Treatment Guidelines for Cervical RadiculopathyWhat's the best way to treat the condition doctors refer to as cervical radiculopathy (better known to patients as a pinched nerve in the neck)? This condition causes symptoms of neck and arm pain that come from pressure on the nerve roots as they exit the spinal column. There can also be sensory and motor changes. In particular, how is cervical radiculopathy treated when it comes from degenerative changes in the cervical spine (neck)?
In this article, the North American Spine Society (NASS) offers an evidence-based clinical guideline that focuses on cervical radiculopathy from degenerative disorders. More than a dozen medical experts worked on this document. The panel included surgeons, medical doctors, and imaging specialists.
Drawing from all the studies published on this topic, they answered 18 questions about the natural history, diagnosis, and treatment of cervical radiculopathy. The focus was on radiculopathy as a result of degenerative changes in the cervical spine. After reviewing the evidence in studies up through 2009, they offer specific ways to approach treatment for this condition. The North American Spine Society (NASS) board reviewed the guidelines and published them here for your consideration.
Let's start with a brief explanation of the changes that occur with degenerative cervical radiculopathy. First and most common is a deterioration of the discs between the vertebrae (bones of the spine). The discs thin out, lose fluid, and compress down. Just that change alone results in a series of other changes as well.
Disc disease means the pressure and load on the vertebrae increases. It also means the facet (spinal) joints move closer together. Compression and added load there can cause bone spurs to form as the body responds to the added friction and shear forces.
A smaller space between the vertebrae also affects the spinal ligaments with resultant increase in stiffness of the spine. All of these factors together reduce the size of the foramen (hole through which the spinal nerve travels as it leaves the spinal cord and travels down the arm). And over time, with thinning of the bones and compression, the front of the vertebral bodies get pushed down. Vertebral compression fractures can develop. These are two more anatomical factors that can contribute to narrowing of the foramen.
The final result? Pinching or pressing on the spinal nerve root(s) and cervical radiculopathy. Of course, a proper diagnosis must be made to rule out other more serious problems like infection, fracture, or tumors. Clinical tests commonly used to test for cervical radiculopathy (e.g., Spurling's, shoulder abduction test) only got a grade of C (low evidence to support the use of these tests).
A better way to diagnose the problem is with X-rays and CT scans (B grade). This still isn't a top A grade because of the number of people with evidence of degenerative disease who don't develop any symptoms, patients with severe degeneration but mild symptoms, and patients with mild degeneration and severe symptoms. That means the tests aren't 100% reliable or accurate.
Other diagnostic tests including MRIs and electromyography (EMG studies) didn't have enough evidence to come to a firm conclusion. Nerve root blocks have also had varying diagnostic results. Sometimes the symptoms suggested a particular nerve was the problem but the block didn't change the symptoms. At the same time, when a nerve was blocked that wouldn't ordinarily cause the symptoms, pain relief was obtained. That's why nerve blocks got a grade C.
Once the problem is clearly defined, we are back to the question of what's the best way to treat this problem given the degenerative changes that brought it on in the first place? And maybe even before that: is treatment even needed?
The consensus of the group was that patients with cervical radiculopathy get better over time. Despite all the degenerative changes, the body seems able to adapt and heal. For that reason, this condition is considered self-limiting. This is the natural history of degenerative-induced cervical radiculopathy.
For those who pursue conservative (nonoperative) care, what works best? The choices are medications, physical therapy, chiropractic care (manipulation), and steroid injections. The group came up with I meaning insufficient evidence. There just haven't been enough studies; there are limited findings, or conflicting findings to come up with any solid recommendations. This is certainly an area where further study and examination would be a good idea.
Okay then -- for those who don't get better despite efforts with conservative (nonoperative) care, what are the treatment options? That leaves surgery as the next potential step. First question, does surgery work better when conservative care has been given first? That's another gray area rated as I -- insufficient information or "unknown". There is moderately good evidence (grade B) that surgery provides better relief than doing nothing.
If you are tracking here with us, then your mind has already jumped to the next question: what kind of surgery has the best outcomes? But beyond that there is actually yet another variable to factor in: single-level versus multilevel procedures. Is there one particular surgery that works best when treating just one spinal level? And same question for the surgical treatment of more than one spinal level.
Here's what the evidence suggests. Posterior decompression (taking pressure off the spinal nerve by removing bone around it) with or without fusion is used most often for multilevel radiculopathy. There weren't even enough studies on single level segments to see any conclusions. And most of the time, cervical radiculopathy from degenerative processes only affected one spinal level. Multilevel problems were usually the result of inflammation, tumors, or infection (rather than degenerative disease).
The more popular procedure (anterior cervical decompression) for single-level problems got a grade B. In fact, decompression combined with fusion worked equally well. The key here is the time frame: these positive outcomes applied to the short-term, acute phase of the disorder. Long-term results (four years or more after surgery) weren't so favorable (grade C).
In summary, physicians evaluating patients with cervical radiculopathy will be aided by this document. It will guide them in making a proper diagnosis and forming the most effective plan of care. The treatment plan will be current based on the best evidence available. Researchers will see the need for future research to further clarify the process.
For anyone who would like to see the complete list of recommendations, the North American Spine Society (NASS) has put these on-line for viewing at www.spine.org. But don't think this is the final word! The authors warn that this topic will be reviewed and the guidelines revised (if necessary) based on any new findings that come up in the near to distant future.
Christopher M. Bono, MD, et al. An Evidence-Based Clinical Guideline for the Diagnosis and Treatment of Cervical Radiculopathy From Degenerative Disorders. In The Spine Journal. January 2011. Vol. 11. No. 1. Pp. 64-72.
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