CHAPTER
23
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Nonoperative Treatment
of Cervical Myelopathy
and Radiculopathy
INTRODUCTION
Spondylosis, a degenerative process increasingly preva­
lent with aging populations, is one of the leading causes
of neural pathologies in the cervical spine.1 Degenerative
changes associated with aging can result in disk hernia­
tion, osteophyte formation, hypertrophy of osteoarthritic
facet joints, and hypertrophy of ligaments. These condi­
tions are often asymptomatic; however, compression
of the cervical spinal cord and nerve roots may occur,
resulting in the symptomatic presentation of cervical
myelopathy or radiculopathy.2
It is essential for physicians to understand how the
severity of cervical myelopathy or radiculopathy affects
the clinical decision-making process and formulation of
an optimal and successful treatment plan. Surgical inter­
vention for myelopathy or radiculopathy is often neces­
sary for patients with progressive neurological symptoms
or severe pain and dysfunction. However, for patients
Copyright 2015. Jaypee Brothers Medical Publishers [P] Ltd.
with mild to moderate symptoms, invasive surgical tech­
niques should be avoided and nonoperative manage­
ment is preferred. This may be achieved through symp­tom
control and activity modification, in conjunc­ tion with
careful clinical and radiographic follow-up. This chapter
examines the efficacy of nonoperative treatment options
to aid in the clinical decision-making process in the
treatment of patients with cervical myelopathy and
radiculopathy.
TASK FORCE FOR NECK PAIN
The task force for neck pain was established as a part of
the bone and joint decade (2000–2010) initiative by the
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Kristina Bianco, Faruk Razzak, Gerard Varlotta
World Health Organization. The task force performed
exten­sive literature reviews and conducted original
research to analyze the prevalence of neck pain and treat­
ment options. This resulted in a four-grade classification
system for neck pain, listed below:3
• Grade I neck pain: No signs of major pathology; little
or no interference with activities of daily living (ADLs)
• Grade II neck pain: No signs of major pathology;
interference with ADLs
• Grade III neck pain: No signs of major structural
pathology, but presence of neurological signs and
symptoms
• Grade IV neck pain: Neck pain with major structural
pathology, instability or infection
This four-grade classification system considers symp­
toms as well as functional and neurological involvement.
Diagnosis and grading clinically, as suggested, would now
parallel decision-making in treat­ment.
Patients with Grade I and II neck pain do not present
with major pathologies or neurological symptoms, so
con­servative nonoperative treatment is optimal. For
patients with Grade III neck pain, clinical judgment and
risk stratification is necessary as there is no clear clinical
advantage between surgical and conservative treatment
in this group. However, surgical interventions are costly
and can involve serious risks, such as damage to the
spinal cord. Thus, nonoperative treatments are usually
the preferred treatment option for patients with Grade III
neck pain. Finally, patients with Grade IV neck pain pre­
sent with major structural pathology or severe myelopathy
and radiculopathy. Surgical interventions are needed for
these patients, especially for traumatic condi­tions that
 160 Section 2: Non-Invasive Therapeutic Intervention
have the potential for rapid progression or neuro­logic
deterioration. Surgery is also recommended for pati­ents
with severe nontraumatic pathologies, such as spinal infec­
tion or neo­plasm with airway or neurologic com­pres­sion.
While patients with Grades I–II and Grade IV neck
pain have a clear treatment plan, the treatment plan for
patients with Grade III neck pain must be determined
on an individual basis. Mild to moderate cervical myelo­
pathy and radiculopathy often present in patients with
Grade III neck pain. Thus, the decision to use nonope­
ra­tive versus operative treatment should be carefully
contemplated for patients with mild to moderate cervical
myelopathy and radiculopathy.
PATHOPHYSIOLOGY
Cervical myelopathy refers to the compression of the
cervical spinal cord that results in neck stiffness and
unilateral or bilateral neck, arm, and shoulder pain. The
most common type of cervical myelopathy occurs due
to spondylitis and degenerative changes of the spine
(Fig. 23.1). The development of cervical spondylotic
myelo­ pathy (CSM) includes three pathophysiological
contributors: (1) static mechanical factors, (2) dynamic
mechanical factors, and (3) spinal cord ischemia.1 Static
mechanical factors, such as congenital deformities, dege­
neration of the intervertebral disk and posterior facet
joints, and the development of osteophytes, result in a
reduction in the spinal canal diameter. Dynamic mecha­
nical factors and normal motion of the cervical spine can
exacerbate the development of CSM. During flexion, the
Fig. 23.1: Radiographic image of a patient with cervical spondylotic
myelopathy.
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spinal cord may lengthen and stretch over osteophytic
regions. During extension, the ligamentum flavum may
buckle into the spinal cord and result in the reduction in
available space for the spinal cord. Spinal cord ischemia
has also been found to play a role in the development of
CSM; however, the exact mechanism is not well known.
Cervical radiculopathy (CR) refers to the compression
of cervical nerve roots in the neural foramen (Fig. 23.2).
CR mostly includes impingement of the anter­ior ramus,
resulting in upper extremity symptoms, such as numb­
ness, weakness, or paresthesia of the arms.4 Though less
prevalent, posterior rami radiculopathy affects the der­
matomes and muscles of the upper back and shoul­ders,
resulting in periscapular dysfunction. This may precede
the onset of traditional radicular sym­ptoms. CR is the
result of nerve root impingement of­ten caused by struc­
tural lesions, such as cervical disk herniation, spondylosis,
or osteophytosis. Additionally, foraminal stenosis can
cause an increase in radicular symptoms. CR caused by
degeneration of intervertebral disk or spondylosis of­ten
causes radicular pain with or without neurologic com­
promise. While this pain sometimes subsides over time
and without intervention, it often progresses to severe
pain and results in disability.
While many cases of cervical myelopathy and radi­
culo­pathy occur due to degenerative changes of the
spine, they can also be caused by traumatic injuries. Blunt
tra­uma often results in severe spinal cord injury (SCI)
follo­wed by a secondary biologic response to the injury
that may include significant swelling. Cervical SCI can
result in cervical myelopathy or cervical radiculopathy
Fig. 23.2: Radiographic image of a patient presenting with cervical
radiculopathy.
 Chapter 23: Nonoperative Treatment of Cervical Myelopathy and Radiculopathy 161

if there is compression of the spinal cord or nerve roots. efficacy of cervical immobilization as a treatment for
The management of patients with SCI from blunt trauma CSM. While some studies find significant improvement
is well studied and defined.5,6 Patients with SCI are often in symptoms with the use of cervical immobilization,
treated with decompression surgery quickly following the others reveal significant deterioration and worsening of
initial injury because blunt trauma often results in very symptoms when patients used cervical immobility as the
severe cervical myelopathy or radiculopathy. only method of treatment.9 This highlights the complexity
Nontraumatic neck injuries, such as whiplash- of managing CSM as improvement of symptoms through
asso­ciated disorders (WADs), are also well defined. In the immobilization often come with reduction in function
past three decades, the number of individuals reporting and strength leading to increased symptoms afterward.
to emergency rooms for traffic-related WADs has skyroc­ Cervical immobilization and collars are also used for
keted.3 WADs are most often treated with nono­perative the treatment and management of radicular pain. Short-
measures, with an emphasis on regaining func­tion and term collar use may reduce symptoms of radiculopathy
returning to work as soon as possible. It is unknown if in the inflammatory phase. Although the use of a cervical
WAD causes an accelerated progression of the natural collar is helpful in alleviating pain and symptoms of
degenerative or preexisting processes.7,8 radiculopathy, it has not been proven to alter the disease
process.10 In general, hard collars are uncomfortable for
patients and while soft collars provide alleviation and
NONOPERATIVE TREATMENT muscle relaxation, they do not provide enough support.
FOR CERVICAL MYELOPATHY If cervical immobilization is the chosen treatment plan,
AND CERVICAL RADICULOPATHY semirigid collars are suggested for activities that provoke
symptoms.
There are various types of nonoperative treatment opti­ons For patients with cervical myelopathy or radiculo­
for the management of cervical myelopathy and radiculo­ pathy from WADs, cervical immobilization has not been
pathy (Table 23.1). found to significantly reduce pain.11 Soft collars have
shown to have no benefit or less benefit when compared
Cervical Immobilization and Cervical Collars with active therapy, rest, and usual care.12 Furthermore,
a randomized study found that patients with WAD
In the United States, cervical immobilization is a com­
experienced pain for 6 weeks after the injury, regardless
monly used treatment for CSM without rapid progression. of collar use.13 Thus, cervical collars are not the optimal
However, studies have shown conflicting results for the treatment option for patients suffering from WADs, but
may be used postoperatively if associated myelopathy or
Table 23.1: The efficacy of nonoperative treatment options for cer-
radiculopathy is present.
vical myelopathy (CM) and cervical radiculopathy (CR). There are
conflicting beliefs about the efficacy of facet injections and acu-
puncture for the treatment of CR Physical Therapy
CM CR Physical therapy is another conservative treatment option
Immobilization/collars No No for patients with mild to moderate myelopathy or radi­
Physical therapy Yes Yes culopathy, with a focus on mobilizing and stabilizing
Manual therapy No No the cervical spine. A prospective, randomized study of
ART/MFR Yes Yes vari­ous treatment techniques revealed that there were
Cervical traction No Yes no statistically significant differences between patients
NSAIDs Yes Yes
treated for CSM with physical therapy and surgery. This
suggests that physical therapy can be just as effective as
Oral steroid drug Yes Yes
surgical techniques.14 Thus, for cervical myelopathy and
ESIs No Yes
cervical radiculopathy, physical therapy is an effective
Facet injections No Yes/No
treatment modality.
Activity modification Yes Yes
Posture and erogonomics Yes Yes Manual Therapy
Acupuncture Yes Yes/No
Manual therapy and spinal manipulation are other
Massage No Yes
nonoperative treatment options. Manual medicine

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 162 Section 2: Non-Invasive Therapeutic Intervention
incorporates manipulations to restore postural balance
and optimal function and to enhance pain-free move­
ment.15 It aims to restore disk or facet function, as well
as optimal muscular and myofascial range.16 However,
cervical spine manipulation carries risk of complica­tions,
including vertebral dissection and spinal cord compres­
sion. High velocity manipulation techniques should not
be used when patients have cervical disk her­niations.16
Manual therapy intervention should be discou­ra­ ged for
patients with cervical myelopathy or radiculo­pathy.17
Myofascial Release and
Active Release Techniques
Soft tissue dysfunction often accompanies the pain and
functional deficits imparted by radiculopathy or myelo­
pathy. Conservative adjunctive treatment such as manual
therapy includes the use of a practitioner’s own hands
to palpate dysfunctions and provide treatment through
adjustments and manipulation of the patient’s body.
Myofascial release (MFR) is a type of manual therapy
that utilizes concepts introduced by Andrew Taylor Still,
the founder of osteopathic medicine, about the influ­
ence and changes in the fibrous fascia of the body relat­
ing to musculoskeletal injury.18 Utilizing knowledge of
the fascial planes and anatomy, the practitioner stretches
and releases adhesive and dysfunctional fascia back
into motion. Without active participation on part of the
patient, MFR is considered a passive therapy. While
manual therapy alone may not address directly the under­
lying cause of radiculopathy and myelopathy, it has
been successful as a supplementary treatment providing
symptom relief and functional improvements in patients
with soft tissue dysfunctions.
Active release techniques (ARTs) are also another
form of manual therapy developed by Dr P Michael
Leahy, DC, employing similar concepts and goals to
that of MFR.19 ART principals focus on muscles, tendons
nerves, fascia and add an active component with the
participation of the patient in the therapeutic maneuvers.
ART employs a shortening as well as stretching of the
soft tissues as part of the thera­peutic maneuver and its
developers believe it to be a comprehensive soft tissue
massage technique. ART has been patented, stream­
lined and offered to practitioners through a course and
certification. As with MFR there have been more anec­
dotal results of improved symptoms and function than
large-scale studies on its efficacy. As with MFR, ART is
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practiced as a supplementary treatment mainly through
physical/occupational therapy sessions in the treatment
of radiculopathy and myelopathy.
Cervical Traction
Cervical traction is sometimes used for the remediation
of pain caused by cervical radiculopathy. Typically,
8–12 lb of traction is applied at an angle of approximately
24° of flexion for 15–20 minute intervals. Traction is best
after significant muscular pain has subsided and it is not
recommended for patients with signs of myelopathy.10
Nonsteroid Anti-inflammatory Drugs
Nonsteroid anti-inflammatory drugs (NSAIDs) are com­
monly used to reduce pain for patients with cervical
myelo­pathy and radiculopathy. Though there are limited
studies on the efficacy of NSAIDs in the cervical spine,
there is much evidence about the effectiveness of NSAIDs
in the alleviation of lower back pain. In practice, a trial of
NSAIDs is usually the first line of treatment for patients
with CSM and CR. Safe use of NSAIDs can have low risks
but significant benefits in improving CSM and CR related
inflammatory pain. However, structural progression may
occur in spite of symptomatic reduction.
Oral Steroid Drugs
Pharmacotherapy with oral steroid drugs is indicated in
the treatment of cervical myelopathy and radiculopathy
acutely or when NSAIDs are not sufficient for significant
inflammation. In the presence of significant radiculo­
pathy, early intervention with corticosteroids has been
shown to result in a rapid decrease in radicular symp­
toms.20 However, excessive or long-term use of steroids
may cause a risk of immunosuppression, hyperglycemia
(iatrogenic diabetes), osteoporosis, and adrenal insuffi­
ciency (Cushing’s syndrome).
Cervical Epidural Steroid Injections
When the above treatment options do not relieve pain
from cervical myelopathy or radiculopathy, epidural
steroid injections (ESIs) may be used for rapid pain relief.
Cervical ESIs are often used to treat herniated disks,
spinal stenosis, and chronic neck pain. Precise delivery of
corticosteroids avoids systemic steroid use and achieves
a strong anti-inflammatory effect, which reaches the
interneural capillaries of the spinal nerve roots. Thus,
 Chapter 23: Nonoperative Treatment of Cervical Myelopathy and Radiculopathy
ESIs have been found to rapidly decrease radicular pain.
The Task Force for Neck Pain confirmed this short-term
relief of radicular symptoms with epidural or selective root
injections of corticosteroids.3 Of note, response to oral
steroids does not predict the success of cervical ESIs.
Cervical perineural injections, such as transforami­
nal ESIs (TFESIs) and interlaminar ESIs, should be used
under radiographic guidance and only after confirma­
tion of pathology by MRI.10 Though ESIs have been shown
to successfully reduce pain and decrease the need for
surgery, several complications, such as severe neurologic
deformity and spinal cord infarction, have been noted.
The procedures must be performed by experienced doc­
tors and great care should be taken to ensure that vulne­
rable structures are not punctured in the injection process.
Transforaminal ESIs
A prospective study by Kolstad et al. found a statistically
significant reduction in radicular pain for patients treated
with TFESIs.21 Furthermore, the study found that TFESIs
resulted in a reduction in operative treatment required
for patients. After receiving TFESIs, 24% of the patients
decided to cancel surgery due to the significant reduction
in pain from the TFESIs alone.21
Interlaminar ESIs
Cervical interlaminar epidural injections significantly red­
uce chronic cervical pain and provide long-term relief.22
Anatomically, there is a higher risk of neural and vascular
complications of TFESIs over interlaminar ESIs.
Facet Injections
Facet joints are a well-recognized source of pain in the
cervical spine. Facet joints are innervated by medial
branches of the dorsal rami and can radiate pain to the
extremities. Cervical facet joints may be a source of pain
for 36–60% of patients with chronic neck pain.23 Facet
joint pain may be managed by intra-articular injections,
medial branch blocks, and neurotomies. Facet joint pain
may coincide with cervical myelopathy and radiculopathy
because facet joint degeneration is directly related to the
degeneration of the intervertebral disk, a contributor to
both cervical myelopathy and cervical radiculopathy.
As a result of aging, the intervertebral disks lose hydration
and disk height, which puts greater stress on the poste­
rior facet joints.24 This degenerative disk process starts as
early as the second decade of life. Osteophytic spurs can
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163
develop due to the stresses and cause direct compression
of the spinal cord, resulting in myelopathy. Facet joint
osteophytes have also been found to contribute to nerve
root compression, which can induce radiculopathy.25
Additionally, facet joint inflammation has been found
to release inflammatory cytokines that induce nerve
root injury and subsequent radiculopathy.25 Thus, facet
injections are important nonoperative considerations as
they address the pain and inflammatory processes often
at the root of multiple neck pain disorders including cer­
vical myelopathy and radiculopathy.
However, there are conflicting results of the efficacy
of facet injections in the cervical spine. According to the
Task Force on Neck Pain, facet injections have not pro­
ven to be effective in the treatment of cervical myelo­
pathy and radiculopathy.26 A literature review by Boswell
et al. found limited to moderate results in the efficacy
of facet injections for the cervical spine.23 The review
examined the short-term (< 3 months) and long-term
(> 3 months) effect of different types of facet injections
for the remediation of pain.23
Intra-articular Injections
There is limited evidence of the efficacy of cervical intra-
articular facet injections and conflicting evidence of the
efficacy of lumbar intra-articular facet injections.23,27,28
Cervical intra-articular facet joint injections have been
found to be ineffective at reducing pain for patients with
WADs.29
Medial Branch Blocks
Therapeutic medial branch blocks have been found to pro­
vide significant pain reduction for patients with cervical
facet joint pain, diagnosed by local anesthetic agents.30-33
Although medial branch blocks have been found to be
effective in providing pain relief for patients with herniated
disks in the cervical spine, patients with myofascial pain,
and patients with WAD,34 they are not typically used for
CSM and CR because myelopathy and radiculopathy are
not directly associated with facet pathology.
Neurotomy
Percutaneous neurotomy of medial branches is a proce­
dure that offers pain relief by the denervation of the nerves
that innervate the painful facet joint. Percutaneous neuro­
tomies have been found to be effective at providing short
 164 Section 2: Non-Invasive Therapeutic Intervention

and long-term pain relief for patients with cervical facet OTHER NONOPERATIVE
joint pain.35,36 However, since CSM and CR are not directly
related to facet pathology, neurotomies are not often used
TREATMENT METHODS
for patients with CSM and CR. Studies on the efficacy of Alternative nonoperative treatment procedures include
neurotomies for CSM and CR are limited and further thermal therapy, electrotherapy, massage, and acupunc­
research should be devoted to this topic.23 ture. These treatment methods have variable efficacy
in reducing pain and are typically used to supplement
Activity and Sports Modification other nonoperative treatment methods. Additional treat­
ment methods of cervical myelopathy and radicu­lopathy
Activity and sports modification are important for the include adjunct medications, such as opiates, muscle
restoration of full range of motion. Enhanced muscular relax­ants, and low-dose tricyclic antidepressants.15 These
strength and increased awareness of proprioception allow adju­nct medications are effective in reducing the level of
the patient to balance the cervical spine.15 Stretching exer­ pain for the patient.
cises restore and maintain normal functional movement
and are essential to prevent scarring, adhesions, and NONOPERATIVE VERSUS OPERATIVE
re­petitive microtrauma to the cervical spine.15,37 Aerobic
conditioning is also important for the restoration of full
TREATMENT OF CERVICAL MYELOPATHY
range of motion; however, aerobic capacity may diminish Evaluating the efficacy of treatment options for cervical
rapidly with the inactivity that often accompanies CR.15 myelopathy can be difficult. Studies show that as many
This may limit a patient’s ability to perform strengthening as 18% of patients with CSM improve spontaneously,
exercises. An exercise program designed to strengthen 40% stabilize without treatment, and 42% deteriorate
deconditioned cervical, shoulder, upper trunk, and peri­ without treatment.38 In order to determine a treatment
pheral musculature is essential for rehabilitation. Activity plan for a patient with cervical myelopathy, the severity
should be limited to moderate exercise to prevent further of the pathology must be evaluated. For patients with
damage to the cervical spine. However, it is clear that severe myelopathy, surgical procedures designed to
moderate activity and exercise allows for the restoration of decom­press the spinal cord and stabilize the spine are
the range of motion of the spine and is a viable option for uti­lized. Though often essential for patients with severe
the conservative treatment of patients with CR and CSM. my­ elo­
pathy, surgery has not shown significant results
for the treatment of mild to moderate myelopathy. There
Posture and Ergonomics is currently no evidence indicating decompression with
an anterior or posterior approach significantly improves
As individuals age, they develop a kyphotic posture,
which includes flexion of the thoracic spine and a com­
pen­satory hyperextension of the cervical spine to main­
tain an effective line of sight. This postural change can
result in the new impingement of the cervical spine or
progression of previous symptoms. Postural training is an
essential nonoperative treatment modality to prevent the
progression of the symptoms of cervical myelopathy and
radiculopathy. The goal of postural training is to teach the
patient to maintain a ‘‘neutral spine,’’ while performing
activities of everyday life.15 These proprioceptive skills are
applied during rehabilitation and strengthening exercises
to teach the patient to keep the cervical spine in a pain-
free and stable position during strenuous exercises.37
Patients should aim to maintain a neutral cervical spine
in everyday life by employing ergonomics such as adjust­ Fig. 23.3: Ergonomics to maintain neutral cervical spine while sitting
at a desk.
ing chair height while sitting at a desk (Fig. 23.3).

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 Chapter 23: Nonoperative Treatment of Cervical Myelopathy and Radiculopathy
the outcomes of patients with mild to moderate cervical
myelopathy. This may indicate other factors, such as
inflammatory reactions, contribute significantly to the
symptoms of mild to moderate myelopathy rather than
compressive factors. Symptoms may progress to CSM in
some patients but not others and it should also be noted
that in patients with CSM undergoing surgical interven­
tion, clinical progression may continue.39 Furthermore,
studies have shown that operative procedures do not yield
better results than conservative procedures for patients
with mild or moderate CSM.40-43
It is essential that physicians educate patients about
nonoperative treatment options so that surgical tech­ni­
ques can be avoided if not necessary. Nonoperative tech­
niques include cervical immobilization (collar or neck
brace), physical therapy, NSAIDs, trigger point injections
(TPIs), facet injections, cervical ESIs, and TFESIs. These
various nonoperative treatment options will be described
in detail later in this chapter.
NONOPERATIVE VERSUS
OPERATIVE TREATMENT OF
CERVICAL RADICULOPATHY
The treatment of CR also varies according to the extent of
cervical spine pathology. Severe cases of CR are commonly
treated with surgical techniques, such as laminectomy,
discectomy, laminoplasty, anterior and posterior fusion,
and/or foraminotomy. However, nonsurgical conservative
management has been found to be successful for most
patients with CR.44,45 Thus, surgery is typically deferred
until all conservative treatment options have failed. In
most cases of cervical spondylotic radiculopathy, the
results of conservative management are quite significant.
Approximately 80–90% of patients respond to conservative
treatment, with improvements in pain, function, and
mood in 3–6 months.17 Nonoperative treatment of CR
parallels that of CSM, including cervical immobilization,
physical therapy, cervical traction, NSAIDs, TPIs, facet
injections, cervical ESIs, and TFESIs. These therapies may
be used alone or in combinations. Given these findings,
surgical intervention may be deferred unless pain persists
or if there is severe neurologic deficit.
CONCLUSION
The severity of the pathology, as well as patient prefer­
ence and response to treatment, must guide the choice
of treatment for the short-term relief of neck pain.
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165
Of­ten, taking a ‘‘less is more’’ approach is preferable for
pati­ents with cervical myelopathy and radiculopathy. If
a patient has mild to moderate cervical myelopathy or
radiculopathy, conservative treatment options should be
thoroughly considered and utilized before performing
surgery. Though conservative treatment options also have
risks and associated complications, the risks from con­
servative procedures are less severe than those associated
with surgery and studies have shown that surgical pro­
cedures do not yield better results than conservative
manage­ment.40-43 Since surgical procedures are much
more costly and invasive than nonoperative procedures,
surgery should only be performed once conservative
tre­atment has failed to relieve symptoms or neurological
pro­gression has been determined.
In most cases, if symptoms can be controlled through
nonoperative treatment prior to surgery, the patient’s
need for surgery can be deferred. However, it is important
to keep in mind that multiple visits and treatments with­
out focused goals may make neck pain and disability
worse rather than better. Conservative treatment meas­
ures, such as injections, should not be administered in
excess and clinical judgment is always necessary when
balancing between continued short-term interventions
versus recommending surgical intervention. On the other
hand, delaying surgery could be potentially problematic
for the patient and result in worsening of symptoms.
Despite the potential drawbacks of using nonoperative
treatment options, it is clear that the use of conservative
treatment should be the first step in addressing neck pain
for patients with mild to moderate cervical myelopathy
or radiculopathy. A multidisciplinary approach including
multiple nonoperative conservative interventions, with
close attention to changing symptoms, is both an excellent
treatment plan on its own and as a prerequisite, should
surgical intervention be needed.
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 Chapter 23: Nonoperative Treatment of Cervical Myelopathy and Radiculopathy 167

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