Treatment
Nonsurgical Management
The main objectives of treatment are to relieve pain, improve neurologic function, and prevent recurrences.39 None of the commonly recommended nonsurgical therapies for cervical radiculopathy has been tested in randomized, placebo-controlled trials. Thus, recommendations derive largely from case series and anecdotal experience. The preferences of patients should be taken into account in decision making.
On the basis of anecdotal experience, analgesic agents, including opioids and nonsteroidal antiinflammatory drugs, are often used as first-line therapy. In patients with acute pain, some physicians advocate a short course of prednisone (for example, starting at a dose of 70 mg per day and decreasing by 10 mg every day).39 This practice is supported only by anecdotal evidence, however, and is associated with potential risks.
Retrospective40,41 and prospective42,43 cohort studies have reported favorable results with translaminar and transforaminal epidural injections of corticosteroids, with up to 60 percent of patients reporting long-term relief of radicular and neck pain and a return to usual activities. However, complications from these injections, although rare, can be serious and include severe neurologic sequelae from spinal cord or brainstem infarction.44 Given the potential for harm, placebo-controlled trials are urgently needed to assess both the safety and the efficacy of cervical epidural injections.
Some investigators have advocated the use of short-term immobilization (less than two weeks) with either a hard or a soft collar (either continuously or only at night) to aid in pain control.45 Use of a cervical pillow during sleep has also been recommended. However, data are needed to assess the benefits of these approaches.
Cervical traction consists of administering a distracting force to the neck in order to separate the cervical segments and relieve compression of nerve roots by intervertebral disks. Various techniques (supine vs. sitting; intermittent vs. sustained; motorized or hydraulic vs. an over-the-door pulley with weights) and durations (minutes vs. up to an hour) have been recommended.46,47 However, a systematic review stated that no conclusions could be drawn about the efficacy of cervical traction because of the poor methodologic quality of the available data.48 Exercise therapy — including active range-of-motion exercises and aerobic conditioning (walking or use of a stationary bicycle), followed by isometric and progressive-resistive exercises — is typically recommended once pain has subsided in order to reduce the risk of recurrence, although this recommendation is not supported by evidence from clinical trials.39
Surgery
In appropriate patients, surgery may effectively relieve otherwise intractable symptoms and signs related to cervical radiculopathy, although there are no data to guide the optimal timing of this intervention.4,5 Commonly accepted indications for surgery differ depending on whether the patient has evidence of radiculopathy alone or whether there are also signs of spinal cord impairment, since the latter can lead to progressive and potentially irreversible neurologic deficits over time.
For cervical radiculopathy without evidence of myelopathy, surgery is typically recommended when all of the following are present: definite cervical-root compression visualized on MRI or CT myelography; concordant symptoms and signs of cervical-root–related dysfunction, pain, or both; and persistence of pain despite nonsurgical treatment for at least 6 to 12 weeks or the presence of a progressive, functionally important motor deficit. Common surgical procedures for cervical radiculopathy are shown in Figure 2.49 Randomized trials are lacking to compare these approaches.
Surgery is also recommended in cases in which imaging shows cervical compression of the spinal cord and there is clinical evidence of moderate-to-severe myelopathy (Table 2). For such patients, anterior approaches (preferred in patients with a cervical kyphosis) include cervical diskectomy and corpectomy (removal of the central portion of the vertebral body) alone or in combination at single or multiple levels. Anterior decompression is generally combined with a strut reconstruction (bridging the space between the end plates of the vertebral bodies) with the use of bone (either autograft or allograft) or synthetic materials (carbon fiber or titanium cages) and plate fixation. Posterior options, which are often used in cases of multilevel decompressions in which there is preserved cervical lordosis, include laminectomy (with or without instrumented fusion) and laminoplasty (involving decompression and reconstruction of the laminae).
Data from prospective observational studies indicate that two years after surgery for cervical radiculopathy without myelopathy, 75 percent of patients have substantial relief from radicular symptoms (pain, numbness, and weakness).50,51 Corresponding response rates for relief of radicular arm pain after surgery appear similar in patients treated for cervical myelopathy.52
Complications of surgery for cervical radiculopathy with or without myelopathy are uncommon but can include iatrogenic injury to the spinal cord (occurring in less than 1 percent of cases), nerve-root injury (2 to 3 percent), recurrent nerve palsy (hoarseness, 2 percent after anterior cervical surgery), esophageal perforation (less than 1 percent), and failure of instrumentation (breakage or loosening of a screw or plate or nonunion, less than 5 percent for single-level surgery).50,51,52
Surgical vs. Nonsurgical Management
As summarized in a recent Cochrane review,53 there are few good-quality studies comparing surgical and nonsurgical treatments for cervical radiculopathy. In one randomized trial comparing surgical and nonsurgical therapies among 81 patients with radiculopathy alone, the patients in the surgical group had a significantly greater reduction in pain at three months than the patients who were assigned to receive physiotherapy or who underwent immobilization in a hard collar (reductions in visual-analogue scores for pain: 42 percent, 18 percent, and 2 percent, respectively).54 However, at one year, there was no difference among the three treatment groups in any of the outcomes measured, including pain, function, and mood.
In patients with mild signs of cervical myelopathy (not meeting the above criteria for surgery), nonsurgical treatment is reasonable. This recommendation is supported by the results of a small, but otherwise well-designed, randomized trial involving 51 patients, which showed that at two-year follow-up, no differences in neurologic outcomes were observed between patients treated medically and those treated surgically.55
Areas of Uncertainty
The natural history of cervical radiculopathy remains uncertain. Data are needed from well-designed, randomized, controlled trials to guide nonsurgical management and decisions regarding whether and when to perform surgery.
Guidelines
There are no published guidelines by professional societies for the assessment and management of cervical radiculopathy.
Summary and Recommendations
Patients who present with acute neck and arm pain suggestive of cervical radiculopathy, such as the woman described in the vignette, should be assessed first by a careful history taking and physical examination. In the absence of red flags suggesting infection or cancer or signs of myelopathy, it is reasonable to defer imaging and treat the patient's pain with analgesics (usually, nonsteroidal antiinflammatory drugs). MRI is indicated if substantial pain is still present four to six weeks after the initiation of treatment or if there are progressive neurologic deficits. Other options include cervical traction or transforaminal injections of corticosteroids, although the latter have potential risks, and neither approach has been well studied. It is reasonable to recommend a progressive exercise program once pain is under control, although it remains uncertain whether such a program reduces the risk of recurrence. Surgery should be reserved for patients who have persistent and disabling pain after at least 6 to 12 weeks of nonsurgical management, progression of neurologic deficits, or signs of moderate-to-severe myelopathy.