Physical Therapy for Cervical Radiculopathy Linked to Improved Post-surgical Outcomes

Peer Reviewed

Non-operative treatments for cervical radiculopathy are commonly used to prevent surgical intervention; however, the value of these interventions in patients who later undergo cervical spine surgery is unclear. New findings suggest that physical therapy (PT) and epidural injections may have beneficial effects on post-surgical outcomes in patients with degenerative non-myelopathic cervical radiculopathy, as reported in the August 2 issue of the International Journal of Spine Surgery.
Patient explaining neck pain to her Doctor.Physical therapy and epidural injections may have beneficial effects on post-surgical outcomes in patients with degenerative non-myelopathic cervical radiculopathy.“The vast majority of patients with cervical radiculopathy could avoid surgery by adhering to a structured non-operative treatment regimen,” said coauthor Alexander R. Vaccaro, MD, PhD, who is the Richard H. Rothman Professor and Chairman of the Department of Orthopaedic Surgery at the Sidney Kimmel Medical Center at Thomas Jefferson University in Philadelphia. However, for the select patients who do require surgery, the study findings show that “those who have maximized their potential for improvement using non-operative modalities tend to do better after surgery than people who are deconditioned prior to surgery,” Dr. Vaccaro said.

“The study is important that it shows that well selected patients without myelopathy (which should be treated surgically) will do well with conservative care including PT and injections,” commented Santhosh A. Thomas, DO, MBA, Medical Director of the Center for Spine Health and Associate Medical Director of the Richard E. Jacobs Medical Center at the Cleveland Clinic in Avon, OH. Dr. Thomas is not affiliated with the study.

Multicenter Prospective Study
The multicenter study analyzed prospective data from patients with degenerative cervical pathology (≤grade 1 spondylolisthesis) who underwent 1- or 2- level surgery. The patients were divided into two cohorts depending on whether they had radiculopathy (n=1,319) or myelopathy (n=203).

More than one-third of patients underwent PT pre-operatively (34%), 34% received opioids, and 24% received epidural injections. Approximately half of the patients (52%) did not receive any of these treatments pre-operatively.

In patients with myelopathy, use of non-operative treatments was not associated with post-operative benefits. However, for patients with radiculopathy, PT prior to surgery was linked to significantly shorter hospitalizations, greater improvements in 36-Item Short Form Health Survey (SF-36) bodily pain norm and physical functioning norm, Pain Catastrophizing Scores (PCS), and lower Visual Analog Scale (VAS) neck and arm pain scores at 2 years post-operative. In addition, patients who underwent PT had a higher return to work rate at 1 and 2 years post-operatively (61% vs 52% at 1 year and 59% vs 46% at 2 years; P<0.05 for both comparisons).
Table. Outcomes of Spinal Surgery in Radiculopathy Patients Treated With or Without Pre-operative Physical Therapy.Outcomes of Spinal Surgery in Radiculopathy Patients Treated With or Without Pre-operative Physical Therapy.In addition, pre-operative epidural steroid injections were linked to a faster return to work in patients with radiculopathy at 1 year post-operatively (63% vs 52%: P<0.05). Patients receiving opioids had greater improvement in Neck Disability Index improvement at 2 years (P<0.05).

“At the Rothman Institute at Thomas Jefferson University, all patients with cervical radiculopathy receive non-operative treatments initially,” Dr. Vaccaro said. “The only time we recommend surgery is if a patient has progressive neurological deficit or unremitting pain that does not respond to 6 weeks to 3 months of non-operative treatment,” he explained.

“There is a segment of spine surgeons who will immediately operate on a patient with a large disc herniation,” Dr. Vaccaro said. “We think it is important for every patient to undergo non-operative therapy before surgery. If you are deconditioned before surgery and go through a debilitating procedure, you tend to do less well than patients who are well conditioned before surgery,” he concluded.

Non-operative Modalities Prevent Surgery in 90% of Cases
“Non-operative modalities include rest, anti-inflammatory medications, physical therapy, and epidural injections. All these options may be used for patients with cervical radiculopathy at Thomas Jefferson University, however, physical therapy and anti-inflammatory agents are the principle non-operative treatments used,” Dr. Vaccaro said.

“Epidural injections are reserved for patients with persistent radicular pain who do not want to undergo surgery,” Dr. Vaccaro said. Concerns have been raised in the spine community that epidural injections may be associated with specific morbidity after surgery, such as an increased risk of infection if given close to the time of the operation, he noted. “However, this increased risk for morbidity with epidural injections has not been supported unequivocally in the literature,” he said.

“The implications of these findings are that those who respond well to PT and injections will do well with surgery if needed,” Dr. Thomas said. “Almost 9 out of 10 patients do not need surgery, and these patients often get better with conservative care. Surgery is far more expensive than injections and PT combined, and suboptimal patient selection will likely add cost to care for these patients.”

“There is a mention [in the study] that injection rates have increased, but a glaring omission is that the surgical cases have also increased significantly,” Dr. Thomas noted. “Studies show that with or without surgery, patients end up being about the same in 5 years as they don’t have myelopathy.”

Thus, “It is always best to proceed with non-invasive options first, like medications and PT, and then consider injections as the majority of patients will not need surgery,” Dr. Thomas told SpineUniverse. “Those who need surgery should have tried PT and injections first, as this could be a clue to long-term results. If patients fail or respond poorly, then surgery should be considered with caution as the outcomes/results correlate well with response to conservative care.”

Findings Are “Relevant and Important”
“This is a really interesting paper utilizing a substantial database,” commented Todd J. Albert, MD, Surgeon in Chief and Medical Director, Korein-Wilson Professor of Orthopaedic Surgery, Hospital for Special Surgery at Weill Cornell Medical College, New York, NY. “The study has some limitation due to non-randomization of the pre-operative treatments. Despite this challenge, the data suggests that pre-operative physical therapy and epidurals may offer beneficial effects on the post-operative course.”

“The study is relevant and important as it opens the door to further questions and potential study of an organized evaluation of pre-operative epidural steroid and/or physical therapy in this patient population,” concluded Dr. Albert.

Updated on: 09/18/18
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Early Physical Therapy for Low Back Pain Shows Modest Benefits
Alexander R. Vaccaro, MD, PhD
Richard H. Rothman Professor
Chairman, Department of Orthopaedic Surgery
Sidney Kimmel Medical Center
Thomas Jefferson University
Santhosh A. Thomas, DO, MBA
Medical Director, Center for Spine Health
Associate Medical Director
Richard E. Jacobs Medical Center
Cleveland Clinic
Todd J. Albert, MD
Surgeon in Chief and Medical Director
Korein-Wilson Professor of Orthopaedic Surgery
Hospital for Special Surgery
Weill Cornell Medical College
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