What are the management options for cervical radiculopathy?

Management of Cervical Radiculopathy

Non-operative treatment should be the initial approach for all patients with cervical radiculopathy, as 75-90% achieve symptomatic improvement without surgery. 1

Initial Conservative Management (First 6-12 Weeks)

Acute Phase (0-6 weeks)

• Patient education and spinal manipulative therapy form the cornerstone of early management 2
• Specific foraminal opening exercises and sustained pain-relieving positions should be prescribed immediately 2
• Short-term cervical collar immobilization (not exceeding a few weeks) may provide temporary relief 3
• Medications including NSAIDs and neuropathic pain agents help control symptoms during this period 4, 3
• Cervical traction may temporarily decompress nerve impingement 3

Subacute Phase (6-12 weeks)

• Transition to individualized physical activity with supervised motor control exercises 2
• Add specific strengthening exercises and neurodynamic mobilization to the treatment regimen 2
• Guided corticosteroid injections or selective nerve blocks can be considered for persistent nerve root pain 4, 3

Chronic Phase (>12 weeks)

• Shift focus to general aerobic exercise and targeted strength training 2
• Incorporate postural education and vocational ergonomic assessment 2
• Continue multimodal pain management as needed 4

Surgical Indications

Surgery is indicated when patients have persistent symptoms despite 6+ weeks of conservative treatment, or when significant functional deficits impact quality of life. 1

Specific criteria for surgical intervention:

• Intractable or persistent pain despite adequate conservative management 5
• Severe or progressive neurological deficits (motor weakness, sensory loss) 5, 6
• Clinically significant motor deficits affecting daily function 6
• Debilitating pain resistant to conservative modalities 6

Surgical Options

Anterior Approach

Anterior cervical decompression and fusion (ACDF) provides rapid relief (within 3-4 months) of arm/neck pain, weakness, and sensory loss, with 80-90% success rates for arm pain relief. 1, 7

• ACDF is preferred for multilevel disease, central disc herniations, and foraminal stenosis from uncovertebral/facet joint hypertrophy 1
• Anterior cervical plating (instrumentation) should be added for 2-level fusions, as it reduces pseudarthrosis risk from 4.8% to 0.7% and improves fusion rates from 72% to 91% 1
• Single-level ACDF may not require plating, though it reduces graft problems and maintains lordosis 1
• Cervical arthroplasty is an alternative in carefully selected patients without segmental instability, recent infection, or adjacent level disease 1

Posterior Approach

Posterior laminoforaminotomy is effective for soft lateral disc herniations or foraminal stenosis, with success rates of 52-99%. 1, 7

• This approach preserves motion and avoids anterior approach risks (dysphagia, recurrent laryngeal nerve injury) 1
• Best suited for soft lateral cervical disc displacement and cervical spondylosis with lateral recess narrowing 1
• Recurrent symptoms occur in up to 30% of patients after anterior cervical foraminotomy 1

Critical Diagnostic Requirements Before Surgery

• MRI is the mandatory initial imaging modality to confirm nerve root compression 1, 4
• CT provides superior bone visualization for assessing osseous causes of compression 1
• Flexion-extension radiographs are required to rule out segmental instability before considering arthroplasty 1
• MRI findings must correlate with clinical symptoms, as false positives and false negatives are common 1

Long-Term Outcomes

At 12 months, surgical and non-surgical treatments achieve comparable clinical improvements, though surgery provides more rapid relief within 3-4 months. 1

• Surgical outcomes for arm pain relief range from 80-90% with either anterior or posterior approaches 1
• Functional improvement reaches 90.9% following surgical intervention 1
• Most non-surgical patients (75-90%) improve with conservative management alone 1

Common Pitfalls to Avoid

• Never proceed to surgery without documenting at least 6 weeks of structured conservative therapy with specific dates, frequency, and response to treatment 1
• Do not operate based on imaging alone—clinical symptoms must correlate with radiographic findings 1
• Avoid multilevel fusion unless both levels meet moderate-to-severe stenosis criteria 1
• Rule out lumbar pathology as the source of symptoms before attributing them to cervical disease 1
• Do not place artificial discs in patients with recent postoperative infection or adjacent level disease after fusion 1