes trauma and non-musculoskeletal disease processes that can be classified as neoplastic, inflammatory, infectious, vascular, endocrinological, or neurological. For example: 
  • Acute disc prolapse — the most common cause of severe secondary torticollis.
  • Acute torticollis — neck pain that is due to acute spasm with no obvious underlying cause. For more information, see the CKS topic on Neck pain - acute torticollis.
  • Acute trauma (for example, whiplash type injury) — neck pain symptoms that follow a recent sudden or excessive hyperextension, flexion, or rotation of the neck. For more information, see the CKS topic on Neck pain - whiplash injury.
  • Adverse drug reactions (for example, antipsychotic drugs, metoclopramide, amphetamines, and cocaine).
  • Arthritis of the cervical spine.
  • Cervical strain/fracture/dislocation/myelopathy.
  • Herpes zoster.
  • Local abscess. 
  • Malignancy — tumours arising from thyroid, oesophageal, pharyngeal, and lung tissue have been reported to compress individual cervical nerves.
  • Meningitis.
  • Neurological disorders leading to dystonia (for example, stroke and encephalitis).
  • Non-specific neck pain — neck pain that varies with different physical activities and with time, or is related to an awkward movement, poor posture, or overuse. For more information, see the CKS topic on Neck pain - non-specific.
  • Parsonage-Turner syndrome (brachial plexopathy).
  • Psychogenic dystonia and genetic conditions and disorders leading to dystonia (for example, Huntington's disease or primary torsion dystonia).
  • Head or neck pain — migraine, tension or cervicogenic headache, and temporomandibular disorder.
  • Shoulder pain — adhesive capsulitis, bicep tendonitis, and impingement syndrome rotator cuff syndrome.
  • Muscle connective tissue disorders — myofascial pain and polymyalgia rheumatica.
  • Vascular conditions — thoracic outlet syndrome.
  • Autonomic conditions — complex regional pain syndrome and reflex sympathetic dystrophy. 
  • Localised wrist or elbow conditions — (for example carpal tunnel syndrome and anterior or posterior interosseous nerve entrapment). 

Scenario: Management

From age 16 years onwards.

Search strategy

Scope of search

A literature search was conducted for guidelines and systematic reviews on primary care management of cervical radiculopathy.

Search dates

August 2018 - October 2023

Key search terms

The terms listed below are the core search terms that were used for EBSCO MEDLINE (searched 28th August 2018). These terms were combined with search filters for systematic reviews and guidelines in EBSCO MEDLINE. The strategy was adapted for The Cochrane Library databases. 

S6 S1 or S2 or S3 or S4 or S5

S5 AB cervicalgia OR TI cervicalgia 

S4 AB ( ((neck or cervical) N2 radiculopath*) ) OR TI ( ((neck or cervical) N2 radiculopath*) ) 

S3 AB (neck N2 pain*) OR TI (neck N2 pain*) 

S2 (MH "Radiculopathy") 

S1 (MH "Neck Pain") 

Sources of guidelines

• National Institute for Health and Care Excellence (NICE)
• Scottish Intercollegiate Guidelines Network (SIGN)
• Royal College of Physicians
• Royal College of General Practitioners
• Royal College of Nursing
• NICE Evidence
• World Health Organization
• Guidelines International Network
• TRIP database
• Agency for Healthcare Research and Quality
• Institute for Clinical Systems Improvement
• National Health and Medical Research Council (Australia)
• Royal Australian College of General Practitioners
• British Columbia Medical Association
• Canadian Medical Association
• Alberta Medical Association
• Michigan Quality Improvement Consortium
• Singapore Ministry of Health
• National Resource for Infection Control
• RefHELP NHS Lothian Referral Guidelines
• Medline (with guideline filter)
• Driver and Vehicle Licensing Agency
• NHS Health at Work (occupational health practice)

Sources of systematic reviews and meta-analyses

• The Cochrane Library:
  • Systematic reviews
  • Protocols
  • Database of Abstracts of Reviews of Effects
• Medline (with systematic review filter)
• EMBASE (with systematic review filter)

Sources of health technology assessments and economic appraisals

• NIHR Health Technology Assessment programme
• The Cochrane Library:
  • NHS Economic Evaluations
  • Health Technology Assessments
• Canadian Agency for Drugs and Technologies in Health
• International Network of Agencies for Health Technology Assessment

Sources of randomized controlled trials

• The Cochrane Library:
  • Central Register of Controlled Trials
• Medline (with randomized controlled trial filter)
• EMBASE (with randomized controlled trial filter)

Sources of evidence based reviews and evidence summaries

• Bandolier
• Drug and Therapeutics Bulletin
• TRIP database
• Central Services Agency COMPASS Therapeutic Notes

Sources of national policy

• Department of Health
• Health Management Information Consortium (HMIC)

Patient experiences

• Healthtalk
• BMJ - Patient Journeys

Sources of medicines information

The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.

• British National Formulary (BNF)
• electronic Medicines Compendium (eMC)
• European Medicines Agency (EMEA)
• LactMed
• Medicines and Healthcare products Regulatory Agency (MHRA)
• REPROTOX
• Scottish Medicines Consortium
• Stockley's Drug Interactions
• TERIS
• TOXBASE
• Micromedex
• UK Medicines Information

Stakeholder engagement

Our policy

The external review process is an essential part of CKS topic development. Consultation with a wide range of stakeholders provides quality assurance of the topic in terms of:

• Clinical accuracy.
• Consistency with other providers of clinical knowledge for primary care.
• Accuracy of implementation of national guidance (in particular NICE guidelines).
• Usability.

Principles of the consultation process

• The process is inclusive and any individual may participate.
• To participate, an individual must declare whether they have any competing interests or not. If they do not declare whether or not they have competing interests, their comments will not be considered.
• Comments received after the deadline will be considered, but they may not be acted upon before the clinical topic is issued onto the website.
• Comments are accepted in any format that is convenient to the reviewer, although an electronic format is encouraged.
• External reviewers are not paid for commenting on the draft topics.
• Discussion with an individual or an organization about the CKS response to their comments is only undertaken in exceptional circumstances (at the discretion of the Clinical Editor or Editorial Steering Group).
• All reviewers are thanked and offered a letter acknowledging their contribution for the purposes of appraisal/revalidation.
• All reviewers are invited to be acknowledged on the website. All reviewers are given the opportunity to feedback about the external review process, enabling improvements to be made where appropriate.

Stakeholders

• Key stakeholders identified by the CKS team are invited to comment on draft CKS topics. Individuals and organizations can also register an interest to feedback on a specific topic, or topics in a particular clinical area, through the Getting involved section of the Clarity Informatics website.
• Stakeholders identified from the following groups are invited to review draft topics:
  • Experts in the topic area.
  • Professional organizations and societies (for example, Royal Colleges).
  • Patient organizations, Clarity has established close links with groups such as Age UK and the Alzheimer’s Society specifically for their input into new topic development, review of current topic content and advice on relevant areas of expert knowledge.
  • Guideline development groups where the topic is an implementation of a guideline.
  • The British National Formulary team.
  • The editorial team that develop MeReC Publications.
• Reviewers are provided with clear instructions about what to review, what comments are particularly helpful, how to submit comments, and declaring interests.

Patient engagement

Clarity Informatics has enlisted the support and involvement of patients and lay persons at all stages in the process of creating the content which include:

• Topic selection
• Scoping of topic
• Selection of clinical scenarios
• First draft internal review
• Second draft internal review
• External review
• Final draft and pre-publication

Our lay and patient involvement includes membership on the editorial steering group, contacting expert patient groups, organizations and individuals.

Evidence exclusion criteria

Our policy

Scoping a literature search, and reviewing the evidence for CKS is a methodical and systematic process that is carried out by the lead clinical author for each topic. Relevant evidence is gathered in order that the clinical author can make fully informed decisions and recommendations. It is important to note that some evidence may be excluded for a variety of reasons. These reasons may be applied across all CKS topics or may be specific to a given topic.

Studies identified during literature searches are reviewed to identify the most appropriate information to author a CKS topic, ensuring any recommendations are based on the best evidence. We use the principles of the GRADE and PICOT approaches to assess the quality of published research. We use the principles of AGREE II to assess the quality of published guidelines.

Standard exclusions for scoping literature:

• Animal studies
• Original research is not written in English

Possible exclusions for reviewed literature:

• Sample size too small or study underpowered
• Bias evident or promotional literature
• Population not relevant
• Intervention/treatment not relevant
• Outcomes not relevant
• Outcomes have no clear evidence of clinical effectiveness
• Setting not relevant
• Not relevant to UK
• Incorrect study type
• Review article
• Duplicate reference

Organizational, behavioural and financial barriers

Our policy

The CKS literature searches take into consideration the following concepts, which are discussed at the initial scoping of the topic.

• Feasibility
  • Studies are selected depending on whether the intervention under investigation is available in the NHS and can be practically and safely undertaken in primary care.
• Organizational and Financial Impact Analysis
• Studies are selected and evaluated on whether the intervention under investigations may have an impact on local clinical service provision or national impact on cost for the NHS. The principles of clinical budget impact analysis are adhered to, evaluated and recorded by the author. The following factors are considered when making this assessment and analysis.
  • Eligible population
  • Current interventions
  • Likely uptake of new intervention or recommendation
  • Cost of the current or new intervention mix
  • Impact on other costs
  • Condition-related costs
  • In-direct costs and service impacts
  • Time dependencies
• Cost-effectiveness or cost-benefit analysis studies are identified where available. 

We also evaluate and include evidence from NICE accredited sources which provide economic evaluations of recommendations, such as NICE guidelines. When a recommended action may not be possible because of resource constraints, this is explicitly indicated to healthcare professionals by the wording of the CKS recommendation.

Declarations of interest

Our policy

Clarity Informatics requests that all those involved in the writing and reviewing of topics, and those involved in the external review process to declare any competing interests. Signed copies are securely held by Clarity Informatics and are available on request with the permission of the individual. A copy of the declaration of interest form which participants are asked to complete annually is also available on request. A brief outline of the declarations of interest policy is described here and full details of the policy is available on the Clarity Informatics website. Declarations of interests of the authors are not routinely published, however competing interests of all those involved in the topic update or development are listed below. Competing interests include:

• Personal financial interests
• Personal family interest
• Personal non-financial interest
• Non-personal financial gain or benefit

Although particular attention is given to interests that could result in financial gains or losses for the individual, competing interests may also arise from academic competition or for political, personal, religious, and reputational reasons. An individual is not obliged to seek out knowledge of work done for, or on behalf of, the healthcare industry within the departments for which they are responsible if they would not normally expect to be informed.

Who should declare competing interests?

Any individual (or organization) involved in developing, reviewing, or commenting on clinical content, particularly the recommendations should declare competing interests. This includes the authoring team members, expert advisers, external reviewers of draft topics, individuals providing feedback on published topics, and Editorial Steering Group members. Declarations of interest are completed annually for authoring team and editorial steering group members, and are completed at the start of the topic update and development process for external stakeholders.

Competing interests declared for this topic:

None.