Friday, March 1, 2013
Is PT as effective as ACDF for cervical radiculopathy?
Cervical radiculopathy is a common problem and the diagnosis that leads to the majority of cervical spine surgery. Similar to lumbar radiculopathy, it generally has a favorable natural history and improves without surgery in the many of patients. Somewhat surprisingly, there has never been a Level I study or even high quality Level II study comparing surgery to non-operative treatment for cervical radiculopathy. In the February 15 issue, Dr. Peolsson and colleagues from Sweden published the results of their RCT comparing functional outcomes between cervical radiculopathy patients randomized to ACDF + physical therapy (PT) or PT alone. All patients had symptoms for over 8 weeks and MRI demonstrating nerve compression at one or two levels consistent with their radicular symptoms. Patients with myelopathy were excluded. Outcome measures included cervical range of motion, neck muscle endurance, hand strength, and manual dexterity, evaluated out to two years. There were no significant differences on any outcome measure at any time point, though the authors indicated there were some trends suggesting more rapid improvement on some outcomes for the ACDF + PT group. An important finding was that only 2 out of 32 patients randomized to PT alone elected to have surgery, and no patient randomized to ACDF crossed over to non-operative treatment. This is in stark contrast to the SPORT RCT for lumbar radiculopathy due to disk herniation in which there was approximately 40% crossover in both directions.
Does this study suggest that ACDF and PT lead to similar outcomes for cervical radiculopathy? This study reports only functional outcomes rather than patient-reported outcomes such as pain and the Neck Disability Index (NDI). As such, it offers no information about pain and disability, outcomes that most patients would probably find more important than range of motion, strength, or dexterity. Additionally, as the authors point out, the study is likely underpowered for these outcomes, so it is possible that Type II error is present and the study failed to demonstrate a true difference in outcomes. Hopefully the authors are going to report the pain and NDI outcomes in another paper. Another aspect of this paper that makes it hard to generalize to the typical ACDF candidate is the relatively low level of pain and disability in this patient population compared to other studies of cervical radiculopathy. At baseline, the patients in this study and neck and arm VAS scores under 50 and an average NDI of 19. This compares to VAS scores in the 60s and an average NDI of over 50 in the Prodisc-C trial comparing ACDF to total disk replacement for cervical radiculopathy.1 The current study is important in that it allows us to inform patients that ACDF is unlikely to lead to marked improvements in functional outcomes compared to PT. It also suggests that a trial comparing surgical to non-operative treatment for cervical radiculopathy can be performed without high levels of crossover (at least in Sweden), so maybe a large-scale RCT will be performed in the future in order to determine if ACDF is truly superior to non-operative treatment.
Please read Dr. Peolsson’s article in the February 15 issue and the accompanying commentary. Does this paper change how you see the role of PT in the treatment of cervical radiculopathy? Let us know by leaving a comment on The Spine Blog.
Adam Pearson, MD, MS
Associate Web Editor
1. Zigler JE, Delamarter R, Murrey D, Spivak J, Janssen M. ProDisc-C and Anterior Cervical Discectomy and Fusion as Surgical Treatment for Single-Level Cervical Symptomatic Degenerative Disc Disease: Five-Year Results of a Food and Drug Administration Study. Spine 2013;38:203-9.