Cervical Radiculopathy Treatment & Management

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. ^[24]

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. ^[28]

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. ^[29] 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. ^[29]

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. ^{[30, 31]} 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, ^[24] 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. ^[32]

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. ^[33] 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. ^[34] 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. ^[34]

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. ^[35]

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. ^[36]

A systematic review by Plener et al found only very-low certainty evidence that supported acupuncture, prednisolone, cervical manipulation, and low-level laser therapy for the management of pain and disability in the immediate to short term. ^[37]

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. ^[38]

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. A systematic review by Borrella-Andrés et al found that manual therapy seems to be effective in reducing chronic cervical pain and decreasing cervical disability in the short term in patients who have cervical radiculopathy. ^[39]

A double-blind randomized trial by Alshami and Bamhair demonstrated that vertebral mobilization of the cervical spine is effective in short-term improvement of pain intensity, neck function, and neck ROM, as well as localized mechanical pressure hypersensitivity, in patients with chronic cervical radiculopathy. However, no change in thermal pain sensitivity was noted. ^[40]

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 meta-analysis of randomized controlled trials by Gutman et al reported that anterior cervical discectomy and fusion, cervical disc replacement and minimally invasive posterior cervical foraminotomy were all effective in treating cervical radiculopathy. Although cervical disc replacement had the lowest rate of secondary surgical procedures (P = .0178) and minimally invasive posterior cervical foraminotomy had the lowest percentage of adverse events (P < .0001), no single technique proved to be the most effective. ^[41]  Another systematic review and meta-analysis by Findlay et al reported total disc replacement as effective as anterior cervical discectomy and fusion. ^[42]

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. ^[43]  A study by Engquist et al found that anterior cervical decompression and fusion combined with physiotherapy were more successful than physiotherapy alone in reducing neck pain and disability. ^[44]

Return to Play

Criteria for return to play are absence of pain, a full pain-free ROM, a negative Spurling test, and a normal neurologic examination. A neck roll should be properly fitted and used in athletes at risk for a repeat injury (eg, a middle linebacker in football).

Some injuries can be prevented by using good technique (eg, when tackling an opponent in football, breathing properly when swimming). Proper head positioning may also be of benefit by stretching the anterior muscles of the neck and chest (ie, the anterior scalenes, pectoralis muscles) and strengthening the scapular muscles. Neck strengthening, including some eccentric strengthening exercises, may be helpful in providing muscular control of the neck.