Barbara Kuijper

Purpose: Cervical Radicular Syndrome is predominantly treated conservatively, but surgical treatment can be considered after shared decision-making. Knowledge about difference in outcome is scarce. The CASINO trial aims to enhance this knowledge to assist patients and physicians in optimizing treatment choices. Methods: A multi-centre observational cohort study was conducted in patients visiting a neurologist or neurosurgeon with CRS and disc-herniation. Conservative and surgical treatment were discussed and in agreement a decision was made. 141 patients with cervical radiculopathy due to intervertebral disc herniations were included, 88 were surgically and 53 were conservatively treated. Visual Analogue Scale for arm pain and Neck Disability Index served as primary outcome parameters. Secondary outcome measures involved VAS neck pain and the EuroQol VAS. Data were collected at baseline, 6, 12, 26, 38, 52 and 104 weeks after inclusion, and analysed using linear mixed-effects models. Results: At baseline, the surgical treatment-arm had more arm pain (VAS Arm Pain, p =.017) but other baseline parameters were comparable. However, during the two years follow up period the surgical arm fared better than the conservatively treated patients: VAS arm pain decreased 12 mm more in the surgical group than in the conservative group (p =.053), exceeding the Minimal Clinical Important Difference (MCID). VAS neck pain decreased 19 mm more in the surgical group than in the conservative group (p =.002), illustrating a significant and clinically relevant difference between the treatment arms. Conclusion: During two years follow up, differences could be substantiated between the two treatment arms regarding arm and neck pain.

Cervical radicular syndrome (CRS) due to a herniated disc can be safely treated by surgical decompression of the spinal root. In the vast majority of cases this relieves pain in the arm and restores function. However, conservative treatment also has a high chance on relieving symptoms. The objective of the present study is to evaluate the (cost-) effectiveness of surgery versus prolonged conservative care during one year of follow-up, and to evaluate the timing of surgery. Predisposing factors in favour of one of the two treatments will be evaluated.

Objectives To evaluate the occurrence of symptomatic and asymptomatic root compression caused by herniated discs and spondylotic foraminal stenosis by MRI in patients with recent onset cervical radiculopathy. Participants 78 patients with symptoms and signs of cervical radiculopathy of less than one month's duration. Methods The authors determined the clinically suspected level of root compression in each patient. Two neuroradiologists independently evaluated MRIs, blinded for the clinical findings. For each patient, the level of root compression on MRI was compared with the clinically affected level. The authors also examined the cause of compression: herniated disc, spondylotic foraminal stenosis or both. Results In 73% of patients, the clinically affected root was compressed on MRI. In 45%, MRI showed root compression without clinical substrate together with, or to a lesser extent without, the coexistence of compression of the clinically affected root. MRIs were assessed as normal in 13–15% of cases, and in 9–10% only asymptomatic roots were compressed. Herniated discs without spondylosis were more often responsible for root compressions only at the clinically affected level and spondylotic foraminal stenosis for multiple root compression including compression of clinically unaffected roots. Conclusion MRI findings in patients with cervical radiculopathy should be interpreted together with the clinical findings, as false-positive and false-negative MRIs occur rather frequently.

Objective To evaluate the effectiveness of treatment with collar or physiotherapy compared with a wait and see policy in recent onset cervical radiculopathy. Design Randomised controlled trial. Setting Neurology outpatient clinics in three Dutch hospitals. Participants 205 patients with symptoms and signs of cervical radiculopathy of less than one month’s duration Interventions Treatment with a semi-hard collar and taking rest for three to six weeks; 12 twice weekly sessions of physiotherapy and home exercises for six weeks; or continuation of daily activities as much as possible without specific treatment (control group). Main outcome measures Time course of changes in pain scores for arm and neck pain on a 100 mm visual analogue scale and in the neck disability index during the first six weeks. Results In the wait and see group, arm pain diminished by 3 mm/week on the visual analogue scale (β=−3.1 mm, 95% confidence interval −4.0 to −2.2 mm) and by 19 mm in total over six weeks. Patients who were treated with cervical collar or physiotherapy achieved additional pain reduction (collar: β=−1.9 mm, −3.3 to −0.5 mm; physiotherapy: β=−1.9, −3.3 to −0.8), resulting in an extra pain reduction compared with the control group of 12 mm after six weeks. In the wait and see group, neck pain did not decrease significantly in the first six weeks (β=−0.9 mm, −2.0 to 0.3). Treatment with the collar resulted in a weekly reduction on the visual analogue scale of 2.8 mm (−4.2 to −1.3), amounting to 17 mm in six weeks, whereas physiotherapy gave a weekly reduction of 2.4 mm (−3.9 to −0.8) resulting in a decrease of 14 mm after six weeks. Compared with a wait and see policy, the neck disability index showed a significant change with the use of the collar and rest (β=−0.9 mm, −1.6 to −0.1) and a non-significant effect with physiotherapy and home exercises. Conclusion A semi-hard cervical collar and rest for three to six weeks or physiotherapy accompanied by home exercises for six weeks reduced neck and arm pain substantially compared with a wait and see policy in the early phase of cervical radiculopathy. Trial registration Clinical trials NCT00129714.

Degenerative cervical radiculopathy: clinical diagnosis and conservative treatment. A review. To provide a state‐of‐the‐art assessment of diagnosis and non‐surgical treatment of degenerative cervical radiculopathy a literature search for studies on epidemiology, diagnosis including electrophysiological examination and imaging studies, and different types of conservative treatment was undertaken. The most common causes of cervical root compression are spondylarthrosis and disc herniation. Diagnosis is made mainly on clinical grounds, although there are no well‐defined criteria. Provocative tests like the foraminal compression test are widely used but not properly evaluated. The clinical diagnosis of degenerative cervical radiculopathy can be confirmed by magnetic resonance imaging. The role of electromyography is mainly to rule out other conditions. Cervical radiculopathy is initially treated conservatively, although no treatment modality has been evaluated in a randomized controlled trial. Degenerative cervical radiculopathy: diagnosis and conservative treatment. A review.