What are the treatment options for cervical radiculopathy?

Treatment of Cervical Radiculopathy

Initial Management: Conservative Treatment First

Non-operative management should be the initial approach for all patients with cervical radiculopathy unless they present with significant motor deficits or myelopathy, as 75-90% of patients achieve symptomatic improvement without surgery. 1, 2

Conservative Treatment Protocol

• Physical therapy is the cornerstone of initial treatment, focusing on neck muscle strengthening, posture correction, and stabilization exercises, with success rates averaging 90% 1, 3
• Patients should remain active rather than resting in bed, as activity is more effective for acute or subacute pain 3
• Cervical traction can be incorporated into the physical therapy regimen 2
• Anti-inflammatory medications help manage pain and reduce inflammation 2, 4
• Epidural steroid injections may provide temporary relief for persistent radicular symptoms despite other conservative measures 1, 3

Duration of Conservative Management

• Continue conservative treatment for at least 6 weeks before considering surgical intervention 2
• Most patients experience improvement within the first 4 weeks with non-invasive management 3

Surgical Indications

Surgery is indicated for patients with: 1, 2

1. Persistent symptoms despite 6+ weeks of conservative treatment with significant functional deficit impacting quality of life
2. Severe or progressive neurological deficits (significant motor weakness)
3. Intractable pain that is debilitating despite adequate conservative management

Surgical Options

Anterior Approaches

Anterior cervical decompression and fusion (ACDF) is the primary surgical option, providing:

• 80-90% relief of arm pain 1, 5, 3
• Rapid relief within 3-4 months of arm/neck pain, weakness, and sensory loss compared to physical therapy 1, 3
• For multilevel disease, instrumentation (cervical plating) is recommended as it reduces pseudarthrosis risk, maintains lordosis, and provides greater stability 1

Anterior cervical foraminotomy is an alternative that:

• Preserves motion at the affected level 5
• Has variable success rates (52-99%) 1, 5
• Carries a 30% recurrence rate of symptoms 1, 5, 3

Posterior Approaches

Posterior laminoforaminotomy is effective for:

• Soft lateral cervical disc displacement 6
• Cervical spondylosis with lateral recess narrowing 6
• Patients preferring motion preservation without anterior approach risks 6

Treatment Algorithm

1. Initial presentation: Start conservative management (physical therapy, NSAIDs, activity modification) 1, 3
2. 2-4 weeks: Assess response; add epidural steroid injections if inadequate improvement 3
3. 6 weeks: If persistent symptoms with functional impairment or neurological deficits, obtain surgical consultation 1, 2
4. Surgical approach selection:
   • ACDF for multilevel disease, central/paracentral disc herniations, or spondylosis with anterior compression 1
   • Posterior laminoforaminotomy for lateral soft disc herniations or foraminal stenosis 6

Critical Pitfalls to Avoid

• Do not operate based on imaging alone: MRI findings must correlate with clinical symptoms, as false positives and false negatives are common 1
• Do not rush to surgery: At 12 months, physical therapy achieves comparable outcomes to surgery, though surgery provides more rapid relief 1, 3
• Do not overlook recurrence risk: Monitor patients after anterior cervical foraminotomy closely, as 30% experience symptom recurrence 1, 5

Diagnostic Confirmation

• MRI is the preferred imaging modality for suspected cervical radiculopathy 1, 5, 3
• CT provides superior bone visualization and is complementary to MRI for assessing osseous compression 1, 5, 3