What is the recommended treatment for cervical radiculopathy in a pregnant woman?

Treatment of Cervical Radiculopathy in Pregnancy

Conservative, non-operative management is the definitive treatment approach for cervical radiculopathy in pregnant women, as 75-90% of patients achieve symptomatic improvement without surgery, and the risks of surgical intervention and anesthesia during pregnancy are unacceptable. 1, 2

Initial Management Strategy

First-Line Conservative Therapy

• Remain active rather than bed rest, as activity is more effective for acute radicular pain 2
• Physical therapy should be initiated immediately as the cornerstone of treatment, with success rates averaging 90% for acute cervical radiculopathy 1, 2
• Focus therapy on foraminal opening exercises, sustained pain-relieving positions, and patient education in the acute stage 3
• Cervical collar immobilization may be used for short periods only, as prolonged use is not recommended 4

Staged Physical Therapy Approach

• Acute stage (0-6 weeks): Patient education, spinal manipulative therapy (if not contraindicated in pregnancy), specific foraminal opening exercises, and sustained pain-relieving positions 3
• Subacute stage (6-12 weeks): Add individualized physical activity including supervised motor control exercises and neurodynamic mobilization 3
• Chronic stage (>12 weeks): Shift focus to general aerobic exercise, strength training, postural education, and ergonomic assessment 3

Pharmacological Considerations

Critical Pregnancy Limitation

• Standard pharmacological management for cervical radiculopathy must be modified or avoided entirely during pregnancy due to fetal safety concerns 5, 4
• NSAIDs, corticosteroids, and neuropathic pain medications commonly used for radiculopathy require careful risk-benefit analysis with obstetric consultation
• Pain education and mind-body interventions such as mindfulness-based stress reduction may be considered as adjunctive non-pharmacological approaches 2

Interventional Procedures During Pregnancy

Epidural Steroid Injections

• Epidural steroid injections are generally contraindicated or deferred during pregnancy unless absolutely necessary for severe, refractory symptoms 2
• The risks of fluoroscopy exposure and corticosteroid effects on the fetus must be weighed against potential benefits
• If considered, ultrasound-guided periradicular injections may theoretically reduce radiation exposure, though evidence in pregnancy is lacking 6

Surgical Management

Absolute Deferral During Pregnancy

• Surgical intervention (ACDF or foraminotomy) should be deferred until after delivery unless there is progressive, severe neurological deficit threatening permanent injury 1, 2
• While anterior cervical decompression provides rapid relief (3-4 months) with 80-90% success rates for arm pain, the risks of general anesthesia and surgery during pregnancy outweigh benefits for typical radiculopathy 1, 2
• At 12 months, physical therapy achieves comparable clinical improvements to surgical interventions, making conservative management the appropriate choice during pregnancy 1, 2

Diagnostic Imaging Considerations

MRI Safety in Pregnancy

• MRI without gadolinium contrast is the preferred imaging modality if diagnostic confirmation is needed, as it avoids ionizing radiation 1, 5
• MRI should only be performed if findings would change management or if there are concerning red flags for serious pathology
• CT scanning should be avoided due to radiation exposure to the fetus 1

Red Flags Requiring Urgent Evaluation

Progressive Neurological Deficits

• Document motor weakness, dermatomal sensory loss, and reflex changes at each visit to monitor for progression 1
• Progressive motor weakness affecting activities of daily living may warrant multidisciplinary consultation including neurosurgery and maternal-fetal medicine
• Bowel or bladder dysfunction would suggest myelopathy rather than radiculopathy and requires urgent evaluation

Expected Outcomes and Timeline

Natural History During Pregnancy

• Most patients with cervical radiculopathy improve within the first 4 weeks with conservative management 2
• Physical therapy demonstrates statistically significant clinical improvement, with outcomes comparable to surgery at 12 months 1
• Symptoms may fluctuate during pregnancy due to hormonal changes, weight gain, and postural alterations

Common Pitfalls to Avoid

• Avoid premature consideration of surgery, as 90% of acute cervical radiculopathy improves with conservative management 1
• Do not use traction therapy in the acute period of root edema, as it may exacerbate symptoms and has shown regression of results in some studies 6
• Ensure clinical symptoms correlate with imaging findings before attributing symptoms to cervical pathology, as MRI false positives are common 1
• Do not prescribe prolonged cervical collar use, as it may lead to muscle deconditioning 4

Postpartum Considerations

• Reassess symptoms 6-8 weeks postpartum, as pregnancy-related biomechanical factors may resolve
• If symptoms persist despite adequate conservative therapy (minimum 6 weeks), surgical consultation may be appropriate postpartum 1, 2
• Breastfeeding status will influence pharmacological options if medication management is reconsidered postpartum