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CervicalRadiculopathy PDF
CervicalRadiculopathy PDF
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 2
Financial Statement
This clinical guideline was developed and funded in its entirety by the North American Spine Society (NASS).
All participating authors have submitted a disclosure form relative to potential conflicts of interest which is
kept on file at NASS.
Comments
Comments regarding the guideline may be submitted to the North American Spine Society and will be consid-
ered in development of future revisions of the work.
ISBN: 1-929988-25-7
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
3
Table of Contents
I. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
V. Appendices
A. Acronyms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
B. Levels of Evidence for Primary Research Questions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
C. Grades of Recommendations for Summaries or Reviews of Studies. . . . . . . . . . . . . . . . . . 74
D. Protocol for NASS Literature Searches. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 75
E. Literature Search Parameters. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
F. Evidentiary Tables. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 4
I. Introduction
Objective
The objective of the North American Spine Society reasonable evaluation of patients suspected to have
(NASS) Clinical Guideline for the Diagnosis and cervical radiculopathy from degenerative disorders
Treatment of Cervical Radiculopathy from Degen- and outlines treatment options for adult patients
erative Disorders is to provide evidence-based rec- with a diagnosis of cervical radiculopathy from de-
ommendations to address key clinical questions generative disorders.
surrounding the diagnosis and treatment of cervi-
cal radiculopathy from degenerative disorders. The THIS GUIDELINE DOES NOT REPRESENT A
guideline is intended to reflect contemporary treat- “STANDARD OF CARE,” nor is it intended as a fixed
ment concepts for cervical radiculopathy from de- treatment protocol. It is anticipated that there will
generative disorders as reflected in the highest qual- be patients who will require less or more treatment
ity clinical literature available on this subject as of than the average. It is also acknowledged that in
May 2009. The goals of the guideline recommenda- atypical cases, treatment falling outside this guide-
tions are to assist in delivering optimum, efficacious line will sometimes be necessary. This guideline
treatment and functional recovery from this spinal should not be seen as prescribing the type, frequen-
disorder. cy or duration of intervention. Treatment should be
based on the individual patient’s need and physi-
Scope, Purpose and Intended User cian’s professional judgment. This document is de-
This document was developed by the North Ameri- signed to function as a guideline and should not be
can Spine Society Evidence-Based Guideline Devel- used as the sole reason for denial of treatment and
opment Committee as an educational tool to assist services. This guideline is not intended to expand or
practitioners who treat patients with cervical radic- restrict a health care provider’s scope of practice or
ulopathy from degenerative disorders. The goal is to to supersede applicable ethical standards or provi-
provide a tool that assists practitioners in improving sions of law.
the quality and efficiency of care delivered to pa-
tients with cervical radiculopathy from degenera- Patient Population
tive disorders. The NASS Clinical Guideline for the The patient population for this guideline encom-
Diagnosis and Treatment of Cervical Radiculopathy passes adults (18 years or older) with a chief com-
from Degenerative Disorders provides a definition plaint of pain in a radicular pattern in one or both
and explanation of the natural history of cervical ra- upper extremities related to compression and/or ir-
diculopathy from degenerative disorders, outlines a ritation of one or more cervical nerve roots.
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 5
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 6
C: Poor quality evidence (Level IV or V studies) for In addition, a number of studies were reviewed sev-
or against recommending intervention. eral times in answering different questions within
I: Insufficient or conflicting evidence not allowing this guideline. How a given question was asked
a recommendation for or against intervention. might influence how a study was evaluated and
interpreted as to its level of evidence in answering
Guideline recommendations are written utilizing that particular question. For example, a random-
a standard language that indicates the strength of ized control trial reviewed to evaluate the differenc-
the recommendation. “A” recommendations indi- es between the outcomes of surgically treated ver-
cate a test or intervention is “recommended”; “B” sus untreated patients with lumbar spinal stenosis
recommendations “suggest” a test or intervention might be a well designed and implemented Level I
and “C” recommendations indicate a test or inter- therapeutic study. This same study, however, might
vention “may be considered” or “is an option.” “I” or be classified as giving Level II prognostic evidence
“Insufficient Evidence” statements clearly indicate if the data for the untreated controls were extracted
that “there is insufficient evidence to make a rec- and evaluated prognostically.
ommendation for or against” a test or intervention.
Work group consensus statements clearly state that Guideline Development Process
“in the absence of reliable evidence, it is the work
group’s opinion that” a test or intervention may be Step 1: Identification of Clinical Questions
appropriate. Trained guideline participants were asked to submit
The levels of evidence and grades of recommenda- a list of clinical questions that the guideline should
tion implemented in this guideline have also been address. The lists were compiled into a master list,
adopted by the Journal of Bone and Joint Surgery, which was then circulated to each member with
the American Academy of Orthopaedic Surgeons, a request that they independently rank the ques-
Clinical Orthopaedics and Related Research, the tions in order of importance for consideration in
journal Spine and the Pediatric Orthopaedic Society the guideline. The most highly ranked questions, as
of North America. determined by the participants, served to focus the
guideline.
In evaluating studies as to levels of evidence for this
guideline, the study design was interpreted as es- Step 2: Identification of Work Groups
tablishing only a potential level of evidence. As an Multidisciplinary teams were assigned to work
example, a therapeutic study designed as a random- groups and assigned specific clinical questions to ad-
ized controlled trial would be considered a poten- dress. Because NASS is comprised of surgical, medi-
tial Level I study. The study would then be further cal and interventional specialists, it is imperative
analyzed as to how well the study design was imple- to the guideline development process that a cross-
mented and significant short comings in the execu- section of NASS membership is represented on each
tion of the study would be used to downgrade the group. This also helps to ensure that the potential for
levels of evidence for the study’s conclusions. In the inadvertent biases in evaluating the literature and
example cited previously, reasons to downgrade the formulating recommendations is minimized.
results of a potential Level I randomized controlled
trial to a Level II study would include, among other Step 3: Identification of Search Terms and
possibilities: an underpowered study (patient sam- Parameters
ple too small, variance too high), inadequate ran- One of the most crucial elements of evidence analy-
domization or masking of the group assignments sis to support development of recommendations for
and lack of validated outcome measures. appropriate clinical care is the comprehensive litera-
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 7
ture search. Thorough assessment of the literature is radiculopathy alone or include a subgroup analysis
the basis for the review of existing evidence and the of patients with radiculopathy. Many of the studies
formulation of evidence-based recommendations. considered for potential inclusion in this guideline
In order to ensure a thorough literature search, NASS included groups of patients with myelopathy, with-
has instituted a Literature Search Protocol (Appen- out appropriate subgroup analyses of those patients
dix D) which has been followed to identify literature with cervical radiculopathy alone. For this reason,
for evaluation in guideline development. In keep- in the absence of subgroup analyses, a large number
ing with the Literature Search Protocol, work group of studies were excluded from consideration in ad-
members have identified appropriate search terms dressing the questions and formulating recommen-
and parameters to direct the literature search. dations. These studies, having been reviewed, are
included in the reference sections.
Specific search strategies, including search terms,
parameters and databases searched, are document- Step 6: Evidence Analysis
ed in the appendices (Appendix E). Members have independently developed evidentia-
ry tables summarizing study conclusions, identify-
Step 4: Completion of the Literature ing strengths and weaknesses and assigning levels
Search of evidence. In order to systematically control for
Once each work group identified search terms/pa- potential biases, at least two work group members
rameters, the literature search was implemented by have reviewed each article selected and indepen-
a medical/research librarian, consistent with the dently assigned levels of evidence to the literature
Literature Search Protocol. using the NASS levels of evidence. Any discrepan-
Following these protocols ensures that NASS recom- cies in scoring have been addressed by two or more
mendations (1) are based on a thorough review of reviewers. The consensus level (the level upon which
relevant literature; (2) are truly based on a uniform, two-thirds of reviewers were in agreement) was then
comprehensive search strategy; and (3) represent assigned to the article.
the current best research evidence available. NASS As a final step in the evidence analysis process,
maintains a search history in Endnote, for future use members have identified and documented gaps in
or reference. the evidence to educate guideline readers about
where evidence is lacking and help guide further
Step 5: Review of Search Results/ needed research by NASS and other societies.
Identification of Literature to Review
Work group members reviewed all abstracts yielded Step 7: Formulation of Evidence-Based
from the literature search and identified the litera- Recommendations and Incorporation of
ture they will review in order to address the clini- Expert Consensus
cal questions, in accordance with the Literature Work groups held webcasts to discuss the evidence-
Search Protocol. Members have identified the best based answers to the clinical questions, the grades of
research evidence available to answer the targeted recommendations and the incorporation of expert
clinical questions. That is, if Level I, II and or III lit- consensus. Expert consensus has been incorporat-
erature is available to answer specific questions, the ed only where Level I-IV evidence is insufficient and
work group was not required to review Level IV or the work group has deemed that a recommendation
V studies. Work group members reviewed the evi- is warranted. Transparency in the incorporation of
dence on the topic of cervical radiculopathy, and consensus is crucial, and all consensus-based rec-
studies eligible for review were required to address
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 8
ommendations made in this guideline very clearly Following NASS Board approval, the guidelines have
indicate that Level I-IV evidence is insufficient to been slated for publication, submitted for endorse-
support a recommendation and that the recom- ment to all appropriate societies and submitted for
mendation is based only on expert consensus. inclusion in the National Guidelines Clearinghouse
(NGC). No revisions were made at this point in the
Consensus Development Process process, but comments have been and will be saved
Voting on guideline recommendations was conduct- for the next iteration.
ed using a modification of the nominal group tech-
nique in which each work group member indepen- Step 11: Identification and Development of
dently and anonymously ranked a recommendation Performance Measures
on a scale ranging from 1 (“extremely inappropri- The recommendations will be reviewed by a group
ate”) to 9 (“extremely appropriate”). Consensus was experienced in performance measure development
obtained when at least 80% of work group members (eg, the AMA Physician’s Consortium for Perfor-
ranked the recommendation as 7, 8 or 9. When the mance Improvement) to identify those recommen-
80% threshold was not attained, up to three rounds dations rigorous enough for measure develop-
of discussion and voting were held to resolve dis- ment. All relevant medical specialties involved in
agreements. If disagreements were not resolved af- the guideline development and at the Consortium
ter these rounds, no recommendation was adopted. will be invited to collaborate in the development of
evidence-based performance measures related to
After the recommendations were established, work spine care.
group members developed the guideline content,
addressing the literature which supports the recom- Step 12: Review and Revision Process
mendations. The guideline recommendations will be reviewed
every three years by an EBM-trained multidisci-
Step 8: Submission of the Draft Guidelines plinary team and revised as appropriate based on a
for Review/Comment thorough review and assessment of relevant litera-
Guidelines were submitted to the full Evidence- ture published since the development of this version
Based Guideline Development Committee and the of the guideline.
Research Council Director for review and comment.
Revisions to recommendations were considered for Use of Acronyms
incorporation only when substantiated by a prepon- Throughout the guideline, readers will see many ac-
derance of appropriate level evidence. ronyms with which they may not be familiar. A glos-
sary of acronyms is available in Appendix A.
Step 9: Submission for Board Approval
Once any evidence-based revisions were incor- Nomenclature for Medical/Interventional
porated, the drafts were prepared for NASS Board Treatment
review and approval. Edits and revisions to recom- Throughout the guideline, readers will see that what
mendations and any other content were considered has traditionally been referred to as “nonoperative,”
for incorporation only when substantiated by a pre- “nonsurgical” or “conservative” care is now referred
ponderance of appropriate level evidence. to as “medical/interventional care.” The term medi-
cal/interventional is meant to encompass pharma-
Step 10: Submission for Endorsement, cological treatment, physical therapy, exercise ther-
Publication and National Guideline apy, manipulative therapy, modalities, various types
Clearinghouse (NGC) Inclusion of external stimulators and injections.
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 9
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 10
vical radiculopathy from degenerative disorders cal approach to the management of patients with cervical
would provide evidence regarding the natural his- radiculopathy: A prospective observational cohort study. J
Manipulative Physiol Ther. May 2006;29(4):279-287.
tory of the disease in this patient population. 15. Peng B, Hao J, Hou S, et al. Possible pathogenesis of
painful intervertebral disc degeneration. Spine. Mar 1
Natural History References 2006;31(5):560-566.
1. Anderberg L, Annertz M, Persson L, Brandt L, Saveland H. 16. Petren-Mallmin M, Linder J. Cervical spine degeneration
Transforaminal steroid injections for the treatment of cer- in fighter pilots and controls: a 5-yr follow-up study. Aviat
vical radiculopathy: a prospective and randomised study. Space Environ Med. May 2001;72(5):443-446.
Eur Spine J. Mar 2007;16(3):321-328. 17. Petren-Mallmin M, Linder J. MRI cervical spine findings
2. Carette S, Fehlings MG. Clinical practice. Cervical radicu- in asymptomatic fighter pilots. Aviat Space Environ Med.
lopathy. N Engl J Med. Jul 28 2005;353(4):392-399. Dec 1999;70(12):1183-1188.
3. Garvey TA, Eismont FJ. Diagnosis and treatment of cer- 18. Radhakrishnan K, Litchy WJ, O’Fallon WM, Kurland LT.
vical radiculopathy and myelopathy. Orthop Rev. Jul Epidemiology of cervical radiculopathy. A population-
1991;20(7):595-603. based study from Rochester, Minnesota, 1976 through
4. Gore DR, Carrera GF, Glaeser ST. Smoking and degen- 1990. Brain. Apr 1994;117 ( Pt 2):325-335.
erative changes of the cervical spine: a roentgenographic 19. Rao R. Neck pain, cervical radiculopathy, and cervical my-
study. Spine J. Sep-Oct 2006;6(5):557-560. elopathy: pathophysiology, natural history, and clinical
5. Gore DR, Sepic SB, Gardner GM, Murray MP. Neck pain: evaluation. J Bone Joint Surg Am. Oct 2002;84-A(10):1872-
a long-term follow-up of 205 patients. Spine. Jan-Feb 1881.
1987;12(1):1-5. 20. Ross JS, Modic MT, Masaryk TJ, Carter J, Marcus RE, Bohl-
6. Hamalainen O, Toivakka-Hamalainen SK, Kuronen P. +Gz man H. Assessment of extradural degenerative disease
associated stenosis of the cervical spinal canal in fighter with Gd-DTPA-enhanced MR imaging: correlation with
pilots. Aviat Space Environ Med. Apr 1999;70(4):330-334. surgical and pathologic findings. AJR Am J Roentgenol. Jan
7. Harrop JS, Hanna A, Silva MT, Sharan A. Neurological 1990;154(1):151-157.
manifestations of cervical spondylosis: an overview of 21. Rubin D. Cervical radiculitis: diagnosis and treatment.
signs, symptoms, and pathophysiology. Neurosurgery. Jan Arch Phys Med Rehabil. Dec 1960;41:580-586.
2007;60(1 Supp1 1):S14-20. 22. Saal JS, Saal JA, Yurth EF. Nonoperative management of
8. Healy JF, Healy BB, Wong WH, Olson EM. Cervical and herniated cervical intervertebral disc with radiculopathy.
lumbar MRI in asymptomatic older male lifelong athletes: Spine. Aug 1996;21(16):1877-1883.
frequency of degenerative findings. J Comput Assist To- 23. Sambrook PN, MacGregor AJ, Spector TD. Genetic influ-
mogr. Jan-Feb 1996;20(1):107-112. ences on cervical and lumbar disc degeneration: a mag-
9. Hendriksen IJ, Holewijn M. Degenerative changes of the netic resonance imaging study in twins. Arthritis Rheum.
spine of fighter pilots of the Royal Netherlands Air Force Feb 1999;42(2):366-372.
(RNLAF). Aviat Space Environ Med. Nov 1999;70(11):1057- 24. Sampath P, Bendebba M, Davis JD, Ducker T. Outcome in
1063. patients with cervical radiculopathy. Prospective, multi-
10. Humphreys SC, Hodges SD, Patwardhan A, Eck JC, Coving- center study with independent clinical review. Spine. Mar
ton LA, Sartori M. The natural history of the cervical fora- 15 1999;24(6):591-597.
men in symptomatic and asymptomatic individuals aged 25. Swezey RL. Conservative treatment of cervical radiculop-
20-60 years as measured by magnetic resonance imaging. athy. J Clin Rheumatol. Apr 1999;5(2):65-73.
A descriptive approach. Spine. Oct 15 1998;23(20):2180- 26. Teresi LM, Lufkin RB, Reicher MA, et al. Asymptomatic
2184. degenerative disk disease and spondylosis of the cervical
11. Kang JD, Stefanovic-Racic M, McIntyre LA, Georgescu spine: MR imaging. Radiology. Jul 1987;164(1):83-88.
HI, Evans CH. Toward a biochemical understanding of 27. Van Zundert J, Harney D, Joosten EA, et al. The role of the
human intervertebral disc degeneration and herniation. dorsal root ganglion in cervical radicular pain: diagnosis,
Contributions of nitric oxide, interleukins, prostaglan- pathophysiology, and rationale for treatment. Reg Anesth
din E2, and matrix metalloproteinases. Spine. May 15 Pain Med. Mar-Apr 2006;31(2):152-167.
1997;22(10):1065-1073. 28. Wainner RS, Gill H. Diagnosis and nonoperative manage-
12. Lees F, Turner JW. Natural history and prognosis of cervi- ment of cervical radiculopathy. J Orthop Sports Phys Ther.
cal spondylosis. Br Med J. Dec 28 1963;2(5373):1607-1610. Dec 2000;30(12):728-744.
13. Murphey F, Simmons JC, Brunson B. Chapter 2. Ruptured 29. Yoo K, Origitano TC. Familial cervical spondylosis. Case
cervical discs, 1939 to 1972. Clin Neurosurg. 1973;20:9-17. report. J Neurosurg. Jul 1998;89(1):139-141.
14. Murphy DR, Hurwitz EL, Gregory A, Clary R. A nonsurgi- 30. Yoshida M, Tamaki T, Kawakami M, Hayashi N, Ando M.
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 11
Indication and clinical results of laminoplasty for cervical 31. Zejda JE, Stasiow B. Cervical spine degenerative changes (nar-
myelopathy caused by disc herniation with developmen- rowed intervertebral disc spaces and osteophytes) in coal
tal canal stenosis. Spine. Nov 1998;23(22):2391-2397. miners. Int J Occup Med Environ Health. 2003;16(1):49-53.
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 12
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 13
foraminotomy (PLF). Evaluating fusion status, pain identifying the level involved. Patients underwent
relief and level of activity based on Odom’s criteria, single level nerve root decompression using a pos-
good or excellent results were obtained in 10 of the terior open foraminotomy. The surgical level was
11 patients. The authors concluded that patients with determined by correlation of symptoms and imag-
neck pain should be evaluated for C4 radiculopathy, ing, with selective nerve root block (SNRB) in five
the examination should include C4 sensory testing, patients. Cervical disc herniation (CDH) was found
and neck pain from C4 radiculopathy can respond in 20 patients and stenosis in 30. Neck or scapu-
to surgical decompression unlike neck pain arising lar pain preceeded the arm/finger symptoms in 35
from degenerative disc disease. patients (70%) and was relieved early in 46 (92%).
When the pain was suprascapular, C5 or C6 radicu-
In critique, no validated outcome measures were lopathy was frequent; when interscapular, C7 or C8
used and the sample size was small. This study pro- radiculopathy was frequent; and when scapular, C8
vides Level IV evidence that neck pain with or with- was frequent. Arm and finger symptoms improved
out upper extremity clinical findings should prompt significantly in all groups after decompression. Six-
evaluation for a C4 radiculopathy and that this eval- ty-one painful sites were noted before surgery: one
uation should include C4 sensory testing. in 39 patients and two in 11 patients. One month af-
ter surgery, 27 patients reported complete pain re-
Post et al38 reported a retrospective case series re- lief, 23 complained of pain in 24 subregions, seven
viewing experience with the surgical management of which were the same as before surgery. Seven-
of a series of 10 patients with C7-T1 herniations. teen pain sites were new since surgery. All but one
Symptoms included shoulder pain radiating into new site were nuchal and suprascapular. At one year
the lateral aspect of the hand, hand weakness and follow-up, 45 patients reported no pain, five patients
weakness in finger flexion, finger extension and in- had pain in six sites, three of which were the same as
trinsic hand muscles. Sensation and DTRs were un- before surgery. The authors concluded that pain in
remarkable. MRI on each patient revealed a soft disc the suprascapular, interscapular or scapular regions
compressing the C8 nerve root. Recovery of hand can orginate from a compressed cervical nerve root
strength was noted in each patient; however, recov- and is valuable for determing the nerve root in-
ery was incomplete in two patients with symptoms volved.
greater than four months. In critique, no validated
outcome measures were used and the sample size This study provides Level I evidence that cervical ra-
was small. This study provides Level IV evidence diculopathy at C5, C6, C7 and C8 frequently causes
that C8 radiculopathy usually presents as weakness pain in suprascapular, interscapular and scapular
of the hand and pain radiating to shoulder, scapu- areas and is useful in determining the level of nerve
lar area, and to the fourth and fifth fingers. Physi- root involvement. Pain in the suprascapular region
cal exam may reveal normal sensation and DTRs. suggests C5 or C6 radiculopathy, pain in the inter-
Motor examination may show weakness of finger scapular region suggests C7 or C8 radiculopathy,
flexion and extension and weakness of the intrinsic and pain in the scapular region suggests C8 radicu-
muscles of the hand. lopathy.
Tanaka et al48 described a prospective observational Yoss et al55 conducted a retrospective observational
study examining whether or not pain in the neck or study of 100 patients to correlate clinical findings
scapular regions in 50 consecutive patients with cer- with surgical findings when a single cervical nerve
vical radiculopathy originated from a compressed root (C5, C6, C7, C8) is compressed by a disc hernia-
nerve root, and whether the site of pain is useful for tion. Symptoms included pain in the neck, shoulder,
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 14
scapular or interscapular regions, arm, forearm or and signs are often present in patients with
hand; paresthesias in forearm, and hand; and weak- cervical radiculopathy, and can improve with
ness of upper extremity. Signs included diminution treatment.
of triceps, biceps and brachioradialis reflexes, mus- Grade of Recommendation: B
cle weakness and sensory loss. Pain or paresthe-
sia in the neck, shoulder, scapular or interscapular Henderson et al30 presented findings of a retrospec-
region were present in cases of C5, C6, C7 or C8 tive observational study reporting results of PLF in
compression. The presence of pain in the arm cor- the treatment of 736 patients with cervical radicul-
responded to the site compression in 23% of cases. opathy. Patients included in the study reported the
The presence of pain or paresthesia in the forearm following symptoms: arm pain (99.4%), neck pain
corresponded to a single root or one of two roots in (79.7%), scapular pain (52.5%), anterior chest pain
32% and 66%, respectively. Hand pain and paresthe- (17.8%) and headache (9.7%). Eleven patients pre-
sia corresponded to a single root or one of two roots sented with only left chest and arm pain (“cervical
in 70% and 27%, respectively. Subjective weakness angina”). Pain or paresthesia in a dermatomal pat-
corresponded to a single level in 22/34 (79%) cases. tern was reported by 53.9% of patients, while 45.5%
experienced pain or paresthesia in a diffuse or non-
When a diminution of DTR was present, the lesion dermatomal pattern. No pain or paresthesia was re-
could be correctly localized to a single level or one ported by 0.6% of patients. Of patients included in
of two levels in 11% and 82%, respectively. Objective the study, 85.2% reported a sensory change to pin-
muscle weakness corresponded to a single root or prick, 68% had a specific motor deficit and 71.2%
one of two roots in 77% and 12%, respectively. In all had a specific decrease in a DTR. One nerve root
cases in which the C5 and C8 nerve root was involved level was thought to be primarily responsible for
and objective weakness was present, the level was symptoms in 87.3% of patients and two levels were
correctly localized. Sensory loss corresponded to a felt to be equally involved for the remaining 12.7%.
single root or one of two roots in 65% and 35%, re- The correlation between pain/paresthesia, motor
spectively. The authors concluded that clinical find- deficit, DTR change and the primary surgical level
ings related to the fingers are the most accurate for was 73.8%, 84.8% and 83.5%, respectively. There was
localizing a CDH to a single level. A single level CDH a 71.5% incidence of correlation between presurgi-
may produce signs and symptoms that correspond cal clinical findings and surgical findings. Good or
to overlapping dermatomal levels. excellent results were reported by 91.5% of patients.
Good or excellent relief of arm pain was found in
This study provides Level II evidence that clinical 95.5% of patients, neck pain in 88.8%, scapular
findings related to the fingers are the most accurate pain in 95.9%, chest pain in 95.4% and headache
for localizing a CDH to a single level. Single level in 89.8%. Resolution of DTR abnormalities was re-
CDH may produce signs and symptoms that corre- ported in 96.9%. Residual sensory deficit was found
spond to overlapping dermatomal levels. in 20.9% of patients and motor deficit in 2.3%. In a
large group of patients with cervical radiculopathy,
RECOMMENDATION: It is suggested that the this study elucidates the common clinical findings
diagnosis of cervical radiculopathy be considered of pain, paresthesia, motor deficit, and decreased
in patients with atypical findings such as deltoid DTRs, along with their respective frequencies. These
weakness, scapular winging, weakness of the data present evidence that the operative site can be
intrinsic muscles of the hand, chest or deep accurately predicted on the basis of clinical findings
breast pain, and headaches. Atypical symptoms 71.5% of the time.
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 15
In critique, no validated outcome measures were small study provides Level IV evidence that scapular
used in the study. Thus, it provides Level II evidence winging can be a feature of C7 radiculopathy.
that 71.5% of the time, the operative site can be ac-
curately predicted on the basis of clinical findings. Ozgur et al35 described a retrospective case series of
the presenting symptomatology of 241 consecutive
Chang et al13 described a retrospective case series patients following C6-7 discectomy . Of the patients,
identifying the characteristics of cervical radicul- 83% had typical C7 radicular signs while 17% had
opathy causing deltoid paralysis, and reporting on atypical symptoms, 12% reporting isolated subscap-
the surgical outcomes of ACDF for the treatment ular pain and 5% deep breast or chest pain. The au-
of deltoid paralysis. All 14 patients had pain radiat- thors reported that patients presenting with atypical
ing to the scapula, shoulder or arm, with weakness symptoms had correlative pathology confirmed by
of shoulder abduction due to paralysis of deltoid surgical findings, 93% of whom experienced symp-
(graded 0-5). Severity of radicular pain was graded tom relief. This study provides Level IV evidence
on a visual analog scale (VAS) from zero to 10. Plain that a substantial percentage of patients may present
radiographs and MRI were correlated with clinical with atypical symptoms associated with C7 nerve
findings. Surgery was performed on patients with root compression
single level CDH or cervical spondylotic radicul-
opathy (CSR). Patients with multilevel disease were Persson et al37 conducted a prospective observation-
excluded. The following lists the single levels im- al study to describe the frequency of headaches in
plicated in deltoid paralysis and their respective patients with lower level cervical radiculopathy and
frequencies: 1-C3-4 CDH (central), 4-C4-5 CDH, its response to a selective nerve root block (SNRB).
1-C5-6 CDH, 3-C4-5 CSR, 5-C5-6 CSR. Both radicu- Of 275 patients, 161 suffered from daily or recurrent
lopathy and deltoid paralysis improved significantly headaches, most often ipsilateral to the patients’ ra-
with surgery. The authors found that a painful cervi- diculopathy. All patients underwent clinical exam
cal radiculopathy with deltoid paralysis arose from and MRI. Patients with significantly compressed
the C4-5, C5-6 and C3-4 levels in 50%, 43% and 7% nerve roots underwent SNRB. All patients with
of the cases, respectively. This small study provides headaches had tender points in the neck/shoulder
Level IV evidence that a painful cervical radiculopa- region ipsilateral to the radiculopathy. Patients with
thy with deltoid paralysis can arise from compres- headache had significantly more limitations in daily
sive disease at the C4-5, C5-6 or C3-4 levels. activities and higher pain in the neck/shoulder. Im-
mediately before the injections, 161 (59%) of pa-
Makin et al34 reported a retrospective case series of tients experienced a headache exceeding 15 on the
six patients with scapular winging as a finding with VAS. Of these 161 patients, 101 (63%) experienced
C7 radiculopathy. Scapular winging from serratus >25% headache reduction following SNRB, 93 (58%)
anterior weakness was detected by pushing for- reported greater than 50% headache reduction, and
ward against a wall with the hands at shoulder level 66 experienced 100% relief (C4 3%, C5 11%, C6 52%,
or with the hands at waist level. The latter method C7 29%, C8 5%). A significant correlation was found
places the serratus anterior muscle at a mechanical between reduced headache and decreased pain in
disadvantage and reveals partial paralysis. Each case the neck and shoulder region. The authors conclud-
of C7 compression was confirmed by surgical find- ed that cervical nerve root compression from degen-
ings or by CT myelography. The authors concluded erative disease in the lower cervical spine produc-
that scapular winging may be a component of C7 ing radiculopathy can also result in headache. Thus,
radiculopathy and when present serves to exclude headache assessment together with muscle palpa-
lesions of the brachial plexus or radial nerve. This tion should be part of the clinical exam for patients
with cervical radiculopathy.
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 16
In critique, the study had a low (50%) threshold and gery and all achieved good results. Two of the 15 had
lack of specificity for the injection. Because of these pain relief with conservative therapy. Of the seven
limitations, this potential Level II study provides patients with negative shoulder abduction signs, five
Level III evidence that complaint of a headache can required surgery and two were successfully treated
be a symptom with C4-C8 nerve root compression. with traction. Of the five surgical patients, three had
SNRB can reduce headache in a substantial percent- surgery for a central lesion and improved after sur-
age of patients and may be a useful diagnostic tool. gery, two had surgery for a lateral disc fragment and
only one had good results. The authors concluded
Post et al38 reported a retrospective case series re- that the shoulder abduction test is a reliable indi-
viewing experience with the surgical management cator of significant cervical extradural compressive
of a series of 10 patients with C7-T1 herniations. radicular disease.
Symptoms included shoulder pain radiating into
the lateral aspect of the hand, hand weakness and In critique, no validated outcome measures were
weakness in finger flexion, finger extension and used and the sample size was small. This study pro-
intrinsic hand muscles. Sensation and DTRs were vides Level III evidence that relief from arm pain
unremarkable. MRI on each patient revealed a soft with shoulder abduction is an indicator of cervical
disc compressing the C8 nerve. Recovery of hand extradural compressive radiculopathy.
strength was noted in each patient; however, recov-
ery was incomplete in two patients with symptoms Shah et al45 conducted a prospective observational
greater than four months. In critique, no validated study to determine the sensitivity and specificity of
outcome measures were used and the sample size the Spurling’s test in predicting the diagnosis of a
was small. This study provides Level IV evidence soft lateral CDH in 50 patients with neck and arm
that C8 radiculopathy can present with weakness of pain. Spurling’s test with cervical extension, lateral
the hand, and pain radiating to the shoulder, scapu- flexion to the side of pain, and downward pressure
lar area, and fourth and fifth fingers. on the head was performed on all patients. Twenty-
five patients underwent surgery (Group 1) and 25
RECOMMENDATION: Provocative tests includ- were managed conservatively (Group 2). Spurling’s
ing the shoulder abduction and Spurling’s tests test was correlated with surgical findings in Group
may be considered in evaluating patients with 1 and with MRI findings in Group 2. Patients with
clinical signs and symptoms consistent with the their first episode of radicular pain and minimal or
diagnosis of cervical radiculopathy. no neurologic deficits, and those who refused sur-
Grade of Recommendation: C gery were managed conservatively. In Group 1, of
the 18 patients with a positive Spurling’s test, all had
Davidson et al16 described observations from a ret- surgically confirmed soft disc herniations. Of seven
rospective case series of 22 patients with cervical patients with a negative Spurling’s test, two had a soft
monoradiculopathy caused by compressive disease disc herniation and five had a hard disc. In Group 2,
in whom clinical signs included relief of pain with of the 10 patients with a positive Spurling’s test, nine
abduction of the shoulder. Twenty-two patients with had a soft disc herniation, one had a hard disc. Of
arm pain had cervical extradural myelographic de- the 15 patients with a negative Spurling’s test, a hard
fects. Of the 22 patients, 15 experienced relief from disc was seen in eight, and MRI was normal in seven.
their pain with shoulder abduction. Motor weak- The Spurling’s test had a sensitivity of 92%, a specific-
ness was present in 15, paresthesias in 11 and reflex ity of 95%, a positive predictive value (PPV) of 96.4%
changes in nine patients. Of the 15 patients with a and a negative predictive power (NPP) of 90.9% for
positive shoulder abduction sign, 13 required sur- a soft disc herniation. The authors concluded that
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 17
the high PPV of the test can be used to improve the Wainner et al51 described a prospective
yield of postivie MRI examinations in patients with comparative study assessing the reliability and
cervical radiculopathy . This study provides Level II accuracy of individual clinical exam items and
evidence that a positive Spurling’s test improves the self reported instruments for the diagnosis of
clinician’s ability to diagnose compressive disease cervical radiculopathy in 82 patients with a goal
in patients with cervical radiculopathy. of identifying and assessing the accuracy of an
optimal cluster of test items. Consecutive patients
Tong et al49 performed a prospective comparative were referred for EMG for the evaluation of cervical
study to determine the sensitivity and specificity of radiculopathy or carpal tunnel syndrome. Only
the Spurling test for 255 patients referred for elec- patients judged by one of seven laboratory providers
trodiagnosis of upper extremity nerve disorders. The to have signs and symptoms compatible with CR or
Spurling test was performed on all patients before CTS were eligible to participate. Patients with Class
electromyography (EMG). The test was scored as 5 or 6 cervical radiculopathy findings were further
positive if it resulted in pain or tingling starting in the classified according to the severity of their EMG
shoulder and radiating distally to the elbow. A dif- findings. Self-reported items included the VAS and
ferential diagnosis based on the history and physical NDI. A standardized clinical exam was performed
exam was made prior to EMG. EMG was performed by two of nine physical therapists and contained 34
and each diagnosis in the differential was scored rel- items. History contained six questions asked by two
ative to the likelihood of its occurrence. Of the 255 physical therapists. Neurological exam included
patients presented, 31 had missing data, leaving 224 strength, DTRs and sensation. Provocative tests
patients for inclusion. Of 20 patients with a positive included Spurling’s test, shoulder abduction test,
EMG for cervical radiculopathy, the Spurling’s test Valsalva maneuver, neck distraction test and the
was positive in seven, for a sensitivity of 7/20 or 30%. upper limb tension test (ULTT). Cervical range
Of 172 patients with no EMG evidence for radicul- of motion was also measured. Fifteen patients
opathy, the Spurling’s test was negative in 160, for a had an EMG diagnosis of cervical radiculopathy,
specificity of 160/172 or 93%. The Spurling’s test was and five patients were diagnosed with cervical
positive in 16.6% of patients with a normal EMG, in radiculopathy and carpal tunnel sydrome, one with
3.4% of patients with an EMG diagnosis of a nerve concomitant ulnar neuropathy. One patient with
problem other than radiculopathy, and in 15% of combined findings dropped out of the study. Of the
patients with nonspecific EMG findings. The odds 19 patients reported, 13 had mild symptoms and
ratio of a positive Spurling’s test in a patient with a six had moderate symptoms. Reliability of different
positive EMG for cervical radiculopathy is 5.71. The clinical items was reported including the Spurling’s
authors concluded that the Spurling’s test is not sen- A/B 0.6/0.62, shoulder abduction 0.2, valsalva 0.69,
sitive but is specific for cervical radiculopathy as di- distraction 0.88, ULTT A/B 0.76/0.83. Sensitivity/
agnosed by EMG. Although not useful as a screening specificity: Spurling’s A/B 0.6/0.62, shoulder
test, it may be useful to confirm the diagnosis. abduction 0.2, valsalva 0.69, distraction 0.88, ULTT
A/B 0.76/0.83. Sensitivity/Specificity of different
In critique, the study uses a poor reference standard clinical items was reported including the Spurling’s
(EMG). This study provides Level IV evidence that A/B - 0.5/0.86 - 0.74; shoulder abduction - 0.17/0.92;
the Spurling’s test is not sensitive but is specific for valsalva - .22/.94; distraction - 0.44/0.9; ULTT A/B
cervical radiculopathy as diagnosed by EMG. Thus, - 0.72-0.97/0.22-0.33; Cluster of ULTT A, cervical
a positive Spurling’s test is clinically useful in help- rotation <60degrees, distraction, and Spurling’s A -
ing confirm the presence of cervical radiculopathy. 0.24/0.99. The authors concluded that many items
were found to have at least a fair level of reliability
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 18
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 19
Slipman et al46 described a prospective observation- could be correctly localized to a single level or one
al study evaluating the distribution of pain and par- of two levels in 11% and 82%, respectively. Objective
esthesias that result from the stimulation of specific muscle weakness corresponded to a single root or
cervical nerve roots in 87 patients with 134 selective one of two roots in 77% and 12%, respectively. In all
nerve root stimulations. Mechanical stimulation of cases in which C5 or C8 radiculopathy was accompa-
nerve roots was carried out: four at C4, 14 at C5; 43 nied by weakness, the level was correctly localized.
at C6; 52 at C7; and 21 at C8. An independent ob- Sensory loss corresponded to a single root or one of
server recorded the location of provoked symptoms two roots in 65% and 35%, respectively. The authors
on a pain diagram. Visual data was compiled using a concluded that clinical findings related to the fin-
793 body sector bit map with 43 body regions identi- gers are the most accurate for localizing a CDH to a
fied. Although the distribution of symptom provoca- single level. A single level CDH may produce signs
tion resembled the classic dermatomal maps, symp- and symptoms that correspond to overlapping der-
toms were frequently provoked outside the classic matomal levels.
descriptions. The authors concluded that there was
a distinct difference between the dynatomal and This study provides Level II evidence that clinical
dermatomal maps. This study provides Level I evi- findings related to the fingers are the most accurate
dence that distribution of pain and paresthesias in for localizing a CDH to a single level. Single level
the arm from nerve root stimulation can be different CDH may produce signs and symptoms that corre-
from traditional dermatomal maps in a substantial spond to overlapping dermatomal levels.
percentage of patients making it difficult to identify
the level based on pain distribution. Future Directions for Research
Further studies are needed to demonstrate the PPV
Yoss et al55 conducted a retrospective observational of specific symptoms and physical exam findings in
study of 100 patients to correlate clinical findings patients with confirmed cervical radiculopathy to
with surgical findings when a single cervical nerve demonstrate their usefulness in predicting a good
root (C5, C6, C7, C8) is compressed by a disc hernia- outcome with conservative or surgical treatment.
tion. Symptoms included pain in the neck, shoulder,
scapular or interscapular region, arm, forearm or History and Physical Exam Findings References
hand; paresthesias in forearm, and hand; and weak- 1. Abbed KM, Coumans JV. Cervical radiculopathy:
ness of upper extremity. Signs included diminution pathophysiology, presentation, and clinical evaluation.
Neurosurgery. Jan 2007;60(1 Supp1 1):S28-34.
of triceps, biceps and brachioradialis reflexes, mus- 2. Al-Hami S. Cervical monosegmental interbody fusion us-
cle weakness and sensory loss. Pain or paresthe- ing titanium implants in degenerative, intervertebral disc
sia in the neck, shoulder, scapular or interscapular disease. Minim Invasive Neurosurg. Mar 1999;42(1):10-
region were present in cases of C5, C6, C7, or C8 17.
compression. The presence of pain in the arm cor- 3. An HS. Cervical root entrapment. Hand Clin. Nov
1996;12(4):719-730.
responded to the site compression in 23% of cases. 4. Anderberg L, Annertz M, Brandt L, Saveland H. Selec-
The presence of pain or paresthesia in the forearm tive diagnostic cervical nerve root block--correlation with
corresponded to a single root or one of two roots in clinical symptoms and MRI-pathology. Acta Neurochir
32% and 66%, respectively. Hand pain and paresthe- (Wien). Jun 2004;146(6):559-565; discussion 565.
sia corresponded to a single root or one of two roots 5. Anderberg L, Annertz M, Rydholm U, Brandt L, Saveland
H. Selective diagnostic nerve root block for the evaluation
in 70% and 27%, respectively. Subjective weakness of radicular pain in the multilevel degenerated cervical
corresponded to a single level in 22/34 (79%) cases. spine. Eur Spine J. Jun 2006;15(6):794-801.
6. Anderson PA, Subach BR, Riew KD. Predictors of outcome
When a diminution of DTR was present, the lesion after anterior cervical discectomy and fusion: a multivari-
ate analysis. Spine. Jan 15 2009;34(2):161-166.
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 20
7. Bartleson JD. Spine Disorder Case Studies. Neurologic 25. Grisoli F, Graziani N, Fabrizi AP, Peragut JC, Vincentelli F,
Clinics. May 2006;24(2):309-330. Diaz-Vasquez P. Anterior discectomy without fusion for
8. Beatty RM, Fowler FD, Hanson EJ, Jr. The abducted arm treatment of cervical lateral soft disc extrusion: A follow-
as a sign of ruptured cervical disc. Neurosurgery. Nov up of 120 cases. Neurosurgery. 1989;24(6):853-859.
1987;21(5):731-732. 26. Hardin JG, Halla JT. Cervical spine and radicular pain syn-
9. Bell GR. The anterior approach to the cervical spine. Neu- dromes. Curr Opin Rheumatol. Mar 1995;7(2):136-140.
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10. Bertalanffy H, Eggert HR. Clinical long-term results of an- A, Neundorfer B. Herniated cervical intervertebral discs
terior discectomy without fusion for treatment of cervical with radiculopathy: An outcome study of conservatively or
radiculopathy and myelopathy. A follow-up of 164 cases. surgically treated patients. J Spinal Disord. 1999;12(5):396-
Acta Neurochirurgica (Wien). 1988;90(3-4):127-135. 401.
11. Bertilson BC, Grunnesjo M, Strender LE. Reliability of clin- 28. Heidecke V, Rainov NG, Marx T, Burkert W. Outcome in
ical tests in the assessment of patients with neck/shoulder Cloward anterior fusion for degenerative cervical spinal
problems-impact of history. Spine (Phila Pa 1976). Oct 1 disease. Acta Neurochir (Wien). 2000;142(3):283-291.
2003;28(19):2222-2231. 29. Heller JG. The syndromes of degenerative cervical disease.
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13. Chang H, Park JB, Hwang JY, Song KJ. Clinical analysis of ford EG. Posterior-lateral foraminotomy as an exclusive
cervical radiculopathy causing deltoid paralysis. Eur Spine operative technique for cervical radiculopathy: a review
J. Oct 2003;12(5):517-521. of 846 consecutively operated cases. Neurosurgery. Nov
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15. Connell MD, Wiesel SW. Natural history and patho- the fourth cervical root: an analysis of 12 surgically treated
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1992;23(3):369-380. 32. Kuijper B, Tans JTJ, Schimsheimer RJ, et al. Degenerative
16. Davidson RI, Dunn EJ, Metzmaker JN. The shoulder ab- cervical radiculopathy: Diagnosis and conservative treat-
duction test in the diagnosis of radicular pain in cervical ment. A review. Eur J Neurol. January 2009;16(1):15-20.
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2004;100(3 SUPPL.):303-306. tance of scapular winging in clinical diagnosis. J Neurol
18. Devereaux M. Neck Pain. Med Clin North Am. March Neurosurg Psychiatry. Jun 1986;49(6):640-644.
2009;93(2):273-284. 35. Ozgur BM, Marshall LF. Atypical presentation of C-7 ra-
19. Dubuisson A, Lenelle J, Stevenaert A. Soft cervical disc diculopathy. J Neurosurg. Sep 2003;99(2 Suppl):169-171.
herniation: A retrospective study of 100 cases. Acta Neuro- 36. Peolsson A, Peolsson M. Predictive factors for long-term
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21. Farmer JC, Wisneski RJ. Cervical spine nerve root com- 37. Persson LCG, Carlsson JY, Anderberg L. Headache in pa-
pression: An analysis of neuroforaminal pressures with tients with cervical radiculopathy: A prospective study
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22. Garvey TA, Eismont FJ. Diagnosis and treatment of cer- 38. Post NH, Cooper PR, Frempong-Boadu AK, Costa ME.
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1991;20(7):595-603. junction: Clinical presentation, imaging, operative man-
23. Gifford L. Acute low cervical nerve root conditions: symp- agement, and outcome after anterior decompressive op-
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24. Goldstein B. Anatomic issues related to cervical and lum- 39. Rao R. Neck pain, cervical radiculopathy, and cervical my-
bosacral radiculopathy. Phys Med Rehabil Clin N Am. Aug elopathy: Pathophysiology, natural history, and clinical
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This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 21
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 22
cervical radiculopathy. MRI was performed in 130 that MRI is a viable alternative to myelography, and
patients, myelography in 30, CTM in 16 and CT in together with CT if needed, provides a thorough
five. Pathologic confirmation was obtained in 13 exam for cervical nerve root compression.
surgically treated patients. MRI was normal in 31
cases and neither myelography nor surgery were Van de Kelft et al54 performed a prospective com-
performed. Extradural defects were detected on parative study describing the value of MRI on a 0.5
MRI in 99/130 patients (52 central, 26 dorsolateral T system plus plain radiography in the evaluation
osteophyte, 4 dorsolateral disc, 17 dorsolateral disc/ of patients with cervical radiculopathy. One hun-
osteophyte). Myelography/CTM and nonenhanced dred patients with cervical radiculopathy and failed
CT confirmed the abnormalities in 20 and five pa- conservative therapy were scheduled for surgery. Of
tients, respectively. Surgical findings from 13 pa- these patients, 18 with myelopathy, history of sur-
tients and 30 sites showed correlation with MRI on gery and history of trauma were referred for CTM
3/3 herniations and 26/27 degenerative abnormali- instead of MRI; 23 with spondylosis, major spurs, or
ties. The authors concluded that MRI is sufficient for instability on plain radiography were also referred
the evaluation of cervical radiculopathy and may for CTM. This excluded 41 from the potential study.
obviate the need for more invasive tests such as my- In the 59 patients that underwent MRI, CDH was
elography or CTM. found in 55, the location corresponding to the pa-
tients’ symptoms. Four patients without CDH were
In critique, since surgical confirmation of cervical referred for CTM; a foraminal herniation was found
radiculopathy was obtained for only 13 patients, the in one. Of the 55 patients with CDH, 50 underwent
relevant sample size was small. Also, the study uti- surgery. In two patients, foraminal spurs were found,
lized an older technique. This study provides Level not seen on MRI. MRI correlated with surgery at a
III diagnostic evidence that MRI is accurate in the rate of 94%. The authors concluded that MRI com-
diagnosis of disc herniation and degenerative ab- bined with plain radiography is an accurate nonin-
normalities in the spine. vasive technique in the evaluation of patients with
cervical radiculopathy.
Modic et al34 conducted a prospective study com-
paring the accuracy of MRI, CTM and myelography In critique, the patients included in this study were
in the evaluation of cervical radiculopathy. Of the 63 not consecutively assigned. This study provides Lev-
patients enrolled in the study, 52 underwent MRI, el III diagnostic evidence that early MRI techniques
myelography and CTM, and 28 underwent surgery. are reasonably accurate in diagnosing CDH in pa-
Findings confirmed in surgery identified diagnostic tients with radiculopathy. This emphasizes that non-
accuracy rates of 74% for MRI, 85% for CTM, and 67% invasive MRI with plain radiography can diagnose
for myelography. Diagnostic agreement with surgi- specific CDH, stenosis and nerve root compression
cal findings was obtained in 90% of patients when with a high degree of useful accuracy.
MR and CTM were used jointly, 92% when CTM
and myelography were used jointly. The authors Wilson et al61 described a retrospective comparative
concluded that MRI is a viable alternative to myel- study evaluating the accuracy of MRI in the detec-
ography, and together with CT if needed, provides tion of compressive lesions in patients with cervical
a thorough exam of the c-spine. MRI is as sensitive, radiculopathy. Surgical diagnoses were disc hernia-
but less specific, for type of disease. CTM is better at tion in 32, spondylosis in two, and a combination of
distinguishing bone from disc. In critique, patients the two in six patients. MRI identified the surgical
were not consecutively assigned in this small study. lesion in 37/40 patients (92%). Two independent
This study provides Level III diagnostic evidence ‘reading radiologists’ knew surgery was performed,
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 23
but were blinded to the diagnosis and the level. MRI opathy and myelopathy without sufficient subgroup
diagnosed an HNP at the correct location in 32/38 analysis.
patients and spondylosis in two. In the six cases, in
which HNP was missed, the MRI was interpreted RECOMMENDATION: CT myelography is sug-
as spondylosis. In three patients MRI did not diag- gested for the evaluation of patients with clini-
nose the surgical lesion. CTM was performed in 13 cal symptoms or signs that are discordant with
patients, and in five of these patients CTM was felt MRI findings (eg, foraminal compression that
to add additional information. There was complete may not be identified on MRI). CT myelography
recovery in 31/40 patients, and incomplete recovery is also suggested in patients who have a con-
in 8/40. One patient was lost to follow-up. The au- traindication to MRI.
thors concluded that MRI is the only preoperative
test necessary in most cases of cervical radiculop- Grade of Recommendation: B
athy. The authors added that CTM might be useful
in patients with a negative MRI, positive EMG and Bartlett et al9 conducted a prospective study com-
neurologic deficits. In critique, the patients includ- paring the accuracy of Gd-enhanced MRI with 3D
ed in this study were not consecutively assigned and GRE images in the evaluation of cervical radiculop-
there was a significant dropout rate. Due to these athy in 30 consecutive patients. 3D GRE images had
limitations, this potential Level II study provides an accuracy of 87% for the diagnosis of foraminal
Level III diagnostic evidence that MRI is an accurate encroachment. CTM had an accuracy of 90%. MRI
tool in the initial preoperative evaluation of patients with Gd conferred no additional benefit. Oblique
with cervical radiculopathy. reconstructions were less accurate than axial im-
ages. The authors concluded that MRI with 3D GRE
RECOMMENDATION: In the absence of reliable images is an acceptable technique for the primary
evidence, it is the work group’s opinion that CT evaluation of cervical radiculopathy. CTM remains
may be considered as the initial study to confirm indicated for patients with incongruent symptoms
a correlative compressive lesion (disc herniation and MRI results. This study provides Level II diag-
or spondylosis) in cervical spine patients who nostic evidence that MRI with 3D T2 technique has
have failed a course of conservative therapy, who an accuracy approaching that of CT myelography
may be candidates for interventional or surgical for the diagnosis of a compressive lesion in patients
treatment and who have a contraindication to with cervical radiculopathy.
MRI.
Work Group Consensus Statement Houser et al24 reported a retrospective case series
correlating the findings on CTM with surgical and
An article by Ilkko et al26 examined the accuracy of path proven cervical herniations. Over three years,
CT, myelography and MR imaging in 120 patients. 734 patients underwent CTM for cervical disc dis-
Gold standard was surgery in 37 patients. The sen- ease. At surgery, CDH was noted in 297 patients. Of
sitivities of CT, myelography, and MRI were 66%, the 297 patients, 280 had a diagnosis of radiculopa-
84%, and 86% however MRI was only available in 8 thy and 17 of myelopathy. Surgical reports noted
patients. The accuracy of CT was degraded by beam one or more prolapsed discs in 258, a prolapsed disc
hardening artifact from the shoulders in the lower and spur in 38 and a prolapsed disc with a fracture in
cervical spine. The authors concluded that CT was one. CTM corresponded to surgical findings in 260
a usable alternative to MRI in selected patients. This of the 280 patients with radiculopathy and in all 17
article was excluded from the formal analysis, how- patients with myelopathy. Surgery was performed in
ever, because it included patients with both radicul- 22 patients on the basis of clinical symptoms alone.
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 24
Of these 22 patients, 19 had herniations not seen Findings confirmed in surgery identified diagnostic
on CTM and three had no herniations based upon accuracy rates of 74% for MRI, 85% for CTM and 67%
surgical findings and CTM. A soft tissue extradural for myelography. Diagnostic agreement with surgi-
deformity appeared to be present on CTM in seven cal findings was obtained in 90% of patients when
patients who had no cervical abnormalities on sur- MR and CTM were used jointly, 92% when CTM
gical exploration. The authors concluded that imag- and myelography were used jointly. The authors
ing of CDHs continues to be difficult and the results concluded that MRI is a viable alternative to myel-
are not always specific. CTM is the most sensitive ography, and together with CT if needed, provides
imaging examination. In critique, patients were not a thorough exam of the c-spine. MRI is as sensitive,
consecutively assigned. This study provides Level III but less specific, for type of disease. CTM is better at
diagnostic evidence that CT myelography can iden- distinguishing bone from disc. In critique, patients
tify 90% of cervical extruded disc herniations con- were not consecutively assigned in this small study.
firmed by surgery. This study provides Level III diagnostic evidence
that MRI is a viable alternative to myelography, and
Houser et al25 presented a retrospective case series together with CT if needed, provides a thorough
reviewing the surgical and CTM findings in 95 pa- exam of the cervical spine.
tients with foraminal stenosis. CTM showed steno-
sis at the entrance in 70 (52%), within the canal itself Russell et al45 reported on a retrospective compara-
in 37 (28%) and site not definitively identified in 27 tive study assessing the value of CT with IV contrast
(20%). At the entrance to the foramen, stenosis sec- in the evaluation of patients with cervical radicu-
ondary to a cartilaginous cap was identified in 10 lopathy. Ventral epidural and intervertebral veins
patients (8%), osteophyte in 17 (13%), synovial cyst were consistently well visualized with CT enhanced
in one and a combination of bone and cartilaginous with IV contrast. Disc protrusions were diagnosed in
cap in 42 (31%). Within the canal, small bone spurs nine of 30 patients. A clear and definitive marginal
arising from the uncovertebral process contributed ring blush between the disc protrusion and the en-
to stenosis in 29 instances and from the facet joint hanced venous system was seen in eight of these
in eight. Diagnosis on the basis of CTM was diffi- patients. Surgical confirmation was obtained in only
cult because stenosis was evident as a bone spur in five of these eight patients since only five of the eight
only 13% of cases, could not be distinguished from came to surgery. Visualization of posterior displace-
a disc herniation in 39%, had to be distinguished ment of the enhance epidural veins and epidural
from a congenitally narrowed foramen in 27% and enhancement surrounding extruded disc fragments
was missed in 20%. The authors concluded that the provided excellent delineation of disc extrusion and
diagnosis of foraminal stenosis on CTM is difficult. in some cases allowed demarcation of multiple dis-
In critique, patients included in this study were not crete disc fragments. The authors concluded that
consecutively assigned. This study provides Level III although routine CT is usually diagnostic, the addi-
diagnostic evidence that there is limited correlation tion of IV contrast improves anatomic information
between CT myelography and foraminal stenosis as and diagnostic certainty and may obviate the need
confirmed by surgical exploration. for myelography in some patients.
Modic et al34 conducted a prospective study com- In critique, patients included in this small study
paring the accuracy of MRI, CTM and myelography were not consecutively assigned. Of the nine cases
in the evaluation of cervical radiculopathy. Of the 63 that reported abnormal findings, only five went on
patients enrolled in the study, 52 underwent MRI, to surgery and obtained surgical confirmation. This
myelography and CTM, and 28 underwent surgery. study provides Level III diagnostic evidence that the
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 25
technique of high dose contrast infusion with CT tion in 32, spondylosis in two and a combination of
provides useful venous enhancement with improved the two in six patients. MRI identified the surgical
visualization of the disc/epidural vein interface and lesion in 37/40 patients (92%). Two independent
improved visualization of disc herniations. Myelog- ‘reading radiologists’ knew surgery was performed,
raphy for cervical discs may be unnecessary unless but were blinded to the diagnosis and the level. MRI
further spinal column delineation is required. diagnosed an HNP at the correct location in 32/38
patients and spondylosis in two. In the six cases in
Van de Kelft et al54 performed a prospective com- which HNP was missed, the MRI was interpreted
parative study describing the value of MRI on a 0.5 as spondylosis. In three patients MRI did not diag-
T system plus plain radiography in the evaluation of nose the surgical lesion. CTM was performed in 13
patients with cervical radiculopathy. The study in- patients, and in five of these patients, CTM was felt
cluded 100 patients with cervical radiculopathy and to add additional information. There was complete
failed conservative therapy scheduled for surgery. recovery in 31/40 patients and incomplete recov-
All patients underwent plain radiography. Patients ery in 8/40. One patient was lost to follow-up. The
with myelopathy, history of previous surgery and authors concluded that MRI is the only preopera-
history of trauma (18), and patients with spondy- tive test necessary in most cases of cervical radicu-
losis, major spurs or instability on plain radiogra- lopathy. The author added that CTM may be useful
phy (23) were referred for CTM. The remaining 59 in patients with a negative MRI, positive EMG and
patients underwent MRI. On MRI, a soft disc her- neurologic deficits. In critique, the patients includ-
niation (CDH) was found in 55 patients, the location ed in this study were not consecutively assigned and
corresponding to the patients’ symptoms. The four there was a significant dropout rate. Due to these
patients without CDH were referred for CTM, and limitations, this potential Level II study provides
a foraminal herniation was found in one. Of the 55 Level III diagnostic evidence that MRI is an accurate
patients with CDH, 50 underwent surgery. Findings tool in the initial preoperative evaluation of patients
on MRI correlated with surgical findings in 94%. In with cervical radiculopathy.
two patients, foraminal spurs were found, not seen
on MRI. The authors concluded that MRI combined RECOMMENDATION: The evidence is insuffi-
with plain radiography is an accurate noninvasive cient to make a recommendation for or against
technique in the evaluation of patients with cervical the use of EMG for patients in whom the diag-
radiculopathy. nosis of cervical radiculopathy is unclear after
clinical exam and MRI.
In critique, the patients included in this study were
not consecutively assigned. This study provides Grade of Recommendation: I (Insufficient
Level III diagnostic evidence that early MRI tech- Evidence)
niques are reasonably accurate in diagnosing CDH
in patients with radiculopathy. This emphasizes that Alrawi et al2 reported a prospective case series inves-
noninvasive MRI with plain radiography can diag- tigating whether preoperative EMG can help identi-
nose CDHs and nerve root compression with a high fy those most likely to benefit from intervention. The
degree of useful accuracy. study included 20 patients with clinical manifesta-
tions of cervical radiculopathy and an MRI showing
Wilson et al61 described a retrospective comparative disc bulges associated with narrowing of the exiting
study evaluating the accuracy of MRI in the detec- foramina. Preoperatively, patients were divided into
tion of compressive lesions in patients with cervical two groups on the basis of EMG findings. Group A
radiculopathy. Surgical diagnoses were disc hernia- consisted of eight patients with denervation changes
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 26
in the distribution of a least one cervical nerve root. patients included in the study were not consecutive.
Group B had 12 patients with no EMG evidence of This study provides Level III diagnostic evidence
cervical radiculopathy. Patients in Group A had bet- that MRI is more accurate and more sensitive than
ter clinical outcomes and patient satisfaction from NPS in the preoperative evaluation of patients with
their ACDF at least 12 months postoperatively than cervical radiculopathy.
patients in Group B. The authors concluded that
preoperative neurophysiologic studies (NPS) can RECOMMENDATION: Selective nerve root
help identify which patients are more likely to ben- block with specific dosing and technique
efit from surgery for cervical radiculopathy. protocols may be considered in the evaluation
of patients with cervical radiculopathy and
In critique, patients were not consecutively assigned compressive lesions identified at multiple
to the study. This study provides Level III diagnostic levels on MRI or CT myelography to discern
evidence that patients with cervical radiculopathy the symptomatic level(s). Selective nerve root
and an MRI showing a disc bulge with narrowing of block may also be considered to confirm a
the exiting foramina have better clinical outcomes symptomatic level in patients with discordant
and patient satisfaction from ACDF if a preoperative clinical symptoms and MRI or CT myelography
EMG shows denervation changes. findings.
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 27
level of more marked pathology in 12, to the level jectate volume. The authors concluded that only 0.6
determined by the neurologic deficits in eight and to ml injections should be used for SNRBs. This small
the level corresponding to the sensory dermatome case series provides Level II diagnostic evidence
in seven. Eleven patients had a positive SNRB at two that transforaminal injectate volumes of 0.6 ml con-
levels. Of 13 patients treated at one level, nine (67%) sistently meet the criteria for a SNRB.
had good or excellent results. Of nine patients treat-
ed at two levels, 100% had good or excellent results. Future Directions for Research
The authors concluded that clinical symptoms and The work group identified the following recommen-
signs in isolation or in combination with MRI find- dations that would assist in generating meaningful
ings are not always reliable indicators of the pain- evidence to assist in further defining the appropri-
generating nerve root. SNRB may be useful in treat- ate diagnostic tests for cervical radiculopathy from
ment planning in patients with radiculopathy and degenerative disorders. Studies should assess a set
degenerative changes at two levels ipsilateral to the of diagnostic criteria established a priori.
patient’s symptoms.
Recommendation #1:
In critique, this small study did not utilize a consis- Studies evaluating the accuracy of MRI, CT and CT
tently applied gold standard and surgical treatment myelography in detecting and characterizing com-
or epidural steroid injection was performed in only pressive lesions in the cervical spine in patients with
22 or the 30 patients. This study provides Level III cervical radiculopathy should be repeated using
diagnostic evidence that SNRB may be useful in the state of the art equipment and imaging techniques
preoperative evaluation of patients with radiculopa- and should implement surgical findings and out-
thy and findings of compressive lesion at multiple comes as gold standards.
levels on MRI.
Recommendation #2:
Anderberg et al reviewed a prospective case series
5
Further studies should be done to evaluate the con-
of nine patients studying the selectivity of cervical tribution of EMG to the evaluation of cervical ra-
transforaminal injections and the distributions of diculopathy patients with discordant MRI findings
a range of injection volumes in patients with cer- and clinical findings using surgical findings and
vical radiculopathy. Three groups of three patients outcomes as gold standards.
received one of the following: 0.6, 1.1 or 1.7 ml of
injectate via the transforaminal root technique used Recommendation #3:
by Kikuchi. The groups injected with 0.6 and 1.1 ml Further studies should be done evaluating the con-
received local anesthetic and contrast. The group in- tribution of SNRB to the evaluation of cervical ra-
jected with 1.7 ml received local anesthetic, corticos- diculopathy patients with discordant MRI findings
teroid and contrast. Contrast distribution was deter- and clinical findings, and to the evaluation of cervi-
mined by a post injection CT scan. An injection was cal radiculopathy patients with findings on MRI at
considered a successful SNRB if the contrast media multiple levels ipsilateral to the patient’s symptoms
surrounded an adjacent nerve root by less than half using surgical findings and outcomes as gold stan-
of its circumference. In all three patients receiving dards.
0.6 ml of injectate the injections were considered se-
lective. In 2 of 3 of patients given 1.1 ml of injectate, Recommendation #4:
the injections were considered selective. None of Studies should be done evaluating the contribution
the three patients receiving 1.7 ml of injectate were of dynamic upright cervical spine MRI to the evalua-
considered selective. The perineural distribution tion of and long term outcome of patients undergo-
length averaged 36 mm, with no correlation to in- ing surgical decompression for cervical radiculopa-
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 28
thy with attention to the following question: Does of cervical spondylotic radiculopathy. Br J Radiol. Aug
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care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
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40. Perneczky G, Bock FW, Neuhold A, Stiskal M. Diagnosis for cervical soft disc herniation. Acta Chir Belg. May-Jun
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Acta Neurochir (Wien). 1992;116(1):44-48. 56. van den Bent MJ, Oosting J, Laman DM, van Duijn H. EMG
41. Persson LCG, Carlsson JY, Anderberg L. Headache in pa- before and after cervical anterior discectomy. Acta Neurol
tients with cervical radiculopathy: A prospective study Scand. Oct 1995;92(4):332-336.
with selective nerve root blocks in 275 patients. Euro Spine 57. Vandekelft E, Vanvyve M. Diagnostic-Imaging Algorhythm
J. Jul 2007;16(7):953-959. for Cervical Soft Disc Herniation. Acta Chirurgica Belgica.
42. Rechtine GR, Bolesta MJ. Cervical radiculopathy. Semin May-Jun 1995;95(3):152-156.
Spine Surg. 1999;11(4):363-372. 58. Villas C, Collia A, Aquerreta JD, et al. Cervicobrachialgia
43. Ross JS, Modic MT, Masaryk TJ, Carter J, Marcus RE, and pancoast tumor: Value of standard anteroposterior
Bohlman H. Assissment of extradural degenerative dis- cervical radiographs in early diagnosis. Orthopedics. Oct
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 30
2004;27(10):1092-1095. 61. Wilson DW, Pezzuti RT, Place JN. Magnetic resonance im-
59. Wainner RS, Gill H. Diagnosis and nonoperative manage- aging in the preoperative evaluation of cervical radicul-
ment of cervical radiculopathy. J Orthop Sports Phys Ther. opathy. Neurosurgery. Feb 1991;28(2):175-179.
Dec 2000;30(12):728-744. 62. Yousem DM, Atlas SW, Hackney DB. Cervical-Spine Disk
60. Wiesel SW, Tsourmas N, Feffer HL, Citrin CM, Patronas Herniation - Comparison of Ct and 3dft Gradient Echo Mr
N. A study of computer-assisted tomography. I. The inci- Scans. J Comput Assist Tomogr. May-Jun 1992;16(3):345-
dence of positive CAT scans in an asymptomatic group of 351.
patients. Spine (Phila Pa 1976). Sep 1984;9(6):549-551.
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 31
What are the most appropriate in the study, all received SNRB with mepivicaine
and their arm and neck pain were assessed 30 min-
outcome measures to evaluate utes following the procedure using VAS. The authors
the treatment of cervical radicu- reported an 86% mean reduction in VAS arm pain
scores and 65% mean reduction in VAS neck pain
lopathy from degenerative disor- scores, and concluded that the VAS can be used to
ders? document response to the anesthetic phase of SNRB
for arm and neck pain. In critique, this study had a
Asking this question about the treatment of cervi- very small sample size and the patients included
cal radiculopathy from degenerative disorders is in- were not enrolled at the same point in their disease,
trinsically valuable. Our review of the literature on with duration of symptoms ranging from one to 60
cervical radiculopathy from degenerative disorders months. This study provides Level II prognostic evi-
confirmed that outcome studies are valuable in de- dence that the VAS pain scale can be used to docu-
termining the course of treatment. ment the immediate anesthetic response to SNRB
for radicular arm pain.
When evaluating studies in terms of the use of out-
come measures, the work group evaluated this liter- Fernandez-Fairen et al19 reported a prospective, ran-
ature as prognostic in nature. Prognostic studies in- domized controlled trial assessing the effectiveness
vestigate the effect of a patient characteristic on the and safety of a tantalum implant in achieving ante-
outcome of a disease. Studies investigating outcome rior cervical fusion following single level discectomy
measures, by their design, are prognostic studies. as treatment for degenerative cervical disc disease
with radiculopathy. Of the 61 patients included in
An appropriate clinical outcome measure must be the study, 28 were treated with ACDF with interbody
validated. Further, the validated outcome measure implant of tantalum and 33 received ACDF with au-
must be used in a high quality, prospective outcome tologous iliac bone graft and plating. At 24 months,
trial in order to be useful. The literature review yield- clinical outcomes, as assessed by the NDI, VAS pain
ed no validated outcome measures utilized for the scale (arm), Odom’s criteria and Zung Depression
subset of patients with cervical radiculopathy from Scale were similar for both treatment groups with-
degenerative disorders. out significant difference. The authors concluded
that clinical outcome as assessed by the VAS, NDI
RECOMMENDATION: The Neck Disability and ZDS demonstrated that tantalum implant was
Index (NDI), SF-36, SF-12 and VAS are rec- equivalent to autogenous graft and anterior plate.
ommended outcome measures for assessing This study provides Level I prognostic evidence that
treatment of cervical radiculopathy from de- the NDI and VAS pain scale (arm) are instruments
generative disorders. that can be used to assess the outcome of surgical
intervention for cervical radiculopathy from degen-
Grade of Recommendation: A erative disorders. Additionally, patient satisfaction
as measured by Odom’s criteria and depression as
Anderberg et al2 described a prospective observa- assessed by the ZDS appear useful.
tional study examining the correlation between
SNRB and MRI findings and clinical symptoms. Of Foley et al22 conducted a prospective randomized
the twenty consecutively assigned patients included controlled trial to determine the efficacy and safety
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 32
of pulsed electromagnetic field stimulation as an II evidence that NDI, VAS and SF-36 can be used to
adjunct to arthrodesis after ACDF in patients with assess outcome of interventional treatment of cervi-
potential risk factors for nonunion. Of the 323 con- cal radiculopathy from degenerative disorders.
secutively assigned patients, 163 received PEMF in
addition to the ACDF. Clinical outcomes as assessed Lofgren et al41 conducted a prospective observational
by the NDI, VAS (arm) and SF-12 demonstrated that study to compare the clinical outcome after surgery
there were no significant differences between the for cervical radiculopathy from degenerative disor-
two treatments. Because less than 80% of patients ders to conservative treatment. Forty-three surgical
were available at 12 month follow-up, this study pro- patients were studied prospectively and received
vides Level II evidence NDI, VAS (arm) and SF-12 ACDF (Cloward, single level). Their outcomes were
can be used to assess outcome after surgical inter- compared with a control group of 39 patients (two
vention for cervical radiculopathy from degenera- did have surgery) who were treated conservatively.
tive disorders. The conservative treatment protocol was not de-
scribed. Outcomes were assessed at three months,
Hacker et al25 described a randomized controlled tri- six months, nine months and two years. Pain reduc-
al to report clinical results with maximum 24 month tion measured with the VAS (arm) was more pro-
follow-up of fusions performed with the BAK/C fu- nounced among the surgically treated patients at
sion cage. Of the 344 patients available at 12 month the final follow-up for maximal neck pain (p=0.03)
follow-up, 245 had been assigned to the BAK/C fu- and at three months and nine months, respectively,
sion cage groups and 105 were assigned to the con- for average neck pain (p=0.02, both). Initially there
trol group. Clinical outcome as assessed with the VAS was no statistically significant difference in pain in-
and SF-36 showed that there were similar outcomes tensity between the surgically and conservatively
between the ACDF group and the BAK/C group at treated groups. Sickness Impact Profile showed that
12 months and 24 months. The authors concluded patients scheduled for surgery had higher sickness
that clinical outcomes after a cervical fusion with impact in the overall index. The authors concluded
a threaded cage are the same as those of a conven- that surgically treated patinets demonstrated an im-
tional uninstrumented bone-only ACDF. This study provement in VAS (arm) pain and SIP scores, as well
provides Level I evidence that the VAS and SF-36 as at the clinical examination, all indicating a true
can be used to assess outcome following surgery for improvement, although only partially maintained.
cervical radiculopathy from degenerative disorders. This study provides Level I evidence that VAS (arm)
may be a useful surgical outcome measure for pa-
Kumar et al38 reported on a retrospective observa- tients with cervical radiculopathy from degenerative
tional study designed to highlight the effectiveness disorders.
and safety of cervical selective nerve root block
(SNRB) using a two needle technique for treatment Mummaneni et al43 reported findings of a prospec-
of radiculopathy. Although the 33 patients included tive randomized controlled trial comparing the re-
in the study were followed for two years, clinical out- sults of cervical disc arthroplasty to ACDF. Of the 541
comes were reported only for the first year. Statisti- patients included in the study, 276 received a Pres-
cal improvements in VAS and NDI scores were seen tige disc and 265 were treated with ACDF and plat-
at six weeks and 12 months following the procedure. ing. Outcomes were assessed at 1.5 months, three
The authors concluded that the VAS and NDI can be months, six months, 12 months and 24 months.
used to show that the two needle technique of cervi- Neck pain, arm pain and NDI scores were improved
cal foraminal SNRB produces improved outcomes at in the Prestige disc group, with statistically superior
six weeks and 12 months. This study provides Level success rates at 12 and 24 months compared with
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 33
the control group. Neck pain improved in both treat- Nunley et al46 conducted a prospective random-
ment groups, but statistically significant improve- ized controlled trial comparing the clinical and ra-
ments were noted in the Prestige group at six weeks, diographic outcomes of patients treated with one-
three months and 12 months. No significant inter- level or multiple level ACDF using cervical plates
group differences in arm pain or return to work were of dynamic/slotted vs. static/fixed hole design. Of
noted at 24 months. The NDI score was statistically the 66 patients included in the study and treated
significantly higher only at three months, but tend- with ACDF, 33 received static plates and 33 received
ed to have higher scores than the control group. The dynamic plates. VAS and NDI score were lower in
authors concluded that the Prestige ST-cervical disc patients with dynamic plates than static plates. At
system maintained physiological segmental motion mean follow-up of 16 months, 49 patients (73.7%)
at 24 months after implanation and was associated had clinical success and 56 (85%) showed radio-
with improved neurologic success, improved clini- graphic fusion. In single-level fusion, no statistical
cal outcomes (SF-36) and reduced rate of secondary difference of outcome was observed between the
surgeries compared to ACDF. In critique, this study two groups, but multilevel fusions with dynamic
had a 75% follow-up in the control group and pro- plate showed significantly lower VAS and NDI scores
vides Level II evidence that NDI and SF-36 can be than those with static plates (ρ=0.050). The authors
used to assess the outcomes of cervical radiculpa- concluded that SF-36 and NDI scores were better in
thy treated by discectomy and articifial disc replace- patients with dynamic plates as compared to those
ment or fusion. with static plates. They stated that clinical improve-
ment is a good predictor of successful ACDF and that
Murrey et al45 described a prospective randomized radiologic evidence of fusion alone is not reliable as
controlled trial comparing the safety and efficacy of a parameter of success. Plate design for single-level
C-TDR with ProDisc-C to ACDF for the treatment of fusion does not affect outcomes, but outcome stud-
a symptomatic cervical disc at one level between C3 ies indicate that multilevel fusions may have better
and C7. Of the 209 patients included in the study, 103 clinical outcomes when dynamic/slotted plates are
received ProDisc-C TDR and 106 were treated with used. This study provides Level I evidence that NDI
single level ACDF. Outcomes were assessed at three and VAS are outcome measures that can be used to
months, six months, 12 months, 18 months and 24 assess cervical radiculopathy from degenerative dis-
months. NDI and SF-36 improved in both groups orders.
as compared to preoperative scores (ρ<0.0001).
VAS neck and arm pain intensity and frequency Park et al49 described a retrospective case control
were statistically lower at all follow-up time points study comparing the clinical and radiographic out-
compared with preoperatively (ρ<0.0001) but were comes of CDR-Mobi-C to ADV-Solis cage. Of the 53
no different between treatment groups. Authors patients included in the study, 21 were treated with
concluded that neurologic success (improvement CDR-Mobi-C and 32 received ADF-Solis-cage. Out-
or maintenance) as determined by NDI, SF-36 and comes were assessed at six weeks, three months, six
VAS neck and arm pain scores was seen in 90.9% of months and 12 months. Mean hospital stay and in-
ProDisc-C and 88% of fusion patients (ρ=0.638) at terval between surgery and return to work were sig-
24 months. Fusion patients had a higher secondary nificantly shorter in the arthroplasty group than the
surgery rate and higher medication usage postop- fusion group. Mean NDI and extremity VAS score
eratively. This study provides Level I evidence that improved after 12 months in both groups. Although
NDI, SF-36 and VAS are outcome tools that can be it was not significant, segmental range of motion
used to assess cervical disc disease, including cervi- (ROM) at adjacent levels was higher in the fusion
cal radiculopathy, following surgery. group than the arthroplasty group. Segmental mo-
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 34
tion at the operative level in the arthroplasty group outcome than were baseline values. NDI was not
maintained more motion than preoperative values only overall the most important factor in explain-
at final follow-up. The authors concluded that clini- ing short- and long-term outcomes, but also was
cal outcomes were similar in both groups. Mean NDI the factor with the highest impact explaining the
and extremity VAS scores improved after 12 months total prediction model. NDI may be regarded as an
in both groups. In critique, this study had a small important outcome measurement in evaluation of
sample size and the authors did not adequately ex- ACDF. This study provides Level I evidence that NDI
plain how assignments to the two treatment groups and VAS are good outcome measures to assess cer-
were made. The two groups were not appropriately vical radiculopathy from degenerative disorders.
matched; the fusion group had more males, iliac
crest graft was only performed in the fusion group Xie et al65 performed a prospective randomized
and the fusion group had cervical orthosis for two controlled trial to determine the clinical outcome
months. Due to these limitations, this potential of ACD, ACDF and anterior cervical discectomy
Level II study provides Level III evidence that NDI and fusion with instrumentation (ACDFI). Of the
and VAS may be appropriate outcome measures to 45 patients included in the study, 15 were assigned
assess cervical radiculopathy from degenerative dis- to each treatment group. Outcomes were asessed at
orders. three weeks, six weeks, three months, six months,
one year and two years. SF-36 scores demonstrated
Peolsson et al51 conducted a prospective random- a dynamic postoperative improvement followed by
ized controlled trial to determine the predictive fac- further gradual improvement in both physical and
tors for short-term and long-term outcome of ACDF mental components as well as other subscale scores
using VAS and NDI multivariate analysis. Of the in all groups during the follow-up period (ρ<0.05).
103 consecutively assigned patients included in the The amount of pain demonstrated by the McGill
study, 95 proceeded with surgical treatment. Of the pain rating index scores significantly decreased for
95 surgically treated patients, 52 received a cervical all three groups immediately after surgery and con-
intervertebral fusion cage and 51 received a Cloward tinued to decline, plateauing at about one year. The
procedure. Outcomes were assessed at 12 months authors concluded that SF-36 scores improved in
and 24 months and compared with preoperative all three groups during the follow-up period, and
data. Using multivariate analysis, the variables’ in- McGill pain scores markedly improved immediately
fluence on projection showed that the most impor- after surgery and continued to improve until the one
tant preoperative variables for predicting short-term year follow-up evaluation before plateauing. In cri-
NDI and pain intensity were: NDI, horizontal active tique, neither patients nor reviewers were masked
range of motion (AROM), pain intensity, smoking, to treatment group and the sample size was small.
right hand strength, gender and kyphosis. Radio- Three of the 45 patients were lost to follow-up. Pa-
logical finding and surgical technique except pre- tients included in the study were enrolled at differ-
operative kyphosis were insignificant as predictors ent points in their disease and received surgery at
of both short- and long-term outcome. The authors single and multiple levels. Due to these limitations,
concluded that a preoperative low neck specific dis- this potential Level I study provides Level II evidence
ability, low pain intensity, nonsmoking status, male that SF-36 may be an appropriate outcome tool for
gender, good preoperative hand strength and neck cervical radiculopathy from degenerative disorders
AROM were significant predictors for a good long- treated with surgery.
term outcome of pain intensity and NDI after ACDF.
Short-term outcome measures of NDI and pain Zoega et al65 described a prospective observation-
intensity were better predictors of the long-term al study of patients undergoing ACDF or ACDFI at
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 35
single or multiple levels to determine the usefulness EMG evidence of nerve root involvement, while 12
of outcome scores in the treatment of degenerative did not. Patient outcomes at minimum of 12 months
disc disease. Of the 46 patients included in the study, as measured with a modified Prolo scale were bet-
12 received single-level ACDF, 10 received two-level ter predicted by EMG. The authors concluded that
ACDF, 15 received single-level ACDFI and 9 received EMG can better predict outcomes as measured by
two-level ACDFI. At two years, 81% of patients were a modified Prolo scale. In critique, this study had a
satisfied with the outcome of surgery. All scores im- very small sample size of nonrandomized patients
proved in the group operated on at two-levels. VAS who were enrolled at different points of their dis-
arm and neck pain decreased in both groups. The ease. Patients still received an operation even if they
improvement in arm pain was significantly more had a negative EMG. Due to these limitations, this
pronounced in patients operated with a plate at two- study provides Level III evidence that the modified
levels compared to those who were operated with- Prolo scale can be used to assess patient outcome
out a plate. At two year follow-up, patients with an after ACDF.
excellent or good result according to Odom’s criteria
had a lower Million Index (ρ<0.0005), Oswestry In- Cleland et al15 described a prospective observational
dex (ρ<0.0005) and Zung Depression Scale (ρ=0.024) study examining the test-retest reliability, construct
score than the group classified as fair or poor. There validity and minimum levels of detectable and clini-
was a significant correlation (ρ<0.0001) for all scores cally important change for the NDI and PSFS in a
between the test and retest. The authors concluded cohort of patients with cervical radiculopathy. All
that Modified Million Index and Oswestry Index are 38 patients included in the study received physical
clinically useful tools in the evaluation of outcome therapy and were assessed at a mean of 21.5 days.
after degenerative cervical disc disease surgery. The Test-retest reliability was moderate for the NDI and
outcome after surgery measured with the Oswestry high for the PSFS. The PSFS was more responsive to
Index, Modified Million Index, and VAS neck and change than the NDI. The minimal detectable change
arm pain seem to correlate well with the classifica- for the NDI was 10.2 and for the PSFS was 2.1. The
tion of outcome by Odom. This study provides Level authors concluded that the PSFS exhibits superior
II evidence that VAS may be an appropriate outcome reliability, construct validity, and responsiveness in
measure for cervical radiculopathy from degenera- this cohort of patients with cervical radiculopathy
tive disorders treated with surgery. compared with the NDI. This study provides Level I
evidence that the PSFS may be better than the NDI
RECOMMENDATION: The Modified Prolo, Pa- for the assessment of outcomes in patients with cer-
tient Specific Functional Scale (PSFS), Health vical radiculopathy.
Status Questionnaire, Sickness Impact Profile,
Modified Million Index, McGill Pain Scores and Davis et al17 conducted a retrospective observa-
Modified Oswestry Disability Index are suggest- tional study assessing the outcome of posterior de-
ed outcome measures for assessing treatment compression for cervical radiculopathy. Of the 170
of cervical radiculopathy from degenerative dis- patients included in the study, patients who had
orders. sedentary occupations and housewives had signifi-
GRADE OF RECOMMENDATION: B cantly higher Prolo scores (p<0.001) than those who
did strenuous work. In 86% of patients, outcome was
Alrawi et al1 reported the findings of a prospective good (defined as a Prolo score of 8 in 5%, 9 in 38%
observational study examining the utility of neuro- and 10 in 43%). The authors concluded that although
physiological EMG to predict outcome after ACDF. outcome studies must have subjective criteria, the
Of the 20 patients included in the study, eight showed Prolo scale is more objective and quantitative than
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 36
currently used methods. This study provides Level impact in the overall index. The authors concluded
II evidence that the author’s modified Prolo scale that surgically treated patients demonstrated an im-
may be reasonable to assess outcomes for cervical provement in VAS (arm) pain and SIP scores, as well
radiculopathy from degenerative disorders. as at the clinical examination, all indicating a true
improvement, although only partially maintained.
Klein et al34 reported results from a prospective ob- This study provides Level I evidence that SIP may be
servational study assessing patient outcomes using a useful surgical outcome measure for patients with
the Health Status Questionnaire after one- or two- cervical radiculopathy from degenerative disorders.
level ACDF. In the 28 patients included in the study,
statistically significant improvements were found Witzmann et al64 described a retrospective observa-
in postoperative scores for bodily pain (p<0.001), tional study designed to determine the clinical and
vitality (p=0.003), physical function (p=0.01), role economic outcome of patients undergoing posteri-
function/physical (p=0.0003) and social function or cervical foraminotomy for the treatment of com-
(p=0.0004). No significant differences were found pressive radiculopathy. At mean follow-up of 3.1
for three health scales: general health, mental years, VAS scores indicated 93% of the 67 patients
health and role function associated with emotional included in the study were improved. Prolo scores
limitations. Authors concluded that the HSQ may be indicated 90% of patients had an excellent economic
a good disease specific outcome tool for one- and outcome and 79% of patients returned to their prior
two-level ACDF. This small study provides Level II employment. In critique, patients were enrolled at
evidence that the HSQ may be a good outcome mea- different points in their disease with 57 single-level
sure for assessing treatment of cervical radiculopa- surgeries and 10 multiple level surgeries. Less than
thy from degenerative disorders. 80% of patients were available for follow-up. Due to
these limitations, this potential Level II study pro-
Lofgren et al41 conducted a prospective observa- vides Level III evidence that the Prolo scale may be
tional study to follow the clinical outcome after an appropriate outcome measure to assess surgical
surgery for cervical radiculopathy from degenera- treatment results for cervical radiculopathy from
tive disorders and to compare it with the outcome degenerative disorders.
after conservative treatment. Forty-three surgical
patients were studied prospectively and received Xie et al65 performed a prospective randomized
ACDF (Cloward-single level). Their outcomes were controlled trial to determine the clinical outcome of
compared with a control group of 39 patients (two ACD, ACDF and ACDFI. Of the 45 patients includ-
did have surgery) who were treated conservatively. ed in the study, 15 were assigned to each treatment
The conservative treatment protocol was not de- group. Outcomes were asessed at three weeks, six
scribed. Outcomes were assessed at three months, weeks, three months, six months, one year and two
six months, nine months and two years. Pain reduc- years. SF-36 scores demonstrated a dynamic post-
tion measured with the VAS (arm) was more pro- operative improvement followed by further gradual
nounced among the surgically treated patients at improvement in both physical and mental compo-
the final follow-up for maximal neck pain (p=0.03) nents as well as other subscale scores in all groups
and at three months and nine months, respectively, during the follow-up period (ρ<0.05). The amount of
for average neck pain (p=0.02, both). Initially there pain demonstrated by the McGill pain scores signif-
was no statistically significant difference in pain in- icantly decreased for all three groups immediately
tensity between the surgically and conservatively after surgery and continued to decline, plateauing
treated groups. Sickness Impact Profile showed that at about one year. The authors concluded that SF-
patients scheduled for surgery had higher sickness 36 scores improved in all three groups during the
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 37
follow-up period. McGill pain scores markedly im- Modified Oswestry Disability Index may be appro-
proved immediately after surgery and continued priate outcome measures for cervical radiculopathy
to improve until the one year follow-up evaluation from degenerative disorders treated with surgery.
before plateauing. In critique, neither patients nor
reviewers were masked to treatment group and the Future Directions for Research
sample size was small. Three of the 45 patients were Disease specific outcome measures like the PSFS
lost to follow-up. Patients included in the study were and the HSQ have been developed and seem to be
enrolled at different points in their disease and re- useful in assessing outcome for the treatment of
ceived surgery at single and multiple levels. Due to cervical radiculopathy from degenerative disorders.
these limitations, this potential Level I study pro- These measures are limited in that they have not
vides Level II evidence that the McGill pain scores been widely used or accepted. Outcome measures
may be an appropriate outcome tool for cervical such as these need to be incorporated into Level I
radiculopathy from degenerative disorders treated studies to confirm their validity and to establish
with surgery. themselves as acceptable research tools to quanti-
tate outcome after cervical radiculopathy from de-
Zoega et al65 described a prospective observation- generative disorders.
al study of patients undergoing ACDF or ACDFI at
single or multiple levels to determine the usefulness References
of outcome scores in the treatment of degenerative 1. Alrawi MF, Khalil NM, Mitchell P, Hughes SP. The value of
disc disease. Of the 46 patients included in the study, neurophysiological and imaging studies in predicting out-
come in the surgical treatment of cervical radiculopathy.
12 received single-level ACDF, 10 received two-level Eur Spine J. Apr 2007;16(4):495-500.
ACDF, 15 received single-level ACDFI and 9 received 2. Anderberg L, Annertz M, Brandt L, Saveland H. Selec-
two-level ACDFI. At two years, 81% of patients were tive diagnostic cervical nerve root block--correlation with
satisfied with the outcome of surgery. All scores im- clinical symptoms and MRI-pathology. Acta Neurochir
proved in the group operated on at two-levels. VAS (Wien). Jun 2004;146(6):559-565; discussion 565.
3. Anderson PA, Subach BR, Riew KD. Predictors of outcome
arm and neck pain decreased in both groups. The after anterior cervical discectomy and fusion: a multivari-
improvement in arm pain was significantly more ate analysis. Spine. Jan 15 2009;34(2):161-166.
pronounced in patients operated with a plate at two- 4. Andrews NB, Lawson HL, Odjidja TL. Elective non-instru-
levels compared to those who were operated with- mented anterior cervical diskectomy and fusion in Ghana:
out a plate. At two year follow-up, patients with an a preliminary report. West Afr J Med. Jun 2003;22(2):128-
132.
excellent or good result according to Odom’s criteria 5. Arnold P, Boswell S, McMahon J. Threaded interbody fu-
had a lower Million Index (ρ<0.0005), Oswestry In- sion cage for adjacent segment degenerative disease af-
dex (ρ<0.0005) and Zung Depression Scale (ρ=0.024) ter previous anterior cervical fusion. Surg Neurol. Oct
score than the group classified as fair or poor. There 2008;70(4):390-397.
was a significant correlation (ρ<0.0001) for all scores 6. Balasubramanian C, Price R, Brydon H. Anterior cervical
microforaminotomy for cervical radiculopathy--results
between the test and retest. The authors concluded and review. Minim Invasive Neurosurg. Oct 2008;51(5):258-
that Modified Million Index and Oswestry Index are 262.
clinically useful tools in the evaluation of outcome 7. Boehm H, Greiner-Perth R, El-Saghir H, Allam Y. A new
after degenerative cervical disc disease surgery. The minimally invasive posterior approach for the treat-
outcome after surgery measured with the Oswestry ment of cervical radiculopathy and myelopathy: surgi-
cal technique and preliminary results. Eur Spine J. Jun
Index, Modified Million Index, and VAS neck and 2003;12(3):268-273.
arm pain seem to correlate well with the classifica- 8. Bolton JE, Humphreys BK. The Bournemouth Question-
tion of outcome by Odom. This study provides Lev- naire: a short-form comprehensive outcome measure. II.
el II evidence that the Modified Million Index and Psychometric properties in neck pain patients. J Manipu-
lative Physiol Ther. Mar-Apr 2002;25(3):141-148.
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 38
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 39
36. Kolstad F, Leivseth G, Nygaard OP. Transforaminal steroid parative analysis of cervical arthroplasty using Mobi-C
injections in the treatment of cervical radiculopathy. A and anterior cervical discectomy and husion using the
prospective outcome study. Acta Neurochir (Wien). Oct Solis-cage. Journal of Korean Neurosurgical Society.
2005;147(10):1065-1070; discussion 1070. 2008;44(4):217-221.
37. Kotil K, Bilge T. Prospective study of anterior cervical mi- 50. Pechlivanis I, Brenke C, Scholz M, Engelhardt M, Harders
croforaminotomy for cervical radiculopathy. J Clin Neuro- A, Schmieder K. Treatment of degenerative cervical disc
sci. Jul 2008;15(7):749-756. disease with uncoforaminotomy--intermediate clinical
38. Kumar N, Gowda V. Cervical foraminal selective nerve root outcome. Minim Invasive Neurosurg. Aug 2008;51(4):211-
block: a ‘two-needle technique’ with results. Eur Spine J. 217.
Apr 2008;17(4):576-584. 51. Peolsson A, Peolsson M. Predictive factors for long-term
39. Li J, Yan DL, Zhang ZH. Percutaneous cervical nucleo- outcome of anterior cervical decompression and fusion: a
plasty in the treatment of cervical disc herniation. Eur multivariate data analysis. Eur Spine J. Mar 2008;17(3):406-
Spine J. Dec 2008;17(12):1664-1669. 414.
40. Lin HL, Cho DY, Liu YF, Lee WY, Lee HC, Chen CC. Change 52. Pimenta L, McAfee PC, Cappuccino A, Cunningham
of cervical balance following single to multi-level inter- BW, Diaz R, Coutinho E. Superiority of multilevel cer-
body fusion with cage. Br J Neurosurg. Dec 2008;22(6):758- vical arthroplasty outcomes versus single-level out-
763. comes: 229 consecutive PCM prostheses. Spine. May 20
41. Lofgren H, Johansen F, Skogar O, Levander B. Reduced 2007;32(12):1337-1344.
pain after surgery for cervical disc protrusion/steno- 53. Rao RD, Currier BL, Albert TJ, et al. Degenerative cervical
sis: a 2 year clinical follow-up. Disabil Rehabil. Sep 16 spondylosis: clinical syndromes, pathogenesis, and man-
2003;25(18):1033-1043. agement. J Bone Joint Surg Am. Jun 2007;89(6):1360-1378.
42. Matsumoto M, Chiba K, Ishikawa M, Maruiwa H, Fujimura 54. Rocchi G, Caroli E, Salvati M, Delfini R. Multilevel oblique
Y, Toyama Y. Relationships between outcomes of conser- corpectomy without fusion: our experience in 48 patients.
vative treatment and magnetic resonance imaging find- Spine. Sep 1 2005;30(17):1963-1969.
ings in patients with mild cervical myelopathy caused by 55. Sasso RC, Smucker JD, Hacker RJ, Heller JG. Artificial disc
soft disc herniations. Spine. Jul 15 2001;26(14):1592-1598. versus fusion: a prospective, randomized study with 2-year
43. Mummaneni PV, Burkus JK, Haid RW, Traynelis VC, Zde- follow-up on 99 patients. Spine. Dec 15 2007;32(26):2933-
blick TA. Clinical and radiographic analysis of cervical 2940; discussion 2941-2932.
disc arthroplasty compared with allograft fusion: a ran- 56. Scheufler KM, Kirsch E. Percutaneous multilevel decom-
domized controlled clinical trial. J Neurosurg Spine. Mar pressive laminectomy, foraminotomy, and instrumented
2007;6(3):198-209. fusion for cervical spondylotic radiculopathy and myel-
44. Murphy DR, Hurwitz EL, Gregory A, Clary R. A nonsurgi- opathy: assessment of feasibility and surgical technique.
cal approach to the management of patients with cervical J Neurosurg Spine. Nov 2007;7(5):514-520.
radiculopathy: A prospective observational cohort study. 57. Schoggl A, Reddy M, Saringer W, Ungersbock K. Social
J Manipulative Physiol Ther. May 2006;29(4):279-287. and economic outcome after posterior microforamino-
45. Murrey D, Janssen M, Delamarter R, et al. Results of the tomy for cervical spondylotic radiculopathy. Wien Klin
prospective, randomized, controlled multicenter Food Wochenschr. Mar 28 2002;114(5-6):200-204.
and Drug Administration investigational device exemp- 58. Shad A, Leach JC, Teddy PJ, Cadoux-Hudson TA. Use of
tion study of the ProDisc-C total disc replacement ver- the Solis cage and local autologous bone graft for anterior
sus anterior discectomy and fusion for the treatment of cervical discectomy and fusion: early technical experi-
1-level symptomatic cervical disc disease. Spine J. Apr ence. J Neurosurg Spine. Feb 2005;2(2):116-122.
2009;9(4):275-286. 59. Suetsuna F, Yokoyama T, Kenuka E, Harata S. Anterior cer-
46. Nunley PD, Jawahar A, Kerr EJ, 3rd, Cavanaugh DA, How- vical fusion using porous hydroxyapatite ceramics for cer-
ard C, Brandao SM. Choice of plate may affect outcomes vical disc herniation. a two-year follow-up. Spine J. Sep-
for single versus multilevel ACDF: results of a prospective Oct 2001;1(5):348-357.
randomized single-blind trial. Spine J. Feb 2009;9(2):121- 60. Tan J, Zheng Y, Gong L, Liu X, Li J, Du W. Anterior cervical
127. discectomy and interbody fusion by endoscopic approach:
47. Odom GL, Finney W, Woodhall B. Cervical disk lesions. J a preliminary report. J Neurosurg Spine. Jan 2008;8(1):17-
Am Med Assoc. 1958;166(1):23-28. 21.
48. Oktenoglu T, Cosar M, Ozer AF, et al. Anterior cervical 61. Waldrop MA. Diagnosis and treatment of cervical radicu-
microdiscectomy with or without fusion. J Spinal Disord lopathy using a clinical prediction rule and a multimodal
Tech. Jul 2007;20(5):361-368. intervention approach: a case series. J Orthop Sports Phys
49. Park JH, Roh KH, Cho JY, Ra YS, Rhim SC, Noh SW. Com- Ther. Mar 2006;36(3):152-159.
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 40
62. Wang MY, Liu CY. Resorbable polylactic acid interbody patients with compressive radiculopathy. Neurosurg Rev.
spacers with vertebral autograft for anterior cervical dis- Dec 2000;23(4):213-217.
cectomy and fusion. Neurosurgery. Jul 2005;57(1):135-140; 65. Xie JC, Hurlbert RJ. Discectomy versus discectomy with
discussion 135-140. fusion versus discectomy with fusion and instrumenta-
63. Wirth FP, Dowd GC, Sanders HF, Wirth C. Cervical discec- tion: a prospective randomized study. Neurosurgery. Jul
tomy. A prospective analysis of three operative techniques. 2007;61(1):107-116; discussion 116-107.
Surg Neurol. Apr 2000;53(4):340-346; discussion 346-348. 66. Zoega B, Karrholm J, Lind B. Outcome scores in degenera-
64. Witzmann A, Hejazi N, Krasznai L. Posterior cervical tive cervical disc surgery. Euro Spine J. Apr 2000;9(2):137-
foraminotomy. A follow-up study of 67 surgically treated 143.
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 41
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 42
after 12 months. Reoperation rate was 29%, mostly of behavioral and emotional dysfunction in cervical
for adjacent segment disease. The low positive mood radiculopathy patients. Medical/interventional and
state (MACL score) did not improve over time. Pa- surgical treatment must include a cognitive, behav-
tients who still had pain after treatment were more ioral component for either method to be successful.
socially withdrawn and ceased to express their emo-
tions. The Hospital Anxiety and Depression (HAD) Future Directions for Research
anxiety score was especially high in patients before The work group identified the following suggestions
and after treatment. In patients with high pain inten- for future studies which would generate meaning-
sity, low function, high depression and anxiety were ful evidence to assist in further defining the role of
seen. The group treated with surgery showed more physical therapy/exercise in the management of
anxiety and depression if pain continued, implying cervical radiculopathy from degenerative disorders.
higher expectations and more disappointment if it
failed. The strongest correlation between depression Recommendation #1:
and pain was seen in the collar group, possibly be- Future studies of the effects of physical therapy/ex-
cause they received less attention overall. In gener- ercise in the management of cervical radiculopathy
al, coping strategies changed. Active coping (cogni- from degenerative disorders should include an un-
tive reappraisal and problem solving) was common treated control group when ethically possible.
before treatment, but disappeared after treatment,
especially in the surgical group. Coping with pain Recommendation #2:
was changed in general into a more passive/escape Future outcome studies including patients with
focused strategy. It appeared that with intervention, cervical radiculopathy from degenerative disorders
especially surgery, healthy active coping strategies treated only with physical therapy/exercise should
tended to be replaced by passive coping strategies include subgroup analysis for this patient popula-
as patients allowed themselves to become more de- tion.
pendent on the intervention. This also implied that
the ability for active coping was present before in- Recommendation #3:
tervention, and thus cognitive behavioral treatment Future studies evaluating the effects of emotional,
started concurrently with other interventions may cognitive and work-related issues would add to our
be particularly successful for maintaining better understanding of how these factors affect outcomes
coping patterns. Function was significantly related in patients with cervical radiculopathy from degen-
to pain intensity. About 40% had anxiety only par- erative disorders.
tially connected to pain. Prior to treatment, 30% of
patients were depressed. After 12 months, 20% suf- Physical Therapy/Exercise References
fered from depression. The authors concluded that 1. Lipetz JS, Misra N, Silber JS. Resolution of pronounced
cognitive and behavioral therapy is important to painless weakness arising from radiculopathy and disk
extrusion. Am J Phys Med Rehabil. Jul 2005;84(7):528-537.
include in multidisciplinary rehabilitation. Patients 2. McClure P. The degenerative cervical spine: pathogen-
need to improve coping strategies, self image and esis and rehabilitation concepts. J Hand Ther. Apr-Jun
mood. 2000;13(2):163-174.
3. McCormack BM, Weinstein PR. Cervical spondylosis. An
In critique, neither patients nor reviewers were update. West J Med. Jul-Aug 1996;165(1-2):43-51.
4. Murphy DR, Beres JL. Is treatment in extension contrain-
masked to treatment group, the sample size was dicated in the presence of cervical spinal cord compres-
small and duration of follow-up was short. Due to sion without myelopathy? A case report. Man Ther. Oct
these limitations, this potential Level I study pro- 2008;13(5):468-472.
vides Level II evidence that there is a high incidence 5. Murphy DR, Hurwitz EL, Gregory A, Clary R. A nonsurgi-
cal approach to the management of patients with cervical
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 43
radiculopathy: A prospective observational cohort study. known, careful consideration should be given
J Manipulative Physiol Ther. May 2006;29(4):279-287. to evidence suggesting that manipulation may
6. Persson LC, Lilja A. Pain, coping, emotional state and
lead to worsened symptoms or significant com-
physical function in patients with chronic radicular neck
pain. A comparison between patients treated with surgery, plications when considering this therapy. Pre-
physiotherapy or neck collar--a blinded, prospective ran- manipulation imaging may reduce the risk of
domized study. Disabil Rehabil. May 20 2001;23(8):325- complications.
335. Work Group Consensus Statement
7. Rosomoff HL, Fishbain D, Rosomoff RS. Chronic cervi-
cal pain: radiculopathy or brachialgia. Noninterventional
treatment. Spine. Oct 1992;17(10 Suppl):S362-366. Future Directions for Research
8. Saal JS, Saal JA, Yurth EF. Nonoperative management of The work group identified the following suggestions
herniated cervical intervertebral disc with radiculopathy. for future studies which would generate meaning-
Spine. Aug 15 1996;21(16):1877-1883. ful evidence to assist in further defining the role of
9. Waldrop MA. Diagnosis and treatment of cervical radicu-
manipulation/chiropractics in the management of
lopathy using a clinical prediction rule and a multimodal
intervention approach: a case series. J Orthop Sports Phys cervical radiculopathy from degenerative disorders.
Ther. Mar 2006;36(3):152-159.
Recommendation #1:
Future studies of the effects of manipulation/chiro-
What is the role of manipulation/ practics in the management of cervical radiculopa-
chiropractics in the treatment of thy from degenerative disorders should include an
untreated control group when ethically possible.
cervical radiculopathy from de-
generative disorders? Recommendation #2:
Future outcome studies including patients with
A systematic review of the literature yielded no stud- cervical radiculopathy from degenerative disor-
ies to adequately address the role of manipulation/ ders treated only with manipulation/chiropractics
chiropractics in the management of cervical radicu- should include subgroup analysis for this patient
lopathy from degenerative disorders. The review did population.
identify several case reports and series describing
serious vascular and nonvascular complications Recommendation #3:
and adverse outcomes associated with manipula- Future studies of the effects of manipulation/chiro-
tion including radiculopathy, myelopathy, disc her- practics in the management of cervical radiculopa-
niation and vertebral artery compression.9,13,14,17 The thy from degenerative disorders should include data
true incidence of such complications is unknown and discussion about any complications associated
and estimates vary widely. Some complications with treatment.
have occurred in patients with previously unrecog-
nized spinal metastatic disease who did not have Manipulation/Chiropractics References
premanipulation imaging. Most patients with seri- 1. Brouillette DL, Gurske DT. Chiropractic treatment of cer-
vical radiculopathy caused by a herniated cervical disc. J
ous complications of manipulation require emer- Manipulative Physiol Ther. Feb 1994;17(2):119-123.
gent surgical treatment. 2. Eriksen K. Management of cervical disc herniation with
upper cervical chiropractic care. J Manipulative Physiol
Ther. Jan 1998;21(1):51-56.
RECOMMENDATION: As the efficacy of ma- 3. Gudavalli S, Kruse RA. Foraminal stenosis with radiculop-
athy from a cervical disc herniation in a 33-year-old man
nipulation in the treatment of cervical radicu- treated with flexion distraction decompression manipula-
lopathy from degenerative disorders is un- tion. J Manipulative Physiol Ther. Jun 2008;31(5):376-380.
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 44
4. Haneline MT, Lewkovich G. Malone D G, Baldwin N G, intervention approach: a case series. J Orthop Sports Phys
Tomecek F J, et al: Complications of cervical spine ma- Ther. Mar 2006;36(3):152-159.
nipulation therapy: 5-year retrospective study in a sin-
gle-group practice. Neurosurg Focus. 13(6):Clinical Pearl,
2002. Neurosurg Focus. Mar 15 2003;14(3):e10; author re- What is the role of epidural ste-
ply e10.
5. Heckmann JG, Lang CJ, Zobelein I, Laumer R, Druschky roid injections for the treatment
A, Neundorfer B. Herniated cervical intervertebral discs
with radiculopathy: an outcome study of conserva- of cervical radiculopathy from
tively or surgically treated patients. J Spinal Disord. Oct
1999;12(5):396-401.
degenerative disorders?
6. Herzog J. Use of cervical spine manipulation under anes-
thesia for management of cervical disk herniation, cer- A systematic review of the literature revealed limited
vical radiculopathy, and associated cervicogenic head- high quality studies to address this question. There
ache syndrome. J Manipulative Physiol Ther. Mar-Apr is Level IV data indicating that transforaminal epi-
1999;22(3):166-170. dural steroid injections may provide relief for 60%
7. Hubka MJ, Phelan SP, Delaney PM, Robertson VL. Rotary
manipulation for cervical radiculopathy: observations on of patients, and about 25% of patients referred with
the importance of the direction of the thrust. J Manipula- clear surgical indications may obtain at least short-
tive Physiol Ther. Nov-Dec 1997;20(9):622-627. term pain relief negating the need for surgery. Inter-
8. Kruse RA, Imbarlina F, De Bono VF. Treatment of cervi- estingly, there is limited Level II evidence that sug-
cal radiculopathy with flexion distraction. J Manipulative gests that the addition of steroid to local anesthetic
Physiol Ther. Mar-Apr 2001;24(3):206-209.
9. Malone DG, Baldwin NG, Tomecek FJ, et al. Complications does not improve pain relief in these patients at three
of cervical spine manipulation therapy: 5-year retrospec- weeks post-injection. All of the studies that qualified
tive study in a single-group practice. Neurosurg Focus. Dec as at least Level IV data used transforaminal epidu-
15 2002;13(6):ecp1. ral injections under fluoroscopic or CT guidance as
10. Murphy DR. Herniated disc with radiculopathy following the method of treatment. For this reason, the work
cervical manipulation: nonsurgical management. Spine J.
Jul-Aug 2006;6(4):459-463. group was unable to make recommendations re-
11. Murphy DR, Beres JL. Cervical myelopathy: a case report garding the safety or efficacy of interlaminar epi-
of a “near-miss” complication to cervical manipulation. J dural steroid injections for the treatment of cervical
Manipulative Physiol Ther. Sep 2008;31(7):553-557. radiculopathy.
12. Murphy DR, Beres JL. Is treatment in extension contrain-
dicated in the presence of cervical spinal cord compres-
sion without myelopathy? A case report. Man Ther. Oct The literature search yielded a number of publica-
2008;13(5):468-472. tions demonstrating that transforaminal epidural
13. Oppenheim JS, Spitzer DE, Segal DH. Nonvascular com- steroid injections are not without risk and the po-
plications following spinal manipulation. Spine J. Nov tential complications, including spinal cord injury
2005;5(6):660-666. and death, need to be considered before performing
14. Padua L, Padua R, LoMonaco M, Tonali PA. Radiculom-
edullary complications of cervical spinal manipulation. this procedure.20,25
Spinal Cord. Aug 1996;34(8):488-492.
15. Pollard H, Tuchin P. Cervical radiculopathy: a case for RECOMMENDATION: Transforaminal epidu-
ancillary therapies? J Manipulative Physiol Ther. May ral steroid injections using fluoroscopic or CT
1995;18(4):244-249. guidance may be considered when developing
16. Saal JS, Saal JA, Yurth EF. Nonoperative management of
herniated cervical intervertebral disc with radiculopathy. a medical/interventional treatment plan for pa-
Spine. Aug 15 1996;21(16):1877-1883. tients with cervical radiculopathy from degen-
17. Tseng SH, Lin SM, Chen Y, Wang CH. Ruptured cervical erative disorders. Due consideration should be
disc after spinal manipulation therapy: report of two cas- given to the potential complications.
es. Spine. Feb 1 2002;27(3):E80-82.
18. Waldrop MA. Diagnosis and treatment of cervical radicu-
lopathy using a clinical prediction rule and a multimodal GRADE OF RECOMMENDATION: C
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 45
Cyteval et al10 described a prospective case series transforaminal epidural steroid injections and were
of 30 patients treated with transforaminal epidural followed until they obtained satisfactory relief or
steroid injections under CT guidance. At six month underwent surgical management. Of these patients,
follow-up 60% of patients obtained good or excel- 65% (45/70) reported good or excellent results with
lent pain relief. In critique of this study, this is a regard to pain relief and 63% (44/70) opted not to
nonrandomized, nonconsecutive case series with have surgery. In critique of this study, no validated
a small sample size and fairly short term follow-up. outcome measures were used, though avoiding sur-
This study provides Level IV evidence that 60% of gery could be considered a valid endpoint. This study
patients can obtain good or excellent pain relief at provides Level IV evidence that 65% of patients with
up to six months following transforaminal epidural cervical radiculopathy can obtain pain relief to the
steroid injections. level necessary to avoid surgery.
Kim et al14 retrospectively reviewed 19 patients who Anderberg et al3 described a prospective random-
underwent cervical transforaminal epidural steroid ized controlled trial of 40 patients with cervical ra-
injections under CT guidance. At 16 week follow-up diculopathy. They were randomized into one group
patients noted an average 50% reduction in pain. In that received transforaminal epidural steroid in-
critique of this study, it is retrospective and excluded jections and a control group that received transfo-
any patients with neurologic deficits. Further limit- raminal injections of local anesthetic. At three week
ing the relevance of this study is the small sample follow-up, 40% (8/20) of the patients in the steroid
size and relatively short term follow-up. This study injection group, and 35% (7/20) of the patients in the
provides Level IV evidence that, on average, patients control group noted improvement in their pain on a
will experience a 50% reduction in pain 16 weeks fol- VAS. This difference was not statistically significant.
lowing transforaminal epidural steroid injections. In critique of this study, no validated outcome mea-
sures were used and the sample size was very small.
Kolstad et al15 described a prospective case series of This potential Level I study was downgraded to a
21 patients with cervical radiculopathy awaiting cer- Level II study because of these shortcomings. This
vical disc surgery. Two cervical transforaminal epi- study provides Level II evidence that the addition
dural steroid injections under fluoroscopic guidance of steroid to local anesthetic in transforaminal epi-
were performed two weeks apart. Patients were fol- dural injections provides no additional therapeutic
lowed for four months with approximately 25% opt- benefit at three weeks post-injection.
ing to cancel surgery because of clinical improve-
ment. In critique of this study, the sample size is Future Directions for Research
small. It is difficult to make any outcome statements The work group identified the following suggestions
regarding these patients other than they opted out for future studies which would generate meaningful
of surgery at four months following this treatment. evidence to assist in further defining the role of epi-
This study provides Level IV evidence that 25% of dural steroid injections in the management of cervi-
patients awaiting cervical disc surgery can obtain cal radiculopathy from degenerative disorders.
enough pain relief at four months following two cer-
vical transforaminal epidural steroid injections to Recommendation #1:
cancel surgery. Future studies of the effects of epidural steroid in-
jections in the management of cervical radiculopa-
Lin et al17 described a retrospective case series of 70 thy from degenerative disorders should include an
patients considered potential surgical candidates for untreated control group when ethically possible.
cervical radiculopathy. Patients underwent cervical
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 46
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 47
What is the role of ancillary treat- approximately six weeks reported some degree of
pain relief with halter traction. In critique, this case
ments such as bracing, traction, series did not utilize any validated outcome mea-
electrical stimulation, acupunc- sures and had a very short follow-up period. Due
to these weaknesses, this potential Level IV study
ture and transcutaneous electri- provides Level V evidence suggesting that 75% of
cal stimulation in the treatment patients with mild radiculopathy may improve with
traction over a six week time frame.
of cervical radiculopathy from
degenerative disorders? Saal et al8 presented a retrospective case series eval-
uating the use of a multifaceted medical/interven-
RECOMMENDATION: Ozone injections, cervi- tional treatment program for 26 patients with cervi-
cal halter traction and combinations of medi- cal radiculopathy. Of the 26 patients who completed
cations, physical therapy, injections and traction the program, 24 were available for follow-up at three
have been associated with improvements in pa- months, with 89% (22/24) of patients reporting a
tient reported pain in uncontrolled case series. good treatment outcome. In critique, this study did
Such modalities may be considered recognizing not utilize any validated outcome measures. This
that no improvement relative to the natural study provides Level IV evidence that a multifaceted
history of cervical radiculopathy has been dem- medical/interventional treatment program is asso-
onstrated. ciated with good outcomes in many patients with
Work Group Consensus Statement cervical radiculopathy.
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 48
in the physical therapy group and five in the collar need to improve coping strategies, self image and
group had surgery with Cloward technique. mood.
Chronic symptoms influenced both function and In critique, neither patients nor reviewers were
mental well being such as emotional state, level of masked to treatment group, the sample size was
anxiety, depression, sleep and coping behavior. Pain small and duration of follow-up was short. Due to
was the most important primary stressor. Surgery these limitations, this potential Level I study pro-
reduced the pain faster, but no difference was seen vides Level II evidence that there is a high incidence
after 12 months. Reoperation rate was 29%, mostly of behavioral and emotional dysfunction in cervical
for adjacent segment disease. The low positive mood radiculopathy patients. Medical/interventional and
state (MACL score) did not improve over time. Pa- surgical treatment must include a cognitive, behav-
tients who still had pain after treatment were more ioral component for either method to be successful.
socially withdrawn and ceased to express their emo-
tions. The Hospital Anxiety and Depression (HAD) Future Directions for Research
anxiety score was especially high in patients before The work group identified the following suggestions
and after treatment. In patients with high pain inten- for future studies which would generate meaning-
sity, low function, high depression and anxiety were ful evidence to assist in further defining the role of
seen. The group treated with surgery showed more ancillary treatments in the management of cervical
anxiety and depression if pain continued, implying radiculopathy from degenerative disorders.
higher expectations and more disappointment if it
failed. The strongest correlation between depression Recommendation #1:
and pain was seen in the collar group, possibly be- Future studies of the effects of ancillary treatments
cause they received less attention overall. In gener- in the management of cervical radiculopathy from
al, coping strategies changed. Active coping (cogni- degenerative disorders should include an untreated
tive reappraisal and problem solving) was common control group when ethically possible.
before treatment, but disappeared after treatment, Recommendation #2:
especially in the surgical group. Coping with pain Future outcome studies including patients with
was changed in general into a more passive/escape cervical radiculopathy from degenerative disorders
focused strategy. It appeared that with intervention, treated only with ancillary treatments should in-
especially surgery, healthy active coping strategies clude subgroup analysis for this patient population.
tended to be replaced by passive coping strategies
as patients allowed themselves to become more de- Recommendation #3:
pendent on the intervention. This also implied that Future studies evaluating the effects of emotional,
the ability for active coping was present before in- cognitive and work-related issues would add to our
tervention, and thus cognitive behavioral treatment understanding of how these factors affect outcomes
started concurrently with other interventions may in patients with cervical radiculopathy from degen-
be particularly successful for maintaining better erative disorders.
coping patterns. Function was significantly related
to pain intensity. About 40% had anxiety only par- Ancillary Treatment References
tially connected to pain. Prior to treatment, 30% of 1. Alexandre A, Coro L, Azuelos A, et al. Intradiscal injection
patients were depressed. After 12 months, 20% suf- of oxygen-ozone gas mixture for the treatment of cervical
disc herniations. Acta Neurochir Suppl. 2005;92:79-82.
fered from depression. The authors concluded that 2. Constantoyannis C, Konstantinou D, Kourtopoulos H,
cognitive and behavioral therapy is important to Papadakis N. Intermittent cervical traction for cervical
include in multidisciplinary rehabilitation. Patients radiculopathy caused by large-volume herniated disks. J
Manipulative Physiol Ther. Mar-Apr 2002;25(3):188-192.
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 49
3. Ellenberg MR, Honet JC, Treanor WJ. Cervical radiculopa- 7. Persson LC, Lilja A. Pain, coping, emotional state and
thy. Arch Phys Med Rehabil. Mar 1994;75(3):342-352. physical function in patients with chronic radicular neck
4. LaBan MM, Macy JA, Meerschaert JR. Intermittent cervi- pain. A comparison between patients treated with surgery,
cal traction: a progenitor of lumbar radicular pain. Arch physiotherapy or neck collar--a blinded, prospective ran-
Phys Med Rehabil. Mar 1992;73(3):295-296. domized study. Disabil Rehabil. May 20 2001;23(8):325-
5. Matsumoto M, Chiba K, Ishikawa M, Maruiwa H, Fujimura 335.
Y, Toyama Y. Relationships between outcomes of conser- 8. Saal JS, Saal JA, Yurth EF. Nonoperative management of
vative treatment and magnetic resonance imaging find- herniated cervical intervertebral disc with radiculopathy.
ings in patients with mild cervical myelopathy caused by Spine. Aug 15 1996;21(16):1877-1883.
soft disc herniations. Spine. Jul 15 2001;26(14):1592-1598. 9. Verbiest H. Chapter 23. The management of cervical spon-
6. Olivero WC, Dulebohn SC. Results of halter cervical trac- dylosis. Clin Neurosurg. 1973;20:262-294.
tion for the treatment of cervical radiculopathy: retro- 10.. Waldrop MA. Diagnosis and treatment of cervical radicu-
spective review of 81 patients. Neurosurg Focus. Feb 15 lopathy using a clinical prediction rule and a multimodal
2002;12(2):ECP1. intervention approach: a case series. J Orthop Sports Phys
Ther. Mar 2006;36(3):152-159.
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 50
D. Surgical Treatment
Does surgical treatment (with or groups and improvement in pain scores in the sur-
gical group was significantly better than in the col-
without preoperative medical/in- lar group. After another year, the pain was about the
terventional treatment) result in same across groups. The surgical group improved
strength a little faster, but at final follow-up strength
better outcomes than medical/in- improvement was equal across groups. At final fol-
terventional treatment for cervi- low-up, there was no difference between groups on
the sensory exam. The authors concluded that there
cal radiculopathy from degenera- was no difference in outcomes after one year be-
tive disorders? tween patients treated with a collar, physical therapy
or surgery.
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 51
In general, pain scores were worse in the surgical cal radiculopathy of at least three months duration
group preoperatively than in the medical/inter- randomly assigned to one of three treatment groups.
ventional treatment group. Both groups improved Of the 81 patients included in the study, 27 were as-
significantly, with greater improvement seen in the signed to cervical bracing, 27 to physical therapy and
surgical group. Patient satisfaction, neurological im- 27 to ACDF (Cloward technique). Three patients as-
provement and functional improvement were seen signed to the surgical group refused the procedure
in both groups, with greater improvement reported and were handled in intent to treat analysis. In the
in the surgical group. There was significant improve- surgical group, eight patients had a second opera-
ment in activities of daily living (ADL) in the surgi- tion: six on adjacent level, one infection and one
cal group. Although there was improvement, there plexus exploration. Eleven patients in the surgery
was still significant pain in about 26% of surgical pa- group also received physical therapy. One patient
tients. The number returning to work did not differ in the physical therapy group and five in the collar
before and after intervention in either group despite group had surgery with Cloward technique.
improved functional ability, implying that the most
important factor for return to work was work status Chronic symptoms influenced both function and
prior to treatment. The authors concluded that sur- mental well being such as emotional state, level of
gery appears to have more success than medical/in- anxiety, depression, sleep and coping behavior. Pain
terventional treatment, although both help. Despite was the most important primary stressor. Surgery
this, a substantial percentage of patients continue reduced the pain faster, but no difference was seen
to have severe pain, neurologic symptoms and no after 12 months. Reoperation rate was 29%, mostly
work activity. for adjacent segment disease. The low positive mood
state (MACL score) did not improve over time. Pa-
In critique, this was a nonrandomized study which tients who still had pain after treatment were more
did not utilize validated outcome measures. There socially withdrawn and ceased to express their emo-
was a high attrition rate to follow-up and the length tions. The Hospital Anxiety and Depression (HAD)
of follow-up was short. Both medical/interventional anxiety score was especially high in patients before
and surgical treatment protocols were nonstandard- and after treatment. In patients with high pain inten-
ized. Due to these limitations, this potential Level II sity, low function, high depression and anxiety were
study provides Level III evidence that surgical treat- seen. The group treated with surgery showed more
ment results in improved outcomes when compared anxiety and depression if pain continued, implying
with medical/interventional treatment on short higher expectations and more disappointment if it
term follow-up. failed. The strongest correlation between depression
and pain was seen in the collar group, possibly be-
RECOMMENDATION: Emotional and cognitive cause they received less attention overall. In gener-
factors (eg, job dissatisfaction) should be consid- al, coping strategies changed. Active coping (cogni-
ered when addressing surgical or medical/inter- tive reappraisal and problem solving) was common
ventional treatment for patients with cervical before treatment, but disappeared after treatment,
radiculopathy from degenerative disorders. especially in the surgical group. Coping with pain
was changed in general into a more passive/escape
GRADE OF RECOMMENDATION: focused strategy. It appeared that with intervention,
I (Insufficient Evidence) especially surgery, healthy active coping strategies
tended to be replaced by passive coping strategies
Persson et al47 conducted a prospective randomized as patients allowed themselves to become more de-
controlled trial comparing coping strategies, pain pendent on the intervention. This also implied that
and emotional relationships of patients with cervi- the ability for active coping was present before in-
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 52
tervention, and thus cognitive behavioral treatment in patients with cervical radiculopathy from degen-
started concurrently with other interventions may erative disorders.
be particularly successful for maintaining better
coping patterns. Function was significantly related References
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include in multidisciplinary rehabilitation. Patients 53.
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In critique, neither patients nor reviewers were plasty. BMC Musculoskelet Disord. 2006;7:85.
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Clinical outcome of patients treated for spondylotic radic-
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This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 53
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This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 54
549; discussion 550. ment of cervical radiculopathy. Acta Neurol Scand. Sep
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threaded titanium cages at cervical and lumbar levels. Re- 52. Ruetten S, Komp M, Merk H, Godolias G. A new full-endo-
sults on 357 cases. Acta Neurochir (Wien). 2000;142(4):425- scopic technique for cervical posterior foraminotomy in
434. the treatment of lateral disc herniations using 6.9-mm en-
41. Mobbs RJ, Rao P, Chandran NK. Anterior cervical discec- doscopes: prospective 2-year results of 87 patients. Minim
tomy and fusion: analysis of surgical outcome with and Invasive Neurosurg. Aug 2007;50(4):219-226.
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blick TA. Clinical and radiographic analysis of cervical center study with independent clinical review. Spine. Mar
disc arthroplasty compared with allograft fusion: a ran- 15 1999;24(6):591-597.
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prospective, randomized, controlled multicenter Food 2940; discussion 2941-2932.
and Drug Administration investigational device exemp- 55. Schneeberger AG, Boos N, Schwarzenbach O, Aebi M.
tion study of the ProDisc-C total disc replacement ver- Anterior cervical interbody fusion with plate fixation for
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44. Nabhan A, Ahlhelm F, Pitzen T, et al. Disc replacement us- 56. Schoggl A, Reddy M, Saringer W, Ungersbock K. Social
ing Pro-Disc C versus fusion: a prospective randomised and economic outcome after posterior microforamino-
and controlled radiographic and clinical study. Euro Spine tomy for cervical spondylotic radiculopathy. Wien Klin
J. Mar 2007;16(3):423-430. Wochenschr. Mar 28 2002;114(5-6):200-204.
45. Nabhan A, Ahlhelm F, Shariat K, et al. The ProDisc-C pro- 57. Shen FH, Samartzis D, Khanna N, Goldberg EJ, An HS.
thesis - Clinical and radiological experience 1 year after Comparison of clinical and radiographic outcome in in-
surgery. Spine. Aug 2007;32(18):1935-1941. strumented anterior cervical discectomy and fusion with
46. Nunley PD, Jawahar A, Kerr EJ, 3rd, Cavanaugh DA, How- or without direct uncovertebral joint decompression.
ard C, Brandao SM. Choice of plate may affect outcomes Spine J. Nov 2004;4(6):629-635.
for single versus multilevel ACDF: results of a prospective 58. Sugawara T, Itoh Y, Hirano Y, Higashiyama N, Mizoi K. Long
randomized single-blind trial. Spine J. Feb 2009;9(2):121- term outcome and adjacent disc degeneration after ante-
127. rior cervical discectomy and fusion with titanium cylin-
47. Persson LC, Lilja A. Pain, coping, emotional state and drical cages. Acta Neurochir (Wien). Apr 2009;151(4):303-
physical function in patients with chronic radicular neck 309.
pain. A comparison between patients treated with surgery, 59. Tegos S, Rizos K, Papathanasiu A, Kyriakopulos K. Re-
physiotherapy or neck collar--a blinded, prospective ran- sults of anterior discectomy without fusion for treatment
domized study. Disabil Rehabil. May 20 2001;23(8):325- of cervical radiculopathy and myelopathy. Eur Spine J.
335. 1994;3(2):62-65.
48. Persson LC, Moritz U, Brandt L, Carlsson CA. Cervical ra- 60. Topuz K, Colak A, Kaya S, et al. Two-level contiguous cer-
diculopathy: pain, muscle weakness and sensory loss in vical disc disease treated with peek cages packed with de-
patients with cervical radiculopathy treated with surgery, mineralized bone matrix: results of 3-year follow-up. Eur
physiotherapy or cervical collar. A prospective, controlled Spine J. Feb 2009;18(2):238-243.
study. Eur Spine J. 1997;6(4):256-266. 61. Wirth FP, Dowd GC, Sanders HF, Wirth C. Cervical discec-
49. Pimenta L, McAfee PC, Cappuccino A, Cunningham tomy. A prospective analysis of three operative techniques.
BW, Diaz R, Coutinho E. Superiority of multilevel cer- Surg Neurol. Apr 2000;53(4):340-346; discussion 346-348.
vical arthroplasty outcomes versus single-level out- 62. Xie JC, Hurlbert RJ. Discectomy versus discectomy with
comes: 229 consecutive PCM prostheses. Spine. May 20 fusion versus discectomy with fusion and instrumenta-
2007;32(12):1337-1344. tion: a prospective randomized study. Neurosurgery. Jul
50. Pointillart V, Cernier A, Vital JM, Senegas J. Anterior dis- 2007;61(1):107-116; discussion 116-107.
cectomy without interbody fusion for cervical disc hernia- 63. Yamamoto I, Ikeda A, Shibuya N, Tsugane R, Sato O.
tion. Eur Spine J. 1995;4(1):45-51. Clinical long-term results of anterior discectomy with-
51. Romner B, Due-Tonnessen BJ, Egge A, Anke IM, Trumpy out interbody fusion for cervical disc disease. Spine. Mar
JH. Modified Robinson-Smith procedure for the treat- 1991;16(3):272-279.
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 55
64. Zeidman SM, Ducker TB. Posterior cervical laminoforami- compared to ICBG had similar outcomes but more
notomy for radiculopathy: review of 172 cases. Neurosur- kyphotic deformity at medium length follow-up.
gery. Sep 1993;33(3):356-362.
65. Zoega B, Karrholm J, Lind B. Outcome scores in degenera-
tive cervical disc surgery. Eur Spine J. Apr 2000;9(2):137- In critique, neither reviewers nor patients were
143. masked to treatment group and the randomization
process was not described. No validated outcome
measures were utilized, the sample size was small
Does ACDF result in better out- and length of follow-up was short. Use of PMMA as
comes (clinical or radiographic) a spacer is not standard practice. Due to these limi-
tations, this potential Level II RCT provides Level III
than ACD alone? evidence that suggests that there are variable out-
comes when comparing ACD to ACDF for the treat-
RECOMMENDATION: Both ACD and ACDF
ment of cervical radiculopathy due to single level de-
are suggested as comparable treatment strate-
generative disease. In one cohort comparing ACD to
gies, producing similar clinical outcomes, in the
fusion with ICBG, outcomes were equivalent, while
treatment of single level cervical radiculopathy
another cohort showed superiority of interbody fu-
from degenerative disorders.
sion with a titanium cage and allograft versus ACD.
Validity of conclusions is weakened by small sample
GRADE OF RECOMMENDATION: B
size and short follow-up.
Barlocher et al3 conducted a prospective random-
Hauerberg et al9 reported results of a prospective
ized controlled trial comparing outcomes of ACD to
randomized controlled trial comparing radiograph-
three different types of ACDF: iliac crest bone graft
ic and clinical outcomes of ACD with ACDF using
(ICBG), polymethylmethacrylate (PMMA) and tita-
a titanium cage. Of the 86 patients included in the
nium cages. All patients had single level degenerative
study, 46 were randomized to the ACD group and 40
disease. Of the 125 patients included in the study,
to ACDF. One patient withdrew in each group. Two
33 were assigned to the ACD group, 30 to ICBG, 26
year follow-up data were available for 36 cage and
to PMMA and 36 to titanium cages. At one year fol-
43 ACD patients. Early outcomes, though not statis-
low-up, 123 patients were available. The functional
tically significant, favored ACD. At two years 63% of
outcomes were grouped by good and excellent to
ACD patients and 78% of cage patients reported good
poor and fair, with good/excellent results reported
outcomes (not statistically significant). Reoperation
for 75% of the ACDF group, 80% for ICBG, 87% for
rates at the same level were reported as follows: at
PMMA and 94% for cage. Average reported kyphosis
three months, three reoperations in ACD group, two
for ACD patients was 24 degrees, with one patient
in cage group; at one year, an additional reoperation
requiring revision surgery (31 degrees); 12 degrees
in each group; at two years, an additional three in
for PMMA and about three degrees for the ICBG and
the ACD group. There were some additional pro-
cage groups. Twelve month fusion results based on
cedures at adjacent levels that were equivalent for
flexion and extension radiographs were reported as
both groups over two years. In total, for the ACD
93% for the ACD patients, 93% for ICBG and 97% for
group, 17/46 were investigated, seven had the same
cage. Fusion rate was faster in the cage group as well
level reoperation and two had adjacent level opera-
with 86% achieving fusion at six months compared
tions. In the cage group, 15/40 were investigated
with 61% in the ACD group and 65% in the ICBG
with three having same level reoperation and three
group. The authors concluded that ACDF with cage
having adjacent level operations. There were no sta-
did significantly better with faster and better re-
tistically significant differences reported in kyphosis
covery and less kyphotic deformity than ACD. ACD
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 56
or fusion rate. The authors concluded that there was outcome measures were utilized and follow-up was
no difference in outcome at two years between ACD short. Due to these limitations, this potential Level
and ACDF with cage and local autograft bone. II study provides Level III evidence that for cervical
radiculopathy due to single level degenerative dis-
In critique, the reviewers were not masked to treat- ease, ACD alone provides satisfactory clinical out-
ment group, no validated outcome measures were comes when compared to ACDF with allograft ICBG
used and the sample size was small. Due to these and semirigid plate. Radiographically, disc height
limitations, this potential Level I RCT provides Level is maintained significantly better with plate and fu-
II evidence that for cervical radiculopathy due to sion although the clinical significance is unknown.
single level degenerative disease, clinical outcomes The validity of the conclusions is uncertain due to
are similar at two years for patients undergoing ACD small sample size.
and ACDF with threaded titanium cage and local
autograft. Fusion rates and symptomatic adjacent Savolainen et al19 reported results of a prospective
segment disease were also similar between the two randomized controlled trial comparing clinical re-
groups. sults of ACD to ACDF with or without plate. Of the 91
patients included in the study, follow-up data were
Oktenoglu et al16 described a prospective random- reported for 88 patients. Good/excellent results were
ized controlled trial comparing radiographic and reported in 76% of ACD patients, 82% ACDF and
clinical outcomes of ACD and ACDF with plate. Of 73% ACDFP. Of the 88 patients, 71 had long term ra-
the 20 patients included in the study, 11 were as- diographic follow-up, with slight kyphosis in 62% of
signed to the ACD group and nine to the ACDF ACD, 41% ACDF, 44% ACDFP and fusion achieved
group. Inclusion criteria required only two weeks in 100% of ACDF and 90% of ACD patients. Compli-
of failed medical/interventional treatment. VAS up- cation rates were similar for all groups, with the ex-
per extremity pain scores (dominant complaint) im- ception of short term ICBG pain which was severe
proved significantly in both groups, from mean 8 to in 80% of both ACDF groups. The authors concluded
3. Although less severe initially than arm pain, VAS that because outcomes were similar for the three
neck pain scores had less improvement overall, but groups, ACD is recommended as the procedure of
statistically significant improvement was noted in choice for ease of surgery and reduced complica-
the ACDF group. CT follow-up at one year showed tions.
disc space collapse in both groups, but significantly
more in the ACD group. There was some subsid- In critique, neither patients nor reviewers were
ence of the graft over the first year. Final foraminal masked to treatment group. The randomization pro-
dimensions were slightly larger in ACDF group, but cess was not specified. No validated outcome mea-
not significant. Reported fusion rates were 100% in sures were used and the sample size was small. Pa-
the ACDF group and 45% (5/11) in the ACD group. tients were seen up to six months following surgery,
The authors concluded that ACD alone provides and then final follow-up at four years was conduct-
satisfactory clinical outcomes when compared to ed via telephone interview. Due to these limitations,
ACDF with semirigid plate. this potential Level II study provides Level III evi-
dence that for patients with cervical radiculopathy
In critique, patients were not masked to treatment due to single level degenerative disease, ACD yields
group and duration of symptoms for study inclusion results equivalent to ACDF with or without a plate.
was short. Randomization was accomplished by The validity of the conclusion is uncertain due to
coin flip and the sample size was small. No validated small sample size.
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 57
Wirth et al24 conducted a prospective randomized tients included in the study, 15 were randomly as-
controlled trial comparing clinical outcomes of signed to each treatment group. Three patients in the
ACD, ACDF and posterior cervical foraminotomy ACD group were lost to follow-up. No graft site pain
for single level HNP with radiculopathy. Of the 72 was reported at two years. In general, clinical results
consecutively assigned patients included in the improved to one year then plateaued. Arm pain was
study, 22 were assigned to foraminotomy, 25 to completely absent in 92% of ACD patients, 93% of
ACD and 25 to ACDF. For immediate postoperative ACDF patients and 100% of ACDFI patients. Neck
results, surgical time, hospital stay and cost were pain was absent in 83%, 80% and 73%, respective-
slightly better for the ACD group. Postoperative ly. All had significant and similar improvements in
pain was worse in the foraminotomy group. At two McGill Pain Questionnaire and SF-36. At two years,
months, according to the non validated grading fusion rate on radiograph was 67%, 93%, and 100%
scheme implemented, all three groups were about respectively. Of patients treated with ACD, 75% had
the same. Reoperations were greater at the operative kyphosis at two years. The authors concluded that
site for foraminotomy and adjacent sites for ACDF patient selection is the key to surgical success. Any
patients. Long-term follow-up was accomplished via of these surgeries are suitable for cervical radicul-
phone interview at 53 months for the foraminotomy opathy due to nerve root compression. Because the
group (14/22 patients), 56 months for the ACD group long term effects of kyphosis are unknown, the po-
(13/25 patients) and 69 months for the ACDF group tential consequences of ACD remain uncertain.
(16/25 patients), with a loss of about 40% of patients
to follow-up. Within the limits of their study design In critique, neither the patients nor reviewers were
and patient capture, pain improvement remained masked to treatment group, and the sample size was
high for all groups. Return to work was 79% for the small. Due to these limitations, this potential Level
foraminotomy group, 92% for ACD and 81% for I study provides Level II evidence that clinical out-
ACDF (not statistically significant). Of the patients comes for treatment of cervical radiculopathy due
available at final follow-up, 100% were satisfied to single level degenerative disease are similar when
and would have the surgery again. The authors comparing ACD to ACDF, with or without plating.
concluded that for single level HNP, all procedures Radiographic outcomes were worse with ACD, re-
are efficacious. sulting in a significant loss of lordosis, although the
clinical consequences of this are unknown. The va-
In critique, neither patients nor reviewers were lidity of the conclusions may be compromised by a
masked to the treatment group and the random- very small sample size.
ization method was poor. No validated outcome
measures were utilized to assess this small patient RECOMMENDATION: The addition of an
sample. Approximately 40% of patients were lost to interbody graft for fusion is suggested to
follow-up. Because of these limitations, this poten- improve sagittal alignment following ACD.
tial Level II study provides Level III evidence that
for single level HNP causing cervical radiculopathy, GRADE OF RECOMMENDATION: B
outcomes for ACD are equivalent to ACDF.
Barlocher et al3 conducted a prospective random-
Xie et al25 reported results of a prospective random- ized controlled trial comparing outcomes of ACD
ized controlled trial comparing clinical and radio- to three different types of ACDF: ICBG, PMMA and
graphic outcomes of ACD, ACDF, and anterior cer- titanium cages. All patients had one level disease. Of
vical discectomy with instrumented fusion (ACDFI) the 125 patients included in the study, 33 were as-
for single level cervical radiculopathy. Of the 45 pa- signed to the ACD group, 30 to ICBG, 26 to PMMA
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 58
and 36 to titanium cages. At one year follow-up, 123 pain was reported at two years. In general, clinical
patients were available. The functional outcomes results improved to one year then plateaued. Arm
were grouped by good and excellent to poor and fair, pain was completely absent in 92% of ACD patients,
with good/excellent results reported for 75% of the 93% of ACDF patients and 100% of ACDFI patients.
ACDF group, 80% for ICBG, 87% for PMMA and 94% Neck pain was absent in 83%, 80% and 73%, respec-
for cage. Average reported kyphosis for ACD patients tively. All had significant and similar improvements
was 24 degrees, with one patient requiring revision in McGill Pain Questionnaire and SF-36. At two
surgery (31 degrees); 12 degrees for PMMA and years, fusion rate on radiograph was 67%, 93%, and
about three degrees for the ICBG and cage groups. 100% respectively. Of patients treated with ACD,
Twelve month fusion results were reported as 93% 75% had kyphosis at two years. Approximately 25%
for the ACD patients, 93% for ICBG and 97% for cage. had kyphosis between 5 and 15 degrees, while the
Fusion rate was faster in the cage group as well with other 50% were between 0 and 5 degrees. It should
86% achieving fusion at six months compared with be noted that 15% of the patients had some measure
61% in the ACD group and 65% in the ICBG group. of preoperative kyphosis. In both the ACDF and
The authors concluded that ACDF with cage did sig- ACDFI groups, less than 5% of patients had a kypho-
nificantly better with faster and better recovery and sis of 5 to 15 degrees at final follow up. There was 0
less kyphotic deformity than ACD. ACD compared to 5 degrees of kyphosis in approximately 30% and
to ICBG had similar outcomes at medium length 20% of the ACDF and ACDFI groups respectively.
follow-up. Pre operative kyphosis was noted in 20% and 30%
respectively. Looking at the data more closely, there
In critique, neither reviewers nor patients were was a clear loss of kyphosis in the ACD group. In the
masked to treatment group and the randomization ACDF group, alignment tended to remain close to
process was not described. No validated outcome the pre operative condition in general, with slight
measures were utilized, the sample size was small subsidence and minimal loss of kyphosis in a small
and length of follow-up was short. Use of PMMA as percent of patients such that at final follow up pre
a spacer is not standard practice. Due to these limi- and post operative sagittal alignment were gener-
tations, this potential Level II RCT provides Level III ally similar. If these patients exhibited pre operative
evidence that suggests that there are variable out- segmental kyphosis, they tended to stay that way, as
comes when comparing ACD to ACDF for the treat- did those with pre operative lordosis. In the ACDFI
ment of cervical radiculopathy due to single level group, there was a trend towards improved sagittal
degenerative disease. While not the primary out- alignment when comparing pre and post operative
come measure, radiographic sagittal alignment was lordosis. The authors concluded that patient selec-
clearly better with ACDF compared to ACD. Validity tion is the key to surgical success. Any of these sur-
of conclusions are weakened by small sample size geries are suitable for cervical radiculopathy due to
and short follow-up. nerve root compression. There was a clear advan-
tage for maintaining sagittal alignment with either
Xie et al25 reported results of a prospective random- ACDF or ACDFI. Because the long term effects of
ized controlled trial comparing clinical and radio- kyphosis are unknown, the potential consequences
graphic outcomes of ACD, ACDF, and anterior cer- of ACD remain uncertain.
vical discectomy with instrumented fusion (ACDFI)
for single level cervical radiculopathy. Of the 45 pa- In critique, neither the patients nor reviewers were
tients included in the study, 15 were randomly as- masked to treatment group, and the sample size was
signed to each treatment group. Three patients in small. Due to these limitations, this potential Level
the ACD group were lost to follow-up. No graft site I study provides Level II evidence that clinical out-
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 59
comes for treatment of cervical radiculopathy due 6. Donaldson JW, Nelson PB. Anterior cervical discectomy
to single level degenerative disease are similar when without interbody fusion. Surg Neurol. Apr 2002;57(4):219-
224; discussion 224-215.
comparing ACD to ACDF, with or without plating. 7. Dowd GC, Wirth FP. Anterior cervical discectomy: is fu-
Radiographic outcomes were worse with ACD, re- sion necessary? J Neurosurg. Jan 1999;90(1 Suppl):8-12.
sulting in a significant loss of lordosis, although the 8. Gaetani P, Tancioni F, Spanu G, Rodriguez y Baena R. Ante-
clinical consequences of this are unknown. The va- rior cervical discectomy: an analysis on clinical long-term
lidity of the conclusions may be compromised by a results in 153 cases. J Neurosurg Sci. Dec 1995;39(4):211-
218.
very small sample size. 9. Hauerberg J, Kosteljanetz M, Boge-Rasmussen T, et al. An-
terior cervical discectomy with or without fusion with ray
Future Directions for Research titanium cage: a prospective randomized clinical study.
The work group identified the following suggestions Spine. Mar 1 2008;33(5):458-464.
for future studies which would generate meaningful 10. Husag L, Costabile G, Vanloffeld W, Keller RJD, Landolt
H. Anterior cervical discectomy without fusion: A com-
evidence to assist in further defining the role of fu- parison with Cloward’s procedure. J Clin Neurosci. Jul
sion with ACD in the surgical treatment of cervical 1997;4(3):331-340.
radiculopathy from degenerative disorders. 11. Jacobs WC, Anderson PG, Limbeek J, Willems PC, Pavlov
P. Single or double-level anterior interbody fusion tech-
Prospective, blinded, RCT comparing clinical out- niques for cervical degenerative disc disease. Cochrane
Database Syst Rev. 2004(4):CD004958.
comes and radiographic alignment of patients treat- 12. Klaiber RD, Vonammon K, Sarioglu AC. Anterior Micro-
ed for cervical radiculopathy due to single level de- surgical Approach for Degenerative Cervical Disk Disease.
generative disease with ACD compared with ACDF Acta Neurochir (Wien). 1992;114(1-2):36-42.
with a uniform surgical technique would generate 13. Maurice-Williams RS, Elsmore A. Extended anterior cervi-
important information about the relative value of cal decompression without fusion: a long-term follow-up
study. Br J Neurosurg. Oct 1999;13(5):474-479.
preserving normal alignment. 14. Murphy MA, Trimble MB, Piedmonte MR, Kalfas IH.
Changes in the cervical foraminal area after anterior
References discectomy with and without a graft. Neurosurgery. Jan
1. Abd-Alrahman N, Dokmak AS, Abou-Madawi A. Anterior 1994;34(1):93-96.
cervical discectomy (ACD) versus anterior cervical fusion 15. Naderi S, Ozgen S, Ozek MM, Pamir MN. Cervical disc her-
(ACF), clinical and radiological outcome study. Acta Neu- niations: When to fuse? Neuro-Orthopedics. 2000;28(1):27-
rochir (Wien). 1999;141(10):1089-1092. 38.
2. Alvarez JA, Hardy RW. Anterior cervical discectomy for 16. Oktenoglu T, Cosar M, Ozer AF, et al. Anterior cervical
one- and two-level cervical disc disease: the controversy microdiscectomy with or without fusion. J Spinal Disord
surrounding the question of whether to fuse, plate, or Tech. Jul 2007;20(5):361-368.
both. Crit Rev Neurosurg. Jul 1999;9(4):234-251. 17. Pointillart V, Cernier A, Vital JM, Senegas J. Anterior dis-
3. Barlocher CB, Barth A, Krauss JK, Binggeli R, Seiler RW. cectomy without interbody fusion for cervical disc hernia-
Comparative evaluation of microdiscectomy only, au- tion. Eur Spine J. 1995;4(1):45-51.
tograft fusion, polymethylmethacrylate interposition, and 18. Rao PJ, Christie JG, Ghahreman A, Cartwright CA, Ferch
threaded titanium cage fusion for treatment of single-level RD. Clinical and functional outcomes of anterior cervi-
cervical disc disease: a prospective randomized study in cal discectomy without fusion. J Clin Neurosci. December
125 patients. Neurosurg Focus. Jan 15 2002;12(1):E4. 2008;15(12):1354-1359.
4. Bartels RH, Donk R, van der Wilt GJ, Grotenhuis JA, Ven- 19. Savolainen S, Rinne J, Hernesniemi J. A prospective ran-
derink D. Design of the PROCON trial: a prospective, ran- domized study of anterior single-level cervical disc opera-
domized multi-center study comparing cervical anterior tions with long-term follow-up: surgical fusion is unnec-
discectomy without fusion, with fusion or with arthro- essary. Neurosurgery. Jul 1998;43(1):51-55.
plasty. BMC Musculoskelet Disord. 2006;7:85. 20. Tegos S, Rizos K, Papathanasiu A, Kyriakopulos K. Re-
5. Bertalanffy H, Eggert HR. Clinical long-term results of an- sults of anterior discectomy without fusion for treatment
terior discectomy without fusion for treatment of cervical of cervical radiculopathy and myelopathy. Eur Spine J.
radiculopathy and myelopathy. A follow-up of 164 cases. 1994;3(2):62-65.
Acta Neurochir (Wien). 1988;90(3-4):127-135. 21. Thorell W, Cooper J, Hellbusch L, Leibrock L. The long-
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 60
term clinical outcome of patients undergoing anterior tween groups for either of these outcome measures.
cervical discectomy with and without intervertebral bone Radiographically, there was no difference in the fre-
graft placement. Neurosurgery. Aug 1998;43(2):268-273;
discussion 273-264.
quency of pseudoarthrosis/nonunion. The authors
22. Watters WC, 3rd, Levinthal R. Anterior cervical discectomy defined inferior “graft quality” as ventral graft dislo-
with and without fusion. Results, complications, and long- cation greater than 2mm and/or loss of disc height
term follow-up. Spine. Oct 15 1994;19(20):2343-2347. by more than 2mm. Based upon these criteria, the
23. White BD, Fitzgerald JJ. To graft or not to graft: rationaliz- plate group had significantly better results (p=.04).
ing choice in anterior cervical discectomy. Br J Neurosurg.
Apr 2005;19(2):148-154.
The authors concluded that addition of an anterior
24. Wirth FP, Dowd GC, Sanders HF, Wirth C. Cervical dis- cervical plate did not lead to an improved clinical
cectomy. A prospective analysis of three operative tech- outcome for patients treated for cervical radiculopa-
niques. Surg neurol. 2000:340-346; discussion 346-348. thy with a one or two level anterior procedure.
25. Xie JC, Hurlbert RJ. Discectomy versus discectomy with
fusion versus discectomy with fusion and instrumenta-
tion: a prospective randomized study. Neurosurgery. Jul
In critique, patients were not masked to treatment
2007;61(1):107-116; discussion 116-107. group and no validated outcome measures were
26. Yamamoto I, Ikeda A, Shibuya N, Tsugane R, Sato O. utilized to assess this small sample of patients. The
Clinical long-term results of anterior discectomy with- authors did not indicate that the patients were con-
out interbody fusion for cervical disc disease. Spine. Mar secutively assigned and utilized a questionable ran-
1991;16(3):272-279.
domization method. Due to these limitations, this
potential Level I study provides Level II evidence that
Does ACDF with instrumentation the addition of a plate does not improve outcomes
following ACDF for cervical radiculopathy from de-
result in better outcomes (clinical generative disorders at an average of 34 months fol-
or radiographic) than ACDF with- low up, although it does appear to improve sagittal
alignment.
out instrumentation?
Mobbs et al8 described a retrospective compara-
RECOMMENDATION: Both ACDF with and tive study comparing clinical and radiographic out-
without a plate are suggested as comparable comes of ACDF with ACDFP in patients with cervi-
treatment strategies, producing similar clinical cal radiculopathy. Of the 212 radiculopathy patients
outcomes and fusion rates, in the treatment of included in the study, 116 received ACDF and 96
single level cervical radiculopathy from degen- were treated with ACDFP. Using Odom’s criteria,
erative disorders. there was no significant difference in good to excel-
lent outcomes between the two groups (87% of the
GRADE OF RECOMMENDATION: B ACDF patient group and 92% of the ACDFP). On
the other hand, the noninstrumented group had a
Grob et al5 conducted a prospective randomized statistically significantly higher frequency of poor
controlled trial comparing clinical and radiographic outcomes at 7% (8/116) compared to the ACDFP
outcomes of ACDF and ACDFP. Of the 50 patients group at 1% (1/96). Poor outcomes were considered
available at follow-up, 24 were randomized to ACD- to be postoperative kyphosis and nonunion. The au-
FP and 26 to ACDF. Both groups had a statistically thors concluded that excellent results were similar
significant decrease in VAS pain scores and improve- for both groups. There was a significantly higher rate
ment in cervical spine range of motion postopera- of poor outcomes in the uninstrumented group and
tively, but there was no significant difference be- this lead to higher rate of second surgery.
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 61
In critique, no validated outcome measures were ment in cervical spine range of motion postopera-
used and the length of follow-up was short. This tively, but there was no significant difference be-
study provides Level III evidence that addition of an tween groups for either of these outcome measures.
anterior locking plate may not lead to an increased Radiographically, there was no difference in the fre-
likelihood of a satisfactory clinical outcome, but it quency of pseudoarthrosis/nonunion. The authors
may lower the likelihood of a poor outcome and defined inferior “graft quality” as ventral graft dislo-
need for reoperation. cation greater than 2mm and/or loss of disc height
by more than 2mm. Based upon these criteria, the
Zoega et al16 reported results of a prospective ran- plate group had significantly better results (p=.04).
domized controlled trial evaluating whether the ad- The authors concluded that addition of an anterior
dition of a plate to a single level cervical fusion for cervical plate did not lead to an improved clinical
degenerative disc disease enhances fusion rate and outcome for patients treated for cervical radiculopa-
contributes to maintaining alignment. Of the 27pa- thy with a one or two level anterior procedure.
tients included in the study, 15 were assigned to the
ACDFP group and 12 to the ACDF group. There was In critique, patients were not masked to treatment
a statistically significant increase in the frequency group and no validated outcome measures were
of postoperative kyphosis in the nonplated group at utilized to assess this small sample of patients. The
one year follow-up (p=.04). At two years statistical authors did not indicate that the patients were con-
significance was lost (p=>06). There was one non- secutively assigned and utilized a questionable ran-
union in the plate group; none in the ACDF group. domization method. Due to these limitations, this
Clinical scores were the same for both groups. The potential Level I study provides Level II evidence that
authors concluded that the plate maintains align- the addition of a plate does not improve outcomes
ment, but provides no advantage for healing or for following ACDF for cervical radiculopathy from de-
clinical outcomes generative disorders at an average of 34 months fol-
low up, although it does appear to improve sagittal
In critique, neither patients nor reviewers were alignment.
masked to treatment group. No validated outcome
measures were utilized in this small sample of pa- Mobbs et al8 described a retrospective compara-
tients. Due to these limitations, this potential Level I tive study comparing clinical and radiographic
study provides Level II evidence that the addition of outcomes of ACDF with ACDFP in patients with
a plate to ACDF maintains alignment. cervical radiculopathy. Of the 212 radiculopathy
patients included in the study, 116 received ACDF
RECOMMENDATION: The addition of a cervi- and 96 were treated with ACDFP. Using Odom’s cri-
cal plate is suggested to improve sagittal align- teria, there was no significant difference in good to
ment following ACDF. excellent outcomes between the two groups (87%
of the ACDF patient group and 92% of the ACDFP).
GRADE OF RECOMMENDATION: B On the other hand, the uninstrumented group had
a statistically significantly higher frequency of poor
Grob et al5 conducted a prospective randomized outcomes at 7% (8/116) compared to the ACDFP
controlled trial comparing clinical and radiographic group at 1% (1/96). Poor outcomes were considered
outcomes of ACDF and ACDFP. Of the 50 patients to be postoperative kyphosis and nonunion. The au-
available at follow-up, 24 were randomized to ACD- thors concluded that excellent results were similar
FP and 26 to ACDF. Both groups had a statistically for both groups. There was a significantly higher rate
significant decrease in VAS pain scores and improve- of poor outcomes in the uninstrumented group and
this lead to higher rate of second surgery.
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 62
In critique, no validated outcome measures were for a future study which would generate meaning-
used and the length of follow-up was short. This ful evidence to assist in further defining the role of
study provides Level III evidence that addition of an instrumentation in addition to ACDF in the surgical
anterior locking plate may not lead to an increased treatment of cervical radiculopathy from degenera-
likelihood of a satisfactory clinical outcome, but it tive disorders.
may lower the likelihood of a poor outcome and
need for reoperation. A well designed, prospective RCT to compare radio-
graphic and clinical outcomes following ACDF with
Zoega et al16 reported results of a prospective ran- or without a plate for degenerative cervical radicu-
domized controlled trial evaluating whether the ad- lopathy would generate meaningful data regarding
dition of a plate to a single level cervical fusion for the potential long term benefits of preserving or
degenerative disc disease enhances fusion rate and restoring sagittal alignment. There should be two
contributes to maintaining alignment. Of the 27pa- cohorts, one with single level disease, and one with
tients included in the study, 15 were assigned to the multilevel disease.
ACDFP group and 12 to the ACDF group. There was
a statistically significant increase in the frequency References
of postoperative kyphosis in the nonplated group at 1. Alvarez JA, Hardy RW. Anterior cervical discectomy for
one year follow-up (p=.04). At two years statistical one- and two-level cervical disc disease: the controversy
surrounding the question of whether to fuse, plate, or
significance was lost (p=>06). There was one non- both. Crit Rev Neurosurg. Jul 1999;9(4):234-251.
union in the plate group; none in the ACDF group. 2. Bolesta MJ, Rechtine GR, 2nd, Chrin AM. One- and two-
Clinical scores were the same for both groups. The level anterior cervical discectomy and fusion: the effect of
authors concluded that the plate maintains align- plate fixation. Spine J. May-Jun 2002;2(3):197-203.
ment, but provides no advantage for healing or for 3. Caspar W, Geisler FH, Pitzen T, Johnson TA. Anterior cer-
vical plate stabilization in one- and two-level degenera-
clinical outcomes. tive disease: overtreatment or benefit? J Spinal Disord. Feb
In critique, neither patients nor reviewers were 1998;11(1):1-11.
masked to treatment group. No validated outcome 4. Connolly PJ, Esses SI, Kostuik JP. Anterior cervical fusion:
measures were utilized in this small sample of pa- outcome analysis of patients fused with and without an-
tients. Due to these limitations, this potential Level I terior cervical plates. J Spinal Disord. Jun 1996;9(3):202-
206.
study provides Level II evidence that the addition of 5. Grob D, Peyer JV, Dvorak J. The use of plate fixation in
a plate to ACDF maintains alignment. anterior surgery of the degenerative cervical spine: a
comparative prospective clinical study. Eur Spine J. Oct
RECOMMENDATION: While plate stabilization 2001;10(5):408-413.
may be indicated in some patients undergoing 6. Kaiser MG, Haid RW, Jr., Subach BR, Barnes B, Rodts GE,
Jr. Anterior cervical plating enhances arthrodesis after dis-
multilevel ACDF, there is insufficient evidence cectomy and fusion with cortical allograft. Neurosurgery.
that this practice results in significant improve- Feb 2002;50(2):229-236; discussion 236-228.
ment in clinical outcomes for degenerative cer- 7. McLaughlin MR, Purighalla V, Pizzi FJ. Cost advantages
vical radiculopathy. of two-level anterior cervical fusion with rigid internal
Work Group Consensus Statement fixation for radiculopathy and degenerative disease. Surg
Neurol. Dec 1997;48(6):560-565.
8. Mobbs RJ, Rao P, Chandran NK. Anterior cervical discec-
A systematic review of the literature yielded no stud- tomy and fusion: analysis of surgical outcome with and
ies to adequately compare outcomes for ACDF with without plating. J Clin Neurosci. Jul 2007;14(7):639-642.
and without a plate for multilevel surgeries. 9. Nabhan A, Pape D, Pitzen T, et al. Radiographic analysis
of fusion progression following one-level cervical fusion
with or without plate fixation. Zentralbl Neurochir. Aug
Future Directions for Research 2007;68(3):133-138.
The work group identified the following suggestion
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 63
10. Resnick DK, Trost GR. Use of ventral plates for cervical
arthrodesis. Neurosurgery. Jan 2007;60(1 Supp1 1):S112- Herkowitz et al7 reported results of a prospective
117.
11. Samartzis D, Shen FH, Lyon C, Phillips M, Goldberg EJ, An
study comparing ACDF to posterior laminoforami-
HS. Does rigid instrumentation increase the fusion rate in notomy (PLF). Of the 33 radiculopathy patients in-
one-level anterior cervical discectomy and fusion? Spine J. cluded in the study, 17 were treated with ACDF and
Nov-Dec 2004;4(6):636-643. 16 with PLF. The average age of the patients assigned
12. Troyanovich SJ, Stroink AR, Kattner KA, Dornan WA, Gu- to the ACDF group was 43, while the average age of
bina I. Does anterior plating maintain cervical lordosis
versus conventional fusion techniques? A retrospective
the patients assigned to the PLF group was 39. Of
analysis of patients receiving single-level fusions. J Spinal the ACDF patients, 94% reported good (5/17) or ex-
Disord Tech. Feb 2002;15(1):69-74. cellent (11/17) results. Of the PLF patients, 75% re-
13. Wang JC, McDonough PW, Endow K, Kanim LE, Delama- ported good (6/16) or excellent (6/16) results. ACDF
rter RB. The effect of cervical plating on single-level ante- was not significantly better (p<0.175). Osteophytic
rior cervical discectomy and fusion. J Spinal Disord. Dec
1999;12(6):467-471.
changes were seen in 9/17 ACDF patients and 8/16
14. Wang JC, McDonough PW, Endow KK, Delamarter RB. PLF patients. The authors concluded that both sur-
Increased fusion rates with cervical plating for two-lev- gical procedures are effective, but ACDF tends to be
el anterior cervical discectomy and fusion. Spine. Jan better over the long term.
2000;25(1):41-45.
15. Wang JC, McDonough PW, Kanim LE, Endow KK, Dela-
marter RB. Increased fusion rates with cervical plating for
In critique, neither patients nor reviewers were
three-level anterior cervical discectomy and fusion. Spine. masked to treatment group and the randomization
Mar 15 2001;26(6):643-646; discussion 646-647. technique employed was questionable. No validat-
16. Zoega B, Karrholm J, Lind B. One-level cervical spine fu- ed outcome measures were utilized to assess this
sion. A randomized study, with or without plate fixation, small patient sample. Due to these limitations, this
using radiostereometry in 27 patients. Acta Orthop Scand.
Aug 1998;69(4):363-368.
potential Level II study provides Level III evidence
17. Zoega B, Karrholm J, Lind B. Plate fixation adds stabil- that ACD with fusion and posterior laminoforami-
ity to two-level anterior fusion in the cervical spine: a notomy appear equally effective in improving pain
randomized study using radiostereometry. Eur Spine J. and weakness.
1998;7(4):302-307.
Korinth et al8 described a retrospective compara-
Does anterior surgery result in tive study comparing clinical results of anterior and
posterior surgery for cervical radiculopathy due to
better outcomes (clinical or ra- soft disc herniation. Of the 363 patients included in
diographic) than posterior sur- the study, 154 were treated with ACDF using PMMA
for median or paramedian discs and 209 received
gery in the treatment of cervical PLF for posterolateral or foraminal discs, and 80%
radiculopathy from degenerative (292/363: 124/154 ACDF, 168/209 PLF) were avail-
able for long term follow-up via clinical outpatient
disorders? examination (14.7%), questionnaire (64.4%), and/or
a telephone interview (20.9%).
RECOMMENDATION: Either ACDF or PLF are
suggested for the treatment of single level de- Complication rates, primarily related to hoarseness
generative cervical radiculopathy secondary to and dysphagia, were reported in 6.5 % of ACDF pa-
foraminal soft disc herniation to achieve com- tients and 1.8% of PLF patients. Reoperation rates
parably successful clinical outcomes. were reported as 2.4% for the ACDF group and 7.1%
for the PLF group. Mean operating time in the ACDF
GRADE OF RECOMMENDATION: B
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 64
group was 112 minutes and 94.1 minutes for the in the study, 22 were assigned to the PLF group, 25
PLF group ( p<0.000). Of the patients in the ACDF to ACD and 25 to ACDF. Age, gender and duration
group, 93.6% (116/124) reported good (36.3%) or of symptoms were similar for all groups. Although
excellent (59.5%) results according to Odom’s crite- not specifically stated, follow-up was inclusive. An-
ria and 0.8% reported poor results (p<0.05). Of the esthesia time, hospital stay, charges and analgesics
patients in the PLF group, 85.1% (142/168) reported were similar. Pain improvement was reported by
good (25.6%) or excellent (59.5%) results accord- more than 96% of patients in all groups. It appears
ing to Odom’s criteria and 7.2% reported poor re- that all groups had similar outcomes. Return-to-
sults (p<0.05). In the ACDF group, a pure soft disc work was reported as greater than 88% in all groups
was removed in 60 cases (48.4%) and a mixture of and there was similar incidence of new weakness
both hard and soft disc elements was removed in 64 and new numbness across all groups. Reoperation
(51.6%). In the PLF group, a pure soft disc was re- rate were reported as 27% for the PLF group, 12%
moved in 148 cases (88.1%) and a mixture of both for ACD and 28% for ACDF. The authors concluded
hard and soft disc elements was removed in 20 cases that although the numbers in this study were small,
(11.9%) (p<0.000). Soft disc herniations did not have none of the procedures could be considered supe-
significantly better outcomes than the mixture of rior to the others. This study suggests that the selec-
soft and hard disc, although there appeared to be a tion of surgical procedure may reasonably be based
trend. In general, shorter duration of preoperative on the preference of the surgeon and tailored to the
symptoms correlated with improved outcomes. The individual patient.
authors concluded that anterior surgery yielded sta- In critique, neither patients nor reviewers were
tistically superior outcomes, but both were effective. masked to the treatment group and no validated
The findings show a higher success rate with ante- outcome measures were utilized. The functional
rior microdiscectomy with PMMA interbody stabili- outcome tools were broad and subjective. The initial
zation for treatment of degenerative cervical mono- clinical visit occurred at two months; the 60 month
radiculopathy compared with PLF. follow-up was poorly coordinated and varied. Num-
bers were small with poor statistical analysis. Due to
In critique, no validated outcome measures were these limitations, this potential Level II study pro-
utilized and there was a tendency for patient se- vides Level III evidence that ACD, ACDF and PLF
lection to posterior procedure for more lateral disc result in comparable clinical outcomes in the treat-
herniations, whereas for paramedian and central ment of cervical radiculopathy from unilateral disc
herniations, there was an anterior bias. This study herniation.
excluded patients with pure hard discs and pure
foraminal stenosis. This study provides Level III RECOMMENDATION: Compared to PLF,ACDF
evidence that patients improve with both PLF and is suggested for the treatment of single level de-
ACDF, but ACDF results in statistically significantly generative cervical radiculopathy from central
better outcomes. However, ACDF is associated with and paracentral nerve root compression and
a higher risk of complications, primarily related to spondylotic disease.
dysphagia/hoarseness. PLF is associated with a Work Group Consensus Statement
higher reoperation rate.
Future Directions for Research
Wirth et al12 reported results of a prospective ran- The work group identified the following suggestion
domized controlled trial comparing clinical out- for a future study which would generate meaning-
comes for surgery for unilateral disc herniation ful evidence to assist in further defining the roles of
causing radiculopathy. Of the 72 patients included PLF and ACDF in the surgical treatment of cervical
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 65
radiculopathy from degenerative disorders. in the treatment of lateral disc herniations using 6.9-mm
endoscopes: prospective 2-year results of 87 patients.
Minim Invasive Neurosurg. Aug 2007;50(4):219-226.
Prospective, RCT with long term follow up to evalu- 12. Wirth FP, Dowd GC, Sanders HF, Wirth C. Cervical discec-
ate clinical outcomes, perioperative complications, tomy. A prospective analysis of three operative techniques.
and long term success including need for revision Surg Neurol. Apr 2000;53(4):340-346; discussion 346-348.
surgery following treatment of degenerative cervi- 13. Witzmann A, Hejazi N, Krasznai L. Posterior cervical
cal radiculopathy with PLF versus ACDF. The study foraminotomy. A follow-up study of 67 surgically treated
patients with compressive radiculopathy. Neurosurg Rev.
group would consist of foraminal stenosis only and Dec 2000;23(4):213-217.
should include two separate cohorts, including “soft 14. Zeidman SM, Ducker TB. Posterior cervical laminoforami-
disc” herniation and hard disc or spondylotic dis- notomy for radiculopathy: review of 172 cases. Neurosur-
ease. gery. Sep 1993;33(3):356-362.
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 66
study. Thus the workgroup would not recommend but no significant difference was seen at 24 months
further pursuit of this question. (p=0.638). NDI improved from baseline for each
group (p<0.0001); however, between groups there
References was a significant difference at three months for TDA
1. Epstein NE. Technical note: unilateral posterior resection (p<0.05) but not at 24 months (p=1.0000). This was
of cervical disc and spondylostenosis with contralateral also true for aggregate patients who had greater
fusion for instability. Surg Neurol. Oct 2001;56(4):256-
258. than a 15 point improvement. Secondary surgical
2. Rhee JM, Yoon T, Riew KD. Cervical radiculopathy. J Am procedures were performed in 1.9% of TDA patients
Acad Orthop Surg. Aug 2007;15(8):486-494. and 8.5% of ACDF patients. Implant revision was
3. Scheufler KM, Kirsch E. Percutaneous multilevel decom- required in 4.7% of the ACDF patients, with 2.8% of
pressive laminectomy, foraminotomy, and instrumented the ACDF patients requiring supplemental fixation,
fusion for cervical spondylotic radiculopathy and myel-
opathy: assessment of feasibility and surgical technique. while no TDA patients required revision. VAS neck
J Neurosurg Spine. Nov 2007;7(5):514-520. pain, arm pain frequency and intensity were similar
for TDA and ACDF patients at 24 months.
Does ACD and reconstruction Success, as defined by greater than 20% improve-
with total disc replacement result ment in VAS scores, was reported for 87.9% of TDA
patients and 86.9% of ACDF patients at 24 months.
in better outcomes (clinical or At 24 months, 80.8% of TDA patients and 74.4% of
radiographic) than ACDF in the ACDF patients had successful outcomes as assessed
by the SF-36 physical component summary. The SF-
treatment of cervical radiculopa- 36 mental component summary showed 71.8% of
thy from degenerative disorders? TDA and 68.9% of ACDF patients were successful.
Patient satisfaction, narcotic use and adverse events
RECOMMENDATION: ACDF and total disc ar- were similar for both groups. The authors concluded
throplasty (TDA) are suggested as comparable that TDA for single level disease is safe and effective
treatments, resulting in similarly successful and at least as good as ACDF.
short term outcomes, for single level degenera-
tive cervical radiculopathy. In critique, neither patients nor reviewers were
masked to treatment group. This study provides Lev-
GRADE OF RECOMMENDATION: B el I evidence that TDA shows equivalent outcomes
to ACDF at two years for treatment of cervical radic-
Murrey et al6 conducted a prospective randomized ulopathy due to single level disease.
controlled trial comparing safety and efficacy of
TDA to ACDF for single level symptomatic cervical Nabhan et al7 reported results of a prospective ran-
disc disease with radiculopathy. Of the 209 patients domized controlled trial comparing radiographic
included in the study, 106 were assigned to the and clinical results of TDA to ACDF. Of the 49 pa-
ACDF group and 103 to TDA. There was no differ- tients included in the study, 25 were assigned to TDA
ence in demographics between the TDA and ACDF and 24 to ACDF; however, only 20 TDA and 21 ACDF
groups. Follow-up rates were 98% for TDA and 94% patients could be measured due to artifact. Range of
for ACDF. ACDF had statistically significantly lower motion decreased in both groups. In the TDA group,
smaller blood loss and operative time (although average motion decreased from 2.3 at one week to
differences small). Neurological improvement was 0.8 at 52 weeks; in ACDF, it decreased from 0.6 at
better for TDA than ACDF at six months (p<0.05), one week to 0.1 at 52 weeks. Comparison between
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 67
groups showed that the motion was significantly less and TDA in the treatment of cervical radiculopathy
in the ACDF group for all time points except three from degenerative disorders.
weeks. Preoperatively, there was no statistical differ-
ence in symptoms between both groups (P=0.1), as Recommendation #1:
measured by the VAS. Both groups showed the same Continued long term follow-up of patients currently
pattern of pain relief in arm pain at all examination enrolled in previously reported RCTs is necessary
times without a statistically significant difference to determine if purported advantages of TDA com-
(P=0.13). The ACDF group showed a higher post- pared with ACDF can be validated, with particular
surgical resolving ratio in neck pain relief at three focus on validated clinical outcomes, revision sur-
weeks, although without any statistically significant gery and adjacent segment disease. Subgroup anal-
differences (P=0.09). The authors concluded that ysis should include soft disc compared with hard
disc motion was maintained by TDA at one year and disc and foraminal compared with paracentral pa-
was greater than ACDF, with similar clinical results thology for cervical radiculopathy patients.
to ACDF.
Recommendation #2:
In critique, neither patients nor reviewers were Additional independent, masked, prospective RCTs
masked to treatment group. No validated outcome comparing ACDF to TDA for the treatment of cer-
measures were used and the sample size was small. vical radiculopathy from degenerative disorders
The study utilized a good radiographic analysis tool, would add substantial unbiased validation to the re-
but investigators chose neutral and extreme exten- sults of the investigational device exemption (IDE)
sion and lateral rotation for their motion analysis. studies.
Clinical evaluation was limited and was not the em-
phasis. Follow-up was only one year. Also the au- References
thors concluded that motion was maintained with 1. Anderson PA, Sasso RC, Riew KD. Comparison of adverse
TDA; however, the data demonstrate that it was not. events between the Bryan artificial cervical disc and ante-
rior cervical arthrodesis. Spine. 2008:1305-1312.
Range of motion was decreased, but significantly 2. Bartels RH, Donk R, van der Wilt GJ, Grotenhuis JA, Ven-
greater than with ACDF. Due to these limitations, derink D. Design of the PROCON trial: a prospective, ran-
this potential Level I study provides Level II evidence domized multi-center study comparing cervical anterior
that compared with ACDF, patients treated with TDA discectomy without fusion, with fusion or with arthro-
have statistically significantly greater range of mo- plasty. BMC Musculoskelet Disord. 2006;7:85.
3. Heidecke V, Burkert W, Brucke M, Rainov NG. Interverte-
tion. Clinical outcomes are similar for both groups. bral disc replacement for cervical degenerative disease--
clinical results and functional outcome at two years in pa-
There were several additional studies reviewed, tients implanted with the Bryan cervical disc prosthesis.
some of them of high quality, that could not be in- Acta Neurochir (Wien). May 2008;150(5):453-459; discus-
cluded in this guideline due to confounding of my- sion 459.
4. Kim SW, Limson MA, Kim SB, et al. Comparison of ra-
elopathy grouped with radiculopathy. Due to lack of diographic changes after ACDF versus Bryan disc ar-
subgroup analyses in these studies, no conclusions throplasty in single and bi-level cases. Euro Spine J. Feb
could be reached in regards to outcomes in patients 2009;18(2):218-231.
with cervical radiculopathy from degenerative dis- 5. Mummaneni PV, Burkus JK, Haid RW, Traynelis VC, Zde-
orders. blick TA. Clinical and radiographic analysis of cervical
disc arthroplasty compared with allograft fusion: a ran-
domized controlled clinical trial. J Neurosurg Spine. Mar
Future Directions for Research 2007;6(3):198-209.
The work group identified the following suggestions 6. Murrey D, Janssen M, Delamarter R, et al. Results of the
for future studies which would generate meaningful prospective, randomized, controlled multicenter Food
evidence to assist in comparing outcomes of ACDF and Drug Administration investigational device exemp-
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 68
tion study of the ProDisc-C total disc replacement ver- level disease, ACD with PMMA interbody spacer re-
sus anterior discectomy and fusion for the treatment of sults in 77% of patients reporting satisfactory clini-
1-level symptomatic cervical disc disease. Spine J. Apr
2009;9(4):275-286.
cal outcomes at 10 to 15 years following surgery.
7. Nabhan A, Ahlhelm F, Shariat K, et al. The ProDisc-C pro-
thesis - Clinical and radiological experience 1 year after Heidecke et al8 reported a case series reviewing out-
surgery. Spine. Aug 2007;32(18):1935-1941. comes of Cloward-type fusion at mean follow-up of
8. Sasso RC, Smucker JD, Hacker RJ, Heller JG. Artificial disc 6.5 years. Of the 28 radiculopathy patients included,
versus fusion: a prospective, randomized study with 2-year
follow-up on 99 patients. Spine. Dec 15 2007;32(26):2933-
long term outcome was reported as good for 93% and
2940; discussion 2941-2932. fair for 7%. No poor results were reported. Adverse
events were dominated by graft site complications.
The authors concluded that Cloward ACDF is a reli-
What is the long-term result (four+ able and safe procedure for single level disease.
years) of surgical management of
In critique, no validated outcome measures were
cervical radiculopathy from de- used in the study including a small sample of radic-
generative disorders? ulopathy patients. This study provides Level IV evi-
dence that for treatment of cervical radiculopathy
RECOMMENDATION: Surgery is an option for due to degenerative disease, ACDF with Cloward
the treatment of single level degenerative ra- technique results in 93% satisfactory results with
diculopathy to produce and maintain favorable long term (4-10 year) follow-up.
long term (greater than four year) outcomes.
Jagannathan et al11 presented findings from a ret-
GRADE OF RECOMMENDATION: C rospective case series reviewing results of PLF for
treatment of single level cervical radiculopathy. Of
Hamburger et al7 described a retrospective case se- the 212 cervical radiculopathy patients included in
ries reviewing results of ACD with PMMA. Of the the study, long term outcomes were reported at a
319 cervical radiculopathy patients included in the mean of 78 months for the 162 patients. While NDI
study, 249 were available for final follow-up at a mean improved in 93% of patients, 20% developed kypho-
of 12.2 years. Of the 249 patients available for final sis. Patients who developed kyphosis reported worse
follow-up, 246 had single level and 3 had two level results overall. During the follow-up period, 3.1%
surgery. Good or excellent results were reported by (5/162) required additional procedures; two had
87% of patients. Lumbar symptoms and high occu- progression of disease at the index level, two devel-
pational stress were correlated with clinical failure. oped stenosis and one developed “instability.” The
Patients with soft disc herniations reported the best authors concluded that PLF is highly successful for
results. Relatively worse outcomes were reported treating cervical radiculopathy. This study provides
when “patients had unclear preoperative findings.” Level IV evidence that posterior laminoforaminoto-
The authors concluded that ACD with PMMA is a my for the treatment of cervical radiculopathy due to
safe and reliable method for treating monosegmen- degenerative disease results in significant improve-
tal radiculopathy with outcomes and complication ment in 93% of cases at 5-15 year follow-up. There
rates similar to other published studies. may be a trend for patients older than 60 years with
initial lordosis of less than 10 degrees to be more
In critique, no validated outcome measures were vulnerable to development of postoperative cervi-
used. This study provides Level IV evidence that for cal kyphosis or translational deformity, though the
the treatment of cervical radiculopathy due to single clinical significance of this is uncertain.
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 69
Wirth et al21 reported results of a prospective ran- An adequately powered, prospective, comparative
domized controlled trial comparing clinical out- study of patients treated with ACDF, ACD, TDA and
comes for surgery for unilateral disc herniation PLF followed for greater than four years and assessed
causing radiculopathy. Of the 72 patients included with validated outcome measures would yield use-
in the study, 22 were assigned to the PLF group, 25 ful information about the long term outcomes of
to ACD and 25 to ACDF. Age, gender and duration surgery for cervical radiculopathy from degenera-
of symptoms were similar for all groups. Although tive disorders.
not specifically stated, follow-up was inclusive. An-
esthesia time, hospital stay, charges and analgesics References
were similar. Pain improvement was reported by 1. Bertalanffy H, Eggert HR. Clinical long-term results of an-
more than 96% of patients in all groups. It appears terior discectomy without fusion for treatment of cervical
radiculopathy and myelopathy. A follow-up of 164 cases.
that all groups had similar outcomes. Return-to- Acta Neurochir (Wien). 1988;90(3-4):127-135.
work was reported as greater than 88% in all groups 2. Cornelius JF, Bruneau M, George B. Microsurgical cervical
and there was similar incidence of new weakness nerve root decompression via an anterolateral approach:
and new numbness across all groups. Reoperation Clinical outcome of patients treated for spondylotic radic-
rates were reported as 27% for the PLF group, 12% for ulopathy. Neurosurgery. Nov 2007;61(5):972-980.
3. Davis RA. A long-term outcome study of 170 surgically
ACD and 28% for ACDF. Of the 72 patients included treated patients with compressive cervical radiculopathy.
in the study, 60% [13/25 (52%) for ACD, 16/25 (64%) Surg Neurol. Dec 1996;46(6):523-530; discussion 530-523.
for ACDF, and 14/22 (64%) for PLF] were available 4. Gaetani P, Tancioni F, Spanu G, Rodriguez y Baena R. Ante-
for final follow-up at a mean of 60 months via tele- rior cervical discectomy: an analysis on clinical long-term
phone interview or clinic visit. The authors conclud- results in 153 cases. J Neurosurg Sci. Dec 1995;39(4):211-
218.
ed that ACD, ACDF or PLF are reasonable surgical 5. Goffin J, Geusens E, Vantomme N, et al. Long-term follow-
choices for cervical radiculopathy due to unilateral up after interbody fusion of the cervical spine. J Spinal
disc herniation. Disord Tech. Apr 2004;17(2):79-85.
6. Goldberg EJ, Singh K, Van U, Garretson R, An HS. Com-
In critique, neither patients nor reviewers were paring outcomes of anterior cervical discectomy and fu-
sion in workman’s versus non-workman’s compensation
masked to the treatment group and no validated population. Spine J. Nov-Dec 2002;2(6):408-414.
outcome measures were utilized. The functional 7. Hamburger C, Festenberg FV, Uhl E. Ventral discectomy
outcome tools were broad and subjective. The initial with pmma interbody fusion for cervical disc disease: long-
clinical visit occurred at two months; the 60 month term results in 249 patients. Spine. Feb 1 2001;26(3):249-
follow-up was poorly coordinated and varied. Num- 255.
8. Heidecke V, Rainov NG, Marx T, Burkert W. Outcome in
bers were small with poor statistical analysis and Cloward anterior fusion for degenerative cervical spinal
40% were lost to follow-up. Due to these limita- disease. Acta Neurochir (Wien). 2000;142(3):283-291.
tions, this potential Level II study provides Level III 9. Hida K, Iwasaki Y, Yano S, Akino M, Seki T. Long-term
evidence that for unilateral radiculopathy caused by follow-up results in patients with cervical disk disease
CDH, ACD, ACDF or PLF result in satisfactory out- treated by cervical anterior fusion using titanium cage im-
plants. Neurol Med Chir (Tokyo). Oct 2008;48(10):440-446;
comes at five year follow-up. discussion 446.
10. Hilibrand AS, Carlson GD, Palumbo MA, Jones PK, Bohl-
Future Directions for Research man HH. Radiculopathy and myelopathy at segments ad-
The work group identified the following suggestion jacent to the site of a previous anterior cervical arthrod-
for future studies which would generate meaningful esis. J Bone Joint Surg Am. Apr 1999;81(4):519-528.
11. Jagannathan J, Sherman JH, Szabo T, Shaffrey CI, Jane JA.
evidence to assist in comparing long term outcomes The posterior cervical foraminotomy in the treatment of
of various surgical procedures to assist in defining cervical disc/osteophyte disease: a single-surgeon experi-
their role in the treatment of cervical radiculopathy ence with a minimum of 5 years’ clinical and radiographic
from degenerative disorders.
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 70
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 71
6. Heidecke V, Rainov NG, Marx T, Burkert W. Outcome in 11. Rao PJ, Christie JG, Ghahreman A, Cartwright CA, Ferch
Cloward anterior fusion for degenerative cervical spinal RD. Clinical and functional outcomes of anterior cervi-
disease. Acta Neurochir (Wien). 2000;142(3):283-291. cal discectomy without fusion. J Clin Neurosci. December
7. Kadoya S, Iizuka H, Nakamura T. Long-term outcome for 2008;15(12):1354-1359.
surgically treated cervical spondylotic radiculopathy and 12. Shapiro S, Connolly P, Donnaldson J, Abel T. Cadaveric
myelopathy. Neurol Med Chir (Tokyo). May 2003;43(5):228- fibula, locking plate, and allogeneic bone matrix for ante-
240; discussion 241. rior cervical fusions after cervical discectomy for radicu-
8. Korinth MC, Kruger A, Oertel MF, Gilsbach JM. Posterior lopathy or myelopathy. J Neurosurg. Jul 2001;95(1 Sup-
foraminotomy or anterior discectomy with polymethyl pl):43-50.
methacrylate interbody stabilization for cervical soft disc 13. Sugawara T, Itoh Y, Hirano Y, Higashiyama N, Mizoi K. Long
disease: results in 292 patients with monoradiculopathy. term outcome and adjacent disc degeneration after ante-
Spine. May 15 2006;31(11):1207-1214; discussion 1215- rior cervical discectomy and fusion with titanium cylin-
1206. drical cages. Acta Neurochir (Wien). Apr 2009;151(4):303-
9. Peolsson A, Peolsson M. Predictive factors for long-term 309.
outcome of anterior cervical decompression and fusion: a 14. Yamamoto I, Ikeda A, Shibuya N, Tsugane R, Sato O.
multivariate data analysis. Eur Spine J. Mar 2008;17(3):406- Clinical long-term results of anterior discectomy with-
414. out interbody fusion for cervical disc disease. Spine. Mar
10. Ramzi N, Ribeiro-Vaz G, Fomekong E, Lecouvet FE, Rafto- 1991;16(3):272-279.
poulos C. Long term outcome of anterior cervical discec- 15. Zeidman SM, Ducker TB. Posterior cervical laminoforami-
tomy and fusion using coral grafts. Acta Neurochir (Wien). notomy for radiculopathy: review of 172 cases. Neurosur-
Dec 2008;150(12):1249-1256; discussion 1256. gery. Sep 1993;33(3):356-362.
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 72
V. Appendices
Appendix A:
Acronyms
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 73
Appendix B:
Levels of Evidence For Primary Research Question1
Types of Studies
Therapeutic Studies – Prognostic Studies – Diagnostic Studies – Economic and Decision
Investigating the results of Investigating the effect of a Investigating a diagnostic Analyses –
treatment patient characteristic on the test Developing an economic or
outcome of disease decision model
Level 1 • High quality randomized trial • High quality prospective • Testing of previously • Sensible costs and
with statistically significant study4 (all patients were developed diagnostic alternatives; values obtained
difference or no statistically enrolled at the same point criteria on consecutive from many studies; with
significant difference but in their disease with ≥ patients (with universally multiway sensitivity analyses
narrow confidence intervals 80% follow-up of enrolled applied reference “gold” • Systematic review2 of Level
• Systematic review2 of Level patients) standard) I studies
I RCTs (and study results • Systematic review2 of Level • Systematic review2 of
were homogenous3) I studies Level I studies
Level II • Lesser quality RCT (eg, < • Retrospective6 study • Development of diagnostic • Sensible costs and
80% follow-up, no blinding, • Untreated controls from an criteria on consecutive alternatives; values obtained
or improper randomization) RCT patients (with universally from limited studies; with
• Prospective4 comparative • Lesser quality prospective applied reference “gold” multiway sensitivity analyses
study5 study (eg, patients enrolled standard) • Systematic review2 of Level
Systematic review2 of Level at different points in their • Systematic review2 of II studies
II studies or Level 1 studies disease or <80% follow-up) Level II studies
with inconsistent results • Systematic review2 of Level
II studies
Level III • Case control study7 • Case control study7 • Study of nonconsecutive • Analyses based on limited
• Retrospective6 comparative patients; without alternatives and costs; and
study5 consistently applied poor estimates
• Systematic review2 of Level reference “gold” standard • Systematic review2 of Level
III studies • Systematic review2 of III studies
Level III studies
Level IV Case series8 Case series • Case-control study • Analyses with no sensitivity
• Poor reference standard analyses
1. A complete assessment of quality of individual studies re- 6. The study was started after the first patient enrolled.
quires critical appraisal of all aspects of the study design. 7. Patients identified for the study based on their outcome,
2. A combination of results from two or more prior studies. called “cases” (eg, failed total arthroplasty) are compared
3. Studies provided consistent results. to those who did not have outcome, called “controls” (eg,
4. Study was started before the first patient enrolled. successful total hip arthroplasty).
5. Patients treated one way (eg, cemented hip arthroplasty) 8. Patients treated one way with no comparison group of pa-
compared with a group of patients treated in another way tients treated in another way.
(eg, uncemented hip arthroplasty) at the same institu-
tion.
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 74
Appendix C:
Grades of Recommendation
for Summaries or Reviews of Studies
A: Good evidence (Level I Studies with consistent findings) for or against recommending intervention.
B: Fair evidence (Level II or III Studies with consistent findings) for or against recommending interven-
tion.
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 75
Appendix D:
Protocol for NASS Literature Searches
One of the most crucial elements of evidence analy- Protocol for NASS Literature Searches
sis to support development of recommendations for The NASS Research Department has a relationship
appropriate clinical care or use of new technologies with Northwestern University’s Galter Health Sci-
is the comprehensive literature search. Thorough as- ences Library. When it is determined that a litera-
sessment of the literature is the basis for the review ture search is needed, NASS research staff will work
of existing evidence, which will be instrumental to with the requesting parties and Galter to run a com-
these activities. prehensive search employing at a minimum the fol-
lowing search techniques:
Background
It has become apparent that the number of litera- 1. A preliminary search of the evidence will be con-
ture searches being conducted at NASS is increas- ducted using the following clearly defined search
ing and that they are not necessarily conducted in parameters (as determined by the content experts).
a consistent manner between committees/projects. The following parameters are to be provided to re-
Because the quality of a literature search directly af- search staff to facilitate this search.
fects the quality of recommendations made, a com- Time frames for search
parative literature search was undertaken to help Foreign and/or English language
NASS refine the process and make recommenda- Order of results (chronological, by journal, etc.)
tions about how to conduct future literature search- Key search terms and connectors, with or with-
es on a NASS-wide basis. out MeSH terms to be employed
Age range
In November-December 2004, NASS conducted a Answers to the following questions:
trial run at new technology assessment. As part of ◆ Should duplicates be eliminated between
the analysis of that pilot process, the same literature searches?
searches were conducted by both an experienced ◆ Should searches be separated by term or as
NASS member and a medical librarian for compari- one large package?
son purposes. After reviewing the results of that ex- ◆ Should human studies, animal studies or ca-
periment and the different strategies employed for daver studies be included?
both searches, it was the recommendation of NASS
Research Staff that a protocol be developed to en- This preliminary search should encompass a search
sure that all future NASS searches be conducted of the Cochrane database when access is available.
consistently to yield the most comprehensive re-
sults. While it is recognized that some searches oc- 2. Search results with abstracts will be compiled
cur outside the Research and Clinical Care Councils, by Galter in Endnote software. Galter typically re-
it is important that all searches conducted at NASS sponds to requests and completes the searches
employ a solid search strategy, regardless of the within two to five days. Results will be forwarded to
source of the request. To this end, this protocol has the research staff, who will share it with the appro-
been developed and NASS-wide implementation is priate NASS staff member or requesting party(ies).
recommended. (Research staff hasve access to EndNote software
and will maintain a database of search results for fu-
ture use/documentation.)
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 76
3. NASS staff shares the search results with an ap- 8. NASS members reviewing full-text articles
propriate content expert (NASS Committee member should also review the references at the end of each
or other) to assess relevance of articles and identify article to identify additional articles which should be
appropriate articles to review and on which to run a reviewed, but may have been missed in the search.
“related articles” search.
Protocol for Expedited Searches
4. Based on content expert’s review, NASS research At a minimum, numbers 1, 2 and 3 should be fol-
staff will then coordinate with the Galter medical lowed for any necessary expedited search. Follow-
librarian the second level searching to identify rel- ing #3, depending on the time frame allowed, deeper
evant “related articles.” searching may be conducted as described by the full
protocol or request of full-text articles may occur. If
5. Galter will forward results to Research Staff to full-text articles are requested, #8 should also be in-
share with appropriate NASS staff. cluded. Use of the expedited protocol or any devia-
tion from the full protocol should be documented
6. NASS staff share related articles search results with explanation.
with an appropriate content expert (NASS Commit-
tee member or other) to assess relevance of this sec- Following these protocols will help ensure that NASS
ond set of articles, and identify appropriate articles recommendations are (1) based on a thorough re-
to review and on which to run a second “related ar- view of relevant literature; (2) are truly based on a
ticles” search. uniform, comprehensive search strategy; and (3)
represent the current best research evidence avail-
7. NASS research staff will work with Galter library able. Research staff will maintain a search history in
to obtain the 2nd related articles search results and EndNote for future use or reference.
any necessary full-text articles for review.
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 77
Appendix E:
Literature Search Parameters
1. What is the best working definition of cervical radiculopathy from degenerative disorders?
Databases Searched:
MEDLINE (PubMed)
EMBASE
Web of Science
Cochrane Database of Systematic reviews
Cochrane Central Register of Controlled Trials
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 78
2. What are the most appropriate diagnostic tests for cervical radiculopathy from degenerative disorders?
Databases Searched:
MEDLINE (PubMed)
EMBASE
Web of Science
Cochrane Database of Systematic reviews
Cochrane Central Register of Controlled Trials
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 79
Databases Searched:
MEDLINE (PubMed)
EMBASE
Web of Science
Cochrane Database of Systematic reviews
Cochrane Central Register of Controlled Trials
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 80
2. What is the role of physical therapy/exercise in the treatment of cervical radiculopathy from degenera-
tive disorders?
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 81
3. What is the role of manipulation/chiropractics in the treatment of cervical radiculopathy from degen-
erative disorders?
4. What is the role of epidural steroid injections for the treatment of cervical radiculopathy from degenera-
tive disorders?
5. What is the role of ancillary treatments such as bracing, traction, electrical stimulation, acupuncture
and transcutaneous electrical stimulation (TENS) in the treatment of cervical radiculopathy from de-
generative disorders?
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 82
Databases Searched:
MEDLINE (PubMed)
EMBASE
Web of Science
Cochrane Database of Systematic reviews
Cochrane Central Register of Controlled Trials
2. Does anterior cervical decompression with fusion result in better outcomes (clinical or radiographic)
than anterior cervical decompression alone?
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 83
3. Does anterior cervical decompression and fusion with instrumentation result in better outcomes (clini-
cal or radiographic) than anterior cervical decompression and fusion without instrumentation?
4. Does anterior surgery result in better outcomes (clinical or radiographic) than posterior surgery in the
treatment of cervical radiculopathy from degenerative disorders?
5. Does posterior decompression with fusion result in better outcomes (clinical or radiographic) than pos-
terior decompression alone in the treatment of cervical radiculopathy from degenerative disorders?
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 84
6. Does anterior cervical decompression and reconstruction with total disc replacement result in better
outcomes (clinical or radiographic) than anterior cervical decompression and fusion in the treatment
of cervical radiculopathy from degenerative disorders?
7. What is the long-term result (four+ years) of surgical management of cervical radiculopathy from de-
generative disorders?
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 85
8. How do long-term results of single-level compare with multilevel surgical decompression for cervical
radiculopathy from degenerative disorders?
Databases Searched:
MEDLINE (PubMed)
EMBASE
Web of Science
Cochrane Database of Systematic reviews
Cochrane Central Register of Controlled Trials
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 86
What history and physical examination findings best support a diagnosis of cervical
radiculopathy from degenerative disorders?
Article Level
(Alpha by of evidence Description of study Conclusion
Author)
Bertilson BC, Level II Prospective Retrospective Critique of methodology:
Grunnesjo M, Patients not enrolled at same
Strender LE. Type of Study design: case series point in their disease
Reliability of evidence: <80% follow-up
clinical tests in diagnostic Stated objective of study: To analyze the reliability No Validated outcome
the assessment of clinical tests in the assessment of neck and arm measures used:
of patients with pain in primary care patients. Tests not uniformly applied
neck/shoulder across patients
problems-impact Number of patients: 100 patients Small sample size
of history. Spine Lacked subgroup analysis
(Phila Pa 1976). Physical examination/diagnostic test description: Other: only two reviewers
Oct 1 66 clinical tests divided into nine categories
2003;28(19):222 Work group conclusions:
2-2231. Results/subgroup analysis (relevant to question): Potential level: I
Reliability of clinical tests was poor to fair. Only a Downgraded level: II
bimanual sensitivity test reached good values.
With known clinical history, the prevalence of Conclusions relative to question:
positive findings increased in all test categories. This paper provides evidence
Sensitivity tests remained diagnostically useful. that:history and physical findings
Usually helpful tests were not as diagnostically are not definitive, and may be
predictable, but also had increased positive susceptable to bias with a
findings when history was prerecorded before an suggestive clinical history.
exam was performed, as opposed to exam first
before history was obtained. Shoulder abduction
test k w/o - with history .77 - .62, Spurling's .28-.46,
traction relieves.63-.8,
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 87
causing deltoid deltoid paralysis, and to report on the surgical Tests not uniformly applied
paralysis. Eur outcomes of anterior cervical decompression with across patients
Spine J. Oct fusion (ACDF) for the treatment of deltoid Small sample size
2003;12(5):517- paralysis. Lacked subgroup analysis
521. Other:
Number of patients: 14
Work group conclusions:
Physical examination/diagnostic test description: Potential level: IV
All patients had radiating pain to scapula, shoulder Downgraded level: IV
or arm, with weakness of shoulder abduction due
to paralysis of deltoid (graded 0-5). Severity of Conclusions relative to question:
radiculopathy graded on VAS 0-10. Plain This paper provides evidence
radiographs and MRI were correlated with clinical that:A painful cervical
findings. Surgery performed on patients with single radiculopathy with deltoid
level cervical disc herniation (CDH) or cervical paralysis arose from compressive
spondylotic radiculopathy (CSR). Patients with disease at the C4-5, C5-6 and
multilevel disease were excluded. C3-4 levels: 50%, 43% and 7% of
the time respectively.
Results/subgroup analysis (relevant to question):
Paralysis of the deltoid with ipsilateral scapular,
shoulder or arm pain may be the result of a single
level CDH or CSR. Following are the single levels
implicated and their respective frequencies: 1-C3-4
CDH (central), 4-C4-5 CDH, 1-C5-6 CDH, 3-C4-5
CSR, 5-C5-6 CSR. Both radiculopathy and deltoid
paralysis improved significantly with surgery.
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 88
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 89
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 90
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 91
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 92
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 93
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 94
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 95
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 96
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 97
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 98
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 99
What are the most appropriate diagnostic tests (including imaging and electrodiagnostics),
and when are these tests indicated in the evaluation and treatment of cervical radiculopathy
from degenerative disorders?
Article Level
(Alpha by of Description of study Conclusion
Author) evidence
Number of patients: 20
Consecutively assigned? No
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 100
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 101
Other:
Number of patients: 30
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 102
Number of patients: 9
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 103
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 104
Number of patients: 45
Consecutively assigned? No
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 105
Number of patients: 20
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 106
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 107
Consecutively assigned? No
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 108
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 109
Consecutively assigned? No
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 110
What are the most appropriate outcome measures to evaluate the treatment of cervical
radiculopathy from degenerative disorders?
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 111
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 112
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 113
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 114
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 115
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 116
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 117
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 118
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 119
Device Success
Adverse Event Occurrence
Return to Work
Other:
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 120
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 121
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 122
What is the role of physical therapy/exercise in the treatment of cervical radiculopathy from
degenerative disorders?
Article Level
(Alpha by of Description of study Conclusion
Author) evidence
Clinical exam/history
Electromyography
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 123
Myelogram
MRI
CT
CT/Myelogram
Other: behavioral and functional
outcomes
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 124
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 125
What is the role of epidural steroid injections for the treatment of cervical radiculopathy from
degenerative disorders?
Article Level
(Alpha by of evidence Description of study Conclusion
Author)
Anderberg L, Level II Prospective Retrospective Critique of methodology:
Annertz M, Nonconsecutive patients
Persson L, Type of Study design: RCT Nonrandomized
Brandt L, evidence: Nonmasked reviewers
Saveland H. therapeutic Stated objective of study: Evaluate role Nonmasked patients
Transforaminal of transforaminal epidural steroid No Validated outcome measures
steroid injections for pain relief following used:
injections for successful SNRB Small sample size
the treatment of Inadequate length of follow-up
cervical Type of treatment(s): transforaminal <80% follow-up
radiculopathy: a epidural injection with steroid/local Lacked subgroup analysis
prospective and anesthetic or saline/local anesthetic Diagnostic method not stated
randomised (control) Other:
study. Eur
Spine J. Mar Total number of patients: 40 Work group conclusions:
2007;16(3):321- Number of patients in relevant Potential level: I
328. subgroup(s): 20 Downgraded level: II
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 126
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 127
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 128
cervical for cervical disc surgery, reduce the Small sample size
radiculopathy. pain of cervical radiculopathy and Inadequate length of follow-up
A prospective hence reduce the need for surgical <80% follow-up
outcome study. intervention. Lacked subgroup analysis
Acta Neurochir Diagnostic method not stated
(Wien). Oct Type of treatment(s): 2 cervical Other:
2005;147(10):1 transforaminal steroid injections, 2
065-1070; weeks apart Work group conclusions:
discussion Potential level: IV
1070. Total number of patients: 21 Downgraded level: IV
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 129
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 130
What is the role of ancillary treatments such as bracing, traction, electrical stimulation,
acupuncture and transcutaneous electrical stimulation (TENS) in the treatment of cervical
radiculopathy from degenerative disorders?
Article Level
(Alpha by of evidence Description of study Conclusion
Author)
Alexandre A, Level V Prospective Retrospective Critique of methodology:
Coro L, Azuelos Nonconsecutive patients
A, et al. Type of Study design: case series Nonrandomized
Intradiscal evidence: Nonmasked reviewers
injection of therapeutic Stated objective of study: Report the Nonmasked patients
oxygen-ozone effects of intervertebral disc and No Validated outcome measures
gas mixture for paravertebral injections of ozone & used:
the treatment of oxygen in patients with cervical disc Small sample size
cervical disc herniations Inadequate length of follow-up
herniations. <80% follow-up
Acta Neurochir Type of treatment(s): Intervertebral Lacked subgroup analysis
Suppl. disc and five paravertebral injections of Diagnostic method not stated
2005;92:79-82. ozone & oxygen Other: No specified duration of
follow-up, no data tables or speed
Total number of patients: 252 of recovery noted.
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 131
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 132
Clinical exam/history
Electromyography
Myelogram
MRI
CT
CT/Myelogram
Other: behavioral and functional
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 133
outcomes
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 134
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 135
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 136
Article Level
(Alpha by of Description of study Conclusion
Author) evidence
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 137
MRI
CT
CT/Myelogram
Other: behavioral and functional
outcomes
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 138
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 139
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 140
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 141
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 142
Does anterior cervical decompression with fusion result in better outcomes (clinical or
radiographic) than anterior cervical decompression alone?
Article Level
(Alpha by of evidence Description of study Conclusion
Author)
Barlocher CB, Level III Prospective Retrospective Critique of methodology:
Barth A, Krauss Nonconsecutive patients
JK, Binggeli R, Type of Study design: RCT Nonrandomized
Seiler RW. evidence: Nonmasked reviewers
Comparative therapeutic Stated objective of study: Compare Nonmasked patients
evaluation of outcomes of anterior cervical No Validated outcome measures
microdiscectom decompression (ACD) to three different used:
y only, autograft types of anterior cervical decompression Small sample size
fusion, and fusion (ACDF): iliac crest bone graft Inadequate length of follow-up
polymethylmeth (ICBG), polymethylmethacrylate (PMMA) <80% follow-up
acrylate and titanium cages. Lacked subgroup analysis
interposition, Diagnostic method not stated
and threaded Type of treatment(s): ACD vs ACDF Other: Single level disease only,
titanium cage PMMA as spacer is not standard
fusion for Total number of patients: 125 practice, randomization process is
treatment of Number of patients in relevant not described
single-level subgroup(s): 33 ACD, 30 ICBG, 26
cervical disc PMMA, and 36 cages Work group conclusions:
disease: a Potential level: II
prospective Consecutively assigned? Yes Downgraded level: III
randomized
study in 125 Duration of follow-up: 12 months Conclusions relative to question:
patients. This paper provides evidence
Neurosurg Validated outcome measures used: that:suggests that there are variable
Focus. Jan 15 outcomes when comparing ACD to
2002;12(1):E4. Nonvalidated outcome measures used: ACDF for the treatment of cervical
Odom Criteria, VAS pain scale radiculopathy due to single level
degenerative disease. In one cohort
Diagnosis of cervical radiculopathy made comparing ACD to fusion with ICBG,
by: outcomes were equivalent, while
Clinical exam/history another cohort showed superiority of
Electromyography interbody fusion with a titanium cage
Myelogram and allograft versus ACD. Validity of
MRI conclusions are weakened by small
CT sample size and short follow-up.
CT/Myelogram
Other: Used imaging; not specified
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 143
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 144
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 145
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 146
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 147
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 148
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 149
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 150
Does anterior cervical decompression and fusion with instrumentation result in better
outcomes (clinical or radiographic) than anterior cervical decompression and fusion without
instrumentation?
Article Level
(Alpha by of Description of study Conclusion
Author) evidence
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 151
CT/Myelogram
Other:
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 152
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 153
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 154
Does anterior surgery result in better outcomes (clinical or radiographic) than posterior
surgery in the treatment of cervical radiculopathy from degenerative disorders?
Article Level
(Alpha by of Description of study Conclusion
Author) evidence
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 155
Other:
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 156
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 157
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 158
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 159
Does anterior cervical decompression and reconstruction with total disc replacement result
in better outcomes (clinical or radiographic) than anterior cervical decompression and fusion
in the treatment of cervical radiculopathy from degenerative disorders?
Article Level
(Alpha by of evidence Description of study Conclusion
Author)
Murrey D, Level I Prospective Retrospective Critique of methodology:
Janssen M, Nonconsecutive patients
Delamarter R, Type of Study design: RCT Nonrandomized
et al. Results of evidence: Nonmasked reviewers
the prospective, therapeutic Stated objective of study: compare safety Nonmasked patients
randomized, and efficacy of total disc arthroplasty No Validated outcome measures
controlled (TDA) to anterior cervical decompression used:
multicenter with fusion (ACDF) for single level Small sample size
Food and Drug symptomatic cervical disc disease with Inadequate length of follow-up
Administration radiculopathy <80% follow-up
investigational Lacked subgroup analysis
device Type of treatment(s): ProDisc TDA, Diagnostic method not stated
exemption ACDF with allograft and plate Other:
study of the
ProDisc-C total Total number of patients: 209 Work group conclusions:
disc Number of patients in relevant Potential level: I
replacement subgroup(s): 106 ACDF, 103 TDA Downgraded level: I
versus anterior
discectomy and Consecutively assigned? Yes Conclusions relative to question:
fusion for the This paper provides evidence
treatment of 1- Duration of follow-up: 2 years with follow- that:TDA shows equivalent outcomes
level up intervals at 6 weeks, 3 months, 6 to ACDF at two years for treatment of
symptomatic months, 12 months and 2 years cervical radiculopathy.
cervical disc
disease. Spine Validated outcome measures used:
J. Apr Neck Disability Index (NDI), SF-36, Visual
2009;9(4):275- Analog Scale (VAS) pain scores
286.
Nonvalidated outcome measures used:
Neurological exam, VAS satisfaction
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 160
Other:
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 161
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 162
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 163
What is the long-term result (four+ years) of surgical management of cervical radiculopathy
from degenerative disorders?
Article Level
(Alpha by of Description of study Conclusion
Author) evidence
Clinical exam/history
Electromyography
Myelogram
MRI
CT
CT/Myelogram
Other: radiograph
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 164
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 165
CT/Myelogram
Other:
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 166
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 167
CT
CT/Myelogram
Other: Imaging not stated
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 168
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 169
T<sub>2</sub> and gadolinium enhanced MRI with CT 42. Brodke DS, Zdeblick TA. Modified Smith-Robinson pro-
myelography in cervical radiculopathy. Br J Radiol. Jan cedure for anterior cervical discectomy and fusion. Spine.
1998;71(JAN.):11-19. Oct 1992;17(10 Suppl):S427-430.
28. Beatty RM, Fowler FD, Hanson EJ, Jr. The abducted arm 43. Brouillette DL, Gurske DT. Chiropractic treatment of cer-
as a sign of ruptured cervical disc. Neurosurgery. Nov vical radiculopathy caused by a herniated cervical disc. J
1987;21(5):731-732. Manipulative Physiol Ther. Feb 1994;17(2):119-123.
29. Bell GR. The anterior approach to the cervical spine. Neu- 44. Brown BM, Schwartz RH, Frank E, Blank NK. Preopera-
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care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
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care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
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care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
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This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 173
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
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care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
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care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
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care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 177
This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
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This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.
NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 179
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This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of
care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to
be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular
to the locality or institution.