Cervical radiculitis is most often manifested by pain due to irritation, inflammation or injury of the cervical spinal nerves. The pain is localized in the arm on the side of the lesion and can be sharp, stabbing, or similar to electric shock. Cervical radiculitis and cervical radiculopathy are not synonymous. Cervical radiculopathy supposes presence of objective signs of sensory and/or motor disorders. These two disorders do not exclude one another, and often occur at the same time. Cervical radiculitis is caused by irritation of the spinal nerves, while the term radiculopathy also includes neurological symptoms such as sensory and/or motor disorders. These two disorders can occur simultaneously and have the same cause, e.g., stenosis of the intervertebral foramen, protrusion of the disc, infection, displacement of the vertebrae, etc. Acute cervical radiculitis, caused by inflammation of the cervical nerves, given the disease progresses, , can result in chronic cervical radiculopathy, manifested by sensitivity disorders and a decrease in muscle strength in the hands.
In most cases, the cause of acute and subacute (6-12 weeks) radiculitis is a protrusion or herniation of the intervertebral disc. The usual cause of chronic (more than 3 months) radiculitis is the formation of adhesions around the nerve root and its constant irritation. The adhesions can be a result of acute inflammation due to disc protrusion or after surgery.
Other causes of cervical radiculitis:
- narrowing (stenosis) of the spinal canal
- narrowing of the intervertebral opening (the place where the nerves exit the spine)
- spondylolisthesis (displacement of the vertebrae relative to each other)
- radiculitis due to chemotherapy or radiotherapy
In young patients, the most common cause of acute cervical radiculitis is protrusion (herniation) of the intervertebral disc and irritation of the spinal nerve. In older people, the cause of radiculitis is most often an excessive growth of bone tissue (the so-called “osteophytes”), combined with an age-related decrease in the height of the intervertebral disc. Radiculitis as a result of protrusion (hernia) of the intervertebral disc usually develops acutely, manifests by pain in the arm and neck and forced position of the head and neck. The pain is aggravated by coughing and sneezing, while motor disorders and muscle atrophy develop later. The usual age of patients suffering from radiculitis due to disc protrusion is 30-45 years. Radiculitis caused by excessive growth of bone tissue develops gradually. Night pains, numbness and tingling in the hands are characteristic. Radiculitis due to bone osteophytes tends to be chronic. Episodes of relapse are usually caused either by sudden injuries (e.g., the so-called “whiplash” injury in a car accident) or prolonged poor postures (working at a desk, watching TV). Asymptomatic periods can last for months or years, intermitted by episodes of severe pain.
Typical cervical radiculitis is presented by pain in the neck and shoulder, limited range of movements in the neck. The pain may worsen when you turn your head and lean forward. Patients often associate the onset of pain with hypothermia (air conditioning) or prolonged poor posture (watching TV, reading, working at a desk).
Typical features of cervical radiculitis:
- sudden onset
- pain worsens at night
The pain often comes along with feeling of pressure, muscle spasm.
Various types of symptoms may appear together or separately – pain in the shoulder and neck, paresthesias (abnormal sensation), occipital pain, ringing in the ears, fainting, feelings of pressure in the chest, migraine-like attacks. Large anterior spondylophytes of the cervical vertebrae can result in dysphagia (impaired swallowing), while respiratory problems caused by compression of the trachea, as well as eye symptoms are relatively rare. Along with the above specific symptoms, patients often complain of fatigue, irritability, inability to concentrate. Patients with cervical radiculopathy are often subject to emotional distress. Lasting severe pain in the neck and arm by day and night, disrupting night sleep, disturbs also emotional balance.
Diagnosis is confirmed by the patient’s complaints, the results of a clinical examination and additional studies. The routine neurological examination includes muscle strength, reflexes, and sensation tests.
Computed tomography is quite informative when diagnosing bony tissue, but not as useful when imaging soft tissues. Magnetic resonance imaging is the method of choice, allowing for revealing changes in the intervertebral discs, spinal cord, nerve roots and surrounding soft tissues. Radiological findings only are not enough for clinical diagnosis! Even massive osteophytes, considerable reduction in disc height, and close contact between adjacent vertebrae may manifest with only mild symptoms or no complaints at all. These morphological changes are often found incidentally. Only the clinical symptoms are decisive for the diagnosis.
Electromyography (EMG) is of essential importance in objectifying dysfunction of the cervical nerves. EMG abnormalities can often be detected before the onset of any clinical manifestations, like sensory disorders and muscle atrophy. EMG requires good rapport with patient, is sometimes painful and time consuming. EMG is not a routine examination method and it is done by specific indications.
Cervical radiculitis manifests by a variety of symptoms and its differential diagnosis is not so easy. The diagnosis of cervical radiculitis can only be confirmed when all other possible conditions have been ruled out. First of all, tumors, infections and vertebral fractures should be excluded.
The following symptoms require immediate evaluation and further examination:
- gradual development of symptoms
- constant pain, regardless of the head and neck position
- elderly age
- high body temperature
- abnormal blood tests (leukocytosis, elevated ESR)
- X-ray confirmed destruction of bony tissue
- abnormal gait
- a history of trauma, tumors, infections
- general symptoms (malaise, unexplained weight loss)
Warmth. It is of importance when treating cervical radiculitis, especially acute one. The neck can be warmed in many ways – soft, warm scarf, application of warming packages, hot water bottle, infrared lamp, etc. Those act via relaxation of spasmodic muscles and reduction of local irritation of the ligaments and periosteum.
Immobilization. A soft cervical orthosis (“collar”) of the right size has three therapeutic effects:
- unloading of the cervical spine
Drug therapy for cervical radiculitis is purely symptomatic and is done along with physiotherapy. There is no evidence that medications have any effect on the consistency or volume of the intervertebral disc. Given that the clinical manifestations of cervical radiculitis are dependent on many pathogenetic mechanisms, no wonder that drugs with different mechanisms of action can be used and provide a good effect. Treatment of severe pain should begin with strong analgesics. NSAIDs are recommended in the treatment of acute pain, but for a short time, given the potential gastrointestinal and cardiovascular adverse events. Drugs like antidepressants (Amitriptyline), anticonvulsants (Finlepsin, Gabapentin, Pregabalin) are used to treat chronic radiculopathy. Should the above medications be ineffective, light opioids (codeine, tramadol) may be prescribed. In the event the drug therapy is ineffective or causes poorly tolerated adverse events, interventional methods of treatment are recommended. Before getting determined for long-term pharmacotherapy, many patients opt for minimally invasive therapy that is aimed at the source of pain, to avoid dependence on drugs with serious adverse effects. In many cases, the optimal result is achieved by combining pharmacotherapy and interventional technologies.
1) Epidural steroid injection
Use of epidural administration of corticosteroids is indicated in acute or subacute forms of cervical radiculitis. Extensive studies have demonstrated that epidural steroid injection is highly effective in the treatment of acute or subacute radiculitis and should always be used before surgical treatment is considered.
2) PRF therapy.
Pulse radiofrequency therapy. Randomized controlled trials demonstrate the effectiveness of PRF stimulation of the spinal ganglia of the cervical spinal cord. According to evidence-based recommendations, the use of this method is highly recommended in cases of chronic radiculopathy.
3) Neurostimulation of the spinal cord.
The essence of this method is the percutaneous implantation of electrodes close to the spinal cord at the level of the affected segment. The electrodes are connected to a pulse generator that disrupts the conduction of pain stimuli. This method can be used when all other less invasive methods have failed. It is recommended to use this method only in dedicated centers.
Surgery is indicated in case of severe compression of the spinal cord, resulting in severe neurological deficit. Surgical treatment of chronic recurrent radiculopathy may be considered in isolated cases when all other methods have failed. Randomized comparative trial of the effectiveness of conservative and surgical treatment demonstrated that a significant pain reduction was observed 3 months after the surgery. However, one year after the treatment, there was no difference between the two patients cohorts. Thus, surgery is justified when there exists a high risk of persistent irreversible neurological deficits.