What is the treatment approach for cervical nerve root compression and facet arthropathy?

Treatment Approach for Cervical Nerve Root Compression and Facet Arthropathy

Initial conservative management for at least 6 weeks is the appropriate first-line treatment for cervical nerve root compression and facet arthropathy, as 75-90% of patients achieve symptomatic improvement without surgery. 1, 2, 3

Initial Conservative Management (First 6+ Weeks)

The following multimodal approach should be implemented before considering surgical intervention:

• Immobilization with a rigid cervical collar for short-term use to reduce nerve root irritation 1, 4
• Anti-inflammatory medications (NSAIDs) to address both nerve root inflammation and facet joint inflammation 1, 4
• Physical therapy including cervical traction, which may temporarily decompress nerve impingement 2, 4
• Activity modification with avoidance of provocative movements that exacerbate radicular symptoms 1
• Selective nerve root blocks or epidural steroid injections to target nerve root pain when conservative measures alone are insufficient 4

Critical timeframe: Most acute cervical radiculopathy resolves spontaneously or with conservative treatment within the first 3 months 1

Diagnostic Imaging Strategy

MRI cervical spine without contrast is the preferred initial imaging modality for confirming nerve root compression and evaluating soft tissue pathology 1, 2

• MRI correctly predicts 88% of lesions causing cervical radiculopathy and provides superior visualization of disc herniations and nerve root compression 1
• CT without contrast is complementary to MRI for evaluating osseous causes of compression, particularly facet joint hypertrophy and uncovertebral joint osteophytes that contribute to foraminal stenosis 1
• Important caveat: MRI findings must always be correlated with clinical symptoms, as degenerative changes are commonly found in asymptomatic patients over age 30, and false-positive/false-negative findings occur frequently 1, 2

Imaging is NOT required at initial presentation in the absence of red flag symptoms (trauma, malignancy, infection, myelopathy, progressive neurological deficits) 1

Surgical Indications

Surgery should be considered when any of the following criteria are met:

• Persistent disabling symptoms despite 6+ weeks of structured conservative therapy with documented failure of multiple modalities 2, 3
• Clinically significant motor deficits (weakness) that impact functional activities and quality of life 2, 3
• Progressive neurological deterioration despite conservative management 2
• Severe radiculopathy with intractable pain resistant to conservative measures 1

Surgical Options

Anterior cervical decompression and fusion (ACDF) is the primary surgical approach for cervical radiculopathy caused by both disc herniation and facet/uncovertebral joint pathology:

• ACDF provides more rapid relief (within 3-4 months) of arm/neck pain, weakness, and sensory loss compared to continued conservative treatment 2
• Success rate for arm pain relief is 80-90% with anterior approaches 2
• Functional improvement occurs in 90.9% of patients following surgical intervention 2
• At 12 months, surgical and conservative outcomes may be comparable, but surgery provides faster symptom resolution 1, 2

Posterior cervical laminoforaminotomy is an alternative approach indicated for:

• Soft lateral disc herniations causing foraminal compression 2, 5
• Cervical spondylosis with lateral recess narrowing from facet arthropathy 2
• Patients preferring motion preservation without anterior approach risks 2
• Success rates range from 78-93% depending on patient factors 2

Anterior cervical plating (instrumentation) should be added for multilevel disease or 2-level fusions, as it:

• Reduces pseudarthrosis risk from 4.8% to 0.7% 2
• Improves fusion rates from 72% to 91% 2
• Maintains cervical lordosis, which is critical for foraminal decompression 2

Treatment Algorithm Based on Severity

For mild cervical radiculopathy (mJOA score >12):

• Conservative management for minimum 6 weeks, up to 3 years 1
• Surgery only if conservative measures fail and symptoms significantly impact quality of life 1

For severe cervical radiculopathy (mJOA score ≤12) or myelopathy:

• Surgical decompression should be strongly considered, as benefits are maintained for 5-15 years postoperatively 1
• Delayed surgery in severe cases may result in irreversible neurological damage 1

Common Pitfalls to Avoid

• Do not operate based on imaging alone - degenerative changes on MRI/CT are ubiquitous in patients over 30 and correlate poorly with symptoms 1
• Do not rush to surgery - 75-90% of patients improve with conservative management, making premature surgical intervention inappropriate 1, 2
• Do not skip adequate conservative trial - minimum 6 weeks of documented, structured conservative therapy is required before surgery is indicated 2, 3
• Do not ignore red flag symptoms - presence of myelopathy, infection, malignancy, or progressive neurological deficits changes management urgency 1
• Do not perform multilevel fusion unless both/all levels demonstrate moderate-to-severe stenosis with clinical correlation 2, 5

Long-Term Outcomes

• Surgical outcomes for arm pain relief remain 80-90% successful at long-term follow-up 2
• Recurrent symptoms occur in up to 30% of patients after anterior cervical foraminotomy 2
• Benefits of surgical decompression for severe disease are maintained for 5-15 years postoperatively 1
• Adjacent segment degeneration may occur after fusion, though this does not always correlate with clinical symptoms 6