What is the management for a patient with a positive Spurling test indicating cervical radiculopathy?

Management of Cervical Radiculopathy with Positive Spurling Test

The initial management for patients with cervical radiculopathy confirmed by a positive Spurling test should begin with conservative treatment including physical therapy, medication for pain control, and activity modification, with MRI as the preferred imaging modality before considering surgical options if symptoms persist.

Diagnostic Confirmation

• A positive Spurling test has high diagnostic value for cervical radiculopathy with 95% sensitivity and 94% specificity for detecting nerve root compression 1
• MRI without contrast is the recommended imaging modality for patients with suspected cervical radiculopathy, as it correctly identifies approximately 88% of lesions compared to 81% for CT myelography 2
• CT scanning can be considered as an alternative when MRI is contraindicated, particularly for evaluating bony structures, though it is less sensitive for nerve root compression 2

Conservative Management (First-Line)

Physical Therapy and Exercise

• Exercise therapy with or without other treatments is beneficial for cervical radiculopathy 3
• Physical therapy should focus on neck positioning that centralizes discomfort and avoids positions that exacerbate radicular symptoms 4

Medication Options

• Limited evidence supports the use of medications including:
  • NSAIDs for pain and inflammation control
  • Neuropathic pain medications (gabapentin, pregabalin, tricyclic antidepressants) may be considered, though evidence is limited 3
  • Short-term oral steroids may be beneficial in acute exacerbations 4

Interventional Procedures

• Epidural corticosteroid injections, preferably using an interlaminar approach, may be effective for acute and subacute cervical radicular pain 3
• For chronic cervical radicular pain, pulsed radiofrequency treatment adjacent to the dorsal root ganglion may be considered 3

Surgical Management (Second-Line)

• Surgical intervention should be considered when conservative treatment fails to provide adequate relief 2
• Posterior laminoforaminotomy is recommended as a surgical treatment option for:
  • Symptomatic cervical radiculopathy resulting from soft lateral cervical disc displacement
  • Cervical spondylosis with resultant narrowing of the lateral recess 2
• Studies show good to excellent outcomes in 93-95% of patients undergoing laminoforaminotomy for cervical radiculopathy 2
• Herniated cervical discs causing radiculopathy may be treated from either an anterior or posterior surgical approach 2

Important Clinical Considerations

• Most patients with cervical radiculopathy improve with conservative, non-operative treatment 5
• Patient education is crucial to avoid positions that exacerbate symptoms, such as neck hyperextension combined with rotation and side-bending (e.g., at salon sinks) 4
• When performing the Spurling test, the most effective technique involves extension, lateral bending, and axial compression, which produces the highest pain scores and most distal pain distribution 6
• MRI findings should be interpreted cautiously as they frequently show false-positive and false-negative results, and abnormalities are often present in asymptomatic patients 2
• Abnormal levels on MRI do not always correspond to clinical examination findings 2

Treatment Algorithm

1. Initial presentation with positive Spurling test:

   • Begin conservative management for 6-8 weeks 5, 3
   • Obtain MRI without contrast if symptoms are severe or persistent 2

2. If symptoms improve with conservative management:

   • Continue physical therapy and gradually return to normal activities 3

3. If symptoms persist despite 6-8 weeks of conservative management:

   • Consider epidural steroid injections 3
   • If still inadequate relief, surgical consultation for possible laminoforaminotomy or other surgical approaches 2

4. For chronic radicular pain:

   • Consider pulsed radiofrequency treatment adjacent to the dorsal root ganglion 3