The evidence for non-surgical cervical stenosis and cervical radiculopathy treatments
Ross A. Hauser, MD.
Narrowing of the bony cervical canal, or spinal stenosis, may not be pathologic (symptom causing) itself but when occurring in conjunction with cervical instability, it can impede neurological function. Cervical radiculopathy is treatable. But not all treatments are successful. In this article, we will explore the problems we have seen in our patients previously diagnosed with cervical radiculopathy. We will show how we handled those problems and the research and information that can be helpful to you in your search for long-term symptomatic relief.
- Your cervical radiculopathy treatment journey.
- Medications and conservative care cervical radiculopathy treatments.
- “Don’t talk me out of surgery, my MRI is bad and I have to get back to work.”
- Are you getting cervical spine surgery for the wrong problem? Cervical radiculopathy mimics.
- How the cervical spine MRI could be “read the wrong way”
- MRI and DMX a brief introduction explaining the difference and accuracy in understanding nerve compression.
- Researchers question the validity of diagnostic tools such as MRI and understanding what these readings and other investigational tools provide the patient by way of treatments that help.
- Did the MRI make the patient’s treatment or understanding of their problems better?
- The MRI wants to show you a significantly herniated disc. We will show you that disc herniation may not be a factor at all.
- So it was not the size of the herniation that caused cervical radiculopathy issues, it was the unstable motion of the cervical vertebrae.
- Our published research on cervical radiculopathy as a problem of instability NOT herniation.
- Dynamic vs. Static Cervical Spinal Stenosis.
- Data may have implications for the diagnosis and treatment of patients with cervical radiculopathy.
- Positional cervical cord compression.
- Risks and complications of cervical epidural steroid injections.
- “Cervical epidural injections provide no long-term benefit and are being performed for minimal to no indications”
- Surgeons give evidence against surgery for Cervical Radiculopathy.
- Minimally invasive procedure for cervical radiculopathy.
- But I need to get back to work – Surgery may prevent that from happening quickly or at all.
- Research: “How Knowledgeable Are Spine Surgeons Regarding EMG-NCS for Cervical Spine Conditions?”
- The neurological manifestations of cervical spine instability and degeneration.
- Cervical instability can be treated in many ways as mentioned above. There are treating symptoms and there are treating the cause. Treating the cause involves treating neck instability whether with surgery or non-surgical methods.
- The non-surgical comprehensive Prolotherapy treatment methods for treating cervical radiculopathy:
Your cervical radiculopathy treatment journey
Your cervical radiculopathy treatment journey likely began with an accelerating degenerative condition in your neck that finally caused you enough discomfort that you had to seek some type of medical treatment. You had a chronic pain that “radiated” from the neck into your upper back, shoulder, down your arms, and into your fingers. Further, you began to recognize a weakness in your arms and numbness that extended into your fingers. Sometimes you have a lack of coordination, especially in the hands. For some, the pain will extend into the low back, buttocks, and legs.
Traditional pain management care involves trying to find the pain-producing structure and then doing something to it to calm the nerve impulses down. An example of this would be if someone has severe pain down their arm, a subsequent MRI shows a lot of arthritis narrowing the intervertebral neural foramina, so neck surgery is done. The decompressive surgery removes the bone spurs and makes more room for the nerve root. However, people sometimes have continued pain after this operation because the nerve was not getting compressed there but more toward the shoulder area.
For the nerve to make it from the neck to the skin and muscles of the arm it has to travel through and by a lot of structures including muscles, fascia, and nearby joints such as the shoulder. Since the scalene muscles attach the transverse processes of the middle to lower cervical vertebrae to the first two ribs, instability in any of these joints would cause muscle spasms and potential hypertrophy of these muscles. This could, in turn, lead to compression of the nerves from the neck in the brachial plexus. In addition, shoulder instability can compress the brachial plexus nerves, as the nerves run just anterior to the shoulder joint. So knowing exactly where the joint instability is located is crucial to curing chronic neck pain and its sequelae and, as you will find out, static (non-motion) MRIs and x-rays are poor judges of this.
If you are like many of the patients we see, you went to your doctor and then were referred to a cervical spine specialist or a neurologist. Here at the specialist’s office, an MRI is ordered and perhaps an Electromyogram (EMG) Test.
Medications and conservative care cervical radiculopathy treatments
At your initial doctor’s visit, you may have received a suggestion for some medications and conservative care treatments.
- You may have inflammation, so you will get an anti-inflammatory to reduce pressure on the nerves.
- You may have pain, so you will get a pain medication
- You may get electronic stimulation in the form of TENS.
- You may get a recommendation to get Physical Therapy.
- You may get a recommendation for chiropractic treatments.
For some people, these treatments will be effective and the pain will go away and take with it the numbness feeling. For others, maybe, you are reading this article because you have done all these things and now there is talk of surgery to correct a herniated disc problem that is pressing on the nerves in the cervical spine.
Many of the people who come into our clinics have “bad MRIs” but they do not need surgery. Some patients are relieved to hear this but some are more concerned. They wanted to be told surgery is the only way. Why?
“Don’t talk me out of surgery, my MRI is bad and I have to get back to work.”
Some people will need surgery, many do not. Many times a spouse will bring in their husband/wife for a second opinion on the realities of non-surgical treatment of their cervical neck problems. The spouse that has the pain issues has probably reached their “wit’s end,” they do not want to live with this problem anymore and just want to get the surgery. The surgery, they hope will be the ultimate answer.
The spouse or loved one who does not have the problem is the one who has spent hours online researching alternatives to the surgery. That spouse may have come across very troubling studies from the world’s leading medical universities and hospitals. One of the things that this spouse may have come across is that a “bad MRI” can be deceiving and send people to a surgery they should not get. How can this be? Let’s look at what the surgeons and radiologists are saying.
Are you getting cervical spine surgery for the wrong problem? Cervical radiculopathy mimics
An April 2022 paper in the journal Muscle & Nerve (17) discusses the possible mimics that can cause a misdiagnosis of cervical radiculopathy.
“Musculoskeletal cervical radiculopathy mimics include: (1) head/neck pain, such as neck tension, cervicogenic headache, and temporomandibular disorder; (2) referred pain from shoulder pathology, such as rotator cuff tears/impingement; (3) elbow (problems such as elbow osteoarthritis, medial epicondylitis, and lateral epicondylitis; (4) wrist/hand conditions, such as DeQuervain’s tenosynovitis and intersection syndrome; (5) muscle connective tissue disorders, including myofascial trigger points; (6) conditions that have decreased range of motion, including frozen shoulder and rounded shoulders with tight pectoral/scalene muscles; (7) conditions with joint hyperlaxity and instability, as seen in post-stroke shoulder subluxation; (8) vascular conditions, such as thoracic outlet syndrome; and (9) autonomic controlled soft tissue changes associated with complex regional pain syndrome.”
How the cervical spine MRI could be “read the wrong way”
The goal of a March 2019 study was to demonstrate that master’s chiropractic students could effectively and properly read an MRI of the cervical spine. What is important in this study from our point of view is that the researchers of this study published in the journal Chiropractic & Manual Therapies (1) made these observations about how MRI could be “read the wrong way,” and possibly send people to a surgery that would not be addressing the cause of their pain or radiculopathy issues.
- The most prevalent MRI findings were foraminal stenosis (77%), uncovertebral arthrosis (74%), and disc degeneration (67%) while the least prevalent finding was nerve root compromise (2%).
- The image above explains what foraminal stenosis is. The narrowing of the vertebral space where the nerves exit the spine.
- Uncovertebral arthrosis is disc degeneration and bone spur formation at the C3-C7 area at the “Luschka’s joint.”
- Cervical disc degeneration is the flattening and rupturing of the disc between the vertebrae. When this disc flattens, problems of foraminal stenosis become more apparent as the loss of disc space creates a narrowing without bone spurring.
- Disc degeneration was categorized as:
- 1) ‘normal’ (normal disc height and disc signal intensity),
- 2) ‘mild disc degeneration (slightly reduced disc height and decreased disc signal intensity),
- 3) ‘moderate disc degeneration’ (moderate reduced disc height) and
- 4) ‘severe disc degeneration (collapsed disc space).
- Disc degeneration was categorized as:
MRI and DMX a brief introduction explaining the difference and accuracy in understanding nerve compression
The concern present above is that the MRI may present evidence for a surgery that is not needed. In our office, we utilize a different diagnostic tool, a DMX.
In the video below of a Digital Motion X-ray or DMX, the patient’s motion (in this case Dr. Hauser is the cervical radiculopathy patient) demonstrates that nerve compression can come and go with neck movement. This may explain why in the above research nerve root compromise was only seen in 2% of patients suffering from cervical radiculopathy. The MRI is a static picture taken of the patient in the “proper MRI position of “don’t move.” During the DMX the patient needs to move to show our doctors and clinicians at what point during the neck’s range of motion that nerve pinching is actually occurring.
In returning to the research reported in the journal Chiropractic & Manual Therapies, the researchers noted the prevailing medical research which agrees that:
- The use of Magnetic Resonance Imaging (MRI) in the search for biological causes of neck pain remains controversial as studies have shown that degenerative changes in the cervical spine are also common in healthy volunteers. In other words, people with pain and no pain can have the same looking problems on MRI.
- There is no available evidence supporting MRI findings as predictive of treatment effects in people with neck pain. In other words, if the MRI is showing a problem, it does not recommend a treatment that will likely work.
Although some MRI findings seem to be more prevalent in symptomatic people compared to those without neck pain, the limitations of the studies described above prevent a clear conclusion. Also, as this is a cross-sectional study of a population with neck pain, the data cannot inform the association between MRI findings and the presence of symptoms, e.g. neck pain.
Researchers question the validity of diagnostic tools such as MRI and understanding what these readings and other investigational tools provide the patient by way of treatments that help.
A February 2018 study published in the journal Musculoskeletal Science and Practice (2) helps to shed light on the challenges doctors and patients share in understanding cervical radiculopathy.
Here researchers from the University of Southampton made observations surrounding the validity of diagnostic tools such as MRI and understanding what these readings and other investigational tools provide the patient. Then the researchers asked the patients what did these MRIs and other investigational findings provide them?
Did the MRI make the patient’s treatment or understanding of their problems better?
Here are the bullet points from this study:
- “Clinical guidelines recommend that investigations, such as magnetic resonance imaging, are offered only when likely to change management. Meanwhile, the optimal process of diagnosing radiculopathy remains uncertain and, in clinical practice, differences of opinion can occur between patient and clinician regarding the perceived importance of investigations.”
- COMMENT: In our experience, we have found most times, it is the patient who wants the MRI and it is the clinician who is trying to give them the realistic opinion that the MRI is not needed.
- “When investigations revealed potentially relevant findings, people experienced relief, validation, empowerment and decisive decision-making.”
- COMMENT: In our experience, no matter what the MRI showed, if it showed any abnormality the patient was pleased. WHY? Because for many patients with cervical problems, many times they are not believed, their problems are considered “all in their head.” The MRI is validation.
- “Disappointment emerged, however, regarding treatment options and waiting times, and long-term prognosis.”
- COMMENT: There is no comment here. If you are reading this article this probably describes you or a loved one. the MRI gave you validation, but not a game plan to help you.
- “When investigations failed to identify relevant findings, people were unable to make sense of their symptoms, relinquish their search to identify the cause, or to move forward in their management.”
- COMMENT: Because the MRI did not correspond with the patient’s symptoms, the patient now feels hopeless. If you are reading this article this probably describes you or a loved one.
Does this sound like your path of treatment?
- You went to a specialist, you had an MRI.
- The MRI showed something.
- You were happy, now you have something to confirm why you suffered from a myriad of symptoms.
- BUT THEN, you were told of the treatment options, likely painkillers, physical therapy, and cortisone injections and if they did not work, then you would need surgery.
The MRI wants to show you a significantly herniated disc. We will show you that disc herniation may not be a factor at all.
Cervical radiculopathy is generally considered to result from pressure from a herniated disc, arthritis, or other injuries that increase pressure on these nerve roots. In 1998, German doctors writing in the journal Investigative Radiology (3) demonstrated that provocative movements such as flexion, extension, and rotation, rather than to the size of the herniated disc, worsened cervical radicular pain. Provocative movements are what we examine with the DMX.
So it was not the size of the herniation that caused cervical radiculopathy issues, it was the unstable motion of the cervical vertebrae.
Provocative movements such as flexion, extension, and rotation, cause pain by variation in the passage size of the neural foramen. This is the opening in the cervical spine vertebrae that allows the passage of spinal nerve roots to exit the spine.
As shown in the graphics and the video below, various motions changed the foraminal size, nerve root motion, and cervical cord rotation. When arthritis or stenosis was present, the increased radicular pain was also related to the movement of the cervical spine as it narrowed the foraminal opening.
If the changes in foraminal size with motion cause an exacerbation in cervical radicular pain, it would follow that any instability in the cervical spine would exacerbate the radicular pain as well, since instability causes even more motion in the joint.
- The foraminal size will change as an individual carries out their normal daily activities, bending and rotating the neck.
- During these activities, the nerve root will get compressed intermittently as it exits the neural foramen.
- When the person assumes a different position, the nerve root contact may be relieved. In the study, movements such as flexion tended to relieve compression caused by cervical stenosis, and extension tended to produce more symptoms.
- Positional narrowing of the foramina or degenerative issues leading to radicular pain is exacerbated by the instability of the cervical spine.
In our experience, the instability of the spine is caused by injury to the cervical ligaments. Ligaments are connective structures that connect bone to bone and aid in the stabilization of the cervical vertebrae.
In this video, DMX displays Prolotherapy before and after treatments that resolved problems of a pinched nerve in the cervical spine
- In this video, we are using a Digital Motion X-Ray (DMX) to illustrate a complete resolution of a pinched nerve in the neck and accompanying symptoms of cervical radiculopathy. A discussion of the Prolotherapy treatment is below.
- A before digital motion x-ray at 0:11
- At 0:18 the DMX reveals completely closed neural foramina and a partially closed neural foramina
- At 0:34 DXM three months later after this patient had received two Prolotherapy treatments
- At 0:46 the previously completely closed neural foramina are now opening more, releasing pressure on the nerve
- At 1:00 another DMX two months later and after this patient had received four Prolotherapy treatments
- At 1:14 the previously completely closed neural foramina are now opening normally during motion
Our published research on cervical radiculopathy as a problem of instability NOT herniation.
A few years back, our research team at Caring Medical wrote in the Journal of Prolotherapy:(4)
“Even when faced with severe disabling pain, many patients desire a non-surgical approach to their problem. While anti-inflammatory medications and oral corticosteroids can decrease nerve inflammation, some cases of cervical radiculopathy necessitate injecting steroids directly into or around the inflamed nerve.
Patients who have not responded to physical therapy, oral medications, and other conservative treatments, or those whose cervical radiculopathy symptoms and radiographic findings make them surgical candidates, can still experience significant benefits with a cervical epidural and periradicular steroid injections and do not need surgical intervention.
An Orthopedic Surgery Task Force on Neck Pain that appraised the scientific literature from 1980 to 2006 on surgical interventions for neck pain alone or with radicular pain concluded, “it is not clear from the evidence that long-term outcomes improved with the surgical treatment of cervical radiculopathy compared to nonoperative measures.”
Dynamic vs. Static Cervical Spinal Stenosis
The effects of ligament damage on cervical spine instability are far-reaching. Neck motions affect the whole neural tree. Any change in the normal stable lordotic architecture of the cervical spine can hamper nerve signal propagation through the neck. Nerves translate in various directions every time the body moves, and this includes the cervical nerve roots. The cervical nerve roots typically occupy one-third of the normal space in the average cervical neural foramina. This means the average, healthy cervical spinal nerve root does not have that much space on each side of it. It is well known that motions of the neck change the neuroforaminal dimensions (the space the nerves travel through). When cervical ligament damage is present, the intervertebral foramina can close off completely (pinch and herniate) with extension (head back looking up) and cause cervical instability-radiculopathy. Osteophytes (bone spurs) and the changes of cervical degenerative disease narrow the neuroforaminal space, producing radicular symptoms in the shoulder, arm, hand, or scapular region. In our office, digital motion x-rays (videofluoroscopy, DMXs) are done with the person upright and in differing motions and can be repeated several times to catch pathology such as cervical instability-radiculopathy.
The caption reads: Digital Motion X-Rays (DMX) documenting the closure of several cervical neural foramina.
- A. Neural foramina C3-C7 are open in this oblique view of neck extension.
- B. The Neural foramina C3-C7 are open in this oblique view of neck extension (arrow).
- C. In this 3rd neck extension, the C4 neural foramen is closed (arrow).
- D. The neural foramina from C4-C7 are all closed (arrows) in this 4th pass of neck extension.
Data may have implications for the diagnosis and treatment of patients with cervical radiculopathy
MRIs have shown that symptoms of cervical radiculopathy correlate more with the changes in neural foraminal space with motions such as extension and axial rotation than with the size of the disc herniation.
This was documented in a 1998 paper in the journal Investigative Radiology (15) which wrote: “In patients with cervical disc herniation or cervical spondylosis, exacerbated pain at defined provocative maneuvers is related more to changes in the foraminal size and to nerve root motion with, in some cases, cervical cord rotation or displacement than to changes in the size of herniated discs.” This research was cited in a 2016 paper from Harvard Medical School published in the Spine Journal (16). The paper notes: “The dimensional changes of the cervical neuroforamina showed segment-dependent characteristics during the dynamic flexion-extension. These data may have implications for the diagnosis and treatment of patients with cervical radiculopathy.
Positional cervical cord compression
Cervical spine instability can also cause positional cervical cord compression. In a normal healthy individual, the spinal cord is round and has 2-3 mm of “extra” space surrounding it. Cervical instability can cause a torque on the spinal cord, causing it to be more oblong and thus filling up the spinal canal space and obstructing cerebrospinal fluid (CSF) flow.
What are we seeing in the image below? Multiple cuts of a CT scan of this neck demonstrate cervical cord tension. The caption reads:
- A. Sagittal view showing many areas of spinal cord kinking (arrows).
- B. Axial view of lower cervical (segment) showing normal, round spinal cord surrounded by (white) spinal fluid.
- C & D. Axial views of the mid-cervical region. Notice the spinal cord is no longer round but oblong and even flat in places on the anterior side (D, arrow), without much cerebrospinal fluid on its anterior surface.
Ultimately, this narrowing of the spinal canal size increases the risk of myelomalacia symptoms can range anywhere from lower extremity weakness, dull or severe pain to the leg or arm, abdominal spasticity, to a disconnection between what the brain wants the legs to do and what they actually do.
Along with the cervical spinal collapse in cervical degenerative disease or cervical dysstructure, comes the narrowing of key spaces in the spinal canal and neuroforamina. The more narrowed the spaces, the more likely compression or tension will be placed on the spinal cord and brainstem attached to it, as well as on the cervical nerve roots. Dynamic or positional radiculopathy and spinal stenosis denote a motion component to the condition whereby certain positions or motions change its symptomatology: typically, flexion by opening the spinal canal and neural foramina relieve symptoms. Contrast that case with static spinal stenosis or radiculopathy where the condition is caused by a narrow space from bony overgrowth or a congenitally narrowed spinal canal.
Comparison of static vs. dynamic spinal stenosis and radiculopathy. In static spinal stenos and radiculopathy, the spinal cord and/or nerve roots are being compressed because the space is always too narrow, whereas in dynamic spinal stenosis and radiculopathy there are positions and movements that narrow the space. This is significant because static stenosis may need surgery and the dynamic spinal stenosis typically responds well to more conservative treatment approaches such as chiropractic adjustments, physiotherapy, and or/Prolotherapy.
Dynamic cervical spine stenosis can be one of the potential etiologies of a person feeling like their legs are disconnected from their brain as spinal nerve impulses are blocked. With cervical spine instability, the ligament weakness is such that it cannot prevent the cervical vertebrae from moving and narrowing in the upright position, thus compromising nerve flow. When symptoms can be relieved by a position or motion, such as laying down or neck flexion, or reducing ligament strain by wearing a cervical collar, it is a good prognostic indicator that conservative therapeutic measures such as chiropractic, physical therapy, and/or Prolotherapy injections will give relief. (Please see my article A Review of Prolotherapy injections for Craniocervical instability with Ross Hauser, MD). When static spinal stenosis progresses to myelomalacia, surgery may be warranted.
The narrowing of specific neurological spaces such as the intervertebral neural foramina and spinal canal, and osteophytosis, can encroach on key neurovascular structures. The key question to answer is whether the encroachment is reversible with a specific posture or motion.
Risks and complications of cervical epidural steroid injections
The idea behind cervical epidural steroid injections is that you do have a disc problem and that the disc’s innards are either bulging or leaking onto the nerve roots causing irritation, inflammation, pain, and numbness down your neck, into your upper back, into your shoulder all the way to your fingers. The hope is that by offering a cervical epidural steroid injection, the clinician can reduce the inflammation surrounding the nerve and the pressure it is creating.
When we determine who would be a good candidate for our treatments if the person had a cervical epidural steroid injection and it provided some degree of relief for the short-term, that gives us a good indication that we can help this patient on a more permanent basis.
Epidural steroid injections are usually not a one-time/long-term solution. The goal of the treatment is to reduce the inflammation enough and long enough to allow the disc time to heal its wounds, so it is not leaking or pressing on the nerves. Most times it does not work.
“Cervical epidural injections provide no long-term benefit and are being performed for minimal to no indications”
Dr. Nancy Epstein Professor of Clinical Neurosurgery, School of Medicine, State University of NY at Stony Brook, published these findings in the April 2018 issue of Surgical Neurology International. (5)
- Too many patients, with or without significant cervical disease, unnecessarily undergo cervical epidural steroid injections. These include interlaminar and transforaminal epidural steroid injections that are not Food and Drug Administration approved, have no documented long-term efficacy, and carry severe risks and complications.
- Major complications included; epidural hematomas, infection (abscess/meningitis), increased neurological deficits due to intramedullary (quadriparesis/quadriplegia), and intravascular injections (e.g., vertebral artery injections leading to the cord, brain stem, and cerebellar strokes). The latter injections leading to strokes were typically attributed to the particulate steroid matter (e.g., within the methylprednisolone injection solution) that embolized into the distal arterial branches.
Cervical epidural injections which are not FDA approved, provide no long-term benefit and are being performed for minimal to no indications. . . . Furthermore, these injections are increasingly required by insurance carriers prior to granting permission for definitive surgery, thus significantly delaying in some cases necessary operative intervention, while also subjecting patients at the hands of the insurance companies, to the additional hazards of these procedures.
In a June 2019 study in the journal Pain Medicine (6), research led by the University of Utah suggested that “Approximately 50% of patients experience better than a 50% pain reduction at short- and intermediate-term follow-up after (cervical epidural). However, the (medical) literature is very low quality primarily due to a lack of studies with placebo/sham or active standard of care control comparison groups.” In other words, it is unclear if some of the patients experienced a placebo effect.
A May 2022 study in The Bone & Joint Journal (18) wrote: “For patients with severe (cervical radiculopathy) and poorly controlled symptoms who may not be candidates for surgical management, treatment with transforaminal epidural steroid injections has gained widespread acceptance. However, (there is a lack of) high-quality evidence supporting their use balanced against perceived high risks of the procedure potentially undermines the confidence of clinicians who use the technique. (However . . . ) Concerns regarding the occurrence of catastrophic complications, widely shared in the case report and anecdotal literature, were not found when reviewing the best available evidence.”
In this video Ross Hauser, MD. discusses when cervical fusion should be considered and when other options should be explored. The video’s summary text is below.
- Many people get great benefits from cervical fusion surgery. These are the people we typically do not see in our office. We see the people with more complicated and undesired results of cervical fusion surgery.
- In the video, Dr. Hauser discussed a case sent to him by a European colleague. The doctor described it as one of the worst-case he has ever seen.
- An example is a 15-year-old patient. Typically doctors do not like to perform cervical fusion on an adolescent because they are still growing.
- In this patient, like some older patients, the segments above and below the fusion became painful and resulted in cervical pressure and instability. Second fusion surgery was needed. The second fusion resulted in less neck movement and worsening severity of the patient’s symptoms.
- At 1:08 of the video, the x-ray is discussed and the massive instability in the cervical spine at C6 and C7 is shown.
- There are times when there is no option but to consider a fusion surgery. These times are when the spinal cord is compressed or there is fracturing from an accident or injury. But if these problems are not present and cervical spine ligament injury and laxity are present, then treatments that address the cervical spine ligaments should be considered. One such treatment is Prolotherapy which we will discuss below.
Surgeons give evidence against surgery for Cervical Radiculopathy
Doctors from the Department of Neurosurgery, McGill University, Montreal, Quebec, Canada wrote in the medical journal Spine (7) their outcomes in measuring the success of surgery for cervical Radiculopathy:
The study was to determine whether anterior cervical discectomy and fusion, cervical disc replacement, or minimally invasive posterior cervical foraminotomy provide the best outcomes for patients with symptomatic single-level, single-side, cervical radiculopathy.
The surgeons of this study do note that surgical treatment of cervical radiculopathy is still controversial.
- Anterior cervical discectomy has been widely used as a “gold standard” for cervical pain.
- Cervical discectomy and fusion have evolved and become a motion-preserving alternative with a potentially lower incidence of adjacent segment disease.
- However, both techniques require anterior neck dissection that carries a potential for serious side effects and a worsening condition for the patient. Minimally invasive posterior cervical foraminotomy is a motion-preserving technique that can be performed with minimal invasiveness but has not gained universal acceptance.
In reviewing over 350 studies, the doctors found all three techniques effective in treating cervical radicular symptoms. Minimally invasive posterior cervical foraminotomy has the lowest rate of adverse events and complications while cervical disc replacement has the lowest rate of secondary procedures.
There is insufficient evidence to show which technique is the most effective and provides the longest-lasting symptom relief.
Minimally invasive procedure for cervical radiculopathy.
A September 2017 study (8) also discusses the short-term/long-term problem with determining the success of a minimally invasive procedure for cervical radiculopathy.
German doctors writing in the medical journal Orthopedics and traumatology examined surgical techniques designed to relieve foraminal root impingement due to lateral soft disc fragments, bony spurs, or other rarer causes. Lateral soft disc fragments or pressing of the disc material on the nerve accounts for possibly 7 – 12 % of disc herniations.
The doctors report success and less than successful outcomes:
- Minimally invasive posterior cervical foraminotomy (the bone was drilled away to allow more room for the nerves) was used to treat 103 patients for unilateral cervical radiculopathy.
- After follow-up to 32 months average Despite 1 cerebrospinal fluid leak, 1 wound hematoma, and 1 radiculitis during the early postoperative period, (10% serious side effect) no patients required revision surgery. No revision surgery but other surgeries were required, see below
- Pain scores for neck/shoulder and arm improved significantly in the early postoperative period (3 months) and were maintained with time.
- Neck Disability Index improved significantly postoperatively but worsened slightly during follow-up.
- Anterior decompression and fusion were required at the index level by 3 patients on average 55 months later
and at the adjacent level by 4 patients (average 27 months later).
Thirty-three patients – nearly 10% risk of complication after surgery, 4 out of 32 require adjacent surgery within 2.5 years, more surgery for three more patients within 5 years. This is considered successful surgery.
Anterior cervical foraminotomy to fix cervical disc replacement surgery failure
An April 2022 paper in the International Journal of Spine Surgery (19) comes from doctors at the Cedars-Sinai Spine Center in Los Angeles International journal of spine surgery. Here the doctors discuss the problems of persistent or recurrent radicular symptoms after cervical artificial disc replacement for cervical spondylotic radiculopathy in some patients and describe using anterior cervical foraminotomy to provide symptom relief in such patients without the need to convert to a fusion or remove the artificial disc replacement implant. (A foraminotomy enlarges the openings through which spinal nerve root branches from the spinal canal.)
- Results: Five patients with recurrent radicular symptoms after artificial disc replacement were reviewed. Two anterior cervical foraminotomies were performed at C5-6, and 2 were performed at C6-7. Four patients developed ipsilateral recurrent radicular symptoms, and only 1 patient developed contralateral new radicular symptoms. Three patients reported complete resolution of their new or recurrent radicular symptoms following anterior cervical foraminotomy, and 2 patients reported only partial resolution. No patients required conversion to a fusion.
Conclusions: In patients with recurrent symptoms of cervical spondylotic radiculopathy following artificial disc replacement, anterior cervical foraminotomy with uncovertebral joint resection can be used to provide direct foraminal decompression without the need for implant removal. This approach also preserves motion at the affected level, preserves cervical spinal stability, and prevents the need for spinal fusion.
But I need to get back to work – Surgery may prevent that from happening quickly or at all
August 2018: A combined research team from New York University NYU Hospital for Joint Diseases, the Rothman Institute, Thomas Jefferson University, Duke University, University of Kansas Hospital, and the NY Spine Institute issued these findings on the factors impacting cervical radiculopathy patients after surgery. (9) Included was when did these people go back to work after the surgery.
- Among 1319 cervical radiculopathy patients,
- 25.7% received preoperative epidural injections,
- 35.3% received physical therapy, and
- 35.5% received opioids.
- Radiculopathy patients receiving epidurals returned to work after 1 year more frequently.
- Physical therapy was associated with shorter hospitalizations and increased return-to-work rates after 1 and 2 years.
“These findings suggest certain preoperative conservative treatment modalities are associated with improved outcomes in radiculopathy patients.”
Please note: The time factors for return to work are being measured in years.
Research: “How Knowledgeable Are Spine Surgeons Regarding EMG-NCS for Cervical Spine Conditions?”
Besides history and physical examination, cervical radiculopathy is diagnosed by doing electromyography and nerve conduction velocity (EMG/NCV) tests of the spine and the extremity that has the symptoms. These diagnostic tools test for spontaneous electrical activity in muscles that are innervated by specific nerve roots as well as the velocity of the conduction of the individual nerves. Together this information can tell if there is a problem in the electric grid (nervous system) from the neck to the arm (or the lower back to the leg).
Doctors at the Department of Neurology, Discipline of Neurosurgery at the University of Campinas in Brazil, Department of Orthopaedics, Department of Neurological Surgery, Weill-Cornell Medical Center, The Och Spine Hospital at New York-Presbyterian, Columbia University Medical Center in New York, conducted a study in the Global spine journal, published January 2022. (14)
This study evaluated the knowledge of spine surgeons regarding the use of electromyography (EMG) and nerve conduction studies (NCS) for degenerative cervical spine conditions. To do this, they mailed all the members of the AO Spine International (“The leading global academic community for innovative education and research in spine care”) were emailed an anonymous survey to evaluate their clinical knowledge about the use of EMG and nerve conduction studies for degenerative cervical spine conditions. Descriptive statistics were used to analyze the results, as well as to compare the answers among different groups of surgeons and assess demographic characteristics.
- There were 221 orthopedic surgeons (55.39%) and 171 neurosurgeons (42.86%), more than half of them with a complete spinal fellowship (56.44%).
- The most common reason that surgeons obtain the test is to differentiate radiculopathy from peripheral nerve compression (88.06%).
- As a group, the responding surgeons’ knowledge regarding EMG-NCS was poor.
- Only 53.46% of surgeons correctly answered that EMG-NCS is unable to differentiate a C5 from C6 radiculopathy.
- Only 23.47% of the surgeons knew that EMG-NCS are not able to diagnose a pre vs a post-fixed brachial plexus.
- Only 25% of the surgeons correctly answered a question regarding the test’s ability to diagnose other neurological diseases.
Conclusions: We found that our respondents’ knowledge regarding EMG-NCS for degenerative cervical spine was poor. Identifying the weak points of knowledge about EMG-NCS may help to educate surgeons on the indications for the test and the proper way to interpret the results.
While disc herniation can easily be seen on routine (static) MRI or CT scans, evidence of radiculopathy from cervical instability cannot. Once you know which nerve root clinically (by symptoms) is involved, you can look for instability at the appropriate vertebral motion segment. The test we recommend is a digital motion x-ray which is documented below.
The neurological manifestations of cervical spine instability and degeneration
When exploring non-surgical options, such as Prolotherapy injections discussed later, the understanding that the neurological manifestations of cervical spine instability and degeneration may be due to a variety of mechanisms is of great importance. These include:
- (1) cord compression (myelopathy),
- (2) nerve root compression (radiculopathy),
- (3) local irritation – irritation of mechanoreceptors and nociceptive nerve structures within the intervertebral motion segments (ligaments),
- (4) vertebral artery compromise, and
- (5) autonomic dysfunction – nerve damage along with autonomic neuropathy or dysautonomia.
It is important to understand the difference between these five mechanisms, as it helps one understand when Prolotherapy is an appropriate treatment option and when a surgical consult is recommended.
Cervical instability can be treated in many ways as mentioned above. There is treating the symptoms and there is treating the cause. Treating the cause involves treating neck instability whether with surgery or non-surgical methods.
Exercise and therapy are one way to address the problems of instability.
September 2017: Investigators writing in the Journal of Back and Musculoskeletal Rehabilitation (10) wrote of “The effect of stabilization exercise training on pain and functional status in patients with cervical radiculopathy.”
In this study, the researchers found a favorable patient response after a 3-month program in pain and neck disability, better postural scores, handgrip, and SF-36 scores (A scoring system that measures pain, social interaction, and general health among other questions), improved.
The researchers were able to conclude that stabilization exercise training could be an effective intervention for decreasing pain and improving quality of life and posture in patients with cervical radiculopathy.
Exercise for people developing cervical radiculopathy because of electronic products, such as computes and cell phones
November 2019: researchers writing in the journal Medicine (11) wrote that some studies have shown that exercise or exercise combined with other treatments can effectively decrease pain and improve functional status in patients with cervical radiculopathy. What they found was exercise alone or exercise plus other treatments (in this research medications) may be helpful to patients with cervical radiculopathy. However, the exercise option should be carefully considered for each patient with cervical radiculopathy in accordance with their different situations.
In other words, exercise will not work for everyone. We have found that the main reason is that for exercise to work, muscles need resistance. If the tendon attachments of the neck muscles and the cervical spinal ligaments are weakened or injured, they will not supply the resistance necessary to make exercise or physical therapy work.
The non-surgical comprehensive Prolotherapy treatment methods for treating cervical radiculopathy: The medical history of two patients including my own.
In spinal stenosis, the altered tension on the spinal cord comes from the dura through the dentate ligaments. This “damaging” pulling of the spinal cord via the dentate-dural connection occurs with motion or specific positions, causing spinal cord signals to be blocked or altered, meaning there is a positional aspect to it. The reversibility of radiographic findings by motion is a key step in resolving symptoms and medical conditions through conservative treatments. When a digital motion x-ray demonstrates that even a posterior osteophyte complex encroaching on the spinal cord is reducible by improvement of the spinal curve, a successful treatment regimen can be instituted to permanently improve the spinal canal space by curve correction and Prolotherapy as needed.
What are we seeing in this image?
Impingement of spinal cord from posterior C4 vertebrae improved with curved correction:
- A. MRI scan
- B. X-ray in a neutral position as can be seen from the X-ray still the posterior portion of this person’s C4 vertebrae body (arrow) is narrowing the spinal canal and causing impingement on the spinal cord
- C. Initial x-ray after putting on chest weight impingement of this person’s spinal cord was significantly reduced by putting on a chest weight. Impingement of this person’s spinal cord was significantly reduced by putting on a chest weight that drastically improved their curve. This can be a prognostic indicator that the person’s spinal cord compression will resolve with the conservative care of curve correction and Prolotherapy.
Below are two case studies, my own and that of a 38-year-old male patient we documented in our medical research. While both studies are male subjects I want to point out in the research that women are more affected by cervical radiculopathy issues than men.
This was documented by Polish researchers who wrote of quality of life assessment in patients with spinal radicular syndromes:
“In the female patients suffering from spinal radicular syndromes, the pathological process was most commonly located in the cervical spine, . . . Ailments associated with spinal radicular syndromes affect the quality of life of the female patients studied in this research to a greater extent than the male patients, both in terms of mental and physical well-being. . . (Also) the intensity of pain associated with spinal radicular syndromes progresses with age.”(12)
Two case studies of treatment for cervical radiculopathy
Subject: A 38-year-old male complains of severe pain in his neck that radiated down his right arm with numbness of his right index finger and posterior wrist (C6 distribution). His pain began earlier that month after lifting a TV. Prior to this injury, he was an active person who was pain-free. The patient stated that his pain was at its worst when lying down (a 10 out of 10 pain), but is helped by wearing a neck brace while sleeping. He was taking Norco two to three times per day for pain, a Medrol dose pack, and Daypro at the time of his first visit. An MRI ordered by his primary doctor revealed a right-sided disc herniation at C5-C6 and C6-C7.
Upon initial exam, his right arm muscle strength was normal but had slightly diminished sensation in the C6 dermatome (an area of skin that the nerves pass through, in this case, the C6 area. Upon extension of his neck and right lateral rotation, he had shooting pains down his right arm. The patient received Prolotherapy on his first visit to his entire neck and right scapular region. He was taken off Norco and Daypro and given Ultram for pain and Ambien to help him sleep.
He returned every 2 weeks for the same treatment and at the 3rd visit he reported a 50% improvement in pain. His pain was down to 5 out of 10. He still had numbness in his right index finger after lying down. He moved his appointments to every 3 to 4 weeks over the next few treatments and at his 5th visit he reported 70% improvement in pain and that he no longer had pain unless he was lying down. His finger was unchanged at this time.
The patient continued Prolotherapy treatment every 6 weeks or so over the next few treatments and, at what would have been treatment #9, he reported that his neck was doing “really good.” He did not receive treatment at this visit to his neck but wanted to get his knees and feet treated for unrelated injuries because Prolotherapy had worked so well on his neck. He was on no pain medication for his cervical radiculopathy after his 8th visit and the sensation in his right index finger and posterior wrist was back to normal. He was also back to full activities including exercise. Six months after his last Prolotherapy treatment he continues to do well.
Actual Prolotherapy treatment
Caring Medical has published dozens of papers on Prolotherapy injections as a treatment for difficult to treat musculoskeletal disorders. We are going to refer to our 2014 study where we published a comprehensive review of the problems related to weakened damaged cervical neck ligaments.
Prolotherapy is referred to as a regenerative injection technique (RIT) because it is based on the premise that the regenerative/reparative healing process can rebuild and repair damaged soft tissue structures. It is a simple injection treatment that addresses very complex issues.
This video jumps to 1:05 where the actual treatment begins.
This patient is having C1-C2 areas treated. Ross Hauser, MD, is giving the injections.
In 2015, our research team published our findings in our paper “The biology of prolotherapy and its application in clinical cervical spine instability and chronic neck pain: a retrospective study.” This peer-review research was published in the European Journal of Preventive Medicine. (6)
Here we wrote: “In an effort to facilitate the diagnosis and treatment of clinical cervical spine instability and chronic neck pain, we investigated the role of proliferative injection Prolotherapy in the reduction of pain and recovery of constitutional and neurological symptoms associated with increased intervertebral motion, structural deformity and irritation of nerve roots. . . 95 percent of patients reported that Prolotherapy met their expectations in regards to pain relief and functionality.”
Ross Hauser MD, Cervical Radiculopathy Patient
Here is my own story:
In January 2008, I had the best race of my life when I ran a 1:29:53 and placed 82nd out of over 12,000 people in the Disney Half Marathon. I made the podium for my age group (45 to 49).
The next day I paced my wife, Marion, to a 5:11 marathon. Within a few weeks after this, I noticed severe pain in my right scapula after a swim workout. I was unable to do my planned workouts over the next few days as the pain grew worse.
Eventually, it was completely disabling, causing me to keep my neck flexed and often my right arm raised with my palm on the back of my head to provide relief. The pain was severe on the right side of my neck, and right scapula and felt like a hot poker digging into the back of my right hand, between my thumb and index finger. The pain was making work very difficult, and despite pain medication, the pain continued.
I eventually had an MRI and X-rays of my neck. The MRI showed no surgical lesions but did show extension degeneration bilaterally, especially in the C5-C6 region. (See Figure 1.)
The neck radiograph showed a straight cervical spine with loss of cervical lordosis and a posterior, right, superior C6 vertebra. (See Figure 2.)
Trying to choose the most conservative treatment, chiropractic, physiotherapy, high-velocity manipulation, and some physical therapy were done. After several weeks and a 50% reduction of the pain, a videofluoroscopic analysis was performed. This still showed a posterior right C6, but the alignment and motion of the upper cervical spine were improved. I was treated with the Pierce Technique of chiropractic. This had me to 85% improvement, but after a bike accident (yes, I was still training), I regressed back to the severe neck, scapular, and arm pain. At this point, a series of Prolotherapy treatments were started using stronger solutions in the left lower cervical region to help with spinal alignment. The first Prolotherapy alone produced definite improvement. Within a couple of weeks after the first Prolotherapy treatment, I was back on my bike and exercising almost daily. By early April, I was back to Ironman training.
In total, I needed four Prolotherapy visits but I am happy to say that in July 2008, I completed the Ironman in Lake Placid, despite it pouring rain the whole time. After swimming 2.4 miles and cycling 112 miles in the pouring rain I was still able to run a 4-hour 20-minute marathon.
Recap and Summary
Even when a person has cervical spinal stenosis and symptoms of cervical radiculopathy, the cause of the symptoms can be cervical instability. Most joint instability symptoms, including those of the cervical spine, occur with motion. When a person’s symptoms are dynamic or change drastically from no symptoms at rest or while sitting to more intense with standing or walking or turning their head, Prolotherapy may be considered. Positional radiculopathy, which denotes a condition where the nerves exiting the spine are being affected (besides the spinal cord), is a condition that responds well to Prolotherapy. Typically, this condition is periodic or positional, meaning symptoms are not present all the time and can be relieved by various neck positions or maneuvers. The principles addressed here can be applied no matter what the symptoms. An example is a patient who had a lot of pain with swallowing that was relieved when not swallowing. Again this symptom was not there 24/7, it had to do with a specific activity. When the swallowing muscles are activated, the person’s symptoms increase. As it turns out, most of the nerves that supply the muscles for swallowing reside in the carotid sheath including the vagus nerve. This patient was found to have an enlarged vagus nerve on the right side, presumed to be from long-standing cervical instability. The patient received a combination of Prolotherapy for their upper cervical instability, along with Nerve Release & Regeneration Injection Therapy to the carotid sheath area (released cranial nerves 9-12) and PRP injected (Please see my article Treatment of neck instability) into and around the same nerves. Over the course of several months and treatments, her symptoms lessened drastically. Interestingly on the same day, I treated a patient similarly who had paresthesias of the tongue and decreased sensation and taste sensation. Again these symptoms are primarily from cranial nerves 9-12 and these nerve compressions must be addressed to resolve these symptoms. I gave the patient a combination of Prolotherapy, and nerve decompression with NRIT, and the symptoms resolved over several months. PRP was not needed to be injected into and around the cranial nerves including the vagus nerve in this patient.
Do you have questions about Cervical Radiculopathy treatment? You can get help and information from our Caring Medical Staff.
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This articles was updated May 7, 2022