There are eight pairs of cervical nerves; each exits the spinal cord and enters their respective foramina in a relatively horizontal orientation (4). The nerves exit above their respective numbered vertebral body. For example, the C5 exits at the C4/C5 neuroforamina. A transition in numbering occurs at the cervicothoracic junction. At the C8/T1 neuroforamina, the C8 nerve exits. At T1/T2, the T1 nerve exits, and all nerve roots below this level exit caudal to their numerical vertebrae.

The cervical nerve root may be compressed from a variety of pathologic conditions. From a degenerative disease perspective, osteophytosis of the end plates or soft disk protrusion or bulge may compress the nerve at the medial foramen. Within the foramen, the nerve may be compressed by uncovertebral or facet spurring or lateral disk herniations.

Patients often complain of intense, stabbing, or burning pain. The pain usually corresponds to a specific dermatome; often, the patient is able to accurately localize the pain. Maneuvers such as coughing may exacerbate the pain, and the pain may be relieved by placing the hand on top of the head (abduction relief sign). There may also be concomitant paresthesias, and these may precede the occurrence of pain. The paresthesias tend to present more caudally, while the pain is often in a more proximal location and at times more diffuse and less localizing. Weakness may also be evident to the patient, and if longstanding, there may be muscle atrophy. In almost all cases, dorsal cervical pain is present (5).

Careful attention to the location of pain and paresthesias may aid in the localization of the surgical lesion. A study by Yoss et al. (5) found that in C5 radiculopathy pain did not occur distal to the elbow and paresthesias were absent from the hand. With C6 compression, pain was localized in the radial forearm and the thumb was paresthetic. In the authors’ experience, the pain in the forearm may be deep and achy. In C7 compression, pain was diffuse in the volar and dorsal forearm and the middle finger was paresthetic. With C8 involvement, pain was in the ulnar forearm and paresthesias were localized to the little and ring fingers.

When taking the patient’s history, one should make note of shoulder pain with movement, shortness of breath or chest pain, and hand pain or paresthesias, which wake the patient at night. A history of trauma, prior cervical surgery, fevers, night sweats, or cancer should be noted. Problems with gait or bowel and bladder incontinence make the diagnosis of myelopathy more likely.

The physical examination should incorporate motor, sensory, reflex, and gait testing. Shoulder abduction, external rotation, elbow flexion/extension, forearm pronation, wrist extension, grip, and finger abduction should be tested. Sensation to light touch and pin prick should be assessed in all upper extremity dermatomes and also in the major lower extremity dermatomes. The biceps, triceps, brachioradialis, and pectoral reflexes should be examined. Lower extremity reflexes should also be included for comparison. Signs of upper motor neuron injury should also be sought, such as Hoffman’s sign and the Babinski response. The patient’s gait should be assessed. This may be accomplished as the patient enters the examination room. The patient should be asked to walk in a heel-to-toe fashion (tandem gait) in a search for signs of myelopathy. The cervical range of motion should be evaluated, and tests used to exaggerate the pain, such as Spurling’s sign, may be used.

Yoss et al.’ (5) series demonstrated that C5 compression leads to weakness in the supraspinatus and infraspinatus, deltoid, biceps, and rhomboid muscles. Findings may include weakness of shoulder abduction, external rotation, or pronation of the arm. C6 involvement affected the biceps and brachioradialis, leading to weakness in elbow flexion and arm pronation. A C7 lesion leads to weakness in elbow extension and also wrist and finger extension. Depression of reflexes was less specific in Yoss et al.’ series (5). Although reflexes were found to be less specific, it is generally accepted that with a C5 radiculopathy, there is a diminished or absent pectoral reflex. The reflex affected for C6 is biceps and brachioradialis, and for C7, the triceps. Table 15.1 offers a comprehensive review of the signs and symptoms of cervical radiculopathy.

The diagnosis of cervical radiculopathy and the level involved may be gleaned solely from the history and physical examination. Imaging should be used for confirmation of the clinical findings. Plain radiographs are usually ordered first, but they usually contributed little to the diagnosis of cervical radiculopathy. The incidence of cervical spondylosis is 96% to 100% by age 70 years (6). Most cervical radiographs, therefore, will show some amount of spondylosis. Despite the aforementioned shortcomings, cervical radiographs are able to provide valuable information regarding the presence of deformity, instability, congenital anomalies, infection, and neoplasia (7). Oblique radiographs are at time helpful in determining the presence of foraminal stenosis.