Best Way to Treat Cervical Radiculopathy

» Best Way to Treat Cervical Radiculopathy
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Imagine severe neck pain that is constant. Now add shooting pains down the arms and/or numbness down to the fingers. Now try to imagine working, dressing, answering emails, or sleeping under those conditions. That's what patients with cervical radiculopathy experience every day.

Cervical radiculopathy refers to symptoms that come from pressure on the nerve roots as they exit the spinal column. People sometimes refer to this problem as a "pinched nerve". Cervical radiculopathy is caused by any condition that puts pressure on the nerves where they leave the spinal column. The main causes of cervical radiculopathy include degeneration, disc herniation, and spinal instability.

Many times this problem can be treated conservatively with antiinflammatory medications and physiotherapy. But when there is no relief from the symptoms after many months, then surgery is considered. Surgeons are still trying to sort out the best way to surgically treat cervical radiculopathy. There are two main choices: discectomy and fusion or disc replacement.

But the treatment options don't end there because fusions can be done from the front of the spine (anterior approach) or from the back (posterior). With both approaches, the fusion is accomplished with bone grafts or titanium cages. And leads to another set of choices: between bone grafts from the patient (autografts) or from a donor bank (allograft).

Each of these choices has positives and negatives associated with it. Weighing the benefits against the disadvantages doesn't always give a clear picture of how the results from each of these approaches compares. That's where this study comes in. This is the first study to compare the results of all four choices: 1) anterior cervical discectomy and fusion (ACDF) with allograft, 2) ACDF with autograft, 3) ACDF with cages, and 4) disc replacement called arthroplasty.

The authors of the article didn't actually treat patients with these four methods and then compare the results. Instead, they reviewed all of the published studies on these topics and analyzed the data to get a general idea of how they compared.

Results were measured based on patient outcomes of neck and arm pain, neck disability, physical and mental function, and fusion rate (based on X-rays). Neck disability was measured using a special patient survey called neck disability index (NDI). There was one other measure used to compare the groups and that was adverse events (complications or problems) during or after surgery.

There wasn't much difference in the final results among all of these surgical treatments. It seems that no matter how it's done, removing the disc and any bone spurs that are pressing on the spinal nerve(s) gives immediate pain relief. But just removing these tissues would leave the spinal segment unstable. That's why the affected spinal segment is supported with fusion or disc replacement.

So the question is still: which one of these approaches to fusion or disc replacement is best? With similar results in pain relief and function, other factors must be considered. For example, autografts require the harvesting of bone from the pelvic bone.

This procedure means a longer time in the operating room under anesthesia. Many studies have shown that the donor site can become a new source of pain or discomfort. There are no such side effects with allograft. The main concern with bone from a donor bank is rejection (rare). The major downside of fusion (no matter how it's done) is the loss of neck motion.

Disc removal and replacement with an implant restores neck motion but is a much more expensive procedure. The surgery is much more complicated and takes much longer. The high cost of the disc implant must be factored in too. And since cervical disc replacements have only been around for the last five years, we don't have long-term studies to see how well they hold up or if there are any problems down the road.

The authors concluded that with the improvements that have been made in preparation of allografts (from the bone bank) the advantages of allograft over autograft are clear. Eliminating the donor site pain that often interferes with daily activities is a big benefit of allograft fusion. The ACDF procedure with allograft costs half that of autografts. Allograft safety record is well-documented making this an excellent choice for anterior discectomy and fusion.

Reference: Larry E. Miller, PhD, and Jon E. Block, PhD. Safety and Effectiveness of Bone Allografts in Anterior Cervical Discectomy and Fusion Surgery. In Spine. November 15, 2011. Vol. 36. No. 24. Pp. 2045-2050.

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