Cervical Radiculopathy: Treating a Pinched Nerve in the Neck
Let's suppose that you have been diagnosed as having a pinched
nerve in your neck, also known as cervical radiculopathy. If so,
you probably have pain in the neck and one shoulder. The pain
might radiate into your arm and you might have weakness or
numbness in the arm as well. Moving your neck in certain
positions probably worsens the pain.
If you're a younger adult, the pinch could be due to a herniated
(slipped) disc. Discs are the soft spacers that separate each
pair of stacked neck-bones (vertebrae). If you're an older
adult, the pinch is more likely due to a bony spur
(spondylosis). In either case, you're in good company. A survey
in Sicily showed 3.5 active cases at any one time of cervical
radiculopathy per population of 100,000. In Rochester,
Minnesota, another survey showed 85 new cases each year of
cervical radiculopathy per population of 100,000.
Let's say that your doctor has evaluated you thoroughly by
taking a history of your symptoms and performing a physical
examination. Perhaps with the additional help of an MRI of your
cervical spine (neck) and electrical tests of nerve and muscle
function (nerve conduction studies and electromyography) the
diagnosis of cervical radiculopathy is deemed definite.
Furthermore, there is no sign that the spinal cord itself is
pinched. Now what?
Now what, indeed. Choosing a treatment for this condition is far
from straightforward. Out of hundreds of published medical
reports concerning treatment of cervical radiculopathy, most are
case reports or case series. A "case series" translates roughly
as: "We gave six patients in a row the same treatment and five
of them got better." What can be concluded from a study of this
kind? Did the treatment make the patients better or would they
have improved anyway? We don't know.
The missing ingredient here is a comparison group of untreated
or differently treated individuals known as a control group. The
other mark of a quality study is that the chosen treatment is
randomized, meaning that the research subjects agreed in advance
to be assigned to one treatment group or another based on the
equivalent of a coin-toss. So out of the hundreds of published
studies involving treatment of this common condition, how many
were randomized controlled trials? Unfortunately, the answer is
just one.
Liselott Persson, Carl-Axel Carlsson and Jane Carlsson at the
University Hospital of Lund, Sweden, randomly allocated 81
patients who had symptoms of cervical radiculopathy present for
at least three months to any of three treatments -- surgery,
physical therapy or a cervical collar. The patients ranged from
28 to 64 years old and 54% of them were male. The surgeons used
the so-called Cloward procedure, removing fragments of
protruding discs and spurs through an incision in the front of
the neck, and then fusing two neck-bones together by means of a
bone-graft. Physical therapy involved 15 sessions over a span of
three months and consisted of whatever the physical therapist
considered appropriate, variously including any of the
following: heat application, cold application, electrical
stimulation, ultrasound, massage, manipulation, exercise and
education. In the cervical collar group, patients wore rigid,
shoulder-resting collars every day for three months.
Additionally, some of the subjects wore soft collars overnight.
How did the study turn out? Three of the subjects who were
assigned to surgery refused the procedure because they had
already improved on their own. For statistical purposes their
outcomes were included with those who actually received the
operation. After three months the surgery and physical therapy
groups reported, on average, less pain. After an additional 12
months patients in all three groups had less pain than at the
beginning of the study and the outcomes of each treatment were
statistically alike. Measurements of mood and overall function
following treatment were likewise equal among the groups.
So, over the long haul, no treatment was better than the others.
Of course, within each group some patients did better or worse
than others and this spread of outcomes was not reflected in the
overall averages. In fact, five patients in the collar group and
one patient in the physical therapy group went on to receive
surgery owing to lack of satisfactory improvement. In addition,
eight patients in the surgery group underwent a second operation
that in one case was due to a complication of the first
operation.
With this Swedish study representing the only rigorous
investigation of treatment outcomes in cervical radiculopathy,
there are a number of unanswered questions. For example, what
are the effects on cervical radiculopathy of painkillers,
anti-inflammatory drugs, local injections, systematic traction
or other forms of surgery? We don't know. What happens if there
is no treatment whatsoever? We don't know the answer to that
question either.
Thus, in the care of individual patients there is a yin-yang
balancing act between the medical edict of "Above all, do no
harm" and the practical dictum of "Do what you have to do." This
balancing act usually means starting with less intrusive
treatments like drugs and physical therapy. If symptoms fail to
improve or become unbearable, an operation may be helpful.
(C) 2006 by Gary Cordingley