From the Guidelines
The initial approach for a patient with radial region radiculopathy of several years duration should begin with a thorough history and physical examination to confirm the diagnosis and identify potential causes, followed by conservative management with nonsteroidal anti-inflammatory drugs (NSAIDs) and physical therapy for 6-8 weeks. This approach is recommended because many cases of radiculopathy improve with time and non-invasive treatments 1. Conservative management typically includes NSAIDs such as ibuprofen 400-800mg three times daily or naproxen 500mg twice daily for 2-4 weeks to reduce inflammation and pain. Physical therapy focusing on cervical spine exercises, posture correction, and nerve gliding techniques should be implemented for 6-8 weeks. Activity modification to avoid positions that exacerbate symptoms is essential. For breakthrough pain, a short course of oral corticosteroids such as prednisone 20mg daily for 5-7 days with a taper may be considered. Neuropathic pain medications like gabapentin (starting at 300mg daily and titrating up to 300mg three times daily) or pregabalin (starting at 75mg twice daily) can be added if pain persists.
The radial nerve distribution radiculopathy typically involves the C6-C7 nerve roots, which control sensation and motor function in the posterior arm, forearm, and first three digits. If symptoms persist beyond 6-8 weeks of conservative management or if there are concerning neurological deficits, advanced imaging (MRI) and referral to a specialist for potential interventional procedures should be considered 1. MRI has become the preferred method to evaluate the cervical spine in the setting of suspected nerve root impingement because of its superior intrinsic soft-tissue contrast and good spatial resolution. However, it is essential to note that degenerative findings on MRI are commonly observed in asymptomatic patients, and there is a high rate of both false-positive and false-negative findings on MRI in the setting of suspected cervical radiculopathy 1.
Some key points to consider in the management of radial region radiculopathy include:
- A thorough history and physical examination to confirm the diagnosis and identify potential causes
- Conservative management with NSAIDs and physical therapy for 6-8 weeks
- Activity modification to avoid positions that exacerbate symptoms
- Consideration of oral corticosteroids or neuropathic pain medications for breakthrough pain
- Advanced imaging (MRI) and referral to a specialist if symptoms persist or if there are concerning neurological deficits.
From the Research
Initial Approach for Radiculopathy in the Radial Region
The initial approach for a patient with radiculopathy in the radial region of several years duration involves a thorough physical examination and history taking to determine the distribution of symptoms and the site of pathology 2.
Key Components of the Initial Approach
- A comprehensive physical examination is necessary to aid in determining the distributions of symptoms and to lead one to the site of pathology 2
- History and physical examination is the cornerstone in the appropriate diagnosis and treatment of any patient 2
- Thorough knowledge of the evidence-based literature is beneficial in maximizing patient care 2
Treatment Options
- Epidural steroid injections have been used to treat radicular pain, and additional medications such as gabapentinoids can be administered to relieve remnant pain 3, 4
- Gabapentin and pregabalin can be equally used to reduce pain in lumbar radiculopathy patients who underwent transforaminal epidural steroid injection 3
- A step-wise approach from diagnosis to conservative therapy to potential surgery can be employed to manage radicular pain syndromes 5
Considerations for Specific Cases
- In patients presenting with an MRI report of "Tarlov cysts", meticulous evaluation of diagnostic images should be an essential first step before considering invasive spinal procedures 6
- Posterior interlaminar epidural steroid injection technique can be preferred to avoid potential risk of dural puncture and associated complications in the presence of multilevel Tarlov cysts in the neural foramina 6