Pressure on the nerves as they exit the neck causes pain in the arm. This is known by a number of terms such as brachial neuralgia or cervical radiculopathy. In everyday terms, this is pinched nerves.

Many people are familiar with a lumbar spine disc prolapse causing sciatica. This is pressure on the nerves leaving the low back pinching the sciatic nerve. The same process can occur in the neck.

In the low back, the problem is generally a disc out of place (prolapsed) resulting in the pinched nerve or sciatica. In the neck, narrowing of the space where the nerves exit the vertebral column is a more common cause of pressure on the nerves, causing cervical radiculopathy.

The space where the nerve exits the spinal cord and vertebral column is known as the foramen.

As we age, in some people earlier than others, that space gets smaller. It may become smaller as the discs dry out and the space between the vertebra gets smaller. In turn this narrows the foramen. As we age, the vertebra lose their nice smooth edge. Small growths at the edges of the vertebra are known as ‘lipping’. This lipping can extend into the foraminal space, resulting in a tight area around the nerve and pressure on the nerve.

Narrowing of the foramen can also be called foraminal stenosis. Stenosis is the narrowing of a hollow space or tubular structure in the body.

What trouble does cervical radiculopathy cause?

When there is pressure on one of the nerves that supplies the arm, symptoms result in the area the nerve supplies.

The most common nerves affected are C6 and C7. These are the nerves that leave through the spaces at the sixth and seventh cervical vertebra. When the nerves are irritated or under pressure there is pain. There may also be pins and needles or tingling, numbness or weakness of the part of the arm controlled by those nerves.

The patient will complain of pain in their arm. The pain will be in a specific distribution that corresponds to the nerve. For example, with a C7 radiculopathy, the pain will generally extend down through the forearm into the long finger.

Many people will have some neck ache, but others don't describe particular problems with their neck.

The pain can be mild, or can be severe and intense.

Who gets the problem?

Cervical radiculopathy is more common as we age. It is more common for people in their 50s and older.

An episode can be precipitated by a range of activities. For many people it occurs without an obvious precipitating factor.

In others it is more likely to occur if they do a heavy forceful task overhead, particularly if there is a jarring episode. It is more likely if a person does heavy lifting with their arms outstretched, which places extra strain on the neck. It is a little more common in people who do heavy manual work.

Diagnosis made – what’s to be done?

A clear cut picture of cervical radiculopathy is generally straightforward to diagnose: the patient has a specific pattern of symptoms.

It is sensible to perform investigations to confirm the diagnosis, particularly if the pattern of symptoms is not easily identifiable as cervical radiculopathy.

An x-ray of the neck can show pressure on the foramen, or foraminal stenosis. The x-rays need to be done at a special angle to have the best look at the foramen. Sometimes doctors need to ask for these specialised views. X-rays that simply looking directly from the front or the side of the patient don't give the best views of the foramen.

If the foramen is narrowed it can be the cause of pressure on the cervical nerves. If the pressure on the nerve corresponds to the patient's symptoms, i.e. is on the correct side and at the correct level, supportive evidence of the diagnosis has been obtained.

An MRI is the next investigation. CAT scans of the neck are not particularly reliable and don't show a good view of the lower part of the neck. Further, CAT scans cause a high level of radiation.

An MRI scan may show a disc pressing on the nerves, i.e. a cervical disc prolapse. Alternatively, the MRI scan may show bony foraminal stenosis.

In terms of treatment, the options include adopting a wait-and-see approach, hands-on treatment, medication, injections, and surgery.

Most times, cervical radiculopathy symptoms will settle with time. There may have been something that irritated the nerve or resulted in the nerve becoming inflamed. Over a matter of weeks or months the inflammation and irritated nerve can settle.

If the patient can tolerate the level of pain, this may be the best approach.

If the pain is more severe, or the individual wishes to have treatment, an injection into the nerve root can be performed. This generally includes local anaesthetic and cortisone. The procedure carries some risks, but can be helpful in settling down cervical radiculopathy pain.

Hands-on treatment, such as physiotherapy, can help alleviate associated pain. This type of treatment doesn't treat the nerve itself, but can help settle down irritation of the adjacent structures such as the muscles. Some, but only a limited number of people, find it of benefit. Forceful manipulation should not be performed as it can worsen pressure on the nerves.

Pain medication is important. Simple analgesics such as aspirin or paracetamol can help if the pain is mild. Tablets to settle down nerve pain help some people. Lyrica or Neurontin are examples of such treatments, but often cause drowsiness or other side effects.

Endep, a low dose antidepressant used to manage pain, can help the individual get better sleep if their problem is interfering with their ability to sleep.

Surgery is appropriate in some cases. The indications for surgery are pain that is unremitting and severe enough to warrant an operation. In some cases an individual has weakness in the arm because of pressure on the nerve. If there are signs the weakness is worsening, the situation is taken more seriously. In this unusual situation there can be justification for surgery, to try and prevent long-term weakness.

Two types of surgery are performed. The first is to remove part of the disc, if the disc is pressing on the nerves. This is a smaller operation. The second is to perform a cervical fusion. This procedure locks one vertebra on the next so there is no movement between these two vertebra. Along with opening up the space around the nerve, this procedure is felt to result in a better outcome. It is a more major procedure.

What about work?

A person who experiences an episode of cervical radiculopathy is at risk of further episodes.

Their condition may settle by itself and there may be the opportunity to return to their usual job. Each case should be assessed on its merits.

Such an assessment needs to take into account the person's age, the job they have been doing, the particular demands of the job and how quickly their problem has settled.

For example, a truck driver who has done a lot of overhead lifting, such as removing heavy gates from the side of the truck using an overhead manoeuvre, has an episode of cervical radiculopathy that settles over two months. Is the truck driver able to get back to their job, which requires significant overhead lifting?

A practical approach would be to identify alternative methods of dealing with the gates. This may involve developing and using an alternate system of securing loads. It may require assistance at either end of the delivery, such as a mechanism that enables the gates to be removed by forklift, or by somebody standing on a platform so there is no requirement for the overhead lifting. It may mean the person should return to driving a different truck, where there isn't a requirement for gates to be inserted and removed.

Many people with an episode of cervical radiculopathy return to the normal jobs and cope adequately. However, there is a risk of recurrence and a sensible approach tries to minimise exposure to activities that may have caused the problem in the first place.

How can we help an employee?

First up, acknowledge their condition and understand they might be in substantial pain. People with a nasty episode of cervical radiculopathy can have difficulty sleeping and can become quickly worn down by the pain.

Understand that the problem can be slow to settle and that there may be a number of delays in seeking treatment. There may be delays while approval is sought for a scan; delays in getting in to see an appropriate surgeon. If a wait-and-see approach is adopted, it may take some weeks or months to see if the problem settles by itself before further decisions regarding surgery are made.

Assist the individual by providing support and modified duties. Appropriate duties allow the person to work with the neck in a neutral position. That means they don't have to constantly look up or down or to the side. A lot of work with the arms outstretched in front of the person at shoulder height, or work above shoulder height, should be minimised. It is sensible to avoid heavy lifting in any modified duties in these circumstances.

Ensure the person is comfortable with any surgical advice and encourage them to ask questions. They may find a second surgical opinion helpful.