Treatment of cervical radiculopathy
- Jenice Robinson, MD
Jenice Robinson, MD
- Assistant Professor Case Medical Center
- Neuroscience Institute
- Milind J Kothari, DO
Milind J Kothari, DO
- Professor of Neurology
- Penn State College of Medicine
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".)
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 . 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.
- LEES F, TURNER JW. NATURAL HISTORY AND PROGNOSIS OF CERVICAL SPONDYLOSIS. Br Med J 1963; 2:1607.
- Radhakrishnan K, Litchy WJ, O'Fallon WM, Kurland LT. Epidemiology of cervical radiculopathy. A population-based study from Rochester, Minnesota, 1976 through 1990. Brain 1994; 117 ( Pt 2):325.
- Ellenberg MR, Honet JC, Treanor WJ. Cervical radiculopathy. Arch Phys Med Rehabil 1994; 75:342.
- Carette S, Fehlings MG. Clinical practice. Cervical radiculopathy. N Engl J Med 2005; 353:392.
- Kuijper B, Tans JT, Beelen A, et al. Cervical collar or physiotherapy versus wait and see policy for recent onset cervical radiculopathy: randomised trial. BMJ 2009; 339:b3883.
- MARTIN GM, CORBIN KB. An evaluation of conservative treatment for patients with cervical disk syndrome. Arch Phys Med Rehabil 1954; 35:87.
- Honet JC, Puri K. Cervical radiculitis: treatment and results in 82 patients. Arch Phys Med Rehabil 1976; 57:12.
- Arnasson O, Carlsson CA, Pellettieri L. Surgical and conservative treatment of cervical spondylotic radiculopathy and myelopathy. Acta Neurochir (Wien) 1987; 84:48.
- Saal JS, Saal JA, Yurth EF. Nonoperative management of herniated cervical intervertebral disc with radiculopathy. Spine (Phila Pa 1976) 1996; 21:1877.
- Fast A, Parikh S, Marin EL. The shoulder abduction relief sign in cervical radiculopathy. Arch Phys Med Rehabil 1989; 70:402.
- Goldie I, Landquist A. Evaluation of the effects of different forms of physiotherapy in cervical pain. Scand J Rehabil Med 1970; 2:117.
- Klaber Moffett JA, Hughes GI, Griffiths P. An investigation of the effects of cervical traction. Part 1: Clinical effectiveness. Clin Rehabil 1990; 4:205.
- Pain in the neck and arm: a multicentre trial of the effects of physiotherapy, arranged by the British Association of Physical Medicine. Br Med J 1966; 1:253.
- van der Heijden GJ, Beurskens AJ, Koes BW, et al. The efficacy of traction for back and neck pain: a systematic, blinded review of randomized clinical trial methods. Phys Ther 1995; 75:93.
- Graham N, Gross AR, Goldsmith C, Cervical Overview Group. Mechanical traction for mechanical neck disorders: a systematic review. J Rehabil Med 2006; 38:145.
- Colachis SC Jr, Strohm BR. Effect of duration of intermittent cervical traction on vertebral separation. Arch Phys Med Rehabil 1966; 47:353.
- Engel A, King W, MacVicar J, Standards Division of the International Spine Intervention Society. The effectiveness and risks of fluoroscopically guided cervical transforaminal injections of steroids: a systematic review with comprehensive analysis of the published data. Pain Med 2014; 15:386.
- Cicala RS, Thoni K, Angel JJ. Long-term results of cervical epidural steroid injections. Clin J Pain 1989; 5:143.
- Slipman CW, Lipetz JS, Jackson HB, et al. Therapeutic selective nerve root block in the nonsurgical treatment of atraumatic cervical spondylotic radicular pain: a retrospective analysis with independent clinical review. Arch Phys Med Rehabil 2000; 81:741.
- Bush K, Hillier S. Outcome of cervical radiculopathy treated with periradicular/epidural corticosteroid injections: a prospective study with independent clinical review. Eur Spine J 1996; 5:319.
- Vallée JN, Feydy A, Carlier RY, et al. Chronic cervical radiculopathy: lateral-approach periradicular corticosteroid injection. Radiology 2001; 218:886.
- Anderberg L, Annertz M, Persson L, et al. Transforaminal steroid injections for the treatment of cervical radiculopathy: a prospective and randomised study. Eur Spine J 2007; 16:321.
- Rathmell JP, Benzon HT, Dreyfuss P, et al. Safeguards to Prevent Neurologic Complications after Epidural Steroid Injections: Consensus Opinions from a Multidisciplinary Working Group and National Organizations. Anesthesiology 2015.
- Benzon HT, Huntoon MA, Rathmell JP. Improving the safety of epidural steroid injections. JAMA 2015; 313:1713.
- Rathmell JP, Aprill C, Bogduk N. Cervical transforaminal injection of steroids. Anesthesiology 2004; 100:1595.
- Wagner AL. CT fluoroscopic-guided cervical nerve root blocks. AJNR Am J Neuroradiol 2005; 26:43.
- Kranz PG, Raduazo PA. Technique for CT fluoroscopy-guided cervical interlaminar steroid injections. AJR Am J Roentgenol 2012; 198:675.
- Malhotra G, Abbasi A, Rhee M. Complications of transforaminal cervical epidural steroid injections. Spine (Phila Pa 1976) 2009; 34:731.
- Scanlon GC, Moeller-Bertram T, Romanowsky SM, Wallace MS. Cervical transforaminal epidural steroid injections: more dangerous than we think? Spine (Phila Pa 1976) 2007; 32:1249.
- FDA requires label changes to warn of rare but serious neurologic problems after epidural corticosteroid injections for pain. www.fda.gov/Drugs/DrugSafety/ucm394280.htm (Accessed on April 28, 2014).
- Santiago-Palma J, Vallejo R, Kornick C, Barna S. Are cervical nerve root blocks "safe and effective"? AJNR Am J Neuroradiol 2005; 26:2434.
- Mendelson J, Muppidi S, Silberstein S. Multiple intracerebral hemorrhages after cervical epidural injections. Neurology 2008; 70:2415.
- Rozin L, Rozin R, Koehler SA, et al. Death during transforaminal epidural steroid nerve root block (C7) due to perforation of the left vertebral artery. Am J Forensic Med Pathol 2003; 24:351.
- Ziai WC, Ardelt AA, Llinas RH. Brainstem stroke following uncomplicated cervical epidural steroid injection. Arch Neurol 2006; 63:1643.
- Nikolaidis I, Fouyas IP, Sandercock PA, Statham PF. Surgery for cervical radiculopathy or myelopathy. Cochrane Database Syst Rev 2010; :CD001466.
- Persson LC, Moritz U, Brandt L, Carlsson CA. Cervical radiculopathy: pain, muscle weakness and sensory loss in patients with cervical radiculopathy treated with surgery, physiotherapy or cervical collar. A prospective, controlled study. Eur Spine J 1997; 6:256.
- Peolsson A, Söderlund A, Engquist M, et al. Physical function outcome in cervical radiculopathy patients after physiotherapy alone compared with anterior surgery followed by physiotherapy: a prospective randomized study with a 2-year follow-up. Spine (Phila Pa 1976) 2013; 38:300.
- Hacker RJ, Cauthen JC, Gilbert TJ, Griffith SL. A prospective randomized multicenter clinical evaluation of an anterior cervical fusion cage. Spine (Phila Pa 1976) 2000; 25:2646.
- Casha S, Fehlings MG. Clinical and radiological evaluation of the Codman semiconstrained load-sharing anterior cervical plate: prospective multicenter trial and independent blinded evaluation of outcome. J Neurosurg 2003; 99:264.
- Bednarík J, Kadanka Z, Vohánka S, et al. The value of somatosensory- and motor-evoked potentials in predicting and monitoring the effect of therapy in spondylotic cervical myelopathy. Prospective randomized study. Spine (Phila Pa 1976) 1999; 24:1593.
- Kadanka Z, Bednarík J, Vohánka S, et al. Conservative treatment versus surgery in spondylotic cervical myelopathy: a prospective randomised study. Eur Spine J 2000; 9:538.
- Storm PB, Chou D, Tamargo RJ. Surgical management of cervical and lumbosacral radiculopathies: indications and outcomes. Phys Med Rehabil Clin N Am 2002; 13:735.
- Wirth FP, Dowd GC, Sanders HF, Wirth C. Cervical discectomy. A prospective analysis of three operative techniques. Surg Neurol 2000; 53:340.
- Zeidman SM, Ducker TB. Posterior cervical laminoforaminotomy for radiculopathy: review of 172 cases. Neurosurgery 1993; 33:356.
- Moatz B, Tortolani PJ. Cervical disc arthroplasty: Pros and cons. Surg Neurol Int 2012; 3:S216.
- Gao Y, Liu M, Li T, et al. A meta-analysis comparing the results of cervical disc arthroplasty with anterior cervical discectomy and fusion (ACDF) for the treatment of symptomatic cervical disc disease. J Bone Joint Surg Am 2013; 95:555.
- Edwards CC 2nd, Heller JG, Murakami H. Corpectomy versus laminoplasty for multilevel cervical myelopathy: an independent matched-cohort analysis. Spine (Phila Pa 1976) 2002; 27:1168.
- Fountas KN, Kapsalaki EZ, Nikolakakos LG, et al. Anterior cervical discectomy and fusion associated complications. Spine (Phila Pa 1976) 2007; 32:2310.
- Inamasu J, Guiot BH. Iatrogenic vertebral artery injury. Acta Neurol Scand 2005; 112:349.
- Neo M, Fujibayashi S, Miyata M, et al. Vertebral artery injury during cervical spine surgery: a survey of more than 5600 operations. Spine (Phila Pa 1976) 2008; 33:779.
- Compressive radiculopathy
- - Triage
- Noncompressive radiculopathy
- NONSURGICAL THERAPY
- Conservative therapy
- - Oral glucocorticoids
- - Exercise therapy
- - Cervical traction
- - Refractory or progressive symptoms
- Epidural glucocorticoid injections
- Indications for surgery
- Anterior cervical discectomy and fusion
- Posterior laminoforaminotomy
- Artificial disc replacement
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS