What is the treatment for a patient with a pinched nerve in the cervical spine?

Treatment for Cervical Radiculopathy (Pinched Nerve in Neck)

Start with conservative nonoperative management for 4-6 weeks, as most patients improve regardless of treatment type, with surgery reserved only for those with persistent symptoms or red flag features. 1, 2

Initial Conservative Treatment Approach

First-Line Therapies (Weeks 0-6)

• Physical therapy is the cornerstone of treatment, incorporating strengthening and stretching exercises, which has the strongest evidence among all conservative treatments 2, 3
• NSAIDs and muscle relaxants are effective for acute neck pain and should be used to alleviate symptoms 2, 3
• Short-term cervical collar immobilization (not prolonged beyond 48-72 hours due to complication risks) may provide temporary relief 4, 5
• Cervical traction may temporarily decompress nerve impingement 5
• Massage therapy has weaker but supportive evidence for symptom relief 3

Reassurance and Prognosis

• Inform patients that 90% of acute cervical radiculopathy cases resolve with nonoperative management, and the overall prognosis is favorable 6, 5
• Most patients improve over time regardless of specific treatment modality chosen 1, 2

When to Obtain Imaging

Do not order imaging initially unless red flags are present. 2

Red Flag Symptoms Requiring Immediate MRI

• History of malignancy 2
• Signs of myelopathy (gait disturbance, bowel/bladder dysfunction) 2
• Suspected infection or abscess 2
• Fever, unexplained weight loss 1
• History of IV drug use 1
• Intractable pain despite therapy 1
• Tenderness to palpation over vertebral body 1

Imaging After Failed Conservative Treatment

• MRI cervical spine without IV contrast is the preferred imaging modality if symptoms persist after 4-6 weeks of conservative treatment 1, 2
• MRI correctly predicts 88% of lesions causing radiculopathy, superior to CT myelography (81%), plain myelography (57%), and CT (50%) 1
• Important caveat: MRI frequently shows abnormalities in asymptomatic patients, so findings must correlate with clinical examination 1

Second-Line Interventions (After 4-6 Weeks)

Epidural Steroid Injections

• Consider selective nerve root blocks or epidural steroid injections for persistent radicular pain after conservative measures fail 2, 5
• These have weak evidence but may provide temporary relief 3
• Warning: Higher risk of serious complications compared to other conservative treatments 2

Alternative Therapies

• Acupuncture, yoga, and spinal manipulation have weaker evidence but may be considered in appropriate contexts 3

Surgical Intervention

Anterior cervical decompression is indicated only when:

• Symptoms persist beyond 4-6 weeks of appropriate conservative treatment 2
• Red flag symptoms are present 2
• Progressive neurological deficits develop 1

Surgical Outcomes

• Surgery provides superior pain relief at 3-4 months compared to physical therapy or cervical collar immobilization 1
• However, by 12 months, clinical improvements are comparable between surgical and conservative groups 1
• Surgery is more effective than conservative treatment in the short term but not in the long term for most patients 3
• Success rates for anterior cervical foraminotomy range from 52-99%, with recurrent symptoms in up to 30% of patients 1

Common Pitfalls to Avoid

• Do not use prolonged cervical collar immobilization beyond 48-72 hours, as complications appear and escalate rapidly after this timeframe 4
• Do not rush to surgery without adequate trial of conservative management, as outcomes at 1 year are equivalent 1, 3
• Do not order MRI immediately unless red flags are present, as degenerative findings are common in asymptomatic patients and may lead to unnecessary interventions 1, 2
• Do not rely on imaging alone - abnormal MRI levels do not always correspond to clinical examination levels 1

Pain Management Considerations

• Nearly half of patients with chronic neck pain have mixed neuropathic-nociceptive or predominantly neuropathic symptoms 3
• Medications targeting neuropathic pain may be beneficial in these cases 5
• Multimodal analgesia combining non-opioid analgesics with antihyperalgesic drugs (such as ketamine) can prevent prolonged pain syndromes 7