Physical Medicine and Rehabilitation

Cervical Radiculopathy (Pinched Nerve)

Anatomy

The spinal column is made up of small bones (vertebrae) stacked on top of one another, creating the natural curves of the back. Between the vertebrae are flat, round, rubbery pads (intervertebral disks) that act as shock absorbers and allow the back to flex or bend. Muscles and ligaments connecting the vertebrae allow motion while providing support and stability for the spine and upper body. Each vertebra has an opening (foramen) in the center and these line up to form the spinal canal. Protected by the vertebrae, the spinal cord and other nerve roots travel through the spinal canal. Nerves branch out from the spinal column through vertebral openings, carrying messages between the brain and muscles. Facet joints align at the back of the spinal column, linking the vertebrae together and allowing for rotation and movement. Like all joints, cartilage covers the surface where facet joints meet.

The spine contains three segments: lumbar, thoracic and cervical. The lumbar spine consists of five vertebrae located in the lower back; lumbar vertebrae are larger because they carry more of the body's weight. The thoracic spine consists of 12 vertebrae and begins at the upper chest, extending to the middle back and connecting to the rib cage. The cervical spine includes the neck and consists of seven small vertebrae, beginning at the base of the skull and ending at the upper chest. Disks in the lumbar spine are composed of a thick outer ring of cartilage (annulus) and an inner gel-like substance (nucleus). In the cervical spine, disks are similar but smaller in size. The cervical spine supports the weight of the head and connects it to the shoulders and body. It is less protected than the rest of the spine, making it more vulnerable to injury and disorders that produce pain and restricted motion.

Description

When there is inflammation, compression (pressure), or irritation of a nerve root exiting the spine, the nerve may be unable to conduct sensory impulses to the brain appropriately, leading to varying degrees of discomfort and pain. The majority of patients with cervical radiculopathy get better over time, with no need for surgery or any type of treatment at all. Pain and discomfort may go away quickly, taking days or weeks to subside. For others, it may take longer. It is not uncommon for cervical radiculopathy to return at some time in the future, improving as before, without specific treatment. For those patients that develop persistent symptoms, evaluation and treatment for pain or weakness is required.

Symptoms

Pain, often described as sharp, may radiate from the neck into the shoulder and down into the arm. Pain may be accompanied by a tingling, prickling or "pins and needles" sensation (paresthesia), or even complete numbness. A feeling of weakness may also be associated with certain activities. Symptoms may worsen with certain movements, such as extending or straining the neck, or turning the head. Symptoms may be improved by placing a hand on the head and stretching the shoulder.

Causes

Cervical radiculopathy has a variety of causes, such as: damage to the spinal nerve root due to injury; nerve damage caused by certain ailments, such as diabetes; repetition of certain movements; or pressure on spinal nerve roots due to bone spurs or narrowing of the foramen on intervertebral disks as a result of the natural aging process. As intervertebral disks age, they lose water content and become stiffer; and they lose height and begin to bulge, allowing vertebrae to move closer together. The body responds to the collapsed disk as a possible weakness and forms additional bone (spurs) around it to strengthen it. Bone spurs contribute to stiffening of the spine, and may also narrow the foramen and pinch the nerve root. This is part of the natural aging process. However it does not always produce symptoms.

Diagnosis

After discussing your medical history and symptoms, your physician will examine your neck and test your strength, sensation and reflexes. You may be asked to perform certain neck and arm movements designed to recreate or relieve your symptoms. Additional imaging studies, such as X-rays, magnetic resonance images (MRI), electromyelography (EMG), or computed tomography (CT) may be required to fully assess and diagnose your condition.

Nonsurgical Treatment

If symptoms do not improve, your surgeon will typically begin treatment by recommending nonsurgical options.

• Soft collars—These limit neck motion and allow neck muscles to rest. Soft collars should be worn for short periods of time only, as long-term wear can weaken neck muscles.
• Physical therapy—This can help with neck muscle stretching and strengthening, and may include traction.
• Medications—These may include nonsteroidal anti-inflammatories (NSAIDS), such as aspirin or ibuprofen, which may alleviate symptoms associated with nerve swelling. A short course of oral corticosteroids may also help reduce swelling and pain. Patients with severe pain that does not respond to other options may be prescribed narcotics for a limited time only. Spinal injections of steroids near the area of the pinched nerve may provide anti-inflammatory effects similar to oral steroids, reducing swelling and pain enough to allow the nerve to recover with time.

Surgery

When symptoms of cervical radiculopathy persist or worsen despite nonsurgical treatments, surgical options can be considered to decompress nerves, maintain stability of the spine, and provide correct spinal alignment. Surgery involves removing parts of bone or soft tissue (such as a herniated disk), or both, in order to create more space for the nerves and relieve pressure.

The procedure that is right for you depends on the type and location of your problem as well as other factors, including your medical condition and history, your surgeon's experience, and your preference. The following surgical options are the three most commonly used to treat cervical radiculopathy.

• Anterior cervical diskectomy and fusion (ACDF)—This is the most commonly used procedure for cervical radiculopathy. ACDF restores alignment of the spine, maintains the space available for nerve roots to exit the spine, and limits motion across the degenerated spine segment. The surgeon approaches the spine from the front (anterior) of the neck through a 1- to 2-inch incision. The problem disk is removed and bone graft is inserted into the area, increasing the space in the foramen for the nerve to exit the spine. After placement of the bone graft, the two vertebrae that were next to the removed disk are fused together to eliminate motion between degenerated vertebrae and lessen pain. A metal plate and screws are commonly used along the front of the cervical spine to provide stability and help increase the rate of fusion.
• Posterior cervical laminoforaminotomy—The surgeon approaches the spine from the back (posterior) of the neck through a 1- to 2-inch incision and removes the parts of bone that are compressing the nerve root. If appropriate, the herniated disk is also removed. This procedure avoids spinal fusion and offers the potential for a quicker recovery, but it is only an option for some patients, depending on the type and location of the problem.
• Artificial disk replacement (ADR)—ADR received approval from the FDA in 2004. During ADR surgery, the surgeon approaches the spine from the front (anterior) of the neck through a 1- to 2-inch incision. The problem disk is removed and a metal or metal/plastic implant is inserted into the disk space. Similar to hip or knee joint replacements, artificial disks can: allow continued motion, restore height between vertebral bodies, increase space in the foramen for the nerve to exit the spine, relieve pressure on facet joints, and help maintain natural curvature of the cervical spine. This procedure may not be an option for some patients, depending on the type and location of the problem.

Rehabilitation

It is typical to spend 1 or 2 days in the hospital following surgery, and to begin walking and eating on the first day. However, recovery and rehabilitation vary for each person and your specific experience will depend on the type of surgery you receive and how you respond to the procedure. You may need to wear a soft or rigid collar for a short period of time. After 4 to 6 weeks, you may be able to gradually begin range-of-motion exercises, depending on your healing. Your physician may prescribe physical therapy during the recovery period to help restore function.

Patients are typically able to return to full activities by 3 to 4 months following surgery, depending on the procedure. Healing may take longer for some people, and spinal fusion (bones to become solid) may take 6 to 12 months.

Complications

As with any surgery, there are some risks, and these vary from person to person. These are typically minor, treatable and unlikely to affect your final outcome. For most people, surgery can provide relief of symptoms and return to function with relatively low risk of complications. Discuss the potential risks and benefits with your surgeon prior to surgery.

In general, the potential risks for cervical spine surgery include: infection, bleeding, injury to the nerves, injury to the spinal cord, reactions to anesthesia, need for additional surgery in the future, failure to relieve symptoms, tear of the sac covering the nerves (dural tear). Potential risks associated with anterior cervical spine surgery and artificial disk replacement include: misplaced, broken, or loosened plates, screws, or implants; soreness or difficulty with swallowing; voice changes; difficulty breathing; or injury to the esophagus. Potential risks specific to anterior cervical diskectomy and fusion include: donor site pain (hip pain) if an autograft is used, and nonunion of vertebral body fusion.

Outcome

The outcome from the surgery for cervical radiculopathy is generally very good, with the majority of patients returning to normal lifestyles after recovery.