Background & Aims

Cervical radiculopathy is initially typically managed conservatively. Surgery is indicated when conservative management fails or with severe/progressive neurological signs. Personalised multimodal physiotherapy could be a promising conservative strategy. However, aggregated evidence on the (cost-)effectiveness of personalised multimodal physiotherapy compared to surgery with/without post-operative physiotherapy is lacking. The aim was to systematically summarise the literature on the (cost-)effectiveness of personalised multimodal physiotherapy compared to surgery with or without post-operative physiotherapy in patients with cervical radiculopathy.

Methods

PubMed, Embase, CINAHL, PsycINFO and Web of Science were searched from inception to 1st of March 2023. Primary outcomes were effectiveness regarding costs, arm pain intensity and disability. Neck pain intensity, perceived recovery, quality of life, neurological symptoms, range-of-motion, return-to-work, medication use, (re)surgeries and adverse events were considered secondary outcomes. Randomised clinical trials comparing personalised multimodal physiotherapy versus surgical approaches with/without post-operative physiotherapy were included. Two independent reviewers performed study selection, data-extraction, and risk of bias assessment using the Cochrane RoB 2 and CHEERS statement. Certainty of the evidence was determined using GRADE.

Results

From 2,109 records, eight papers from two original trials, with 117 participants in total were included. Low certainty evidence showed there were no significant differences on arm pain intensity and disability, except for the subscale ‘heavy work’ related disability (12-months) and disability at 5-8 years. Cost-effectiveness was not assessed. There was low certainty evidence that physiotherapy improved significantly less on neck pain intensity, sensory loss and perceived recovery compared to surgery with/without physiotherapy. Low certainty evidence showed there were no significant differences on numbness, range of motion, medication use, and quality of life. No adverse events were reported.

Conclusions

Considering the clinical importance of accurate management recommendations and the current low level of certainty, high-quality cost-effectiveness studies are needed.

References

1.Sleijser-Koehorst MLS, Coppieters MW, Epping R, Rooker S, Verhagen AP, Scholten-Peeters GGM. Diagnostic accuracy of patient interview items and clinical tests for cervical radiculopathy. Physiotherapy. 2021 Jun 1;111:74–82. doi: 10.1016/j.physio.2020.07.007.
2.Van Zundert J, Huntoon M, Patijn J, Lataster A, Mekhail N, Van Kleef M. 4. Cervical radicular pain. Pain Practice. 2010 Jan-Feb;10(1):1–17. doi: 10.1111/j.1533-2500.2009.00319.x.
3.Tampin B, Lind C, Jacques A, Slater H. Disentangling ‘sciatica’ to understand and characterise somatosensory profiles and potential pain mechanisms. Scandinavian Journal of Pain. 2021 Aug 2;22(1):48-58. doi: 10.1515/sjpain-2021-0058. PMID: 34333881.
4.Sleijser-Koehorst MLS, Coppieters MW, Heymans MW, Rooker S, Verhagen AP, Scholten-Peeters GGM. Clinical course and prognostic models for the conservative management of cervical radiculopathy: a prospective cohort study. European Spine Journal. 2018 Nov;27(11):2710-2719. doi: 10.1007/s00586-018-5777-8.
5.He A, Xie D, Qu B, Cai X, Kong Q, Yang L, et al. Comparison between cervical disc arthroplasty and conservative treatment for patients with single level cervical radiculopathy at C5/6. International Journal of Surgery. 2018 Jun 1;54:124–8. doi: 10.1016/j.ijsu.2018.01.033.
6.Wong JJ, Côté P, Quesnele JJ, Stern PJ, Mior SA. The course and prognostic factors of symptomatic cervical disc herniation with radiculopathy: A systematic review of the literature. The Spine Journal. 2014 Aug 1;14(8):1781–9. doi: 10.1016/j.spinee.2014.02.032.
7.Hush JM, Lin CC, Michaleff ZA, Verhagen A, Refshauge KM. Prognosis of acute idiopathic neck pain is poor: a systematic review and meta-analysis. Archives of Physical Medicine and Rehabilitation. 2011 May;92(5):824-9. doi: 10.1016/j.apmr.2010.12.025.
8.Thoomes E, Thoomes-De Graaf M, Cleland JA, Gallina A, Falla D. Timing of Evidence-Based Nonsurgical Interventions as Part of Multimodal Treatment Guidelines for the Management of Cervical Radiculopathy: A Delphi Study. Physical Therapy. 2022 May 5;102(5):1–9. doi: 10.1093/ptj/pzab312.
9.Woods BI, Hilibrand AS. Cervical Radiculopathy Epidemiology, Etiology, Diagnosis, and Treatment. Journal of Spinal Disorder and Techniques. 2015 Jun;28(5):E251-9. doi: 10.1097/BSD.0000000000000284.
10.Luyao H, Xiaoxiao Y, Tianxiao F, Yuandong L, Ping Wang. Management of Cervical Spondylotic Radiculopathy: A Systematic review. Global Spine Journal. 2022 Oct;12(8):1912–24. doi: 10.1177/21925682221075290.
11.Goedmakers CMW, Janssen T, Yang X, Arts MP, Bartels RHMA, Vleggeert-Lankamp CLA. Cervical radiculopathy: is a prosthesis preferred over fusion surgery? A systematic review. European Spine Journal. 2020 Nov;29(11):2640-2654. doi: 10.1007/s00586-019-06175-y.
12.Nikolaidis I, Fouyas IP, Sandercock PA, Statham PF. Surgery for cervical radiculopathy or myelopathy. Cochrane Database of Systematic Reviews. 2010 Jan 20;2010(1): CD001466. doi: 10.1002/14651858.CD001466.pub3.
13.Epstein NE. A review of complication rates for anterior cervical diskectomy and fusion (ACDF). Surgical Neurology International. 2019 Jun 7;10:100. doi: 10.25259/SNI-191-2019.
14.Tasiou A, Giannis T, Brotis AG, Siasios I, Georgiadis I, Gatos H, et al. Anterior cervical spine surgery-associated complications in a retrospective case-control study. Journal of Spine Surgery. 2017 Sep;3(3):444-459. doi: 10.21037/jss.2017.08.03.
15.Dutch Society of Neurosurgery (NVvN). Guideline for the Treatment of Cervical Radicular Syndrome due to Cervical Herniated Nucleus Pulposus, 2010. Available via: https://richtlijnendatabase.nl/richtlijn/cervicaal_radiculair_syndroom_tgv_chnp/conservatieve_therapie_bij_crs_tgv_chnp.html.
16.Savva C, Korakakis V, Efstathiou M, Karagiannis C. Cervical traction combined with neural mobilization for patients with cervical radiculopathy: A randomized controlled trial. Journal of Bodywork and Movement Therapies. 2021 Apr 1;26:279–89. doi: 10.1016/j.jbmt.2020.08.019.
17.Alshami AM, Bamhair DA. Effect of manual therapy with exercise in patients with chronic cervical radiculopathy: a randomized clinical trial. Trials. 2021 Oct 18;22(1):176. doi: 10.1186/s13063-021-05690-y.
18.McCracken LM. Personalized pain management: Is it time for process-based therapy for particular people with chronic pain? European Journal of Pain. 2023 Oct;27(9):1044-1055. doi: 10.1002/ejp.2091.
19.Page MJ, Mckenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. British Medical Journal. 2021 Mar 29;372:n71. doi: 10.1136/bmj.n71.
20.Ouzzani M, Hammady H, Fedorowicz Z, Elmagarmid A. Rayyan-a web and mobile app for systematic reviews. Systematic Reviews. 2016 Dec 5;5(210);1–10. doi: 10.1186/s13643-016-0384-4.
21.Hoffmann TC, Glasziou PP, Boutron I, Milne R, Perera R, Moher D, et al. Better reporting of interventions: Template for intervention description and replication (TIDieR) checklist and guide. British Medical Journal. 2014 Mar 7;348:g1687. doi: 10.1136/bmj.g1687.
22.Higgins JPT, Altman DG, Gøtzsche PC, Jüni P, Moher D, Oxman AD, et al. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. British Medical Journal. 2011 Oct 18;343:d5928. doi: 10.1136/bmj.d5928.
23.Husereau D, Drummond M, Augustovski F, De Bekker-Grob E, Briggs AH, Carswell C, et al. Consolidated Health Economic Evaluation Reporting Standards 2022 (CHEERS 2022) statement: Updated reporting guidance for health economic evaluations. Value in Health. 2022 Jan;25(1):3–9. doi: 10.1016/j.jval.2021.11.1351.
24.Andrade, C. Mean Difference, Standardized Mean Difference (SMD), and Their Use in Meta-Analysis: As Simple as It Gets. Journal of Clinical Psychiatry. 2020 Sep 22;81(5):20f13681. doi: 10.4088/JCP.20f13681.
25.Guyatt GH, Oxman AD, Vist GE, Kunz R, Falck-Ytter Y, Alonso-Coello P, et al. GRADE: an emerging consensus on rating quality of evidence and strength of recommendations. British Medical Journal. 2008 Apr 26;336(7650):924–6. doi: 10.1136/bmj.39489.470347.AD.
26.Schünemann H, Bro?ek J, Guyatt G, Oxman A. GRADE handbook for grading quality of evidence and strength of recommendations. The GRADE Working Group. 2013 Oct. doi: -.
27.Persson L, Lilja A. Pain, coping, emotional state and physical function in patients with chronic radicular neck pain. A comparison between patients treated with surgery, physiotherapy or neck collar – a blinded, prospective randomized study. Disability and Rehabilitation. 2001 May 20;23(8):325–35. doi: 10.1080/09638280010005567.
28.Persson L, Karlberg M, Magnussont M. Effects of different treatments on postural performance in patients with cervical root compression – A Randomized Prospective Study Assessing the Importance of the Neck in Postural Control. Journal of Vestibular Research. 1996 Nov-dec;6(6):439–53. doi: -.
29.Persson LCG, Carlsson CA, Carlsson JY. Long-lasting cervical radicular pain managed with surgery, physiotherapy, or a cervical collar. Spine. 1997;22(7):751–8. doi: 10.1097/00007632-199704010-00007.
30.Persson LCG, Moritz U, Brandt L, Carlsson CA. Cervical radiculopathy: pain, muscle weakness and sensory loss in patients with cervical radiculopathy treated with surgery, physiotherapy or cervical collar. A prospective, controlled study. European Spine Journal. 1997;6(4):256–66. doi: 10.1007/BF01322448.
31.Engquist M, Löfgren H, Öberg B, Holtz A, Peolsson A, Söderlund A, et al. A 5- to 8-year randomized study on the treatment of cervical radiculopathy: Anterior cervical decompression and fusion plus physiotherapy versus physiotherapy alone. Journal of Neurosurgery: Spine. 2017 Jan 1;26(1):19–27. doi: 10.3171/2016.6.SPINE151427.
32.Engquist M, Löfgren H, Öberg B, Holtz A, Peolsson A, Söderlund A, et al. Surgery versus nonsurgical treatment of cervical radiculopathy: A prospective, randomized study comparing surgery plus physiotherapy with physiotherapy alone with a 2-year follow-up. Spine. 2013 Sep 15;38(20):1715–22. doi: 10.1097/BRS.0b013e31829ff095.
33.Engquist M, Löfgren H, Öberg B, Holtz A, Peolsson A, Söderlund A, et al. Factors affecting the outcome of surgical versus nonsurgical treatment of cervical radiculopathy: A randomized, controlled study. Spine. 2015 Oct 15;40(20):1553–63. doi: 10.1097/BRS.0000000000001064.
34.Peolsson A, Söderlund A, Engquist M, Lind B, Löfgren H, Vavruch L, et al. Physical function outcome in cervical radiculopathy patients after physiotherapy alone compared with anterior surgery followed by physiotherapy: A prospective randomized study with a 2-year follow-up. Spine. 2013 Feb 15;38(4):300–7. doi: 10.1097/BRS.0b013e31826d2cbb.
35.Van Geest S, Kuijper B, Oterdoom M, Van Den Hout W, Brand R, Stijnen T, et al. CASINO: Surgical or nonsurgical treatment for cervical radiculopathy, a randomised controlled trial. BMC Musculoskeletal Disordorders. 2014 April 14;15(129). doi: 10.1186/1471-2474-15-129.
36.Taso M, Sommernes JH, Kolstad F, Sundseth J, Bjorland S, Pripp AH, et al. A randomised controlled trial comparing the effectiveness of surgical and nonsurgical treatment for cervical radiculopathy. BMC Musculoskeletal Disorders. 2020 Mar 16;21(1):171. doi: 10.1186/s12891-020-3188-6.
37.Plener J, Csiernik B, To D, da Silva-Oolup, Hofkirchner C, Cox J, et al. Conservative management of cervical radiculopathy: a systematic review. The Clinical Journal of Pain. 2023 Mar 1;39(3):138–146. doi: 10.1097/AJP.0000000000001092.
38.Mallard F, Wong JJ, Lemeunier N, Côté P. Effectiveness of Multimodal Rehabilitation Interventions for Management of Cervical Radiculopathy in Adults: An Updated Systematic Review from the Ontario Protocol for Traffic Injury Management (Optima) Collaboration. Journal of Rehabilitation Medicine. 2022 Aug 22;54:jrm00318. doi: 10.2340/jrm.v54.2799.
39.Kamper SJ. Interpreting Outcomes 3-Clinical Meaningfulness: Linking Evidence to Practice. Journal of Orthopaedic & Sports Physical Therapy. 2019 Sep;49(9):677-678. doi: 10.2519/jospt.2019.0705.
40.Abdel Shaheed C, Mathieson S, Wilson R, Furmage AM, Maher CG. Who should judge treatment effects as unimportant? Journal of Physiotherapy. 2023 Jul;69(3):133-135. doi: 10.1016/j.jphys.2023.04.001.

Presenting Author

Sebastiaan Klein Heerenbrink

Poster Authors

Sebastiaan Klein Heerenbrink

Master of Science

Vrije Universiteit Amsterdam

Lead Author

Pieter Coenen

Lead Author

Michel Coppieters

Vrije Universiteit Amsterdam

Lead Author

Hanneke van Dongen

Lead Author

Carmen Vleggeert-Lankamp

Lead Author

Servan Rooker

Lead Author

Bas ter Meulen

Lead Author

Hans Bosboom

Lead Author

Gert Bouma

Lead Author

Ivo Lutke Schipholt

VU Amsterdam

Lead Author

Marije Sleijser-Koehorst

Lead Author

Ralph de Vries

Vrije Universiteit Amsterdam

Lead Author

Raymond Ostelo

Lead Author

Wendy Scholten-Peeters

Vrije universiteit Amsterdam

Lead Author

Topics

  • Specific Pain Conditions/Pain in Specific Populations: Neck Pain