Management of Cervical Radiculopathy
Non-operative treatment is the appropriate initial approach for most patients with cervical radiculopathy, with 75-90% achieving symptomatic improvement. 1
Clinical Presentation and Diagnosis
- Cervical radiculopathy presents with arm pain, sensory dysfunction, and motor function loss, often accompanied by neck pain, due to compression and inflammation of cervical nerve roots 1
- Common causes include cervical disc herniation (soft disc) causing direct nerve root compression, and cervical spondylosis with osteophyte formation (hard disc) from facet or uncovertebral joints 1, 2
- MRI is the preferred initial imaging modality for suspected cervical radiculopathy, while CT offers superior visualization of bone structures 1
Treatment Algorithm
First-Line: Conservative Management (Initial 6 Weeks)
- All patients without myelopathy or significant muscle weakness should receive conservative treatment for at least 6 weeks 3
- Treatment approach should be stage-specific:
Acute Stage
- Patient education about the condition and expected recovery 4
- Spinal manipulative therapy to reduce pain and improve mobility 4
- Specific foraminal opening exercises to relieve nerve compression 4
- Sustained pain-relieving positions to reduce nerve root irritation 4
- Immobilization with cervical collar for short-term symptom relief 3
Subacute Stage
- Increasing individualized physical activity 4
- Supervised motor control exercises 4
- Specific exercises targeting affected nerve root 4
- Neurodynamic mobilization techniques 4
- Cervical traction to decompress nerve roots 3
Chronic Stage
- General aerobic exercise to improve overall conditioning 4
- Focused strength training for cervical and upper extremity muscles 4
- Postural education to prevent recurrence 4
- Vocational ergonomic assessment for workplace modifications 4
Pharmacological Management
- Anti-inflammatory medications to reduce nerve root inflammation 3
- Pregabalin may be beneficial for neuropathic pain components, with studies showing 38% of patients maintaining therapeutic response at 26 weeks compared to 19% with placebo 5
- Epidural steroid injections for patients with persistent radicular pain despite other conservative measures 3
Surgical Indications
- Surgical intervention is indicated for patients with: 1, 3
- Intractable or persistent pain despite 6+ weeks of conservative management
- Severe or progressive neurological deficits
- Significant functional deficit impacting quality of life
Surgical Options
- Anterior cervical decompression and fusion (ACDF): 90% good to excellent outcomes for arm pain relief 6, 1
- Posterior foraminotomy: Success rates ranging from 52-99% 6, 1
- Anterior cervical foraminotomy: May improve symptoms but has variable success rates 1
Treatment Outcomes and Prognosis
- Surgical outcomes for relief of arm pain range from 80% to 90% with either anterior or posterior approaches 1
- Long-term outcomes (12 months) may be comparable between surgical and non-surgical treatments 1
- Recurrent symptoms have been reported in up to 30% of patients after anterior cervical foraminotomy 1
- One study showed 90.9% functional improvement in 26/28 patients following surgical intervention 7
Important Considerations
- MRI findings must always be correlated with clinical symptoms, as false positives and false negatives are common 1
- The patient's specific pathophysiology, clinical symptoms, and radiographic findings should guide treatment selection 2
- Most patients (75-90%) will improve with conservative care alone, making it the appropriate first-line approach 3
- Surgical treatment should be reserved for specific indications after failed conservative management 8