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Cervical radiculopathy

51 citationsUpdated Sep 2026

Overview

Cervical radiculopathy is a clinical condition encompassing diagnosis, epidemiology, and management strategies [1]. The acute presentation generally follows a self-limited course, with up to 75% of patients experiencing spontaneous improvement [11]. Consequently, nonsurgical treatment is the appropriate initial approach for most patients [11]. For those with symptoms persisting for approximately 6 weeks, 75% will respond to further conservative treatment, such as halter traction and cervical collar, over the subsequent 6 weeks [10]. While most patients improve with nonoperative care, a small percentage require further diagnostic evaluation and ultimately surgical intervention [2]. The indication for resection includes intractable radicular symptoms with correlating radiographic evidence of lateral recess, foraminal, or central stenosis [30]. Notably, the type and extent of disc herniation measured on MRI prior to surgery does not correlate to the severity of symptoms at presentation [12] nor to clinical outcomes at two years postoperatively [12].

Surgical management for pure cervical radiculopathy lacks a single superior intervention based on clinical outcome and safety [8]. Long-term data indicate that arthroplasty and fusion did not differ for disability, quality of life, or pain at 5 years [15]. Similarly, after a 2-year follow-up, posterior surgery was noninferior to anterior surgery with regard to the success rate and arm pain reduction [26]. The clinical effectiveness of surgery for degenerative cervical radiculopathy performed in public and private hospitals was equivalent 12 months after surgery [9]. Alternative techniques, including single-segment anterior cervical disc replacement (ACDR) [16], unilateral biportal endoscopic decompression for unilateral radiculopathy or coexisting myelopathy [41], and tandem keyhole foraminotomy (TKF) [29], are safe and effective options. TKF specifically requires no invasive preoperative examination [29]. If there is a greater than 50% surgery avoidance rate with injections, cervical epidural injections are considered a cost-effective strategy before surgery [32].

Important racial and ethnic disparities exist in cervical radiculopathy treatment [54]. Black patients are less likely to undergo cervical disc replacement (CDR) than anterior cervical discectomy and fusion (ACDF) [54], while Hispanic patients have higher complication rates in cervical radiculopathy treatment [54].

Anatomy & Pathophysiology

Degenerative Cascade & Structural Changes

Cervical spondylosis is a generalized disease process affecting the entire cervical spine, directly associated with chronic disk degeneration [33]. The degenerative cascade begins with biochemical and biomechanical changes that result in tears in the posterolateral region of the annulus [6, 33]. Loss of water content and proteoglycans in the nucleus leads to a decrease in disk height [33]. As the disk degenerates, a fragment of the nucleus pulposus or anulus fibrosus can break off and herniate into the canal [44]. Initial disk changes are followed by facet arthropathy, osteophyte formation, and ligamentous instability [33]. Longitudinal ligaments degenerate and form bony spurs at their insertion into the vertebral body [33]. Segmental instability results in hypertrophic formation of osteophytes by the uncovertebral joint of Luschka and by the facet joints [33]. These prominent spurs result in compression of both the exiting nerve roots and the spinal cord [33].

The intervertebral disc gradually loses height, causing posterior portions of the disc to bulge into the spinal canal and neuroforamina [6]. Concurrently, the ligamentum flavum and facet joint capsule infold, and osteophytes form [6]. These degenerative changes lead to decreases in canal and foraminal size [6]. Subluxation and hypermobility between vertebral bodies may occur as a result of the degenerative cascade [6]. Progressive collapse of cervical discs results in loss of normal lordosis and chronic anterior cord compression across the kyphotic spine or anterior chondroosseous/discoosteophytic spurs [34]. Subsequent loading of facet and uncovertebral joints results in spondylotic changes in foramina that may restrict motion and lead to spinal cord and/or nerve root compression [34].

The most frequently involved levels are the more mobile segments: C5-C6, C6-C7, and C4-C5 [33]. In approximately 90% of men older than 50 years and 90% of women older than 60 years, degeneration of the cervical spine can be demonstrated by radiographs [33]. Cervical degenerative disc disease is a pathophysiologic process that incorporates a spectrum of disease states, with manifestations ranging from neck pain and headache to cervical radiculopathy and/or myelopathy [49]. Bulging of the disks and osteophyte formation can compress the nerves and spinal cord, leading to pain and loss of function [44].

Nerve Root & Spinal Cord Pathophysiology

Nerve fibers and nociceptive nerve endings are present in the peripheral portions of the disc and in the capsule and synovium of the facet joints [6]. Facet joint capsules contain sensory receptors that may play a role in pain and proprioceptive sensation in the cervical spine [34]. Facet arthropathy may present with referred pain in specific sclerotomes [34]. It is generally believed that only an inflamed or irritated nerve root can result in radicular pain on compression [6]. Neurogenic chemical mediators of pain released from the cell bodies of the sensory neurons and non-neurogenic mediators released from disc tissue may play a role in initiating and perpetuating an inflammatory response [6]. The prolapsed nucleus pulposus elutes inflammatory mediators, initiating a local inflammatory response that leads to increased permeability at the dorsal root ganglion and pain [6]. The dorsal root ganglion is exquisitely sensitive to deformation and may be the source of pain [6]. Chronic edema and fibrosis within the nerve root caused by compression can potentially alter the response threshold and increase the sensitivity of the nerve root to pain [6].

Cervical radiculopathy usually results from compression and inflammation of the cervical nerve root or roots in the region of the neural foramen [27]. It is frequently caused by cervical disc herniation and cervical spondylosis [27]. Nerve root compromise can be due to herniated disc, discoosteophytic complex, facet arthropathy, thickened ligamentum flavum, uncovertebral osteophyte, and other problems [38]. Cervical radiculopathy can involve one or multiple roots (polyradiculopathy) [38]. Overlapping findings in cervical radiculopathy occur because of intraneural intersegmental connections of sensory nerve roots [38]. The caudal nerve root at a given level is usually affected [38]. Cervical nerve roots exit above their corresponding vertebrae, e.g., C5 exits at the C4–C5 neural foramen [38]. Disc herniation at C5 to 6 involves the C6 nerve root [38]. Disc herniation at C7 to T1 involves the C8 root [38]. The seventh cervical nerve root is most commonly involved in cervical radiculopathy (60%), followed by the sixth [51].

Cord compression can cause myelopathy by an ischemic effect secondary to compression of the anterior spinal artery or by a direct mechanical effect on cord function [52]. Anterior structures (such as bulging, ossified, or herniated disks) and osteophytic anterior spurs are the usual cause of cord compression in cervical spondylotic myelopathy [52]. Less commonly, conditions involving the posterior structures, such as ligamentum flavum hypertrophy or ossification of the ligamentum flavum, may contribute to cord compression [52]. Degenerative spondylolisthesis can exacerbate or cause compression [52]. Cervical spondylotic myelopathy commonly arises in the setting of a congenitally narrowed cervical canal [52]. It often does not become symptomatic until the later decades of life because the cord may have sufficient space to avoid compression until a threshold amount of space-occupying degenerative changes accumulate [52].

The natural history of cervical spondylotic myelopathy is characterized by stepwise deterioration in symptomatology followed by a period of stability in 65%–80% of cases [38]. Slowly progressive decline over months to years occurs in 20%–25% of cases [38]. Rapidly progressive decline over days to weeks occurs in 3%–5% of cases [38]. The natural history typically includes stable periods punctuated by unpredictable stepwise progression [52]. Dorsal column (proprioceptive) dysfunction occurs with advanced cervical myelopathy and carries a poor prognosis [52]. A compression ratio of less than 0.4 is associated with a poor prognosis in cervical myelopathy [52]. An increase in the compression ratio to more than 0.4 postoperatively correlates with clinical recovery [52]. Myeloradiculopathy is associated with spinal stenosis with concurrent compression of the neuroforaminal contents, which produces lower motor neuron signs at the level of the cervical cord lesion and upper motor neuron signs caudal to the level of compression [28]. The presence of cervical Modic changes did not impact clinical outcomes in cervical spine procedures [20].

Clinical Presentation & Examination Findings

Cervical radiculopathy symptoms may initially manifest as neck pain, then radicular symptoms develop [38]. Pain, numbness, and paresthesia in a dermatomal distribution to the upper extremity are common symptoms of cervical radiculopathy [38]. Sensory pain, numbness, or dysesthesias along dermatomal distribution are common in cervical radiculopathy [38]. Motor weakness in cervical radiculopathy is uncommon but, when present, is associated with the myotome [38]. Reflexes in cervical radiculopathy are typically normal or below normal (hyporeflexia) [38]. In cervical spondylotic radiculopathy, sensory involvement in the form of paresthesias or hyperesthesia is more common than motor or reflex changes [33]. Several dermatomal levels may be involved in cervical spondylotic radiculopathy, with radiation into the anterior chest and back [33]. Patients with cervical spondylotic radiculopathy typically have proximal arm pain and distal paresthesias [33].

Patients with disk degeneration may complain of axial neck pain that is often chronic and insidious in nature [28]. Patients with a cervical disk herniation will complain of a sudden and acute pain that is very intense [28]. Depending on the level of the herniation, patients will have loss of sensation and motor weakness in a distribution that is consistent with the nerve root affected [28]. The motor examination may be completely normal even in cases of nerve root or spinal cord compression [28]. When upper extremity weakness is present, it often presents as diminished grip and/or intrinsic strength [28]. The finding of severe weakness of major muscle groups in the upper or lower extremities is relatively uncommon [28]. Sensory examination findings in cervical degenerative disorders are often subtle [28].

The Spurling test involves rotation and lateral bend of the neck with vertical compression on the head; the occurrence of radicular symptoms during this test suggests nerve root pain [38]. Extension of the neck with rotation toward the side of neural impingement (Spurling sign) can reproduce the patient’s pain pattern in cervical spondylotic radiculopathy [33]. The shoulder abduction sign, defined as relief of radicular pain with shoulder abduction, is suggestive of a cervical etiology [38].

Hyperreflexia may be present in the upper and/or lower extremities and is suggestive of spinal cord compression with upper motor neuron signs [28]. Hyperreflexia findings can be masked or diminished in patients who have concomitant diabetes mellitus, peripheral neuropathy, or lumbar stenosis [28]. Spinal cord compression with myelopathy can manifest with abnormal upper motor neuron signs such as Hoffman’s sign, inverted radial reflex, pathological clonus, and Babinski’s sign [28]. The Hoffman’s sign is described as quick flexion of both the thumb and index finger when the middle finger nail is snapped [28]. Clonus is a series of abnormal reflex movements of the foot in plantar flexion, induced by sudden dorsiflexion [28]. The Babinski reflex occurs after the sole of the foot has been firmly stroked, resulting in the big toe moving upward or toward the top surface of the foot while the other toes fan out [28]. The inverted radial reflex is noted by flexion of the fingers without flexion of the forearm when the distal end of the radius is tapped [28]. Lhermitte’s sign is an electric shock-like sensation that runs down the center of the patient’s back and enters the limbs during flexion of the neck [28].

Myelopathy can often be accompanied by radicular findings in some patients [28]. Cervical myelopathy presents with a variety of subtle neurologic findings that can present insidiously [28]. Characteristic signs and symptoms of myelopathy include the loss of manual dexterity in the hands, weakness, stiffness, urinary symptoms, spasticity in their extremities, and gait disturbance including a stiff or spastic gait [28]. Patients with myelopathy demonstrate a wide-based gait and report a history of loss of balance and falls [28]. Sensory findings in myelopathy often include proprioceptive loss [28]. Patients with myelopathy may report difficulty with buttons, a change in their handwriting, or that they are dropping objects [28]. Generalized feeling of clumsiness of the arms and hands is a clinical manifestation of cervical myelopathy [52]. Inability to manipulate fine objects such as coins or buttons is a clinical manifestation of cervical myelopathy [52]. Trouble with handwriting is a clinical manifestation of cervical myelopathy [52]. Diffuse (typically nondermatomal) numbness is a clinical manifestation of cervical myelopathy [52]. Gait instability, described as a sense of imbalance and bumping into walls when walking, is a lower extremity symptom of cervical myelopathy [52]. Patients with severe cord compression may report the Lhermitte phenomenon: electric shock–like sensations that radiate down the spine or into the extremities with certain offending positions of the neck [52]. Subjective weakness, bowel and bladder symptoms, loss of motor strength, neck pain, and radicular symptoms or signs may occur late or not at all in cervical myelopathy [52]. Severe weakness of the major muscle groups in the upper or lower extremities is uncommon in cervical myelopathy [52].

Hyperreflexia, which may be present in the upper and/or lower extremities, suggests spinal cord compression [52]. Patients with concomitant myelopathy and peripheral nerve disease from conditions such as diabetes, hypothyroidism, peripheral neuropathy, or severe multilevel cervical foraminal stenosis can have diminished or absent reflexes [52]. Patients with cervical myelopathy who have coexisting lumbar stenosis may exhibit brisk upper extremity reflexes consistent with upper motor neuron findings yet diminished lower extremity reflexes because of the root level compression in the lumbar spine [52]. Finger clumsiness, deterioration of handwriting, difficulty in fine motor control of hands, and weakness of pinch are presenting symptoms of cervical myelopathy [38]. Ataxia with wide-based gait, leg heaviness, and inability to perform tandem walk are presenting symptoms of cervical myelopathy [38]. Urinary retention, urgency, or frequency are presenting symptoms of cervical myelopathy [38]. Lower extremity weakness (corticospinal tracts) can be associated with worse prognosis in cervical myelopathy [38]. The myelopathy hand and the finger escape sign (small finger spontaneously abducts because of weak intrinsic muscles) are physical examination findings in cervical myelopathy [38]. Funicular pain, described as central burning and stinging with or without Lhermitte sign, is a physical examination finding in cervical myelopathy [38]. Upper motor neuron findings are not always present in all patients with cervical myelopathy [38]. Upper extremities may have radicular (lower motor neuron) signs along with evidence of distal myelopathy [38].

Headache may be the presenting symptom of cervical spondylosis [33]. The headache associated with cervical spondylosis is usually worse in the morning and improves throughout the day [33]. The headache associated with cervical spondylosis is commonly located in the occipital region and radiates toward the frontal area [33]. Infrequently, patients with cervical spondylosis complain of a painful, stiff neck [33]. Signs of cervical spondylosis include decreased range of motion, crepitus, or both [33].

Classification

Cervical spondylosis encompasses three main categories: cervicalgia (non-radiating neck pain), cervical radiculopathy, and cervical myelopathy [27]. Cervical radiculopathy is a common condition that usually results from compression and inflammation of the cervical nerve root or roots in the region of the neural foramen [27]. Degenerative changes lead to decreases in canal and foraminal size [6]. Subluxation and hypermobility between vertebral bodies may occur with degenerative changes [6]. The dorsal root ganglion may be the source of pain, as it is exquisitely sensitive to deformation [6].

Other Considerations: A variety of disorders have a presentation similar to that of cervical radiculopathy [23]. A thorough history and physical examination can differentiate mimickers from cervical radiculopathy [23]. Entrapment neuropathies can mimic or coexist with cervical radiculopathy [27].

Clinical Presentation

Symptoms and History

Cervical radiculopathy is frequently caused by cervical disc herniation and cervical spondylosis [27]. Symptoms may initially manifest as neck pain, followed by the development of radicular symptoms [38]. Patients commonly present with shoulder and arm pain, paresthesias, and numbness [38]. Pain, numbness, or paresthesia in a dermatomal distribution to the upper extremity is characteristic of cervical radiculopathy [38]. In cervical spondylotic radiculopathy, the chief complaint is radiation of pain into the interscapular area and into the arm [33]. Patients typically have proximal arm pain and distal paresthesias [33]. Nerve root involvement can occur at one or more levels and may be unilateral or bilateral [33]. The onset of cervical spondylotic radiculopathy may be acute, subacute, or chronic [33]. In patients with symptoms present for approximately 6 weeks, 75% will respond to further conservative treatment over the next 6 weeks [10].

Cervical radiculopathy is characterized by motor, reflex, and/or sensory changes such as paraesthesia or numbness, often provoked by neck posture(s) and/or movement(s) [82]. Radicular pain is often described as “lancinating”, “shocking”, or “electric” [82]. Mixed pain presentations with nociceptive and/or neuropathic components are common in cervical radiculopathy [82]. Headache may be the presenting symptom of cervical spondylosis, usually located in the occipital region and radiating toward the frontal area [33]. Neck pain and cervical radiculopathy are common among orthopaedic surgeons, with associated factors including older age, higher stress levels, and performing arthroscopy [47].

Physical Examination Findings

Motor weakness is uncommon in cervical radiculopathy but, when present, is associated with the myotome [38]. Sensory findings of pain, numbness, or dysesthesias along a dermatomal distribution are common [38]. Reflexes are typically normal or below normal (hyporeflexia) in cervical radiculopathy [38]. The motor examination may be completely normal even in cases of nerve root compression [28]. Severe weakness of major muscle groups in the upper or lower extremities is relatively uncommon [28]. Sensory examination findings are often subtle [28]. C5 and C6 lesions can produce shoulder muscle atrophy [50]. Loss of cervical lordosis or posturing from paravertebral muscle spasm may be observed on physical examination [50]. Lack of point tenderness in the shoulder girdle area and point tenderness over the posterior cervical spine usually imply cervical spine pathology [50]. Painful neck motion with full and painless shoulder motion suggests cervical problems [50].

Extension of the neck with rotation toward the side of neural impingement (Spurling sign) can reproduce the patient’s pain pattern [33]. The Spurling test is not useful as a screening test but is clinically useful in helping to confirm a cervical radiculopathy [25]. Relief of radicular pain with shoulder abduction (shoulder abduction sign) is suggestive of a cervical etiology [38]. There is limited evidence for the accuracy of physical examination tests for the diagnosis of cervical radiculopathy [21]. Many items of the clinical examination are reliable and have acceptable diagnostic properties, but a test item cluster is more useful for indicating cervical radiculopathy than any single test item [45].

Anatomical and Pathophysiological Context

Cervical nerve roots exit above their corresponding vertebrae, such that the C5 root exits at the C4–C5 neural foramen [38]. Disc herniation at C5 to C6 involves the C6 nerve root [38]. Disc herniation at C7 to T1 involves the C8 nerve root [38]. The most frequently involved levels in cervical spondylosis are the more mobile segments: C5-C6, C6-C7, and C4-C5 [33]. Neurogenic chemical mediators of pain released from sensory neuron cell bodies and non-neurogenic mediators released from disc tissue may initiate and perpetuate an inflammatory response [6]. Chronic edema and fibrosis within the nerve root caused by compression can alter the response threshold and increase the sensitivity of the nerve root to pain [6]. Prolapsed nucleus pulposus elutes inflammatory mediators, initiating a local inflammatory response that leads to increased permeability at the dorsal root ganglion and pain [6]. Facet joint capsules contain sensory receptors that may play a role in pain and proprioceptive sensation in the cervical spine [34].

Differential Diagnosis and Mimickers

The differential diagnosis of unilateral upper-extremity pain, weakness, and sensory loss includes cervical radiculopathy, entrapment neuropathies, thoracic outlet syndrome, and neuralgic amyotrophy [85]. Shoulder pain can be produced by extrinsic causes such as cervical radiculopathy which may coexist with a rotator cuff tear [40]. Cervical disk disease and spondylosis often lead to pain in the neck and shoulder girdle area, which can be confused with shoulder pathology [50]. Pain that radiates and worsens with neck motion suggests cervical spine etiology, whereas pain made worse with shoulder movement or positional night pain is more likely to come from a shoulder condition [50]. Any myelopathic symptom, such as clumsiness or gait or balance disturbance, should alert the surgeon to closely evaluate the cervical spine [50]. Myeloradiculopathy is associated with spinal stenosis with concurrent compression of the neuroforaminal contents, producing lower motor neuron signs at the level of the cervical cord lesion and upper motor neuron signs caudal to the level of compression [28].

Investigations

Clinical Examination

The Spurling test is not useful as a screening test for cervical radiculopathy [25]. However, it is clinically useful in helping to confirm a cervical radiculopathy [25]. Future research should address issues to establish the clinical utility of the neurological examination for cervical radiculopathy [4].

Imaging

The diagnosis of cervical radiculopathy can be established by history and physical examination, but care should be taken as diagnoses can mimic or coexist with the condition [27]. Adequate imaging is essential to diagnosis of cervical spine disorders [74]. Imaging must include the entire cervical spine and the occipitocervical and cervicothoracic junctions [74]. Inadequate imaging will miss over 20% of cervical injuries [74].

Plain radiography: The lateral cervical spine view is the most important view in radiographic imaging of the cervical spine [74].

CT: CT scans allow excellent visualization of the bony architecture and the paravertebral soft tissues of the cervical spine [74]. CT is an appropriate modality for evaluating congenital variations and malformations, including spinal canal stenosis and spina bifida [74]. Although cervical disk disease is detectable when thin cuts and contrast enhancement are used with CT, it is better visualized with MRI [74]. In the trauma patient with questionable findings on plain radiographs, CT is integral in evaluating possible fractures or instability [74]. With the advent of MRI, CT is now reserved for the assessment of the bony architecture, which it does better than MRI [74]. Advances in computed tomography scanning allow better diagnosis of the cause of radiculopathy in the presence of a cervical block vertebra [17].

MRI: MRI is complementary to CT, with its primary role being to evaluate the integrity of the spinal cord and soft tissues supporting the spine after an injury [77]. MRI allows for a more detailed assessment of the integrity of the posterior ligamentous complex, anterior longitudinal ligament, posterior longitudinal ligament, intervertebral disc, and other surrounding soft tissues [77]. MRI plays an important role in characterizing the degree of spinal cord injury by providing a better assessment of the degree of edema, compression, and continuity of the spinal cord and nerve roots [77]. The presence and extent of spinal cord signal and of hematoma within the spinal cord are helpful in determining the prognosis for neurologic recovery [77]. The relatively low specificity of MRI in distinguishing clinically relevant tension band injuries from less worrisome soft tissue injuries means that indiscriminately relying on MRI findings may result in overestimating the degree of spinal instability [77]. MRI is used primarily as a complementary study to CT, particularly when there is the need to evaluate spinal cord integrity or compression [77]. In patients with cervical radiculopathy, the type and extent of disc herniation measured on MRI prior to surgery correlated neither to the severity of the symptoms at presentation nor to clinical outcomes at two years postoperatively [12].

Electrodiagnostics and Injection Studies

EMG should always be used in conjunction with MRI scan for the evaluation of patients with cervical radiculopathy, especially if surgery is to be considered [37]. Findings of discography and provocative injections of the facet joint have supported the role of these structures in the causation of neck pain [6]. CT discography is a useful adjuvant in the precise diagnosis of pure foraminal-type cervical disc herniation [24]. The ability of pressure-controlled discography to predict surgical and nonsurgical outcomes has been evaluated [24].

Diagnostic Criteria and Guidelines

The definition provided by AIM for neurologic symptoms includes “documented abnormality on neurologic examination in a dermatomal/radicular distribution that has not been previously imaged or has progressed since a prior imaging study has been conducted” [36]. MCG and NIA guidelines require “new or worsening deficits on examination,” for which weakness and “new onset of abnormal sensory changes along a particular dermatome” are included [36]. EVG guidelines define “3/5 motor weakness” and “severe radicular pain with documented significant functional loss and unresponsive to seven days of provider-directed treatment” as indications for MRI [36].

Treatment

Non-Operative

Acute cervical radiculopathy generally follows a self-limited clinical course, with up to a 75% rate of spontaneous improvement [11]. For mild degenerative cervical conditions, nonsurgical options may be tried with careful observation [22]. Nonsurgical treatment for cervical radiculopathy includes nonsteroidal anti-inflammatory drugs (NSAIDs), cervical epidural injections, isometric exercises, traction, and occasionally temporary collar immobilization [38].

Operative

Indications: Surgical intervention is indicated for cervical radiculopathy when there is progressive motor weakness or persistent disabling pain despite conservative measures [38]. The indication for surgical resection includes intractable radicular symptoms with correlating radiographic evidence of lateral recess, foraminal, or central stenosis [30]. Surgical intervention has shown to be superior for cervical degenerative conditions where there is symptomatic moderate to severe spinal cord and nerve root compression [22].

Surgical Approach / Technique: Anterior cervical discectomy and fusion (ACDF) involves removal of the herniated disc with excision of associated osteophytes followed by strut graft fusion with or without instrumentation [38]. Anterior cervical corpectomy and fusion (ACCF) is necessary if neural compression is due to pathology behind the vertebral body, involving removal of the vertebral body with subsequent bony fusion [38]. Posterior keyhole laminoforaminotomy is an option for radiculopathy secondary to posterior compression (facet hypertrophy) or for lateral soft disc herniations [38]. Central disc herniations are a contraindication to posterior keyhole laminoforaminotomy because of the inability to safely access the herniation [38]. In a single-center series, posterior foraminotomy (PF) was considered the first-line treatment if the morphology of the pathology is suitable, due to better overall outcome and greater relief of radicular and neck pain [18]. Tandem keyhole foraminotomy (TKF) is a safe and highly effective procedure for patients with cervical radiculopathy and requires no invasive preoperative examination [29]. Unilateral biportal endoscopic decompression can be used safely and effectively as an alternative to ACDF for treating unilateral cervical radiculopathy or coexisting cervical myelopathy [41]. Three anterior cervical surgical approaches have good curative effects on single level cervical spondylotic myelopathy [123].

Implant Selection: Application of anterior plating may increase the fusion rate in multilevel discectomies with fusion and will protect a strut graft in multilevel corpectomies [38]. While both stand-alone titanium cage and cage with plate fixation are effective for managing two-level cervical disc herniation, each approach has distinct advantages and limitations [137]. Cervical total disc replacement aims to maintain normal kinematics at the index level, thereby reducing the stress experienced at adjacent segments [38]. Indications for cervical total disc replacement include patients with cervical radiculopathy and/or myelopathy secondary to single-level spondylosis [38]. The US Food and Drug Administration recently approved Simplify (Nuvasive) for two-level disease in cervical total disc replacement [38]. Contraindications for cervical total disc replacement include cervical deformity, segmental spinal instability, facet arthropathy, and inability to adequately visualize the implant on intraoperative fluoroscopy [38].

Comparative Outcomes: After a 2-year follow-up, posterior surgery was noninferior to anterior surgery with regard to the success rate and arm pain reduction in patients with cervical radiculopathy [26]. Among patients with single-level unilateral cervical radiculopathy, posterior cervical foraminotomy (PCF) has comparable effectiveness and complication rate compared with ACDF [88]. In appropriately selected patients, cervical disc replacement demonstrated equivalent patient-reported outcomes and lower reoperation rates compared to ACDF at 7- and 10-year follow-up [38]. In patients with cervical radiculopathy, arthroplasty and fusion did not differ for disability, quality of life, or pain at 5 years [15].

Setting of Care: After ACDF for cervical radiculopathy, postoperative ambulatory care was noninferior to inpatient overnight surveillance for neck-pain-related disability at 6 months [31].

Other Considerations: Formation of heterotopic bone is specific to cervical disc arthroplasty and occurs in between 7.3% and 69.2% of cases [38]. The type and extent of disc herniation measured on MRI prior to surgery correlated neither to the severity of the symptoms at presentation, nor to clinical outcomes at two years postoperatively in patients with cervical radiculopathy [12]. Important racial and ethnic disparities exist in cervical radiculopathy treatment, with Black patients less likely to undergo cervical disc replacement (CDR) than ACDF and Hispanic patients having higher complication rates [54].

Complications

Intravascular Penetration: The incidence of intravascular penetration associated with transforaminal cervical epidural steroid injections has been characterized in the literature [24].

Nerve Root Injection Complications: Complications and side effects of cervical and lumbosacral selective nerve root injections have been documented [24].

Other Considerations: Complications of fluoroscopically guided extraforaminal cervical nerve blocks were analyzed in a study of 1036 injections [24].

Recovery

Non-Operative Recovery

Other Considerations: Most patients with cervical radiculopathy will improve with nonoperative treatment [2]. In patients in whom symptoms of cervical radiculopathy were present for approximately 6 weeks, 75% will respond to further conservative treatment (halter traction and cervical collar) over the next 6 weeks [10].

Operative Recovery

Other Considerations: Despite initially more neck pain after posterior surgery, patients swiftly improved and, as of postoperative week 5, results similar to those after anterior surgery were observed [142]. Patients undergoing CDR at C5-C6 demonstrated an improved ability to maintain 1-year postoperative progress for neck disability with improved 1-year NDI MCID achievement [110]. Single-segment ACDR may improve the functional outcome of patients with cervical spondylotic radiculopathy [16]. No iatrogenic progressive radiculopathy nor myelopathy was observed in the 3D-printed spacer group [56].

Key Evidence

  • [Paper] This article is a clinical practice review of cervical radiculopathy, covering diagnosis, epidemiology, and management strategies. [1] (10.1056/nejmcp043887)
  • [L4] Most patients with cervical radiculopathy will improve with nonoperative treatment, while a small percentage will require further diagnostic evaluation and ultimately surgical intervention. [2] (10.5435/00124635-199611000-00003)
  • [L4] Future research should address these issues to establish the clinical utility of the neurological examination for cervical radiculopathy. [4] (10.1186/s12891-025-08560-9)
  • [L5] [6] (10.2106/00004623-200706000-00026)
  • [L1] On the basis of clinical outcome and safety, there is no superior surgical intervention for pure cervical radiculopathy. [8] (10.2106/jbjs.20.00324)
  • [L3] The clinical effectiveness of surgery for degenerative cervical radiculopathy performed in public and private hospitals was equivalent 12 months after surgery. [9] (10.1302/0301-620x.105b1.bjj-2022-0591.r1)
  • [L4] It would appear that in patients in whom symptoms of cervical radiculopathy were present for approximately 6 weeks that 75% will respond to further conservative treatment (halter traction and cervical collar) over the next 6 weeks. [10] (10.3171/foc.2002.12.2.4)
  • [L5] Acute cervical radiculopathy generally has a self-limited clinical course, with up to a 75% rate of spontaneous improvement, making nonsurgical treatment the appropriate initial approach for most patients. [11] (10.5435/00124635-200708000-00005)
  • [L2] In patients with cervical radiculopathy, the type and extent of disc herniation measured on MRI prior to surgery correlated neither to the severity of the symptoms at presentation, nor to clinical outcomes at two years postoperatively. [12] (10.1302/0301-620x.104b11.bjj-2022-0657.r2)
  • [L1] In patients with cervical radiculopathy, arthroplasty and fusion did not differ for disability, quality of life, or pain at 5 years. [15] (10.2106/jbjs.22.00305)
  • [L3] Single-segment ACDR may improve the functional outcome of patients with cervical spondylotic radiculopathy. [16] (10.1186/s12891-022-05705-y)
  • [L4] Due to a better overall outcome as well as greater relief of radicular and neck pain in our cohort, we consider PF the first-line treatment if morphology of the pathology is suitable. [18] (10.1055/s-0037-1607225)
  • [L1] The presence of cervical Modic changes did not impact clinical outcomes in cervical spine procedures. [20] (10.3390/ijerph191610158)
  • [L4] There is limited evidence for accuracy of physical examination tests for the diagnosis of cervical radiculopathy. [21] (10.1016/j.spinee.2017.08.241)
  • [L4] A variety of disorders have a presentation similar to that of cervical radiculopathy, and a thorough history and physical examination can differentiate mimickers from cervical radiculopathy. [23] (10.2106/jbjs.rvw.m.00080)
  • [L4] Therefore, it is not useful as a screening test, but it is clinically useful in helping to confirm a cervical radiculopathy. [25] (10.1097/00007632-200201150-00007)
  • [L1] This trial demonstrated that, after a 2-year follow-up, posterior surgery was noninferior to anterior surgery with regard to the success rate and arm pain reduction in patients with cervical radiculopathy. [26] (10.2106/jbjs.23.00775)
  • [L5] [27] (10.1227/01.neu.0000249223.51871.c2)
  • [L4] TKF is a safe and highly effective procedure for patients with cervical radiculopathy and requires no invasive preoperative examination. [29] (10.1186/1749-799x-9-38)
  • [L4] The indication for resection includes intractable radicular symptoms with correlating radiographic evidence of lateral recess, foraminal, or central stenosis. [30] (10.1097/bsd.0000000000000284)
  • [L1] After ACDF for cervical radiculopathy, postoperative ambulatory care was noninferior to inpatient overnight surveillance for neck-pain-related disability at 6 months. [31] (10.2106/jbjs.25.00633)
  • [L4] If there is a greater than 50% surgery avoidance rate with injections, then cervical epidural injections would be considered a cost-effective strategy with a role in the management of cervical radiculopathy before surgery. [32] (10.5435/jaaos-d-17-00379)
  • [L4] [36] (10.5435/jaaos-d-22-00517)
  • [L2] EMG, therefore, should always be used in conjunction with MRI scan for the evaluation of patient with cervical radiculopathy, especially if surgery is to be considered. [37] (10.1007/s00586-006-0189-6)
  • [L5] This review examines the overlap between rotator cuff tears and cervical radiculopathy, noting that shoulder pain can be produced by extrinsic causes such as cervical radiculopathy which may coexist with a cuff tear and influence the treatment process. [40] (10.1016/j.jse.2010.05.007)
  • [L1] Consequently, this procedure can be used safely and effectively as an alternative to ACDF for treating unilateral cervical radiculopathy or coexisting cervical myelopathy. [41] (10.1186/s12891-024-07697-3)
  • [L2] Many items of the clinical examination were found to be reliable and to have acceptable diagnostic properties, but the test item cluster identified was more useful for indicating cervical radiculopathy than any single test item. [45] (10.1097/00007632-200301010-00014)
  • [L3] Neck pain and cervical radiculopathy/myelopathy are common among orthopaedic surgeons, with associated factors including older age, higher stress levels, and performing arthroscopy. [47] (10.5435/jaaos-d-19-00834)
  • [L5] [51] (10.1016/j.jhsa.2013.07.020)
  • [L4] Important racial and ethnic disparities exist in cervical radiculopathy treatment, with Black patients less likely to undergo CDR than ACDF and Hispanic patients having higher complication rates. [54] (10.5435/jaaos-d-21-01017)
  • [L4] Not a single case of neurologic progression was observed in the 3D-printed spacer group— no iatrogenic progressive radiculopathy nor myelopathy, unlike the control group. [56] (10.5435/jaaosglobal-d-24-00245)
  • [L1] [82] (10.1186/s12891-026-09551-0)
  • [L5] The differential diagnosis of unilateral upper-extremity pain, weakness, and sensory loss includes cervical radiculopathy, entrapment neuropathies, thoracic outlet syndrome, and neuralgic amyotrophy. [85] (10.3171/spi.2004.1.2.0179)
  • [L1] Among patients with single-level unilateral cervical radiculopathy, PCF has comparable effectiveness and complication rate compared with ACDF. [88] (10.1186/s13018-020-01723-5)
  • [L3] Both procedural cohorts demonstrated similar long-term clinical outcomes for arm/neck pain and physical function; however, patients undergoing CDR at C5-C6 demonstrated an improved ability to maintain 1-year postoperative progress for neck disability with improved 1-year NDI MCID achievement. [110] (10.5435/jaaos-d-21-01276)
  • [L3] Three anterior cervical surgical approaches have good curative effects on single level cervical spondylotic myelopathy. [123] (10.1186/1471-2474-15-233)
  • [L3] While both approaches are effective for managing cervical disc herniation, each has distinct advantages and limitations. [137] (10.1186/s13018-025-05654-x)
  • [L1] Despite initially more neck pain after posterior surgery, patients swiftly improved and, as of postoperative week 5, results similar to those after anterior surgery were observed. [142] (10.2106/jbjs.22.01211)

See Also

References

[1] Cervical Radiculopathy. New England Journal of Medicine. 2005. DOI: 10.1056/nejmcp043887

[2] Cervical Radiculopathy: Diagnosis and Nonoperative Management. Journal of the American Academy of Orthopaedic Surgeons. 1996. DOI: 10.5435/00124635-199611000-00003

[4] Neurological examination for cervical radiculopathy: a scoping review. BMC Musculoskeletal Disorders. 2025. DOI: 10.1186/s12891-025-08560-9

[6] Degenerative Cervical Spondylosis. The Journal of Bone & Joint Surgery. 2007. DOI: 10.2106/00004623-200706000-00026

[8] Surgical Interventions for Cervical Radiculopathy without Myelopathy. Journal of Bone and Joint Surgery. 2020. DOI: 10.2106/jbjs.20.00324

[9] Clinical outcomes after surgery for cervical radiculopathy performed in public and private hospitals. The Bone & Joint Journal. 2023. DOI: 10.1302/0301-620x.105b1.bjj-2022-0591.r1

[10] Results of halter cervical traction for the treatment of cervical radiculopathy: retrospective review of 81 patients. Neurosurgical Focus. 2002. DOI: 10.3171/foc.2002.12.2.4

[11] Cervical Radiculopathy. Journal of the American Academy of Orthopaedic Surgeons. 2007. DOI: 10.5435/00124635-200708000-00005

[12] The type of cervical disc herniation on MRI does not correlate to clinical outcomes. The Bone & Joint Journal. 2022. DOI: 10.1302/0301-620x.104b11.bjj-2022-0657.r2

[15] In Patients with Cervical Radiculopathy, Arthroplasty and Fusion Surgical Treatment Did Not Differ for Disability at 5 Years. Journal of Bone and Joint Surgery. 2022. DOI: 10.2106/jbjs.22.00305

[16] Effect of facet joint distraction on the functional and radiological outcomes after anterior cervical disc replacement. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-05705-y

[17] Cervical radiculopathy associated with an anomaly of the cervical vertebrae: successful surgical treatment. A case report.. The Journal of Bone and Joint Surgery. American Volume. 1988.

[18] Anterior Cervical Decompression and Fusion or Posterior Foraminotomy for Cervical Radiculopathy: Results of a Single-Center Series. Journal of Neurological Surgery Part A: Central European Neurosurgery. 2017. DOI: 10.1055/s-0037-1607225

[20] Evaluating the Impact of Modic Changes on Operative Treatment in the Cervical and Lumbar Spine: A Systematic Review and Meta-Analysis. International Journal of Environmental Research and Public Health. 2022. DOI: 10.3390/ijerph191610158

[21] Value of physical tests in diagnosing cervical radiculopathy: a systematic review. The Spine Journal. 2018. DOI: 10.1016/j.spinee.2017.08.241

[22] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Cervical Degenerative Conditions > Summary.

[23] Mimickers of Cervical Radiculopathy. JBJS Reviews. 2014. DOI: 10.2106/jbjs.rvw.m.00080

[24] Campbell S Operative Orthopaedics 4 Volume Set. FIBULAR STRUT GRAFT IN CERVICAL SPINE ARTHRODESIS WITH CORPECTOMY > INJECTION STUDIES.

[25] The Spurling Test and Cervical Radiculopathy. Spine. 2002. DOI: 10.1097/00007632-200201150-00007

[26] Posterior Cervical Foraminotomy Compared with Anterior Cervical Discectomy with Fusion for Cervical Radiculopathy. Journal of Bone and Joint Surgery. 2024. DOI: 10.2106/jbjs.23.00775

[27] CERVICAL RADICULOPATHY. Neurosurgery. 2007. DOI: 10.1227/01.neu.0000249223.51871.c2

[28] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Cervical Degenerative Conditions > Evaluation.

[29] Tandem keyhole foraminotomy in the treatment of cervical radiculopathy: retrospective review of 35 cases. Journal of Orthopaedic Surgery and Research. 2014. DOI: 10.1186/1749-799x-9-38

[30] Cervical Radiculopathy. Journal of Spinal Disorders & Techniques. 2015. DOI: 10.1097/bsd.0000000000000284

[31] After ACDF for Cervical Radiculopathy, Postoperative Ambulatory Care Was Noninferior to Inpatient Overnight Surveillance for Neck-Pain-Related Disability at 6 Months. Journal of Bone and Joint Surgery. 2025. DOI: 10.2106/jbjs.25.00633

[32] Economic and Outcomes Analysis of Recalcitrant Cervical Radiculopathy: Is Nonsurgical Management or Surgery More Cost-Effective?. Journal of the American Academy of Orthopaedic Surgeons. 2019. DOI: 10.5435/jaaos-d-17-00379

[33] A Lange Medical Book Current Diagnosis Treatment In Orthopedics Fifth Edition. 4Disorders, Diseases, and Injuries of the Spine > CERVICAL SPONDYLOSIS.

[34] Miller S Review Of Orthopaedics. CERVICAL SPINE.

[36] Comparison of Clinical Guidelines for Authorization of MRI in the Evaluation of Neck Pain and Cervical Radiculopathy in the United States. Journal of the American Academy of Orthopaedic Surgeons. 2023. DOI: 10.5435/jaaos-d-22-00517

[37] The value of neurophysiological and imaging studies in predicting outcome in the surgical treatment of cervical radiculopathy. European Spine Journal. 2006. DOI: 10.1007/s00586-006-0189-6

[38] Miller S Review Of Orthopaedics. 2. Discogenic neck pain > 3. Cervical radiculopathy.

[40] Rotator cuff tears with cervical radiculopathy. Journal of Shoulder and Elbow Surgery. 2010. DOI: 10.1016/j.jse.2010.05.007

[41] Unilateral biportal endoscopic decompression versus anterior cervical decompression and fusion for unilateral cervical radiculopathy or coexisting cervical myelopathy: a prospective, randomized, controlled, noninferiority trial. BMC Musculoskeletal Disorders. 2024. DOI: 10.1186/s12891-024-07697-3

[44] Orthopaedic Knowledge Update 13 Ebook Without Multimedia. Cervical Degenerative Conditions > Introduction.

[45] Reliability and Diagnostic Accuracy of the Clinical Examination and Patient Self-Report Measures for Cervical Radiculopathy. Spine. 2003. DOI: 10.1097/00007632-200301010-00014

[47] Occupation-related Cervical Spine Disease in Orthopaedic Surgeons. Journal of the American Academy of Orthopaedic Surgeons. 2020. DOI: 10.5435/jaaos-d-19-00834

[49] Campbell S Operative Orthopaedics 4 Volume Set. POSTERIOR APPROACH TO THE LUMBAR SPINE, L1 TO L5 > OVERVIEW OF DISC DEGENERATION AND HERNIATION IN THE CERVICAL SPINE.

[50] Rockwood And Matsen S The Shoulder. Risk Factors for Failure of Arthroscopic Stabilization > Cervical Radiculitis.

[51] Cervical Radiculopathy and Myelopathy: Presentations in the Hand. The Journal of Hand Surgery. 2013. DOI: 10.1016/j.jhsa.2013.07.020

[52] Aaos Comprehensive Orthopaedic Review 3. Degenerative Conditions of the Cervical Spine > IV. Cervical Myelopathy.

[54] Gender, Racial, and Ethnic Differences in the Utilization of Cervical Disk Replacement for Cervical Radiculopathy. Journal of the American Academy of Orthopaedic Surgeons. 2022. DOI: 10.5435/jaaos-d-21-01017

[56] Three-Dimensional Printed Anterior Cervical Standalone Combined Cage-Plate—300 Consecutive Medical Implants. JAAOS: Global Research and Reviews. 2025. DOI: 10.5435/jaaosglobal-d-24-00245

[74] A Lange Medical Book Current Diagnosis Treatment In Orthopedics Fifth Edition. 4Disorders, Diseases, and Injuries of the Spine > Image DISEASES AND DISORDERS OF THE CERVICAL SPINE.

[77] Rockwood And Green S Fractures In Adults. Imaging of Cervical Spine Fractures and Dislocations > Magnetic Resonance Imaging.

[82] Diagnostic accuracy of physical examination tests for painful cervical radiculopathy: update of a systematic review and meta-analysis. BMC Musculoskeletal Disorders. 2026. DOI: 10.1186/s12891-026-09551-0

[85] Cervical radiculopathy, entrapment neuropathy, and thoracic outlet syndrome: how to differentiate?. Journal of Neurosurgery: Spine. 2004. DOI: 10.3171/spi.2004.1.2.0179

[88] Anterior cervical discectomy and fusion versus posterior cervical foraminotomy for the treatment of single-level unilateral cervical radiculopathy: a meta-analysis. Journal of Orthopaedic Surgery and Research. 2020. DOI: 10.1186/s13018-020-01723-5

[110] Level-specific Perioperative and Clinical Outcome Comparison: Cervical Disk Replacement Versus Anterior Cervical Diskectomy and Fusion at C5-C6 in Patients With Myeloradiculopathy. Journal of the American Academy of Orthopaedic Surgeons. 2022. DOI: 10.5435/jaaos-d-21-01276

[123] Comparisons of three anterior cervical surgeries in treating cervical spondylotic myelopathy. BMC Musculoskeletal Disorders. 2014. DOI: 10.1186/1471-2474-15-233

[137] A retrospective comparative analysis of anterior cervical discectomy and fusion using stand-alone titanium cage versus cage and plate fixation in two-level cervical disc herniation. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-05654-x

[142] Short-Term Neck Pain After Posterior Foraminotomy Compared with Anterior Discectomy with Fusion for Cervical Foraminal Radiculopathy. Journal of Bone and Joint Surgery. 2023. DOI: 10.2106/jbjs.22.01211

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