What is the optimal inpatient management for an adult patient with cervical radiculopathy and no significant medical comorbidities, prior to surgery?

Inpatient Management of Cervical Radiculopathy Prior to Surgery

For adult patients with cervical radiculopathy awaiting surgery, implement a structured 10-day multimodal pain management program centered on cervical epidural steroid injections, combined with physical therapy, anti-inflammatory medications, and activity modification. 1

Core Inpatient Management Strategy

The optimal inpatient approach combines multiple therapeutic modalities delivered simultaneously rather than sequentially:

Pain Control Protocol

• Cervical translaminar epidural steroid injection is the cornerstone intervention, reducing arm pain by 43.4% and neck pain by 40.1% within 2 days of administration 1
• Administer anti-inflammatory medications throughout the admission to manage both neuropathic and inflammatory pain components 2, 3
• Consider topical analgesics as adjunctive therapy for localized pain management 4
• Multimodal pain management achieves 62.5% reduction in arm pain and 57.4% reduction in neck pain over a 10-day inpatient course 1

Physical Therapy and Mobilization

• Initiate structured physical therapy immediately upon admission, as physiotherapy demonstrates statistically significant clinical improvement comparable to surgical outcomes at 12 months (though surgery provides faster relief within 3-4 months) 5, 4
• Short-term cervical collar immobilization may be used for brief periods, but prolonged immobilization should be avoided 2, 6
• Cervical traction can provide temporary decompression of nerve root impingement 6

Preoperative Diagnostic Optimization

Complete the following imaging studies during admission to optimize surgical planning:

• MRI remains the gold standard for confirming nerve root compression and must correlate with clinical symptoms, as false positives and false negatives are common 5, 4
• Flexion-extension radiographs are mandatory to rule out segmental instability before proceeding with surgery, as static MRI cannot adequately assess dynamic instability 5, 4
• CT scanning provides complementary information for evaluating bony causes of compression including osteophytes and facet hypertrophy 4

Critical Prognostic Assessment

Inform patients about MRI findings that predict poor surgical outcomes:

• Multilevel T2 hyperintensity in the cervical cord predicts poor surgical outcome 7
• T1 hypointensity combined with T2 hyperintensity at the same level predicts poor surgical outcome 7
• Spinal cord atrophy with transverse area <45 mm² predicts poor surgical outcome 7

Electromyography Considerations

• Reserve EMG for patients with atypical symptoms or multifactorial presentations, as EMG has poor sensitivity (56% of cervical radiculopathy cases show no EMG abnormalities) and mixed utility in predicting surgical outcomes 7
• EMG may help differentiate central versus peripheral nervous system pathology when clinical presentation is unclear 7

Patient Education and Expectation Setting

Provide realistic outcome expectations based on surgical approach:

• Anterior cervical decompression and fusion (ACDF) achieves 80-90% success rates for arm pain relief and 90.9% functional improvement 5, 2
• Motor function recovery occurs in 92.9% of patients with long-term improvements maintained over 12 months 5
• Strength improvements are maintained but may not achieve 100% return to baseline 5
• Complication rate for ACDF is approximately 5%, with good or better outcomes in 99% of patients 5

Common Pitfalls to Avoid

• Do not proceed to surgery without documenting adequate conservative therapy duration and response, as 75-90% of patients achieve symptomatic improvement with nonoperative care 4, 2
• Avoid anatomic mismatch by ensuring symptoms correlate with cervical pathology rather than lumbar or peripheral nerve pathology 5
• Do not rely solely on imaging findings without clinical correlation, as degenerative changes are ubiquitous and must match the patient's symptom distribution 2
• Document smoking status, as cigarette smoking diminishes fusion rates particularly with allograft, though differences are not always statistically significant 5

Red Flag Assessment

Immediately escalate surgical timing if any of the following develop during admission:

• Progressive neurological deficits, particularly myelopathy with gait instability and fine motor deterioration 5
• Cauda equina syndrome (though rare in cervical pathology) 4
• Signs of infection, tumor, or fracture 4