In patients with symptomatic cervical spondylosis, there are three main clinical syndromes:
The last two syndromes may overlap and both include degrees of axial neck pain.[3]Guzman J, Haldeman S, Carroll LJ, et al. Clinical practice implications of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders: from concepts and findings to recommendations. J Manipulative Physiol Ther. 2009 Feb;32(2 suppl):S227-43.
http://www.ncbi.nlm.nih.gov/pubmed/19251069?tool=bestpractice.com
[12]Binder AI. Cervical spondylosis and neck pain. BMJ. 2007 Mar 10;334(7592):527-31.
http://www.ncbi.nlm.nih.gov/pubmed/17347239?tool=bestpractice.com
[13]Rao RD, Currier BL, Albert TJ, et al. Degenerative cervical spondylosis: clinical syndromes, pathogenesis and management. J Bone Joint Surg Am. 2007 Jun;89(6):1360-78.
http://www.ncbi.nlm.nih.gov/pubmed/17575617?tool=bestpractice.com
[24]Binder AI. Neck pain. BMJ Clin Evid. 2008 [internet publication].
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2907992
http://www.ncbi.nlm.nih.gov/pubmed/19445809?tool=bestpractice.com
Neck pain may be acute or chronic, and may occur with or without neurologic symptoms due to radiculopathy and/or myelopathy. It is the most common symptom, and the most easily treatable.
The evidence about the effects of individual interventions for these clinical syndromes is often contradictory because of the poor-quality randomized controlled trials (RCTs) conducted in diverse groups and the tendency for interventions to be given in combination.[3]Guzman J, Haldeman S, Carroll LJ, et al. Clinical practice implications of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders: from concepts and findings to recommendations. J Manipulative Physiol Ther. 2009 Feb;32(2 suppl):S227-43.
http://www.ncbi.nlm.nih.gov/pubmed/19251069?tool=bestpractice.com
[24]Binder AI. Neck pain. BMJ Clin Evid. 2008 [internet publication].
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2907992
http://www.ncbi.nlm.nih.gov/pubmed/19445809?tool=bestpractice.com
[47]Hegmann KT. Cervical and thoracic spine disorders. In: Occupational medicine practice guidelines: evaluation and management of common health problems and functional recovery in workers. 3rd ed. Elk Grove Village, IL: American College of Occupational and Environmental Medicine (ACOEM); 2011.
Most treatments are symptomatic and have no effect on the underlying cervical spondylosis or affect the long-term nature of the cervical degenerative changes. Many treatments are only effective in the short term.[22]Gross AR, Goldsmith C, Hoving JL, et al.; Cervical Overview Group. Conservative management of mechanical neck disorders: a systematic review. J Rheumatol. 2007 May;34(5):1083-102.
http://www.ncbi.nlm.nih.gov/pubmed/17295434?tool=bestpractice.com
Axial neck pain
First-line treatment of acute (<6 weeks), nontraumatic axial neck pain is physical therapy, including cervical traction.[48]Evans R, Bronfort G, Nelson B, et al. Two-year follow-up of a randomized clinical trial of spinal manipulation and two types of exercise for patients with chronic neck pain. Spine. 2002 Nov 1;27(21):2383-9.
http://www.ncbi.nlm.nih.gov/pubmed/12438988?tool=bestpractice.com
[49]Gross A, Kay TM, Paquin JP, et al. Exercises for mechanical neck disorders. Cochrane Database Syst Rev. 2015 Jan 28;(1):CD004250.
https://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004250.pub5/full
http://www.ncbi.nlm.nih.gov/pubmed/25629215?tool=bestpractice.com
The degree of axial neck pain can be assessed by simple outcome measures to determine the effects of subsequent treatment.[40]Cook CE, Richardson JK, Pietrobon R, et al. Validation of the NHANES ADL scale in a sample of patients with report of cervical pain: factor analysis, item response theory analysis, and line item validity. Disabil Rehabil. 2006 Aug 15;28(15):929-35.
http://www.ncbi.nlm.nih.gov/pubmed/16861200?tool=bestpractice.com
[48]Evans R, Bronfort G, Nelson B, et al. Two-year follow-up of a randomized clinical trial of spinal manipulation and two types of exercise for patients with chronic neck pain. Spine. 2002 Nov 1;27(21):2383-9.
http://www.ncbi.nlm.nih.gov/pubmed/12438988?tool=bestpractice.com
[49]Gross A, Kay TM, Paquin JP, et al. Exercises for mechanical neck disorders. Cochrane Database Syst Rev. 2015 Jan 28;(1):CD004250.
https://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004250.pub5/full
http://www.ncbi.nlm.nih.gov/pubmed/25629215?tool=bestpractice.com
[50]Pietrobon R, Coeytaux RR, Carey TS, et al. Standard scales for the measurement of functional outcome for cervical pain or dysfunction. Spine. 2002 Mar 1;27(5):515-22.
http://www.ncbi.nlm.nih.gov/pubmed/11880837?tool=bestpractice.com
[51]Graham N, Gross A, Goldsmith CH, et al. Mechanical traction for neck pain with or without radiculopathy. Cochrane Database Syst Rev. 2008 Jul 16;(3):CD006408.
https://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006408.pub2/full
http://www.ncbi.nlm.nih.gov/pubmed/18646151?tool=bestpractice.com
It is unclear whether patient education alone is helpful for treatment.[52]Gross A, Forget M, St George K, et al. Patient education for neck pain. Cochrane Database Systematic Rev. 2012 Mar 14;(3):CD005106.
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD005106.pub4/full
http://www.ncbi.nlm.nih.gov/pubmed/22419306?tool=bestpractice.com
[53]Furlan AD, Yazdi F, Tsertsvadze A, et al. A systematic review and meta-analysis of efficacy, cost-effectiveness, and safety of selected complementary and alternative medicine for neck and low-back pain. Evid Based Complement Alternat Med. 2011 Nov 24;2012:953139.
http://www.ncbi.nlm.nih.gov/pubmed/22203884?tool=bestpractice.com
Complementary and alternative treatments demonstrate minimal long-term efficacy.[54]Furlan JC, Kalsi-Ryan S, Kailaya-Vasan A, et al. Functional and clinical outcomes following surgical treatment in patients with cervical spondylotic myelopathy: a prospective study of 81 cases. J Neurosurg Spine. 2011 Mar;14(3):348-55.
http://www.ncbi.nlm.nih.gov/pubmed/21235299?tool=bestpractice.com
Physical therapy
Physical therapy is the first-line treatment for axial neck pain.[22]Gross AR, Goldsmith C, Hoving JL, et al.; Cervical Overview Group. Conservative management of mechanical neck disorders: a systematic review. J Rheumatol. 2007 May;34(5):1083-102.
http://www.ncbi.nlm.nih.gov/pubmed/17295434?tool=bestpractice.com
Advice on posture, sleeping position, daily activities, work and hobbies, stretching exercises, mobility exercises, and head, neck, and shoulder exercises may benefit individual patients.[48]Evans R, Bronfort G, Nelson B, et al. Two-year follow-up of a randomized clinical trial of spinal manipulation and two types of exercise for patients with chronic neck pain. Spine. 2002 Nov 1;27(21):2383-9.
http://www.ncbi.nlm.nih.gov/pubmed/12438988?tool=bestpractice.com
[49]Gross A, Kay TM, Paquin JP, et al. Exercises for mechanical neck disorders. Cochrane Database Syst Rev. 2015 Jan 28;(1):CD004250.
https://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004250.pub5/full
http://www.ncbi.nlm.nih.gov/pubmed/25629215?tool=bestpractice.com
Although physical therapy is of most value in the first 6 weeks, it can be continued intermittently as required to treat exacerbations of pain or chronic pain beyond 6 weeks.
Analgesia
Depending on the severity of pain, the use of nonsteroidal anti-inflammatory drugs (NSAIDs; e.g., ibuprofen, naproxen, diclofenac, meloxicam) may be beneficial in individual patients.[47]Hegmann KT. Cervical and thoracic spine disorders. In: Occupational medicine practice guidelines: evaluation and management of common health problems and functional recovery in workers. 3rd ed. Elk Grove Village, IL: American College of Occupational and Environmental Medicine (ACOEM); 2011.
Cyclo-oxygenase-2 (COX-2) inhibitors (e.g., celecoxib) may be preferred in patients with a history of gastroesophageal reflux disease (GERD) or peptic ulcers.
There is no clinical efficacy difference between various NSAIDs, but many patients tolerate one better than others or may have individual-based treatment preferences. NSAIDs are associated with an increased risk of cardiovascular thrombotic events and gastrointestinal toxicity (bleeding, ulceration, perforation). NSAIDs should be used at the lowest effective dose for the shortest effective treatment course.
Acetaminophen may be used in patients who have a contraindication to the use of NSAIDs, but should be used with caution in patients with hepatic impairment.
Muscle relaxants and maneuvers
If muscle spasm is a feature of the pain, muscle relaxants and maneuvers (including heat, massage, and cervical pillows) may be beneficial in some patients.[55]Salt E, Wright C, Kelly S, Dean A. A systematic literature review on the effectiveness of non-invasive therapy for cervicobrachial pain. Man Ther. 2011 Feb;16(1):53-65.
http://www.ncbi.nlm.nih.gov/pubmed/21075037?tool=bestpractice.com
There is no clinical efficacy difference between various muscle relaxants.
Trigger-point injections
These injections are usually performed by either a radiologist (under computed tomography [CT] or fluoroscopy control) or a pain management anesthesiologist (under fluoroscopic control) as needed.[56]Falco FJ, Erhart S, Wargo BW, et al. Systematic review of diagnostic utility and therapeutic effectiveness of cervical facet joint interventions. Pain Physician. 2009 Mar-Apr;12(2):323-44.
http://www.ncbi.nlm.nih.gov/pubmed/19305483?tool=bestpractice.com
A long-acting corticosteroid preparation is usually added to a long-acting local anesthetic.[3]Guzman J, Haldeman S, Carroll LJ, et al. Clinical practice implications of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders: from concepts and findings to recommendations. J Manipulative Physiol Ther. 2009 Feb;32(2 suppl):S227-43.
http://www.ncbi.nlm.nih.gov/pubmed/19251069?tool=bestpractice.com
[57]Mazanec D, Reddy A. Medical management of cervical spondylosis. Neurosurgery. 2007 Jan;60(1 suppl 1):S43-50.
http://www.ncbi.nlm.nih.gov/pubmed/17204885?tool=bestpractice.com
In practice, trigger-point injections to local muscle, fascia, and/or ligaments (using local anesthetic) may be considered medically necessary if trigger points have been identified by palpation. If this option does not improve the patient's condition and cervical facet-mediated pain sources are suspected based on both physical exam and imaging, then image-guided cervical facet joint injections (intra-articular injections to the joint(s) using a mixture of local anesthetic and a corticosteroid, or alternatively, diagnostic medial branch nerve blocks, followed by therapeutic radiofrequency ablation/denervation) may be considered if medical management consisting of at least activity modification, physical therapy, analgesia, and muscle relaxants have not succeeded in alleviating the patient's pain.
Other therapies
Additional treatment modalities include transcutaneous electrical nerve stimulator, chiropractic treatment, acupuncture, and other, less orthodox approaches, particularly electrotherapy, laser therapy, and cervical spine manipulation therapy.[35]Levin JH. Prospective, double-blind, randomized placebo-controlled trials in interventional spine: what the highest quality literature tells us. Spine J. 2009 Aug;9(8):690-703.
http://www.ncbi.nlm.nih.gov/pubmed/18789773?tool=bestpractice.com
[48]Evans R, Bronfort G, Nelson B, et al. Two-year follow-up of a randomized clinical trial of spinal manipulation and two types of exercise for patients with chronic neck pain. Spine. 2002 Nov 1;27(21):2383-9.
http://www.ncbi.nlm.nih.gov/pubmed/12438988?tool=bestpractice.com
[51]Graham N, Gross A, Goldsmith CH, et al. Mechanical traction for neck pain with or without radiculopathy. Cochrane Database Syst Rev. 2008 Jul 16;(3):CD006408.
https://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006408.pub2/full
http://www.ncbi.nlm.nih.gov/pubmed/18646151?tool=bestpractice.com
[55]Salt E, Wright C, Kelly S, Dean A. A systematic literature review on the effectiveness of non-invasive therapy for cervicobrachial pain. Man Ther. 2011 Feb;16(1):53-65.
http://www.ncbi.nlm.nih.gov/pubmed/21075037?tool=bestpractice.com
[58]Kroeling P, Gross A, Graham N, et al. Electrotherapy for neck pain. Cochrane Database Syst Rev. 2013 Aug 26;(8):CD004251.
https://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004251.pub5/full
http://www.ncbi.nlm.nih.gov/pubmed/23979926?tool=bestpractice.com
[59]Chow RT, Johnson MI, Lopes-Martins RA, et al. Efficacy of low-level laser therapy in the management of neck pain: a systematic review and meta-analysis of randomised placebo or active-treatment controlled trials. Lancet. 2009 Dec 5;374(9705):1897-908.
http://www.ncbi.nlm.nih.gov/pubmed/19913903?tool=bestpractice.com
[60]Martimbianco ALC, Porfírio GJ, Pacheco RL, et al. Transcutaneous electrical nerve stimulation (TENS) for chronic neck pain. Cochrane Database Syst Rev. 2019 Dec 12;(12):CD011927.
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD011927.pub2/full
http://www.ncbi.nlm.nih.gov/pubmed/31830313?tool=bestpractice.com
[61]Malone D, Baldwin NG, Tomecek FJ, et al. Complications of cervical spine manipulation therapy: 5-year retrospective study in a single-group practice. Neurosurg Focus. 2002 Dec 15;13(6):ecp1.
https://thejns.org/doi/pdf/10.3171/foc.2002.13.6.8
http://www.ncbi.nlm.nih.gov/pubmed/15766233?tool=bestpractice.com
[62]Benyamin RM, Singh V, Parr AT, et al. Systematic review of the effectiveness of cervical epidurals in the management of chronic neck pain. Pain Physician. 2009 Jan-Feb;12(1):137-57.
http://www.ncbi.nlm.nih.gov/pubmed/19165300?tool=bestpractice.com
[63]Canadian Chiropractic Association; Canadian Federation of Chiropractic Regulatory and Education Boards. Clinical practice guideline for the chiropractic treatment of adults with neck pain. March 2014 [internet publication].[64]Fu LM, Li JT, Wu WS. Randomized controlled trials of acupuncture for neck pain: systematic review and meta-analysis. J Altern Complement Med. 2009 Feb;15(2):133-45.
http://www.ncbi.nlm.nih.gov/pubmed/19216662?tool=bestpractice.com
Although these approaches may be beneficial for symptomatic relief in some patients, high-quality evidence supporting their use in this setting is lacking.[3]Guzman J, Haldeman S, Carroll LJ, et al. Clinical practice implications of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders: from concepts and findings to recommendations. J Manipulative Physiol Ther. 2009 Feb;32(2 suppl):S227-43.
http://www.ncbi.nlm.nih.gov/pubmed/19251069?tool=bestpractice.com
[12]Binder AI. Cervical spondylosis and neck pain. BMJ. 2007 Mar 10;334(7592):527-31.
http://www.ncbi.nlm.nih.gov/pubmed/17347239?tool=bestpractice.com
[60]Martimbianco ALC, Porfírio GJ, Pacheco RL, et al. Transcutaneous electrical nerve stimulation (TENS) for chronic neck pain. Cochrane Database Syst Rev. 2019 Dec 12;(12):CD011927.
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD011927.pub2/full
http://www.ncbi.nlm.nih.gov/pubmed/31830313?tool=bestpractice.com
[61]Malone D, Baldwin NG, Tomecek FJ, et al. Complications of cervical spine manipulation therapy: 5-year retrospective study in a single-group practice. Neurosurg Focus. 2002 Dec 15;13(6):ecp1.
https://thejns.org/doi/pdf/10.3171/foc.2002.13.6.8
http://www.ncbi.nlm.nih.gov/pubmed/15766233?tool=bestpractice.com
[65]Diwan S, Manchikanti L, Benyamin RM, et al. Effectiveness of cervical epidural injections in the management of chronic neck and upper extremity pain. Pain Physician. 2012 Jul-Aug;15(4):E405-34.
http://www.ncbi.nlm.nih.gov/pubmed/22828692?tool=bestpractice.com
In addition, some of these therapies may entail additional risks; for example, cervical manipulation can be associated with serious neurologic complications.[51]Graham N, Gross A, Goldsmith CH, et al. Mechanical traction for neck pain with or without radiculopathy. Cochrane Database Syst Rev. 2008 Jul 16;(3):CD006408.
https://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006408.pub2/full
http://www.ncbi.nlm.nih.gov/pubmed/18646151?tool=bestpractice.com
[61]Malone D, Baldwin NG, Tomecek FJ, et al. Complications of cervical spine manipulation therapy: 5-year retrospective study in a single-group practice. Neurosurg Focus. 2002 Dec 15;13(6):ecp1.
https://thejns.org/doi/pdf/10.3171/foc.2002.13.6.8
http://www.ncbi.nlm.nih.gov/pubmed/15766233?tool=bestpractice.com
Chronic pain
Chronic neck pain (>6 weeks) may be managed by continuing these symptomatic treatments if they improve the patient's discomfort. Axial neck pain is starting to receive consideration for cervical arthroplasty, although this procedure is not Food and Drug Administration-approved for axial neck pain alone.[13]Rao RD, Currier BL, Albert TJ, et al. Degenerative cervical spondylosis: clinical syndromes, pathogenesis and management. J Bone Joint Surg Am. 2007 Jun;89(6):1360-78.
http://www.ncbi.nlm.nih.gov/pubmed/17575617?tool=bestpractice.com
[66]Burkus JK, Haid RW, Traynelis VC, et al. Long-term clinical and radiographic outcomes of cervical disc replacement with the Prestige disc: results from a prospective randomized controlled clinical trial. J Neurosurg Spine. 2010 Sep;13(3):308-18.
http://www.ncbi.nlm.nih.gov/pubmed/20809722?tool=bestpractice.com
Physicians should refer to attending surgeons on indications for the procedure in their region. In general, surgery is not helpful for treatment of neck pain, but the evidence is of low quality.[67]van Middelkoop M, Rubinstein SM, Ostelo R, et al. Surgery versus conservative care for neck pain: a systematic review. Eur Spine J. 2013 Jan;22(1):87-95.
http://www.ncbi.nlm.nih.gov/pubmed/23104514?tool=bestpractice.com
Cervical spondylotic radiculopathy (CSR)
Radiating arm pain can be severe and is initially managed with oral analgesia combined with physical therapy and cervical traction.[12]Binder AI. Cervical spondylosis and neck pain. BMJ. 2007 Mar 10;334(7592):527-31.
http://www.ncbi.nlm.nih.gov/pubmed/17347239?tool=bestpractice.com
[22]Gross AR, Goldsmith C, Hoving JL, et al.; Cervical Overview Group. Conservative management of mechanical neck disorders: a systematic review. J Rheumatol. 2007 May;34(5):1083-102.
http://www.ncbi.nlm.nih.gov/pubmed/17295434?tool=bestpractice.com
Analgesia
NSAIDs are typically used first-line, with escalation to an opioid or gabapentin if the patient’s pain remains uncontrolled.
Escalation to an opioid (e.g., hydrocodone or oxycodone) should only be considered if the patient’s pain is not adequately controlled with nonopioid analgesics, muscle relaxants, physical therapy, and image-guided interventional spine injections to decrease reliance of this drug class.
Gabapentin may be used as a second-line option for neuropathic pain. Patients should be cautioned regarding potential sedation or cognitive adverse effects at the beginning of treatment. Once the patient's symptoms have improved, the dose may be tapered.
Physical therapy
All patients with cervical radicular pain who have physical difficulty with daily activities should be offered physical therapy, including posture correction, stretching exercises, and active range-of-movement exercises.[22]Gross AR, Goldsmith C, Hoving JL, et al.; Cervical Overview Group. Conservative management of mechanical neck disorders: a systematic review. J Rheumatol. 2007 May;34(5):1083-102.
http://www.ncbi.nlm.nih.gov/pubmed/17295434?tool=bestpractice.com
Physical therapy and particularly cervical traction can help to enlarge foramina narrowed by cervical spondylosis. It may provide further room for nerve roots and subsequently decrease the severity of the nerve tightness (hence partially alleviating the radicular pain).[29]Braga-Baiak A, Shah A, Pietrobon R, et al. Intra- and inter-observer reliability of MRI examination of intervertebral disc abnormalities in patients with cervical myelopathy. Eur J Radiol. 2008 Jan;65(1):91-8.
http://www.ncbi.nlm.nih.gov/pubmed/17532165?tool=bestpractice.com
Traction regimen of 12-18 pounds for 30-45 minutes several times a day is recommended.
Oral corticosteroids
Oral corticosteroid therapy may benefit individual patients.[22]Gross AR, Goldsmith C, Hoving JL, et al.; Cervical Overview Group. Conservative management of mechanical neck disorders: a systematic review. J Rheumatol. 2007 May;34(5):1083-102.
http://www.ncbi.nlm.nih.gov/pubmed/17295434?tool=bestpractice.com
Usually limited to 8-10 days due to systemic toxicity, but can be helpful as an adjunctive initial treatment to decrease nerve irritation and radicular pain.[22]Gross AR, Goldsmith C, Hoving JL, et al.; Cervical Overview Group. Conservative management of mechanical neck disorders: a systematic review. J Rheumatol. 2007 May;34(5):1083-102.
http://www.ncbi.nlm.nih.gov/pubmed/17295434?tool=bestpractice.com
[26]Bono CM, Ghiselli G, Gilbert TJ, et al; North American Spine Society. An evidence-based clinical guideline for the diagnosis and treatment of cervical radiculopathy from degenerative disorders. Spine J. 2011 Jan;11(1):64-72.
http://www.ncbi.nlm.nih.gov/pubmed/21168100?tool=bestpractice.com
[57]Mazanec D, Reddy A. Medical management of cervical spondylosis. Neurosurgery. 2007 Jan;60(1 suppl 1):S43-50.
http://www.ncbi.nlm.nih.gov/pubmed/17204885?tool=bestpractice.com
Subsequent interventions
In most patients (around 75%), severe arm pain will spontaneously relent by 4-6 weeks. The pain eventually resolves with conservative measures, but it may take 1-2 years to completely disappear.[13]Rao RD, Currier BL, Albert TJ, et al. Degenerative cervical spondylosis: clinical syndromes, pathogenesis and management. J Bone Joint Surg Am. 2007 Jun;89(6):1360-78.
http://www.ncbi.nlm.nih.gov/pubmed/17575617?tool=bestpractice.com
[25]Van Zundert J, Huntoon M, Patijn J, et al. 4. Cervical radicular pain. Pain Pract. 2010 Jan-Feb;10(1):1-17.
http://www.ncbi.nlm.nih.gov/pubmed/19807874?tool=bestpractice.com
[68]Persson LC, Lilja A. Pain, coping, emotional state and physical function in patients with chronic radicular neck pain. Disabil Rehabil. 2001 May 20;23(8):325-35.
http://www.ncbi.nlm.nih.gov/pubmed/11374522?tool=bestpractice.com
Depending on the timing and outcome of first-line treatments, subsequent more invasive treatments may consist of epidural corticosteroids or cervical nerve root block at the suspected level to maintain a positive effect from the oral corticosteroids, or surgical nerve decompression.[13]Rao RD, Currier BL, Albert TJ, et al. Degenerative cervical spondylosis: clinical syndromes, pathogenesis and management. J Bone Joint Surg Am. 2007 Jun;89(6):1360-78.
http://www.ncbi.nlm.nih.gov/pubmed/17575617?tool=bestpractice.com
[25]Van Zundert J, Huntoon M, Patijn J, et al. 4. Cervical radicular pain. Pain Pract. 2010 Jan-Feb;10(1):1-17.
http://www.ncbi.nlm.nih.gov/pubmed/19807874?tool=bestpractice.com
[26]Bono CM, Ghiselli G, Gilbert TJ, et al; North American Spine Society. An evidence-based clinical guideline for the diagnosis and treatment of cervical radiculopathy from degenerative disorders. Spine J. 2011 Jan;11(1):64-72.
http://www.ncbi.nlm.nih.gov/pubmed/21168100?tool=bestpractice.com
[28]Joint Section on Disorders of the Spine and Peripheral Nerves of the American Association of Neurological Surgeons and Congress of Neurological Surgeons. Guidelines for the surgical management of cervical degenerative disease. 2009 [internet publication].
https://www.cns.org/guidelines/surgical-management-cervical-degenerative-disease/cervical-surgical-techniques-treatment-of-cervical
[35]Levin JH. Prospective, double-blind, randomized placebo-controlled trials in interventional spine: what the highest quality literature tells us. Spine J. 2009 Aug;9(8):690-703.
http://www.ncbi.nlm.nih.gov/pubmed/18789773?tool=bestpractice.com
[62]Benyamin RM, Singh V, Parr AT, et al. Systematic review of the effectiveness of cervical epidurals in the management of chronic neck pain. Pain Physician. 2009 Jan-Feb;12(1):137-57.
http://www.ncbi.nlm.nih.gov/pubmed/19165300?tool=bestpractice.com
[65]Diwan S, Manchikanti L, Benyamin RM, et al. Effectiveness of cervical epidural injections in the management of chronic neck and upper extremity pain. Pain Physician. 2012 Jul-Aug;15(4):E405-34.
http://www.ncbi.nlm.nih.gov/pubmed/22828692?tool=bestpractice.com
[69]Borton ZM, Oakley BJ, Clamp JA, et al. Cervical transforaminal epidural steroid injections for radicular pain : a systematic review. Bone Joint J. 2022 May;104-B(5):567-74.
http://www.ncbi.nlm.nih.gov/pubmed/35491579?tool=bestpractice.com
Epidural treatments
Epidural anesthesia or cervical nerve root block should be administered by a fellowship-trained or board-certified interventional spine specialist, who may be an interventional radiologist, pain management physician (generally anesthesia trained), physiatrist (physical drug & rehabilitation), and/or neurologist.
Surgical nerve decompression
If the pain does not resolve and if all symptoms, signs, and diagnostic studies converge to indicate pressure on a single nerve root, then surgical nerve decompression may be helpful.[13]Rao RD, Currier BL, Albert TJ, et al. Degenerative cervical spondylosis: clinical syndromes, pathogenesis and management. J Bone Joint Surg Am. 2007 Jun;89(6):1360-78.
http://www.ncbi.nlm.nih.gov/pubmed/17575617?tool=bestpractice.com
[25]Van Zundert J, Huntoon M, Patijn J, et al. 4. Cervical radicular pain. Pain Pract. 2010 Jan-Feb;10(1):1-17.
http://www.ncbi.nlm.nih.gov/pubmed/19807874?tool=bestpractice.com
[26]Bono CM, Ghiselli G, Gilbert TJ, et al; North American Spine Society. An evidence-based clinical guideline for the diagnosis and treatment of cervical radiculopathy from degenerative disorders. Spine J. 2011 Jan;11(1):64-72.
http://www.ncbi.nlm.nih.gov/pubmed/21168100?tool=bestpractice.com
[28]Joint Section on Disorders of the Spine and Peripheral Nerves of the American Association of Neurological Surgeons and Congress of Neurological Surgeons. Guidelines for the surgical management of cervical degenerative disease. 2009 [internet publication].
https://www.cns.org/guidelines/surgical-management-cervical-degenerative-disease/cervical-surgical-techniques-treatment-of-cervical
There are a variety of surgical approaches for nerve decompression. Either anterior cervical discectomy with fusion (ACDF) or posterior nerve decompression procedures are generally selected, based on the patient's symptoms, number of levels of involvement, and specific anatomy from the cervical MRI scan. A minimum of 2-3 months of conservative therapy is usually required. Because significant weakness or neurologic change is rarely associated with radiculopathy, the primary decision for considering surgical decompression is the patient's subjective degree of pain and the significance of the discomfort.
Another approach is cervical arthroplasty, where an artificial disk is placed instead of a bone graft and plate to avoid a fusion and retain motion; multiple randomized studies have been carried out, but these procedures are not yet routinely performed everywhere.[70]Gao F, Mao T, Sun W, et al. An updated meta-analysis comparing artificial cervical disc arthroplasty (CDA) versus anterior cervical discectomy and fusion (ACDF) for the treatment of cervical degenerative disc disease (CDDD). Spine (Phila Pa 1976). 2015 Dec;40(23):1816-23.
http://www.ncbi.nlm.nih.gov/pubmed/26571063?tool=bestpractice.com
[71]Janssen ME, Zigler JE, Spivak JM, et al. ProDisc-C total disc replacement versus anterior cervical discectomy and fusion for single-level symptomatic cervical disc disease: seven-year follow-up of the prospective randomized US Food and Drug Administration investigational device exemption study. J Bone Joint Surg Am. 2015 Nov 4;97(21):1738-47.
http://www.ncbi.nlm.nih.gov/pubmed/26537161?tool=bestpractice.com
Despite these multiple randomized studies, there is not yet any clear evidence regarding improved relief of radicular arm pain with arthroplasty compared with ACDF. However, although there are no clear data yet on the prevention of adjacent segment stenosis over time, arthroplasty may provide a lower rate of reoperation compared with ACDF.[70]Gao F, Mao T, Sun W, et al. An updated meta-analysis comparing artificial cervical disc arthroplasty (CDA) versus anterior cervical discectomy and fusion (ACDF) for the treatment of cervical degenerative disc disease (CDDD). Spine (Phila Pa 1976). 2015 Dec;40(23):1816-23.
http://www.ncbi.nlm.nih.gov/pubmed/26571063?tool=bestpractice.com
[71]Janssen ME, Zigler JE, Spivak JM, et al. ProDisc-C total disc replacement versus anterior cervical discectomy and fusion for single-level symptomatic cervical disc disease: seven-year follow-up of the prospective randomized US Food and Drug Administration investigational device exemption study. J Bone Joint Surg Am. 2015 Nov 4;97(21):1738-47.
http://www.ncbi.nlm.nih.gov/pubmed/26537161?tool=bestpractice.com
[72]Shriver MF, Lubelski D, Sharma AM, et al. Adjacent segment degeneration and disease following cervical arthroplasty: a systematic review and meta-analysis. Spine J. 2016 Feb;16(2):168-81.
http://www.ncbi.nlm.nih.gov/pubmed/26515401?tool=bestpractice.com
Degenerative cervical myelopathy
Surgical decompression is the preferred first-line acute treatment in patients with moderate and severe symptoms who are good surgical candidates, although two RCTs do not show any short-term benefit for mild to moderate myelopathy.[27]Rao RD, Gourab K, David KS. Operative treatment of cervical spondylotic myelopathy. J Bone Surg Am. 2006 Jul;88(7):1619-40.
http://www.ncbi.nlm.nih.gov/pubmed/16818991?tool=bestpractice.com
[33]Nikolaidis I, Fouyas IP, Sandercock PA, et al. Surgery for cervical radiculopathy or myelopathy. Cochrane Database Syst Rev. 2010 Jan 20;(1):CD001466.
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001466.pub3/full
http://www.ncbi.nlm.nih.gov/pubmed/20091520?tool=bestpractice.com
[38]Fehlings MG, Tetreault LA, Riew KD, et al. A clinical practice guideline for the management of patients with degenerative cervical myelopathy: recommendations for patients with mild, moderate, and severe disease and nonmyelopathic patients with evidence of cord compression. Global Spine J. 2017 Sep;7(3 suppl):70S-83S.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5684840
http://www.ncbi.nlm.nih.gov/pubmed/29164035?tool=bestpractice.com
Surgical treatment of all levels of cervical myelopathy is considered the standard of care in the US, with supporting evidence from one prospective multicenter study.[26]Bono CM, Ghiselli G, Gilbert TJ, et al; North American Spine Society. An evidence-based clinical guideline for the diagnosis and treatment of cervical radiculopathy from degenerative disorders. Spine J. 2011 Jan;11(1):64-72.
http://www.ncbi.nlm.nih.gov/pubmed/21168100?tool=bestpractice.com
[28]Joint Section on Disorders of the Spine and Peripheral Nerves of the American Association of Neurological Surgeons and Congress of Neurological Surgeons. Guidelines for the surgical management of cervical degenerative disease. 2009 [internet publication].
https://www.cns.org/guidelines/surgical-management-cervical-degenerative-disease/cervical-surgical-techniques-treatment-of-cervical
[73]Fehlings MG, Wilson JR, Kopjar B, et al. Efficacy and safety of surgical decompression in patients with cervical spondylotic myelopathy: results of the AOSpine North America prospective multi-center study. J Bone Joint Surg Am. 2013 Sep 18;95(18):1651-8.
http://www.ncbi.nlm.nih.gov/pubmed/24048552?tool=bestpractice.com
Surgical decompression is therefore typically offered to all patients on presentation, although there is variability between individual surgeons. Due to this bias and the worry that patients may experience irreversible deterioration if surgical decompression is delayed, no randomized surgical trials for cervical myelopathy are planned in the US.[37]Benatar M. Clinical equipoise and treatment decisions in cervical spondylotic myelopathy. Can J Neurol Sci. 2007 Feb;34(1):47-52.
http://www.ncbi.nlm.nih.gov/pubmed/17352346?tool=bestpractice.com
Surgical treatment
Adequate treatment of the severe underlying degenerative joint disease (DJD) usually requires fusion or immobilization of the segments, leading to loss of range of motion of the cervical spine.[26]Bono CM, Ghiselli G, Gilbert TJ, et al; North American Spine Society. An evidence-based clinical guideline for the diagnosis and treatment of cervical radiculopathy from degenerative disorders. Spine J. 2011 Jan;11(1):64-72.
http://www.ncbi.nlm.nih.gov/pubmed/21168100?tool=bestpractice.com
[28]Joint Section on Disorders of the Spine and Peripheral Nerves of the American Association of Neurological Surgeons and Congress of Neurological Surgeons. Guidelines for the surgical management of cervical degenerative disease. 2009 [internet publication].
https://www.cns.org/guidelines/surgical-management-cervical-degenerative-disease/cervical-surgical-techniques-treatment-of-cervical
With anterior approaches, adjacent segments often develop DJD over time, leading to adjacent segment stenosis. With posterior approaches there can be either instability (following laminectomy alone) or near complete loss of cervical range of motion, with the typical extensive posterior fusion needed. Furthermore, decompression surgery typically only stabilizes spinal cord function (with only mild improvement in symptoms) because there is usually existing permanent damage to the spinal cord at the time of surgery. The trend is consequently toward earlier surgery, while the patient has more of a chance of returning to normal function, or surgery while the patient is asymptomatic.[26]Bono CM, Ghiselli G, Gilbert TJ, et al; North American Spine Society. An evidence-based clinical guideline for the diagnosis and treatment of cervical radiculopathy from degenerative disorders. Spine J. 2011 Jan;11(1):64-72.
http://www.ncbi.nlm.nih.gov/pubmed/21168100?tool=bestpractice.com
[28]Joint Section on Disorders of the Spine and Peripheral Nerves of the American Association of Neurological Surgeons and Congress of Neurological Surgeons. Guidelines for the surgical management of cervical degenerative disease. 2009 [internet publication].
https://www.cns.org/guidelines/surgical-management-cervical-degenerative-disease/cervical-surgical-techniques-treatment-of-cervical
[33]Nikolaidis I, Fouyas IP, Sandercock PA, et al. Surgery for cervical radiculopathy or myelopathy. Cochrane Database Syst Rev. 2010 Jan 20;(1):CD001466.
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001466.pub3/full
http://www.ncbi.nlm.nih.gov/pubmed/20091520?tool=bestpractice.com
[36]Matz PG. Does nonoperative management play a role in the treatment of cervical spondylotic myelopathy? Spine J. 2006 Nov-Dec;6(6 suppl):175S-81S.
http://www.ncbi.nlm.nih.gov/pubmed/17097536?tool=bestpractice.com
[37]Benatar M. Clinical equipoise and treatment decisions in cervical spondylotic myelopathy. Can J Neurol Sci. 2007 Feb;34(1):47-52.
http://www.ncbi.nlm.nih.gov/pubmed/17352346?tool=bestpractice.com
Conservative treatment
Conservative treatment is the preferred treatment for patients who are poor surgical candidates. In some countries, although not in the US, conservative treatment is used for those who have mild symptoms.
The approach is immobilization in a hard cervical collar.[36]Matz PG. Does nonoperative management play a role in the treatment of cervical spondylotic myelopathy? Spine J. 2006 Nov-Dec;6(6 suppl):175S-81S.
http://www.ncbi.nlm.nih.gov/pubmed/17097536?tool=bestpractice.com
This conservative treatment has been shown to be equivalent (over 1-3 years) to surgical decompression in patients with mild to moderate myelopathy.[33]Nikolaidis I, Fouyas IP, Sandercock PA, et al. Surgery for cervical radiculopathy or myelopathy. Cochrane Database Syst Rev. 2010 Jan 20;(1):CD001466.
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD001466.pub3/full
http://www.ncbi.nlm.nih.gov/pubmed/20091520?tool=bestpractice.com
Pharmacologic treatment
There are no long-term drug treatments that are helpful in management of degenerative cervical myelopathy; short-term corticosteroids may be used as a bridge prior to possible surgical decompression, but for <2 weeks due to their side-effects profile.