Treating cervical radiculopathy

Let’s look at how to treat patients with cervical radiculopathy. The treatment approach differs based on the length of time and symptom severity, so let’s take a look at the conservative management of this condition and treatment options for when the symptoms are more severe.

It is perfectly acceptable to hold off on imaging and treat conservatively if there is no rapidly progressive weakness or red flags. The most critical and effective component of conservative therapy is time. Often, cervical radiculopathy will start to abate within two to six weeks. As long as the symptoms are improving, no intervention is needed. Reassure the patient that most cervical radiculopathies go away on their own.

Advise the patient to do whatever is comfortable and to avoid activities that make the pain worse. There is no single activity or therapy that settles down raging radiculopathy. If the patient says that hanging upside down takes the pain away, by all means, they should hang upside down. Generally, the patient should refrain from heavy activities and overhead work since these often make the pain worse.

Anytime the pain gets worse, the nerve root is being further irritated. The goal of the conservative approach is to get the nerve root to settle down. This is often possible without needing to remove the compression of the nerve. Remember, most of us walk around with several areas of spinal nerve root compression and have no signs or symptoms.

For patients with severe pain, try a 5–7 day course of oral corticosteroids, such as a methylprednisolone dose pack. The corticosteroids should be followed by a course of nonsteroidal anti-inflammatory drugs (NSAIDs).

Milder symptoms can be treated with a 2–4 week course of nonsteroidal anti-inflammatory medications or non-narcotic analgesics as needed.

Be very clear with your patients about the duration and rules of narcotic prescriptions. Patients failing a short course of narcotics may need to be admitted for inpatient pain control and management rather than simply reordering the narcotics.

Other interventions such as physical therapy, soft cervical collars, and cervical traction may help your patient through the most painful periods of the disorder. When encouraging the patient to see a physical therapist, warn them that if the therapy seems to exacerbate their pain, they should discuss modifying the regimen with their therapist.

The diagnosis of cervical radiculopathy can usually be made in the clinic. Imaging is predominately used as a preoperative evaluation to help confirm the structural pathology that will be the surgical target.

So, imaging is seldom indicated early in the course of the disorder. However, patients with profound or progressive muscle group weakness, severe and intractable pain, or evidence of cervical myelopathy should undergo magnetic resonance imaging (MRI). The worse the neurological deficits, the greater the indication for prompt imaging.

Likewise, if the pain persists despite 4–6 weeks of conservative management, order a cervical non-contrast MRI for diagnostic purposes. If an MRI is not available or contraindicated, order a computed tomography (CT) myelogram.

Then, try to correlate your exam with the findings on the MRI. For example, C3–C4 disc herniation will not cause C7 radiculopathy; C5–C6 disc herniation on the right will not cause C6 radiculopathy on the left.

Be aware that significant degenerative findings can be seen up and down the cervical spine in some patients. Most of these will be asymptomatic. Radiologists, however, will usually provide a very comprehensive report and comment on degenerative changes seen at any disc space level. This can make clinical interpretations challenging, and alarm patients who have read their imaging study reports! Ideally, you should review the images yourself or with the radiologist and help your patient understand that their neck isn’t about to fall to pieces.

Generally, electromyography (EMG) is not helpful in straightforward cases and is not recommended. However, EMG is often performed and can lead to confusion if overinterpreted. Remember, EMG is a very subjective test. Only request EMG when you suspect disorders other than radiculopathy (such as peripheral neuropathy).

Option 1: Epidural steroid injections

Consider a referral for epidural steroid injections for patients who are in extreme pain or have persistent pain despite weeks of conservative management. They will need to have undergone cervical imaging before the procedure to identify the appropriate injection site.

There is no solid evidence that epidural steroid injections increase the rate of pain resolution. However, it seems to make many patients feel better and often removes the need for surgery.

Option 2: Surgery

If the history, exam, and imaging studies correlate with one another, and the patient is not responding to conservative management, consult a spine surgeon for consideration of surgical intervention.

Static, mild to moderate muscle weakness does not warrant urgent surgery, but progressive weakness should be evaluated by a spinal surgeon as soon as possible. There is no guarantee that muscle strength will improve with any treatment—including surgery.

Cervical surgery for radiculopathy is generally safe and highly effective for pain syndromes. Depending on the pathology, it can be performed through the front or back of the neck. When surgery is performed through the front of the neck, it is usually augmented by fusion and some form of plate and screw instrumentation.

Posterior decompression for simple radiculopathy should not require instrumentation or fusion. Be suspicious of surgeons who routinely use instruments for posterior radiculopathy surgeries.

Muscle weakness often improves with surgery, but is not guaranteed—no matter the timing of the surgery. Often, sensory complaints and findings are the last symptoms to go, and small areas of residual numbness are not uncommon.

After surgery, radicular pain relief should occur almost immediately. If the pain persists or recurs over the next 4–6 weeks, notify the spine surgeon. In this case, the patient will go back into conservative management before a new MRI is obtained. Often, the nerve root is simply still irritable and will eventually calm down. A short course of steroids will often help the pain.

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