In the last post we discussed neck pain in the setting of degenerative disc disease (DDD). In this second installment we’ll discuss arm pain and DDD. As I mentioned in my last post, arm pain typically is much easier to fix with surgery versus neck pain.
Arm pain associated with cervical DDD is quite common. The patient’s pain will often start on one side of the neck and then radiate down the arm in a specific, reproducible region. This occurs when a bulging disc or a bone spur narrows the channel where the nerve exits (the foramen) thus compressing the nerve as it exits the spine (see figure 1). This causes a condition called cervical radiculopathy in which there is pain, numbness or weakness in the region of the arm supplied by the “pinched” nerve. Notice in the figure how bone spurs and arthritis (or spondylosis) also contribute to the narrowing of the foramen around the nerve. In fact, only in about 25% of cases of cervical radiculopathy is the nerve root compression caused only by disc bulging or disc herniation (versus the lumbar spine where it’s much more common.) Typically, in the cervical spine the disc degeneration often coincides with bone spurs at the uncovertebral joint (see figure) and facet joint and all of these factors collectively lead to nerve root compression.
Figure 1: Axial view of the spinal cord and nerve roots within the bony canal of the cervical spine. Notice how the exiting nerves can be compressed by a herniated disc as well as by spondylosis of the uncovertebral and facet (zygapophyseal) joints. Source: Carette et al, 2005.
Patients with cervical radiculopathy can be in severe pain (I’ve seen grown men crying in my office) and can also have quite significant numbness or weakness in their arm or hand. However, in the absence of compression of the spinal cord (a condition called myelopathy which will be discussed in a later post) I always tell my patients that surgery to treat cervical radiculopathy is not mandatory. This is because in up to 75% of patients, the pain will get better with time and conservative therapy alone. Also, there have been very few randomized, controlled studies showing that surgery is better than non-surgical management at treating cervical radiculopathy. In one study, patients who had surgery had better pain relief at 3 months compared to patients in the non-surgical group. However, at the 1-year mark there was no difference in pain level, function and mood between the two groups. (Persson et al, 1997) While studies like these are unclear about the benefits of surgery versus non-surgical management in the long-term, one thing they do show is that patients who undergo surgery feel better faster. Thus, in patients with severe, disabling pain that want pain relief so that they can get back to their lives as quickly as possible one could argue in favor of early surgery. Otherwise, in my opinion, in the absence of myelopathy or profound, progressive weakness in the arm or hand, surgery should only be considered after the patient has tried at least 6 weeks of non-surgical management of their symptoms.
Non-surgical treatments for cervical radiculopathy include NSAIDs or other anti-inflammatory medications, physical therapy, cervical traction and acupuncture. Cervical epidural steroid injections or nerve blocks have also been shown to provide real, long-lasting relief of symptoms in many patients. I will often try a course of steroid injections in my patients when less invasive therapies just aren’t providing the relief that they need.
There are several different types of surgical treatments used to treat cervical radiculopathy. These include posterior cervical foraminotomy, anterior cervical discectomy and fusion (ACDF) and cervical disc arthroplasty (or cervical disc replacement.) Each of these interventions is quite effective at relieving pain associated with cervical radiculopathy with success rates exceeding 95%. These interventions will be discussed more in future posts.
In the next post we’ll discuss cervical spondylitic myelopathy.
J. Alex Thomas, M.D.
North American Spine Society Evidence Based Clinical Guidelines for Multidisciplinary Spine Care: Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders.
Carette S, Fehlings MG. Clinical practice. Cervical radiculopathy. N Engl J Med. Jul 28 2005;353(4):392-399.
Mazane D, Reddy A. Medical management of cervical spondylosis. Neurosurgery Jan 2007; 60 (1 Suppl 1): S43-50.
Persson LC, Carlsson CA, Carlsson JY. Long-lasting cervical radicular pain managed with surgery, physiotherapy, or a cervical collar: a prospective, randomized study. Spine 1997; 22: 751-758.