Cervicobrachial neuralgia (cervical radiculopathy) Updated 2026

Clinical synthesis based on the most recent meta-analyses and guidelines: Blanpied 2017 JOSPT, the OPTIMa 2022 update, the Thoomes 2026 update and the 2025 NMA.

How is this condition defined, who does it affect and what are the risk factors?

Cervicobrachial neuralgia, more formally called cervical radiculopathy, is a neurological condition resulting from compression or inflammation of one or more nerve roots at the cervical spine.^1,2 Patients typically describe pain radiating from the neck into the shoulder, arm, forearm and sometimes the hand, following the sensory territory (dermatome) of the affected root.^1,3 This pain may be accompanied by paraesthesia (tingling, numbness), reduced sensation or muscle weakness (myotome).^1,2

🧠 Epidemiologically, cervical radiculopathy is a common disorder. The landmark study by Radhakrishnan et al. (Rochester cohort, Minnesota, 1976-1990, n=561 patients) reports a mean annual incidence of 83.2 cases per 100,000 population, with a peak in individuals aged 50 to 54 years.³ Men are slightly more affected than women (ratio 1.4:1, Kelsey 1984 on 205 cases of acute cervical disc prolapse).⁴

The causes of this nerve compression are mostly degenerative. Cervical spondylosis (vertebral osteoarthritis) and degenerative disc disease account for about 70-75% of cases, notably through the formation of osteophytes narrowing the intervertebral foramen.^2,5 In younger patients, disc herniation is a more common cause than degenerative bone disease.⁶

Several risk factors have been identified. The landmark case-control study by Kelsey 1984 found significant associations with:

• The heavy manual work (frequent handling of heavy objects at work at the time symptoms appeared)
• The active smoking (accelerates disc degeneration through tissue hypoxia)
• The frequent driving of vehicles (vibration transmitted to the spine)
• The repeated diving from a diving board (repeated cervical microtrauma)⁴

What happens in the body and how does it evolve naturally?

The pathophysiology of cervical radiculopathy is twofold : mechanical and biochemical.^5,7 The mechanical compression acting directly on the nerve root and its feeding vessels can cause ischaemia, intraneural oedema and focal demyelination, altering nerve conduction.⁵

Compression alone, however, does not explain the whole symptom picture. Inflammatory processes play a crucial role, especially with a disc herniation. When the nucleus pulposus of the intervertebral disc extrudes, it releases pro-inflammatory mediators (TNF-α, interleukins, prostaglandins) that create an “inflammatory soup” around the root, causing chemical irritation and sensitisation that contribute significantly to the neuropathic pain experienced.⁵

📈 One of the most important points for management is to know the natural history, which is generally very favourable. Several systematic reviews confirm that most patients improve with conservative treatment alone, without needing surgery.^8,9 Eubanks (Am Fam Physician 2010) reports that 75 to 90% of patients achieve significant improvement or complete resolution with non-operative care, generally within 4 to 6 months, sometimes within a few weeks.¹⁰ The prospective Kuijper 2009 cohort (BMJ, n=205) even showed that simple interventions (a semi-rigid collar or physiotherapy) substantially reduce pain from the 6th week onwards compared with a wait-and-see policy.¹¹

The diagnosis of cervical radiculopathy is a demanding clinical process that rests not on a single test or symptom, but on the convergence of findings from the history, the physical examination and, if necessary, imaging.¹ Cervical radiculopathy is defined as a set of neurological symptoms and signs resulting from compression or irritation of a cervical root.^1,2

Which questions should you ask to understand the patient and their history?

History-taking is the foundation of the diagnosis. Particular attention should be paid to the following elements:

• 🗺️ Mapping and quality of the pain : it is essential to ask the patient to describe the topography of their pain precisely. Pain that radiates below the elbow is strongly associated with nerve compression confirmed on MRI (Rainville 2017).³ The description (shooting pain, burning, electric shock) and the paraesthesia (tingling, pins and needles) are more reliable than assessing motor strength during the examination.
• 🔄 Influencing factors : identify the positions that aggravate or relieve the symptoms. Aggravation on coughing or sneezing suggests a radicular origin (Valsalva effect). The “shoulder abduction sign” (relief with the arm placed in abduction over the head) is specific and clinically useful.⁴
• 🗓️ History of the condition and risk factors : mode of onset (traumatic or gradual), duration, course. Look for heavy manual work, smoking, previous cervical trauma, frequent driving, repeated diving (Kelsey 1984).⁵
• 🚩 Systematic screening for red flags : signs of myelopathy, progressive deficit, unexplained weight loss, fever, night sweats, history of cancer, sphincter disturbance (Finucane 2020).⁶

Which clinical tests should you perform and which diagnostic cluster should you use?

The physical examination aims to confirm or refute the hypotheses raised by the history. Research has clearly established that no clinical test taken in isolation is sufficient to diagnose cervical radiculopathy with certainty.^7,8 The strength of the diagnosis lies in the combination of several tests. The updated meta-analysis by Thoomes 2026 (BMC MSD, 8 studies) confirms and refines this finding.⁹

The 3 key tests to master

• Spurling A test : axial compression of the head in extension + ipsilateral rotation + side bending towards the symptomatic side. Very high specificity (0.89-1.00) but low sensitivity (~0.50): a positive test makes radiculopathy very likely; a negative one does not rule it out.^8,10
• Cervical distraction test : manual axial traction applied to the head in supine lying. Relief of the patient's symptoms = positive test. High specificity (0.90-1.00), low to moderate sensitivity.⁸
• Upper limb neurodynamic test 1 (ULNT1) : places the median nerve and the C5-C7 roots under tension. Sequence: shoulder abduction 110°, forearm supination, wrist and finger extension, elbow extension, contralateral cervical side flexion. Very high sensitivity (0.83-0.97), low specificity: its main use is to rule out the diagnosis when it is negative.^8,9

The Wainner cluster: the validated combination

The combination of tests considerably increases diagnostic certainty. The cluster originally validated by Wainner et al. (2003, n=82 patients referred for EMG, the electrophysiological gold standard) is the most studied.¹⁰ If the following 4 tests are positive at the same time, the post-test probability is very high (LR+ > 30):

Which other conditions must you rule out?

Cervical radiculopathy is a great imitator 🧠: it can mimic (and conversely be mimicked by) many upper limb conditions. A structured cervical examination is mandatory in the face of any persistent upper limb pain or neurological symptom, and conversely a full upper limb examination is required in the face of any cervicobrachial pain.

Where do you start? What is the hierarchy of interventions?

The current consensus, carried by the most recent guidelines (Blanpied 2017 JOSPT, a CPG currently under revision for 2026; OPTIMa 2022 update; Bono 2011 NASS), points towards a multimodal, patient-centred approach rather than a rigid hierarchy of isolated interventions.^1,2,3 The network meta-analysis by Núñez de Arenas-Arroyo 2025 (36 RCTs, 25 interventions) confirms this additive effect of the components experimentally.⁴

🧠 The first, fundamental step is patient education. Explain the nature of the radiculopathy, reassure the patient about its generally favourable prognosis and deconstruct catastrophic beliefs about pain and imaging.⁵

The recommended initial approach systematically combines:

• Therapeutic education , with information about the condition, self-management strategies and the importance of the patient's active role.^1,2
• Therapeutic exercise , introduced early: mobility, strength, motor control of the neck and shoulder girdle.⁶
• Manual therapy , with mobilisations or manipulations for short-term relief, making it easier to engage in exercise.⁷
• Mechanical cervical traction , a first-line option when radicular symptoms are present (Romeo 2018, meta-analysis of 7 RCTs).⁸

What is the place of exercise and is there a superior approach?

Therapeutic exercise is a cornerstone of conservative treatment, with solid evidence supporting its effectiveness (Liang 2019 meta-analysis, n=534 patients).⁹ 💪 However, current research does not demonstrate any clear superiority of one type of exercise over another. The network meta-analysis by Núñez de Arenas-Arroyo 2025 assessed 25 interventions made up of 8 active components: none proved universally superior.⁴

The most commonly validated exercise strategies include:

• Specific strengthening : deep neck flexors (longus colli, longus capitis) and scapulothoracic stabilisers (lower trapezius, serratus anterior, rhomboids). This strengthening improves postural support and reduces the load on irritated cervical structures.⁹
• Mobility and range of motion exercises : controlled pain-free movement, segmental glides, prevention of stiffness after irritation.
• Neurodynamic mobilisations (sliders/tensioners) : Nee 2012 (n=60, RCT) demonstrated a clinically relevant immediate benefit (NDI -7.8 points, NNT 2.7 for global perceived improvement).¹⁰ The meta-analysis by Gillot 2025 (Clin Rehabil) confirms an additive effect on pain and function.¹¹
• Cervical proprioceptive exercises : oculomotor retraining, postural control, particularly useful after whiplash-type cervical trauma.

Manual therapy, traction, neurodynamics: how effective are they?

Manual therapies, such as spinal mobilisations and manipulations, are widely used. Their main effectiveness lies in short-term pain reduction and in making active participation easier.^7,12 The J Pain Res 2025 network meta-analysis (PMC 12008560) confirms that manual therapy + exercise combined is more effective than either intervention alone on the NDI and on pain.¹²

Focus: mechanical cervical traction

The meta-analysis by Romeo 2018 (Phys Ther 98(4):231-242) analysed 7 RCTs on adding cervical traction to standard physiotherapy.⁸ Conclusion: traction added to physiotherapy significantly reduces pain and disability in the short term (SMD -0.87) and the medium term (SMD -0.69) compared with physiotherapy alone. Preferred indication : patients whose symptoms decrease with manual decompression during the distraction test. Typical protocol: 8-12 kg, intermittent (60s on/20s off), 15-20 min, 3x a week.

How do you educate the patient and address psychosocial factors?

Education is a therapeutic intervention in its own right. Communication should focus on reassurance, on explaining the largely favourable prognosis of cervical radiculopathy and on promoting self-efficacy. Addressing the psychosocial factors, the yellow flags , is essential to prevent the problem becoming chronic.

• Explaining pain : use accessible metaphors to take the drama out of imaging (Brinjikji 2015: 87.6% of asymptomatic subjects > 60 years have disc degeneration on MRI) and explain pain as a protective alarm system rather than an indicator of ongoing tissue damage.^13,14
• Identifying and managing limiting beliefs : kinesiophobia, catastrophising, anxiety and depression predict poorer recovery. The Fear-Avoidance Beliefs Questionnaire (FABQ) or the Tampa Scale of Kinesiophobia (TSK) can be used.
• Setting functional goals : work with the patient to set meaningful, achievable goals (Patient-Specific Functional Scale, PSFS).

Long-term management of cervical radiculopathy aims to go beyond simply relieving acute symptoms and to move towards functional resilience and the prevention of recurrence. A lasting strategy rests on the synergistic combination of patient empowerment, targeted strengthening and a progressive, safe return to activities.¹

How do you make the patient an active participant in their own recovery through self-management?

Patient empowerment is the pillar of lasting recovery. 🧠 This approach reduces dependence on the therapist and significantly improves long-term outcomes.²

Structured therapeutic education

The first step is therapeutic patient education (TPE). Explaining the nature of the radiculopathy, its generally favourable prognosis and the mechanisms of pain is fundamental. Education in pain neuroscience (PNE) can reduce fear of movement, reduce pain intensity and improve function in patients with chronic musculoskeletal pain.^2,3 Most cases of acute cervical radiculopathy improve considerably with conservative treatment within 4-6 months: a reassuring piece of information.⁴

The progressive home exercise programme

Personalised and progressive, it typically includes:

• Motor control and strengthening exercises: strengthening the deep neck flexors (cranio-cervical flexion test, CCFT) and the scapular stabilisers (lower trapezius, serratus anterior) improves the dynamic stability of the cervical spine and reduces the load on the neural structures.^5,6
• Neural mobility exercises: sliders and tensioners for the median nerve (the one most often involved at C6-C7), the ulnar nerve (C8-T1) or the radial nerve. Reference: Nee 2012, a protocol of 5 progressive movements performed 3x a day in sets of 10.⁷
• Postural correction and ergonomics: maintain a neutral posture, particularly during prolonged activities (computer, driving). Simple ergonomic advice (screen at eye height, chair position, a break every 45 min).⁸
• Postural endurance exercises: wall angels, prone Y/T/I, scapular setting: progression towards function.

Why should you remain critical of imaging?

The correlation between MRI and clinical symptoms is weak. The major systematic review by Brinjikji 2015 (3,110 asymptomatic subjects) quantified the prevalence of degenerative abnormalities in people without pain :

Cervical radiculopathy in the athlete deserves particular attention because it can sit on a continuum with specific entities: “stingers” and “burners” (transient brachial plexus injuries, common in rugby and American football), post-traumatic cervical instability, and injuries related to repeated axial loading (weightlifting, wrestling). 🏉 The clinical challenge is twofold: (1) treat the radiculopathy effectively so that the athlete can return, (2) avoid a premature return that would expose them to more serious neurological injury.

Specific features of the athlete with cervical radiculopathy

Athletes have specific risk factors:

• Contact sports (rugby, American football, MMA, wrestling, judo, hockey): repeated impacts, tackles and falls, hence a high risk of “stinger” episodes (a transient shock down the arm after trauma) that share their pathophysiology with radiculopathy.
• Axial loading sports (weightlifting, crossfit, gymnastics): repeated axial compression favouring early disc disease.
• Racket and throwing sports (tennis, baseball, javelin): postural asymmetry, unilateral hypertrophy, forced extension and rotation stresses.
• Diving / water polo : cervical impacts on entering the water (Kelsey 1984 identified repeated diving as a risk factor).¹

How do you plan a safe return to play in 5 phases?

Return to play (RTP) must be progressive and based on functional criteria, not on a fixed timetable.² 🏋️‍♀️ A premature or poorly managed return is a major risk factor for recurrence and, in contact sports, can expose the athlete to more serious injury.

Special case: the “stinger / burner”

A stinger is a transient unilateral episode of lightning pain + paraesthesia + temporary weakness (< 24h) typically occurring after a tackle or a fall. It shares the pathophysiology of radiculopathy: compression or stretching of the C5-C6 root during forced side bending. Practical rule : a first isolated stinger that resolves in less than 15 minutes generally allows the player to carry on with the match after examination. Any stinger persisting > 24h, recurrent or bilateral calls for immediate withdrawal and a full work-up (MRI + Torg-Pavlov cervical canal measurement). Congenital cervical stenosis (canal < 13 mm) is a relative contraindication to contact sports according to several expert opinions.

Analysing clinical cases published in the scientific literature offers a valuable insight into the presentation, the diagnostic reasoning and the treatment strategies applied to specific individuals. 🧐 Although they rank lower in level of evidence than randomised controlled trials, they illustrate the complexity and variability of everyday clinical practice.

Analysis of a classic case: from assessment to resolution

The reference case series by Cleland, Whitman, Fritz & Palmer (JOSPT 2005, 11 consecutive patients) illustrates an identifiable trajectory.¹ The patients showed clinical signs typical of a C5 to C7 radiculopathy, with: pain aggravated by neck movements, positive provocation tests (Spurling and cervical distraction), a motor deficit in the territory concerned and dermatomal loss of sensation.

The treatment approach, based on the evidence emerging at the time and confirmed since, was multimodal. It combined:

• Manual therapy including thoracic manipulations and cervical mobilisations to improve segmental mobility
• Mechanical cervical traction intermittent (10 to 25 lbs, 15-20 min)
• Specific therapeutic exercises : strengthening the deep neck flexors + scapulothoracic stabilisers + neurodynamic mobilisations (median nerve gliding)

The treatment plan was progressive, adapted to the decreasing irritability of the symptoms. 10 of the 11 patients (91%) achieved a clinically significant improvement in 7-8 sessions. Despite its methodological limitations (level 4), this case series was a founding text for evidence-based practice in cervical physiotherapy and inspired the subsequent RCT by Cleland 2007 (Phys Ther, n=96, predictors).²

The diagnostic challenge: the great imitator and double crush syndrome

One of the greatest clinical challenges is that cervical radiculopathy is a great imitator. 🧠 Its symptoms can mimic (and conversely be mimicked by) many musculoskeletal conditions of the upper limb, leading to diagnostic errors and ineffective treatment.

The “double crush syndrome” concept

First described by Upton and McComas in 1973, the double crush syndrome holds that a proximal nerve compression (cervical radiculopathy) makes the nerve more vulnerable to a distal compression (carpal tunnel, cubital tunnel) and vice versa. The concept remains debated but clinically useful: it is a reminder of how important it is to examine the whole course of the nerve. The incidence of a coexisting double crush between cervical radiculopathy and carpal tunnel syndrome in surgical patients has been estimated at about 3.5% in a recent study (Lo 2022, J Hand Surg Am).³ Patients without and with a double crush achieve similar rates of improvement after carpal tunnel release (Patton 2024, n=370+).⁴

Classic diagnostic errors

• Mimicking a shoulder disorder : C5 radiculopathy often mimics a rotator cuff tendinopathy (lateral deltoid pain, weak abduction). Diagnostic key : normal passive shoulder examination + positive Wainner cluster.
• Mimicking a lateral epicondylalgia : C6-C7 radiculopathy can mimic a tennis elbow. Diagnostic key : positive ULNT1 + no pain on palpation of the epicondyle.
• Mimicking a carpal tunnel syndrome : paraesthesia in the 1st-3rd fingers can arise from a C6-C7 root. Diagnostic key : specific EMG + cervical tests + search for a double crush.
• Mimicking a Pancoast syndrome ⚠️: C8-T1 pain, weakness of the intrinsic hand muscles, unilateral Horner's sign, smoking. Urgent action : chest radiograph + CT.

Study of a complex case: chronicity and central sensitisation

Some cases go beyond the classic picture. Chronic cervical radiculopathy (> 3 months), particularly with documented central sensitisation, calls for a broader approach. Key strategies:

• Pain neuroscience education (Moseley 2015), with explanation of the central mechanisms, taking the drama out of imaging and cognitive reframing.⁵
• Graded exposure to provocative movements within a reassuring, structured framework.
• Biopsychosocial approach addressing the comorbidities (depression, anxiety, sleep disorders).
• Multidisciplinary collaboration : general practitioner, rehabilitation physician, psychologist specialising in chronic pain, or even a chronic pain team.

Hierarchy of evidence: where do clinical cases sit?

Applying evidence-based recommendations is not limited to knowing the techniques: it also takes in the clinical judgement needed to refer patients, the objective measurement of outcomes and the ability to overcome systemic and individual barriers. 🧐

When and to which other professionals should you refer?

The physiotherapist is often the first point of contact for musculoskeletal disorders, which gives them a crucial responsibility in triage. The decision to refer rests on structured clinical reasoning. 🤝

1) Red flags: immediate medical referral

Detecting red flags is the absolute priority, because it aims to rule out any serious underlying pathology. Signs and symptoms such as intense non-mechanical night pain, unexplained weight loss, persistent fever, progressive neurological deficits or a history of cancer must trigger an immediate medical referral.¹ See the detailed table in chapter 1 (Finucane 2020).

2) Yellow flags: biopsychosocial approach

Referral is also indicated in the presence of predominant psychosocial factors (yellow flags) that hinder progress. High levels of catastrophising, fear-avoidance, anxiety or depression are powerful predictors of pain becoming chronic. Collaboration with, or referral to, a psychologist specialising in pain is recommended.

3) Failure of conservative care: specialist referral

Referral to other specialists may be necessary in the event of stagnation or deterioration after 4-6 weeks of well-conducted treatment :

• MPR physician (physical and rehabilitation medicine specialist) : for a change of therapeutic direction, assessment of comorbidities, discussion of a guided epidural injection.
• Rheumatologist : if an inflammatory condition is suspected (spondyloarthritis, rheumatoid arthritis).
• Neurosurgeon / spinal surgeon : if there is a progressive neurological deficit, prolonged failure of conservative care or signs of myelopathy.
• Neurologist : if the picture is atypical or if EMG/ENMG is required.

How do you measure outcomes and overcome barriers to implementation?

The PROMs (Patient-Reported Outcome Measures) validated in cervical radiculopathy

Systematic use of PROMs has become a standard. The tools validated for cervical radiculopathy include:

Barriers to evidence-based implementation

Several systematic reviews (Alshehri 2020, Wilkinson 2024) have identified the barriers most frequently cited by physiotherapists:

• Lack of time to read and appraise the literature (cited by 60-80% of practitioners)
• Lack of skills in research and critical appraisal
• Limited access to scientific databases (paywalls)
• Lack of organisational support (private practice, private settings)
• Habits and clinical expertise perceived as superior to the data

Strategies for overcoming the barriers

• Targeted continuing education : workshops on critical appraisal of the literature
• Accessible resources : PEDro (Physiotherapy Evidence Database), the Cochrane Library, JOSPT free access, syntheses such as Physio Learning
• Mentoring and communities of practice : clinical discussion groups, experienced mentoring
• Technological integration : patient record software with built-in PROMs (automation)
• Patient-centred approach : shared decision-making, collaborative goals

Critique and controversies: beyond the recommendations

Several important tensions persist. First: the gap between research and practice. Research, conducted under controlled conditions on homogeneous populations, does not always reflect the complexity of the patients seen in clinic. Applying a recommendation “to the letter” without adapting it can be counterproductive.

Second: the red flag paradox. Screening for them is essential for safety, but most individual red flags have a low positive predictive value. Real skill lies in the ability to group the signs together and to use probabilistic clinical reasoning.

Third: the risk of “box ticking” with PROMs. PROMs are essential but can become a bureaucratic exercise. Measurement must never replace the conversation and a deep understanding of the patient's experience.