What is the treatment for cervical radiculopathy?

Treatment of Cervical Radiculopathy

Most cases of cervical radiculopathy should be treated conservatively for at least 6 weeks before considering surgical intervention, as 75-90% of patients achieve symptomatic improvement with nonoperative care. 1

Initial Assessment and Conservative Management

First-Line Treatment (0-6 weeks)

• Physical therapy and activity modification

  • Remain active rather than resting in bed
  • Heat application for short-term relief
  • Cervical traction may temporarily decompress nerve impingement 2

• Medications

  • Anti-inflammatory medications for pain control
  • Consider neuropathic pain medications for radicular symptoms 3
  • Caution: Opioids should be used at the lowest possible dose for the shortest time possible with close monitoring of efficacy and side effects 3

• Immobilization

  • Short-term use of cervical collar for temporary immobilization 1, 2
  • Patients should be encouraged to return to normal activities as soon as possible

Second-Line Treatment (if symptoms persist beyond 6 weeks)

• Epidural steroid injections

  • Consider for persistent radicular pain
  • Should be image-guided (fluoroscopy preferred for targeted epidural or transforaminal injections) 3
  • Most appropriate for patients with correlating MRI findings of nerve root compression

• Selective nerve blocks

  • Target specific nerve root pain 2

Imaging Considerations

• Initial imaging may not be required at time of presentation as most cases resolve with conservative treatment 3
• MRI is preferred if imaging is needed for persistent symptoms (superior to CT for nerve root impingement) 3
• Caution: MRI findings often show abnormalities in asymptomatic individuals and must correlate with clinical symptoms 3
• CT myelography can be considered if MRI is contraindicated or findings are equivocal 3

Surgical Intervention

Surgical treatment is appropriate for patients who:

1. Have persistent symptoms despite 6+ weeks of conservative treatment
2. Present with significant motor deficits
3. Have debilitating pain resistant to conservative management 1

Surgical options include:

• Anterior cervical decompression and fusion
• Cervical disk arthroplasty
• Posterior foraminotomy 1, 4

Important Clinical Considerations

• Red flags requiring immediate evaluation include: trauma, malignancy history, prior neck surgery, spinal cord injury, systemic diseases, suspected infection, IV drug use history, or intractable pain despite therapy 3

• Prognosis: The overall prognosis is favorable with most patients improving over time with focused nonoperative treatment 2

• Common pitfall: Relying solely on imaging findings without clinical correlation. MRI and CT often show degenerative changes in asymptomatic individuals, so symptoms must correlate with pathology for successful diagnosis and treatment 1, 3

• Patient selection: Critical for optimizing outcomes, especially when considering surgical intervention 1

A multimodal approach combining appropriate medications, physical therapy, and selective interventions when indicated provides the best outcomes for most patients with cervical radiculopathy.