Cervical radiculopathy is largely due to mechanical compression of the exiting cervical nerve roots.

The intervertebral foramen is bounded by the following structures (FIG 1):

In the subaxial cervical spine, the foramen averages 9 to 12 mm in height and 4 to 6 mm in width, and in a young person, the cervical nerve root occupies approximately onethird of the available space in the foramen.

With increasing age, degenerative changes (osteophyte formation), disc protrusion, or cervical instability, this proportion may increase and signs of radiculopathy may develop.

Any process that causes impingement of the exiting cervical nerve roots can lead to cervical radiculopathy.

Potential etiologies of cervical radiculopathy include cervical spondylosis leading to foraminal stenosis due to uncinate or facet hypertrophy, disc herniation, instability, and anterolisthesis or retrolisthesis.

The natural history of cervical radiculopathy is not well studied, but about half of the adult population will have neck and radicular symptoms at some point during their lifetime.

In patients treated nonoperatively, up to 66% will have persistent symptoms and up to 23% of patients with persistent neck or radicular pain will be unable to return to their original occupation.

When a patient presents with radiculopathy, a complete history and physical examination is of paramount importance.

Questions about the duration of the symptoms, location and nature of the pain, distribution of altered sensation and numbness (axial or radicular), presence of weakness, and any associated manifestations must be asked to understand the underlying pathology and target the offending level of cervical pathology.

Because radiculopathy can be associated with myelopathy, the presence or absence of balance difficulties, loss of bowel or bladder control, presence of constitutional symptoms, trauma, signs of dysdiadochokinesia, or change in neurologic status must be elucidated.

The physical examination should include motor and sensory evaluation (both gross and pinprick), reflex testing, upper and lower motor neuron signs, and cerebellar functional testing.

Plain radiographs of the cervical spine, including anteroposterior (AP), lateral, odontoid, oblique, and lateral flexion/extension
views, are used initially to evaluate for the presence of cervical pathology.

If symptoms have been present for at least 6 weeks, additional imaging is indicated and usually includes cervical spine magnetic resonance imaging (MRI).

If MRI is contraindicated, a cervical computed tomography (CT) myelogram may be beneficial.

A CT scan with coronal and sagittal reconstructions may be helpful in operative planning.

Cervical radiculopathy

Myelopathy

Myeloradiculopathy

Entrapment syndromes (eg, pronator syndrome, carpal tunnel syndrome, cubital tunnel syndrome)

Thoracic outlet syndrome

Although cervical radiculopathy is common, only a few patients require surgical intervention, and despite a heightened clinical acumen for the diagnosis and treatment of cervical spondylosis, the mainstay of treatment remains nonsurgical.

Nonsurgical modalities that are initiated first include physical therapy, nonsteroidal anti-inflammatory drugs, and activity modification.

If these methods fail, a selective nerve root injection at a designated level can be attempted with a high degree of safety and efficacy.

The purpose of the nerve root injection is twofold: to provide pain relief by decreasing inflammation through the use of a corticosteroid and to serve as a diagnostic tool to localize the offending pathology.

Posterior cervical foraminotomy is indicated for foraminal stenosis or a foraminal disc herniation resulting in a neurologic deficit such as a sensory deficit, motor weakness, and/or progressive symptoms that fail to respond to an appropriate course of nonsurgical treatment.

As with any surgical intervention, a thorough discussion with the patient and family about the desired outcomes and risks and benefits of the procedure must be undertaken before surgery.