Treatment of cervical radiculopathy

Treatment of cervical radiculopathy

Author
Jenice Robinson, MD
Milind J Kothari, DO
Section Editor
Jeremy M Shefner, MD, PhD
Deputy Editor
John F Dashe, MD, PhD

Last literature review version 16.2: May 2008 | This topic last updated: June 9, 2008 (More)


INTRODUCTION — The optimum treatment of compressive cervical radiculopathy is the subject of continued debate, and initial management may vary significantly among practitioners. There is sparse evidence that any treatment improves upon the natural history of the condition. Part of the problem is that cervical radiculopathy is a clinical, and to some extent subjective, diagnosis with no "gold standard" test to establish or exclude the disease. Depending upon the diagnostic criteria used, clinical studies evaluating the treatment of cervical radiculopathy have tended to select one subset of patients more than another. As an example, studies that require the presence of a surgically demonstrated lesion to establish the diagnosis of cervical radiculopathy are likely to exclude patients with mild or improving symptoms.

The treatment of cervical radiculopathy will be reviewed here. The clinical features and diagnosis of cervical radiculopathy are discussed separately. (See "Clinical features and diagnosis of cervical radiculopathy").

PROGNOSIS — The prognosis varies in part upon whether the cervical radiculopathy is compressive or noncompressive. The majority of radiculopathies arise from nerve root compression; the two predominant mechanisms are cervical spondylosis and disc herniation. Noncompressive radiculopathy includes diabetes and infectious, granulomatous, and infiltrating neoplastic disorders. (See "Clinical features and diagnosis of cervical radiculopathy", section on Pathophysiology).

Compressive radiculopathy — Although data are limited, some, if not most, patients with compressive cervical radiculopathy improve without specific treatment [1,2] . Evidence that improvement is not treatment specific comes from a population-based study of 561 patients with cervical radiculopathy from Rochester, Minnesota [2] . This was not a natural history study, since most patients received some treatment and 26 percent had surgery for cervical radiculopathy. Nevertheless, at last follow-up, 90 percent of patients were asymptomatic or only mildly incapacitated.

Given the apparent overall good prognosis for recovery, conservative therapies are preferred in most patients.

Triage — In general, patients without evidence of specific weakness who have clear radicular pain and/or symptoms of only paresthesia or numbness should be managed conservatively. (See "Conservative therapy" below).

It is important to examine the patient carefully for any evidence of superimposed spinal cord dysfunction (ie, myelopathy), since cervical spondylosis may cause spinal cord compression as well as nerve root compression. In addition, all patients with objective weakness should have early cervical spine imaging and electrodiagnostic studies.

Myelopathy results in specific abnormalities on neurologic examination. Motor signs of myelopathy below the level of spinal cord involvement include upper motor neuron type weakness, increased reflexes and tone, and Babinski signs. Lower motor neuron type weakness may occur at the level of spinal cord compression. Sensory signs include decreased pinprick sensation below the level of spinal cord involvement and loss of position or vibration sensation in the lower extremities. These examination findings may be subtle if spinal cord compression is mild.

Evidence of myelopathy, as determined by the presence of myelopathic signs on examination, combined with neuroimaging evidence of spinal cord compression, is an indication for surgery. (See "Indications for surgery" below and see "Clinical features and diagnosis of cervical radiculopathy")

In the absence of myelopathy, conservative initial management is usually indicated for patients with stable motor weakness, as it is for patients without motor deficits on examination. All patients with motor weakness should be closely followed for evidence of progression.

Noncompressive radiculopathy — The causes of noncompressive cervical radiculopathy or polyradiculopathy include infectious processes (especially herpes zoster and Lyme disease), nerve root infarction, root avulsion, infiltration by tumor, infiltration by granulomatous tissue, and demyelination (show table 1). (See "Clinical features and diagnosis of cervical radiculopathy", section on Noncompressive causes).

The prognosis of cervical radiculopathy in these settings is influenced by the natural history and response to therapy of the underlying condition.

NONSURGICAL THERAPY — There are two main components of nonsurgical therapy: conservative therapy and epidural glucocorticoid injections.

Conservative therapy — Conservative therapy of cervical radiculopathy typically consists of the following modalities, alone or in some combination [3,4] :

• Oral analgesics
• A short course of oral corticosteroids
• Avoidance of provocative activities
• Cervical traction
• Short-term neck immobilization with the use of a hard or soft cervical collar
• Use of a cervical pillow
• Physical therapy with exercise and gradual mobilization

Despite uncertainty regarding effectiveness, we suggest conservative therapy as initial treatment for most patients with cervical radiculopathy who have clear radicular pain and symptoms of paresthesia or numbness. In addition, we suggest conservative therapy as initial treatment for patients with cervical radiculopathy who have nonprogressive neurologic deficits, including dermatomal sensory loss, myotomal weakness, and sensory changes, as long as myelopathy is not suspected.

There is no consensus regarding the sequence or time course of conservative modalities. We generally start treatment with oral analgesics and avoidance of provocative activities, accompanied by a short course of oral prednisone if pain is severe. For oral analgesia, we typically use nonsteroidal antiinflammatory drugs (NSAIDs) as first-line therapy. We avoid the use of narcotic agents.

A muscle relaxant such as cyclobenzaprine may be added if muscle spasm or muscle tightness is prominent. Cyclobenzaprine is generally started at a modest dose of 5 mg two or three times a day to reduce the side effect of drowsiness. The dose can be increased to 10 mg three times a day after one week if spasm is not relieved and side effects are not prominent.

Shoulder abduction, which can be used as a diagnostic sign, can also be useful for temporary symptom relief [9] . (See "Clinical features and diagnosis of cervical radiculopathy", section on Shoulder abduction relief test).

Once the pain is tolerable, we initiate physical therapy with exercise and gradual mobilization. In our opinion, prolonged inactivity may delay recovery and is not advisable.

The patient should be seen and reexamined in six to eight weeks if there is no improvement with these conservative measures. In this setting, neuroimaging studies of the cervical spine and electrodiagnostic studies should be performed if they were not done initially. (See "Refractory or progressive symptoms" below).

Oral glucocorticoids — A short course of high-dose oral glucocorticoid therapy may be used as initial treatment for patients with severe cervical radicular pain. The only evidence supporting the effectiveness of oral glucocorticoids for cervical radiculopathy is anecdotal [4] . In our clinical experience, for example, this treatment is associated with pain relief in many patients.

Prednisone 60 to 80 mg/day for five days, followed by a taper off the medication over the ensuing 5 to 14 days, is a typical regimen. We suggest not using prophylaxis against gastrointestinal bleeding in patients taking prednisone alone. In contrast, patients taking prednisone in combination with aspirin or other NSAIDs may require prophylaxis. (See "NSAIDs (including aspirin): Primary prevention of gastroduodenal toxicity", section on Prevention strategies).

Exercise therapy — Physical therapy, range-of-motion exercises, strengthening exercises, and aerobic exercises are frequently employed as conservative measures for cervical radiculopathy. These treatments are unproven, and the only controlled study showed no significant benefit [10] .

Many patients report benefit with exercise therapy, but this could reflect the natural history of the disease or a placebo response. Because of possible benefit and no proven harm, we suggest exercise therapy as part of the initial treatment of symptomatic cervical radiculopathy in the absence of myelopathy. Exercise therapy is contraindicated in the presence of myelopathy.

Cervical traction — Cervical traction is the application of a distracting force to the neck, which can in theory separate the cervical segments, expand the intervertebral joint spaces, and relieve compression of the nerve roots [4] .

However, controlled studies of cervical traction delivered in the course of a physical therapy program for a variety of causes of neck and arm pain have not demonstrated benefit over sham traction [11] or placebo [12] .

There are no meta-analyses or systematic reviews of traction as treatment for the specific diagnosis of cervical radiculopathy. A 1995 systematic review of traction for patients with neck or back pain was unable to determine if traction was effective, mainly because the included studies had methodologic flaws, including insufficient power [13] . Similarly, a 2006 systematic review of traction for patients with mechanical neck disorders reported that the evidence of benefit for traction was inconclusive, due to low methodologic quality of the trials [14] .

The 2006 systematic review suggested that intermittent as opposed to continuous traction may be beneficial, although the evidence came from low-quality trials [14] . In addition, an early observational study found that intermittent cervical traction was associated with symptom relief in some patients with cervical radiculopathy [15] .

Traction should not be used unless neuroimaging has been performed, and should be discontinued if symptoms worsen with the application of distracting force. Traction is not recommended in the presence of spinal cord compression or large disc protrusion.

We generally do not prescribe cervical traction as initial therapy for patients with cervical radiculopathy. Nevertheless, cervical traction is a reasonably safe alternative for patients with persistent or refractory pain who do not want epidural glucocorticoid injections or surgery.

Refractory or progressive symptoms — Some patients with cervical radiculopathy have symptoms that are refractory to conservative treatments, and a smaller number develop progressive symptoms.

Clinical reevaluation should be performed with careful assessment for motor weakness and myelopathic findings in patients who have not improved after six to eight weeks of conservative treatment or in those who have progressive symptoms. Neuroimaging and electrodiagnostic studies are indicated, particularly if not done initially, and repeat electrodiagnostic studies may be needed if an initial study was unrevealing.

Reevaluation, neuroimaging, and electrodiagnostic studies are important to ensure that the initial diagnosis of radiculopathy is correct, and to assess for evidence of progressive neurologic deficit that could be an indication for surgery. (See "Clinical features and diagnosis of cervical radiculopathy", section on Diagnosis, and see "Indications for surgery" below).

There are no clinical trials that clearly establish whether more aggressive interventions, such as epidural steroid injections or surgery, are beneficial for patients who are refractory to conservative therapy or beneficial for those who have progressive symptoms or signs. (See "Epidural glucocorticoid injections" below and see "Surgery" below).

Nevertheless, many experts consider unremitting radicular pain despite six to eight weeks of conservative treatment, progressive motor weakness, or signs and symptoms of myelopathy (in the context of imaging studies showing a surgically remediable anatomic spinal cord compression) as indications for surgery. (See "Indications for surgery" below).

Symptoms of cervical radiculopathy recur in up to one-third of patients after initial improvement [2] . Conservative management should be reemployed when symptoms recur, unless a significant motor deficit or myelopathy is present. (See "Conservative therapy" above).

Epidural glucocorticoid injections — Patients with persistent cervical radicular pain, with or without radiculopathy, may benefit from epidural glucocorticoid injections [16-18] . Supporting evidence comes from small prospective [19,20] and retrospective [21,22] observational studies, which suggest that transforaminal or interlaminar epidural glucocorticoid injections provide substantial relief lasting six months or longer in 40 to 60 percent of patients. However, these observational studies cannot distinguish between improvement due to treatment or to the natural history of cervical radiculopathy.

Unlike lumbar injections, fluoroscopic guidance is mandatory for cervical epidural injections. The needle should remain in contact with the posterior wall of the intervertebral foramen; this position avoids contact with the nerve root, spinal nerve, and associated vessels [16,23] . Test injections of small amounts of nonionic contrast can confirm entry of the needle into the epidural space and demonstrate whether the injectate spreads onto the injured nerve root(s). Test contrast injections can also reveal inadvertent intraarterial injection. Preliminary data suggest that guidance with computed tomography (CT) fluoroscopy may provide improved anatomic detail compared with standard fluoroscopy [23] .

Serious complications of cervical epidural glucocorticoid injections are rare, but the exact incidence of such complications is unknown. There have been well-documented reports of death or severe neurologic sequelae from brainstem hemorrhage and infarction, and from cerebellar and spinal cord infarction [24] . The exact cause of neurologic injury is unknown in most reported cases, but possible mechanisms include embolism of glucocorticoid particles due to inadvertent injection into a vertebral or a radicular artery, arterial dissection, and needle-induced vasospasm [16,24,25] .

In one autopsy study, death due to a stroke with massive cerebral edema occurred following dissection of and subsequent thrombus formation in the vertebral artery during a C7 epidural injection [26] .

In another report, death due to extensive brainstem and thalamic infarction occurred following epidural injection despite the use of fluoroscopic guidance; at autopsy, there was a small area of hemorrhage within the adventitia of the left vertebral artery but no dissection [27] .

A physician survey evaluating complications of cervical transforaminal epidural glucocorticoid injections found that all neurologic complications occurred after injections of particulate glucocorticoids (eg, betamethasone, methylprednisolone, triamcinolone), whereas none occurred after injections of the nonparticulate glucocorticoid dexamethasone [24] .

For patients with confirmed cervical radiculopathy who have severe or disabling pain despite a reasonable course (six to eight weeks) of conservative therapy, and who do not have a progressively worsening neurologic deficit, we suggest the use of epidural steroid injections rather than surgery, provided that the injections are performed by experienced centers and interventionalists under fluoroscopic guidance using test contrast injection to identify accidental vessel injection. Use of a nonparticulate glucocorticoid such as dexamethasone may reduce the risk of ischemic complications.

The role of epidural glucocorticoid injections in patients with low back pain is discussed elsewhere. (See "Subacute and chronic low back pain: Nonsurgical interventional treatment").

SURGERY — The benefit of surgery for the treatment of cervical radiculopathy has not been clearly established, and data from controlled trials are sparse.

A 2001 systematic review from the Cochrane database [28] identified only a single small randomized trial of surgery versus conservative management for the treatment of cervical radiculopathy that met criteria for inclusion [29] . This study evaluated 81 patients with clinical and radiological signs of nerve root compression lasting more than three months [29] . Patients were randomly assigned to treatment with either surgery (anterior cervical discectomy), physiotherapy, or immobilization with a hard cervical collar. Those with spinal cord compression, whiplash, and other serious associated diseases were excluded.

The following results were reported [29] :

At four months, the surgically treated patients showed greater improvement in pain, muscle strength, and sensory loss than the nonsurgically treated patients
At one year, there was no significant difference in pain or sensory disturbances between the surgical and nonsurgical treatment groups, although the surgical group had a small advantage in muscle strength [29]

In contrast to this single randomized trial, two prospective observational studies suggest that surgery is beneficial for patients with cervical radiculopathy, with substantial improvement in pain and weakness in approximately 75 percent of patients [30,31] . These studies did not document the percentage of patients with complete pain resolution. Earlier observational studies had found that improved outcome with surgery was more likely in patients with radicular pain than those without radicular pain [3] .

Similar to cervical radiculopathy, the benefit of surgery for the treatment of cervical myelopathy has not been established, and data are sparse. A few small randomized controlled trials have found that surgery did not improve long-term outcome compared with conservative management [28,32,33] . However, surgery was beneficial in one of these studies at two years for a subgroup of 12 patients who had severe disability at baseline [32] .

Indications for surgery — Proposed indications for surgery in patients with cervical radiculopathy are unremitting radicular pain despite six to eight weeks of conservative treatment, progressive motor weakness, or the presence of myelopathy [3] .

More stringent indications for surgery have also been proposed that require the presence of all of the following criteria [4] :

• Symptoms and signs of cervical radiculopathy (ie, nerve root dysfunction, pain, or both)
• Evidence of cervical nerve root compression by magnetic resonance imaging (MRI) or computed tomography (CT) myelography at the appropriate side and level(s) to explain the clinical symptoms and signs
• Persistence of radicular pain despite nonsurgical therapy for at least six to 12 weeks or progressive motor weakness that impairs function

In patients with myelopathy, the more stringent indications for surgery require the following [4] :

Neuroimaging evidence of cervical spinal cord compression

Objective motor or sensory signs of myelopathy
We suggest surgery only for patients who meet these stringent criteria for cervical radiculopathy or myelopathy. As part of a presurgical evaluation, flexion and extension plain films are necessary to assess the stability of the cervical spine [34] . There are two main surgical approaches: anterior cervical discectomy and fusion, and posterior laminoforaminotomy. Artificial disc replacement is a surgical strategy that we regard as investigational.

Anterior cervical discectomy and fusion — Anterior cervical discectomy and fusion (ACDF) is the most commonly used decompressive procedure in the cervical spine.

The advantages of ACDF are that it requires little manipulation of the spinal cord or cervical roots and allows for removal of both lateral and midline disc herniation and osteophytes. Disadvantages include a small risk of damage to the carotid artery, trachea, esophagus, or recurrent laryngeal nerve, and alteration of the architecture of the spine. Some authors suggest that ACDF may lead to further degenerative changes [36] .

Posterior laminoforaminotomy — A posterior surgical approach may be used when a single lateral disc herniation is present. A posterior laminoforaminotomy (POF) is frequently performed, although many variations have been described. Midline pathology is not easily accessible with POF. As a result, this approach is not useful in patients with midline disc herniation or osteophytes.

The main advantages of POF are that it involves no alteration of the architecture of the cervical spine and no risk of damage to anterior neck structures. The main disadvantage is that there may be more postoperative pain with POF than with ACDF, although this is controllable with medications [34,36,37] .

Artificial disc replacement — Artificial disc replacement surgery is a developing technique for the treatment of single level cervical radiculopathy that has been used in situations when an ACDF would otherwise be appropriate. One randomized trial with 115 patients found that artificial disc replacement compared favorably to ACDF at two-year follow-up [35] . There are, however, few rigorous studies, and the long-term durability of the devices that have been developed is not known.

Complications — Complications of surgery for cervical radiculopathy and/or myelopathy are uncommon, but include spinal cord injury (<1 percent of cases), nerve root injury (2 to 3 percent), and instrumentation or device failure (≤4 percent). Additional complications seen with anterior surgical approaches in retrospective studies include transient dysphagia (10 percent), recurrent laryngeal nerve injury (2 to 3 percent), esophageal perforation (<1 percent), and vertebral artery injury (<1 percent) [4,30,31,38-41] .

INFORMATION FOR PATIENTS — Educational materials on this topic are available for patients. (See "Patient information: Neck pain"). We encourage you to print or e-mail this topic, or to refer patients to our public web site www.uptodate.com/patients, which includes this and other topics.

SUMMARY AND RECOMMENDATIONS — The optimum treatment of compressive cervical radiculopathy is the subject of continued debate, and there is little convincing evidence that any treatment improves upon the natural history of the condition.

Limited data suggest that most patients with compressive cervical radiculopathy improve without specific treatment. (See "Prognosis" above).
For patients with cervical radiculopathy who have clear radicular pain and symptoms of paresthesia, numbness, or nonprogressive neurologic deficits, we suggest conservative therapy as initial treatment (Grade 2C). We typically start treatment with oral analgesics (eg, NSAIDs) and avoidance of provocative activities, and add a short course of oral prednisone if pain is severe. Once the pain is tolerable, we initiate physical therapy with exercise and gradual mobilization. (See "Conservative therapy" above).

Symptoms of cervical radiculopathy may recur in up to one-third of patients after initial improvement. Conservative management should be reemployed if symptoms recur unless a significant motor deficit or myelopathy is present. (See "Refractory or progressive symptoms" above).


For patients with confirmed cervical radiculopathy who have severe or disabling pain despite a reasonable course of conservative therapy, and who do not have a progressively worsening neurologic deficit, we suggest the use of epidural steroid injections rather than surgery (Grade 2C). The injections should be performed by experienced centers and interventionalists under fluoroscopic guidance using test contrast injection to identify acciental vessel injection. (See "Epidural glucocorticoid injections" above).

The benefit of surgery for the treatment of cervical radiculopathy has not been clearly established, and data from controlled trials are sparse. For patients with cervical radiculopathy who have all of the following conditions, we suggest surgery rather than nonsurgical therapy (Grade 2B):

- Symptoms and signs of cervical radiculopathy


- Cervical nerve root compression by MRI or CT myelography at the appropriate side and level(s)

- Persistence of radicular pain despite nonsurgical therapy for at least 6 to 12 weeks, or progressive motor weakness that impairs function (See "Surgery" above)

As with cervical radiculopathy, the benefit of surgery for the treatment of cervical myelopathy has not been established, and controlled trial data are sparse. For patients with neuroimaging evidence of cervical spinal cord compression, objective motor or sensory signs of myelopathy, and progressive weakness or disability, we suggest surgery rather than nonsurgical therapy (Grade 2B). (See "Surgery" above).