NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 1 North American Spine Society Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders NASS Evidence-Based Guideline Development Committee Christopher M. Bono, MD, Committee Chair Robert Fernand, MD Gary Ghiselli, MD, Outcome Measures Chair Tim Lamer, MD Thomas J. Gilbert, MD, Diagnosis/Imaging Chair Paul Matz, MD D. Scott Kreiner, MD, Medical/Interventional Chair Dan Mazanec, MD Charles Reitman, MD, Surgical Treatment Chair Daniel K. Resnick, MD Jeffrey Summers, MD, Natural History Chair William O. Shaffer, MD Jamie Baisden, MD Anil Sharma, MD John Easa, MD Reuben Timmons, MD John Toton, MD This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular to the locality or institution. NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 2 Financial Statement This clinical guideline was developed and funded in its entirety by the North American Spine Society (NASS). All participating authors have submitted a disclosure form relative to potential conflicts of interest which is kept on file at NASS. Comments Comments regarding the guideline may be submitted to the North American Spine Society and will be consid- ered in development of future revisions of the work. North American Spine Society Evidence-Based Clinical Guidelines for Multidisciplinary Spine Care Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders Copyright © 2010 North American Spine Society 7075 Veterans Boulevard Burr Ridge, IL 60527 630.230.3600 www.spine.org ISBN: 1-929988-25-7 This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular to the locality or institution. 3 Table of Contents I. Introduction . 4 II. Guideline Development Methodology . .5 III. Natural History of Cervical Radiculopathy from Degenerative Disorders. .9 IV. Recommendations for Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders A. Diagnosis/Imaging. 12 B. Outcome Measures for Treatment. 31 C. Medical and Interventional Treatment. 41 D. Surgical Treatment. 50 V. Appendices A. Acronyms. 72 B. Levels of Evidence for Primary Research Questions. 73 C. Grades of Recommendations for Summaries or Reviews of Studies. 74 D. Protocol for NASS Literature Searches. 75 E. Literature Search Parameters. 77 F. Evidentiary Tables. 86 VI. References. 168 This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular to the locality or institution. NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 4 I. Introduction Objective The objective of the North American Spine Society reasonable evaluation of patients suspected to have (NASS) Clinical Guideline for the Diagnosis and cervical radiculopathy from degenerative disorders Treatment of Cervical Radiculopathy from Degen- and outlines treatment options for adult patients erative Disorders is to provide evidence-based rec- with a diagnosis of cervical radiculopathy from de- ommendations to address key clinical questions generative disorders. surrounding the diagnosis and treatment of cervi- cal radiculopathy from degenerative disorders. The THIS GUIDELINE DOES NOT REPRESENT A guideline is intended to reflect contemporary treat- “STANDARD OF CARE,” nor is it intended as a fixed ment concepts for cervical radiculopathy from de- treatment protocol. It is anticipated that there will generative disorders as reflected in the highest qual- be patients who will require less or more treatment ity clinical literature available on this subject as of than the average. It is also acknowledged that in May 2009. The goals of the guideline recommenda- atypical cases, treatment falling outside this guide- tions are to assist in delivering optimum, efficacious line will sometimes be necessary. This guideline treatment and functional recovery from this spinal should not be seen as prescribing the type, frequen- disorder. cy or duration of intervention. Treatment should be based on the individual patient’s need and physi- Scope, Purpose and Intended User cian’s professional judgment. This document is de- This document was developed by the North Ameri- signed to function as a guideline and should not be can Spine Society Evidence-Based Guideline Devel- used as the sole reason for denial of treatment and opment Committee as an educational tool to assist services. This guideline is not intended to expand or practitioners who treat patients with cervical radic- restrict a health care provider’s scope of practice or ulopathy from degenerative disorders. The goal is to to supersede applicable ethical standards or provi- provide a tool that assists practitioners in improving sions of law. the quality and efficiency of care delivered to pa- tients with cervical radiculopathy from degenera- Patient Population tive disorders. The NASS Clinical Guideline for the The patient population for this guideline encom- Diagnosis and Treatment of Cervical Radiculopathy passes adults (18 years or older) with a chief com- from Degenerative Disorders provides a definition plaint of pain in a radicular pattern in one or both and explanation of the natural history of cervical ra- upper extremities related to compression and/or ir- diculopathy from degenerative disorders, outlines a ritation of one or more cervical nerve roots. This clinical guideline should not be construed as including all proper methods of care or excluding other acceptable methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding any specific procedure or treatment is to be made by the physician and patient in light of all circumstances presented by the patient and the needs and resources particular to the locality or institution. NASS Clinical Guidelines – Diagnosis and Treatment of Cervical Radiculopathy from Degenerative Disorders 5 II. Guideline Development Methodology Through objective evaluation of the evidence and and exercises, or interactivities, to prepare guideline transparency in the process of making recommen- developers for systematically evaluating literature dations, it is NASS’ goal to develop evidence-based and developing evidence-based guidelines. The on- clinical practice guidelines for the diagnosis and line course takes approximately 15-30 hours to com- treatment of adult patients with various spinal con- plete, and participants have been awarded CME ditions. These guidelines are developed for educa- credit upon completion of the course. tional purposes to assist practitioners in their clini- cal decision-making processes. It is anticipated that Disclosure of Potential Conflicts of where evidence is very strong in support of recom- Interest mendations, these recommendations will be opera- All participants involved in guideline development tionalized into performance measures. have disclosed their relationships with other entities and potential conflicts of interest to their colleagues Multidisciplinary Collaboration and their potential conflicts have been documented With the goal of ensuring the best possible care for for future reference. They will not be published in adult patients suffering with spinal disorders, NASS any guideline, but kept on file for reference, if need- is committed to multidisciplinary involvement in ed. Participants have been asked to update their dis- the process of guideline and performance measure closures regularly throughout the guideline devel- development. To this end, NASS has ensured that opment process. representatives from medical, interventional and surgical spine specialties have participated in the Levels of Evidence and Grades of development and review of all NASS guidelines. It is also important that primary care providers and Recommendation musculoskeletal specialists who care for patients NASS has adopted standardized levels of evidence with spinal complaints are represented in the de- (Appendix B) and grades of recommendation (Ap- velopment and review of guidelines that address pendix C) to assist practitioners in easily under- treatment by first contact physicians, and NASS has standing the strength of the evidence and recom- involved these providers in the development pro- mendations within the guidelines. The levels of cess as well. To ensure broad-based representation, evidence range from Level I (high quality random- NASS has invited and welcomes input from other ized controlled trial) to Level V (expert consensus).