The evidence for non-surgical cervical radiculopathy treatments
Ross Hauser, MD, Caring Medical Regenerative Medicine Clinics, Fort Myers, Florida
David N. Woznica, MD, Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
Danielle R. Steilen-Matias, MMS, PA-C, Caring Medical Regenerative Medicine Clinics, Oak Park, Illinois
The evidence for non-surgical cervical radiculopathy treatments
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 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 a 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.
Initially, you went to your doctor and then were referred onto a cervical spine specialist or a neurologist. Here at the specialist’s office, an MRI is ordered and perhaps an Electromyogram (EMG) Test.
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.
- Even a suggestion to 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, 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 have probably reached their “wit’s end,” they do not want to live with this problem any more add 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.
How MRI could be “read the wrong way”
The goal of a March 2019 study was to demonstrate that masters 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 for treatment effect in people with neck pain. In other words, 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 is what we examine with the DMX.
So it was not the size of the herniation that caused cervical radiculopathy issues, it was 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 a 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 is 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 is 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 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.”
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 a 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, which are not FDA approved, 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 ESI 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 lead 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.
In this video Ross Hauser, MD. discusses when cervical fusion should be considered and when other options should be explored. The video’s summary test 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 the 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 ever saw.
- The example is a 15 year old patient. Typically doctors do not like to perform cervical fusion in 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. A 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 is 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. Not 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 was 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.
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.
Cervical instability can be treated in many ways as mentioned above. There is treating symptoms and there is treated 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 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. (10)
The non-surgical comprehensive H3 Prolotherapy treatment methods for treating cervical radiculopathy: The medical history of two patients including my own.
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.”(11)
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 C6 dermatome (an area of skin that the nerves that 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 at 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 of his right index finger with 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 to 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.
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, 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 at 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, including high-velocity manipulation, and some physical therapy was 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.
Figure 1. MRI of Ross Hauser showing extensive degeneration at C5-C6. This overgrowth of bone was one of the causes of my cervical radiculopathy.
Figure 2. Lateral C-spine X-ray. The curved line shows the normal curve of the cervical spine. This X-ray demonstrates a straight cervical spine, indicative of a lot of muscle spasms which commonly occur with cervical radiculopathy.
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.
Do you have questions about Cervical Radiculopathy treatment? You can get help and information from our Caring Medical Staff.
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