From the Guidelines
For cervical radiculopathy treatment when steroids have been used and both Tylenol and NSAIDs are contraindicated, consider gabapentinoids such as gabapentin (starting at 300mg daily and gradually increasing to 300mg three times daily as tolerated) or pregabalin (starting at 75mg twice daily) as first-line treatments, as recommended by the International Association for the Study of Pain consensus panel 1. These medications have been shown to be effective in treating neuropathic pain, including cervical radiculopathy, by modulating pain pathways in different ways - gabapentinoids affect calcium channels and reduce neurotransmitter release. Tricyclic antidepressants like amitriptyline (10-25mg at bedtime) or nortriptyline (10-25mg at bedtime) can also be effective in treating cervical radiculopathy, as they modulate pain perception through serotonin and norepinephrine pathways 1. Muscle relaxants such as baclofen (5-10mg three times daily) or tizanidine (2-4mg every 6-8 hours) may help with associated muscle spasms. Non-pharmacological approaches are equally important, including physical therapy focusing on gentle cervical traction, posture correction, and strengthening exercises; activity modification to avoid positions that worsen symptoms; and application of heat or ice for 15-20 minutes several times daily. If symptoms persist beyond 6-8 weeks despite these interventions, consider referral for interventional procedures such as cervical epidural injections or surgical evaluation, as suggested by the British Pain Society 1 and the American College of Radiology 1. It is essential to note that the treatment approach should be individualized, and the patient's response to treatment should be closely monitored, as the effectiveness of these treatments may vary depending on the underlying cause of the cervical radiculopathy. In the absence of red flag symptoms, imaging may not be required at the time of initial presentation, and a stepped care approach can be recommended, with earlier referral to specialist services for assessment and management if the pain is severe or if there are neurological deficits 1.
From the Research
Treatment Options for Cervical Radiculopathy
After steroid therapy, patients who cannot tolerate Acetaminophen (Tylenol) or Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) have several treatment options for cervical radiculopathy, including:
- Cervical collars for short-term immobilization 2
- Traction to temporarily decompress nerve impingement 2
- Physical therapy and manipulation to improve neck discomfort 2, 3
- Selective nerve blocks to target nerve root pain 2
- Epidural steroid injections, which have been shown to be effective in treating cervical radiculopathy 3, 4, 5, 6
- Multimodal approach, which may benefit patients with cervical radiculopathy and associated neck pain 2
Epidural Steroid Injections
Epidural steroid injections have been used to treat cervical radiculopathy for several decades, with generally favorable results 5. These injections can be used to treat patients with cervical radiculopathy caused by various factors, including vertebral artery loops 4 and cervical disc disease 6. The injections have been shown to be safe and effective in allowing athletes to return to competition without negative clinical sequelae or need for operative intervention 6.
Conservative Treatment
Conservative treatment, including activity modification, strengthening, rehabilitation, and NSAIDs, can be used in conjunction with epidural steroid injections to manage cervical radiculopathy 6. A focused, nonoperative treatment course can improve symptoms and allow patients to return to normal activities 2, 3.