Nonoperative Management of Cervical Radiculopathy

 


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Am Fam Physician. 2016 May 1;93(9):746-754.

  Patient information: See related handout on cervical radiculopathy, written by the authors of this article.

Author disclosure: No relevant financial affiliations.

Cervical radiculopathy describes pain in one or both of the upper extremities, often in the setting of neck pain, secondary to compression or irritation of nerve roots in the cervical spine. It can be accompanied by motor, sensory, or reflex deficits and is most prevalent in persons 50 to 54 years of age. Cervical radiculopathy most often stems from degenerative disease in the cervical spine. The most common examination findings are painful neck movements and muscle spasm. Diminished deep tendon reflexes, particularly of the triceps, are the most common neurologic finding. The Spurling test, shoulder abduction test, and upper limb tension test can be used to confirm the diagnosis. Imaging is not required unless there is a history of trauma, persistent symptoms, or red flags for malignancy, myelopathy, or abscess. Electrodiagnostic testing is not needed if the diagnosis is clear, but has clinical utility when peripheral neuropathy of the upper extremity is a likely alternate diagnosis. Patients should be reassured that most cases will resolve regardless of the type of treatment. Nonoperative treatment includes physical therapy involving strengthening, stretching, and potentially traction, as well as nonsteroidal anti-inflammatory drugs, muscle relaxants, and massage. Epidural steroid injections may be helpful but have higher risks of serious complications. In patients with red flag symptoms or persistent symptoms after four to six weeks of treatment, magnetic resonance imaging can identify pathology amenable to epidural steroid injections or surgery.

Cervical radiculopathy describes pain in one or both of the upper extremities, often in the setting of neck pain, secondary to compression or irritation of nerve roots in the cervical spine. It can be accompanied by motor, sensory, or reflex deficits.1 The annual incidence is 107 per 100,000 men, and 64 per 100,000 women. It is most prevalent in persons 50 to 54 years of age.2

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BEST PRACTICES IN NEUROLOGY: RECOMMENDATIONS FROM THE CHOOSING WISELY CAMPAIGN

RecommendationSponsoring organization

Do not do nerve conduction studies without also doing needle electromyography to test for radiculopathy, a pinched nerve in the neck or back.

American Association of Neuromuscular & Electrodiagnostic Medicine


Source: For more information on the Choosing Wisely Campaign, see http://www.choosingwisely.org. For supporting citations and to search Choosing Wisely recommendations relevant to primary care, see http://www.aafp.org/afp/recommendations/search.htm.

BEST PRACTICES IN NEUROLOGY: RECOMMENDATIONS FROM THE CHOOSING WISELY CAMPAIGN

RecommendationSponsoring organization

Do not do nerve conduction studies without also doing needle electromyography to test for radiculopathy, a pinched nerve in the neck or back.

American Association of Neuromuscular & Electrodiagnostic Medicine


Source: For more information on the Choosing Wisely Campaign, see http://www.choosingwisely.org. For supporting citations and to search Choosing Wisely recommendations relevant to primary care, see http://www.aafp.org/afp/recommendations/search.htm.

View/Print Table

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Cervical radiculopathy can be diagnosed with the patient history and physical examination alone.

C

1, 5, 6

Diagnostic sensitivity and specificity is improved with the use of the Spurling and upper limb tension tests.

C

7, 1012

Magnetic resonance imaging is the preferred imaging modality in patients who have no improvement after four to six weeks of nonoperative treatment or progression of objective neurologic deficit.

C

1, 1418

Physical therapy with strengthening and stretching can be beneficial in acute cervical radiculopathy.

A

16, 22

Most patients with cervical radiculopathy will improve regardless of nonoperative treatment modality.

C

1, 2, 21

Surgical referral or epidural steroid injections should be considered if there is no improvement after four to eight weeks of nonoperative treatment.

C

1, 38, 42


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Cervical radiculopathy can be diagnosed with the patient history and physical examination alone.

C

1, 5, 6

Diagnostic sensitivity and specificity is improved with the use of the Spurling and upper limb tension tests.

C

7, 1012

Magnetic resonance imaging is the preferred imaging modality in patients who have no improvement after four to six weeks of nonoperative treatment or progression of objective neurologic deficit.

C

1, 1418

Physical therapy with strengthening and stretching can be beneficial in acute cervical radiculopathy.

A

16, 22

Most patients with cervical radiculopathy will improve re

The Authors

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MARC A. CHILDRESS, MD, is the associate director of the Primary Care Sports Medicine Fellowship at Virginia Commonwealth University Fairfax Family Practice....

BLAIR A. BECKER, MD, is a faculty physician at the Group Health Family Medicine Residency, Seattle, Wash.

Address correspondence to Marc A. Childress, MD, Fairfax Family Practice, 3650 Joseph Siewick Dr., Ste. 400, Fairfax, VA 22033 (e-mail: mchildress@ffpcs.com). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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