Cervical Radiculopathy (Brachialgia)

Axial cervical spine: normal (left) versus posterolateral disc herniation compressing the nerve root (right).

By far the most common cause is a cervical disc herniation (also known as a “slipped disc” or “prolapsed disc”). Intervertebral discs sit between each vertebra and act as shock absorbers. With age, repetitive load or injury, the tough outer ring can tear, allowing the inner gel to herniate into the spinal canal or neural foramen and compress or inflame the adjacent nerve root. The most commonly affected levels are C5/6 and C6/7, accounting for the majority of cases.

Less common causes include:

• Foraminal stenosis — bony narrowing of the nerve exit channel, typically from a combination of loss of disc height and bony facet or uncovertebral joint arthritic overgrowth.
• Spondylolisthesis — forward slippage of one vertebra on the one below.
• Synovial cysts — fluid-filled sacs arising from the facet joints.
• Tumour or infection — uncommon but important to exclude

Symptoms depend on which nerve is involved but typically include:

• Arm pain that is sharp, burning, electric or shooting in nature, radiating from the neck into the shoulder, arm or hand — often more severe than any associated neck pain. The distribution of arm pain guides the treating doctor as to which nerve is involved.
• Pain aggravated by neck extension, lateral rotation, or Valsalva manoeuvres (coughing, sneezing, straining).
• Numbness or pins-and-needles in the affected nerve distribution.
• Weakness of specific muscle groups (e.g. deltoid weakness with C5, wrist extension weakness with C6, tricep or finger extension weakness with C7).

A large central disc herniation or severe cervical spondylosis may compress the spinal cord itself (not just the nerve root), causing cervical myelopathy. This is a serious and potentially irreversible condition. Unlike radiculopathy, myelopathy typically worsens progressively without surgery. Warning features include:

• Clumsy or weak hands — difficulty with fine motor tasks such as buttoning clothes, writing or placing a key in a lock.
• Unsteady gait or difficulty walking.
• New numbness or electric sensations running down the spine or into the limbs with neck flexion (Lhermitte’s sign).
• Difficulty with bladder or bowel control.

If any of these symptoms develop, seek urgent medical review — do not wait.

The diagnosis is primarily clinical, based on a careful history and examination. Imaging confirms the anatomical cause:

• MRI — gold standard; provides detailed images of discs, nerves and spinal cord without radiation.
• CT scan — useful when MRI cannot be performed; excellent for bony anatomy and foraminal stenosis.
• Plain X-rays — assesses alignment and instability; useful with flexion/extension views.
• Nerve conduction studies (NCS/EMG) — occasionally helpful when the diagnosis is uncertain or peripheral nerve compression (e.g. carpal tunnel syndrome) needs to be excluded.

Most patients are managed conservatively in the first instance:

• Activity modification — gentle activity is encouraged, avoiding high impact activities.
• Analgesics — paracetamol and NSAIDs (e.g. ibuprofen, naproxen, celecoxib) are first line; short courses of steroids may occasionally be needed.
• Neuropathic agents — amitriptyline, gabapentin (Neurontin) or pregabalin (Lyrica) help reduce burning and electric pain; common side effects include drowsiness and brain fog.
• Physiotherapy — once severe acute pain has improved, for neck strengthening, posture and flexibility; traction-based programs may provide additional relief.
• Image-guided cervical injections — CT guided corticosteroid injection to the affected nerve root; significant relief in 50–80% of patients, rarely lasts beyond a month.

Surgery is indicated for arm pain rather than neck pain, and is considered when:

• Conservative treatment has failed after an adequate trial (typically 6–12 weeks).
• Pain is severe and disabling.
• There is significant or progressive neurological weakness.
• Cervical myelopathy is present — surgery is generally recommended to prevent further deterioration.

Three main operations are performed for cervical radiculopathy:

Anterior cervical discectomy and fusion (ACDF) is the most common procedure. Under general anaesthesia, a small incision (3–4 cm) is made on the front of the neck. The disc is removed and the affected nerve decompressed. A cage filled with bone graft is inserted to maintain disc height and the adjacent vertebrae are fused. Most patients stay one night and are mobile the same day. 85–95% experience significant or complete relief of arm pain. ACDF is preferred for patients with significant instability, multilevel disease, or where the anatomy is not suitable for motion-preserving surgery.

Cervical disc arthroplasty or artificial disc replacement (ADR) is an alternative to ACDF that preserves motion at the treated level. The approach is identical to ACDF — a small incision on the front of the neck — but instead of fusing the vertebrae, an artificial disc prosthesis is inserted. This maintains the natural movement of the neck and reduces stress on adjacent levels. It is suitable for carefully selected patients with single or two-level disease without significant instability, facet joint arthritis, or osteoporosis. Outcomes for arm pain relief are equivalent to ACDF, and the preservation of motion can help reduce the long-term risk of adjacent segment degeneration.

Posterior cervical foraminotomy is an alternative for single or multi-level lateral disc herniation or foraminal stenosis where fusion is not required. An incision is made at the back of the neck, and a window is created in the bone to decompress the nerve without fusion. This preserves motion at the treated level and avoids an anterior approach, though is far more painful than anterior approaches with a much longer recovery period.

Link to ACDF information

Link to Dr Jeremy Russell spine information

Expected recovery times

• Walking and light activity: from day 1.
• Driving: 1–2 weeks (when pain allows safe emergency braking and neck rotation).
• Office or sedentary work: 2–4 weeks.
• Heavier physical work and sport: 6–12 weeks.
• Full recovery: typically 3 months; fusion is complete by 3–6 months.

Cervical spine surgery is generally safe with high patient satisfaction. Risks include:

• Nerve injury — <1%; risk of permanent deficit is very small.
• Spinal cord injury — <0.1% for elective surgery.
• Persistent or unchanged pain — ~10%.
• Dysphagia (difficulty swallowing) — common temporarily after ACDF; persistent in <1%.
• Hoarse voice (recurrent laryngeal nerve) — <1%; usually temporary.
• Dural tear (CSF leak) — <1%; most managed without long-term consequence.
• Adjacent segment degeneration — longer-term risk of disease developing at levels above or below
  the fusion.
• Hardware failure (plate, cage, screw) — rare; re-operation occasionally required.
• Wound infection — <1%.
• Bleeding requiring further surgery — <1%.
• General anaesthetic and hospital risks (heart attack, stroke, DVT/PE, anaphylaxis, pneumonia) — collectively <1% in routine cases.
• Death — <0.1% for elective surgery.

Following successful surgery or recovery from conservative management, patients can reduce the risk of recurrence by:

• Maintaining good posture — particularly when using screens or devices; ergonomic workstation setup is important.
• Regular neck and core-strengthening exercise (physiotherapy, Pilates, yoga).
  Maintaining a healthy body weight.
• Quitting smoking — smoking is strongly associated with disc degeneration and poorer surgical outcomes.

1. Eubanks JD. Cervical radiculopathy: nonoperative management of neck pain and radicular symptoms. Am Fam Physician. 2010;81(1):33-40.
2. Carette S, Fehlings MG. Cervical radiculopathy. N Engl J Med. 2005;353(4):392-399. doi:10.1056/NEJMcp043887
3. Bono CM, Ghiselli G, Gilbert TJ, et al. An evidence-based clinical guideline for the diagnosis and treatment of cervical radiculopathy from degenerative disorders. Spine J. 2011;11(1):64-72. doi:10.1016/j.spinee.2010.10.023

• https://www.healthdirect.gov.au/neck-pain
• https://www.spine-health.com/conditions/cervical-radiculopathy
• https://www.nhs.uk/conditions/cervical-spondylosis/