Management of cervical spondylotic radiculopathy: a systematic review

Key points

1. 01Surgery produced significantly greater pain relief (VAS) than conservative treatment at all follow-up points up to 12 months
2. 02The disability advantage of surgery (NDI) was clear at 3 and 6 months but was not significant at 12 months (MD = -5.17, P = .16)
3. 03No significant difference was found between surgery and conservative care for cervical range of motion (MD = 2.91, P = .44) or mental health (SMD = .05, P = .74)
4. 04Conservative treatment at 1-2 sessions per week for at least 3 months appears effective for long-term benefit
5. 05Natural history of CSR is favorable: 83% of patients recover within 24-36 months without surgery

How it was conducted

Design

Systematic review and meta-analysis of randomized controlled trials

Databases searched

PubMed, EMbase, Cochrane Library, Web of Science, ClinicalTrials (inception to September 2021)

Participants

464 patients across 6 RCTs; 206 surgical, 258 conservative

Surgical interventions

ACDF, anterior cervical discectomy, plasma disc decompression, posterior cervical transfacet fusion

Conservative interventions

Physiotherapy, cervical collar, TENS, mechanical cervical traction, exercise, pain education, NSAIDs

Primary outcomes

Neck and arm VAS pain scores, Neck Disability Index (NDI)

What they found

• Overall neck VAS: surgery superior to conservative (MD = -17.90, 95% CI -23.54 to -12.26, P < .00001)
• Overall arm VAS: surgery superior to conservative (MD = -23.13, 95% CI -26.01 to -20.25, P < .00001)
• Neck VAS at <3 months: MD = -29.44, 95% CI -41.62 to -17.27, P < .00001
• Neck VAS at 3-6 months: MD = -20.97, 95% CI -26.36 to -15.57, P < .00001
• Neck VAS at 6 months: MD = -13.40, 95% CI -19.39 to -7.41, P < .0001
• Neck VAS at 12 months: MD = -15.53, 95% CI -28.38 to -2.68, P = .02
• Arm VAS at 12 months: MD = -21.91, 95% CI -27.09 to -16.72, P < .00001
• NDI overall: surgery superior (MD = -6.67, 95% CI -10.93 to -2.41, P = .002)
• NDI at 12 months: no significant difference (MD = -5.17, 95% CI -12.33 to 2.00, P = .16)
• Cervical ROM: no significant difference (MD = 2.91, 95% CI -4.51 to 10.33, P = .44)
• Mental health: no significant difference (SMD = .05, 95% CI -0.24 to 0.33, P = .74)

Limitations

• Only 6 RCTs with 464 total patients were available, limiting statistical power for long-term and subgroup analyses
• Surgical techniques and conservative treatment protocols varied considerably across studies, producing high heterogeneity (I2 up to 94% for NDI)
• Blinding of patients and treating clinicians was not possible due to the nature of surgical vs. conservative care, introducing potential performance and response bias
• Only English-language studies were included, risking publication bias; studies with follow-up beyond 1 year were too few for quantitative pooling

Why it matters

For patients

Patients with severe or rapidly worsening neck and arm pain may benefit from earlier surgery, but those with tolerable symptoms can reasonably try conservative therapy for at least 3 months before considering an operation.

For clinicians

Surgery provides faster and greater short-term pain relief than conservative care, but the functional (NDI) advantage is not maintained at 12 months, supporting a conservative-first approach except when pain is severe or there is progressive neurological deficit.

For readers

This meta-analysis of RCTs confirms surgery beats conservative care on pain in the short term but finds no long-term functional superiority, underscoring that treatment choice should be individualized based on pain severity, patient preference, and surgical risk.