Cervical Radiculopathy and Myelopathy

Glenn R. Rechtine II

CERVICAL RADICULOPATHY AND MYELOPATHY

Neck pain is ubiquitous. Even 75% of children aged 9 to 12 will have intermittent complaints of neck pain (1). The incidence of neck pain is higher in girls and increases with age, even in adolescence (2). The nonsurgical management of neck pain or radiculopathy and myelopathy is very effective in the vast majority of cases (3). At least 90% with radiculopathy will recover without surgery (4). In the absence of a progressive neurologic deficit, the first treatment should involve nonsurgical means. Within the last few years, much more evidence-based medicine has become available. However, there is very little strong evidence to support any of the treatments now used (5). This review is an attempt to assess individual treatments and the strength of the evidence recommending their use.

As stated by Moffett, “Initially, advice providing simple messages of explanation and reassurance, will form the basis of a patient education package.” Self-management is emphasized throughout. A return to normal activities is encouraged. For the patient who is not recovering after a few weeks, a short course of physiotherapy may be offered. This should be based on an active management approach, such as exercise therapy. Manual therapy should also be considered. Passive treatments should only be used if required to relieve pain and assist in helping patients “get moving” (6).

Since there are very few randomized, placebo-controlled series, treatment should be prioritized to relieve pain, return function, and decrease the likelihood of relapses (7,8). In a study by Cleland, they looked at patients with cervical radiculopathy who were treated with physical therapy. There was no specific treatment, and the treatment was at the discretion of the therapist.

They found four factors to be predictive of success with nonsurgical treatment. They were (a) age less than 54 years, (b) dominant arm not involved, (c) looking down does not increase the pain, and (d) multimodal therapy including exercise, traction, and manual therapy used on at least 50% of therapy visits. If three were present, 85% of patients were successfully treated nonoperatively. If all four were present, there was a 90% likelihood of success within 4 weeks (9).

PSYCHOSOCIAL FACTORS

The patients should be educated about their disease process. This should be provided in an objective manner. Avoiding sensationalism and accurately representing the situation is critical. Fear avoidance is an obstacle to recovery. The patient’s attitude, presence of secondary gain, and other psychosocial issues are as important to recovery as the physical aspects (10). “All health professionals dealing with the patient need to provide the same message, encouraging a gradual return to normal activities, including work. Patients need to be clear that (a) although movement may hurt, this does not mean that damage is occurring; (b) they should return to work (or usual activities) even if the pain is not completely resolved; (c) they should use regular analgesics; and (d) they may need to modify duties at work for a limited period” (6).

Rehabilitation and exercise programs that incorporate a cognitive-behavioral approach show better return to work and fewer sick days than programs that do not include such an approach (11). No one modality by itself is the answer. Multimodal therapy that is customized to the patient is most likely to be successful (12).

Poor results can be predicted by some psychosocial markers. Risk factors for poorer outcomes included manual social class, catastrophizing, anxiety, depression, low treatment expectations, severity of baseline neck pain and disability, presence of comorbid back pain, and age over 60 years (13). Another risk factor for poorer outcomes is a motor vehicle injury, with 20% to 70% of patients still symptomatic at 6 months (3).

A very dramatic negative effect from workers’ compensation and litigation status of patients was documented by Landers. They report higher pain scores on presentation and at 3 months. The patients with secondary gain were 9.5 times more likely to have long-term functional limitations (14). Similar poor results and a high incidence
of somatization, kinesiophobia, and catastrophizing were shown by Karels et al (15).

MEDICATIONS

Analgesics

Nonsteroidal Anti-inflammatory Drugs

Nonsteroidal anti-inflammatory drugs (NSAIDs) are the most commonly used medications for cervical symptoms (16). There are no specific trials in cervical radiculopathy to substantiate this use. It is extrapolated from osteoarthritis and low back trials (17,18). The use of NSAIDs showed better results than acetaminophen. With NSAID use, gastrointestinal side effects commonly occur. There is an increased risk in the elderly and those with previous peptic ulcer symptoms. There may be advantages to the use of COX-2 inhibitors in high-risk populations (19).

Acetaminophen

Acetaminophen is a good first-line drug for mild to moderate pain. It has a good pain relief effect with fewer side effects than NSAIDs. The daily dose of acetaminophen should be kept to less than 2 g, or the gastrointestinal side effects are similar to NSAIDs (20).

Opioids

Opioids may be used for moderate to severe pain. This is done carefully after trials of less potent analgesics. In the elderly patient, the increased risk of gastrointestinal side effects from NSAIDs must be weighed against the risks of sedation and increased propensity for falls with narcotic pain medications. Other psychosocial aspects must be considered as well. Underlying depression can be aggravated by this family of medications (19).

Muscle Relaxants

The use of muscle relaxants is done empirically to reduce spasms and to induce sedation to promote sleep during the acute phase of symptoms. Some, particularly carisoprodol, are extremely habit forming. This family of drugs should be used for short periods of time. The greatest benefit will be within the first two weeks of symptoms (19).

Antidepressants

The use of antidepressants can be beneficial as depression symptoms are commonly associated with pain disorders. They also will work synergistically with analgesics. There is a real question as to whether depression and stress are causes of the symptoms or a result of persistent pain. The practitioner must look specifically for signs of depression and treat them aggressively (3).

Anticonvulsants

Gabapentin is used commonly in an off-label indication for radicular pain (3). This is based on the demonstrated effectiveness in diabetic neuropathy (21). Approximately a fourth of patients will experience somnolence or dizziness (19). Pregabalin is also used for radicular symptoms, although no data specifically related to cervical radiculopathy are currently available.

Corticosteroids

Oral steroids in a tapering dose are commonly used for cervical radiculopathy. There are no studies to show effectiveness of this regimen (19). A pulse with a large dose (˜1 mg/kg/d) initially that is tapered down over 1 to 2 weeks is commonly used (16).

INJECTIONS

Prolotherapy

In a small series with no control group, Hooper showed positive effects from injection of 20% dextrose into the zygapophysial joint. The patients were selected based on physical exam that showed joint laxity. The results were improved in patients who participated in a regular physical therapy program as well (22).

Trigger Point Injections

Injections of trigger points with local anesthetics, steroids, or dry needling have been done with equal effectiveness. The use of local anesthetics is often recommended, since it diminishes the soreness related to the injection (23). Stretching should be done after the injections. Initially, stretches are done several times per day and eventually progressing to daily stretching. Nonballistic stretching of each muscle group for 30 to 60 seconds is recommended (3).

Epidural Injections

Epidural injections are given by the midline translaminar route and the transforaminal approach. There are advantages and disadvantages of both techniques. If the patient has not responded to first-line treatments and remains symptomatic with radicular pain after 2 to 6 weeks, an epidural injection can be considered (3). Both techniques must be done with fluoroscopic control. Interlaminar injections have been done without x-ray control using the loss of resistance technique. Stojanovic demonstrated that at least half of such injections are not in the epidural space. In addition, half of those in the epidural space were unintentional unilateral injections (24).

Lin presented a series of transforaminal injections in patients with cervical radiculopathy. The patients received an average of 2.5 injections. In this series, 63% were able to avoid surgery. Follow-up averaged 39 months. Patients over the age of 50 and those who received the injections in the first 100 days of symptoms seemed to do better (25). Slipman reported a smaller series of 20 patients with an average of 2.2 injections. They also found 60% to have good or excellent results. Interestingly, the younger patients seemed to do better (26). Subsequently, they reported another 15 patients with traumatically induced cervical radiculopathy and found only a 20% good or excellent outcome (27).

There is a risk of epidural abscess following any epidural procedure including a cervical epidural injection (28). Diabetes, steroids, an immunocompromised state,
malnourishment, and advanced age will result in a greater risk of an infectious complication. Increasing pain after the injection should raise a concern for infection. An emergent MRI would be indicated to provide the diagnosis and direct appropriate treatment.

The risk of transforaminal injections is neurologic deterioration. This is felt to be related to intravascular injections, which can have catastrophic consequences (29,30). A vertebral artery injection can result in an acute stroke and death (31,32). A radicular artery injection can result in tetraplegia and death (29,33). An anatomic dissection showed that 21 of 95 specimens had an arterial vessel in the vicinity of the foramen with at least 7 of these definitely forming a radicular vessel extending into the spinal cord (34). The use of particulate steroid preparations has been implicated in these complications (35,36). The incidence of these complications varies dramatically depending on the series. In a prospective study of 337 patients, Furman showed a 19% incidence of intravascular injections. He showed that getting blood in the needle hub was very specific (97%) for an intravascular injection. Unfortunately this was only 45% specific. From this study, they recommend not only fluoroscopic control for the needle placement but also radiopaque contrast for the injected steroid preparation (37).

There is an argument that the transforaminal injections should be abandoned in favor of the interlaminar injections because of the safety profile (35). Another approach is transforaminal injection of only nonparticulate steroid preparations (36). Ma presented a series of 844 patients and 1,036 extraforaminal cervical nerve blocks with no major complications. There were only 14 (1.6%) minor complications. They describe a different needle placement technique too (38).

Translaminar injections are not without risks. Botwin reported a 16% minor complication rate with 157 patients with fluoroscopically guided translaminar injections. All of the complications resolved spontaneously and none required hospitalization (39). A review of complications of translaminar injections showed a range from 0% to 16%. Minor complications such as axial neck pain, headache, facial flushing, vasovagal episodes, nausea, vomiting, soreness at the injection site, respiratory insufficiency, subjective upper extremity weakness, insomnia, and upper torso acne have been reported (40). Tetraplegia and death have also resulted from translaminar injections from a multitude of causes from epidural hematoma or intramedullary injection (40).

Diagnostic Selective Nerve Root Blocks

MRI is so sensitive that almost all patients will demonstrate pathology. Diagnostic selective nerve root blocks can be done to try to provide specificity and confirm the symptomatic pathology (41).

NONPHARMACOLOGIC INTERVENTIONS

Physical Therapy

Exercise

Exercise is incorporated into almost every nonoperative regimen. Multiple studies have shown various exercise routines to be effective (42,43). Isometric exercise and proprioceptive reeducation has demonstrated improvement in pain and function (10,44). For initial treatment, instruction in a home daily self-stretching program can be as effective as regular physical therapy at a much lower cost (45). Even minimal isometric exercise, combined with a contoured pillow for sleep, was effective at decreasing symptoms (46). After traumatic whiplash-associated disorders, the higher the pain levels, the better the response to exercise. Exercise and advice provided better results than exercise alone in this randomized series (47).

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