What is the initial management for cervical radiculopathy that radiates to the armpit?

Initial Management of Cervical Radiculopathy Radiating to the Armpit

Non-operative treatment is the appropriate initial approach for cervical radiculopathy, with 75-90% of patients achieving symptomatic improvement without surgery. 1, 2

Understanding Cervical Radiculopathy

• 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
• Radiation to the armpit typically indicates involvement of the C5-C6 or C6-C7 nerve roots, which follow dermatomal patterns into the axillary region 3

Initial Management Algorithm

Step 1: Conservative Treatment (First 6 Weeks)

• Begin with non-operative management for at least 6 weeks in the absence of myelopathy or significant muscle weakness 2
• Conservative treatment components include:
  • Short-term cervical collar immobilization (3-4 weeks maximum) to reduce nerve root irritation 4
  • Anti-inflammatory medications to decrease inflammation and pain 4
  • Physical therapy focusing on cervical traction, postural education, and gentle strengthening exercises 1
  • Cervical traction to temporarily decompress nerve impingement 4

Step 2: If Symptoms Persist After Initial Conservative Treatment

• Consider epidural steroid injections for targeted relief of inflammation around the affected nerve root 2
• Continue physical therapy with progression to more active rehabilitation 1
• Selective nerve blocks may be used to target specific nerve root pain 4

Step 3: Surgical Consideration (After 6+ Weeks of Failed Conservative Treatment)

• Surgical intervention should be considered for:
  • Patients with persistent symptoms despite 6+ weeks of conservative treatment 5
  • Those with significant functional deficit impacting quality of life 1
  • Patients with progressive neurological deficits 1

Evidence-Based Treatment Outcomes

• At 12 months, physical therapy can achieve comparable clinical improvements to surgical interventions, though surgical approaches may provide more rapid relief (within 3-4 months) 5, 1
• Anterior cervical decompression via anterior cervical discectomy (ACD) with or without fusion provides rapid relief (3-4 months) of arm/neck pain, weakness, and sensory loss compared to physical therapy or cervical collar immobilization 5
• Surgical outcomes for relief of arm pain range from 80% to 90% with either anterior or posterior approaches 1

Important Considerations and Pitfalls

• MRI findings must always be correlated with clinical symptoms, as false positives and false negatives are common in cervical imaging 1
• Avoid prolonged immobilization with cervical collars (>4 weeks) as this can lead to muscle atrophy and deconditioning 4
• A multimodal approach combining several conservative treatments often yields better results than single-modality treatment 6
• Chiropractic manipulation should be approached with caution in acute radiculopathy and is contraindicated in cases with myelopathy or severe neurological deficits 7

Monitoring and Follow-Up

• Regular reassessment of neurological status is essential to detect any progression of symptoms 3
• If symptoms worsen or do not improve with conservative management, imaging studies (preferably MRI) should be obtained to confirm the diagnosis and assess for surgical indications 1
• Monitor for red flags that would necessitate immediate surgical referral: progressive neurological deficits, myelopathy signs, or cauda equina syndrome 3