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Cervicogenic Headache

DEFINITION AND SYMPTOMS

Cervical radiculopathy is a condition that consists of radiating pain from the neck to the arm or hand, which is often associated with numbness, tingling, and possibly weakness. The causes of cervical radiculopathy can be a herniated disc, a bone spur, misaligned vertebrae or a combination of the above. Presentation could be acute or chronic symptoms and could involve one or both arms. Pain may start in the neck or around the shoulder blade and may develop into arm pain. It could have a mild presentation of numbness, tingling and burning or could be severe electrical shooting pain as well as weakness. Dependent on which nerve root is impinged upon, a different portion of the arm may be affected. Clinicians can determine which nerve root is impinged based on pattern of pain, area of numbness, abnormal reflexes, and specific muscle weakness at the time of examination. The radiculopathy is named after the nerve root which is encroached. Most common areas for cervical radiculopathy are C5, C6 & C7. 

DIAGNOSIS

If the first episode is acute and severe, patients often go to the emergency room. Clinical diagnosis is made based on x-rays, and physical examination. If there is no progressive neurological loss, further care is often deferred to primary care physician and/or a specialist in an outpatient setting. A spine specialist will examine the patient and determine proper workup. A thorough physical examination is performed by the spine specialists, which includes range of motion evaluation, sensory testing, strength testing and evaluation of reflexes. If there are alarming signs of spinal cord compression, a recommendation for further workup is made. The 1st diagnostic test is often an x-ray. The most accurate clinical test to identify if a herniated disc is present is an MRI. Some patients are unable to have an MRI in which case a CT scan and EMG test will help make a diagnosis. 

NON-SURGICAL TREATMENT

If there are no alarming neurological deficits possible recommended treatments include: 6-8 weeks of physical therapy, a short course of prednisone taper, cervical traction, soft tissue treatments along with use of nonsteroidal anti-inflammatory and muscle relaxants. In most cases, this conservative treatment results in substantial improvement in symptoms. After physical therapy treatment, the patient is reexamined to evaluate for any residual deficits or symptoms. If the pain subsides and function fully recovers, the patient is discharged with the recommendation to continue a home exercise program and observe correct ergonomics. In some patients, the pain and dysfunction is not managed on oral medications or does not improve with physical therapy. In such cases, an x-ray guided cervical epidural injection can help reduce the inflammation in the nerve root and help with the recovery. The effect of an epidural injection may last several weeks to several months. If the symptom(s) return, such treatment could be repeated. In the acute phase of cervical radiculopathy, sometimes mild opioid medication is prescribed to help with sleep and function. There is no indication for long-term use of narcotic medications, to treat cervical radiculopathy.

SURGICAL TREATMENT

If there is persistent weakness in the patient’s arm, or there is persistent neck and arm pain despite proper nonoperative treatments, then the patient may consider a surgical solution. A careful risk assessment should be done by the primary care physician, spine surgeon and the patient before considering surgery. In most cases, the patient would benefit from anterior discectomy and fusion (ACDF) with or without a foraminotomy. Surgery takes a few hours to complete, with a short course of inpatient hospitalization and a few weeks of outpatient rehabilitation after the patient is discharged from the hospital.