Non-Surgical Cervical radiculopathy treatments
The difficulty in diagnosing cervical neck pain origins can be seen in the medical discussion and myriad of symptoms circulating around the diagnosis of cervical radiculopathy. In this article we will explore these challenges as well as present treatment options including the use of Prolotherapy, a non-surgical treatment for cervical radiculopathy as well as examine the latest research on cervical radiculopathy surgery.
Before you continue reading, if you have a question, get help and information from our Caring Medical staff.
Cervical radiculopathy is a condition of nerve function disturbance resulting from the compression of the nerve roots near the cervical vertebrae. This disturbance can damage the nerve roots in the cervical area and cause pain and loss of sensation in different parts of the upper extremities, depending on the location of the damaged roots.
Pain is the main symptom of cervical radiculopathy and is experienced spreading into the arm, neck, chest, upper back and shoulders. There may also be weakness, numbness, or tingling in these various areas. Sometimes there is a lack of coordination, especially in the hands.
Cervical radiculopathy diagnosis and treatment confusion
A February 2018 study published in the journal Musculoskeletal science and practice helps to shed light on the challenges doctors and patients share in understanding cervical radiculopathy.(1)
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 it make their treatment or understanding of their problems better? Here are 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.”
- “When investigations revealed potentially relevant findings, people experienced relief, validation, empowerment and decisive decision-making.”
- “Disappointment emerged, however, regarding treatment options and waiting times, and long-term prognosis.”
- “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.”
Does this sound like your path of treatment?
You went to a specialist, you had an MRI. The MRI showed something. You were happy because now you had a reason for your myriad of symptoms. BUT THEN, you were told of the treatment options, likely painkillers, physical therapy, and cortisone injections. If they don’t work, surgery. Now you have research to confirm your disappointment with your treatment up until now.
Cervical radiculopathy causes – herniation is not THE factor
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 demonstrated that provocative movements such as flexion, extension, and rotation, rather than to the size of the herniated disc, worsened cervical radicular pain.(2)
So it was not the size of the herniation that caused cervical radiculopathy issues, it was unstable motion. How?
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 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 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.
Our published research on cervical radiculopathy
A few years back, I wrote in the Journal of Prolotherapy:
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.”(3)
Fall 2017 research updates: Surgery for Cervical Radiculopathy
Doctors from the Department of Neurosurgery, McGill University, Montreal, Quebec, Canada wrote in the medical journal Spine 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.(4)
A September 2017 study also discusses 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.(5)
Treating Cervical Radiculopathy is a matter of treating cervical instability
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, hand grip 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. (6)
The non-surgical comprehensive Prolotherapy treatment methods for treating cervical radiculopathy
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.”(7)
Two case studies of treatment for cervical radiculopathy
Subject: A 38 year-old male complaints 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 his 3rd visit he reported 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 a 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 right back of my 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 video fluoroscopic 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 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.
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