Last revised in January 2009 Neck pain - cervical radiculopathy

NICE GUIDELINES

Cervical radiculopathy is usually due to compression or injury to a nerve root in the cervical spine. This may present as pain, motor dysfunction, sensory deficits, or alteration in tendon reflexes. The most common causes of cervical radiculopathy are cervical disc herniation and degenerative changes. Levels C5 to T1 are most commonly affected. Assessment of a person with neck pain includes: Cervical radiculopathy should be suspected if there is unilateral neck, shoulder, or arm pain that approximates to a dermatome. There may be altered sensation or numbness, or weakness in related muscles. Levels C5 to T1 are most commonly affected. Retro-orbital and temporal pain suggests referral from the upper cervical levels (C1 to C3) and can mimic giant cell arteritis. Excluding non-musculoskeletal causes, such as cardiovascular, respiratory, and oesophageal diseases, and acute upper respiratory tract infection and sore throat. Looking for 'red flag' features suggestive of a serious spinal or other abnormality, Examining for signs of cervical radiculopathy, including postural asymmetry, muscle wasting, restricted and painful neck movements, and neurological signs such as upper limb weakness, paraesthesiae, and dermatomal sensory or motor deficits. Identifying psychosocial factors that may indicate increased risk for chronicity and disability. Identifying any excessive concerns about the neck pain, unrealistic expectations of treatment, disabling sickness behaviour, and problems with compensation, work, family,

mood, and emotions. Identify risk factors for developing neck pain (e.g. workplace associated risks and excessive use of pillows). Cervical X-rays, and other imaging studies and investigations are not routinely required to diagnose or assess neck pain with radiculopathy. If 'red flag' features are present, referral (or admission) should be arranged, depending on the severity of the clinical findings. Immediate specialist advice should be sought if the person has severe or progressive motor weakness, or severe or progressive sensory loss. Signs of serious spinal or other abnormalities include: Compression of the spinal cord (myelopathy) neurological symptoms and signs, sensory changes. Cancer, infection, or inflammation malaise, fever, unexplained weight loss; unremitting pain affecting sleep; lymphadenopathy; bony tenderness. Severe trauma or skeletal injury a history of violent trauma, neck surgery, risk factors for osteoporosis. Vascular insufficiency dizziness and blackouts on movement and extension of the neck, or drop attacks. For people with neck pain for less than 46 weeks and no objective neurological signs, management includes: Providing reassurance and information 90% of people are either asymptomatic or only mildly symptomatic after 5 years. Offering simple analgesia to relieve symptoms. For people with cervical radiculopathy that has been present for 6 weeks, or objective neurological signs, management includes:

Referral to confirm the diagnosis with magnetic resonance imaging, and to consider invasive procedures, such as interlaminar cervical epidural injections, transforaminal injections, or spinal surgery. Offering analgesia to relieve symptoms, such as paracetamol or ibuprofen as required. Considering a trial of a low-dose tricyclic antidepressant (for example, start with amitriptyline 1025 mg and titrate accordingly) if the pain is unresponsive to full-dose standard analgesics.