Oftentimes, neck pain stays in the neck. But not always.
Neck pain is something that I see in practice on a daily basis. Sometimes it is as simple as someone slept wrong and sometimes it is chronic neck pain that refers into the head or into the arm.
Today’s blog post is going to talk about neck pain & its referral down the arm, known as cervical radiculopathy.
A lot of my patients are coming to me right now complaining of a few things:
Neck pain that (almost) always presents on the dominant side
The pain extends to the top of the shoulders & down into the mid back between the shoulder blades
Numbness & tingling in the arm/wrist/hand
This is a pretty classic presentation of what is known in the biz as cervical radiculopathy. It sounds scary - but let’s dive in and break it down.
What is cervical radiculopathy?
Cervical radiculopathy is defined clinically as: “a neurologic condition characterized by the dysfunction of a cervical spinal nerve, the roots of the nerve, or both. It usually presents with pain in the neck and one arm, with the combination of sensory loss, loss of motor function, or reflex changes in the affected nerve root distribution.”
Time to break it down into some English.
Essentially, cervical radiculopathy is a dysfunction of one of the nerves that exists from the joints of the neck. Its symptoms usually present as pain in the neck & one arm, loss of sensation, weakness and/or reflex changes.
As you can imagine, cervical radiculopathy can be pretty detrimental & can cause significant impairment economically, physiologically & from a social contact standpoint.
Now before we go any further, I do want to talk a little bit about the anatomy of cervical radiculopathy. I’m going to make it short, sweet and (hopefully) simple.
Anatomy of cervical radiculopathy
In order to really understand what is going on here, we need to have a basic understanding of what is going on in the joints & nerves of the neck.
Starting in between the first & second cervical vertebrae, the spinal cord gives off nerve roots that exit the spine through a hole called a neural foramina. From these neural foramina, the nerve roots of 5 of these nerves (C5-T1) come together to form the brachial plexus.
In the brachial plexus, these nerves talk to each other, intermingle, and come out as new nerves. Kind of like Pride Sunday. These are called the musculocutaneous, axillary, radial, median and ulnar nerves and each one follows a pretty set out path down the arm and into the hand called a dermatome. These five nerves supply all of the muscles, joints & skin with sensory & motor function all the way down to the tip of your middle finger.
I mentioned the brachial plexus being from C5-T1, but that isn’t to say that you cannot experience these symptoms in the C1-C4 dermatomes, it just isn’t nearly as common.
Cervical radiculopathy happens when the nerve gets inflamed or damaged somewhere along the way. This can happen in a number of different ways, but most often by a narrowing of the neural foramina. And how does the narrowing of the neural foramina happen? Well this can be caused by immobility of the facet joints (which is the most common) or encroachment of the intervertebral disc.
Before I move onto what I look for when diagnosing cervical radiculopathy, I wanted to touch on dermatomes in a little bit more detail because they are an important clue in determining what nerve roots are affected.
Dermatomes are fluid anatomical skin regions supplied by one single nerve. These dermatomes allow us to narrow down the origin of the radiculopathy (either in the neck or low back) which makes treatment so much easier.
Okay, enough anatomy. Now let’s chat symptomatology.
Causes & symptomatology of cervical radiculopathy
Like most things in the medical world, there is no one finite cause for cervical radiculopathy. And also like most things in the medical world, it can just happen. But there are some common causes that we look for during an exam:
Forward head posture: yup - that bad office posture & hunchback look can be a contributing cause to your numbness & tingling
Injuries: motor vehicle accidents and sports accidents are common causes as well. Anything that could cause a concussion can also cause a cervical radiculopathy
Repetitive lifting, especially with weights >25lbs
Carrying heavy bags: called traction cervical radiculopathy, it is not uncommon for those who carry a lot of heavy bags (travelling, groceries, etc) to experience symptoms
Similar to most conditions I treat in my office, patient history is the most important part in diagnosing cervical radiculopathy. So what are the two major things I look for?
Arm pain/paresthesis (numbness & tingling) that corresponds with a specific dermatome. This is by and large the most common symptom seen in cervical radiculopathy.
Often the arm symptoms are felt in conjunction with neck pain. Research says that not all cervical radiculopathy presents with neck pain, but my clinical experience has shown otherwise. In my experience, neck pain is present.
There are also several physical tests that are done to rule in or out a diagnosis of cervical radiculopathy.
Decrease in range of motion. This is seen in all sorts of conditions & cervical radiculopathy is no exception. Generally the most common limitations are in extension (looking towards the sky) because it inherently narrows those neural foramina. Rotation & side bending are also often compromised to an extent.
Spurling’s test (lateral flexion & compression) is a test often done to recreate symptoms in the neck & arm however it can only confirm that there is something happening, not where it is happening. Nonetheless, it does provide us with useful information, so I do this one on every neck patient I have.
Upper limb tension tests are a group of commonly done tests that aid us in narrowing down the dermatome that may be affected in each individual case.
Sensory testing. It is important to test how the patient responds to physical touch in the area that is compromised. This gives us a baseline to compare to as we move along with the treatment plan.
Motor testing. Done for the same reason as sensory testing, I test the muscles of the upper limb to get a baseline on how the muscles are functioning with the ultimate goal of improving strength & function.
Now that we’ve gone through what the clinical picture of a cervical radiculopathy looks like, let’s talk about some treatment. The reason you are here!
Treatment of cervical radiculopathy
Now by this point I am sure you are wondering how one with cervical radiculopathy might go about getting some relief. That is where I come in.
A systematic review in 2011 (which is considered the highest quality of research) looked at how cervical radiculopathy responds to manual therapy & exercise as a form of treatment. In this study, manual therapy techniques were described as: muscle energy techniques, soft tissue therapy, non-thrust mobilizations & manipulations.
This systematic review concluded that a combination of manual therapy & exercise therapy is at least as effective & beneficial as surgery. They also concluded because of the study designs & individuality of patients, determining exactly which manual therapy provides the best results was impossible.
So what does this look like for someone coming into my office?
Well after an exam & treatment consent, the first thing I generally start off with is muscle therapy. This is individualized depending on what is going on with that patient, but generally the upper trapezius muscle, scalenes, and the muscles that line the spine are at play.
I then like to start to gently stretch the area and mobilize the joints with gentle oscillating movements. This gets a little bit of motion into the area and loosens up the joints a little bit so that the adjustment is easier and holds better.
Then it is time for the adjustment. This is the pop & crack that you generally think of when you hear the term chiropractor. The whole goal of the adjustment is to encourage movement in the facet joints. The facet joints make up a part of the neural foramina, so it stands to reason that encouraging movement in the area will help with cervical radiculopathy symptoms. And in my experience … it does.
I also stated that therapeutic exercise is incredibly important in treating cervical radiculopathy. But which exercises?
Well my friend, this is a loaded question because it really depends on what is going on, which nerve root is impinged and what symptoms you have as an individual, but I did want to give you one stretch that I tend to give to a lot of patients. And that is a simple upper traps stretch.
If you have been following me for a while, you’ll know that I love this one and give it out often, but what can I say … effective is effective.
Upper trapezius stretch instructions:
Sit on your right hand to keep your shoulder blade down so you can get the most out of the stretch
With your left hand, grab your head just above your right ear
Pull your head to the left and hold it for 60 seconds
The symptoms of cervical radiculopathy can be unnerving. Neck pain with numbness & tingling in the arm is something that startles a lot of people, and that is okay. If you are experiencing these symptoms, please do not hesitate to reach out. We can chat about what I can do to help you relieve those symptoms and get you back on track.