Oral prednisolone in the treatment of cervical radiculopathy: A randomized placebo controlled trialI have had three cervical spine surgeries: I have permanent cervical radiculopathy on the right. I had a completely torn rotator cuff on that side with tendonosis leaving me with oral corticosteroids for cervical radiculopathy use of that arm. Steroids sarcoidosis my left shoulder and arm are exhibiting the same symptoms. At 47 years of age I am struggling to work-no one knows what to do and there is oral corticosteroids for cervical radiculopathy information on how to function with this or what the prognosis is. All articles I find end where my problem begins.
Primary Care articles: Treatment of cervical radiculopathy
I have had three cervical spine surgeries: I have permanent cervical radiculopathy on the right. I had a completely torn rotator cuff on that side with tendonosis leaving me with limited use of that arm. Now my left shoulder and arm are exhibiting the same symptoms. At 47 years of age I am struggling to work-no one knows what to do and there is no information on how to function with this or what the prognosis is. All articles I find end where my problem begins.
Will someone do an article or study on those of us who have permanent cervical radiculopathy? I would volunteer to be part of that study! Antimicrobial therapy of prosthetic valve endocard Complications and outcome of infective endocarditi Surgery for prosthetic valve endocarditis Diagnostic approach to infective endocarditis Presentation and diagnosis of prosthetic valve end Approach to the patient with a suspected spider bi Evaluation of the patient with neck pain and cervi Evaluation of the patient with shoulder complaints Shoulder dislocation and reduction Acupuncture Spinal manipulation in the treatment of musculoske Cervantes View my complete profile.
Saturday, August 30, Treatment of cervical radiculopathy. May This topic last updated: There is sparse evidence that any treatment improves upon the natural history of the condition. Part of the problem is that cervical radiculopathy is a clinical, and to some extent subjective, diagnosis with no "gold standard" test to establish or exclude the disease. Depending upon the diagnostic criteria used, clinical studies evaluating the treatment of cervical radiculopathy have tended to select one subset of patients more than another.
As an example, studies that require the presence of a surgically demonstrated lesion to establish the diagnosis of cervical radiculopathy are likely to exclude patients with mild or improving symptoms. The treatment of cervical radiculopathy will be reviewed here. The clinical features and diagnosis of cervical radiculopathy are discussed separately. See "Clinical features and diagnosis of cervical radiculopathy". The majority of radiculopathies arise from nerve root compression; the two predominant mechanisms are cervical spondylosis and disc herniation.
Noncompressive radiculopathy includes diabetes and infectious, granulomatous, and infiltrating neoplastic disorders. See "Clinical features and diagnosis of cervical radiculopathy", section on Pathophysiology.
Compressive radiculopathy — Although data are limited, some, if not most, patients with compressive cervical radiculopathy improve without specific treatment [1,2].
Evidence that improvement is not treatment specific comes from a population-based study of patients with cervical radiculopathy from Rochester, Minnesota . This was not a natural history study, since most patients received some treatment and 26 percent had surgery for cervical radiculopathy.
Nevertheless, at last follow-up, 90 percent of patients were asymptomatic or only mildly incapacitated. Given the apparent overall good prognosis for recovery, conservative therapies are preferred in most patients. See "Conservative therapy" below. It is important to examine the patient carefully for any evidence of superimposed spinal cord dysfunction ie, myelopathy , since cervical spondylosis may cause spinal cord compression as well as nerve root compression.
In addition, all patients with objective weakness should have early cervical spine imaging and electrodiagnostic studies. Myelopathy results in specific abnormalities on neurologic examination.
Motor signs of myelopathy below the level of spinal cord involvement include upper motor neuron type weakness, increased reflexes and tone, and Babinski signs. Lower motor neuron type weakness may occur at the level of spinal cord compression. Sensory signs include decreased pinprick sensation below the level of spinal cord involvement and loss of position or vibration sensation in the lower extremities.
These examination findings may be subtle if spinal cord compression is mild. Evidence of myelopathy, as determined by the presence of myelopathic signs on examination, combined with neuroimaging evidence of spinal cord compression, is an indication for surgery. See "Indications for surgery" below and see "Clinical features and diagnosis of cervical radiculopathy" In the absence of myelopathy, conservative initial management is usually indicated for patients with stable motor weakness, as it is for patients without motor deficits on examination.
All patients with motor weakness should be closely followed for evidence of progression. Noncompressive radiculopathy — The causes of noncompressive cervical radiculopathy or polyradiculopathy include infectious processes especially herpes zoster and Lyme disease , nerve root infarction, root avulsion, infiltration by tumor, infiltration by granulomatous tissue, and demyelination show table 1.
See "Clinical features and diagnosis of cervical radiculopathy", section on Noncompressive causes. The prognosis of cervical radiculopathy in these settings is influenced by the natural history and response to therapy of the underlying condition.
Conservative therapy — Conservative therapy of cervical radiculopathy typically consists of the following modalities, alone or in some combination [3,4]: In addition, we suggest conservative therapy as initial treatment for patients with cervical radiculopathy who have nonprogressive neurologic deficits, including dermatomal sensory loss, myotomal weakness, and sensory changes, as long as myelopathy is not suspected.
There is no consensus regarding the sequence or time course of conservative modalities. We generally start treatment with oral analgesics and avoidance of provocative activities, accompanied by a short course of oral prednisone if pain is severe. For oral analgesia, we typically use nonsteroidal antiinflammatory drugs NSAIDs as first-line therapy.
We avoid the use of narcotic agents. A muscle relaxant such as cyclobenzaprine may be added if muscle spasm or muscle tightness is prominent. Cyclobenzaprine is generally started at a modest dose of 5 mg two or three times a day to reduce the side effect of drowsiness. The dose can be increased to 10 mg three times a day after one week if spasm is not relieved and side effects are not prominent. Shoulder abduction, which can be used as a diagnostic sign, can also be useful for temporary symptom relief .
See "Clinical features and diagnosis of cervical radiculopathy", section on Shoulder abduction relief test. Once the pain is tolerable, we initiate physical therapy with exercise and gradual mobilization. In our opinion, prolonged inactivity may delay recovery and is not advisable. The patient should be seen and reexamined in six to eight weeks if there is no improvement with these conservative measures. In this setting, neuroimaging studies of the cervical spine and electrodiagnostic studies should be performed if they were not done initially.
See "Refractory or progressive symptoms" below. Oral glucocorticoids — A short course of high-dose oral glucocorticoid therapy may be used as initial treatment for patients with severe cervical radicular pain. The only evidence supporting the effectiveness of oral glucocorticoids for cervical radiculopathy is anecdotal . In our clinical experience, for example, this treatment is associated with pain relief in many patients.
We suggest not using prophylaxis against gastrointestinal bleeding in patients taking prednisone alone. In contrast, patients taking prednisone in combination with aspirin or other NSAIDs may require prophylaxis.
Primary prevention of gastroduodenal toxicity", section on Prevention strategies. Exercise therapy — Physical therapy, range-of-motion exercises, strengthening exercises, and aerobic exercises are frequently employed as conservative measures for cervical radiculopathy. These treatments are unproven, and the only controlled study showed no significant benefit .
Many patients report benefit with exercise therapy, but this could reflect the natural history of the disease or a placebo response. Because of possible benefit and no proven harm, we suggest exercise therapy as part of the initial treatment of symptomatic cervical radiculopathy in the absence of myelopathy. Exercise therapy is contraindicated in the presence of myelopathy.
Cervical traction — Cervical traction is the application of a distracting force to the neck, which can in theory separate the cervical segments, expand the intervertebral joint spaces, and relieve compression of the nerve roots .
However, controlled studies of cervical traction delivered in the course of a physical therapy program for a variety of causes of neck and arm pain have not demonstrated benefit over sham traction  or placebo . There are no meta-analyses or systematic reviews of traction as treatment for the specific diagnosis of cervical radiculopathy. A systematic review of traction for patients with neck or back pain was unable to determine if traction was effective, mainly because the included studies had methodologic flaws, including insufficient power .
Similarly, a systematic review of traction for patients with mechanical neck disorders reported that the evidence of benefit for traction was inconclusive, due to low methodologic quality of the trials . The systematic review suggested that intermittent as opposed to continuous traction may be beneficial, although the evidence came from low-quality trials .
In addition, an early observational study found that intermittent cervical traction was associated with symptom relief in some patients with cervical radiculopathy . Traction should not be used unless neuroimaging has been performed, and should be discontinued if symptoms worsen with the application of distracting force.
Traction is not recommended in the presence of spinal cord compression or large disc protrusion. We generally do not prescribe cervical traction as initial therapy for patients with cervical radiculopathy. Nevertheless, cervical traction is a reasonably safe alternative for patients with persistent or refractory pain who do not want epidural glucocorticoid injections or surgery. Refractory or progressive symptoms — Some patients with cervical radiculopathy have symptoms that are refractory to conservative treatments, and a smaller number develop progressive symptoms.
Clinical reevaluation should be performed with careful assessment for motor weakness and myelopathic findings in patients who have not improved after six to eight weeks of conservative treatment or in those who have progressive symptoms. Neuroimaging and electrodiagnostic studies are indicated, particularly if not done initially, and repeat electrodiagnostic studies may be needed if an initial study was unrevealing. Reevaluation, neuroimaging, and electrodiagnostic studies are important to ensure that the initial diagnosis of radiculopathy is correct, and to assess for evidence of progressive neurologic deficit that could be an indication for surgery.
See "Clinical features and diagnosis of cervical radiculopathy", section on Diagnosis, and see "Indications for surgery" below. There are no clinical trials that clearly establish whether more aggressive interventions, such as epidural steroid injections or surgery, are beneficial for patients who are refractory to conservative therapy or beneficial for those who have progressive symptoms or signs.
See "Epidural glucocorticoid injections" below and see "Surgery" below. Nevertheless, many experts consider unremitting radicular pain despite six to eight weeks of conservative treatment, progressive motor weakness, or signs and symptoms of myelopathy in the context of imaging studies showing a surgically remediable anatomic spinal cord compression as indications for surgery. See "Indications for surgery" below.
Symptoms of cervical radiculopathy recur in up to one-third of patients after initial improvement . Conservative management should be reemployed when symptoms recur, unless a significant motor deficit or myelopathy is present. See "Conservative therapy" above. Epidural glucocorticoid injections — Patients with persistent cervical radicular pain, with or without radiculopathy, may benefit from epidural glucocorticoid injections .
Supporting evidence comes from small prospective [19,20] and retrospective [21,22] observational studies, which suggest that transforaminal or interlaminar epidural glucocorticoid injections provide substantial relief lasting six months or longer in 40 to 60 percent of patients.