What is the recommended initial and stepwise treatment plan for cervical radiculopathy, including medications (NSAIDs, oral corticosteroids, gabapentin, muscle relaxants), physical therapy, and criteria for epidural steroid injection or surgical referral?

Treatment of Cervical Radiculopathy

Begin with a minimum 6-week trial of structured conservative management, as 75-90% of patients achieve symptomatic improvement without surgery. 1, 2

Initial Conservative Management (First-Line Treatment)

All patients without red flag symptoms should receive multimodal conservative therapy before considering advanced imaging or surgical intervention. 1

Medications

• NSAIDs are the cornerstone pharmacologic treatment to address both nerve root inflammation and facet joint inflammation 1
• Gabapentin provides small, short-term benefits specifically for radiculopathy and is an appropriate option for neuropathic pain 3
• Muscle relaxants (such as tizanidine) are an option for short-term relief but carry central nervous system adverse effects, primarily sedation 3
• Oral corticosteroids are NOT recommended for cervical radiculopathy, as systemic corticosteroids have not been shown to be more effective than placebo for radiculopathy 3

Physical Interventions

• Cervical immobilization with a rigid collar for short-term use reduces nerve root irritation 1
• Physical therapy including cervical traction may temporarily decompress nerve impingement 1
• Activity modification with avoidance of provocative movements that exacerbate radicular symptoms 1

Duration and Expectations

• Maintain conservative therapy for a minimum of 6 weeks before considering escalation 1, 4
• At 12 months, conservative management achieves comparable clinical improvements to surgical interventions, though surgery provides more rapid relief within 3-4 months 5, 1

When to Obtain Imaging

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 1

Red Flag Symptoms Requiring Urgent MRI

• Progressive neurological deficits 5
• Myelopathy signs (gait instability, fine motor deterioration, bladder/bowel dysfunction) 5
• Recent trauma 5
• Suspected infection or malignancy 4

Imaging After Failed Conservative Management

• MRI cervical spine without contrast is the preferred modality after 4-6 weeks of persistent symptoms, correctly predicting 88% of lesions causing cervical radiculopathy 1, 4
• CT without contrast is complementary for evaluating osseous causes like facet joint hypertrophy 1

Epidural Steroid Injections

Consider epidural steroid injections for patients with persistent radicular symptoms despite 4-6 weeks of conservative management who have imaging-confirmed nerve root compression 3, 4

• Injections may be helpful but carry higher risks of serious complications 4
• Clinical correlation between symptoms and imaging findings is mandatory, as degenerative changes on MRI are ubiquitous in patients over 30 and correlate poorly with symptoms 1

Criteria for Surgical Referral

Refer for surgical consultation when any of the following criteria are met:

Absolute Indications

• Progressive neurological deterioration despite conservative management 1, 6
• Clinically significant motor deficits (weakness) impacting functional activities and quality of life 1, 7
• Myelopathy with progressive symptoms (55-70% of untreated patients experience progressive deterioration) 5

Relative Indications

• Persistent disabling symptoms despite 6+ weeks of structured conservative therapy 1, 2
• Severe radiculopathy with intractable pain resistant to conservative measures 1

Surgical Outcomes

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

Critical 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 and correlate poorly with symptoms 1
• Ensure clinical correlation between symptoms (dermatomal pain, motor weakness, reflex changes) and imaging findings before proceeding with invasive interventions 1, 6
• Avoid systemic corticosteroids, as they have not been shown to be effective for radiculopathy 3
• Limit muscle relaxant use to short-term courses due to sedation and abuse potential 3

Stepwise Treatment Algorithm

1. Week 0-6: Structured conservative management with NSAIDs, activity modification, cervical collar, physical therapy, and consider gabapentin for neuropathic pain 1
2. Week 4-6: If persistent symptoms, obtain MRI cervical spine to confirm diagnosis and rule out surgical pathology 1, 4
3. Week 6-12: If imaging confirms nerve root compression, consider epidural steroid injection 4
4. Week 6+: If significant motor deficits, progressive neurological deterioration, or intractable pain despite conservative measures, refer for surgical evaluation 1, 2