Version May 2024
INTRODUCTION — The treatment of cervical radiculopathy will be reviewed here, focusing on the treatment of compressive radiculopathy due to disc degeneration and cervical spondylosis. The clinical features and diagnosis of cervical radiculopathy are discussed separately. (See "Clinical features and diagnosis of cervical radiculopathy".)
The management of patients with cervical spondylotic myelopathy is reviewed in detail elsewhere. (See "Cervical spondylotic myelopathy", section on 'Treatment'.)
OUR APPROACH — 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.
Despite uncertainty regarding effectiveness, we suggest conservative therapy as initial treatment for most patients with compressive cervical radiculopathy who have clear radicular pain and symptoms of paresthesia or numbness (algorithm 1). In addition, we suggest conservative therapy as initial treatment for patients with cervical radiculopathy who have nonprogressive neurologic deficits, including dermatomal sensory loss and myotomal weakness, as long as myelopathy is not suspected. All patients with motor weakness should be closely followed for evidence of progression. (See 'Conservative therapy' below.)
Clinical reevaluation should be performed after six to eight weeks of conservative treatment, with assessment for motor weakness and myelopathic findings in patients who have not improved or in those who have progressive symptoms. (See 'Refractory or progressive symptoms' below.)
For patients with confirmed cervical radiculopathy who have severe or disabling pain despite a reasonable course (six to eight weeks) of conservative therapy, and who do not have a progressively worsening neurologic deficit, we suggest the use of epidural glucocorticoid injections rather than surgery. (See 'Epidural glucocorticoid injections' below.)
We suggest surgery only for patients with cervical radiculopathy who have cervical nerve root compression by magnetic resonance imaging (MRI) or computed tomography (CT) myelography at the appropriate side and level(s) and progressive motor weakness regardless of duration. However, some experts consider persistent radicular pain for more than 6 to 12 weeks despite aggressive nonsurgical treatment as an indication for surgery. (See 'Surgery' below.)
NONSURGICAL THERAPY — There are two main components of nonsurgical therapy: conservative therapy and epidural glucocorticoid injections.
Conservative therapy — Given the apparent overall good prognosis for recovery (see 'Prognosis' below), conservative therapies are preferred for most patients with compressive cervical radiculopathy (algorithm 1). Conservative therapy typically consists of the following modalities, alone or in some combination [1,2]:
●Oral analgesics
●A short course of oral glucocorticoids
●Avoidance of provocative activities
●Short-term neck immobilization with a hard or soft cervical collar and/or cervical pillow
●Physical therapy with exercise, manual therapy, and gradual mobilization
●Cervical traction
Few randomized trials have evaluated the effectiveness of these treatments. A systematic review of clinical trials that assessed nonsurgical therapy among 4018 patients with cervical radiculopathy found very low certainty evidence to support the use of glucocorticoids, manual therapy, or multimodal conservative therapy [3]. One trial of 205 adults with acute cervical radiculopathy diagnosed by a neurologist found that treatment with either physical therapy and home exercises for six weeks or a cervical collar and rest for three to six weeks was superior to no treatment (control) for reduction in neck and arm pain [4]. Observational studies suggest that conservative therapy for cervical radiculopathy is associated with complete resolution of pain and neurologic deficits in 40 to 80 percent of patients [5-8]. However, it remains uncertain whether conservative therapy improves upon the natural history of cervical radiculopathy.
There is no consensus regarding the sequence or time course of conservative modalities. We generally start treatment with oral analgesics and avoidance of provocative activities, accompanied by a short course of oral prednisone if pain is severe. For oral analgesia, we typically use nonsteroidal anti-inflammatory drugs (NSAIDs) as first-line therapy. We avoid the use of narcotic agents. Medications for neuropathic pain, such as gabapentin and pregabalin, are sometimes used in the treatment of in cervical radiculopathy, but this practice is not well supported by evidence.
A muscle relaxant such as cyclobenzaprine may be added if muscle spasm or muscle tightness is prominent. Cyclobenzaprine is generally started at a modest dose of 5 mg two or three times a day to reduce the side effect of drowsiness. The dose can be increased to 10 mg three times a day after one week if spasm is not relieved and side effects are not prominent.
Shoulder abduction, which can be used as a diagnostic sign, can also be useful for temporary symptom relief [9]. (See "Clinical features and diagnosis of cervical radiculopathy", section on 'Shoulder abduction relief test'.)
Once the pain is tolerable, we initiate physical therapy with exercise and gradual mobilization. In our opinion, prolonged inactivity may delay recovery and is not advisable.
The patient should be seen and reexamined in six to eight weeks if there is no improvement with these conservative measures. In this setting, neuroimaging studies of the cervical spine and electrodiagnostic studies should be performed if they were not done initially. (See 'Refractory or progressive symptoms' below.)
Oral glucocorticoids — A short course of high-dose oral glucocorticoid therapy may be used as initial treatment for patients with severe cervical radicular pain. The evidence supporting the effectiveness of oral glucocorticoids for cervical radiculopathy is limited [2,10]. In our clinical experience, for example, this treatment is associated with pain relief in many patients.
Prednisone 60 to 80 mg/day for five days, followed by a taper off the medication over the ensuing 5 to 14 days, is a typical regimen. We suggest not using prophylaxis against gastrointestinal bleeding in patients taking prednisone alone. By contrast, patients taking prednisone in combination with aspirin or other NSAIDs may require prophylaxis. (See "NSAIDs (including aspirin): Primary prevention of gastroduodenal toxicity".)
Exercise therapy — Physical therapy, range-of-motion exercises, strengthening exercises, and aerobic exercises are frequently employed as conservative measures for cervical radiculopathy. A 2019 meta-analysis suggested some benefit, but the few controlled trials showed conflicting results [4,11,12].
Many patients report benefit with exercise therapy, but this could reflect the natural history of the disease or a placebo response. Because of possible benefit and no proven harm, we suggest exercise therapy as part of the initial treatment of symptomatic cervical radiculopathy in the absence of myelopathy. Some experts advise that exercise therapy is contraindicated in the presence of myelopathy. (See "Cervical spondylotic myelopathy", section on 'Conservative measures'.)
Manual therapy — Manual therapy is the application of hand force for mobilization of joints, muscles, or neural tissues (eg, myofascial release) and is often used with exercise therapy for cervical radiculopathy. While data are still sparse and limited by specific diagnosis and exact techniques performed, a 2021 systemic review of clinical trials reported manual therapy appeared to be effective in reducing chronic cervical pain and disability in the short term [13]. A small trial also reported greater improvement in mechanical pain and range of motion compared with manual therapy and exercise than sham therapy and exercise [14].
Cervical traction — Cervical traction is the application of a distracting force to the neck, which can in theory separate the cervical segments, expand the intervertebral joint spaces, and relieve compression of the nerve roots [2]. We generally do not prescribe cervical traction as therapy for patients with cervical radiculopathy. Nevertheless, cervical traction is a reasonably safe alternative for patients with persistent or refractory pain who do not want epidural glucocorticoid injections or surgery.
Controlled studies of cervical traction delivered in the course of a physical therapy program have shown conflicting results [15-17]. A 2006 systematic review of traction for patients with mechanical neck disorders reported that the evidence of benefit for traction was inconclusive due to the low methodologic quality of the trials [18]. However, a 2018 meta-analysis and systematic review of studies for cervical radiculopathy found that adding traction to physical therapy was associated with some benefit in both pain and disability [19].
Traction should not be used unless neuroimaging has been performed and should be discontinued if symptoms worsen with the application of distracting force. Traction is not recommended in the presence of spinal cord compression or large disc protrusion.
Refractory or progressive symptoms — Some patients with cervical radiculopathy have symptoms that are refractory to conservative treatments, and a smaller number develop progressive symptoms.
Clinical reevaluation should be performed with careful assessment for motor weakness and myelopathic findings in patients who have not improved after six to eight weeks of conservative treatment or in those who have progressive symptoms. Neuroimaging and electrodiagnostic studies are indicated, particularly if not done initially, and repeat electrodiagnostic studies may be needed if an initial study was unrevealing.
Reevaluation, neuroimaging, and electrodiagnostic studies are important to ensure that the initial diagnosis of radiculopathy is correct, and to assess for evidence of progressive neurologic deficit that could be an indication for surgery. (See "Clinical features and diagnosis of cervical radiculopathy", section on 'Diagnostic evaluation' and 'Indications for surgery' below.)
There are no clinical trials that clearly establish whether more aggressive interventions, such as epidural glucocorticoid injections or surgery, are beneficial for patients who are refractory to conservative therapy or beneficial for those who have progressive symptoms or signs. (See 'Epidural glucocorticoid injections' below and 'Surgery' below.)
Nevertheless, many experts consider unremitting radicular pain despite six to eight weeks of conservative treatment, progressive motor weakness, or signs and symptoms of myelopathy (in the context of imaging studies showing a surgically remediable anatomic spinal cord compression) as indications for surgery. (See 'Indications for surgery' below.)
Epidural glucocorticoid injections — Patients with persistent cervical radicular pain, with or without radiculopathy, may benefit from epidural glucocorticoid injections, but the data are weak and inconsistent [20,21].
●Transforaminal or interlaminar epidural glucocorticoid injections have been associated with substantial relief (≥50 percent pain reduction) in approximately 50 percent of patients one to three months after injection in small observational studies [20,21]. A systematic review of six studies that included 443 patients who received transforaminal epidural glucocorticoid injections reported the mean short-term pain relief at four to eight weeks that ranged from 18 to 60 percent [22]. However, these studies cannot distinguish between improvement due to treatment, placebo effect, or the natural history of cervical radiculopathy.
●No benefit of epidural glucocorticoid injection was found in a small trial that randomly assigned patients with cervical radiculopathy to treatment with either local anesthesia and epidural glucocorticoid injection (n = 20) or local anesthesia and saline injection (n = 20) [23]. At three weeks, there was no difference between the two groups for the outcome of a reduction of arm pain and/or neurologic symptoms (30 percent each).
Treatment begins with a single injection, and the response is assessed. Although clinical practice varies, the injections may be repeated one or two times if needed, separated by three weeks between injections [24].
Fluoroscopic guidance is mandatory for cervical epidural injections [25,26]. The needle should remain in contact with the posterior wall of the intervertebral foramen; this position avoids contact with the nerve root, spinal nerve, and associated vessels (figure 1) [27,28]. Test injections of small amounts of nonionic contrast can confirm entry of the needle into the epidural space and demonstrate whether the injectate spreads onto the injured nerve root(s). Test contrast injections can also reveal inadvertent intraarterial injection. The use of computed tomography (CT) fluoroscopy for guidance may provide improved anatomic detail compared with standard fluoroscopy [28,29].
Serious complications of cervical epidural glucocorticoid injections are rare, but the precise incidence of such complications is unknown [30]. There have been well-documented reports of death or severe neurologic sequelae from hemorrhage or infarction involving the brain, brainstem, cerebellum, or spinal cord [20,31,32]. The exact cause of neurologic injury is uncertain in most reported cases, but possible mechanisms include embolism of glucocorticoid particles due to inadvertent injection into a vertebral or a radicular artery, arterial dissection, needle-induced vasospasm, and unintentional dural puncture [27,30,31,33,34].
●In one autopsy study, death due to a stroke with massive cerebral edema occurred following dissection of and subsequent thrombus formation in the vertebral artery during a C7 epidural injection [35].
●In another report, death due to extensive brainstem and thalamic infarction occurred following epidural injection despite the use of fluoroscopic guidance; at autopsy, there was a small area of hemorrhage within the adventitia of the left vertebral artery but no dissection [36].
●A physician survey evaluating complications of cervical transforaminal epidural glucocorticoid injections found that all neurologic complications occurred after injections of particulate glucocorticoids (eg, betamethasone, methylprednisolone, triamcinolone), whereas none occurred after injections of the nonparticulate glucocorticoid dexamethasone [31].
For patients with confirmed cervical radiculopathy who have severe or disabling pain despite a reasonable course (six to eight weeks) of conservative therapy, and who do not have a progressively worsening neurologic deficit, we suggest the use of epidural glucocorticoid injections rather than surgery, provided that the injections are performed by experienced centers and interventionalists under fluoroscopic guidance using test contrast injection to identify accidental vessel injection. Use of a nonparticulate glucocorticoid such as dexamethasone may reduce the risk of ischemic complications. Consensus guidelines recommend the following [25,26]:
●Cervical interlaminar epidural glucocorticoid injections should be performed using image guidance, with appropriate anteroposterior, lateral, or contralateral oblique views and a test dose of contrast medium
●Cervical transforaminal epidural glucocorticoid injections should be performed by injecting contrast medium under real-time fluoroscopy or digital subtraction imaging, before injecting any substance that may be hazardous to the patient
●Cervical interlaminar epidural glucocorticoid injections should be performed at the C7-T1 levels, and no higher than the C6-7 level, because the cervical epidural space is widest at the C6-T1 levels, while gaps in the ligamentum flavum are more frequent at higher cervical levels
●Particulate glucocorticoids should not be used in therapeutic cervical transforaminal injections
The role of epidural glucocorticoid injections in patients with low back pain is discussed elsewhere. (See "Subacute and chronic low back pain: Nonsurgical interventional treatment".)
SURGERY — The benefit of surgery for the treatment of cervical radiculopathy has not been clearly established, and data from controlled trials are sparse.
Efficacy — A 2010 systematic review identified only a single small randomized trial of surgery versus conservative management for the treatment of cervical radiculopathy that met criteria for inclusion [37]. In this trial, which evaluated 81 patients with clinical and radiologic signs of nerve root compression lasting more than three months, patients were randomly assigned to treatment with either surgery (anterior cervical discectomy), physiotherapy, or immobilization with a hard cervical collar [38]. Those with spinal cord compression, whiplash, and other serious associated diseases were excluded.
The following results were reported [38]:
●At four months, the surgically treated patients showed greater improvement in pain, muscle strength, and sensory loss than the nonsurgically treated patients
●At one year, there was no significant difference in pain or sensory disturbances between the surgical and nonsurgical treatment groups, although the surgical group had a small advantage in muscle strength
A subsequent two-year randomized trial of 63 patients with cervical radiculopathy due to disc disease assigned patients to either anterior cervical discectomy and fusion (ACDF) combined with physical therapy or physical therapy alone [39]. There was no significant difference between the groups for any of the outcome measures, which included neck active range of motion, neck muscle endurance, and hand-related function. Patients in both groups improved over time to a similar degree on these measures, though function remained below normative values.
In contrast to the evidence from these randomized trials, the findings from two prospective observational studies suggest that surgery is beneficial for patients with cervical radiculopathy, with substantial improvement in pain and weakness in approximately 75 percent of patients [40,41]. These studies did not document the percentage of patients with complete pain resolution. Earlier observational studies had found that improved outcome with surgery was more likely in patients with radicular pain than those without radicular pain [1].
Indications for surgery — Proposed indications for surgery in patients with cervical radiculopathy are unremitting radicular pain despite 6 to 12 weeks of conservative treatment, progressive motor weakness, or the presence of myelopathy [1,2].
More stringent proposed indications for surgery require the presence of all of the following criteria [2]:
●Symptoms and signs of cervical radiculopathy (ie, nerve root dysfunction, pain, or both)
●Evidence of cervical nerve root compression by magnetic resonance imaging (MRI) or computed tomography (CT) myelography at the appropriate side and level(s) to explain the clinical symptoms and signs
●Progressive motor weakness
We suggest surgery only for patients who meet these stringent criteria for cervical radiculopathy (algorithm 1). As part of a presurgical evaluation, flexion and extension plain films are necessary to assess the stability of the cervical spine [42]. There are two main surgical approaches: ACDF, and posterior laminoforaminotomy (PLF) [43,44]. Artificial disc replacement is a promising surgical strategy that may lead to improved outcomes.
Surgical approaches — Several procedures are available for patients undergoing surgery for cervical radiculopathy without myelopathy. A 2018 meta-analysis of four randomized controlled trials and a subsequent 2020 meta-analysis of 1567 patients from 21 trials found that efficacy outcomes and safety profiles were similar among the procedures evaluated [45,46]. A 2023 Dutch trial of 265 patients with cervical radiculopathy also found efficacy and safety outcomes were similar for patients assigned either to posterior foraminotomy or to anterior cervical discectomy with fusion [47].
Surgical approaches for patients with cervical radiculopathy with myelopathy are discussed separately. (See "Cervical spondylotic myelopathy", section on 'Surgical decompression'.)
Anterior cervical discectomy and fusion — ACDF is the most commonly used decompressive procedure in the cervical spine.
The advantages of ACDF are that it requires little manipulation of the spinal cord or cervical roots and allows for removal of both lateral and midline disc herniation and osteophytes. Disadvantages include a small perioperative risk of damage to the carotid artery, trachea, esophagus, or recurrent laryngeal nerve. There is also a risk of pseudoarthrosis and further degenerative changes of adjacent segments [48].
Posterior laminoforaminotomy — A posterior surgical approach may be used when a single lateral disc herniation is present. A PLF is frequently performed, although many variations have been described. Midline pathology is not easily accessible with PLF. As a result, this approach is not useful in patients with midline disc herniation or osteophytes.
The main advantages of PLF are that it involves no alteration of the architecture of the cervical spine and no risk of damage to anterior neck structures. The main disadvantage is that there may be more postoperative pain with PLF than with ACDF, although this is controllable with medications [42,48,49].
Artificial disc replacement — Artificial cervical disc replacement surgery or cervical disc arthroplasty (CDA) is a developing technique for the treatment of cervical radiculopathy that has been used in situations when an ACDF would otherwise be appropriate. Mounting evidence suggests that CDA is equal or superior to ACDF in terms of clinical outcomes [50-55]. In a 2016 systematic review and meta-analysis of eight randomized controlled trials and over 2300 subjects comparing CDA with ACDF with at least four years of follow-up, pooled analysis found that CDA led to significantly higher rates of success on most clinical outcome measures (eg, overall success, neurologic success, improvement of disability scores) and lower rates of implant or surgically related serious adverse events [52], but follow-up review in 2018 reported that initial outcomes were similar, but CDA had lower rates of repeat surgeries [46].
Complications — Complications of surgery for cervical radiculopathy and/or myelopathy are uncommon but include spinal cord injury (<1 percent of cases), nerve root injury (2 to 3 percent), and instrumentation or device failure (≤4 percent). Additional complications seen with anterior surgical approaches in retrospective studies include transient dysphagia (10 percent), recurrent laryngeal nerve injury (2 to 3 percent), esophageal perforation (<1 percent), vertebral artery injury (<1 percent), and superficial wound infection (<1 percent) [2,40,41,56-59].
Procedures performed with autologous bone grafts may be associated with a higher risk of infection and chronic pain at the donor site [45].
PROGNOSIS — The prognosis of cervical radiculopathy varies in part upon whether the cause is compressive or nondegenerative. (See "Clinical features and diagnosis of cervical radiculopathy", section on 'Pathophysiology'.)
Compressive radiculopathy — The majority of radiculopathies arise from nerve root compression; the two predominant mechanisms are cervical spondylosis and disc herniation. Although data are limited, some, if not most, patients with compressive cervical radiculopathy improve without specific treatment [60-62]. Evidence that improvement is not treatment specific comes from a population-based study of 561 patients with cervical radiculopathy from Rochester, Minnesota [61]. 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.
Symptoms of cervical radiculopathy recur in up to one-third of patients after initial improvement [61]. Conservative management should be reemployed when symptoms recur, unless a significant motor deficit or myelopathy is present. (See 'Conservative therapy' above.)
Nondegenerative radiculopathy — Nondegenerative causes of cervical radiculopathy or polyradiculopathy include diabetes mellitus, infectious processes (especially herpes zoster and Lyme disease), nerve root infarction, root avulsion, infiltration by tumor, infiltration by granulomatous tissue, inflammatory, and neurodegenerative causes (table 1). (See "Clinical features and diagnosis of cervical radiculopathy", section on 'Nondegenerative causes'.)
The prognosis of cervical radiculopathy in these settings is influenced by the natural history and response to therapy of the underlying condition.
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Upper spine and neck disorders" and "Society guideline links: Radiculopathy".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topics (see "Patient education: Neck pain (The Basics)" and "Patient education: Radiculopathy of the neck and back (including sciatica) (The Basics)")
●Beyond the Basics topics (see "Patient education: Neck pain (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
●Initial conservative therapy for most patients – We suggest conservative therapy as initial treatment for most patients with compressive cervical radiculopathy who have clear radicular pain with paresthesia or numbness (algorithm 1). In addition, we suggest conservative therapy as initial treatment for patients with cervical radiculopathy who have weakness that is nonprogressive, as long as myelopathy is not suspected (Grade 2C). (See 'Conservative therapy' above.)
We typically start treatment with oral analgesics (eg, nonsteroidal anti-inflammatory drugs [NSAIDs]) and avoidance of provocative activities and add a short course of oral prednisone if pain is severe. Once the pain is tolerable, we initiate physical therapy with exercise and gradual mobilization.
●Epidural glucocorticoid injections for persistent symptoms – For patients with confirmed cervical radiculopathy who have persisting, severe, or disabling pain despite a reasonable course (six to eight weeks) of conservative therapy and who do not have progressive weakness, we suggest the epidural glucocorticoid injections rather than surgery (Grade 2C). (See 'Epidural glucocorticoid injections' above.)
The injections should be performed by experienced centers and interventionalists under fluoroscopic guidance using test contrast injection to identify accidental vessel injection.
●The role of surgical therapy – The benefit of surgery for the treatment of cervical radiculopathy has not been clearly established, and data from controlled trials are sparse. For patients with cervical radiculopathy who have all of the following conditions, we suggest surgery rather than nonsurgical therapy (Grade 2C) (see 'Surgery' above):
•Symptoms and signs of cervical radiculopathy
•Cervical nerve root compression by magnetic resonance imaging (MRI) or computed tomography (CT) myelography at the appropriate side and level(s)
•Progressive motor weakness
Several procedures are used for patients undergoing surgery for cervical radiculopathy without myelopathy. These include anterior cervical discectomy and fusion, posterior laminoforaminotomy, and artificial disc replacement. Outcomes and safety profiles among available techniques are similar.
●Prognosis – Limited data suggest that most patients with compressive cervical radiculopathy improve without specific treatment. However, symptoms may recur in up to one-third of patients after initial improvement. Conservative management should be re-employed if symptoms of cervical radiculopathy recur unless a significant motor deficit or myelopathy is present. (See 'Prognosis' above.)
ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Jenice Robinson, MD, who contributed to earlier versions of this topic review.
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