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Eur Spine J (1997) 6 : 256-266

Springer-Verlag 1997

L. C. G. Persson Cervical radiculopathy: pain,


U. Moritz
L. Brandt muscle weakness and sensory loss
C.-A. Carlsson
in patients with cervical radiculopathy
treated with surgery, physiotherapy
or cervical collar
A prospective, controlled study

Abstract This prospective, ran- conservative treatment groups. After


Received: 14 October 1996
Revised: 11 January 1997 domised study compares the efficacy a further year (control 3), there were
Accepted: 28 January 1997 of surgery, physiotherapy and cervi- no differences in pain intensity, sen-
cal collar with respect to pain, motor sory loss or paraesthesia between the
weakness and sensory loss in 81 pa- groups. An improvement in muscle
tients with long-lasting cervical strengths, measured as the ratio of
radiculopathy corresponding to a the affected to the non-affected side,
nerve root that was significantly was seen in the surgery group com-
compressed by spondylotic en- pared to the physiotherapy group in
croachment, with or without an addi- wrist extension, elbow extension,
tional bulging disk, as verified by shoulder abduction and internal rota-
MRI or CT-myelography. Pain inten- tion, but there were no differences in
sity was registered on a visual ana- the ratios between the collar group
logue scale (VAS), muscle strength and the other treatment groups. With
was measured by a hand-held dy- respect to absolute muscle strength
namometer, Vigorometer and pin- of the affected sides, there were no
chometer. Sensory loss and paraes- differences at control 1. At control 2,
thesia were recorded. The measure- the surgery group performed some-
ments were performed before treat- what better than the two other groups
ment (control 1), 4 months after the but at control 3 there were no differ-
start of treatment (control 2) and af- ences between the groups. We con-
ter a further 12 months (control 3). A clude that pain intensity, muscle
healthy control group was used for weakness and sensory loss can be
comparison and to test the reliability expected to improve within a few
of the muscle-strength measure- months after surgery, while slow im-
ments. The study found that before provement with conservative treat-
L. C. G. Persson ( ~ ) . L. Brandt start of treatment the groups were ments and recurrent symptoms in the
C.-A. Carlsson uniform with respect to pain, motor surgery group make the 1-year re-
Department of Neurosurgery, weakness and sensory loss. At con- sults about equal.
University Hospital,
S-22185 Lund, Sweden trol 2 the surgery group reported less
Tel. +46-46-172426; Fax +46-46-171276 pain, less sensory loss and had better Key words Anterior cervical
muscle strength, measured as the ra- fusion Cervical collar - Cervical
U. Moritz
Department of Physical Therapy, tio of the affected side to the non-af- radicular pain Muscle strength
University Hospital, Lund, Sweden fected side, compared to the two Physiotherapy
257

Introduction Materials and methods

N e c k p a i n and cervical r a d i c u l o p a t h y is a c o m m o n spinal Patients


disease after the age o f 40, but there are m a n y controver- The study included 81 consecutive patients of both sexes, with cer-
sies as to the choice o f treatment: whether, for instance, vico-brachial pain of more than 3 months' duration. Thirty-seven
m e t h o d s o f surgical d e c o m p r e s s i o n and stabilization are (46%) were women and 44 (54%) were men. The mean age was
p r e f e r a b l e to various c o n s e r v a t i v e r e g i m e n s [41]. M a n y 47.5 years (SD 7.9) and ranged from 28 to 64 years. The patients
had been referred to the out-patient clinic at the Department of
causes o f r a d i c u l o p a t h y m a y be f o u n d such as i m p i n g e - Neurosurgery, University Hospital of Lund, because of neck/
m e n t from d i s k herniations, osteophytes and loss o f disk shoulder/arm pain, for consideration of surgical treatment. Plain
height. Pain, m u s c u l a r weakness, n u m b n e s s or paraesthe- radiographs and MR tomography of the cervical spine or cervical
sias in the arms and fingers are c o m m o n s y m p t o m s [17, CT-myelography had been performed. The patients underwent a
full neurological examination by a senior neurosurgeon (C-A.C.).
54]. R a d i c u l o p a t h y caused b y a significant nerve root
Reflex disturbances, motor and sensory deficits, together with the
c o m p r e s s i o n should be e x p e c t e d to p r o d u c e w e a k n e s s in distribution of pain were evaluated to determine the clinical level
the m u s c l e innervated b y the i n v o l v e d nerve root [25]. of radiculopathy.
T h e clinical signs and s y m p t o m s are used to settle the di-
agnosis and to localize the level o f cervical pathology.
Inclusion criteria
H o w e v e r , radiating pain f r o m the n e c k is not e x c l u s i v e l y
an e x p r e s s i o n o f nerve root c o m p r e s s i o n . M u s c u l a r pain Pateints were included if they showed clinical and radiological
and c o n n e c t i v e tissue p a t h o l o g y m a y induce referred pain, signs that indicated nerve root compression corresponding to the
o b s c u r i n g the clinical picture [23, 54, 58]. The natural distribution of pain but without spinal cord compression.
course o f the c e r v i c o - b r a c h i a l pain is not a l w a y s pre-
dictable. In m a n y patients p a i n m~d other radicular s y m p - Exclusion criteria
toms are s p o n t a n e o u s l y o f a transient nature [20]. Further-
more, n e w or recurrent s y m p t o m s can arise after surgery Patients with spinal cord compression, whiplash, other traumatic
injuries and serious associated somatic or psychiatric diseases
[36, 49]. were excluded.
M o t o r or sensory loss m a y not a l w a y s indicate the true
level o f p a t h o l o g y b e c a u s e o f overlap or intersegmental Social and demographic data of the groups were recorded by com-
c o n n e c t i o n o f cervical roots or due to a n a s t o m o s e s be- prehensive history and by a questionnaire (Table 1). The patients
were given written information about the study, which had been
t w e e n p e r i p h e r a l nerves [6, 16, 19, 22, 39, 53]. S o m e -
accepted by the Ethics Committee of Lund University. They were
times, the patients are not a w a r e of any m o t o r w e a k n e s s randomized by the use of sealed envelopes into three treatment
[22]. groups: surgery, physiotherapy and cervical collar.
Different m o d a l i t i e s o f p h y s i o t h e r a p y are often a p p l i e d
in the acute as w e l l as the chronic phase [17, 19, 25, 56].
Control group
M a n y authors a d v o c a t e a soft or s e m i - r i g i d collar [5, 44],
while s o m e suggest early m o b i l i z a t i o n as being most im- Thirty healthy subjects were recruited from the hospital staff as a
portant for the r e l i e f o f n e c k p a i n [3511. There are several sex- and age-matched control group. None of these subjects had
studies d e m o n s t r a t i n g g o o d surgical results in patients any history of neck pain or major injury affecting the upper limbs.
The healthy subjects were tested on two occasions with 7-14 days
with cervical nerve root c o m p r e s s i o n [14, 26, 30]. H o w - in between. There was a significant correlation (r = 0.66-0.97) in
ever, m o s t studies are either personal series or uncon- muscular strength between the two test occasions, which indicates
trolled in other respects. the intra-reliability of the test method. In the control group the
In a p r e v i o u s study w e e v a l u a t e d pain intensity visual dominant side was about 5% stronger than the non-dominant side
(Table 2).
a n a l o g u e scale, function ( m e a s u r e d b y the Sickness Im-
pact Profile) and m o o d ( m e a s u r e d b y the M o o d A d j e c t i v e
C h e c k List) in patients with cervical radicular pain [47]. Study design
To our k n o w l e d g e , there is so far no prospective, con-
Tile clinical evaluation was made before treatment (control 1), and
trolled study in which surgery is c o m p a r e d with conserv-
repeated at the same time of the day 14-16 weeks after surgery or
ative treatments r e g a r d i n g m o t o r weakness and sensory after the start of the conservative treatments (control 2), and after a
loss in patients with cervical radiculopathy. The aim o f further 12 months (control 3). Control 3 always took place at the
this study was therefore to evaluate pain, m u s c u l a r w e a k - predetermined time, even if the patients were reoperated between
ness and sensory loss in patients with long-lasting cer- control 2 and 3. The clinical evaluation was done by a physiother-
apist (L.P.) according to a fixed protocol with emphasis on the
v i c o - b r a c h i a l p a i n c o n s i d e r e d to be c a u s e d b y nerve root neurological and musculoskeletal examination. The same physio-
c o m p r e s s i o n a c c o r d i n g to the clinicaI'~ picture and M R I therapist performed all three examinations, but did not take part in
and to c o m p a r e the effects o f three r a n d o m i z e d treat- the physiotherapy treatment.
ments: surgical d e c o m p r e s s i o n , p h y s i o t h e r a p y and i m m o - The clinical trials were carried out according to the "intention
to treat" principle [2]. Three patients, randomized to the surgical
bilization in a cervical c o l l a r in a 1-year follow-up. group, rejected surgery because of spontaneous improvement at
the time of operation, but the allocation to the surgical group was
258

Table 1 Characteristics of the


81 patients by treatment group Group
and of the 30 control subjects
Surgery Physiotherapy Cervical collar Con~ol
(n = 27) (n = 27) (n = 27) (n = 30)

Men (%) 16 (59) 11 (41) 17 (63) 18 (60)


Women (%) 11 (41) 16 (59) 10 (37) 12 (40)
Height (cm) 173 10 171 9 172 7 175 8.9
Weight (kg) 74 13 75 15 76 12 75 13
Age at examination (years)
Mean (median) 45 (47) 48 (48) 49 (50) 46 (46)
SD + 8.5 + 8.1 8.5 9.7
Range 28 -58 31 -61 38 -64 28 -64
Age at pain onset (years)
Mean (median) 42 (43) 44 (45) 47 (49)
SD 8.4 7.4 6.6
Range 20 -56 28 -58 36 -63
Pain duration (months)
Mean (median) 34 (15) 40 (31) 28 (21)
SD 34.8 32.5 + 24.3
Range 5 -120 6 -120 8 -120

Affected side (control 1)


Right (%) 12 (44) 15 (55) 14 (49)
Left (%) 15 (55) 12 (44) 13 (51)
Dominant side
Right (%) 24 (89) 27 (100) 24 (89)
Left (%) 3 (11) 0 (0) 3 (11)

Earlier treatment
Physiotherapy (%) 26 (96) 22 (81) 21 (77)
Cervical collar (%) 11 (41) 13 (54) 10 (37)
Affected levela
C3-C4 (%) 1 (4) 0 (0) 0 (0)
C4-C5 (%) 2 (7) 4 (15) 2 (7)
C5-C6 (%) 13 (48) 12 (44) 15 (56)
C6-C7 (%) 10 (37) 10 (10) 10 (37)
C7-C8 (%) 0 (0) 1 (4) 0 (0)
C8-T1 (%) 1 (4) 0 (0) 0 (0)
Sick leave (months) (n = 23) (n = 18) (n = 21)
Mean (median) 13 (10) 15 (13) 13 (9)
SD 9.6 10.3 13.0
a The worst affected level Range 1 -45 6 --40 0 -50
based on MRI records

retained. In the physiotherapy and cervical collar groups, all pa- Drop-outs
tients carried out the allocated treatment. No other treatments were
given between control 1 and 2. Between control 2 and 3 some pa- At control 3 one patient in the surgery group had moved and was
tients received treatments other than those determined by the ran- not examined and one patient in the collar group did not keep the
domization. In the surgery group, eight patients had a second oper- appointment because she had completely recovered.
ation, six on levels adjacent to the originally operated disc, one be-
cause of an infected bone graft, and one underwent a plexus ex-
Measurements
ploration. Eleven individuals in the surgery group received physio-
therapy. One patient in the physiotherapy group and five patients Pain intensity was assessed by means of a visual analogue scale
in the collar group were operated upon using the Cloward tech- (VAS) [32]. Current pain and the worst pain during the previous
nique. Twelve patients in the collar group received physiotherapy. week had to be filled in on two different scales. Pain intensity as-
sessment forms were sent together with the appointment for the
ctinical examination. Patients were asked to fill in the form and to
259

T a b l e 2 Differences in muscle strength between the affected side and non-affected side in patients before treatment (control 1) and in
the control group (muscle strengths measured in kilograms, hand grip in kilopascals)

Variables Right-side affected (n = 41) Left-side affected (n = 40) Control group (n = 30)

Right side Differ- Left side Right side Differ- Left side Right side Differ- Left side
Mean ence Mean Mean ence Mean Mean ence Mean
(+ SD) P-level (+ SD) (+ SD) P-level (+ SD) (+ SD) P-level (_+ SD)

Pinch grip 2.09 (1.03) *** 2.43 (0.98) 2.29 (0.81) *** 1.93 (0.87) 3.30 (0.63) 3.24 (0.64)
Hand grip 77 (0.32) *** 94 (0.26) 87 (0.31) ** 74 (0.34) 126 (0.25) 127 (0.27)
Wrist extensors 15.3 (5.43) *** 17.7 (4.82) 16.7 (4.76) ns 15.5 (5.50) 24.6 (4.04) 25.4 (5.30)
Wrist flexors 16.2 (5.99) ** 17.9 (5.35) 17.8 (5.27) ** 15.9 (5.88) 26.0 (4.98) 25.4 (5.29)
Elbow extensors 14.1 (5.86) *** 17.2 (5.67) 15.2 (4.96) *** 13.1 (5.63) 20.0 (4.78) * 19.1 (4.37)
Elbow flexors 17.5 (7.49) *** 22.4 (4.87) 20.1 (7.06) ns 19.7 (7.03) 29.6 (5.32) * 28.6 (5.07)
Shoulder abductors 15.6 (6.20) * 16.9 (5.47) 16.9 (6.76) *** 14.2 (5.65) 25.4 (6.39) 24.6 (6.09)
Shoulder adductors 18.7 (6.60) ns 20.1 (5.83) 19.9 (7.70) *** 17.4 (7.37) 30.6 (6.17) * 29.8 (6.76)
Shoulder elevator 19.5 (7.66) ** 21.7 (6.77) 21.0 (7.69) *** 18.2 (7.33) 31.1 (6.39) * 28.7 (8.74)
Shoulder extensors 19.8 (8.19) *** 22.5 (6.65) 20.8 (8.02) ** 19.0 (7.90) 31.9 (7.13) 31.6 (7.18)
Shoulder internal
rotators 13.6 (5.09) *** 16.0 (4.60) 14.7 (4.89) ** 12.8 (4.64) 23.3 (5.07) * 20.2 (4.22)
Shoulder external
rotators 11.7 (4.43) ** 13.2 (3.99) 12.4 (4.95) *** 10.7 (4.37) 15.9 (4.32) 15.4 (4.13)

* P < 0.05; ** P < 0.01; *** P < 0.001

bring it to the appointment. The pain intensity assessment was re- The pinch strength between index finger and thumb in opposition
peated at the appointment 8-12 days after the patients had received was measured with a Mannerfelt Intrinsicmeter (Metron, Stockholm,
the forms by mail. (Reproducibility coefficients for current pain Sweden). The tests were performed with patients sitting with the
and worst pain were at control 1 r = 0.82 and 0.60, control 2 r = arm neutrally adducted, the elbow at 90 of flexion and the wrist in
0.82 and 0.66 and control 3 r = 0.78 and 0.87). Mean current pain neutral position, resting on a table in front of the patient. The pa-
intensity and mean worst pain during the previous week were used tients and controls were asked to put maximal pressure on the in-
for statistical analysis. trinsic meter. The tests were performed twice, alternating between
Muscular strength in the upper limb was measured in patients the hands. The best values were chosen for statistical analysis. The
and controls by means of a hand-held spring dynamometer (Svanto- ratio of the affected to the non-affected hand was calculated.
meter, Lund, Sweden) giving the results in kilograms (1 kg = 10 N). Sensibility in the upper extremity was evaluated with a wad of
Maximal isometric breaking force was measured for elbow flexors, cotton wool. Both sides were tested synchronously. The extent of
elbow extensors, shoulder abductors, shoulder adductors, shoulder reduced sensation was recorded on an anatomical figure by the ex-
rotators, shoulder flexors, shoulder extensors, wrist flexors and aminer and graded as normal, reduced or lost. For statistical analy-
wrist extensors. All measurements were performed by one experi- sis the course of events between control 1, 2 and 3 were classified
enced physiotherapist (L.P.) using a standardized protocol and as improved, unchanged or worse.
standardized test positions. Patients and controls were instructed to Sensations of numbness or tingling were noted by the patients
pull or push maximally against the force of the dynamometer for on their own anatomical figure (anterior and posterior), which was
3-5 s up to breaking point. Before testing each muscle group, the also used to record their pain [46]. Information on frequency and
test was demonstrated to the patient in detail. The measurements trigger factors was obtained from the questionnaire and from pa-
were made in the same order, starting with the non-affected side. tient's histories. For statistical analysis, data from the coded pain
Each muscle group was tested twice, with 2 0 - 3 0 s of rest in be- maps and the questionnaire items on sensation and numbness were
tween (reproducibility coefficients, r = 0.96-0.99). The score was used to calculate the course of events between the controls with re-
recorded to the nearest kilogram and the best value was used for spect to distribution and frequency, and patients were classified as
the statistical analysis. The ratio of the affected to the non-affected improved, unchanged or worse.
side was calculated. The results of the muscle group measurements
are described in Table 2.
Hand-grip strength was measured with a Martin Vigorometer Treatments
(Gebriider Martin, Tuttlingcn, Germany). The dynamometer consists
of a rubber ball connected by a rubber tube to a manometer. The The surgery was performed by eight neurosurgeons according to
manometer scale records in kilopascals. Two ball sizes were avail- the anterior cervical discectomy technique described by Cloward
able: large (60 m m in diameter) for the men, and medium (47 m m [ 15]. The fragments of the protruded disk and the osteophytes were
in diameter) for the women. The tests were performed with the pa- removed and a bone graft from purified cow bone was used for fu-
tient sitting in a chair with the arm adducted in a neutral position sion. One of the patients underwent a laminectomy by a posterior
and the elbow resting on the chair arm at 90 of flexion and the approach technique [29]. The patients were mobilized on the 1st
wrist free in a neutral or a slight dorsiflexio~ position. The patients postoperative day. A cervical collar was sometimes used postoper-
and controls were asked to squeeze the ball maximally for some atively for 1-2 days. No physiotherapeutic treatment was given be-
seconds. The test was performed twice, alternating between the tween control 1 and 2.
hands. Both scores were used for test-retest evaluation and the the The physical therapy was provided by physiotherapists work-
highest values were chosen for statistical analysis. The ratio of the ing in the patient's geographical neighbourhood. They all had doc-
affected to the non-affected hand was calculated. umented experience with n e c k / s h o u l d e r / a r m pain patients. The
260

Table 3 Number of patients and types of physical treatment sult was significant, a pairwise comparison with Mann-Whitney
modalities in the 27 patients randomized to physical therapy U-test was performed. For comparison within groups before and
after treatment the Wilcoxon matched-pairs signed-ranks test and
Treatment modality No. of Chi-square test were used. Correlations between variables were
patients analysed with the Spearman rank correlation coefficients. An ad-
justment for multiple comparisons of the strength value was done
Manual cervical traction 19 with the Bonferoni test [1]. A difference of P < 0.05 was consid-
Ergonomics education 18 ered statistically significant.
Strengthening exercises for arm, shoulder and back 15
Isometric strengthening exercises for the neck 14
Relaxation exercises 14 Results
Stretching exercises for the neck muscles 14
Home exercises 13 To compare the three treatment groups, differences in
Mobilization 11 pain, muscle strength, sensation and sensory loss b e t w e e n
Body awareness exercises (Feldenkrais, body awareness) 9 and within groups will be described.
Massage 9
Superficial heat (hot moist-packs) 9
Balance and coordination exercises 8 Pain
Deep heat (ultrasound) 8
Transcutaneous electrical stimulation (TNS) 6 In the series of patients there were 40 left- and 41 right-
Neckpillow 2 sided pain syndromes. The average current pain rating on
Workplace evaluation 2
the VAS was 49 (median 51, range 0 - 9 7 ) and worst pain
Cryotherapy 1
during the previous week was 70 (median 71, range
2 0 - 1 0 0 ) . The pain score in the different treatment groups
before treatment is shown in Table 4. There was no sig-
treatments were given on 15 occasions, each of 30-45 min dura- nificant difference before treatment (control 1) with re-
tion, during a 3-month period. The type of therapy was decided by gard to m e a n current pain or m e a n worst pain in the pre-
the physiotherapist according to the patient's symptoms and indi-
vidual preferences. Information about clinical, radiographic and vious week.
MRI findings was given to the treating physiotherapists by phone At control 2, 4 months after the start of the treatment
or letter. Treatment procedures were recorded and returned to the programmes, there was an i m p r o v e m e n t in the surgery
Department of Neurosurgery (Table 3). Neither chiropractic ma- group and the physiotherapy group regarding worst pain
nipulation nor acupuncture was used.
In the cervical collar group, several different collars were used. during the previous week, and a significant difference was
Rigid collars were always shoulder resting and intended to be used seen b e t w e e n the surgery group and the collar group.
during day time only (Lundakrage, Miami J collar, Necky, Ortho- M e a n current pain was significantly higher in the cervical
collar, Philadelphia collar). A soft collar to be used during the night collar group than in the surgery and physiotherapy groups.
was supplied if wanted (Adams, Camp-19, Necky). Patients were In the within-groups comparison, m e a n current pain had
instructed to wear the collar over a 3-month period. If they had any
difficulties with the collar another type was provided (n = 2). i m p r o v e d only within the surgery group (Table 4).
One year later (control 3) there was no statistically sig-
nificant difference b e t w e e n the three groups with respect
Statistical methods to pain.
Non-parametric tests were chosen. For inter-group comparisons a
Kruskal-Wallis one-way analysis of variance was used. If the re-

Table 4 Pain intensity within


Control 1 (Diff. Control 2 (Diff. Control 3 (Diff
the different treatment groups
Mean 1-2) Mean 2-3) Mean 1-3)
at control 1 (before treatment),
(median) + SD P-level (median) + SD P-level (median) + SD P-level
control 2 (after 4 months) and
control 3 (after 16 months)
presented as mean, median and Surgery group
SD of visual analogue scale Mean current pain 47 (54) 25.5 *** 27 (28) 23.0 ns 30 (25) 28.1 *
values (in millimetres) Mean worst pain 72 (74) 21.3 *** 43 (37) 36.1 ns 42 (28.5)48 ***
Physiotherapy group
Mean current pain 50 (50) 20.7 ns 41 (42) 28.6 ns 39 (37) 25.8 ns
Mean worst pain 70 (68) 18.4 *** 51 (61) 29.2 ns 53 (51) 28.6 **
Collar group
Mean current pain 49 (51) 19.9 ns 48 (54) 23.2 ** 35 (37) 23.6 *
* P < 0.05; ** P < 0.01; Mean worst pain 68 (71) 16.5 ns 64 (65) 21.7 ** 52 (62) 27.1 **
*** P < 0.001
261

Table 5 The ratio of the affected side to the non-affected side between the treatment groups at control 1 (before treatment)
Variables Surgery group (n = 27) Physiotherapy group (n = 27) Cervical collar group (n = 27)

Mean Median + SD Range Mean Median + SD Range Mean Median + SD Range

Pinch grip 0.78 0.80 0.22 0.36-1.12 0.91 0.96 0.29 0.10-1.80 0.87 0.84 0.221 0.43-1.25
Hand grip 85 87 24 40-150 84 88 25 25-140 85 86 29 24-157
Wrist extensors 0.86 0.92 0.23 0.29-1.27 0.94 0.94 0.14 0.63-1.17 0.89 0.89 0.27 0.24-1.64
Wrist flexors 0.81 0.9l 0.21 0.23-1.20 0.93 0.95 0.17 0.50-1.15 0.92 0.94 0.25 0.29-1.58
Elbow extensors 0.75 0.8l 0.23 0.33-1.09" 0.92 0.95 0.19 0.44-t.33 0.85 0.90 0.28 0.72-1.00
Elbow flexors 0.87 0.90 0.22 0.35-1.39 0.93 0.98 0.37 0.27-1.85 0.85 0.87 0.29 0.35-1.67
Shoulder abductors 0.85 0.88 0.20 0.50-1.27 0.92 0.94 0,24 0.47-1.54 0.86 0.88 0.25 0.42-1.50
Shoulder adductors 0.87 0.89 0.21 0.46-1.25 0.91 0.90 0.26 0.44-1.65 0.96 0.89 0.31 0.42-1.82
Shoulder elevator 0.91 0.88 0.29 0.43-2.00 0.89 0.91 0.18 0.50-1.21 0.85 0.90 0.16 0.40-1.23
Shoulder extensors 0.88 0.91 0.17 0.58-1.25 0.93 1.00 0.22 0.38-1.33 0.87 0.91 0.18 0.40-1.13
Shoulder internal
rotators 0.78 0.79 0.23 0.31-t.18 0.92 0.92 0.18 0.50-1.25 0.91 0.86 0.32 0.33-1.73
Shoulder external
rotators 0.88 0.89 0.20 0.43-1.25 0.91 0.94 0.16 0.50-1.14 0.86 0.89 0.24 0.40-1.33

* P < 0.05 (P-level adjusted for multiple comparisons of test occasions (Bonferroni))

Muscle strength corresponding muscles in the physiotherapy group. There


were no longer any differences in strength ratio of the
Six patients were left handed. There was no significant tested muscular groups between the surgery group and the
difference in muscular strength with respect to side domi- cervical collar group, nor between the physiotherapy
nance. Men were stronger than women (P < 0.001). For group and the cervical collar group.
all patients the strength in the affected side was signifi- In addition to change in ratios, the effect of treatment
cantly less than in the non-affected side in almost all on the absolute muscle strength was studied. When values
measured groups at control 1 (Table 2). Controls were for the absolute muscle strength on the affected side were
stronger than patients in all muscle groups (P < 0.001). In compared, there was no difference between the treatment
58 patients (72%) the strength in one'. or several muscle groups at control 1. At control 2, a significant improve-
groups was more than 15% reduced in the affected side. ment of elbow flexion was noted in the surgery group
Pain appearing during muscle testing was reported by compared to the physical therapy group and of wrist flex-
20% of the patients during testing of shoulder abduction ion and elbow flexion compared to the cervical collar
and 10% during shoulder external rotation. In general, group. At control 3 no significant difference was seen be-
however, the correlation between muscle strength and tween the groups with respect to absolute muscle strength.
current pain was low (r = 0.24-0.37). There was no sig-
nificant correlation between reduction of strength and
pain duration. Within-groups comparison
Some improvement in the affected side/non-affected side
Between-groups comparison ratios was noted in the surgery and physiotherapy groups.
At control 2 the surgery group had significantly strength-
When muscular strength was expressed as the ratio of the ened pinch grip, elbow extension and flexion and shoul-
affected side to the non-affected side, there was no statis- der rotation compared to control 1 (Table 6). At control 3
tical difference before treatment (control 1) between the the surgery group had improved in the elbow extensors,
three treatment groups except for elbow extensors (Table shoulder internal rotators and adductors as compared to
5). At control 2 (after 4 months), the surgery group had control 1. In the physiotherapy group hand grip had im-
improved compared to the physiotherapy group concern- proved at control 3 compared to control 1. In the collar
ing pinch grip, elbow extension and shoulder internal ro- group no significant improvements were noted.
tation, when measured as differences in ratios. The The absolute muscle strength values improved within
surgery group had also improved compared to the cervical all groups over time. In the surgery group at control 2, the
collar group concerning wrist flexion and elbow flexion. absolute values of muscle strength in the affected sides
At control 3, 1 year later, wrist extension, elbow extension had improved with respect to hand grip, wrist flexors,
and shoulder abduction and internal rotation showed a wrist extensors, elbow extensors, shoulder abductors and
significantly higher ratio value in the ,mrgery group than shoulder extensors. Between control 2 and 3 no signifi-
262

Table 6 Ratio ofthe affected side to the non-affected side within the surgery group (n = 27) at control 1, 2 and 3, and P-level of dig
ference

Variables Control 1 Control 2 Control 3

Mean Median _+SD (Diff 1-2) Mean Median + SD (Diff 2-3) Mean Median + SD (Diffl-3)

Pinch grip 0.78 0.80 0.22 ** 0.90 0.95 0.14 ns 0.83 0.90 0.28 ns
Hand grip 85 87 24 ns 89 83 30 ns 89 98 28 ns
Wrist extensors 0.86 0.92 0.23 ns 0.93 0.96 0.18 ns 0.90 1.00 0.28 ns
Wrist flexors 0.81 0.91 0.21 ns 0.94 1.00 0.17 ns 0.90 1.00 0.23 ns
Elbow extensors 0.75 0.81 0.23 * 0.89 0.87 0.20 ns 0.86 0.86 0.16 *
Elbow flexors 0.87 0.90 0.21 ** 1.03 0.99 0.29 ns 0.95 1.00 0.21 *
Shoulder abductors 0.85 0.88 0.20 ns 0.89 0.92 0.22 ns 0.97 1.00 0.24 *
Shoulder adductors 0.87 0.89 0.20 ns 0.84 0.89 0.22 ns 0.96 0.95 0.30 ns
Shoulder elevator 0.91 0.88 0.29 ns 0.90 0.93 0.28 ns 0.91 0.91 0.16 ns
Shoulder extensors 0.88 0.91 0.17 ns 0.97 0.96 0.23 ns 0.94 0.92 0.21 ns
Shoulder internal
rotators 0.78 0.79 0.23 * 0.91 0.91 0.16 ns 0.96 0.91 0.18 **
Shoulder external
rotators 0.88 0.89 0.20 ns 0.94 1.00 0.17 ns 0.90 0.86 0.23 ns

* P < 0.05; ** P < 0.01 (P-level adjusted for multiple comparisons of test occasions (Bonferroni))

Table 7 Occurrence, location and frequency of paraesthesia, and cant i m p r o v e m e n t was seen. W h e n control 3 is c o m p a r e d
sensory loss in all patients (n = 81) before randomization (control 1) with control 1 it appears that the patients had i m p r o v e d
Paresthesia Sensory loss significantly in all m u s c l e groups in the affected side ex-
(n = 79; 98%) (n = 44; 54%) cept for the shoulder adductors, shoulder elevators, shoul-
der extensors and shoulder external rotations.
Location In the p h y si o t h er ap y group, the absolute v al u e o f mus-
Right side 25 22 cle strength o f wrist extensors in the affected sides had
Left side 31 19
i m p r o v e d at control 2. B e t w e e n control 2 and control 3 an
Bilateral 23 3
i m p r o v e m e n t was seen in the p h y si o t h er ap y group in the
Radial fingers 15 15 pinch grip, hand grip, e l b o w extensors and shoulder ele-
Middle fingers 15 3 vators, and in the collar group there was an i m p r o v e m e n t
Ulnar fingers 29 17 in the wrist flexors, wrist extensors, e l b o w flexors and
Hand (whole) 15 2 shoulder abductors, adductors, elevators and internal rota-
Arm only 5 7 tors.
M o s t patients in the two c o n s e r v a t i v e l y treated groups
Frequency
s h o w e d increased m u s c l e strength w h e n control 3 was
Constantly/several times a day 59 44
c o m p a r e d with control 1.
Occasionally 20 0

Table 8 A Change in paraes-


Group Paraesthesia Sensory loss
thesia and sensory loss after 4
months of treatment (control 2)
Improved Unchanged Worse Improved Unchanged Worse
a Improvement in sensory loss
was significantly greater in the Surgery (n = 27) 14 (52%) 9 (33%) 4 (15%) 11 (41%) a 15 (55%) I (4%)
surgery group than in the other Physiotherapy (n = 27) 12 (45%) 14 (51%) 1 (4%) 4 (15%) 21 (78%) 2 (7%)
two patient groups (* P < 0.05, Cervical collar (n = 27) 10 (37%) 13 (48%) 4 (15%) 4 (15%) 21 (78%) 2 (8%)
Chi-square)

Table 8B Change in paraes-


Group Paraesthesia Sensory loss
thesia and sensory loss 16
months after treatment (con-
Improved Unchanged Worse Improved Unchanged Worse
trol 3)
Surgery (n--26) 15 (58%) 6 (23%) 5 (19%) 7 (27%) 18 (69%) 1 (4%)
Physiotherapy(n=27) 18 (67%) 6 (22%) 3 (11%) 4 (14%) 18 (67%) 5 (19%)
Cervical collar (n = 26) 17 (66%) 5 (19%) 4 (15%) 4 (15%) 20 (77%) 2 (8%)
263

Sensation and sensory loss weakness and sensory loss. The development of symp-
toms after the treatments can be due both to recurrent
The prevalence of paraesthesia and numbness is described symptoms in the surgery group and the slow improve-
in the Table 7. Almost all patients felt numbness and ments over time in the other two groups. Similarly, some
about half of them (n = 44) experienced sensory loss. authors have reported late deterioration after a period of
Comparisons between the treatment groups showed a sig- improvement in the early post-operative course [36, 53,
nificant improvement in sensory loss in the surgery group 60]. Lunsford et al. considered that there is sometimes a
at control 2 (Table 8a), but at control 3 there were no sig- need for some form of conservative treatment during the
nificant differences between the groups (Table 8b). post-operative period [36].
Our patients had suffered their symptoms for more
than 3 months. The most common cause of pain in our pa-
Discussion tients is compression from hard disks or osteophytes. In
contrast, the acute cervical syndromes with sometimes in-
There are several studies about conservative treatment of tractable radicular pain are usally caused by herniation of
cervical myelopathy [50], but only a few concern patients a soft disk. Surgery in such syndromes of sudden onset
with cervical radiculopathy. In a study of 14 patients by gives very good results. Evidently, long-standing syn-
Highland and co-workers, improved pain and neck dromes present more difficult treatment problems and the
strength after an 8-week clinical rehabilitation programme response to conservative treatment is more likely to be ef-
was found [31]. DePalma and Subin followed one conser- fective. Some authors have found that compression of
vatively treated group (n = 255) and one surgically treated normal nerves leads to paraesthesias, sensory deficits and
group (n = 75) for 1 year. In the former, 29% obtained motor loss, but not to pain. Pain occurs if an inflamed
complete relief and 49% improved. In those who had nerve is compressed [24]. Pain associated with root com-
surgery, 64% were rated as excellent and 21% as im- pression in patients with disk herniation or spinal degen-
proved [16]. In this study, surgically treated patients im- eration is considered to be caused by a combination of
proved regarding pain, muscle strength and sensory loss mechanical, biochemical and metabolic irritation, leading
compared to the physiotherapy and the collar-treated to electrophysiologic and microcirculation changes with
groups when examined shortly after tile treatment. After a ischaemia, intraneural oedema and demyelination [51,
further year, however, there were no significant differ- 52]. Patients with long-standing root compression may
ences between the surgically and nen-surgically treated not consider radicular pain as a significant symptom and
groups of patients with respect to pain and other sensory the patients may instead complain of muscle weakness
disturbances, but the surgery group retained a minor ad- and sensory loss, depending on the duration of root com-
vantage concerning muscle strength. In a previous report pression [27].
[47] on the same patients, it was found that the patients' Whether a cervical collar provides a reduction of me-
well-being (physical, psychological and social) measured chanical stress on the nerve roots is questionable [33]. In
by the Sickness Impact Profile Inventory and mood mea- our study, several of the patients in the collar group im-
sured by the Mood Adjective Check List followed a simi- proved. Naylor and Mulley found that about 75% of
lar pattern: while there was an improvement in the surgery emergency out-patients experienced a reduction in pain
group compared to the conservatively treated groups and paraesthesia by wearing a collar [43]. Paraesthesia
shortly after the treatments, there were no significant dif- was the symptom that did not differ between the groups at
ferences between the groups at the 1-year follow-up. control 2. Paresthesia and numbness are symptoms that
The similar courses of the three groups with respect to can occur as a consequence of pure mechanical root com-
pain, muscle weakness, sensory loss and well-being is no- pression without inflammatory irritation at the spinal root
table. While the surgical group showed better results im- [51, 52].
mediately after the treatments (control 2) the groups were Quantification of muscle strength is one method to
uniform after a further 12 months (control 3). This con- evaluate the patients' functional ability and response to
formity per se strengthens the overall validity of the study. treatment. Muscular weakness may be caused by nerve
The muscular weakness in the affected arm usually in- root involvement, but also by pain, lack of motivation and
volved many muscle groups in the same patient. It there- mood disturbance, or secondary muscular inactivity be-
fore seems most plausible that the muscular weakness was cause of long-lasting pain. Sensory loss in the cervical
mainly due to inactivity caused by the pain and/or pain-in- root dermatomes can be another explanation for patients
duced motor inhibition at the time of the muscle tests. The feeling weakness.
conformity of the measurements of pain and muscle Few of the clinical tests for musculoskeletal disorders
strength is therefore most likely governed by the pain. in the neck/shoulder have been tested for validity and re-
No other prospective, randomized treatment study has, liability [59]. Measurements of maximal isometric
to our knowledge, compared surgery to conservative treat- strength in the upper limb have mostly been used as diag-
ment for cervical radiculopathy with respect to motor nostic tools, but have not been correlated to existing neck
264

symptoms or used as an outcome measurement for treat- really strengthens their validity as measures of the effect
ment. Hand-held dynamometer testing is well documented of treatment on muscle strength.
and is a reliable tool both for intra- and inter-testing [ 1, 9, The pain duration in our patients was long lasting and
10, 48]. The vigorimeter and Mannerfelt Intrinsicmeter most patients had undergone different forms of treatment,
have also been shown to be reliable [18, 38]. High in- such as physiotherapy, chiropractic, massage, acupuncture
trareliability of muscle strength measurements was seen or zone therapy, or tried a soft collar, which is commonly
in our control group. Three types of pinch may be mea- used in clinical practice, before they were referred to the
sured [8]. In our study the pinch was performed with Department of Neurosurgery. Patients without earlier treat-
thumb tip to the tip of the index finger. Arm position is ment with a collar or other forms of physiotherapy were
important and a standard position is required for score equally distributed between the treatment groups. Some
comparisons [37, 55]. For the statistical analysis we chose investigators have studied the effects of cervical collar in
the best value of two scores. Hamilton et al. did not find patients with cervical spondylotic myelopathy and found
any difference between using the mean values or the best good results [50]. Some authors reject the use of a collar
value to determine the grip strength score [28]. The inter- and consider early motion as important for good outcome
individual differences of muscular strength are wide even of neck pain [35]. In a prospective study with patients
in healthy people and differ depending on sex, age, height with cervico-brachial pain there was, however, no differ-
and weight [3, 34, 42]. Pain condition on the day of test- ence between those treated by collar and those treated
ing may also play an important role. Differences between with physiotherapy and traction [13].
sexes were seen also in our study. In the physiotherapy From the literature it is difficult to compare measure-
group there were slightly more women than in the other ments of muscle weakness and sensory loss after surgical
two groups. In women, strength is about 65% that of men or conservative treatment. Most of the articles are retro-
[42], and in older persons it is between 66% and 93% of spective, the follow-up times differed widely, as did the
that in younger people [42]. Such differences can also be selection of patients. Patients with myelopathy and radi-
seen in the strength of hand grip [4, 18, 44, 57]. In our culopathy are sometimes mixed. The pre-surgery treat-
study the patients were their own references and the dif- ment is not always described, nor whether a patient was
ference in values were used for statistical comparisons. treated with a collar, bed rest or physiotherapy after
We have not taken into consideration differences be- surgery. The outcome is usually described only with re-
tween the dominant and the non-dominant side (six pa- spect to pain, and the neurological deficit is not always
tients were left-side dominant). The dominant side is on documented. If signs are describedl the measurements are
average 7% stronger in hand grip, with little variation often not objective and seldom performed by an unbiased
with age and sex [57]. In the shoulder no such difference observer.
could be shown [42]. In our control group the differences Motor loss in the arms without myelopathy has been
in muscle strength between the dominant and the non- reported by several authors [12, 20, 40], but this has not
dominant side were also low. been objectively measured. Few studies have shown the
For evaluation of muscular weakness the side differ- occurrence of specific symptoms after surgery. Function-
ence is of importance. By using the ratio of the affected to ally good results are sometimes claimed based on combi-
the non-affected side, bias from age, sex, motivation, and nation scores of symptoms such as pain, numbness, sensi-
day-to-day variations can be reduced. In this study we bility loss and muscle weakness mixed together, as in the
found a significant difference between the affected side studies by White et al. [60] and Henderson et al. [29],
and non-affected side. The difference was moderate with 91% and 98% good results respectively, or by Es-
(20-30%), and could have been difficult to evaluate with- persen et al. [21], with a 46% good functional result after
out a dynamometer. It must be noted, however, that if a surgery. In one long-term follow up of 122 patients, 63%
patient has a severe pain in one side, this can also influ- had sensory loss and 45% had muscle weakness before
ence the muscle strength recordings on the non-affected surgery (manually tested). At follow-up 2-15 years after
side and the ratio might not reflect the true difference be- surgery, 96% had recovered motor function and 92% had
tween the sides. The ratio of the affected side to the non regained sensation [11]. Motor deficit and brachialgia
affected side might not change with time even if the mus- showed the best improvements after surgery in another
cular strength increased because of less pain. Because of study of 109 patients treated with surgery for cervical
this, we also analysed the absolute value of muscle radiculopathy [7]. Of these, 77% had motor deficit symp-
strength of the affected side. It was found to improve in all toms before surgery. Sensory deficit before surgery was
groups over time. In between-groups comparison, there 81%, and 53% improved or were cured. Lunsford et al.
was a slight preference for surgery at control 2, but at con- [36] found in a postoperative questionnaire that about
trol 3 there was no such difference between groups. This 75% of patients responded positively regarding sensory
shows that the calculation using the ratios of affected to symptoms. They also found a significant difference in the
non-affected side and that using the absolute value of improvement of motor function between soft disk and
muscle strength both follow a similar pattern, which mu- hard disk cases (80% vs 64% recovery).
265

In a retrospective study o f 43 patients with r a d i c u l o p a - Conclusions


thy due to f o r a m i n a l stenosis or herniated nucleus pulpo-
sus, 23% had residual s y m p t o m s in their arms and 14% Pain intensity, m u s c l e w e a k n e s s and sensory loss can be
had subjective n u m b n e s s in the fingers [12]. R e c u r r e n t e x p e c t e d to i m p r o v e within a few months after surgery,
s y m p t o m s requiring a s e c o n d o p e r a t i o n were found b y while with c o n s e r v a t i v e treatment there is a slower im-
W i l l i a m s et al. in 25% o f patients w h o h a d b e e n c o m - provement. S o m e o f the surgery-treated patients i m p r o v e d
pletely a s y m p t o m a t i c i m m e d i a t e l y after surgery [61]. i m m e d i a t e l y but had recurrent s y m p t o m s , p r o b a b l y re-
Eriksen and c o - w o r k e r s , in a study o f 1,106 patients with lated to the p r e c e d i n g d e g e n e r a t i o n o f adjacent cervical
cervical disk disease, f o u n d that d i s a b l i n g s y m p t o m s were levels. The 1-year o u t c o m e shows no significant differ-
still present in 45% o f the patients after surgery, and that ences b e t w e e n surgical and c o n s e r v a t i v e therapy.
patients with a duration o f paresis o f over 6 months had
p o o r e r results [20]. In our study all patients had suffered Acknowledgements This investigation was supported by grants
m o r e than 3 m o n t h s pain, with a m e d i a n o f 21 months, al- from the Thelma Zoegas Fondation for Medical Research, the
Malm6hus County Council Care Committee, and Medical Health
though not a l w a y s continuously. P r e - o p e r a t i v e s i c k - l e a v e Care Research in South Sweden (HSF).
was 11 months (median). It is p o s s i b l e that the overall im-
p r o v e m e n t w o u l d have b e e n better in all groups if pain
history h a d been shorter.

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