Cervical Radicular Pain

Tim D Angkatan 3 FIPM

Introduction
Location : Quality :
Upper limb Shooting, electric
• Ectopic impulse formation
Radicular Pain • Narrowing of the foramen
Radicular Pain ≠ Radiculopathy
Cervical Radicular Pain
intervertebralis
• Discus intervertebralis
herniation
IASP classification :
Etiology :
• Neurologic signs such as • Radiculitis due to arthritis,
sensory or motor changes o-Ectopic activation of nociceptive
Radiculopathy • Mayinjury
Irritation and or of cervical afferent fibers
advance from initial
infection, or inflammatory
spinal nerve exudates
radicular pain o-Other neuropathic mechanism
 C6 and C7 :
Diagnosis : History Radiates from
Neck pain
the neck to
theC4shoulder,
:
C5
the :
forearm,
Cervical Radicular Confined
•Posterior to
Pain Radiates up to the
andthethe
shoulder hand
neck and
upper arm
suprascapular
•Radiation •Arm
region

•Hand
Diagnosis : Physical Examination
Neurological examination
•Strength
•Sensation
•Tendon reflexes
Diagnosis : Physical Examination

Specific clinical tests

Valuable aids in
• Neck compression test the clinical
(Spurling test) diagnosis
High Specificity,
of a
• Shoulder abduction test patient
Low Sensitivity
with
neck and arm
• Axial manual traction test pain
Diagnosis : Additional Tests
CT scan

Medical imaging

MRI

Needle
electromyography
Additional Tests

Nerve conduction
Electrophysiologic
tests

Diagnostic Quantitative
selective nerve Sensory Testing
block (QST)
Differential Diagnosis
Tumor

• Pancoast tumor
• Primary spinal tumors or metastases
• Neurofibroma

Infections

Vascular disorder

Carpal tunnel syndrome

Brachialgia

Facet joint pain

Treatment Options
• NSAID
Conservative • Anti-convulsant

• Epidural corticosteroid administration

• Radiofrequency
Interventional • Surgical
• Spinal cord stimulation
Treatment Options :
Epidural corticosteroid administration

Interlaminar
Inhibition of the
Epidural
Epidural phospholipase A2 - Anti - inflammatory
corticosteroid
corticosteroid initiated arachidonic response
administration
administration acid cascade
Transforaminal
Treatment Options :
Epidural corticosteroid administration
Provide a significant effect
Efficacy
on cervical radicular pain

Interlaminar corticosteroid
administration
Relatively safe

Complication
Incidence of complications
is low
Treatment Options :
Epidural corticosteroid administration
More accurate
administration of drug
Efficacy
Positive outcomes, but
Transforaminal could not be confirmed by
corticosteroid RCT
administration

Various serious
Complications
complications reported
Treatment Options : Review of serious complication with cervical
transforaminal epidural corticosteroid administration
Treatment Options :
Anatomical Consideration in Epidural
corticosteroid administration

Origin on the arteria

V1 subclavia to its entrance in
the foramen transversum.

Area from entrance of the

Arteria vertebralis V2
foramen transversum to C2

Course through the C1

V3
foramen transversum
 93% in C6
V2 and V3 segments of
Majority in C5
the arteria vertebralis
Anomalies

Others : C3, C4, C7

 Arise from arteria subclavia directly, or from a
very short truncus costocervicalis

Arteriae cervicales profundae

Enter the foramen intervertebrale in its aspect

near sites of recommended transforaminal
needle placement

Enter the foramen intervertebrale at C4

Arteria cervicalis ascendens

No specific “ safe zone ” for needle placements in the posterior cervical foramina
Supply the intervertebralia
arteria spinalis anterior

Variation of normal anatomy

Supplier to the arteria spinalis anterior when the

A large segmental medullary contributing artery ipsilateral arteria vertebralis entered the spine at
C5 instead of C6

Anastomoses between all three main supply

arteries

If the arteria cervicalis profunda tended to enter

the foramina intervertebralia it was at either
C7/T1 or C6/C7, and the arteria cervicalis
ascendens tended to enter the foramina
intervertebralia at C5/C6 or higher
Treatment Options :
Pharmacological Consideration in Epidural
corticosteroid administration
Hypothesis :
• Particulate steroids may act as an embolus  cause spinal cord infarction and
permanent impairment
Patients with central symptoms (nystagmus, confusion, and coma)
• Less obvious to indicate an embolus caused by particulate steroids
Treatment Options :
Practical recommendation for Epidural
corticosteroid administration
Complication of Recommendation
Transforaminal

• Various • Curtailing use of

• Serious transforaminal
• Inexplicable cervical epidural
corticosteroid
administration
Treatment Options :
Practical recommendation for Epidural
corticosteroid administration

Positive RCT of
Direct comparison:
Interlaminar

Interlaminar vs Not available

Transforaminal
Preference for
interlaminar
administration

Reports of
serious
complications
after
Transforaminal
Treatment Options : Interventional

Significant decrease in the

Efficacy visual analog scale pain
score

Radiofrequency treatment
Transient neuritis and/or a
burning sensation
Complications
A slight loss of muscular
strength in the hand and
arm of the treated side
Treatment Options : Interventional

More effective than placebo

Efficacy
3 months post - treatment
PRF

Complications No reported complications

Treatment Options : Interventional

Surgical Treatment
• Provide pain relief in patients whose symptoms seem to be refractory to all
other treatments
• Indicated in cervical radiculopathy with spinal cord compression
(myelomalacia)
Treatment Options : Interventional

Spinal Cord Stimulation

• Percutaneously applying an electrode at the level of the involved segment of
the spinal cord
• Connected to a generator that delivers electric shocks  stimulate the painful
dermatome  introduce an altered pain pathway
• No literature on the outcome of SCS in the treatment of cervical radicular pain
Technique:
Interlaminar cervical epidural steroid administration

Flex the cervical

Sitting position Disinfect skin
spinal

Put index and middle

Switch to lateral Midline needle
finger on both sides
view placement
of processus spinosi

Slowly advance the Loss of resistance or

Dye injection
needle hanging drop

Inject the solution Aspiration

Technique: diagnostic block
C arm placement :
-Beam is parallel to the axis of
Determine entry point :
Supine position the foramen intervertebrale
same as diagnostic block
-Axis points 25 to 35 ° oblique
and 10 ° caudally

Introduce needle Change beam direction Needle introduction :

further to anteroposterior tunnel vision

Slowly inject 0.4 mL

iohexol contrast dye, 0.5 Observe pain relief in
to 1.0 mL lidocaine 30 minutes
around nerve
Technique: (Pulsed) Radiofrequency
C arm placement :
Needle introduction parallel to
-Beam is parallel to the axis of the foramen
beam/tunnel vision
Supine position intervertebrale
(60 - mm 24G neuroradiography
-Axis points 25 to 35 ° oblique and 10 °
needle )
caudally

Exchange stylet to RF Introduce needle Change beam direction

Start 50 Hz stimulation
electrode further to anteroposterior

Patient must feel a

tingling at less than
0.5 V.
Recommendation

Chronic
Subacute
Symptomscervical
phase radicular
: :
persist pain:
• Interlaminar
PRF adjacent epidural
to the cervical
administration
DRG is the
offirst
localline
anesthetic
recommended
and corticosteroids is recommended
• Spinal cord stimulation performed in specialized centers.
• If
Cervical
PRF hastransforaminal
poor or short epidural
term effect  RF treatment
corticosteroid retained a negative
adjacent to therecommendation
cervical DRG
THANK YOU