➢ A variety of disorders have a presentation similar to that of cervical radiculopathy.
➢ A thorough history and physical examination can differentiate mimickers from cervical radiculopathy.
➢ Adjunctive studies such as radiographs, magnetic resonance images, and electrodiagnostic studies aid in diagnosing radicular and nonradicular etiologies.
➢ The astute clinician should have a broad differential when cervical radiculopathy is suspected.
Degenerative changes of the cervical spine are the primary cause of nerve root compression leading to symptomatic radiculopathy. Genetic and age-related changes, including loss of intervertebral disc height, as well as facet and uncovertebral joint hypertrophy, produce narrowing of the neural foramen. A herniated nucleus pulposus may cause acute foraminal stenosis. Symptomatic nerve root compression may ensue, leading to pain radiating from the neck into the shoulder, arm, forearm, and/or hand, with or without accompanying numbness and paresthesias. Several musculoskeletal and nonmusculoskeletal entities have a presentation similar to that of cervical radiculopathy and can be easily overlooked if the diagnosis of radiculopathy is assumed (Table I). Therefore, the clinician should be familiar with the classic signs and symptoms of cervical radiculopathy as well as a spectrum of differential diagnoses that may mimic it.
Patients with cervical radiculopathy may report antecedent trauma, but the typical onset is more insidious. Acute, severe pain in a dermatomal distribution typically results from cervical disc herniation, whereas subacute, chronic, or intermittent radicular pain tends to be secondary to a chronically herniated disc or degenerative foraminal stenosis. Henderson et al.1, in a report on >700 patients who had been diagnosed with cervical radiculopathy, noted upper extremity pain in 99.4% of the patients, sensory changes to pinprick in 85.2%, neck pain in 79.7%, diminished reflexes in 71.2%, and diminished strength in 68%. Nearly 54% of the patients experienced pain or paresthesias in a dermatomal pattern, whereas 45.5% reported pain in a nondermatomal pattern. Radicular symptoms may be exacerbated with neck extension or rotation and relieved with flexion. Rarely, anterior chest pain (17.8%) or headaches (9.7%) may be of cervicogenic origin1; however, it is critical to rule out cardiac and cranial etiologies as such presentations could represent myocardial ischemia or a pathologic intracranial process, respectively1-6.
Various clinical examination findings assist in the diagnosis of radiculopathy and help to eliminate potential confounders. In a systematic review of the accuracy of clinical maneuvers for the diagnosis of cervical radiculopathy, Rubinstein et al.7 identified four studies that attempted to calculate the sensitivity and specificity of the Spurling test (reproduction of radicular pain with neck extension, with or without compression, and ipsilateral bending to the painful side). Three of the four studies showed that the test had a sensitivity and specificity of 30% to 50% and 86% to 93%, respectively, and one demonstrated a sensitivity and specificity of 92% and 95%, respectively. The authors concluded that the Spurling test has low to moderate sensitivity and high specificity. In addition, they noted that the shoulder abduction sign (relief of radicular pain by holding the arm over the head) is not highly sensitive (17% to 78%) but is moderately specific (75% to 92%), whereas the upper limb tension test (pain with lateral extension of the upper extremity with contralateral head rotation) was highly sensitive (72% to 97%) but nonspecific (11% to 33%) for cervical radiculopathy.
Motor function and sensation to light touch and pinprick should be tested in dermatomes C3 through T1 (Table II)8. Deep tendon reflexes of the biceps (C5), brachioradialis (C6), and triceps (C7) should be inspected for evidence of hyporeflexia (indicative of a lower motor neuron lesion) or hyperreflexia (indicative of an upper motor neuron lesion).
The patient should also be examined for long-tract signs, which may indicate cervical myelopathy with or without concomitant radiculopathy. These signs include exaggerated deep tendon reflexes, inverted radial reflex (flexion of the fingers on tapping of the brachioradialis tendon), the Hoffman sign (flexion of the index finger and/or thumb with flicking of the distal phalanx of the long finger while holding the proximal interphalangeal joint of the long finger in hyperextension), more than three beats of clonus after the ankle jerk maneuver, and a positive Babinski sign (upgoing of the great toe and/or splaying of the lesser toes on stroking of the underside of the lateral aspect of the foot).
Along with physical examination, radiographic imaging and electrodiagnostic studies can help the clinician to diagnose cervical radiculopathy. Surgical findings have been shown to correlate with magnetic resonance imaging (MRI) findings 74% to 94% of the time and with computed tomography-myelography (CTM) findings 85% to 90% of the time9. Investigators from the American Association of Neuromuscular & Electrodiagnostic Medicine (AANEM), in a meta-analysis of nine studies, reported that electromyography (EMG) had a sensitivity of 50% to 71% for the diagnosis of cervical radiculopathy, although other studies have demonstrated sensitivities of between 94% and 98% when six or more limb muscles and the cervical paraspinal muscles were tested10.
With advancing age, the incidence of cervical and other musculoskeletal abnormalities increases. These entities often have similar, overlapping pain-referral profiles and may exist concurrently, making the diagnosis challenging11,12. Cannon et al.13 found that twenty-nine (29%) of ninety-nine patients with an electrodiagnostically confirmed cervical radiculopathy also had one or more coexisting musculoskeletal disorders. Vad et al.14 reported that seven (28%) of twenty-five patients with a full-thickness rotator cuff tear had a coexisting plexopathy, peripheral neuropathy, or cervical radiculopathy. Therefore, the clinician should consider musculoskeletal and neurologic abnormalities when confronted with upper extremity complaints and should be cognizant of the potential for two coinciding diagnoses.
Shoulder Girdle Arthritides and Tendinopathies
The region between the neck and the shoulder can be diagnostically challenging because the shoulder girdle is replete with potentially painful anatomic structures that often have pain-referral patterns similar to those of cervical radiculopathy. Impingement syndrome, rotator cuff tears, and shoulder girdle arthritis (glenohumeral and acromioclavicular) are a continuum of abnormalities that may produce trapezial and shoulder pain radiating to the middle part of the arm or elbow, imitating a C5 radiculopathy. Pain with overhead activity and sleeping on the affected side distinguish a shoulder abnormality from a cervical spine abnormality. Several physical examination maneuvers help to assess for the presence of shoulder abnormality (Table III). However, a recent meta-analysis of thirty-three studies from the Cochrane database demonstrated substantial heterogeneity in the performance and interpretation of these maneuvers, calling into question their diagnostic validity15. Likewise, Hegedus et al.16 could not recommend a single physical examination finding as being pathognomonic for a given shoulder condition.
Subacromial shoulder impingement occurs as a consequence of compression of the rotator cuff tendons between the head of the humerus and osteophytic spurs on the undersurface of the coracoacromial arch, resulting in inflammation and pain with overhead activity17,18. The Neer and Hawkins tests reproduce the symptoms, which may be relieved with a diagnostic and therapeutic subacromial injection of steroid and local anesthetic. Tears of the rotator cuff have pain patterns similar to those associated with impingement; however, concomitant weakness with abduction and external rotation tends to be more prevalent with rotator cuff tears because of supraspinatus, teres minor, and infraspinatus tendon involvement. The preservation of sensation and strength in the dermatomes and myotomes of C5 or C6 distal to the shoulder girdle should be unaffected when a rotator cuff tear is responsible for the symptoms. Cervical MRI demonstrating concordant pathology and electrodiagnostic studies that are positive for fibrillation potentials and sharp waves in the paraspinal muscles may help to further distinguish cervical radiculopathy from shoulder pathology12,18-21.
Posttraumatic osteoarthritis or rheumatoid arthritis of the glenohumeral joint may be sources of neck and shoulder pain. Difficulty with overhead activity and diminished range of motion with palpable and audible crepitus of the affected shoulder may be present22. Acromioclavicular joint arthritis causes pain with shoulder adduction as well as tenderness to palpation over the joint on physical examination. Radiographs of the shoulder may demonstrate osteophyte formation, joint-space narrowing, and sclerosis.
Patients with an insidious onset of shoulder pain with markedly decreased range of motion may be diagnosed with a so-called frozen shoulder (adhesive capsulitis), an idiopathic inflammatory thickening of the glenohumeral capsule. A history of diabetes is commonly associated with this diagnosis23. Radiographs usually reveal normal findings and, although not necessary for diagnosis, MRI of the shoulder will show capsular thickening and obliteration of the axillary pouch24. Active and passive range of motion of the affected shoulder will be diminished and painful, with complete resolution of symptoms potentially taking several years25.
Tendinitis of the long head of the biceps presents as anterior shoulder pain with activity. A positive Yergason or Speed test on physical examination may reproduce pain, and there may be tenderness to palpation over the bicipital groove.
Other Upper Extremity Tendinopathies and Arthritides
Radiating lateral forearm pain that is worse with activities involving wrist extension (carrying luggage, holding a coffee cup) and concomitant tenderness to palpation over the lateral epicondyle of the humerus suggest the diagnosis of lateral epicondylitis. Angiofibroblastic hypertrophy of the extensor carpus radialis brevis muscle at its origin on the lateral epicondyle is the idiopathic process that is believed to be responsible for symptoms, which can imitate a C6 radiculopathy. An injection of local anesthetic over the point of maximum tenderness can help to make the diagnosis of lateral epicondylitis25-28.
Pain on the medial side of the elbow that radiates to the medial aspect of the wrist with wrist flexion may indicate medial epicondylitis, which has a presentation similar to that of a C8 radiculopathy. Patients who perform activities involving repetitive wrist flexion (e.g., golfers and baseball pitchers) are at risk. Reproduction of pain with resisted wrist flexion and pronation with tenderness to palpation over the medial epicondyle are hallmark physical examination findings. Lee and Lee-Robinson29 studied 102 patients with a C6 and/or C7 radiculopathy, fifty-five (54%) of whom were also diagnosed with medial epicondylitis. The authors theorized that weakness of the wrist flexor muscles due to radiculopathy leads to a predilection for medial epicondylitis.
Carpometacarpal arthritis of the thumb and de Quervain tenosynovitis (inflammation of the first dorsal compartment of the wrist, including the extensor pollicis brevis and abductor pollicis longus) can both cause lateral wrist pain. Patients with carpometacarpal arthritis, especially women over the age of sixty years, may complain of pain when opening jars. A grind test, performed by compression and circumduction of the thumb, reproduces symptoms. de Quervain tenosynovitis affects women between the ages of thirty and fifty years. Physical examination findings include tenderness to palpation over the lateral aspect of the wrist at the base of the thumb. A positive Finkelstein test, in which the thumb is grasped within the fist while the wrist is ulnarly deviated, is pathognomonic for de Quervain tenosynovitis30. An injection of local anesthetic and steroid may reduce pain due to both carpometacarpal arthritis and de Quervain tenosynovitis31,32.
Peripheral Nerve Entrapments of the Upper Extremity
Symptomatic upper extremity peripheral neuropathies develop insidiously as a result of narrowing at distinct anatomic sites through which the peripheral nerves traverse. Fibrosis and ischemia ensue, resulting in the onset of pain and paresthesias. The term double crush syndrome has been used to describe the simultaneous presence of cervical nerve root compression and peripheral nerve entrapment33. In a retrospective review of the clinical presentation and electrodiagnostic features of patients who presented to the clinic with upper extremity complaints, 20% of patients were diagnosed solely with carpal tunnel syndrome, 47% were diagnosed solely with cervical radiculopathy, and 26% were diagnosed with double crush syndrome34.
Suprascapular nerve (C5) entrapment within the scapular or spinoglenoid notch causes nonspecific pain in the posterolateral scapular region with possible atrophy and weakness of the supraspinatus and infraspinatus muscles. This entity may be mistaken for a C5 nerve radiculopathy or a rotator cuff tear. In athletes who perform repetitive overhead activity, i.e., volleyball and tennis players, repeated traction on or compression of the suprascapular nerve by labral cysts may lead to pain and dysfunction35. MRI of the shoulder should be performed to identify potential compressive lesions and to rule out a rotator cuff tear (Fig. 1). Electrodiagnostic evaluation is considered the gold standard for diagnosis; in one study, it confirmed the suspected diagnosis in 43% (forty) of ninety-two patients36.
Although median nerve (C6-T1) compression can occur at several different anatomic locations along its course, compression within the carpal canal is the most common site. Carpal tunnel syndrome is the most common peripheral nerve entrapment of the upper extremity, with a prevalence of 3.7% in the general population and 7.8% in the working population of the United States37,38. Carpal tunnel syndrome classically involves paresthesias in the long finger, index finger, thumb, and radial half of the ring finger and may be confused with a C6 or C7 radiculopathy. Chow et al.39 performed a retrospective study in which the symptomology of carpal tunnel syndrome (forty-four patients) was compared with that of cervical spondylosis (forty-one patients). The authors found that the rates of nocturnal hand paresthesias, numbness or discomfort with use of the affected hand, and hand pain were much higher in the carpal tunnel syndrome group (84%, 82%, and 64%, respectively) than in the cervical spondylosis group (10%, 7%, and 10%, respectively). Neck pain was far more common in the cervical spondylosis group than in the carpal tunnel group (74% compared with 14%). A Tinel sign (elicited by tapping the median nerve at the volar side of the wrist) (sensitivity, 0.28 to 0.73; specificity, 0.44 to 0.95) or a positive result on the Phalen test (reproduction of symptoms with maximum wrist flexion for more than sixty seconds) (sensitivity, 0.46 to 0.80; specificity, 0.51 to 0.91) may be an indication of carpal tunnel syndrome40.
The anterior interosseous nerve (C8, T1), a branch of the median nerve, innervates the flexor pollicus longus and flexor digitorum profundus to the index and long fingers and the pronator quadratus muscle. Weakness of these muscles along with vague volar forearm pain without sensory changes is consistent with the diagnosis of anterior interosseous nerve syndrome41. External compression or trauma to the forearm is a frequent cause of anterior interosseous nerve dysfunction; however, the nerve may become compressed by a hypertrophied tendinous origin of the deep head of the pronator muscle, an anomalous muscle belly, or a lipoma or ganglion42. Affected patients may have a weak pinch grip manifesting as the inability to maintain grip on a piece of paper between the index finger and the thumb against a pulling force42. Anterior interosseous nerve syndrome can be differentiated from a C8 or T1 radiculopathy by intact strength of the deep flexors of the ring and small fingers as well as intact intrinsic strength. Electrodiagnostic studies may show spontaneous fibrillation and sharp waves in the anterior interosseous nerve with normal findings in the median nerve43.
Cubital tunnel syndrome, caused by entrapment of the ulnar nerve (C8, T1), is the second most common upper extremity neuropathy. Ulnar nerve compression occurs at sites around the medial epicondyle of the humerus, including the two heads of flexor carpi ulnaris, the arcade of Struthers, and the Osborne ligament. Cubital tunnel syndrome manifests as numbness and paresthesias of the small finger and the ulnar side of the ring finger44, whereas sensory examination of a C8 radiculopathy should demonstrate decreased sensibility of the small finger and both the radial and ulnar sides of the ring finger45. Furthermore, the deep digital flexors of the index and middle fingers and flexor pollicus longus (all innervated by C8 and carried on median nerve) may be weak in patients with C8 radiculopathy, whereas only the ring and small fingers may be weak in those with cubital tunnel syndrome46. A positive Tinel sign over the medial epicondyle, a positive cubital tunnel compression test (reproduction of symptoms with prolonged elbow flexion and digital pressure over ulnar nerve at the medial aspect of the elbow), and absence of neck pain with a negative Spurling test help to distinguish cubital tunnel syndrome from a C8 radiculopathy. Electrodiagnostic studies are indicated to help confirm the diagnosis of cubital tunnel syndrome in equivocal cases. Bäumer et al.47 reported that MRI neurography had a sensitivity of 83% and a specificity of 85% for the diagnosis of ulnar neuropathy of the elbow, which may be helpful if the findings of physical examination and electrodiagnostic studies are inconclusive.
Posterior interosseous nerve palsy (C7, C8), a rare condition with an incidence of 0.003%, presents as weakness of thumb and finger extension48. The ability to extend the wrist, albeit with radial deviation, is maintained secondary to preserved function of the extensor carpi radialis longus, which is innervated by the radial nerve. Weakness of resisted wrist extension resulting from a C6 radiculopathy can be distinguished clinically from a posterior interosseous nerve palsy by maintenance of the ability to extend the thumb and fingers and by the lack of radial deviation with wrist extension. Because the posterior interosseous nerve is a purely motor nerve, paresthesias are absent in contrast to radiculopathy. MRI of the forearm may show a lipoma or ganglion compressing the posterior interosseous nerve (Fig. 2).
Radial tunnel syndrome, which is caused by entrapment of the posterior interosseous nerve, presents as a deep ache in the proximal aspect of the dorsal part of the forearm, 4 cm distal to the lateral epicondyle, without motor deficits. Similar to lateral epicondylitis, radial tunnel syndrome may be confused for a C6 or C7 radiculopathy. Because of a lack of objective findings, the existence of radial tunnel syndrome is controversial49. Resisted wrist extension should not reproduce pain in radial tunnel syndrome, distinguishing it from lateral epicondylitis. However, resisted supination and extension of the long finger may illicit pain in the presence of tenderness 4 cm distal to the lateral epicondyle50. Radial tunnel syndrome is a diagnosis of exclusion as electrophysiologic studies are often normal.
The vertebral arteries are paired structures that originate from the subclavian artery and classically enter the transverse foramen of the cervical spine at C6. They traverse cephalad through the transverse foramen and enter the foramen magnum, where they supply the posterior vasculature of the circle of Willis. Vascular anomalies of the vertebral artery can lead to vertebrobasilar insufficiency; however, a vertebral loop anomaly in particular may cause compressive radiculopathy by encroachment into the cervical neuroforamen51-53. In a study of 173 patients with cervicobrachialgic symptoms, Paksoy et al.54 diagnosed the presence of a vertebral loop causing radiculopathy in thirteen patients (prevalence, 7.5%). Females were more commonly affected than males (female:male ratio, 9:4), and the loop occurred most commonly at C6-C7. Elevated blood pressure may exacerbate symptoms. While noncontrast MRI will not adequately demonstrate the vascular loop anomaly, it may show a widened neuroforamen, suggestive of a space-occupying lesion. A vertebral loop is best visualized with CT or MRI angiography (Fig. 3).
As nerve roots exit the cervical spine, they form the trunks of the brachial plexus and run through the thoracic outlet, the area bordered by the anterior scalene muscle (medial), middle scalene muscle (lateral), and first thoracic rib (floor). Thoracic outlet syndrome occurs when anomalous bands, scalene muscle insertions, or large cervical ribs decrease the space available for nerve trunk and vasculature passage55. Because its presentation is similar to that of cervical radiculitis and because of its relative rarity, thoracic outlet syndrome is a diagnosis of exclusion. Nocturnal symptoms of ulnar-sided numbness or numbness of the entire upper extremity are common. Venous congestion, cold intolerance, and upper extremity swelling may be present in association with the vascular form of the disease. However, the Adson test (in which abduction and external rotation of the extremity with contralateral rotation of neck leads to loss of radial pulse and the reproduction of symptoms), the Wright test (in which arm extension and ipsilateral neck rotation and extension leads to loss of radial pulse), or the Roos test (in which rapid opening and closing of fist held overhead leads to reproduction of symptoms) may be positive only in about 10% of patients56. Tenderness to palpation in the supraclavicular fossa and a bruit may be present57. An anteroposterior cervical spine radiograph should be carefully examined for the presence of a cervical rib. Angiography or Doppler studies may provide objective evidence of vascular compression, whereas electrodiagnostic studies are often normal.
Immunologic and Neurologic Disorders
Patients with Parsonage-Turner syndrome (neuralgic amyotrophy) complain of atraumatic, insidious-onset, unilateral (or, less commonly, bilateral) neck, shoulder, and arm pain that resolves over several weeks, followed by shoulder girdle weakness. Idiopathic and familial forms exist. The idiopathic form is due to autoimmune dysfunction, with the onset being preceded by a viral illness as often as 55% of the time, and typically affects the upper brachial plexus58,59. T2-weighted MRI of the shoulder may show increased signal within the periscapular musculature (Fig. 4), whereas EMG will be positive for sharp waves and fibrillations 96% of the time60. Natural history studies have indicated that nearly 90% of patients regain nearly complete function of the involved upper extremity by three years61.
Although cervical dermatome involvement accounted for only 12% (139) of 1199 cases of herpes zoster (also known as shingles) in the study by Thomas and Howard62, shingles should not be overlooked as a mimicker of radiculopathy. The varicella zoster (chickenpox) virus usually infects patients in early childhood and remains dormant within the dorsal root ganglia63. However, immunocompromised individuals and the elderly are particularly susceptible to symptomatic reactivation of latent virus. When this occurs, the virus migrates down the axon of the infected nerve root into the extremity, resulting in burning pain that precedes the eruption of a vesicular rash along a dermatomal distribution. The characteristic rash helps to differentiate it from degenerative cervical radiculopathy. Occasionally, weakness may be present involving single or multiple motor roots64,65.
Neurologic diseases such as multiple sclerosis and amyotrophic lateral sclerosis (also known as Lou Gehrig disease) can be diagnostically challenging as both disorders can mimic several other diseases66,67. Multiple sclerosis usually presents as weakness, bowel and bladder dysfunction, visual disturbances, and paresthesias; however, acute, painful radiculopathy or myeloradiculopathy has been reported66,68,69. MRI of the cervical or thoracic spine may be positive for demyelinating plaques, which are visualized as hypointense signal changes on T2-weighted images. The presence of hyperreflexia and long-tract physical examination findings help to distinguish multiple sclerosis from radiculopathy caused by cervical spondylosis, which causes lower motor neuron findings.
Extremity weakness and muscle atrophy are the initial presenting symptoms of amyotrophic lateral sclerosis 66% of the time, with frequent misdiagnosis70. This form of amyotrophic lateral sclerosis has been associated with longer time to diagnosis when a patient presents to an orthopaedic surgeon rather than a neurologist, possibly because of a lack of bulbar symptoms71. Gait disturbances and long-tract signs may confound the diagnosis of amyotrophic lateral sclerosis with cervical spondylotic myelopathy. However, the presence of fasciculations and spastic paresis, the absence of neck or radicular pain, and difficulty with speech and swallowing help to clinically rule out radiculopathy and myelopathy72. Cervical spine radiographs, MRI, EMG, and nerve conduction velocity testing help to rule out cervical spondylotic myelopathy or other confounding disorders, although like all mimickers of radiculopathy, the two conditions may coexist73,74.
Diabetic neuropathy is one of the most common sequelae of diabetes, affecting two-thirds of patients who have the disease75. Distal sensory polyneuropathy of the lower extremities is the most common form of neuropathy, and diabetic cervical radiculoplexus neuropathy is a rarer form76. Massie et al., in a study of eighty-five patients, reported that the latter form presented with an acute onset of pain (fifty-three patients; 62%), weakness (twenty-two patients; 26%), and paresthesias (fifteen patients; 18%)76. Patients usually present with unilateral pain in the upper extremity; however, in the study by Massie et al., thirty (35%) of eighty-five patients had progression to bilateral upper extremity involvement76. The mean duration of diabetes at the time of presentation is 5.5 years, and approximately 35% of patients experience weight loss around the onset of symptoms77. Ischemic injury and microvasculitis are the pathological mechanisms through which neuronal impairment occurs. Nerve conduction studies and EMG studies are positive for axonal injury affecting motor, sensory, and autonomic nerves.
Neoplastic disease is occasionally encountered in the cervical spine and may produce symptoms consistent with cervical radiculopathy that are caused by osseous expansion or destruction by a bone tumor. While benign tumors such as an aneurysmal bone cyst can occur in young adults and children, metastatic neoplasms are most common in adults. A high index of suspicion should be maintained in the case of any patient who has a known history of metastatic disease, and axial imaging should be performed early (Fig. 5). Primary benign neurogenic tumors such as a nerve sheath tumor (schwannoma or neurofibroma) can produce identical symptoms as cervical radiculopathy arising from the more common disc herniation. Tumor invasion into the lower trunk of the brachial plexus, classically from a superior sulcus lung tumor (Pancoast tumor) also may be responsible for C8 or T1 radicular-type symptoms. The unexplained onset of Horner syndrome or hoarseness and the absence of neck pain or a Spurling sign should alert the practitioner to the possibility of this type of tumor78. Fortunately, most of these rare but serious tumors will be clearly visible in the field of most cervical MRI scans and may be rapidly identified. An anteroposterior cervical spine radiograph should be studied for an asymmetric appearance in the lung apices, a finding suggestive of tumor, in the workup of cervical radiculopathy.
Although degenerative changes of the cervical spine are responsible for the vast majority of cases of cervical radiculopathy, a number of differential diagnoses exist, including musculoskeletal, neurologic, vascular, and neoplastic processes. A thorough history and physical examination is the starting point for ruling in cervical radiculopathy and ruling out other abnormalities, with particular attention being paid to cervical range of motion, shoulder examination, upper extremity motor strength, and sensation and abnormal deep tendon reflexes. Magnetic resonance imaging and/or CTM along with electrodiagnostic studies aid in making the appropriate diagnosis.
Source of Funding: There were no external sources of funding.
Investigation performed at OrthoCarolina Spine Center, Charlotte, North Carolina
Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. None of the authors, or their institution(s), have had any financial relationship, in the thirty-six months prior to submission of this work, with any entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, no author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
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