What is the recommended treatment for radicular neck pain?

Management of Radicular Neck Pain

For radicular neck pain, a multimodal approach is recommended with conventional radiofrequency ablation as a primary interventional treatment for those who have failed conservative therapy. 1

Initial Assessment and Imaging

• Radiographs are appropriate as first-line imaging for initial assessment of chronic neck and cervical radiculopathy 1
• MRI should not be used at primary care level for initial evaluation as it has high sensitivity but low specificity for screening purposes 2
• MRI without contrast is indicated when red flags or persistent radicular symptoms are present despite conservative management 1
• CT offers superior depiction of bone structures but is less sensitive for nerve root compression evaluation compared to MRI 1

First-Line Treatment Options

• NSAIDs are recommended as first-line pharmacological treatment for acute radicular pain due to their moderate efficacy and favorable safety profile 2, 3
• Physical therapy and therapeutic exercise should be incorporated early in the treatment plan 3, 4
• Conservative management should be attempted for at least 4-6 weeks before considering more invasive interventions 3
• Most cases of cervical radiculopathy (75-90%) achieve symptomatic relief with nonoperative conservative therapy 1

Second-Line Pharmacological Options

• Duloxetine (60mg daily) has better evidence for pain relief in radicular context than other antidepressants 2
• Short-term use of muscle relaxants may be considered for acute symptom management 3
• Systemic corticosteroids have not shown significant benefit over placebo for radicular pain 2
• Benzodiazepines may actually result in lower likelihood of pain improvement compared to placebo 2

Interventional Treatments

• Conventional radiofrequency ablation may be performed for neck pain when previous diagnostic or therapeutic injections have provided temporary relief 1
• Image-guided epidural steroid injections should be considered for severe radicular pain, with fluoroscopic guidance being the gold standard 2, 5
• Blind injections should not be used in radicular pain management 2
• Epidural methylprednisolone and lidocaine injections may provide short-term symptomatic improvement of radicular symptoms 1, 5
• Intramuscular injection of lidocaine has shown effectiveness for chronic neck pain 6

Timing of Specialist Referral

• Patients with severe radicular pain (disabling, preventing normal activities) should be referred to specialist services within 2 weeks of presentation 2
• Patients with less severe radicular pain should be referred to specialist services not later than 3 months if symptoms persist 2
• If symptoms have not resolved in 4-6 weeks, re-evaluation and additional workup should be considered 3

Important Considerations and Pitfalls

• Conventional or thermal radiofrequency ablation of the dorsal root ganglion should not be routinely used for the treatment of lumbar radicular pain 1
• Chemical denervation (e.g., alcohol, phenol) should not be used in routine care of patients with chronic noncancer pain 1
• Botulinum toxin intramuscular injections are not better than saline for chronic neck pain 6
• Polypharmacy increases risk of adverse events and drug interactions, requiring careful monitoring 2
• Opioids should only be used if other treatments are ineffective and continued only if improved function outweighs impairment 3

Surgical Considerations

• It is not clear from evidence that long-term outcomes are improved with surgical treatment compared to nonoperative measures 5
• Surgical treatment may be considered for patients with severe impairments who have not responded to conservative management 5, 7
• Relatively rapid and substantial symptomatic relief can be achieved with surgical treatment in appropriate cases 5