What is the workup and treatment for cervical radiculopathy?

Workup and Treatment for Cervical Radiculopathy

Initial Clinical Assessment

Cervical radiculopathy should be diagnosed clinically through identification of arm pain in a dermatomal distribution, with or without motor weakness, sensory deficits, or reflex changes that correlate with specific nerve root compression. 1

Key Clinical Features to Identify:

• Pain pattern: Neck pain radiating into arm following specific dermatomal distribution (e.g., C6 radiculopathy causes pain into thumb/index finger, C7 into middle finger) 2, 3
• Motor examination: Test specific myotomes - C5 (deltoid/shoulder abduction), C6 (biceps/wrist extension), C7 (triceps/elbow extension), C8 (finger flexion) 1
• Sensory examination: Map dermatomal sensory loss corresponding to suspected nerve root 2
• Reflex testing: C5-C6 (biceps), C6-C7 (brachioradialis), C7 (triceps) 3

Imaging Workup

MRI of the cervical spine without contrast is the imaging modality of choice for suspected cervical radiculopathy, with sensitivity of 96%, specificity of 93%, and accuracy of 94%. 4, 1

Imaging Algorithm:

• First-line: MRI cervical spine without IV contrast - provides excellent visualization of disc herniation, foraminal stenosis, and nerve root compression 4, 1
• Complementary imaging: CT cervical spine when superior bone detail needed to assess osteophyte formation, uncovertebral joint hypertrophy, or facet joint arthropathy 1
• Avoid: Plain radiographs as initial imaging - they have low specificity and require 30-40% bone destruction before abnormalities become visible 4
• Dynamic imaging: Flexion-extension radiographs only if segmental instability suspected before considering arthroplasty 1

Critical Imaging Pitfall:

MRI findings must always be correlated with clinical symptoms, as false positives and false negatives are common - degenerative changes are ubiquitous in asymptomatic patients, so anatomic findings without corresponding clinical symptoms do not warrant treatment 1, 5

Initial Treatment Approach

Non-operative management is the appropriate initial treatment for 75-90% of patients, who will achieve symptomatic improvement without surgery. 1, 6, 5

Conservative Treatment Protocol (Minimum 6 Weeks):

• Immobilization: Short-term cervical collar use (avoid prolonged use to prevent deconditioning) 7, 5
• Pharmacotherapy: Anti-inflammatory medications for pain and inflammation 7, 5
• Physical therapy: Structured program with demonstrated statistically significant clinical improvement 1
• Cervical traction: May provide temporary decompression of nerve impingement 7
• Activity modification: Avoid provocative positions and activities 1
• Epidural steroid injections: Consider for targeted nerve root pain relief 7, 5

Expected Timeline:

At 12 months, physical therapy achieves comparable clinical improvements to surgical interventions, though surgery provides more rapid relief within 3-4 months. 1, 6

Surgical Indications

Surgery is indicated for patients with persistent symptoms despite 6+ weeks of adequate conservative treatment, or those with significant functional deficits impacting quality of life. 1, 5

Absolute Requirements Before Surgery:

• Clinical correlation: Symptoms must match radiographic pathology at specific level 1
• Radiographic confirmation: Moderate-to-severe foraminal stenosis or disc herniation on MRI 1
• Failed conservative therapy: Documented minimum 6 weeks of structured conservative treatment with specific dates, frequency, and response 1
• Functional impact: Significant symptoms affecting activities of daily living or sleep 1

Surgical Options:

Anterior Cervical Decompression and Fusion (ACDF) is the primary surgical approach, providing 80-90% success rate for arm pain relief and 90.9% functional improvement. 1, 6, 5

ACDF Indications:

• Single or multilevel disease with moderate-to-severe foraminal stenosis 1
• Central or paracentral disc herniation 2, 3
• Provides rapid relief (3-4 months) of arm/neck pain, weakness, and sensory loss 1
• Motor function recovery occurs in 92.9% of patients with long-term improvements maintained over 12 months 1

Instrumentation Considerations:

• Single-level fusion: Anterior cervical plating reduces pseudarthrosis risk and maintains lordosis 1
• Two-level fusion: Plating reduces pseudarthrosis from 4.8% to 0.7% and improves fusion rates from 72% to 91% 1
• Multilevel fusion: Instrumentation provides greater stability and improved outcomes 1

Posterior Laminoforaminotomy is recommended for soft lateral disc herniation or foraminal stenosis when motion preservation desired, with 78-93% success rate. 1

Posterior Approach Indications:

• Soft lateral cervical disc displacement 1
• Cervical spondylosis with lateral recess narrowing 1
• Patients preferring motion preservation without anterior approach risks 1

Surgical Outcomes:

• Arm pain relief: 80-90% success rate with either anterior or posterior approach 1, 6
• Complication rate: Approximately 5% for ACDF 1
• Recurrence: Up to 30% after anterior cervical foraminotomy 1

Common Pitfalls to Avoid

• Premature surgery: The 90% success rate with conservative management mandates adequate 6-week trial before surgical intervention 1
• Anatomic mismatch: Ensure symptoms correlate with cervical pathology, not lumbar or other sources 1
• Insufficient stenosis: Performing fusion at levels without moderate-to-severe stenosis is not guideline-supported 1
• Missing documentation: Lack of documented conservative therapy duration is an absolute barrier to establishing surgical medical necessity 1