What is the recommended treatment for a patient with cervical radiculopathy?

Treatment for Cervical Radiculopathy

Initial Management: Conservative Treatment First

Non-operative treatment is the appropriate initial approach for most patients with cervical radiculopathy, as 75-90% achieve symptomatic improvement without surgery. 1, 2, 3

Conservative Treatment Protocol (Minimum 6 Weeks)

• Physical therapy focusing on neck muscle strengthening, posture correction, and stabilization exercises should be initiated as first-line treatment 2
• Cervical immobilization with a collar for short periods may provide temporary relief 1, 4
• Anti-inflammatory medications to address both mechanical compression and inflammatory cytokines released from damaged disks 3, 4
• Cervical traction may temporarily decompress nerve root impingement 4
• Epidural steroid injections can provide temporary relief for radicular symptoms when other conservative measures are insufficient 2, 4

The natural course of cervical radiculopathy is generally favorable, with most patients improving over time through a multimodal conservative approach 4, 5

Surgical Indications: When Conservative Treatment Fails

Surgery should be considered for patients with persistent symptoms despite 6+ weeks of conservative treatment, or those with significant functional deficits impacting quality of life. 1, 3, 6

Specific Surgical Triggers

• Persistent radicular pain despite adequate 6-week conservative trial 1, 3, 6
• Progressive motor weakness or significant functional deficit (e.g., deltoid palsy, wrist drop) 1, 6
• Symptoms significantly impacting activities of daily living and sleep 1
• Clinical symptoms that correlate with MRI-confirmed moderate-to-severe foraminal stenosis or nerve root compression 1, 7

Surgical Options and Selection Algorithm

Anterior Cervical Decompression and Fusion (ACDF) is the preferred surgical approach for most patients, providing 80-90% success rates for arm pain relief and 90.9% functional improvement 1, 2, 6

ACDF is Specifically Indicated When:

• Central or paracentral disk herniation is present 6
• Significant axial neck pain accompanies radiculopathy 6
• Moderate-to-severe foraminal stenosis from uncovertebral or facet joint hypertrophy exists 1
• Any degree of segmental kyphosis is present 6
• Multilevel disease requires treatment 1

ACDF provides rapid relief within 3-4 months of arm/neck pain, weakness, and sensory loss compared to continued conservative treatment 1, 2

Posterior Laminoforaminotomy is Preferred When:

• Soft lateral disk herniation with predominant arm pain (minimal neck pain) 1, 6
• Isolated foraminal stenosis from lateral recess narrowing 1
• Patient desires motion preservation without anterior approach risks 1
• Caudal lesions in large, short-necked individuals 6

Success rates for posterior laminoforaminotomy range from 78-95.5%, though recurrent symptoms occur in up to 30% of patients 1, 2

Surgical Instrumentation Considerations

• Anterior cervical plating reduces pseudarthrosis risk from 4.8% to 0.7% and improves fusion rates from 72% to 91% in two-level disease 1
• For single-level fusion, plating reduces graft problems and maintains cervical lordosis 1
• Allograft achieves equivalent fusion rates (93.4% at 24 months) to autograft while eliminating the 20% rate of prolonged donor site pain from iliac crest harvest 1

Long-Term Outcomes

• Motor function recovery occurs in 92.9% of patients, with improvements maintained over 12 months 1
• At 12 months, physical therapy achieves comparable clinical improvements to surgical interventions, though surgery provides more rapid relief 1, 2
• Surgical outcomes show good-to-excellent results in 90-99% of cases using validated outcome measures 1, 2

Critical Diagnostic Requirements Before Surgery

• MRI is the preferred initial imaging modality to confirm nerve root compression 1, 2, 7
• Clinical symptoms must correlate with imaging findings, as false positives and false negatives are common on MRI 1, 3
• Flexion-extension radiographs are required to rule out segmental instability before considering arthroplasty 1

Common Pitfalls to Avoid

• Do not proceed to surgery without documenting at least 6 weeks of structured conservative therapy with specific dates, frequency, and response to treatment 1, 3
• Avoid operating on imaging findings alone—clinical correlation with dermatomal sensory loss, motor weakness, and reflex changes is mandatory 1, 7
• Do not perform multilevel fusion unless both levels meet moderate-to-severe stenosis criteria on imaging 1
• Recognize that 75-90% of patients improve with conservative care, making premature surgical intervention inappropriate 1, 2, 3