Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Cervical Radiculopathy Treatment & Management

  • Author: Gerard A Malanga, MD; Chief Editor: Sherwin SW Ho, MD  more...
 
Updated: Oct 08, 2015
 

Acute Phase

Rehabilitation Program

Physical Therapy

Little is known about the natural history of cervical radiculopathy, and there are few controlled randomized studies comparing operative with nonoperative treatment for this condition. A best-evidence synthesis by the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders concluded that there is not clear evidence that surgical treatment of cervical radiculopathy provides better long-term outcomes than nonoperative measures.[14]

Initial treatment should be directed at reducing pain and inflammation. The treatment can begin with local icing, NSAIDs, and measures that reduce the forces compressing the nerve root: relative rest; avoiding positions that increase arm and/or neck symptoms; manual traction; and, if necessary, mechanical traction.

In addition, a cervical collar can be used for patient comfort and some support. A cervical pillow at night can be helpful in maintaining the neck in a neutral position and limiting head positions that cause narrowing of the neural foramen. Manual and, if necessary, mechanical traction can be used to reduce radicular symptoms by decreasing foraminal compression and intradiscal pressures.

Kuijper et al found that, with patients in the early phase of cervical radiculopathy, the use of a semi-hard cervical collar and rest for 3-6 weeks, or physiotherapy accompanied by home exercises for 6 weeks, reduced neck and arm pain substantially compared with a wait-and-see policy.[27] In a randomized controlled trial in 205 patients with symptoms and signs of cervical radiculopathy of less than 1 month's duration, neck pain did not decrease significantly in the first 6 weeks, whereas the cervical collar and rest resulted in a 17-mm reduction on the visual analogue scale and physiotherapy resulted in a decrease of 14 mm. The neck disability index showed a significant change with the use of the collar and rest and a nonsignificant effect with physiotherapy and home exercises, compared with a wait-and-see policy.[27]

Most studies of modalities such as electrical stimulation have been uncontrolled. Although these modalities appear to be helpful in reducing the associated muscle pain and spasm that are often found with cervical problems, they should be limited to the initial pain control phase of treatment.

Other Treatment

Cervical epidural steroids have been used in patients whose conditions have not had satisfactory responses to medications, traction, and a well-designed physical therapy program.[28, 29] When properly performed by experienced physicians under fluoroscopic guidance, a significant number of patients' cervical radiculopathies respond to cervical epidural steroids when other treatments have not helped. The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders found support in the literature for short-term symptomatic improvement of radicular symptoms with epidural corticosteroids,[14] while the American Society of Interventional Pain Physicians found moderate evidence that cervical interlaminar epidural steroid injections can provide short-term and long-term improvement in cervical radiculopathy.[30]

Studies have reported favorable results with translaminar and transforaminal epidural corticosteroid injections. These studies have shown up to 60% long-term relief of radicular pain and neck pain and a return of the patients to their usual activities. Complications from these procedures are rare, but some case studies show that complications can be catastrophic and include severe sequelae from spinal cord or brainstem infarction. SNRBs can be helpful in patients with electrodiagnostically demonstrated single-root lesions.[31] This has rarely been necessary in the author's experience. In general, the vast majority of patients with cervical radiculopathy can be successfully managed without the need for injections. They should be reserved for the patient with persistent radicular pain who has not responded to a course of oral medications, active physical therapy, and relative rest. There is no indication for performing these injections in a “series”. In the majority of casesonly1-2injectionsarenecessary to reduce the nerve root inflammation and progress the patient on an active exercise program.

Engel et al conducted a systematic literature review to study the effectiveness and risks of fluoroscopically guided cervical transforaminal injection of corticosteroids in the treatment of radicular pain.[32] The researchers found evidence that suggests that approximately 50% of patients experience 50% relief of radicular pain for at least 4 weeks after cervical transforaminal injection of steroids (CTFIS), and the intervention may have surgery-sparing effects. The literature also contained 21 articles that report complications, including 13 deaths and many catastrophic neurological injuries. The authors concluded that in patients with cervical radicular pain, fluoroscopically guided CTFIS may be effective in easing pain and reducing need for surgery. However, the evidence of effectiveness is of very low quality, and the benefits of the procedure are compromised by the risks of serious complications.[32]

Acupuncture has been used to treat radicular pain with some success. This treatment can be considered if pain control is not achieved with physical therapy and medications or in conjunction with these treatments. In addition, acupuncture can be tried instead of cervical epidural injection in patients who are hesitant or who do not wish to proceed with this procedure. Evidence-based treatment guidelines from the Council of Acupuncture and Oriental Medicine Associations recommend acupuncture and electroacupuncture as appropriate for patients with cervical radiculopathy.[33]

A double-blind sham-controlled randomized clinical trial found that pulsed radiofrequency treatment of the cervical dorsal root ganglion may provide pain relief for a limited number of carefully selected patients with chronic cervical radicular pain.[34]

Next

Recovery Phase

Rehabilitation Program

Physical Therapy

Once pain and inflammation are controlled, the patient's therapy should be progressed to the restoration of full ROM and flexibility of the neck and shoulder girdle muscles. Various soft-tissue mobilization techniques can be helpful to stretch the noncontractile elements of the soft tissues. Instruct patients on the proper stretching techniques, which they can complete 1-2 times per day. Gentle prolonged stretching is recommended. Stretching is best completed after a warm-up activity (eg, using an exercise bike or brisk walking).

As ROM and flexibility improve, cervical muscle strengthening should begin with isometric strengthening in a single plane and include flexion, extension, lateral bending, and rotation. In addition, the scapular stabilizing muscles, including the trapezius, rhomboids, serratus anterior, and latissimus dorsi, should be strengthened with progressive isotonic activity. Strength training can progress to manual resistive cervical stabilization exercises in various planes. All exercises should be performed without pain, although some degree of postexercise soreness can be expected.

Isokinetic exercises of the neck and upper extremities are not functional and are not recommended as a strengthening tool. In contrast, isolated strengthening of individual muscles that have become weak as a result of the radiculopathy is important before beginning more complex activities involving multiple muscles. In the initial phases of treatment, strengthening should be limited to isometric exercises in the involved extremity. Once all radicular symptoms have resolved, then progressive isotonic strengthening may begin. This should initially stress low weight and high repetitions (15-20 repetitions). Closed kinetic chain activities can be very helpful in rehabilitating weak shoulder girdle muscles. However, a multicenter randomized controlled trial found no significant difference with the addition of specific neck stabilization exercises to a program of general neck advice and exercise.[35]

Patients should be encouraged to maintain their level of cardiovascular fitness as much as possible throughout the rehabilitation process. This is accomplished by alternative conditioning that does not increase patients' symptoms as they progress through the rehabilitation process. Cardiovascular conditioning should be started as soon as possible to prevent deconditioning. These exercises also serve as an excellent warm-up before a stretching program. Finally, the patient should be told that these exercises (stretches and strengthening) should be continued indefinitely with the goal of preventing recurrences.

Other Treatment (Injection, manipulation, etc.)

Spinal manipulation is not indicated in patients with frank radiculopathy. An application for manual therapy only may exist in patients with radicular symptoms.

Previous
Next

Maintenance Phase

Rehabilitation Program

Physical Therapy

Patients should be independent in a stretching and strengthening program and continue with these exercises under the supervision of an athletic trainer initially and then completely on their own. Emphasis is placed on stretching the anterior neck and shoulder muscle groups and strengthening the neck and scapular muscles. Once the goals of physical therapy have been met, proper head and neck positioning is then maintained in everyday activity and sports.

Surgical Intervention

Patients whose condition fails to improve with a comprehensive rehabilitation program and selective injections should be offered a surgical evaluation. Generally, patients should show progressive improvement over the first 6-8 weeks with conservative treatment. If there is no significant improvement in this time frame, consider a surgical evaluation.

Early surgical intervention is recommended in any athlete found to have cervical instability. In addition, refer patients with a progressive neurologic deficit or long tract signs to a spine surgeon.

Surgery is best indicated in patients with radiculopathy with clearly identified pathology — for example, single-level disc herniation that correlates with the findings on history and physical examination. Procedures include laminectomy, discectomy, corpectomy, and fusion. With appropriate indications, surgery can result in resolution of symptoms and excellent outcomes in the majority of patients.

A study that compared outcomes between the concepts of an artificial disc to treatment with anterior cervical decompression and fusion found that artificial disc replacement did not result in better outcome compared to treatment with anterior cervical decompression and fusion 2 years after surgery.[36]

 

Previous
 
 
Contributor Information and Disclosures
Author

Gerard A Malanga, MD Founder and Partner, New Jersey Sports Medicine, LLC and New Jersey Regenerative Institute; Director of Research, Atlantic Health; Clinical Professor, Department of Physical Medicine and Rehabilitation, University of Medicine and Dentistry of New Jersey-New Jersey Medical School; Fellow, American College of Sports Medicine

Gerard A Malanga, MD is a member of the following medical societies: Alpha Omega Alpha, American Institute of Ultrasound in Medicine, North American Spine Society, International Spine Intervention Society, American Academy of Physical Medicine and Rehabilitation, American College of Sports Medicine

Disclosure: Received honoraria from Cephalon for speaking and teaching; Received honoraria from Endo for speaking and teaching; Received honoraria from Genzyme for speaking and teaching; Received honoraria from Prostakan for speaking and teaching; Received consulting fee from Pfizer for speaking and teaching.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Sherwin SW Ho, MD Associate Professor, Department of Surgery, Section of Orthopedic Surgery and Rehabilitation Medicine, University of Chicago Division of the Biological Sciences, The Pritzker School of Medicine

Sherwin SW Ho, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Arthroscopy Association of North America, Herodicus Society, American Orthopaedic Society for Sports Medicine

Disclosure: Received consulting fee from Biomet, Inc. for speaking and teaching; Received grant/research funds from Smith and Nephew for fellowship funding; Received grant/research funds from DJ Ortho for course funding; Received grant/research funds from Athletico Physical Therapy for course, research funding; Received royalty from Biomet, Inc. for consulting.

Additional Contributors

Janos P Ertl, MD Assistant Professor, Department of Orthopedic Surgery, Indiana University School of Medicine; Chief of Orthopedic Surgery, Wishard Hospital; Chief, Sports Medicine and Arthroscopy, Indiana University School of Medicine

Janos P Ertl, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, Hungarian Medical Association of America, Sierra Sacramento Valley Medical Society

Disclosure: Nothing to disclose.

Acknowledgements

Michael A Romello, MD Staff Physician, Department of Physical Medicine and Rehabilitation, Kessler Institute for Rehabilitation, University of Medicine and Dentistry of New Jersey, New Jersey Medical School

Disclosure: Nothing to disclose.

References
  1. Bogduk N, Twomey LT. Clinical Anatomy of the Lumbar Spine. 2nd ed. Edinburgh, UK: Churchill Livingstone Inc; 1991.

  2. Ellenberg MR, Honet JC, Treanor WJ. Cervical radiculopathy. Arch Phys Med Rehabil. 1994 Mar. 75(3):342-52. [Medline].

  3. Malanga GA. The diagnosis and treatment of cervical radiculopathy. Med Sci Sports Exerc. 1997 Jul. 29(7 suppl):S236-45. [Medline].

  4. 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 Apr. 117(pt 2):325-35. [Medline].

  5. van Gijn J, Reiners K, Toyka KV, Braakman R. Management of cervical radiculopathy. Eur Neurol. 1995. 35(6):309-20. [Medline].

  6. White AA, Panjabi MM. Clinical Biomechanics of the Spine. 2nd ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 1990. 102.

  7. Parminder SP. Management of cervical pain. Delisa JA, Gans BM, eds. Rehabilitation Medicine: Principles and Practice. 3rd ed. Philadelphia, Pa: Lippincott Williams & Wilkins; 1988. 753.

  8. Murphey F, Simmons JC, Brunson B. Chapter 2. Ruptured cervical discs, 1939 to 1972. Clin Neurosurg. 1973. 20:9-17. [Medline].

  9. Shelerud RA, Paynter KS. Rarer causes of radiculopathy: spinal tumors, infections, and other unusual causes. Phys Med Rehabil Clin N Am. 2002 Aug. 13(3):645-96. [Medline].

  10. Soubrier M, Dubost JJ, Tournadre A, et al. Cervical radiculopathy as a manifestation of giant cell arteritis. Joint Bone Spine. 2002 May. 69(3):316-8. [Medline].

  11. Tong HC, Haig AJ, Yamakawa K. The Spurling test and cervical radiculopathy. Spine. 2002 Jan 15. 27(2):156-9. [Medline].

  12. Fryholm R. Cervical nerve root compression resulting from disc degeneration and root-sleeve fibrosis. Acta Chiru. Scand. 1951. 160(suppl):1-149.

  13. Letchuman R, Gay RE, Shelerud RA, VanOstrand LA. Are tender points associated with cervical radiculopathy?. Arch Phys Med Rehabil. 2005 Jul. 86(7):1333-7. [Medline].

  14. Nordin M, Carragee EJ, Hogg-Johnson S, et al for the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Assessment of neck pain and its associated disorders: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine. 2008 Feb 15. 33(4 suppl):S101-22. [Medline].

  15. Furusawa N, Baba H, Miyoshi N, et al. Herniation of cervical intervertebral disc: immunohistochemical examination and measurement of nitric oxide production. Spine. 2001 May 15. 26(10):1110-6. [Medline].

  16. Kang JD, Stefanovic-Racic M, McIntyre LA, Georgescu HI, Evans CH. Toward a biochemical understanding of human intervertebral disc degeneration and herniation. Contributions of nitric oxide, interleukins, prostaglandin E2, and matrix metalloproteinases. Spine. 1997 May 15. 22(10):1065-73. [Medline].

  17. Viikari-Juntura E, Porras M, Laasonen EM. Validity of clinical tests in the diagnosis of root compression in cervical disc disease. Spine. 1989 Mar. 14(3):253-7. [Medline].

  18. Anderberg L, Annertz M, Rydholm U, Brandt L, Säveland H. Selective diagnostic nerve root block for the evaluation of radicular pain in the multilevel degenerated cervical spine. Eur Spine J. 2006 Jun. 15(6):794-801. [Medline].

  19. Sasso RC, Macadaeg K, Nordmann D, Smith M. Selective nerve root injections can predict surgical outcome for lumbar and cervical radiculopathy: comparison to magnetic resonance imaging. J Spinal Disord Tech. 2005 Dec. 18(6):471-8. [Medline].

  20. Anderberg L, Annertz M, Brandt L, Säveland H. Selective diagnostic cervical nerve root block--correlation with clinical symptoms and MRI-pathology. Acta Neurochir (Wien). 2004 Jun. 146(6):559-65; discussion 565. [Medline].

  21. Huston CW, Slipman CW. Diagnostic selective nerve root blocks: indications and usefulness. Phys Med Rehabil Clin N Am. 2002 Aug. 13(3):545-65. [Medline].

  22. Chesnut RM, Abitbol JJ, Garfin SR. Surgical management of cervical radiculopathy. Indication, techniques, and results. Orthop Clin North Am. 1992 Jul. 23(3):461-74. [Medline].

  23. Johnson EW, ed. Practical Electromyography. 2nd ed. Baltimore, Md: Lippincott Williams & Wilkins; 1979. 229-45.

  24. American College of Radiology. ACR Appropriateness Criteria: chronic neck pain. National Guideline Clearinghouse. Available at http://guideline.gov/summary/summary.aspx?doc_id=8297. Accessed: March 24, 2009.

  25. Cantu RC. Cervical spine injuries in the athlete. Semin Neurol. 2000. 20(2):173-8. [Medline].

  26. Boden SD, McCowin PR, Davis DO, Dina TS, Mark AS, Wiesel S. Abnormal magnetic-resonance scans of the cervical spine in asymptomatic subjects. A prospective investigation. J Bone Joint Surg Am. 1990 Sep. 72(8):1178-84. [Medline]. [Full Text].

  27. Kuijper B, Tans JT, Beelen A, Nollet F, de Visser M. Cervical collar or physiotherapy versus wait and see policy for recent onset cervical radiculopathy: randomised trial. BMJ. 2009 Oct 7. 339:b3883. [Medline]. [Full Text].

  28. Cohen SP, Gupta A, Strassels SA, Christo PJ, Erdek MA, Griffith SR, et al. Effect of MRI on Treatment Results or Decision Making in Patients With Lumbosacral Radiculopathy Referred for Epidural Steroid Injections: A Multicenter, Randomized Controlled Trial. Arch Intern Med. 2011 Dec 12. [Medline].

  29. Friedly J, Deyo RA. Imaging and Uncertainty in the Use of Lumbar Epidural Steroid Injections: Comment on "Effect of MRI on Treatment Results or Decision Making in Patients With Lumbosacral Radiculopathy Referred for Epidural Steroid Injections". Arch Intern Med. 2011 Dec 12. [Medline].

  30. American Society of Interventional Pain Physicians. Interventional techniques: evidence-based practice guidelines in the management of chronic spinal pain. National Guideline Clearinghouse. Available at http://guideline.gov/summary/summary.aspx?doc_id=10531. Accessed: March 25, 2009.

  31. Pobiel RS, Schellhas KP, Eklund JA, Golden MJ, Johnson BA, Chopra S, et al. Selective cervical nerve root blockade: prospective study of immediate and longer term complications. AJNR Am J Neuroradiol. 2009 Mar. 30(3):507-11. [Medline].

  32. Engel A, King W, MacVicar J. 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 Mar. 15(3):386-402. [Medline].

  33. Council of Acupuncture and Oriental Medicine Associations. Acupuncture and electroacupuncture: evidence-based treatment guidelines. National Guideline Clearinghouse. Available at http://guideline.gov/summary/summary.aspx?doc_id=9343. Accessed: March 24, 2009.

  34. Van Zundert J, Patijn J, Kessels A, Lamé I, van Suijlekom H, van Kleef M. Pulsed radiofrequency adjacent to the cervical dorsal root ganglion in chronic cervical radicular pain: a double blind sham controlled randomized clinical trial. Pain. 2007 Jan. 127(1-2):173-82. [Medline].

  35. Griffiths C, Dziedzic K, Waterfield J, Sim J. Effectiveness of specific neck stabilization exercises or a general neck exercise program for chronic neck disorders: a randomized controlled trial. J Rheumatol. 2009 Feb. 36(2):390-7. [Medline].

  36. Skeppholm M, Lindgren L, Henriques T, Vavruch L, Löfgren H, Olerud C. The Discover artificial disc replacement versus fusion in cervical radiculopathy--a randomized controlled outcome trial with 2-year follow-up. Spine J. 2015 Jun 1. 15 (6):1284-94. [Medline].

  37. Ahlgren BD, Garfin SR. Cervical radiculopathy. Orthop Clin North Am. 1996 Apr. 27(2):253-63. [Medline].

  38. Carragee EJ, Hurwitz EL, Cheng I, et al, and the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Treatment of neck pain: injections and surgical interventions: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. Spine. 2008 Feb 15. 33(4 suppl):S153-69. [Medline].

  39. Chiba S, Koge N, Oda M, et al. Synovial chondromatosis presenting with cervical radiculopathy: a case report. Spine. 2003 Oct 1. 28(19):E396-400. [Medline].

  40. Dreyfus P. The cervical spine: non-surgical care. Presented at: The Tom Landry Sports Medicine and Research Center. April 8, 1993; Dallas, Tex.

  41. Friedenberg ZB, Edeiken J, Spencer HN, Tolentino SC. Degenerative changes in the cervical spine. J Bone Joint Surg Am. 1959 Jan. 41-A(1):61-70 passim. [Medline]. [Full Text].

  42. Leblhuber F, Reisecker F, Boehm-Jurkovic H, Witzmann A, Deisenhammer E. Diagnostic value of different electrophysiologic tests in cervical disk prolapse. Neurology. 1988 Dec. 38(12):1879-81. [Medline].

  43. Lipetz JS, Malanga GA. Oral medications in the treatment of acute low back pain. Occup Med. 1998 Jan-Mar. 13(1):151-66. [Medline].

  44. Lo YL, Chan LL, Leoh T, et al. Diagnostic utility of F waves in cervical radiculopathy: electrophysiological and magnetic resonance imaging correlation. Clin Neurol Neurosurg. 2008 Jan. 110(1):58-61. [Medline].

  45. Malanga GA, Campagnolo DI. Clarification of the pronator reflex. Am J Phys Med Rehabil. 1994 Sep-Oct. 73(5):338-40. [Medline].

  46. Marks MR, Bell GR, Boumphrey FR. Cervical spine injuries and their neurologic implications. Clin Sports Med. 1990 Apr. 9(2):263-78. [Medline].

  47. Miwa M, Doita M, Takayama H, et al. An expanding cervical synovial cyst causing acute cervical radiculopathy. J Spinal Disord Tech. 2004 Aug. 17(4):331-3. [Medline].

  48. Thomas M, Bell GB. Radiologic evaluation and imaging of the spine. Nicholas JA, Hershman EB, eds. The Lower Extremity and Spine in Sports Medicine. 2nd ed. 1995. 1096-7.

  49. Wilbourn AJ, Aminoff MJ. AAEE minimonograph #32: the electrophysiologic examination in patients with radiculopathies. Muscle Nerve. 1988 Nov. 11(11):1099-114. [Medline].

 
Previous
Next
 
Sagittal magnetic resonance image of the cervical spine. This image reveals a C6-C7 herniated nucleus pulposus.
Axial magnetic resonance image of the cervical spine. This image reveals a C6-C7 herniated nucleus pulposus.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.