What is the recommended initial pain management for a patient with cervical radiculopathy?

Initial Pain Management for Cervical Radiculopathy

Nonoperative conservative therapy is the recommended initial pain management for patients with cervical radiculopathy, with 75-90% of patients achieving symptomatic relief through this approach. 1

Understanding Cervical Radiculopathy

Cervical radiculopathy is characterized by:

• Upper limb pain or sensorimotor deficit due to cervical nerve root impingement/irritation 1
• Annual incidence of approximately 83 per 100,000 persons 1
• Presentation typically includes neck and/or upper limb pain with varying degrees of sensory or motor deficits 1
• Caused by compression from herniated disc material, spondylarthrosis (facet or uncovertebral joints), or a combination 1, 2

First-Line Pain Management

Medications

• NSAIDs and acetaminophen may help alleviate pain, though evidence is limited 3
• Neuropathic pain medications such as gabapentin, pregabalin, tricyclic antidepressants, and anticonvulsants can be considered, though evidence for their efficacy is limited 4, 3

Physical Interventions

• Short-term cervical collar use for temporary immobilization 4
• Physical therapy and manipulation to improve neck discomfort 2, 4
• Cervical traction may temporarily decompress nerve impingement 4

Second-Line Interventions

• Epidural corticosteroid injections may be beneficial for acute and subacute cervical radicular pain, preferably using an interlaminar approach 3
• Selective nerve blocks can target nerve root pain 2, 4
• For chronic cervical radicular pain with limited response to epidural steroids, pulsed radiofrequency treatment adjacent to the dorsal root ganglion may be considered 3

Diagnostic Considerations

Clinical Assessment

• Diagnosis is made through a combination of clinical history, physical examination, and imaging 1, 3
• Spurling and shoulder abduction tests are commonly used to identify cervical radicular pain 3

Imaging

• MRI without contrast is the recommended imaging modality before interventional treatments 3
• MRI findings should always be interpreted in combination with clinical findings due to frequent false-positive and false-negative results 1
• CT may offer complementary benefit in assessing osseous structures when MRI is contraindicated 1

Important Caveats

• Despite the common use of medications for symptom management, high-quality evidence supporting specific pharmacological interventions is limited 4, 3
• MRI alone should not be used to diagnose symptomatic cervical radiculopathy due to high rates of abnormal findings in asymptomatic individuals 1
• Most patients improve over time with focused nonoperative treatment, with a favorable overall prognosis 2, 5
• Surgical intervention should be considered only after failure of conservative management or in cases of severe/progressive neurological deficits 6, 5

Treatment Algorithm

1. Initial approach: Conservative management with medications and physical interventions for 6-12 weeks 4
2. If symptoms persist: Consider epidural steroid injections or selective nerve blocks 3
3. For refractory cases: Evaluate for surgical candidacy, especially with persistent neurological deficits 6, 5