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1. Introduction
Cervical spondylosis is a degenerative disease of the intervertebral disks and facet joints which causes neck pain and motor or sensory dysfunction in elderly and middle-aged people. The pain of this disease usually is triggered by physical activity, neck mobilization, or exercises [1]. Mainly, it affects the intervertebral disk or vertebral bodies, which leads to ligament hypertrophy or osteophytes. It also causes compression of the spinal cord or nerve roots. Cervical spondylosis is most commonly identified in people older than 40 [2]. According to recent studies, pain, numbness and tingling, and other major symptoms of cervical spondylosis are related to depression and insomnia, headache, abdominal cramps, nausea, vertigo, palpitations, and blurred vision [3].
Neck pain is the second most common complaint after back pain. The most common symptoms of cervical spondylosis are neck pain, muscle stiffness, pain radiating to the arm and fingers, tingling, and numbness of the hands [4]. It is reported that 50% of people over the age of 50 are suffering from cervical spondylosis or have common radiographic changes of cervical spondylosis [5]. The main factors responsible for cervical spondylosis are forward head posture, stress, neck strain, depression, occupational activities, and sports [6]. The prevalence of neck pain is 23.1%, and about 21.3% in office or computer workers [7].
Cervical radiculopathy is the subdivision or the main symptom of cervical spondylosis with severe neck or shoulder pain [8]. It is also identified as the objective motor or sensory loss function due to the blockage of conduction of nerve roots [9]. Mostly cervical radiculopathy occurs due to nerve root compression, which causes pain, muscle weakness, abnormal numbness, atrophy of muscle, and decreased reflexes of the tendon of the upper limb. In the case of cervical radiculopathy, conservative treatment shows good results, whereas, in myelopathy, surgical treatment is mostly required [10].
The main causes of cervical spondylotic radiculopathy are mostly prolapse of the nucleus pulpous, post-facet joint bone hyperplasia or traumatic arthritis, hook joint bone spur formation, displacement and loosening of three adjoining joints, etc. which cause spinal nerve root repression and stimulation. The treatment of cervical spondylosis included surgical and non-surgical treatment. Conservational treatment has continuous head and neck traction, a fixed neck circumference, and abnormal postural correction. Manual massage is also effective in avoiding trauma, but it should be performed carefully and gently. Non-conservative treatment is appropriate for anterior decompression of the cervical spondylosis; it is efficient and affects cervical spine stability. For patients with instability of the vertebral body, stenosis of the root canal, internal fixation with the inter-vertebral interface can be used to fix and expand the vertebral segment [11].
A recent report found associations between cervical pain, radiculopathy, and a person’s physical and mental well-being. They discovered that cervical pain with or without cervical radiculopathy had a negative impact on the patient’s physical and mental health. Also, it imposes a significant negative impact on their well-being, personal life, their families, and their societies. According to this research, the prevalence of cervical radiculopathy or cervical spine pain lies between 10.4% and 21.5%, which ultimately causes cervical spine disability [9]. A recent study, it is also revealed the relationship between intense pain and disability in patients who are suffering from cervical radiculopathy. The relationship between pain or disability in cervical radiculopathy depends on many factors of the population, so recent studies have determined the significant relationship between pain and disability. Another study revealed the relationship between pain intensity and work status. After completing the survey, it is concluded that the pain is significantly more severe in patients with a sedentary lifestyle and who do not work compared to those with full-time jobs or part-time work [12].
Many research studies mentioned that cervical spine surgery is the treatment of cervical radiculopathy. After the surgery, pain, disability, satisfaction, and quality of life (QoL) are measured to find out the outcome of the surgery. Identification of major factors to improve the communication gap between patients or surgeons helps a lot in managing the situation or the condition of the patient after surgery [12]. Another retrospective cohort study was conducted in 2018 to determine the relationship between cervical spondylosis and migraine. Migraine is the most widespread neuromuscular disorder, which affects the QoL of people and also exerts a socioeconomic burden [13].
There are many studies on cervical radiculopathy or cervical spondylosis, but all co-relate radiculopathy with anxiety, depression, and psychosocial factors or determine the prevalence of cervical radiculopathy, which is also performed in many countries [14]. Yet no study has been conducted in Pakistan determining the exact frequency of cervical radiculopathy and its association with QoL in patients with cervical spondylosis. This study investigates the QoL and health status of patients in the betterments in future concerning their disease.

2. Materials and Methods
The research is a cross-sectional study. The study data were collected from Chaudhary Muhammad Akram Research and Teaching Hospital, AL Mustafa Trust Medical Center, Fuqraj Sharif Hospital, and National Hospital. This study was conducted from May 2021 to December 2021, so the duration of our research, after the approval of the synopsis was 6 months. A convenient sampling technique was used to recruit 273 patients. The study population comprised people aged 30 to 65 who suffered from cervical pain or neck pain and had poor QoL with a diagnosis of cervical spondylosis. The included patients with cervical spondylosis volunteered for the study and met the inclusion criteria. Patients were excluded if they were mentally and physically ill, pregnant, patients diagnosed with depression and anxiety, and those who had undergone cervical spine surgery. After data collection, they were entered into SPSS for analysis. The Spurling test was used for the assessment of cervical radiculopathy. The test was described in 1994 to measure cervical radiculopathy and its symptoms. It has 30% sensitivity and 93% specificity [15]. The test was performed by the following procedure [16].
The patient in a sitting position was asked to bend his neck laterally, then apply the axial compression, and after the complete the procedure, the patient was assessed by the World Health Organization quality of life (WHOQoL) scale. The scale is highly reliable, and its reliability ranges from 0.41 to 0.78, and its validity ranges from 0.53 to 0.71 [17]. The instrument is supposed to assess the QoL in those patients with different diseases or in the post-operative phase. WHOQOL is defined as the individual’s perception of their QoL. It consists of 24 questions which cover 4 categories plus 2 questions related to scale and health satisfaction [17]. The statistical analysis was done by the Chi-square test in SPSS.

3. Results
Percentages of male and female participants were almost equal (42.9% men and 57.1% women) (Table 1), and their Mean±SD age was 42.22±11.94 years (Table 2).

Out of the 273 patients, 70.3% had positive Spurling test, and 29.7% had negative results (Table 3). 

Their Mean±SD physical health score was 11.70±1.74 out of a total of 20, and the Mean±SD psychological health score was 11.75±1.78 out of a total of 20. Their Mean±SD social relationships score was 11.19±2.98 out of a total of 20, and the Mean±SD environment health score was 11.13±3.08 out of a total of 20, with greater scores indicating higher QoL (Table 4).

P indicate a significant difference between the positive or negative Spurling tests regarding the QoL. Patients with Spurling test negative have a higher QoL scores. Greater scores indicate higher QoL (Table 4).

4. Discussion
This study evaluated the association between cervical radiculopathy with QoL in patients with cervical spondylosis. Based on the findings, there is an association between cervical radiculopathy and QoL in patients diagnosed with cervical spondylosis.
Yanwei Lv et al. performed cross-sectional research to determine the prevalence and associated factors of cervical spondylosis in Chinese students. The data were collected through questionnaires or face-to-face interviews with 3899 Chinese adults. They concluded that 13.71% is the prevalence of cervical spondylosis, and menopause was the main factor for women [13]. But this study showed that out of the total 273 patients (42.9% male and 57.1% female with a Mean±SD age of 42±11.9 years), 70.3% had positive Spurling test and 29.7% negative results. Their Mean±SD physical health score was 11.70±1.74 out of 20. It is concluded that there is a significant difference between patients’ QoL with positive and negative Spurling tests. Patients with negative Spurling tests have a higher QoL. Hence there is a significant association between diagnosed cervical radiculopathy and QoL.
Diebo conducted a retrospective study in 2018 to measure the effect of mental health on patients’ reported outcomes in cervical radiculopathy or myelopathy surgery. Data were collected through the neck disability index, health-related life questionnaire, and SF-36 questionnaire. He concluded that after the surgery for cervical radiculopathy, the patients with low mental status showed less improvement than those with normal or high mental status [18]. The purpose of this study was to the QoL in patients with cervical spondylosis. In this study, the association between cervical radiculopathy and QoL was determined because it is very important to know the positive or negative relationship between these factors to make awareness or good health-related programs for the betterment of their life.
Wang-Sheng Lin conducted a recent study in 2018 to find the relationship between cervical spondylosis and migraine. A total of 27933 patients with cervical spondylosis were in the case group, and 111723 participants were in the control group. Univariate and multivariate analyses were used to measure the relationship between cervical spondylosis and migraine. After 10 years of follow-up, it was concluded that patients with cervical spondylosis are at greater risk of developing migraine other than the non-cervical spondylosis participants, and the rate of migraine is greater in the patients who suffered from cervical myelopathy [19]. However, this study showed the relationship between cervical radiculopathy and QoL in patients with cervical spondylosis. Because in recent studies, there is no study in which the relationship between these two variables was found. If we know the QoL of such patients, we can make better strategies for their healthy lifestyles.
Recently, a descriptive cross-sectional study was conducted in the Department of PT, Azra Naheed Medical School, Lahore Advanced Institute, from September 2015 to February 2016, and included patients aged 20-50 (both genders) with chronic neck pain lasting more than 6 months [20]. The data were collected using a 14-point self-reported questionnaire. The Spurling test was used to determine the occurrence of chronic cervical radiculopathy, and the visual analog scale was used to evaluate the pain intensity. SPSS software, version 21 was used to analyze the data. It was found that cervical spondylosis of radiculopathy is related to chronic neck pain [20]. But this study associates the two variables of cervical radiculopathy and QoL. After the completion of the study, we concluded that there is a significant association between cervical radiculopathy and QoL in patients with cervical radiculopathy, and these results will help us in the future for the awareness programs or help in lifestyle modification of those patients who suffer from cervical radiculopathy.

5. Conclusion
There is a significant difference between patients with positive and negative Spurling tests regarding the QoL. Patients with negative Spurling tests have higher QoL scores. Hence there is a significant association between diagnosed cervical radiculopathy and QoL.

Weakness and strength of the study
The study’s strong points included patients’ cooperation, staff cooperation, using the same language, and focus of interest.
The study weak points included collecting the data from 2 to 3 hospitals due to pandemic lockdown, which does not represent the whole country, collecting data through a questionnaire, not by clinical examination or follow-ups for quality-of-life assessment, non-random sampling technique due to pandemic and closing the institute, less accuracy in data collection due to online data collection, and collecting data only from the people of Lahore.

Study limitations
Like other research studies, there are some limitations in this research, which future researchers can compensate for them. We collected the data from 2 to 3 hospitals due to the pandemic lockdown, which does not represent the whole country. The data were collected through a questionnaire, not by clinical examination or follow-ups for quality-of-life assessment. We could not use the random sampling technique for data collection because the university was closed due to the pandemic. There was less accuracy in data collection due to online data collection or surveys. The current study covers only the people of Lahore.

Recommendations
This study should be conducted all over Pakistan. There should be an experimental study on cervical radiculopathy in Pakistan. Further research must be focused on a healthy diet and adaptive techniques to avoid the negative impact of cervical radiculopathy on the QoL of patients.

Ethical Considerations
Compliance with ethical guidelines
Consent of the patients was taken for participation in this study. They were assured of the privacy of their data; all the religious perspectives of the patients were addressed. The written consent form was signed by the patients. Ethical approval was obtained from the Ethics Committee of Lahore University before the study. All data were kept confidential. Patients remained anonymous throughout the study. The patients were informed that there were no dangers in the study process. They were also known that they would be free to leave at any time during the process of the study.

Funding
This research did not receive any grant from funding agencies in the public, commercial, or non-profit sectors. The researchers collected data from their workplace after the permission of the Head of the Department of Physiotherapy at Azra Naheed Medical College.

Authors' contributions
Analysis and interpretation: Hafiz Sheraz Arshad; Critical revision and final approval: Faryal Safdar; conceptualisation, study design, drafting the manuscript: Zohaib Shahid; Data collection: Rafia Sultana.

Conflict of interest
The authors declared no conflict of interest in this study. 

Acknowledgments
We appreciate the participants, friends, and group members who helped us to complete my study.


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