North American Spine Society Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care

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2 NASS Clinical Guidelines Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 1 North American Spine Society Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders NASS Evidence-Based Guideline Development Committee Christopher M. Bono, MD, Committee Chair Gary Ghiselli, MD, Outcome Measures Chair Thomas J. Gilbert, MD, Diagnosis/Imaging Chair D. Scott Kreiner, MD, Medical/Interventional Chair Charles Reitman, MD, Surgical Treatment Chair Jeffrey Summers, MD, Natural History Chair Jamie Baisden, MD John Easa, MD Robert Fernand, MD Tim Lamer, MD Paul Matz, MD Dan Mazanec, MD Daniel K. Resnick, MD William O. Shaffer, MD Anil Sharma, MD Reuben Timmons, MD John Toton, MD

3 NASS Clinical Guidelines Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 2 Financial Statement This clinical guideline was developed and funded in its entirety by the North American Spine Society (NASS). All participating authors have submitted a disclosure form relative to potential conflicts of interest which is kept on file at NASS. Comments Comments regarding the guideline may be submitted to the North American Spine Society and will be considered in development of future revisions of the work. North American Spine Society Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders Copyright 2010 North American Spine Society 7075 Veterans Boulevard Burr Ridge, IL ISBN:

4 3 Table of Contents I. Introduction II. Guideline Development Methodology III. Natural History of Cervical Radiculopathy from Degenerative Disorders...9 IV. Recommendations for Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders A. Diagnosis/Imaging B. Outcome Measures for Treatment C. Medical and Interventional Treatment D. Surgical Treatment V. Appendices A. Acronyms B. Levels of Evidence for Primary Research Questions C. Grades of Recommendations for Summaries or Reviews of Studies D. Protocol for NASS Literature Searches E. Literature Search Parameters F. Evidentiary Tables VI. References...168

5 NASS Clinical Guidelines Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 4 I. Introduction Objective The objective of the North American Spine Society (NASS) Clinical Guideline for the Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders is to provide evidence-based recommendations to address key clinical questions surrounding the diagnosis and treatment of cervical radiculopathy from degenerative disorders. The guideline is intended to reflect contemporary treatment concepts for cervical radiculopathy from degenerative disorders as reflected in the highest quality clinical literature available on this subject as of May The goals of the guideline recommendations are to assist in delivering optimum, efficacious treatment and functional recovery from this spinal disorder. Scope, Purpose and Intended User This document was developed by the North American Spine Society Evidence-Based Guideline Development Committee as an educational tool to assist practitioners who treat patients with cervical radiculopathy from degenerative disorders. The goal is to provide a tool that assists practitioners in improving the quality and efficiency of care delivered to patients with cervical radiculopathy from degenerative disorders. The NASS Clinical Guideline for the Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders provides a definition and explanation of the natural history of cervical radiculopathy from degenerative disorders, outlines a reasonable evaluation of patients suspected to have cervical radiculopathy from degenerative disorders and outlines treatment options for adult patients with a diagnosis of cervical radiculopathy from degenerative disorders. THIS GUIDELINE DOES NOT REPRESENT A STANDARD OF CARE, nor is it intended as a fixed treatment protocol. It is anticipated that there will be patients who will require less or more treatment than the average. It is also acknowledged that in atypical cases, treatment falling outside this guideline will sometimes be necessary. This guideline should not be seen as prescribing the type, frequency or duration of intervention. Treatment should be based on the individual patient s need and physician s professional judgment. This document is designed to function as a guideline and should not be used as the sole reason for denial of treatment and services. This guideline is not intended to expand or restrict a health care provider s scope of practice or to supersede applicable ethical standards or provisions of law. Patient Population The patient population for this guideline encompasses adults (18 years or older) with a chief complaint of pain in a radicular pattern in one or both upper extremities related to compression and/or irritation of one or more cervical nerve roots.

6 NASS Clinical Guidelines Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 5 II. Guideline Development Methodology Through objective evaluation of the evidence and transparency in the process of making recommendations, it is NASS goal to develop evidence-based clinical practice guidelines for the diagnosis and treatment of adult patients with various spinal conditions. These guidelines are developed for educational purposes to assist practitioners in their clinical decision-making processes. It is anticipated that where evidence is very strong in support of recommendations, these recommendations will be operationalized into performance measures. Multidisciplinary Collaboration With the goal of ensuring the best possible care for adult patients suffering with spinal disorders, NASS is committed to multidisciplinary involvement in the process of guideline and performance measure development. To this end, NASS has ensured that representatives from medical, interventional and surgical spine specialties have participated in the development and review of all NASS guidelines. It is also important that primary care providers and musculoskeletal specialists who care for patients with spinal complaints are represented in the development and review of guidelines that address treatment by first contact physicians, and NASS has involved these providers in the development process as well. To ensure broad-based representation, NASS has invited and welcomes input from other societies and specialties. Evidence Analysis Training of All NASS Guideline Developers NASS has initiated, in conjunction with the University of Alberta s Centre for Health Evidence, an online training program geared toward educating guideline developers about evidence analysis and guideline development. All participants in guideline development for NASS have completed the training prior to participating in the guideline development program at NASS. This training includes a series of readings and exercises, or interactivities, to prepare guideline developers for systematically evaluating literature and developing evidence-based guidelines. The online course takes approximately hours to complete, and participants have been awarded CME credit upon completion of the course. Disclosure of Potential Conflicts of Interest All participants involved in guideline development have disclosed their relationships with other entities and potential conflicts of interest to their colleagues and their potential conflicts have been documented for future reference. They will not be published in any guideline, but kept on file for reference, if needed. Participants have been asked to update their disclosures regularly throughout the guideline development process. Levels of Evidence and Grades of Recommendation NASS has adopted standardized levels of evidence (Appendix B) and grades of recommendation (Appendix C) to assist practitioners in easily understanding the strength of the evidence and recommendations within the guidelines. The levels of evidence range from Level I (high quality randomized controlled trial) to Level V (expert consensus). Grades of recommendation indicate the strength of the recommendations made in the guideline based on the quality of the literature. Grades of Recommendation: A: Good evidence (Level I studies with consistent findings) for or against recommending intervention. B: Fair evidence (Level II or III studies with consistent findings) for or against recommending intervention.

7 NASS Clinical Guidelines Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 6 C: Poor quality evidence (Level IV or V studies) for or against recommending intervention. I: Insufficient or conflicting evidence not allowing a recommendation for or against intervention. Guideline recommendations are written utilizing a standard language that indicates the strength of the recommendation. A recommendations indicate a test or intervention is recommended ; B recommendations suggest a test or intervention and C recommendations indicate a test or intervention may be considered or is an option. I or Insufficient Evidence statements clearly indicate that there is insufficient evidence to make a recommendation for or against a test or intervention. Work group consensus statements clearly state that in the absence of reliable evidence, it is the work group s opinion that a test or intervention may be appropriate. The levels of evidence and grades of recommendation implemented in this guideline have also been adopted by the Journal of Bone and Joint Surgery, the American Academy of Orthopaedic Surgeons, Clinical Orthopaedics and Related Research, the journal Spine and the Pediatric Orthopaedic Society of North America. In evaluating studies as to levels of evidence for this guideline, the study design was interpreted as establishing only a potential level of evidence. As an example, a therapeutic study designed as a randomized controlled trial would be considered a potential Level I study. The study would then be further analyzed as to how well the study design was implemented and significant short comings in the execution of the study would be used to downgrade the levels of evidence for the study s conclusions. In the example cited previously, reasons to downgrade the results of a potential Level I randomized controlled trial to a Level II study would include, among other possibilities: an underpowered study (patient sample too small, variance too high), inadequate randomization or masking of the group assignments and lack of validated outcome measures. In addition, a number of studies were reviewed several times in answering different questions within this guideline. How a given question was asked might influence how a study was evaluated and interpreted as to its level of evidence in answering that particular question. For example, a randomized control trial reviewed to evaluate the differences between the outcomes of surgically treated versus untreated patients with lumbar spinal stenosis might be a well designed and implemented Level I therapeutic study. This same study, however, might be classified as giving Level II prognostic evidence if the data for the untreated controls were extracted and evaluated prognostically. Guideline Development Process Step 1: Identification of Clinical Questions Trained guideline participants were asked to submit a list of clinical questions that the guideline should address. The lists were compiled into a master list, which was then circulated to each member with a request that they independently rank the questions in order of importance for consideration in the guideline. The most highly ranked questions, as determined by the participants, served to focus the guideline. Step 2: Identification of Work Groups Multidisciplinary teams were assigned to work groups and assigned specific clinical questions to address. Because NASS is comprised of surgical, medical and interventional specialists, it is imperative to the guideline development process that a crosssection of NASS membership is represented on each group. This also helps to ensure that the potential for inadvertent biases in evaluating the literature and formulating recommendations is minimized. Step 3: Identification of Search Terms and Parameters One of the most crucial elements of evidence analysis to support development of recommendations for appropriate clinical care is the comprehensive litera-

8 NASS Clinical Guidelines Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 7 ture search. Thorough assessment of the literature is the basis for the review of existing evidence and the formulation of evidence-based recommendations. In order to ensure a thorough literature search, NASS has instituted a Literature Search Protocol (Appendix D) which has been followed to identify literature for evaluation in guideline development. In keeping with the Literature Search Protocol, work group members have identified appropriate search terms and parameters to direct the literature search. Specific search strategies, including search terms, parameters and databases searched, are documented in the appendices (Appendix E). Step 4: Completion of the Literature Search Once each work group identified search terms/parameters, the literature search was implemented by a medical/research librarian, consistent with the Literature Search Protocol. Following these protocols ensures that NASS recommendations (1) are based on a thorough review of relevant literature; (2) are truly based on a uniform, comprehensive search strategy; and (3) represent the current best research evidence available. NASS maintains a search history in Endnote, for future use or reference. Step 5: Review of Search Results/ Identification of Literature to Review Work group members reviewed all abstracts yielded from the literature search and identified the literature they will review in order to address the clinical questions, in accordance with the Literature Search Protocol. Members have identified the best research evidence available to answer the targeted clinical questions. That is, if Level I, II and or III literature is available to answer specific questions, the work group was not required to review Level IV or V studies. Work group members reviewed the evidence on the topic of cervical radiculopathy, and studies eligible for review were required to address radiculopathy alone or include a subgroup analysis of patients with radiculopathy. Many of the studies considered for potential inclusion in this guideline included groups of patients with myelopathy, without appropriate subgroup analyses of those patients with cervical radiculopathy alone. For this reason, in the absence of subgroup analyses, a large number of studies were excluded from consideration in addressing the questions and formulating recommendations. These studies, having been reviewed, are included in the reference sections. Step 6: Evidence Analysis Members have independently developed evidentiary tables summarizing study conclusions, identifying strengths and weaknesses and assigning levels of evidence. In order to systematically control for potential biases, at least two work group members have reviewed each article selected and independently assigned levels of evidence to the literature using the NASS levels of evidence. Any discrepancies in scoring have been addressed by two or more reviewers. The consensus level (the level upon which two-thirds of reviewers were in agreement) was then assigned to the article. As a final step in the evidence analysis process, members have identified and documented gaps in the evidence to educate guideline readers about where evidence is lacking and help guide further needed research by NASS and other societies. Step 7: Formulation of Evidence-Based Recommendations and Incorporation of Expert Consensus Work groups held webcasts to discuss the evidencebased answers to the clinical questions, the grades of recommendations and the incorporation of expert consensus. Expert consensus has been incorporated only where Level I-IV evidence is insufficient and the work group has deemed that a recommendation is warranted. Transparency in the incorporation of consensus is crucial, and all consensus-based rec-

9 NASS Clinical Guidelines Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 8 ommendations made in this guideline very clearly indicate that Level I-IV evidence is insufficient to support a recommendation and that the recommendation is based only on expert consensus. Consensus Development Process Voting on guideline recommendations was conducted using a modification of the nominal group technique in which each work group member independently and anonymously ranked a recommendation on a scale ranging from 1 ( extremely inappropriate ) to 9 ( extremely appropriate ). Consensus was obtained when at least 80% of work group members ranked the recommendation as 7, 8 or 9. When the 80% threshold was not attained, up to three rounds of discussion and voting were held to resolve disagreements. If disagreements were not resolved after these rounds, no recommendation was adopted. After the recommendations were established, work group members developed the guideline content, addressing the literature which supports the recommendations. Step 8: Submission of the Draft Guidelines for Review/Comment Guidelines were submitted to the full Evidence- Based Guideline Development Committee and the Research Council Director for review and comment. Revisions to recommendations were considered for incorporation only when substantiated by a preponderance of appropriate level evidence. Step 9: Submission for Board Approval Once any evidence-based revisions were incorporated, the drafts were prepared for NASS Board review and approval. Edits and revisions to recommendations and any other content were considered for incorporation only when substantiated by a preponderance of appropriate level evidence. Step 10: Submission for Endorsement, Publication and National Guideline Clearinghouse (NGC) Inclusion Following NASS Board approval, the guidelines have been slated for publication, submitted for endorsement to all appropriate societies and submitted for inclusion in the National Guidelines Clearinghouse (NGC). No revisions were made at this point in the process, but comments have been and will be saved for the next iteration. Step 11: Identification and Development of Performance Measures The recommendations will be reviewed by a group experienced in performance measure development (eg, the AMA Physician s Consortium for Performance Improvement) to identify those recommendations rigorous enough for measure development. All relevant medical specialties involved in the guideline development and at the Consortium will be invited to collaborate in the development of evidence-based performance measures related to spine care. Step 12: Review and Revision Process The guideline recommendations will be reviewed every three years by an EBM-trained multidisciplinary team and revised as appropriate based on a thorough review and assessment of relevant literature published since the development of this version of the guideline. Use of Acronyms Throughout the guideline, readers will see many acronyms with which they may not be familiar. A glossary of acronyms is available in Appendix A. Nomenclature for Medical/Interventional Treatment Throughout the guideline, readers will see that what has traditionally been referred to as nonoperative, nonsurgical or conservative care is now referred to as medical/interventional care. The term medical/interventional is meant to encompass pharmacological treatment, physical therapy, exercise therapy, manipulative therapy, modalities, various types of external stimulators and injections.

10 NASS Clinical Guidelines Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 9 III. Definition and Natural History of Cervical Radiculopathy from Degenerative Disorders What is the best working definition of cervical radiculopathy from degenerative disorders? Cervical radiculopathy from degenerative disorders can be defined as pain in a radicular pattern in one or both upper extremities related to compression and/or irritation of one or more cervical nerve roots. Frequent signs and symptoms include varying degrees of sensory, motor and reflex changes as well as dysesthesias and paresthesias related to nerve root(s) without evidence of spinal cord dysfunction (myelopathy). Work Group Consensus Statement What is the natural history of cervical radiculopathy from degenerative disorders? To address the natural history of cervical radiculopathy from degenerative disorders, the work group performed a comprehensive literature search and analysis. The group reviewed 31 articles that were selected from a search of MEDLINE (PubMed), Cochrane Register of Controlled Trials, Web of Science and EMBASE Drugs & Pharmacology. However, all identified studies failed to meet the guideline s inclusion criteria because they did not ade-quately present data about the natural history of cervical radiculopathy. The plurality of studies did not report results of untreated patients, thus limiting conclusions about natural history. This includes works that have been frequently cited as so-called natural history studies but are in fact reports of the results of one or more medical/interventional treatment measures. 5,12,18,22,28 In other investigations, data were reported for untreated and conservatively-treated patients together without an analysis specific to the untreated group. Other commonly cited studies did not report subgroup analyses of patients with cervical radiculopathy alone and thereby presented generalized natural history data regarding a heterogeneous cohort of patients with isolated neck pain, cervical radiculopathy or cervical myelopathy. Because of the limitations of available literature, the work group was unable to definitively answer the question posed related to the natural history of cervical radiculopathy from degenerative disorders. In lieu of an evidence-based answer, the work group did reach consensus on the following statement addressing natural history. It is likely that for most patients with cervical radiculopathy from degenerative disorders signs and symptoms will be self-limited and will resolve spontaneously over a variable length of time without specific treatment. Work Group Consensus Statement Future Directions for Research The work group identified the following potential studies, which could generate meaningful evidence to assist in further defining the natural history of cervical radiculopathy from degenerative disorders. Recommendation #1: A prospective study of patients with cervical radiculopathy from degenerative disorders without treatment, notwithstanding nonprescription analgesics, would provide Level I evidence regarding the natural history of this disorder. Recommendation #2: A systematic study of patients with untreated cer-

11 NASS Clinical Guidelines Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 10 vical radiculopathy from degenerative disorders would provide evidence regarding the natural history of the disease in this patient population. Natural History References 1. Anderberg L, Annertz M, Persson L, Brandt L, Saveland H. Transforaminal steroid injections for the treatment of cervical radiculopathy: a prospective and randomised study. Eur Spine J. Mar 2007;16(3): Carette S, Fehlings MG. Clinical practice. Cervical radiculopathy. N Engl J Med. Jul ;353(4): Garvey TA, Eismont FJ. Diagnosis and treatment of cervical radiculopathy and myelopathy. Orthop Rev. Jul 1991;20(7): Gore DR, Carrera GF, Glaeser ST. Smoking and degenerative changes of the cervical spine: a roentgenographic study. Spine J. Sep-Oct 2006;6(5): Gore DR, Sepic SB, Gardner GM, Murray MP. Neck pain: a long-term follow-up of 205 patients. Spine. Jan-Feb 1987;12(1): Hamalainen O, Toivakka-Hamalainen SK, Kuronen P. +Gz associated stenosis of the cervical spinal canal in fighter pilots. Aviat Space Environ Med. Apr 1999;70(4): Harrop JS, Hanna A, Silva MT, Sharan A. Neurological manifestations of cervical spondylosis: an overview of signs, symptoms, and pathophysiology. Neurosurgery. Jan 2007;60(1 Supp1 1):S Healy JF, Healy BB, Wong WH, Olson EM. Cervical and lumbar MRI in asymptomatic older male lifelong athletes: frequency of degenerative findings. J Comput Assist Tomogr. Jan-Feb 1996;20(1): Hendriksen IJ, Holewijn M. Degenerative changes of the spine of fighter pilots of the Royal Netherlands Air Force (RNLAF). Aviat Space Environ Med. Nov 1999;70(11): Humphreys SC, Hodges SD, Patwardhan A, Eck JC, Covington LA, Sartori M. The natural history of the cervical foramen in symptomatic and asymptomatic individuals aged years as measured by magnetic resonance imaging. A descriptive approach. Spine. Oct ;23(20): Kang JD, Stefanovic-Racic M, McIntyre LA, Georgescu HI, Evans CH. Toward a biochemical understanding of human intervertebral disc degeneration and herniation. Contributions of nitric oxide, interleukins, prostaglandin E2, and matrix metalloproteinases. Spine. May ;22(10): Lees F, Turner JW. Natural history and prognosis of cervical spondylosis. Br Med J. Dec ;2(5373): Murphey F, Simmons JC, Brunson B. Chapter 2. Ruptured cervical discs, 1939 to Clin Neurosurg. 1973;20: Murphy DR, Hurwitz EL, Gregory A, Clary R. A nonsurgical approach to the management of patients with cervical radiculopathy: A prospective observational cohort study. J Manipulative Physiol Ther. May 2006;29(4): Peng B, Hao J, Hou S, et al. Possible pathogenesis of painful intervertebral disc degeneration. Spine. Mar ;31(5): Petren-Mallmin M, Linder J. Cervical spine degeneration in fighter pilots and controls: a 5-yr follow-up study. Aviat Space Environ Med. May 2001;72(5): Petren-Mallmin M, Linder J. MRI cervical spine findings in asymptomatic fighter pilots. Aviat Space Environ Med. Dec 1999;70(12): Radhakrishnan K, Litchy WJ, O Fallon WM, Kurland LT. Epidemiology of cervical radiculopathy. A populationbased study from Rochester, Minnesota, 1976 through Brain. Apr 1994;117 ( Pt 2): Rao R. Neck pain, cervical radiculopathy, and cervical myelopathy: pathophysiology, natural history, and clinical evaluation. J Bone Joint Surg Am. Oct 2002;84-A(10): Ross JS, Modic MT, Masaryk TJ, Carter J, Marcus RE, Bohlman H. Assessment of extradural degenerative disease with Gd-DTPA-enhanced MR imaging: correlation with surgical and pathologic findings. AJR Am J Roentgenol. Jan 1990;154(1): Rubin D. Cervical radiculitis: diagnosis and treatment. Arch Phys Med Rehabil. Dec 1960;41: Saal JS, Saal JA, Yurth EF. Nonoperative management of herniated cervical intervertebral disc with radiculopathy. Spine. Aug 1996;21(16): Sambrook PN, MacGregor AJ, Spector TD. Genetic influences on cervical and lumbar disc degeneration: a magnetic resonance imaging study in twins. Arthritis Rheum. Feb 1999;42(2): Sampath P, Bendebba M, Davis JD, Ducker T. Outcome in patients with cervical radiculopathy. Prospective, multicenter study with independent clinical review. Spine. Mar ;24(6): Swezey RL. Conservative treatment of cervical radiculopathy. J Clin Rheumatol. Apr 1999;5(2): Teresi LM, Lufkin RB, Reicher MA, et al. Asymptomatic degenerative disk disease and spondylosis of the cervical spine: MR imaging. Radiology. Jul 1987;164(1): Van Zundert J, Harney D, Joosten EA, et al. The role of the dorsal root ganglion in cervical radicular pain: diagnosis, pathophysiology, and rationale for treatment. Reg Anesth Pain Med. Mar-Apr 2006;31(2): Wainner RS, Gill H. Diagnosis and nonoperative management of cervical radiculopathy. J Orthop Sports Phys Ther. Dec 2000;30(12): Yoo K, Origitano TC. Familial cervical spondylosis. Case report. J Neurosurg. Jul 1998;89(1): Yoshida M, Tamaki T, Kawakami M, Hayashi N, Ando M.

12 NASS Clinical Guidelines Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 11 Indication and clinical results of laminoplasty for cervical myelopathy caused by disc herniation with developmental canal stenosis. Spine. Nov 1998;23(22): Zejda JE, Stasiow B. Cervical spine degenerative changes (narrowed intervertebral disc spaces and osteophytes) in coal miners. Int J Occup Med Environ Health. 2003;16(1):49-53.

13 NASS Clinical Guidelines Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 12 IV. Recommendations for Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders A. Diagnosis and Imaging What history and physical examination findings best support a diagnosis of cervical radiculopathy from degenerative disorders? RECOMMENDATION: It is suggested that the diagnosis of cervical radiculopathy be considered in patients with arm pain, neck pain, scapular or periscapular pain, and paresthesias, numbness and sensory changes, weakness, or abnormal deep tendon reflexes in the arm. These are the most common clinical findings seen in patients with cervical radiculopathy. Grade of Recommendation: B Henderson et al 30 presented findings of a retrospective observational study reporting results of PLF in the treatment of 736 patients with cervical radiculopathy. Patients included in the study reported the following symptoms: arm pain (99.4%), neck pain (79.7%), scapular pain (52.5%), anterior chest pain (17.8%) and headache (9.7%). Eleven patients presented with only left chest and arm pain ( cervical angina ). Pain or paresthesia in a dermatomal pattern was reported by 53.9% of patients, while 45.5% experienced pain or paresthesia in a diffuse or nondermatomal pattern. No pain or paresthesia was reported by 0.6% of patients. Of patients included in the study, 85.2% reported a sensory change to pinprick, 68% had a specific motor deficit and 71.2% had a specific decrease in a DTR. One nerve root level was thought to be primarily responsible for symptoms in 87.3% of patients and two levels were felt to be equally involved for the remaining 12.7%. The correlation between pain/paresthesia, motor deficit, DTR change and the primary operative level was 73.8%, 84.8% and 83.5%, respectively. There was a 71.5% incidence of correlation between preoperative clinical findings and operative findings. Good or excellent results were reported by 91.5% of patients. Good or excellent relief of arm pain was found in 95.5% of patients, neck pain in 88.8%, scapular pain in 95.9%, chest pain in 95.4% and headache in 89.8%. Resolution of DTR abnormalities was reported in 96.9%. Residual sensory deficit was found in 20.9% of patients and motor deficit in 2.3%. In a large group of patients with cervical radiculopathy, this study elucidates the common clinical findings of pain, paresthesia, motor deficit and decreased DTRs, along with their respective frequencies. These data present evidence that the surgical site can be accurately predicted on the basis of clinical findings 71.5% of the time. In critique, no validated outcome measures were used in the study. Thus, it provides Level II evidence that 71.5% of the time, the surgical site can be accurately predicted on the basis of clinical findings. Jenis et al 31 described a retrospective case series reporting the results of surgical intervention in 11 cervical radiculopathy patients with neck pain from C4 radiculopathy. Pain was localized to the posterior aspect of the neck and lateralized to the side with C4 root involvement. Pain was also reported in trapezial areas and upper extremities depending on the presence of more caudal radiculopathies. Neck pain was exacerbated by flexion and extension in all patients. Decreased sensation in the C4 dermatome was present in all patients. MRI was obtained in all patients and CT scan in three patients prior to surgery. Excluding a single myelopathic patient, four patients were treated with anterior cervical discectomy and fusion (ACDF) and seven with posterior

14 NASS Clinical Guidelines Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 13 foraminotomy (PLF). Evaluating fusion status, pain relief and level of activity based on Odom s criteria, good or excellent results were obtained in 10 of the 11 patients. The authors concluded that patients with neck pain should be evaluated for C4 radiculopathy, the examination should include C4 sensory testing, and neck pain from C4 radiculopathy can respond to surgical decompression unlike neck pain arising from degenerative disc disease. In critique, no validated outcome measures were used and the sample size was small. This study provides Level IV evidence that neck pain with or without upper extremity clinical findings should prompt evaluation for a C4 radiculopathy and that this evaluation should include C4 sensory testing. Post et al 38 reported a retrospective case series reviewing experience with the surgical management of a series of 10 patients with C7-T1 herniations. Symptoms included shoulder pain radiating into the lateral aspect of the hand, hand weakness and weakness in finger flexion, finger extension and intrinsic hand muscles. Sensation and DTRs were unremarkable. MRI on each patient revealed a soft disc compressing the C8 nerve root. Recovery of hand strength was noted in each patient; however, recovery was incomplete in two patients with symptoms greater than four months. In critique, no validated outcome measures were used and the sample size was small. This study provides Level IV evidence that C8 radiculopathy usually presents as weakness of the hand and pain radiating to shoulder, scapular area, and to the fourth and fifth fingers. Physical exam may reveal normal sensation and DTRs. Motor examination may show weakness of finger flexion and extension and weakness of the intrinsic muscles of the hand. Tanaka et al 48 described a prospective observational study examining whether or not pain in the neck or scapular regions in 50 consecutive patients with cervical radiculopathy originated from a compressed nerve root, and whether the site of pain is useful for identifying the level involved. Patients underwent single level nerve root decompression using a posterior open foraminotomy. The surgical level was determined by correlation of symptoms and imaging, with selective nerve root block (SNRB) in five patients. Cervical disc herniation (CDH) was found in 20 patients and stenosis in 30. Neck or scapular pain preceeded the arm/finger symptoms in 35 patients (70%) and was relieved early in 46 (92%). When the pain was suprascapular, C5 or C6 radiculopathy was frequent; when interscapular, C7 or C8 radiculopathy was frequent; and when scapular, C8 was frequent. Arm and finger symptoms improved significantly in all groups after decompression. Sixty-one painful sites were noted before surgery: one in 39 patients and two in 11 patients. One month after surgery, 27 patients reported complete pain relief, 23 complained of pain in 24 subregions, seven of which were the same as before surgery. Seventeen pain sites were new since surgery. All but one new site were nuchal and suprascapular. At one year follow-up, 45 patients reported no pain, five patients had pain in six sites, three of which were the same as before surgery. The authors concluded that pain in the suprascapular, interscapular or scapular regions can orginate from a compressed cervical nerve root and is valuable for determing the nerve root involved. This study provides Level I evidence that cervical radiculopathy at C5, C6, C7 and C8 frequently causes pain in suprascapular, interscapular and scapular areas and is useful in determining the level of nerve root involvement. Pain in the suprascapular region suggests C5 or C6 radiculopathy, pain in the interscapular region suggests C7 or C8 radiculopathy, and pain in the scapular region suggests C8 radiculopathy. Yoss et al 55 conducted a retrospective observational study of 100 patients to correlate clinical findings with surgical findings when a single cervical nerve root (C5, C6, C7, C8) is compressed by a disc herniation. Symptoms included pain in the neck, shoulder,

15 NASS Clinical Guidelines Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 14 scapular or interscapular regions, arm, forearm or hand; paresthesias in forearm, and hand; and weakness of upper extremity. Signs included diminution of triceps, biceps and brachioradialis reflexes, muscle weakness and sensory loss. Pain or paresthesia in the neck, shoulder, scapular or interscapular region were present in cases of C5, C6, C7 or C8 compression. The presence of pain in the arm corresponded to the site compression in 23% of cases. The presence of pain or paresthesia in the forearm corresponded to a single root or one of two roots in 32% and 66%, respectively. Hand pain and paresthesia corresponded to a single root or one of two roots in 70% and 27%, respectively. Subjective weakness corresponded to a single level in 22/34 (79%) cases. When a diminution of DTR was present, the lesion could be correctly localized to a single level or one of two levels in 11% and 82%, respectively. Objective muscle weakness corresponded to a single root or one of two roots in 77% and 12%, respectively. In all cases in which the C5 and C8 nerve root was involved and objective weakness was present, the level was correctly localized. Sensory loss corresponded to a single root or one of two roots in 65% and 35%, respectively. The authors concluded that clinical findings related to the fingers are the most accurate for localizing a CDH to a single level. A single level CDH may produce signs and symptoms that correspond to overlapping dermatomal levels. This study provides Level II evidence that clinical findings related to the fingers are the most accurate for localizing a CDH to a single level. Single level CDH may produce signs and symptoms that correspond to overlapping dermatomal levels. RECOMMENDATION: It is suggested that the diagnosis of cervical radiculopathy be considered in patients with atypical findings such as deltoid weakness, scapular winging, weakness of the intrinsic muscles of the hand, chest or deep breast pain, and headaches. Atypical symptoms and signs are often present in patients with cervical radiculopathy, and can improve with treatment. Grade of Recommendation: B Henderson et al 30 presented findings of a retrospective observational study reporting results of PLF in the treatment of 736 patients with cervical radiculopathy. Patients included in the study reported the following symptoms: arm pain (99.4%), neck pain (79.7%), scapular pain (52.5%), anterior chest pain (17.8%) and headache (9.7%). Eleven patients presented with only left chest and arm pain ( cervical angina ). Pain or paresthesia in a dermatomal pattern was reported by 53.9% of patients, while 45.5% experienced pain or paresthesia in a diffuse or nondermatomal pattern. No pain or paresthesia was reported by 0.6% of patients. Of patients included in the study, 85.2% reported a sensory change to pinprick, 68% had a specific motor deficit and 71.2% had a specific decrease in a DTR. One nerve root level was thought to be primarily responsible for symptoms in 87.3% of patients and two levels were felt to be equally involved for the remaining 12.7%. The correlation between pain/paresthesia, motor deficit, DTR change and the primary surgical level was 73.8%, 84.8% and 83.5%, respectively. There was a 71.5% incidence of correlation between presurgical clinical findings and surgical findings. Good or excellent results were reported by 91.5% of patients. Good or excellent relief of arm pain was found in 95.5% of patients, neck pain in 88.8%, scapular pain in 95.9%, chest pain in 95.4% and headache in 89.8%. Resolution of DTR abnormalities was reported in 96.9%. Residual sensory deficit was found in 20.9% of patients and motor deficit in 2.3%. In a large group of patients with cervical radiculopathy, this study elucidates the common clinical findings of pain, paresthesia, motor deficit, and decreased DTRs, along with their respective frequencies. These data present evidence that the operative site can be accurately predicted on the basis of clinical findings 71.5% of the time.

16 NASS Clinical Guidelines Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 15 In critique, no validated outcome measures were used in the study. Thus, it provides Level II evidence that 71.5% of the time, the operative site can be accurately predicted on the basis of clinical findings. Chang et al 13 described a retrospective case series identifying the characteristics of cervical radiculopathy causing deltoid paralysis, and reporting on the surgical outcomes of ACDF for the treatment of deltoid paralysis. All 14 patients had pain radiating to the scapula, shoulder or arm, with weakness of shoulder abduction due to paralysis of deltoid (graded 0-5). Severity of radicular pain was graded on a visual analog scale (VAS) from zero to 10. Plain radiographs and MRI were correlated with clinical findings. Surgery was performed on patients with single level CDH or cervical spondylotic radiculopathy (CSR). Patients with multilevel disease were excluded. The following lists the single levels implicated in deltoid paralysis and their respective frequencies: 1-C3-4 CDH (central), 4-C4-5 CDH, 1-C5-6 CDH, 3-C4-5 CSR, 5-C5-6 CSR. Both radiculopathy and deltoid paralysis improved significantly with surgery. The authors found that a painful cervical radiculopathy with deltoid paralysis arose from the C4-5, C5-6 and C3-4 levels in 50%, 43% and 7% of the cases, respectively. This small study provides Level IV evidence that a painful cervical radiculopathy with deltoid paralysis can arise from compressive disease at the C4-5, C5-6 or C3-4 levels. Makin et al 34 reported a retrospective case series of six patients with scapular winging as a finding with C7 radiculopathy. Scapular winging from serratus anterior weakness was detected by pushing forward against a wall with the hands at shoulder level or with the hands at waist level. The latter method places the serratus anterior muscle at a mechanical disadvantage and reveals partial paralysis. Each case of C7 compression was confirmed by surgical findings or by CT myelography. The authors concluded that scapular winging may be a component of C7 radiculopathy and when present serves to exclude lesions of the brachial plexus or radial nerve. This small study provides Level IV evidence that scapular winging can be a feature of C7 radiculopathy. Ozgur et al 35 described a retrospective case series of the presenting symptomatology of 241 consecutive patients following C6-7 discectomy. Of the patients, 83% had typical C7 radicular signs while 17% had atypical symptoms, 12% reporting isolated subscapular pain and 5% deep breast or chest pain. The authors reported that patients presenting with atypical symptoms had correlative pathology confirmed by surgical findings, 93% of whom experienced symptom relief. This study provides Level IV evidence that a substantial percentage of patients may present with atypical symptoms associated with C7 nerve root compression Persson et al 37 conducted a prospective observational study to describe the frequency of headaches in patients with lower level cervical radiculopathy and its response to a selective nerve root block (SNRB). Of 275 patients, 161 suffered from daily or recurrent headaches, most often ipsilateral to the patients radiculopathy. All patients underwent clinical exam and MRI. Patients with significantly compressed nerve roots underwent SNRB. All patients with headaches had tender points in the neck/shoulder region ipsilateral to the radiculopathy. Patients with headache had significantly more limitations in daily activities and higher pain in the neck/shoulder. Immediately before the injections, 161 (59%) of patients experienced a headache exceeding 15 on the VAS. Of these 161 patients, 101 (63%) experienced >25% headache reduction following SNRB, 93 (58%) reported greater than 50% headache reduction, and 66 experienced 100% relief (C4 3%, C5 11%, C6 52%, C7 29%, C8 5%). A significant correlation was found between reduced headache and decreased pain in the neck and shoulder region. The authors concluded that cervical nerve root compression from degenerative disease in the lower cervical spine producing radiculopathy can also result in headache. Thus, headache assessment together with muscle palpation should be part of the clinical exam for patients with cervical radiculopathy.

17 NASS Clinical Guidelines Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 16 In critique, the study had a low (50%) threshold and lack of specificity for the injection. Because of these limitations, this potential Level II study provides Level III evidence that complaint of a headache can be a symptom with C4-C8 nerve root compression. SNRB can reduce headache in a substantial percentage of patients and may be a useful diagnostic tool. Post et al 38 reported a retrospective case series reviewing experience with the surgical management of a series of 10 patients with C7-T1 herniations. Symptoms included shoulder pain radiating into the lateral aspect of the hand, hand weakness and weakness in finger flexion, finger extension and intrinsic hand muscles. Sensation and DTRs were unremarkable. MRI on each patient revealed a soft disc compressing the C8 nerve. Recovery of hand strength was noted in each patient; however, recovery was incomplete in two patients with symptoms greater than four months. In critique, no validated outcome measures were used and the sample size was small. This study provides Level IV evidence that C8 radiculopathy can present with weakness of the hand, and pain radiating to the shoulder, scapular area, and fourth and fifth fingers. RECOMMENDATION: Provocative tests including the shoulder abduction and Spurling s tests may be considered in evaluating patients with clinical signs and symptoms consistent with the diagnosis of cervical radiculopathy. Grade of Recommendation: C Davidson et al 16 described observations from a retrospective case series of 22 patients with cervical monoradiculopathy caused by compressive disease in whom clinical signs included relief of pain with abduction of the shoulder. Twenty-two patients with arm pain had cervical extradural myelographic defects. Of the 22 patients, 15 experienced relief from their pain with shoulder abduction. Motor weakness was present in 15, paresthesias in 11 and reflex changes in nine patients. Of the 15 patients with a positive shoulder abduction sign, 13 required surgery and all achieved good results. Two of the 15 had pain relief with conservative therapy. Of the seven patients with negative shoulder abduction signs, five required surgery and two were successfully treated with traction. Of the five surgical patients, three had surgery for a central lesion and improved after surgery, two had surgery for a lateral disc fragment and only one had good results. The authors concluded that the shoulder abduction test is a reliable indicator of significant cervical extradural compressive radicular disease. In critique, no validated outcome measures were used and the sample size was small. This study provides Level III evidence that relief from arm pain with shoulder abduction is an indicator of cervical extradural compressive radiculopathy. Shah et al 45 conducted a prospective observational study to determine the sensitivity and specificity of the Spurling s test in predicting the diagnosis of a soft lateral CDH in 50 patients with neck and arm pain. Spurling s test with cervical extension, lateral flexion to the side of pain, and downward pressure on the head was performed on all patients. Twentyfive patients underwent surgery (Group 1) and 25 were managed conservatively (Group 2). Spurling s test was correlated with surgical findings in Group 1 and with MRI findings in Group 2. Patients with their first episode of radicular pain and minimal or no neurologic deficits, and those who refused surgery were managed conservatively. In Group 1, of the 18 patients with a positive Spurling s test, all had surgically confirmed soft disc herniations. Of seven patients with a negative Spurling s test, two had a soft disc herniation and five had a hard disc. In Group 2, of the 10 patients with a positive Spurling s test, nine had a soft disc herniation, one had a hard disc. Of the 15 patients with a negative Spurling s test, a hard disc was seen in eight, and MRI was normal in seven. The Spurling s test had a sensitivity of 92%, a specificity of 95%, a positive predictive value (PPV) of 96.4% and a negative predictive power (NPP) of 90.9% for a soft disc herniation. The authors concluded that

18 NASS Clinical Guidelines Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 17 the high PPV of the test can be used to improve the yield of postivie MRI examinations in patients with cervical radiculopathy. This study provides Level II evidence that a positive Spurling s test improves the clinician s ability to diagnose compressive disease in patients with cervical radiculopathy. Tong et al 49 performed a prospective comparative study to determine the sensitivity and specificity of the Spurling test for 255 patients referred for electrodiagnosis of upper extremity nerve disorders. The Spurling test was performed on all patients before electromyography (EMG). The test was scored as positive if it resulted in pain or tingling starting in the shoulder and radiating distally to the elbow. A differential diagnosis based on the history and physical exam was made prior to EMG. EMG was performed and each diagnosis in the differential was scored relative to the likelihood of its occurrence. Of the 255 patients presented, 31 had missing data, leaving 224 patients for inclusion. Of 20 patients with a positive EMG for cervical radiculopathy, the Spurling s test was positive in seven, for a sensitivity of 7/20 or 30%. Of 172 patients with no EMG evidence for radiculopathy, the Spurling s test was negative in 160, for a specificity of 160/172 or 93%. The Spurling s test was positive in 16.6% of patients with a normal EMG, in 3.4% of patients with an EMG diagnosis of a nerve problem other than radiculopathy, and in 15% of patients with nonspecific EMG findings. The odds ratio of a positive Spurling s test in a patient with a positive EMG for cervical radiculopathy is The authors concluded that the Spurling s test is not sensitive but is specific for cervical radiculopathy as diagnosed by EMG. Although not useful as a screening test, it may be useful to confirm the diagnosis. In critique, the study uses a poor reference standard (EMG). This study provides Level IV evidence that the Spurling s test is not sensitive but is specific for cervical radiculopathy as diagnosed by EMG. Thus, a positive Spurling s test is clinically useful in helping confirm the presence of cervical radiculopathy. Wainner et al 51 described a prospective comparative study assessing the reliability and accuracy of individual clinical exam items and self reported instruments for the diagnosis of cervical radiculopathy in 82 patients with a goal of identifying and assessing the accuracy of an optimal cluster of test items. Consecutive patients were referred for EMG for the evaluation of cervical radiculopathy or carpal tunnel syndrome. Only patients judged by one of seven laboratory providers to have signs and symptoms compatible with CR or CTS were eligible to participate. Patients with Class 5 or 6 cervical radiculopathy findings were further classified according to the severity of their EMG findings. Self-reported items included the VAS and NDI. A standardized clinical exam was performed by two of nine physical therapists and contained 34 items. History contained six questions asked by two physical therapists. Neurological exam included strength, DTRs and sensation. Provocative tests included Spurling s test, shoulder abduction test, Valsalva maneuver, neck distraction test and the upper limb tension test (ULTT). Cervical range of motion was also measured. Fifteen patients had an EMG diagnosis of cervical radiculopathy, and five patients were diagnosed with cervical radiculopathy and carpal tunnel sydrome, one with concomitant ulnar neuropathy. One patient with combined findings dropped out of the study. Of the 19 patients reported, 13 had mild symptoms and six had moderate symptoms. Reliability of different clinical items was reported including the Spurling s A/B 0.6/0.62, shoulder abduction 0.2, valsalva 0.69, distraction 0.88, ULTT A/B 0.76/0.83. Sensitivity/ specificity: Spurling s A/B 0.6/0.62, shoulder abduction 0.2, valsalva 0.69, distraction 0.88, ULTT A/B 0.76/0.83. Sensitivity/Specificity of different clinical items was reported including the Spurling s A/B - 0.5/ ; shoulder abduction /0.92; valsalva -.22/.94; distraction /0.9; ULTT A/B / ; Cluster of ULTT A, cervical rotation <60degrees, distraction, and Spurling s A /0.99. The authors concluded that many items were found to have at least a fair level of reliability

19 NASS Clinical Guidelines Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 18 and to have acceptable diagnostic properties. The test item cluster identified was found to be the most useful. In critique, the small study utilized EMG as a gold standard with an apparent test selection bias. Because of these limitations, this potential Level III study provides Level IV evidence that provocative tests, including the Spurling s test, shoulder abduction test, Valsalva and distraction test had a low sensitivity but high specificity for cervical radiculopathy as diagnosed by EMG. Bertilson et al 11 reported a prospective case series analyzing the reliability of clinical tests, including provocative maneuvers, in the assessment of neck and arm pain in 100 primary care patients. Reliability of clinical tests was poor to fair in several test categories. Only a bimanual sensitivity test reached good values. However, when the examiner knows the clinical history, the prevalence of positive findings increased in 80% of test categories. Bias was apparent in all test categories except for sensitivity. The authors concluded that sensitivity testing was the most reliable and was exempt from bias. Knowledge of the patient s history had no impact on reliability, however it increased the incidence of positive findings. In critique, patients were not enrolled at the same point in their disease and there were only two reviewers. Because of these limitations, this potential Level I study provides Level II evidence that history and physical findings are not definitive, that the incidence of positive findings can increase with known history, and that several categories may be susceptable to bias with a suggestive clinical history. RECOMMENDATION: Because dermatomal arm pain alone is not specific in identifying the pathologic level in patients with cervical radiculopathy, further evaluation including CT, CT myelography, or MRI is suggested prior to surgical decompression. Grade of Recommendation: B Henderson et al 30 presented findings of a retrospective observational study reporting results of PLF in the treatment of 736 patients with cervical radiculopathy. Patients included in the study reported the following symptoms: arm pain (99.4%), neck pain (79.7%), scapular pain (52.5%), anterior chest pain (17.8%) and headache (9.7%). Eleven patients presented with only left chest and arm pain ( cervical angina ). Pain or paresthesia in a dermatomal pattern was reported by 53.9% of patients, while 45.5% experienced pain or paresthesia in a diffuse or nondermatomal pattern. No pain or paresthesia was reported by 0.6% of patients. Of patients included in the study, 85.2% reported a sensory change to pinprick, 68% had a specific motor deficit and 71.2% had a specific decrease in a DTR. One nerve root level was thought to be primarily responsible for symptoms in 87.3% of patients and two levels were felt to be equally involved for the remaining 12.7%. The correlation between pain/paresthesia, motor deficit, DTR change and the primary operative level was 73.8%, 84.8% and 83.5%, respectively. There was a 71.5% incidence of correlation between preoperative clinical findings and operative findings. Good or excellent results were reported by 91.5% of patients. Good or excellent relief of arm pain was found in 95.5% of patients, neck pain in 88.8%, scapular pain in 95.9%, chest pain in 95.4% and headache in 89.8%. Resolution of DTR abnormalities was reported in 96.9%. Residual sensory deficit was found in 20.9% of patients and motor deficit in 2.3%. In a large group of patients with cervical radiculopathy, this study elucidates the common clinical findings of pain, paresthesia, motor deficit, and decreased DTRs, along with their respective frequencies. These data present evidence that the surgical site can be accurately predicted on the basis of clinical findings 71.5% of the time. In critique, no validated outcome measures were used in the study. Thus, it provides Level II evidence that 71.5% of the time, the operative site can be accurately predicted on the basis of clinical findings.

20 NASS Clinical Guidelines Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 19 Slipman et al 46 described a prospective observational study evaluating the distribution of pain and paresthesias that result from the stimulation of specific cervical nerve roots in 87 patients with 134 selective nerve root stimulations. Mechanical stimulation of nerve roots was carried out: four at C4, 14 at C5; 43 at C6; 52 at C7; and 21 at C8. An independent observer recorded the location of provoked symptoms on a pain diagram. Visual data was compiled using a 793 body sector bit map with 43 body regions identified. Although the distribution of symptom provocation resembled the classic dermatomal maps, symptoms were frequently provoked outside the classic descriptions. The authors concluded that there was a distinct difference between the dynatomal and dermatomal maps. This study provides Level I evidence that distribution of pain and paresthesias in the arm from nerve root stimulation can be different from traditional dermatomal maps in a substantial percentage of patients making it difficult to identify the level based on pain distribution. Yoss et al 55 conducted a retrospective observational study of 100 patients to correlate clinical findings with surgical findings when a single cervical nerve root (C5, C6, C7, C8) is compressed by a disc herniation. Symptoms included pain in the neck, shoulder, scapular or interscapular region, arm, forearm or hand; paresthesias in forearm, and hand; and weakness of upper extremity. Signs included diminution of triceps, biceps and brachioradialis reflexes, muscle weakness and sensory loss. Pain or paresthesia in the neck, shoulder, scapular or interscapular region were present in cases of C5, C6, C7, or C8 compression. The presence of pain in the arm corresponded to the site compression in 23% of cases. The presence of pain or paresthesia in the forearm corresponded to a single root or one of two roots in 32% and 66%, respectively. Hand pain and paresthesia corresponded to a single root or one of two roots in 70% and 27%, respectively. Subjective weakness corresponded to a single level in 22/34 (79%) cases. When a diminution of DTR was present, the lesion could be correctly localized to a single level or one of two levels in 11% and 82%, respectively. Objective muscle weakness corresponded to a single root or one of two roots in 77% and 12%, respectively. In all cases in which C5 or C8 radiculopathy was accompanied by weakness, the level was correctly localized. Sensory loss corresponded to a single root or one of two roots in 65% and 35%, respectively. The authors concluded that clinical findings related to the fingers are the most accurate for localizing a CDH to a single level. A single level CDH may produce signs and symptoms that correspond to overlapping dermatomal levels. This study provides Level II evidence that clinical findings related to the fingers are the most accurate for localizing a CDH to a single level. Single level CDH may produce signs and symptoms that correspond to overlapping dermatomal levels. Future Directions for Research Further studies are needed to demonstrate the PPV of specific symptoms and physical exam findings in patients with confirmed cervical radiculopathy to demonstrate their usefulness in predicting a good outcome with conservative or surgical treatment. History and Physical Exam Findings References 1. Abbed KM, Coumans JV. Cervical radiculopathy: pathophysiology, presentation, and clinical evaluation. Neurosurgery. Jan 2007;60(1 Supp1 1):S Al-Hami S. Cervical monosegmental interbody fusion using titanium implants in degenerative, intervertebral disc disease. Minim Invasive Neurosurg. Mar 1999;42(1): An HS. Cervical root entrapment. Hand Clin. Nov 1996;12(4): Anderberg L, Annertz M, Brandt L, Saveland H. Selective diagnostic cervical nerve root block--correlation with clinical symptoms and MRI-pathology. Acta Neurochir (Wien). Jun 2004;146(6): ; discussion Anderberg L, Annertz M, Rydholm U, Brandt L, Saveland H. Selective diagnostic nerve root block for the evaluation of radicular pain in the multilevel degenerated cervical spine. Eur Spine J. Jun 2006;15(6): Anderson PA, Subach BR, Riew KD. Predictors of outcome after anterior cervical discectomy and fusion: a multivariate analysis. Spine. Jan ;34(2):