eMedicine Specialties > Sports Medicine > Spine
Cervical Radiculopathy: Treatment & Medication
Updated: Mar 31, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Acute Phase
Rehabilitation Program
Physical Therapy
Little is known about the natural history of cervical radiculopathy or about controlled randomized studies comparing operative versus nonoperative treatment for this condition. The initial treatment should be directed at reducing pain and inflammation. The treatment can begin with local icing, NSAIDs, and with reducing the forces compressing the nerve root by relative rest, avoiding positions that increase arm and/or neck symptoms, manual traction, and if necessary, mechanical traction.
In addition, a cervical collar can also 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. Modalities such as electrical stimulation have also been found to be helpful in uncontrolled studies. These modalities appear to be helpful in reducing the associated muscle pain and spasm that are often found with cervical problems, but they should be limited to the initial pain control phase of treatment.
Related eMedicine topics:
Electrophysiology
Nerve Entrapment Syndromes
Transcutaneous Electrical Nerve Stimulation
Related Medscape topics:
Resource Center Pain Management: Advanced Approaches to Chronic Pain Management
Resource Center Pain Management: Pharmacologic Approaches
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. 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.
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. This has rarely been necessary in the author's experience.
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.
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. Isolated strengthening of the weakened muscle secondary to 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.
Patients should be encouraged to maintain their level of cardiovascular fitness as much as possible throughout the rehabilitation process. This is completed 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 a great 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.
Related Medscape topics:
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Surgical Intervention
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.
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.
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. If completed correctly, 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.
Medication
NSAIDs are commonly prescribed for their effects on pain and inflammation. In cervical radiculopathy, a great deal of the pain is secondary to inflammation of the nerve root, usually due to a mechanical irritation of the nerve.
Oral steroids have been used to reduce the associated inflammation from compression. No controlled study exists to support the use of oral steroids in the treatment of cervical radiculopathy; however, these agents have been found to be clinically useful. Doses as high as 60 mg daily for 7 days and continuing for 5 days have been recommended without evidence of adrenal suppression. Tricyclic antidepressants can be a useful adjunct in controlling radicular pain. Opioid medications are generally not necessary for pain relief, but these drugs can be used when other medications fail to provide adequate relief or if other agents are contraindicated. When opioid medications are prescribed, adequate doses and appropriate dosing schedules should be used.
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Related Medscape topics:
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Nonsteroidal anti-inflammatory drugs
Various NSAIDs are available either over the counter or by prescription. Proper doses should be used in the acute phase around the clock for approximately 7-10 days.
Ibuprofen (Motrin, Ibuprin)
DOC for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Adult
400-600 mg PO q6h with food
Pediatric
Not established
Coadministration with aspirin increases the risk of inducing serious NSAID-related side effects; probenecid may increase the concentrations and, possibly, the toxicity of NSAIDs; may decrease the effect of hydralazine, captopril, and beta-blockers; may decrease the diuretic effects of furosemide and thiazides; monitor PT duration closely (instruct patients to watch for signs of bleeding); may increase the risk of methotrexate toxicity; phenytoin levels may be increased when administered concurrently
Documented hypersensitivity; peptic ulcer disease, asthma, recent GI bleeding or perforation, renal insufficiency, or high risk of bleeding
Pregnancy
C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in patients with congestive heart failure, hypertension, and decreased renal and hepatic function; caution in the presence of anticoagulation abnormalities or during anticoagulant therapy
Tricyclic antidepressants
Tricyclic antidepressants are a complex group of drugs that have central and peripheral anticholinergic effects, as well as sedative effects. These agents have central effects on pain transmission and block the active reuptake of norepinephrine and serotonin.
Amitriptyline (Elavil)
By inhibiting the reuptake of serotonin and/or norepinephrine by the presynaptic neuronal membrane, may increase the synaptic concentration in the CNS. Useful as an analgesic for certain chronic and neuropathic pain.
Adult
30-100 mg PO hs
Pediatric
Children: 0.1 mg/kg PO hs and increase, as tolerated, over 2-3 wk to 0.5-2 mg/d hs
Adolescents: 25-50 mg/d PO and increase gradually to 100 mg/d in divided doses
Phenobarbital may decrease effects; coadministration with CYP2D6 enzyme system inhibitors (eg, cimetidine and quinidine) may increase amitriptyline levels; amitriptyline inhibits the hypotensive effects of guanethidine; may interact with thyroid medications, alcohol, CNS depressants, barbiturates, and disulfiram
Documented hypersensitivity; patient has taken MAO inhibitors in past 14 d; patient has history of seizures, cardiac arrhythmias, glaucoma, and urinary retention
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in the presence of cardiac conduction disturbances and in patients with a history of hyperthyroidism, renal or hepatic impairment; avoid using in elderly patients
Nortriptyline (Pamelor, Aventyl HCl)
Has demonstrated effectiveness in the treatment of chronic pain. By inhibiting the reuptake of serotonin and/or norepinephrine by presynaptic neuronal membrane, may increase synaptic concentration in the CNS.
Pharmacodynamic effects, such as the desensitization of adenylate cyclase and downregulation of beta-adrenergic receptors and serotonin receptors, also appear to play a role in its mechanisms of action.
Adult
25 mg PO tid/qid, up to 150 mg/d
Pediatric
<25 kg: Not established
25-35 kg: 10-20 mg/d PO
35-54 kg: 25-35 mg/d PO
>54: Administer as in adults
Cimetidine may increase nortriptyline levels when used concurrently; nortriptyline may increase prothrombin time in patients stabilized with warfarin
Documented hypersensitivity; narrow-angle glaucoma; do not administer to patients that have taken MAO inhibitors in the past 14 d
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Caution in patients with cardiac conduction disturbances and a history of hyperthyroidism, renal or hepatic impairment; best to avoid in elderly patients due to pronounced effects in cardiovascular system
More on Cervical Radiculopathy |
| Overview: Cervical Radiculopathy |
| Differential Diagnoses & Workup: Cervical Radiculopathy |
 Treatment & Medication: Cervical Radiculopathy |
| Follow-up: Cervical Radiculopathy |
| Multimedia: Cervical Radiculopathy |
| References |
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Further Reading
Keywords
burner syndrome, pinched nerve, nerve root dysfunction, disk herniation, disc herniation, foraminal impingement of exiting nerve, uncovertebral joints, joints of Luschka, atlantoaxial joint, occipital atlantal joint, occipitoatlantal joint, intervertebral foramina, neuroforamen, neural foramen, ipsilateral nerve root injury, foraminal compression test, Spurling test, manual cervical distraction, Lhermitte sign
