URAC
The Arizona HOPCo Specialty Care Network is the only
URAC-accredited MSK clinically integrated network in the country.

Management of Cervical Radiculopathy (Adult)

Clinical Region

Florida

PRACTICE APPROACH

Expected practice

Clinical Approach

The clinical approach is based on consensus guidelines and includes expected practices which will be designed and implemented for the patients with cervical radiculopathy. Cervical radiculopathy occurs at a lower frequency than lumbar radiculopathy.

Expected Clinical Care

History and Physical Examination

The history and physical examination are integral to the diagnosis and management of cervical radiculopathy and should Identify the clinical presentation and pertinent history.

  1. What activities and head positions increase or decrease symptoms?
    1. Are there symptoms of cervical myelopathy such as changes in gait, bowel or bladder dysfunction, clumsiness of the hands, or lower extremity sensory changes or weakness.
  2. Identify the involvement of nerve roots and their anatomic level including motor, sensory or reflex abnormalities and pain patterns.
  3. Perform maneuvers to assist in determining if symptoms are radicular in nature or related to other musculoskeletal disease processes.
  4. The foraminal compression test, or Spurling test, as well as the shoulder abduction sign are useful for is confirming the diagnosis of cervical radiculopathy.
  5. Long tract signs of myelopathy can include ankle clonus on dorsiflexion, hyperreflexia, Hoffman sign, finger escape, and inverted radial reflex.

Diagnosis/Initial Treatment

  1. The diagnosis of cervical radiculopathy can usually be made based on correlation of symptoms and examination findings and diagnostic imaging.
  2. The objectives of initial treatment in patients without red flag signs are to ameliorate pain and address underlying causes of radiculopathy.
    1. Pharmacologic therapy
      1. First line pharmacologic therapy includes non-steroidal anti-inflammatory drugs (NSAIDs) or acetaminophen.
      2. Opioids should be used judiciously and limited to short term use.
      3. Systemic glucocorticoids have limited evidence. Steroid injection should be considered with patients whose symptoms persist after 4-6 weeks of conservative treatment. Clinicians should use cautiously in patients taking NSAIDs.
      4. Muscle relaxants in cases of spasm may be of benefit
      5. Consider the use of gabapentin or pregabalin for neuromodulation
    2. The following conservative treatments may be beneficial
      1. Short term activity modification
      2. Physical therapy/exercise therapy
      3. Traction has limited evidence and should be reserved for refractory cases (limit to<6 visits unless objective improvement is documented)
      4. Short term use of soft collar for cases with significant axial neck pain
      5. Spinal manipulation has limited evidence and consideration should be given to the possibility of manipulation leading to worsened symptoms or complications.
        Obtaining 3D imaging prior to manipulation may reduce the risk of such complications.
  3. In patients without acute trauma or red flag signs, symptomatic treatment without diagnostic imaging is reasonable.
  4. Urgent imaging is needed for patients with the following conditions red flag signs:
    1. Acute radiculopathy with progressive neurological deficits
    2. Suspected neoplasm
    3. Suspected abscess, clinical suspicion of inflammatory disease or infection.
    4. Long traction signs of myelopathy

Imaging

  1. Plain radiographs are usually not indicated in the atraumatic, acute phase but may be helpful to rule out structural pathologic conditions/instability during the course of treatment.
  2. MRIs are a reasonable modality for confirming nerve root compression in patients who may be a candidate for further intervention after a trial of conservative management. CT offers better assessment of boney pathology but not neurologic pathology but is reasonable for patients that cannot have an MRI.
  3. CT is the test of choice to clarify nerve root impingement in patients with equivocal MRI findings or those that cannot have MRI. Usually ordered by the treated surgeon if needed.
  4. CT Myelography is suggested for patients with clinical symptoms and discordant MRI findings or patients that are unable to have an MRI. Usually ordered by the treated surgeon if needed.

Additional Testing

Electrodiagnostic studies are useful in evaluating those with persistent radiculopathy when imaging is non- diagnostic or not consistent with the patient’s presentation or in cases of ruling out other peripheral nerve entrapment diagnosis. These include nerve conduction studies (NCS) and electromyography (EMG).

Invasive Therapies to Consider After MRI As Second Line Treatment of Conservative Care

  1. Epidural glucocorticoid injections
  2. Selective nerve root blocks to discern symptomatic level in cases of multilevel nerve pain generators.

Surgical Management

Surgical intervention may be considered for the following:

  1. Those with a progressive neurological deficit that is affecting patient’s function
  2. Those who have failed conservative treatment
  3. Tumor/infectious causes of cervical myelopathy

Preoperative Care

  1. Surgeons are responsible for gathering all of the necessary documentation to demonstrate that minimum requirements for surgery have been met.
  2. Patients should meet the following minimum requirements prior to surgery:
    1. Conservative treatment, managed by the PCP and/or Specialist, for a minimum of 6 weeks unless neurologic signs or imaging findings are severe or rapidly progressive.
    2. Documentation of persistent disability despite non-surgical therapy
    3. Diabetic patients: HbA1cfor posterior-instrumented cases
      1. ≤ 7.0 within last 12 weeks prior to surgery may proceed with surgery
      2. > 7.0 within last 12 weeks prior to surgery postpone until:
        1. Repeat HgbA1C is ≤7.0 OR
        2. After a three-month period, patient receives a letter from an endocrinologist or PCP stating that patient is at optimal control OR
        3. Patient has exhausted options for improved control of diabetes, has improved control of diabetes, but unlikely to make further gains due to underlying condition for which they need surgery, and their HgbA1C is considered clinically reasonable to proceed with proposed surgery.
    4. Confirmatory 3D
    5. imaging should be performed prior to surgical intervention
    6. Follows peri-operative optimization document for all major orthopedic cases
  3. Surgery scheduler contacts patient and schedules:
    1. Pre-op appointment
    2. Surgery date
    3. 2-week post op appointment for wound check
  4. Pre-op holding orders
    1. Consent
    2. Pre-op antibiotics
      1. Cefazolin (Ancef) 2gm (less than 120 kg) or 3 gm (120 kg or greater) IV within 1 hour of cut time, or
      2. Options for penicillin/cephalosporin allergic/intolerant patients:
        1. Vancomycin 1 gm (less than 90 kg) or 1.5 gm (90 kg or greater) IV within 2 hours of cut time
    3. Any additional testing that was not performed or needs to be re-done morning of surgery (INR/urine HCG)
    4. H&P must be dictated within 30 days of the procedure.

Intraoperative Care

Surgeon will perform fluoroscopy with metallic implant on a boney structure to confirm the surgical level and save image in PACs.

Postoperative Care

  1. Discontinue prophylactic post-op antibiotics within 24 hours of surgery
  2. Mechanical DVT prophylaxis while in-patient.
  3. Routine discharge medications:
    1. Stool softener daily
    2. Multi-vitamin PO daily
    3. Consider GI prophylaxis-as needed for aspirin or NSAID usage and patient risk factors.
  4. Consider multi-modal approach to pain management to minimize need for prolonged narcotics

Other

Avoid transfusions until the patients Hgb is <7, the patient is clinically symptomatic or considered high risk. Transfusions are ordered by the surgeon or if ordered by another provider, will be cleared by the surgeon.

References

  1. Childress, M., Becker, B., Nonoperative management of Cervical Radiculopathy. American Family Physician 2016 May 1;93(9):746-754.
  2. North American Spine Society. Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care. Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 2010.
  3. Brown, S., Guthmann, R., Hitchcock, K., (2009) Which treatments are effective for cervical radiculopathy, The Journal of Family Practice 2009 February, Vol 58, NO 2, 97-99.
  4. Loftus, T., Agee, C., Jaffe, R., Tao, J., & Jacofsky, D. J. (2014). A simplified pathway for total knee arthroplasty improves outcomes. Journal of Knee Surgery,27(03), 221-228.
  5. Donk, R., Verbeek, A., Verhagen, W., Groenewoud, H., Hosman, A., Bartels, R., What’s the best surgical treatment for patients with cervical radiculopathy due to single-level degenerative disease? A randomized controlled trial. PLOSONE. https://doi.org/10.1371/journal.pone.0183603