What is the initial management for cervical radiculopathy due to cervical spondylosis?

Initial Management of Cervical Radiculopathy Due to Cervical Spondylosis

Conservative treatment is the appropriate initial approach for most patients with cervical radiculopathy due to cervical spondylosis, as the condition has a favorable natural course with up to 75% rate of spontaneous improvement.

Clinical Presentation and Diagnosis

• Cervical radiculopathy presents as pain radiating from the neck into the distribution of the affected nerve root
• May be accompanied by:
  • Sensorimotor impairment in the affected nerve root distribution
  • Multiple nerve roots affected simultaneously (multilevel radiculopathy)
  • Rarely, coexisting cervical myelopathy

Conservative Management Approach

First-Line Treatments

1. Pain Management:

   • NSAIDs at lowest effective dose for shortest duration 1
   • Options include naproxen, diclofenac, or celecoxib
   • Monitor for gastrointestinal, renal, and cardiovascular side effects

2. Physical Interventions:

   • Exercise therapy 1, 2:
     • Neck-specific exercises
     • Scapular resistance exercises
     • Postural correction exercises
     • Deep cervical flexor strengthening
   • Manual therapy including mobilization/manipulation of upper thoracic and cervical spine 2
   • Intermittent mechanical cervical traction 2

3. Activity Modification and Education:

   • Patient education about the condition and its generally favorable natural history 1
   • Activity modification to avoid exacerbating movements

Second-Line Treatments

• Targeted epidural steroid injections for persistent radicular pain 3
• Cervical collar (limited use to avoid muscle deconditioning) 4
• Pain management education 4

Monitoring and Follow-up

• Regular assessment of pain levels using validated tools (e.g., Visual Analog Scale)
• Evaluation of neurological function
• Assessment of functional improvement using Neck Disability Index (NDI)
• Monitor for "red flags" requiring urgent intervention:
  • Progressive or profound motor weakness
  • Signs of myelopathy
  • Intractable pain despite therapy

When to Consider Surgical Management

Surgical intervention should be considered when:

1. Persistent radicular pain after 6-12 weeks of conservative treatment 5, 4
2. Progressive or profound motor weakness 5
3. Significant neurological deficit 6

Surgical options include:

• Posterior laminoforaminotomy for lateral disc displacement or foraminal stenosis 7
• Anterior cervical discectomy with fusion (ACDF) for severe foraminal narrowing causing radiculopathy 1

Evidence on Treatment Outcomes

• Conservative treatment shows good long-term outcomes in most patients 3
• In geriatric patients with cervical spondyloarthrosis and radiculopathy, a multimodal conservative approach (manual therapy, traction, and home exercises) demonstrated substantial improvement in pain and function 2
• Surgical outcomes for relief of arm pain range from 80% to 90% with either anterior or posterior approaches 6
• Surgical treatment provides faster pain relief compared to conservative treatment, but may not have significant advantages in range of motion or long-term NDI scores 4

Important Considerations

• The natural history of cervical radiculopathy is generally favorable 5, 6
• For patients without severe or progressive neurological deficits, conservative management for at least 3 months is appropriate 4
• Surgery should be reserved for cases that fail to respond to conservative treatment or have significant neurological deficits 5, 6