What is the initial treatment for a patient presenting with cervical radiculopathy?

Initial Treatment for Cervical Radiculopathy

Conservative management for a minimum of 6 weeks is the appropriate initial treatment for cervical radiculopathy, as 75-90% of patients achieve symptomatic improvement without surgery. 1, 2

Conservative Treatment Protocol

The initial approach should consist of a structured multimodal regimen including:

• Cervical immobilization with a rigid collar for short-term use to reduce nerve root irritation 2
• Anti-inflammatory medications (NSAIDs) to address both nerve root inflammation and facet joint inflammation 2
• Physical therapy including cervical traction, which may temporarily decompress nerve impingement 2, 3
• Activity modification with avoidance of provocative movements that exacerbate radicular symptoms 2

When to Image

Imaging is NOT required at initial presentation in the absence of red flag symptoms, as most acute cervical radiculopathy resolves spontaneously or with conservative treatment. 4 Red flags include trauma, malignancy, infection, progressive neurological deficits, or myelopathic features. 4

• If imaging becomes necessary after failed conservative management, MRI cervical spine without contrast is the preferred modality, correctly predicting 88% of lesions causing cervical radiculopathy 2
• CT without contrast is complementary for evaluating osseous causes like facet joint hypertrophy 2

Duration of Conservative Management

• Minimum 6 weeks of structured conservative therapy is required before considering surgical intervention 1, 2
• The natural history is favorable, with up to 75% spontaneous improvement in acute cases 5
• At 12 months, conservative management achieves comparable clinical improvements to surgical interventions, though surgery provides more rapid relief within 3-4 months 1

Indications to Escalate Beyond Conservative Care

Surgical consultation should be considered when:

• Persistent disabling symptoms despite 6+ weeks of structured conservative therapy 2
• Clinically significant motor deficits (weakness) impacting functional activities and quality of life 2, 6
• Progressive neurological deterioration despite conservative management 2, 7
• Severe radiculopathy with intractable pain resistant to conservative measures 2, 8

Common Pitfalls to Avoid

• Do not rush to imaging or surgery prematurely, as 75-90% of patients improve with conservative management alone 1, 2
• Do not operate based on imaging findings alone, as degenerative changes on MRI/CT are ubiquitous in patients over 30 and correlate poorly with symptoms 2
• Ensure clinical correlation between symptoms and imaging findings, as MRI has high rates of false-positive and false-negative findings in cervical radiculopathy 4

Surgical Outcomes When Conservative Management Fails

If surgery becomes necessary after adequate conservative trial:

• Anterior cervical decompression and fusion (ACDF) provides 80-90% success rates for arm pain relief 1, 2, 5
• Functional improvement occurs in 90.9% of patients following surgical intervention 1
• Motor function recovery is maintained in 92.9% of patients over 12 months 1
• Surgery provides more rapid relief (within 3-4 months) compared to continued conservative treatment 1, 2