Ross A. Hauser, MD.

Narrowing of the bony cervical spine canal, or cervical spinal stenosis, may not be pathologic (symptom-causing) itself. But when occurring in conjunction with cervical neck instability, it can impede neurological function. What is it I am saying here? It is that your MRI can reveal cervical stenosis, it can show boney overgrowth, but that in itself may not be creating the typical symptoms of cervical radiculopathy. When you add to the boney overgrowth, cervical spine instability, and the looseness of the cervical ligaments that allow the neck bones to wander out of place, you now have a combination of problems that can lead to a worsening yet “come and go” series of symptoms of numbness, “pins and needles” and “nerve pain.”

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

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.

When your doctor looked at you, he/she may have relied on published criteria for determining a diagnosis of cervical radiculopathy. The latest comes from a  multi-national team of researchers led by the University of Birmingham in the United Kingdom who published criteria that experts agree would help define and classify cervical radiculopathy. This is what they published in the journal Musculoskeletal science & practice. (23)

• Radicular pain with arm pain is worse than neck pain.
• Paraesthesia or numbness and/or weakness and/or altered reflex.
• MRI confirmed nerve root compression compatible with clinical findings.

At this point, physical therapy or pain management will be suggested if the symptoms are not severe enough to call in an immediate surgical consultation. 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, therefore a neck surgery may be suggested. The decompressive surgery removes the bone spurs and makes more room for the nerve root. However, people sometimes have continued pain after this operation. This is explained below.

A brief introduction to understanding cervical radiculopathy

A very common problem that we see here at the Hauser Neck Center is cervical radiculopathy. It is not so much a mystery illness in that it is generally diagnosed by family physicians, and neurologists and intuitively by patients who understand that if they have arm pain and neck pain they may likely have a pinched nerve in their neck. Therefore, basically, cervical radiculopathy is a pinched nerve in the person’s neck.

A February 2024 study in the medical journal Pain (27) found that patients who suffer from degenerative cervical radiculopathy faced challenges with family support, mental health, physical pain, among others and found these factors were influenced by their health care provider, and uncertainty surrounding their degenerative cervical radiculopathy  progression. “Pain and paraesthesia (tingling, numbness) were the most common symptoms experienced by participants, leading to significant psychological distress and impact to daily activities, most notably driving, housecleaning, sleep, and ability to work. Participants described the uncertainty they experienced as a result of the unpredictable nature of degenerative cervical radiculopathy and the important role that health care providers play in their journey with degenerative cervical radiculopathy. Health care providers were seen acting as either a facilitator or a barrier to their recovery.”

In this video, Ross Hauser, MD discusses cervical instability and how we approach this diagnosis in our center with Digital Motion X-ray to see the neck in motion and why this is helpful for cases where the symptoms are intermittent, as well as with Prolotherapy for these cases and why it’s important to address the ligaments of the neck and shoulder.

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.

A January 2023 study from researchers at the Canadian Memorial Chiropractic College, Toronto, Canada and the University of Toronto evaluated conservative care options in the treatment of cervical radiculopathy. The paper appeared in the Clinical journal of pain. (x). “There is very-low certainty evidence supporting the use of acupuncture, Prednisolone, cervical manipulation, and low-level laser therapy for pain and disability in the immediate to short-term, and thoracic manipulation and low-level laser therapy for improvements in cervical range of motion (ROM) in the immediate term. There is low to very-low certainty evidence for multimodal interventions, providing inconclusive evidence for pain, disability, and ROM. There is inconclusive evidence for pain reduction following conservative management compared to surgery, rated as very-low certainty.”

What does this all mean? It means that while some of these treatments will help some people a lot. There is no standardized way to administer these treatments where they will help many people. For the most part, these treatments fail as administered.

Many of the people who come into our clinics have “bad MRIs” but they do not need surgery.

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?

A July 2022 Canadian paper published in the Journal of Rehabilitation Medicine (21) “evaluate(d) the effectiveness and safety of multimodal rehabilitation interventions compared to other interventions, placebo/sham interventions, or no intervention for the management of adults with cervical radiculopathy.” To do this researchers examined previously published research. This is what they found:

Shi-style cervical manipulations trivial and non-clinically important reduction in neck pain at 6 months

• “In adults with recent-onset cervical radiculopathy, multimodal rehabilitation that includes Shi-style cervical manipulations (this is a traditional Chinese manipulation treatment that includes massaging for increased blood flow and drainage) was associated with a trivial and non-clinically important reduction in neck pain at 6 months compared to mechanical cervical traction.”

Neck-specific exercises and education versus physical therapy

• “In adults with cervical radiculopathy of any duration, the evidence suggests that: 1) multimodal rehabilitation that combines neck-specific exercises, education, and a cognitive-behavioral program(s) may be more effective than prescribed physical activity and brief cognitive-behavioral approach; specifically, a small reduction in arm pain was found and function at 6 months – no difference in pain reduction was found at 6 months.

Epidural steroid injection alone is as effective as epidural steroid injection plus medication, etc.

• No difference in pain reduction was found at 6 months between a treatment program that combined gabapentin and/or nortriptyline, education, electrical stimulations, ultrasound, massage, exercise, and epidural steroid injection to an epidural steroid injection alone.

Exercise, stress management as effective as surgery

• Compared to surgery, combined with neck exercises, exercises combined with education, pain coping, self-efficacy, and stress management strategies lead to similar arm pain reduction and similar improvement in function at 6 months.

Treatments not as helpful as hoped:

Conclusion of research: “The evidence suggests that some multimodal rehabilitation care may provide a small and trivial reduction in neck pain or improvement in function to patients with cervical radiculopathy. However, the effectiveness of these interventions has not been demonstrated and more research is needed.”

Static spinal stenosis and dynamic spinal stenosis

Severe spinal stenosis requiring surgery. The image below is of a patient we saw at our clinic. The patient had horrific nerve symptoms along with signs and symptoms compatible with spinal cord compression. Severe compression of the spinal canal can be seen by an extremely large bone spur from the C5 vertebrae in the A Neutral panel to the left. Panel compression is made significantly worse by extension (looking up). In the far left panel the neutral view spinal canal is narrowed by 25% in the center panel the spinal canal is narrowed by 50%.

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 the 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 received four Prolotherapy treatments
• At 1:14 the previously completely closed neural foramina are now opening normally during motion

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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 dynamic spinal stenosis typically responds well to more conservative treatment approaches such as chiropractic adjustments, physiotherapy, and or/Prolotherapy.

Dynamic cervical spinal 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.

Treatment choices

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.

Can you return to work after degenerative cervical myelopathy and cervical radiculopathy surgery

Risks and complications of cervical epidural steroid injections

Please see my companion article: Cervical epidural steroid injections in complicated neck pain cases.

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”

April 2018 research

Dr. Nancy Epstein Professor of Clinical Neurosurgery, School of Medicine, the 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 some cases necessary operative intervention, while also subjecting patients at the hands of the insurance companies, to the additional hazards of these procedures.

June 2019 research

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.

May 2022 research

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.”

June 2022 research

A June 2022 study (20) compared cervical transforaminal epidurals and cervical facet joint steroid injections. The researchers write: “A cervical transforaminal epidural steroid injection is a useful treatment option for cervical radicular pain, but it carries a small risk of catastrophic complications. Several studies have reported that cervical facet joint steroid injections can reduce cervical radicular pain through an indirect epidural spread.” The aim of their study then was “to evaluate the pain scores and functional disability in subjects receiving cervical facet joint steroid injections or cervical transforaminal epidural steroid injection for the treatment of cervical radicular pain due to foraminal stenosis.

The researchers selected 278 patients 18 years of age and older who underwent cervical facet joint steroid injections (130 patients) or cervical transforaminal epidural steroid injections (148 patients) steroid injection for cervical radicular pain. The comparison was made using pain scores and functional disability during hospital visits one, three, and six months after the initial injection.

Results: Pain and disability scores showed a significant improvement in one, three, and six months after the initial injection in both groups, with no significant differences between the groups. No significant differences were observed in the success rates of the procedure one, three, and six months after the initial injection for either group. The efficacy of cervical facet joint steroid injections may be just as effective as cervical transforaminal epidural steroid injections in patients with cervical radicular pain due to foraminal stenosis.

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 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 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.

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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 which 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 of 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, and 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.

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.

An April 2025 study from Oslo University Hospital (x) compared surgery versus nonsurgical treatment for cervical radiculopathy. Two randomized clinical trials among 180 patients presenting to the Oslo University Hospital in Norway with disabling radicular arm pain and cervical disc herniation or spondylosis were randomly assigned to receive either surgical or nonsurgical treatment. Surgery involved anterior cervical discectomy and fusion. Nonsurgical treatment involved three sessions with physical medicine/rehabilitation physicians and three sessions with physiotherapists for functional and cognitive behavioral support. The primary outcome in both trials was the Neck Disability Index (NDI) score (range, 0 to 100; higher scores indicate greater disability; minimal important difference is 15) at 12 months, which was self-reported by the patients.

• Among the 87 patients in the disc herniation trial with 12-month data (surgical group, (45 patients); nonsurgical group, (42 patients), the researchers found a statistically significant difference for Neck Disability Index (NDI) score at 12 months in favor of surgical versus nonsurgical treatment in the disc herniation trial, but no difference in patients in spondylosis trial.

Prolotherapy injections for cervical radiculopathy

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.

Our published research

Cervical Spine Instability

References

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