What is the recommended initial evaluation and management for cervical radiculopathy?

Cervical Radiculopathy: Initial Evaluation and Management

Initial Clinical Assessment

Start with conservative management without imaging in the absence of red flags—75-90% of patients improve spontaneously within 6-12 weeks. 1, 2, 3

Red Flag Screening (Requires Urgent MRI)

Immediately obtain MRI cervical spine without contrast if any of the following are present:

• Progressive motor weakness not explained by pain alone 2, 4
• Bilateral upper extremity symptoms or combined upper/lower extremity involvement suggesting myelopathy 2, 4
• Gait disturbance, difficulty with fine motor tasks (dropping objects, buttoning), or hyperreflexia 2, 4
• New bladder/bowel dysfunction or loss of perineal sensation 2, 4
• Constitutional symptoms (fever, unexplained weight loss, night sweats) 1, 4
• Elevated inflammatory markers (ESR, CRP, leukocytosis) 1, 4
• History of malignancy, immunosuppression, or IV drug use 1, 4
• Intractable pain despite appropriate conservative therapy 1, 4
• Palpable vertebral body tenderness 1, 4
• Age >50 with concomitant vascular disease 1, 4

Physical Examination Specifics

• Perform Spurling's test (axial compression with lateral flexion toward symptomatic side)—highly specific for nerve root compression when positive 4
• Test motor strength in specific myotomes: C5 (shoulder abduction), C6 (elbow flexion, wrist extension), C7 (elbow extension, wrist flexion), C8 (finger flexion), T1 (finger abduction) 5, 6
• Assess reflexes: biceps (C5-C6), brachioradialis (C6), triceps (C7) 5, 6
• Screen for upper motor neuron signs (hyperreflexia, Hoffman's sign, clonus, Babinski) to detect myelopathy 4
• Document sensory deficits in dermatomal distribution 5, 6

Critical caveat: Physical examination findings correlate poorly with MRI evidence of nerve root compression, with high rates of both false-positive and false-negative findings. 1, 2, 4

Initial Management (First 6-12 Weeks)

Conservative Treatment Protocol

Initiate multimodal conservative therapy immediately—this is the standard of care for all patients without red flags: 1, 3, 7

• NSAIDs or acetaminophen for pain control 8, 7
• Consider short course of oral corticosteroids for acute severe pain 8
• Structured physical therapy targeting cervical spine, scapulothoracic region, and upper extremities with strengthening and mobility exercises 8, 7
• Short-term cervical collar immobilization (days, not weeks) if needed for severe pain 1, 7
• Cervical traction may provide temporary symptom relief 7
• Patient reassurance about favorable natural history 8, 7

Expected Clinical Course

• Most patients improve within 6-12 weeks 8, 3
• 30-50% may experience residual or recurrent symptoms up to 1 year 8
• Overall, 75-90% achieve symptomatic improvement with nonoperative care 1, 3

Imaging Strategy

When to Image

Do not obtain imaging at initial presentation in the absence of red flags—degenerative changes are present in approximately 65% of asymptomatic adults aged 50-59 and correlate poorly with symptoms. 1, 2, 4

• Obtain MRI cervical spine without contrast only after 6-12 weeks of failed conservative therapy 2, 8, 3
• Plain radiographs are rarely indicated and do not change management in uncomplicated radiculopathy 1, 2, 4

Imaging Modality Selection

MRI cervical spine without contrast is the imaging modality of choice when imaging is indicated—it correctly predicts 88% of cervical radiculopathy lesions compared to 81% for CT myelography, 57% for plain myelography, and 50% for CT alone. 1, 2, 8

• MRI provides superior soft-tissue contrast and spatial resolution for evaluating nerve root compression, disc herniation, and spinal cord pathology 1, 2
• CT cervical spine is less sensitive than MRI for nerve root compression, particularly from disc herniation 1
• CT myelography should only be considered when MRI is contraindicated (pacemaker, severe claustrophobia) or when MRI findings are equivocal despite clear clinical radiculopathy 1, 2

Critical pitfall: MRI findings must always be interpreted in clinical context—degenerative changes are frequently observed in asymptomatic individuals, and prospective studies show high rates of both false-positive and false-negative findings in recent-onset cervical radiculopathy. 1, 2, 4

Escalation of Care

Indications for Surgical Referral

Refer to spine surgery when:

• Symptoms persist after 6-12 weeks of adequate conservative therapy 1, 8, 3
• Severe or progressive neurological deficits present 1, 2, 4
• Confirmed cord compression or myelopathic signs on examination 4
• Patient preference after informed discussion of surgical versus continued nonoperative options 8

Surgical Outcomes

Anterior cervical decompression (with or without fusion) provides rapid relief (within 3-4 months) of arm/neck pain, weakness, and sensory loss compared to physical therapy or cervical collar immobilization, with maintained gains at 12 months. 1

• However, at 12 months, comparable clinical improvements are also present with physical therapy or cervical immobilization 1
• 80-90% of appropriately selected surgical patients achieve relief of arm pain 8
• Anterior cervical foraminotomy shows conflicting evidence with success rates of 52-99% and recurrent symptoms in up to 30% of patients 1

Additional Interventions for Persistent Symptoms

• Cervical epidural steroid injection may be offered for persistent radicular pain 4, 7
• EMG/nerve conduction studies only if diagnosis remains uncertain after clinical assessment and MRI 4

Critical Pitfalls to Avoid

• Do not order MRI solely based on radiographic degenerative changes—spondylotic changes in patients >30 years correlate poorly with symptoms 2, 8, 4
• Do not use CT as first-line imaging—it lacks soft-tissue resolution necessary to evaluate nerve root compression and disc pathology 1, 2, 4
• Do not rely on physical examination alone—exam findings correlate poorly with imaging evidence of compression 1, 2, 4
• Do not use provocative discography or diagnostic facet/nerve blocks—current evidence does not support their utility 4
• Do not treat shoulder pain as isolated orthopedic pathology when it follows dermatomal pattern or worsens with neck movement—this is often referred cervical pain 8