What is the initial treatment approach for cervical radiculopathy?

Initial Treatment Approach for Cervical Radiculopathy

Conservative management should be the initial approach for cervical radiculopathy, consisting of NSAIDs/COXIBs at maximum tolerated dosage for at least 6 weeks before considering more invasive interventions. 1

First-Line Management

Medication

• Start with NSAIDs or acetaminophen as first-line medications 1
  • Evaluate response at 2-4 weeks
  • If insufficient response, consider NSAID/COXIB rotation
  • Re-evaluate at 12 weeks if symptoms improve
  • Consider tapering or on-demand treatment with sustained response

Physical Interventions

• Short-term cervical collar use for temporary immobilization 2
• Physical therapy focusing on cervical spine exercises 1
• Heat therapy for symptom relief 1
• Spinal manipulation may be considered for acute symptoms 1

Adjunctive Measures

• Patient education about the condition and self-management strategies 1
• Short courses of oral prednisolone may be used as bridging options (avoid long-term use) 1
• Multimodal approach combining several conservative treatments often yields better results than single interventions 1, 2

When to Consider Imaging

• Imaging is typically not indicated initially unless red flags are present 1
• Consider imaging after 6 weeks of failed conservative management if:
  • Symptoms persist despite adequate treatment
  • Patient is considered a candidate for surgery or intervention 1
• MRI without contrast is the preferred initial study to evaluate neural foraminal narrowing, disc herniation, and nerve root compression 1

When to Consider More Advanced Interventions

• For persistent symptoms despite 6+ weeks of comprehensive conservative management 1
• For patients with progressive neurological deficits 1
• For evidence of myelopathy 1

Clinical Considerations and Pitfalls

• Cervical radiculopathy has a favorable prognosis with 75-90% of patients achieving symptomatic improvement with nonoperative care 1
• Overreliance on imaging can lead to misdiagnosis, as abnormalities are common in asymptomatic individuals 1
• Incomplete neurological examination may miss specific nerve root involvement 1
• Avoid routine early imaging in the absence of red flags 1

Advanced Treatment Options (if conservative measures fail)

• Epidural corticosteroid administration may be beneficial for acute and subacute cervical radicular pain, preferentially using an interlaminar approach 3
• For chronic cervical radicular pain, pulsed radiofrequency treatment adjacent to the dorsal root ganglion may be considered 3
• Surgical options include anterior cervical decompression with fusion and posterior cervical laminoforaminotomy for patients with:
  • Clinically significant motor deficits
  • Debilitating pain resistant to conservative treatment
  • Instability in the setting of disabling radiculopathy 4

The evidence strongly supports starting with conservative management for cervical radiculopathy, as most patients will improve with time and non-surgical treatments 1, 2. Only when conservative management fails after an adequate trial period should more invasive interventions be considered.