Cervical Radiculopathy Pain Management
Conservative non-operative treatment should be the initial approach for all patients with cervical radiculopathy without red flags, as 75-90% achieve symptomatic improvement without surgery. 1, 2
Initial Conservative Management (First 6-12 Weeks)
Start with a structured multimodal conservative approach:
- Physical therapy focusing on neck muscle strengthening, posture correction, and stabilization exercises is the cornerstone of initial treatment 3
- Immobilization with cervical collar for short-term symptom relief (avoid prolonged use to prevent deconditioning) 4
- Anti-inflammatory medications (NSAIDs) to reduce nerve root inflammation 5, 4
- Cervical traction may provide mechanical decompression 4
- Epidural steroid injections can provide temporary relief for radicular symptoms when conservative measures alone are insufficient 3, 5
The evidence strongly supports this conservative approach, with success rates averaging 90% in the acute phase 2. Physical therapy demonstrates statistically significant clinical improvement and can achieve comparable outcomes to surgery at 12 months, though surgery provides more rapid relief within 3-4 months 2.
Indications for Surgical Intervention
Surgery is appropriate when:
- Persistent symptoms despite 6+ weeks of adequate conservative treatment 2, 4
- Clinically significant motor deficits impacting quality of life 2
- Progressive neurological deficits 2
- Debilitating pain resistant to conservative modalities 6, 4
Surgical Options
When surgery is indicated, choose based on pathoanatomy:
Anterior Approach (Preferred for Most Cases)
- Anterior cervical discectomy and fusion (ACDF) provides rapid relief (3-4 months) of arm/neck pain, weakness, and sensory loss with 80-90% success rates for arm pain relief 2, 4
- Anterior cervical plating (instrumentation) reduces pseudarthrosis risk and maintains cervical lordosis, particularly important for multilevel disease 2
- Interbody cage provides immediate structural support and maintains disc height for foraminal decompression 2
Posterior Approach (Selective Indications)
- Posterior laminoforaminotomy is effective for soft lateral disc herniation, lateral recess narrowing from spondylosis, or patients preferring motion preservation without anterior approach risks 2
- Variable success rates (52-99%) with recurrent symptoms reported in up to 30% of patients 2, 3
Diagnostic Imaging Algorithm
Do not routinely image at initial presentation without red flags:
- MRI without contrast is the preferred initial imaging modality when imaging is indicated, as it best visualizes soft tissue pathology including disc herniation and nerve root compression 1, 2, 3
- CT without contrast offers superior bone visualization and is complementary to MRI for assessing osseous causes (osteophytes, uncovertebral/facet joint hypertrophy) 1, 3
- Plain radiographs are useful for initial screening of spondylosis, degenerative disc disease, and malalignment, but findings correlate poorly with symptoms 1
Critical caveat: MRI findings must always be correlated with clinical symptoms, as false positives and false negatives are common—asymptomatic abnormalities are detected in over 50% of individuals over 30 years of age 1, 2. Never diagnose cervical radiculopathy on imaging alone 1.
Red Flags Requiring Urgent Evaluation
Image immediately if present:
Treatment Timeline
Follow this algorithmic approach:
- Weeks 0-6: Conservative management with physical therapy, NSAIDs, and activity modification 4
- Weeks 6-12: Add epidural steroid injections if inadequate response 5, 4
- After 12 weeks: Consider surgical consultation if persistent disabling symptoms or any time if progressive neurological deficits develop 2, 4
Important pitfall: Avoid ordering MRI in the first 6 weeks unless red flags are present, as imaging abnormalities are common in asymptomatic individuals and may lead to unnecessary interventions 1. The natural history is self-limiting in most cases, with spontaneous resolution occurring in 75-90% of patients 1, 2, 4.