Name of the Condition

• Cervical Disc Disorder at C4-C5 Level with Radiculopathy
• Also known as Cervical Radiculopathy or Pinched Nerve in the Neck.

Summary

Cervical disc disorder at the C4-C5 level with radiculopathy involves a condition where a disc in the neck region, specifically between the fourth and fifth cervical vertebrae, is damaged. This damage can lead to pressure on the adjacent nerve roots, causing pain, numbness, or weakness radiating from the neck into the shoulder and arm.

Causes

• Degenerative disc disease due to aging.
• Herniated or bulging discs.
• Traumatic injury to the neck.
• Lifestyle stresses that strain the neck (e.g., poor posture, repetitive motions).

Risk Factors

• Age: More common as people get older.
• Smoking: Affects blood flow and accelerates disc degeneration.
• Poor posture and lack of physical fitness.
• Occupations requiring repetitive neck movements.

Symptoms

• Sharp or burning pain in the neck, shoulder, or arm.
• Tingling or numbness in the arms or hands.
• Muscle weakness, particularly in the upper extremities.
• Limited range of motion in the neck.

Diagnosis

• Physical examination focusing on reflexes, motor skills, and sensory perception.
• Imaging tests such as MRI or CT scans to visualize disc condition.
• Electromyography (EMG) may be used to assess nerve function.

Treatment Options

• Medications: Pain relievers, anti-inflammatory drugs, and muscle relaxants to help manage pain and swelling.
• Physical Therapy: Exercises to strengthen neck muscles and improve range of motion.
• Corticosteroid Injections: Reduce inflammation and pain at the affected site.
• Surgery: Options like discectomy or spinal fusion when conservative treatments are ineffective.

Prognosis and Follow-Up

• Many cases improve with conservative treatment over time.
• Regular follow-ups are crucial to monitor progress and make necessary adjustments in treatment.
• Possible need for long-term physical therapy to maintain neck strength and flexibility.

Complications

• Chronic pain or permanent nerve damage if untreated.
• Persistent numbness or weakness in the arms and shoulders.
• Possible mobility limitations affecting daily activities.

Lifestyle & Prevention

• Maintain good posture while sitting, standing, and sleeping.
• Regular exercise focusing on strengthening the neck and back.
• Ergonomic adjustments in the workplace.
• Avoid smoking and manage weight to relieve stress on spinal discs.

When to Seek Professional Help

• Unrelenting or severe neck pain.
• Gradual muscle weakness or significant loss of sensation.
• Sudden onset of symptoms suggesting spinal cord involvement.

Additional Resources

• American Association of Neurological Surgeons
• National Institute of Neurological Disorders and Stroke
• Support groups for cervical radiculopathy patients.

Tips for Medical Coders

• Ensure documentation specifies the exact level of the cervical disc disorder (C4-C5) with radiculopathy.
• Verify medical records for clear evidence of nerve involvement at the specified cervical level.
• Avoid over-specifying if the level of the disorder is not indicated; defer to broader categories if necessary.