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Clinical Supplement: Head and Spine Trauma

The diagnosis and treatment of cervical radiculopathy

MALANGA, GERARD A.

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Medicine & Science in Sports & Exercise: July 1997 - Volume 29 - Issue 7 - p 236-245
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Abstract

Cervical radiculopathy is a dysfunction of the nerve root of the cervical spine. It occurs at an annual incidence rate of 85 per 100,000 with much less frequency than radiculopathy of the lumbar spine(1). The seventh (C7, 60%) and sixth (C6, 25%) cervical nerve roots are the most commonly affected(55,63,82). In the younger population, it is a result of a disc herniation or an acute injury causing foraminal impingement of an exiting nerve. In the older patient, it often is a result of foraminal narrowing from osteophyte formation. There is limited information regarding the true incidence of cervical radiculopathy in sports. One study found increased cervical disc disease from diving and weight lifting(45,74). Golfing was found to have a modest though statistically insignificant increase in cervical disc disease. Other factors associated with increased risk include: heavy manual labor requiring lifting of more than 25 lb, smoking, and driving or operating vibrating equipment(42,74). Certain sports such as football and wrestling have an increased potential for cervical nerve root injuries from acute foraminal compression due to the potential for flexion/extension and rotational neck injuries in addition to the increased contact nature of these sports.

The “burner” or “stinger” is felt to be an injury caused by either traction or compressive forces to the brachial plexus or cervical nerve roots(2,10,11,51,76). Several articles have reported the incidence and have attempted to identify the exact level of injury (15,62,74,86). Most studies have found the upper trunk of the brachial plexus or the upper cervical nerve roots as the site of injury (62,66,69). Recently, Levitz et al. described the characteristics of the “chronic burner syndrome.” This syndrome was felt to occur from nerve root compression at the intervertebral foramina secondary to disc disease, osteophyte formation, or both during cervical extension and ipsilateral deviation(47). A finding of this study that caused concern was the fact that 72% of these athletes had persistent weakness of their deltoid muscle and the “spinati”, suggesting that there was persistent neurological injury. The evaluation and treatment of burners have been previously described (10,32,54,72); however, there is limited information regarding the evaluation and treatment of athletes presenting with the more “classical” cervical radiculopathy. The purpose of this article is to provide a comprehensive approach on the presentation, evaluation, differential diagnosis, treatment, and return-to-play criteria which can be helpful to the clinician caring for these athletes.

ANATOMY AND BIOMECHANICS

An understanding of the anatomy and biomechanics of the cervical spine is essential in diagnosing and treating cervical radiculopathy. There are seven cervical vertebra and eight cervical nerve roots. The upper cervical segment is formed by the C1-C2 or the atlantoaxial joint. This joint allows for 50% of all cervical rotation motion (84). The occipital atlantal joint is responsible for 50% of flexion and extension. Below the C2-C3 level lateral bending of the cervical spine is coupled with rotation in the same direction (59). This is due to the 45° inclination of the cervical facet joints. The vertebral bodies of C3-C7 are similar in appearance and function. The individual vertebral segments are linked via the zygoapophyseal or facet joints which are responsible for motion of the cervical spine. These joints may develop osteoarthritic changes including osteophitic spurs which can narrow the intervertebral foramina. Intervertebral discs are located between the vertebral bodies of C2 through C7. The discs are composed of an outer annulus fibrosus and an inner nucleus pulposus which serve as force dissipaters and transmit compressive loads throughout a range of motion (6,14,17,41,58). They are thicker anteriorly and therefore contribute to normal cervical lordosis. The foramina are largest at C2-C3 and progressively decrease in size to the C6-C7 level. The nerve root occupies between 25 and 33% of the foraminal space(4,22). The neuroforamina are bordered anteromedially by the uncovertebral joint; posterolaterally by the facet or zygoapophyseal joint; superiorly by the pedicle of the vertebra above; and inferiorly by the pedicle of the vertebra below. Medially, the foramina are formed by the edge of the vertebral end plates and the intervertebral discs(1,9). The nerve roots exit above their correspondingly numbered vertebral body from C2 to C7. C1 exits between the occiput and atlas, and C8 exits below the C7 vertebral body. Degenerative changes of the structures which form the foramina can cause nerve root compression. This can occur from osteophyte formation, disc herniation, or a combination of the two.

HISTORY

It is important to obtain a detailed history to establish a diagnosis of a cervical radiculopathy and to rule out other causes of the athlete's complaints. The examiner should first determine the main complaint, i.e., pain, numbness, weakness, and location of symptoms. A visual analog scale(VAS) from 0-10 can be used to determine the patient's perceived level of pain. Anatomic pain drawings can also be helpful by supplying the physician with a quick review of the pain pattern. Activities and head positions that increase or decrease symptoms are also helpful in making the diagnosis as well as in guiding the treatment. When did the injury occur, what was the mechanism of injury, and what was done should always be asked. The position of the head and neck at the time of injury should also be noted. Prior episodes of similar symptoms or localized neck pain are important for diagnosis and ultimate treatment. Symptoms suggestive of a cervical myelopathy, such as changes in gait, bowel or bladder dysfunction, and lower extremity sensory changes or weakness, should also be obtained. The examiner should ask what previous treatments have been tried, including the use of ice and/or heat or medications, e.g., acetominophen, aspirin, or nonsteroidal antiinflammatory drugs. A history of previous diagnostic tests and their results is important. Questions on previous medical treatment should include these topics: physical therapy, traction, manipulation, and previous injection, or surgical treatments. A social history should include the athlete's sport (and position), occupation, and the use of nicotine and alcohol.

The typical patient will present with insidious onset of neck and arm discomfort. The discomfort can range from a dull ache to severe burning pain. The pain radiation pattern is variable and may include referred pain to the medial scapula initially and then along the upper or lower arm and into the hand, depending on the nerve root that is involved. The older athlete may have had previous episodes of neck pain or give a history of having“arthritis” of the cervical spine. Acute disc herniations and sudden narrowing of the neural foramen may also occur from injuries involving cervical extension, lateral bending, or rotation and axial loading(14,31,52). This is a common mechanism for“burner” injuries which may involve traction to the brachial plexus or cervical nerve roots or foraminal compression of nerve roots. These patients will complain of increased pain with neck positions which cause foraminal narrowing: extension, lateral bending, or rotating toward the symptomatic side. Many patients will note a reduction in their radicular symptoms by abducting their shoulder and placing their hand behind their head. This is felt to occur by decreasing tension at the nerve root(25). Patients may complain of sensory changes along the involved nerve root dermatome which can include tingling, numbness, or loss of sensation (Fig. 1). Athletes may also complain of motor weakness, especially those involved in sports that require upper extremity strength. For example, a weight lifter with a C5 radiculopathy may quickly recognize biceps weakness during heavy dumbbell curls. In fact, a small percentage of patients will present only with weakness without significant pain or sensory complaints. Bilateral upper extremity symptoms would suggest a more central injury, i.e., spinal cord and should be worked up as a probable cervical stenosis problem.

EXAMINATION

Observation

The examination begins with observation of the patient during the history portion of the evaluation. This includes head and neck posture and movement during normal conversation. Typically, the patient will have a head list away from the side of injury and hold their neck stiffly. Active range of motion is usually reduced, particularly extension, rotation, and lateral bending, either toward or away from the affected nerve root. Lateral bending away from the affected side can cause increased displacement of a disc herniation upon a nerve root whereas same-side bending induces pain by an impingement of a nerve root at the site of the neural foramen.

Palpation

On palpation, tenderness is usually noted along the cervical paraspinals and is usually more pronounced along the ipsilateral side of the affected nerve root. There may also be muscle tenderness along muscles where the symptoms are referred, e.g., the medical scapula, the proximal arm, and the lateral epicondyle. There may be associated hypertonicity or“spasm” on palpation in these painful muscles.

Motor

Manual muscle testing is an important aspect of determining a nerve root level on physical examination. Proper manual muscle testing should be performed to detect subtle weakness in a myotomal distribution. The limb should be placed in the antigravity position and the force applied just proximal to the next distal joint. For example, the extensor carpi ulnaris muscle should be tested with the forearm in full pronation and resting on a table or supported and then resisting against the dorsum of the fifth metacarpal bone in the direction of flexion toward the radial side(43). Weakness of shoulder abduction suggests C5 pathology. Elbow flexion and wrist extension weakness would be found in C6 radiculopathies. Weakness of elbow extension and wrist flexion would occur with a C7 radiculopathy, and weakness of thumb extension and ulnar deviation of the wrist would be seen in C8 radiculopathies (48).

Sensory

On sensory examination, a dermatomal pattern of decrease or loss of sensation should be present in patients with clear-cut radiculopathy. In addition, patients with radiculopathy may also have hyperesthesia to light touch and pin-prick examination (30,74). The sensory examination, however, can be quite subjective in as much as it requires patient response.

Deep Tendon Reflexes

Deep tendon reflexes, or more properly termed muscle stretch reflexes as the reflex is induced by a muscle stretch, are helpful in the evaluation of patients presenting with limb symptoms suggestive of a radiculopathy. It is important to position the limb properly in obtaining these reflexes and to keep the patient as relaxed as possible. Any grade of reflex can be normal(7), and so it is the asymmetry of reflexes which is most helpful. The biceps brachii reflex is obtained by tapping the distal tendon in the antecubital fossa. This reflex occurs at the C5-C6 level. The brachioradialis is another C5-C6 reflex that can be obtained by tapping the radial aspect of the wrist. The triceps reflex can be obtained by tapping the distal tendon at the posterior aspect of the elbow with the elbow relaxed at about 90° of flexion; this tests the C7-C8 nerve roots. The pronator reflex can be helpful in differentiating C6 and C7 nerve root problems. If it is abnormal in conjunction with an abnormal triceps reflex then the level of involvement is more likely to be C7. This reflex is performed by tapping the volar aspect of the distal radius with the forearm in a neutral position and the elbow flexed. It results in a stretch of the pronator teres resulting in a reflex pronation (7,49). To rule out the presence of a possible myelopathy, lower extremity reflexes along with Hoffman and Babinski reflexes should be elicited. Diffuse hyperreflexia, and/or positive Hoffman and abnormal Babinski reflexes, would indicate that the patient has a cervical myelopathy (57,74).

Provocative Tests

The foraminal compression test or Spurling test is performed by extending the neck and rotating the head and then applying downward pressure on the head(22,77). The test is considered positive if pain radiates into the limb ipsilateral to the side at which the head is rotated(39). The Spurling test has been found to be very specific but not sensitive in diagnosing acute radiculopathy(22,81). Levitz et al. found a positive Spurling's sign in 71% of collegiate and professional football players with a history of recurrent burners (47). Manual cervical distraction can also be used as a physical examination test. This is performed on the supine patient with gentle manual distraction applied. A positive response is indicated by a reduction of neck or limb symptoms. L'hermitte's sign is performed by flexing the neck and asking the patient about symptoms of electric-like sensation radiating down the spine and in some patients into the extremities. This has been found in patients with cervical cord compression from cervical spondylosis but is also seen in patients with tumor and multiple sclerosis (22,60).

DIFFERENTIAL DIAGNOSIS

It is important to rule out other possible causes of neck and limb symptoms prior to establishing a diagnosis of radiculopathy. The differential diagnosis includes musculoskeletal disorders, including rotator cuff tendinitis or tears, subacromial bursitis, bicipital tendinits, and lateral epicondylitis. These disorders are distinguished by positive provocative maneuvers specific to them in the absence of the other previously mentioned neurological findings and provocative nerve root tests (Table 1). Upper trunk brachial plexus disorders can also be confused with a C5 or C6 radiculopathy. Idiopathic brachial plexopathy often involves the upper trunk of the brachial plexus. The etiology is unknown but usually presents first with severe pain which resolves and then is followed by weakness and subsequent atrophy(18,22,26). There generally is an absence of neck symptoms, and the Spurling test is negative. At times, electrodiagnostic studies and magnetic resonance imaging (MRI) are needed to establish the diagnosis. The brachial plexus can also be involved in patients with metastatic cancer or from direct encroachment from a lung tumor. Thoracic outlet syndrome can also present with upper limb symptoms, particularly along the ulnar aspect of the hand. Various tests, including Adson's, costoclavicular, and hyperabduction, have been described to assess patients for thoracic outlet syndrome (16,88). Roos(70) described the 3-min elevated arm exercise test with the patient seated and the arms held abducted to 90° and the elbows flexed 90° with the shoulder girdle slightly retracted. Roos believed that an inability to sustain this position for 3 min indicated a problem with the neurovascular structures of the thoracic outlet.

Peripheral nerve entrapment within the upper limb may also be confused with a cervical radiculopathy. This includes entrapment or compression of suprascapular, median, and ulnar nerves. A suprascapular neuropathy can be confused with a C5 or C6 radiculopathy but would spare the deltoid and biceps muscles. C6 and C7 radiculopathies are most likely to be confused with median neuropathies, whereas C8 radiculopathy must be differentiated from ulnar neuropathies and thoracic outlet syndrome.

DIAGNOSTIC TESTS

Plain Radiographs

X-rays of the cervical spine are usually the first diagnostic test ordered in patients presenting with neck and limb symptoms. They are very helpful in detecting fractures and subluxations in patients with a history of neck trauma(74). In patients with trauma, lateral, anteroposterior, and oblique views should be ordered. An openmouth view should also be ordered to rule out injury to the atlantoaxial joint. The atlantodens interval (ADI) is the distance from the posterior aspect of the anterior C1 arch and the odontoid process. This should be less than 3 mm in the adult and less than 4 mm in children (27,78). An increase in the ADI suggests atlantoaxial instability. Flexion and extension views can be helpful in assessing spinal mobility and stability (74) and should be ordered in the acutely injured athlete where there is a high degree of suspicion of cervical spine injury. Greater than 2 mm of motion at any segment would suggest instability and warrant further evaluation.

The clinician should be aware of the limitations of plain radiographs. Problems exist with both specificity and sensitivity. Comparison of findings on plain x-rays and cadaver dissections have found a 67% correlation between disc space narrowing and presence of disc generation(28). However, x-rays identified only 57% of large posterior osteophytes and only 32% of the abnormalities of the apophyseal joints found on dissection. Degenerative changes can also be found in asymptomatic subjects. Radiographic evidence of degenerative changes on x-rays have been found in 35% of subjects by the age of 40 and up to 83% by the age of 60 (33). Friedenberg and Miller(29) compared x-ray findings of symptomatic versus asymptomatic patients. Degenerative changes were found most commonly at the C5-C6 and C6-C7 levels in both groups. There was a statistically significant difference in the number of patients with C5-C6 changes in the symptomatic group (62%) compared to the asymptomatic group at that level (35%). No differences were noted between groups regarding foraminal stenosis and facet arthrosis. Gore et al. (34) found no predictive value of x-ray findings on the outcome of patients with a history of neck pain.

From these studies, it appears that the predictive value of degenerative changes found on x-rays is limited. They can provide a gross assessment of the severity of the degenerative changes of the spine. As with any diagnostic study, the findings on x-ray must be correlated with the history and physical examination. Plain x-rays remain an important initial test in patients with a significant neck injury to rule out fractures, dislocations, and significant instability in the acutely injured athlete.

Computed Tomography

Computed tomography (CT) provides good visualization of bony elements and can be helpful in the assessment of acute fractures. The accuracy of CT imaging of the cervical spine ranges from 72-91% in the diagnosis of disc herniation (1,39,44,53). The accuracy has approached 96% when combining CT with myelography(1,39,44,53). The addition of contrast allows for the visualization of the subarachnoid space and assessment of the spinal cord and nerve roots. CT with myelography is felt to best assess and localize spinal cord compression and underlying atrophy(38,74). It can also determine the“functional reserve” of the spinal canal in evaluation athletes with possible cervical stenosis (8). Because of the improved soft tissue visualization provided by MRI, CT is being replaced by MRI for most cervical spine disorders (74).

Magnetic Resonance Imaging

MRI has become the method of choice for imaging the neck to detect significant pathology. It can detect ligament and disc disruption which cannot be demonstrated by other imaging studies(23,35,78). The entire spinal cord, nerve roots, and axial skeleton can be visualized. This is usually done in axial and saggital planes. It has been found to be quite useful in evaluating the amount of cerebral spinal fluid surrounding the cord in the evaluation of patients with cervical canal stenosis, although the T2-weighted images tend to exaggerate the degree of stenosis (37,74). Cantu has reviewed the use of MRI in the evaluation of athletes with possible cervical stenosis and has noted that it can be quite helpful in determining the “functional reserve” of the spinal canal(8). In collegiate and professional football players with a history of chronic, recurrent burners, 85% were found to have degenerative disc disease of the cervical spine on MRI (47). This was greater than expected when compared to asymptomatic athletes and raises the possibility that these burners may arise from nerve root compression secondary to degenerative disc disease. Although it is felt to be the imaging method of choice in the evaluation of cervical radiculopathy(22,56), abnormalities have also been found in asymptomatic subjects. Ten percent of subjects under the age of 40 yr were noted to have disc herniations in one study (5,74). Over the age of 40, 20% had evidence of foraminal stenosis, and 8% had disc protrusion or herniation. Therefore, as with all imaging studies, the MRI findings must be used in conjunction with the history and physical examination findings.

Electrodiagnosis

Electrodiagnostic studies are important in identifying physiologic abnormalities of the nerve root and in ruling out other neurological causes for the athlete's complaints. It has been shown to be a useful diagnostic test in the diagnosis of radiculopathy (22,85) and has correlated well with findings on myelography and surgery(22,36,50). There are two parts to the electromyogram (EMG): nerve conduction studies and needle electrode examination. The nerve conduction studies are performed by placing surface electrodes over a muscle belly or sensory area and stimulating the nerve, supplying either the muscle or sensory area from fixed points along the nerve. From this, the amplitude, distal latency, and conduction velocity can be measured. The amplitude reflects the number of intact axons, whereas the distal latency and conduction velocity is more of a reflection of the degree of myelination. There are other special nerve conduction tests such as the H-reflex, which is the electrophysiologic equivalent of the muscle stretch reflex, and the F-wave which tests the proximal segment of the nerve root by causing a backfiring of antidromically activated anterior horn cells. The H-reflex and F-wave have been found to be of limited value in the evaluation of cervical radiculopathy (19,22,45). The needle EMG portion of the electrodiagnostic examination involves inserting a fine needle electrode into a muscle. Electrical activity is generated by needle insertion into the muscle, voluntary muscle contraction, and spontaneous firing of motor units. These are observed on an oscilloscope screen and quantified and also generate an audible sound. Denervated muscle will produce spontaneous electrical activity while the muscle is at rest. These potentials are called fibrillations or positive sharp waves based on their characteristic shape and sound. There can also be changes seen in the configuration of the individual motor unit as well as an increase in the firing rate of the individual motor units. The timing of the EMG evaluation is important as positive sharp waves and fibrillation potentials will first occur 18-21 d after the onset of a radiculopathy (22,40). It is therefore best to delay this study until 3 wk after injury so that it can be as precise a study as possible. The primary use of electromyography is to diagnose nerve root dysfunction when the diagnosis is uncertain or to distinguish a cervical radiculopathy from other lesions that are unclear on physical examination (22). Electrodiagnostic abnormalities can persist after clinical recovery for months to years and in some may persist indefinitely (3,76). Therefore, in general EMG is not recommended when making decisions about return to play.

TREATMENT

There is little known about the natural history of cervical radiculopathy or controlled randomized studies comparing operative versus nonoperative treatment (22,64). The pathogenesis of radiculopathy occurs from the inflammatory process initiated by nerve root compression. This results in nerve root swelling(24,66,74). The compression may be from a disc herniation, degenerative changes about the neural foramen, or a combination of the two. A study on patients under local anesthesia found that compression of a nerve root produced limb pain whereas pressure on the disc produced pain in the neck and the medial border of the scapula(54,74). Intradiscal injection and electrical stimulation of the disc has also suggested that neck pain is referred by a damaged outer annulus (12,54). Muscle spasms of the neck have also been found after electrical stimulation of the disc. Thus, the initial treatment should be directed at reducing pain and inflammation. Treatment can begin with local icing, nonsteroidal antiinflammatory drugs(NSAIDs), and reducing the forces compressing the nerve root by relative rest, avoiding positions that increase arm and or neck symptoms, and manual and if necessary mechanical traction. In addition, a cervical collar can also be used for patient comfort and some support. A cervical pillow at night can be helpful in maintaining the neck in a neutral position and limiting head positions that cause narrowing of the neuroforamen. Manual, and if necessary, mechanical traction can be used to reduce radicular symptoms by decreasing foraminal compression and intradiscal pressures(13,87).

Oral steroids have been used to reduce the associated inflammation from compression. There is no controlled study to support the use of oral steroids in the treatment of cervical radiculopathy; however, they have been found to be clinically useful (14,22). Doses as high as 60 mg daily for 7 d and continuing for 5 d have been recommended without evidence of adrenal suppression (22). Tricyclic antidepressants can also be a useful adjunct in controlling radicular pain. Opioid medications are generally not necessary for pain relief but can be used when other medications fail to provide adequate relief or if other agents are contraindicated. When opioid medications are prescribed, adequate doses and appropriate dosing schedules should be used.

Modalities such as electrical stimulation have also been found helpful in uncontrolled studies (14). They appear to be helpful in reducing the associated muscle pain and spasm often found with cervical problems but should be limited to the initial pain control phase of treatment.

Cervical epidural steroids have also been used in patients who have not responded to medications, traction, and a well-designed physical therapy program. When properly performed by experienced physicians under flouroscopic guidance, a significant number of patients will respond when other treatments have not helped (14,22,71,73,83). Selective nerve root blocks can also be helpful in patients with electrodiagnostically demonstrated single root lesions. This has rarely been necessary in the author's experience.

Once there is control of pain and inflammation, the patient's therapy should be progressed to restoration of full range of motion and flexibility of the neck and shoulder girdle muscles. Various soft tissue mobilization techniques can be helpful to stretch the noncontractile elements of soft tissues (14,82). Patients should be instructed on proper stretching technique that they can do 1-2 times per day. Gentle, prolonged stretching is recommended. This is best done after a warm-up activity such as using an exercise bike, brisk walking, etc.

As range of motion and flexibility improve, cervical muscle strengthening should begin with isometric strengthening in a single plane and include flexion, extension, lateral bending, and rotation. In addition, the scapular stabilizing muscles including the trapezius, rhomboids, serratus anterior, and the latissimus dorsi should be strengthened with progressive isotonic activity. Strength training can progress to manual resistance cervical stabilization exercises in various planes. It should be emphasized that all exercises should be performed without pain, although some degree of postexercise soreness can be expected. Isokinetic exercises of the neck and upper extremities are not functional and are not recommended as a strengthening tool. Isolated strengthening of weakened muscle secondary to the radiculopathy is important before beginning more complex activities involving multiple muscles. In the initial phases of treatment strengthing should be limited to isometric exercises in the involved extremity. Once all radicular symptoms have resolved then progressive isotonic strengthening may begin. This should initially stress low weight and high repetitions (15-20 repetitions). Closed kinetic chain activities can also be very helpful in rehabilitating weak shoulder girdle muscles.

The final phase of rehabilitation involves sport-specific training. It is important that athletes be able to maintain a neutral head neck position during various aspects of their sport. This is especially important in swimmers during their breathing, tennis players during their serves, cyclists in their drops, and so on. In addition, more strenuous upper-extremity strengthening and even plyometric-type activities, such as tossing a medicine ball, can prepare athletes for returning to the high demands of their sport. Once athletes have demonstrated the ability to tolerate these activities then they are prepared to return to their sport. Protective padding such as neck rolls and collars, interval pads, and customized orthoses can also be helpful.

It is important throughout the rehabilitation process for athletes to maintain their level of cardiovascular fitness as much as possible. This is done by alternative conditioning that does not increase athletes' symptoms as they progress through the rehabilitation process.

Cardiovascular conditioning should be started as soon as possible to prevent deconditioning. These exercises also serve as a great warm-up prior to a stretching program. Finally, the athlete should be told that these exercises(stretches and strengthening) should be continued indefinitely with the hope of preventing recurrences.

With this type of treatment, 80-90% of athletes can be treated nonoperatively (22,46,61). Surgery is indicated when nonoperative treatment has failed. The time frame for this decision depends on the ability to progress through the various phases of rehabilitation. For example, if a patient has not had any improvement in symptoms after a step-wise progression of medication, proper physical therapy, and oral and epidural steroids over a 3-4 w period, then operative intervention should be considered. Certainly, if the patient has aprogressive neurological myelopathy, early referral to a spine surgeon is indicated. A static neurological deficit is not an indication for surgical intervention in and of itself. Neurological deficits of the lumbar spine have improved with nonoperative treatment(20-22), and this appears to be true for most cervical radiculopathies. The surgical approach for cervical radiculopathy is beyond the scope of this article. Various approaches have been described and include anterior or posterior compression, discectomy, laminectomy, or foraminotomy (1,67,68,75). The surgical procedure should be the one that best addresses the pathology. Torg and Glasgow (79) have outlined criteria for return to contact activities following disc herniations treated conservatively or with fusion. There is no contraindication to playing contact sports following conservatively or surgically treated disc disease in the absence of facet instability.

Recommendations for the Evaluation and Treatment of Athletes with Cervical Radiculopathy

The acutely injured athlete seen on the field with neck and arm symptoms should initially be treated as a possible cervical spine-injured patient. Once a spinal cord injury has been ruled out, then the athlete should be removed from competition and reassessed. Athletes with bilateral upper extremity symptoms should not be allowed to return to competition until they have been evaluated for cervical spine abnormalities such as cervical stenosis. This would include x-rays with atlantoaxial flexion and extension views. Further workup would usually include an MRI of the cervical spine.

An athlete with persistent radicular symptoms and/or an abnormal neurological examination also should not return to competition until full cervical x-rays and usually an MRI are obtained. In addition, an EMG performed 3 wk after the injury will provide diagnostic (localization of the lesion) and prognostic (based on the amount of axonal injury) information. The initial treatment will address pain and inflammation as outlined above. For mild to moderate symptoms, nonsteroidal antiinflammatory medications are usually adequate. For more severe symptoms, a narcotic medication for pain and oral corticosteroids to control inflammation should be considered in conjunction with physical therapy. If adequate pain control is not achieved within the first 1-2 wk, then cervical epidural or selective nerve root injection should be considered. Treatment can then progress as outlined above.

For the athlete who presents with a more insidious onset of symptoms without an inciting event, the evaluation and treatment are slightly different. If there is no previous history of trauma then atlantoaxial flexion and extension x-rays are generally not necessary. Oblique views can be helpful in evaluating for foraminal stenosis or osteophytes. MRI and EMGs can also be deferred initially, particularly in the older athlete with minimal neurological findings. These studies can later be obtained if there is a lack of improvement with the treatment or if there is any change in the neurological examination.

RETURN TO PLAY

General guidelines for returning to competition from any injury include: no pain, pain-free and full range of motion state, and normal strength. This is also true for athletes recovering from cervical radiculopathy. The athlete should have no symptoms with Spurling's maneuver and full extension and lateral bending. Strength is usually assessed by manual muscle testing; however, this is a crude way to determine motor unit dysfunction. Patients with normal strength on manual muscle testing can have significant strength deficits when measured by isokinetic machines. However, there are questions regarding the relevance of isokinetic strength data when it does not correspond to the findings of clinical examination and functional testing. It may be that testing a muscle in isolation and in nonfunctional positions is not an adequate assessment of more complexly integrated motor activities that are required for sports. Therefore, isokinetic testing after a cervical radiculopathy is not usually necessary or recommended. In addition, the EMG needle examination can remain abnormal for months to years and therefore is not recommended as a guide for returning to sports participation(76). The athlete should be followed closely, and manual muscle testing should be done using mechanical advantage and sufficient force by the examiner to pick up more subtle side-to-side weakness. In addition, functional testing comparing isotonic strength can be useful in determining clinically relevant weakness.

CONCLUSION

Cervical radiculopathy is a result of compression and inflammation of the nerve root. In the younger population, it is often a result of a disc herniation or an acute injury causing foraminal impingement of an exiting nerve. In the older patient, it often is a result of foraminal narrowing from osteophyte formation. The diagnosis is made by obtaining a detailed history and examination. Plain x-rays are used if there is a history of significant trauma to rule out fractures and dislocations. It can also provide a gross assessment of the severity of degenerative changes of the spine. MRI is the method of choice for imaging soft tissues of the spine. The findings on MRI should be used in conjunction with the patient's complaints and physical examination findings. The EMG is helpful when the diagnosis is unclear to rule out other causes of upper-limb sensory symptoms and to assess for axonal injury in patients with weakness of greater duration than 2 wk. It is best to delay this study until 3 wk after injury. It is not recommended as a means to determine return to play. The athlete should be followed closely with serial neurological and strength evaluations.

The treatment of cervical radiculopathy involves a systematic, step-wise approach. This involves first treating pain and inflammation and then progressing to restoration of motion, strength, and finally sport-specific training. Any upper-extremity weakness should be fully rehabilitated with a progressive strengthening program. Protective and supportive padding can also be helpful in some athletes to control excessive cervical extension and lateral bending. The vast majority of athletes will respond to this type of nonoperative treatment plan and return to full and safe sport participation. Return-to-play criteria require no pain, full range of motion, a negative Spurling test, normal strength, and the ability to maintain a neutral neck position during activities of daily living and sports. This will allow for safe return-to-sport participation and reduced risk of reinjury with possible permanent neurological injury.

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Figure 1-Representation of the anterolateral aspect of the neck, shoulder, and upper limb. The :
thick black line represents the sharp, radiating pain, which often has a dermatomal distribution. Interrupted lines indicate sharp pain with a C8 radiculopathy, which is on the inner aspects of the arm and forearm. The diffuse gray areas represent the poorly localized dull ache. A dull ache medial to the shoulder blade is a common complaint in all cervical radiculopathies and is of no localizing value. The area covered by small dots indicates the location of paresthesias and sensory impairment. (A) C5 radiculopathy. (B) C6 radiculopathy. (C) C7 radiculopathy. (D) C8 radiculopathy. Reprinted with permission from Schutter, H: Intervertebral Disc Disorders, Clinical Neurology Vol 3, Ch 41, Philadelphia, Lippincott-Raven, 1995.
T1-6

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Keywords:

CERVICAL RADICULOPATHY; EVALUATION; MANAGEMENT

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