Ross Hauser, MD.

In this article, we will examine some of the more recent research surrounding the avoidance of anterior cervical decompression and fusion through the use of physical therapy.

It is very difficult to compare conservative care or physical therapy outcomes versus anterior cervical decompression and fusion because the research is not there. That is not my statement, that is the opinion of leading UK researchers publishing in the Global Spine Journal (1) in March of 2023. Listen to what they have to say: “The published (research) does not allow direct comparison of conservative vs surgical management in addressing motor deficits in degenerative cervical radiculopathy. This is because of (non-consistent data collection)  in the reporting of motor deficits, and the (small amount) of studies investigating motor outcomes in conservative cohorts, where the focus was commonly on pain relief and global (as opposed to motor-specific) outcome measures. (While one study) showed that conservative management resulted in 90.2% of patients with painful motor radiculopathy experiencing motor improvements, (this was) a stark contrast to the 10% reported (in another study which) however omitted to state the baseline prevalence of motor deficits and only reported short-term follow-up.”

To these researchers, the hope of offering comparison research to provide guidance in helping to decide whether to go to surgery or not was not there.

A comparison between physical therapy and anterior cervical decompression and fusion. After two years, the same result between physical therapy and surgery was seen – no difference in the outcome.

The rush to surgery is based on the immediate goals of the patients, that is the alleviation of pain. Spinal cervical fusion and decompression seem to offer a solution – short-term. This is supported in the medical literature. In one study in the medical journal Spine,(2)  patients with cervical radiculopathy, treated with surgery and physiotherapy resulted in a more rapid patient improvement during the first year after surgery, with significantly greater improvement in neck pain and global assessment scores compared to physiotherapy alone.

However . . . 

However, the differences between the groups decreased after two years. In this paper where surgery was touted as being so successful – the researchers concluded: “Structured physiotherapy should be tried before surgery is chosen.” After two years, the same result between physical therapy and surgery was seen – no difference in the outcome.

That study is from 2013.

In 2017, the same group of doctors in Sweden writing in the Journal of Spine, (3)  evaluated the 5- to 8-year outcome of anterior cervical decompression and fusion (ACDF) combined with a structured physiotherapy program as compared with that following the same physiotherapy program alone in patients with cervical radiculopathy.

Citing the 2013 research above, the doctors noted that no study went beyond two years in describing the comparison effect of surgery vs. physical therapy for cervical radiculopathy.

In this study, Fifty-nine patients were randomized to ACDF surgery with postoperative physiotherapy (30 patients) or to structured physiotherapy alone (29 patients).

• The physiotherapy program included general and specific exercises as well as pain-coping strategies.
• Patient results were measured as improvement in neck disability, neck and arm pain intensity, and a patient’s overall health assessment.

RESULTS

• After 5-8 years, the neck disability was reduced by an average of 21% (based on the standard scoring system) in the surgical group and 11% in the nonsurgical group.
• This prospective randomized study of 5- to 8-year outcomes of surgical versus nonsurgical treatment in patients with cervical radiculopathy, anterior cervical decompression, and fusion combined with physiotherapy reduced neck disability and neck pain more effectively than physiotherapy alone. Self-rating by patients as regards treatment outcome was also superior in the surgery group. No significant differences were seen between the 2 patient groups as regards arm pain and health outcomes. 

A 2013 randomized controlled trial in the journal Spine (4) examined cervical radiculopathy patients for functionality after physiotherapy (no surgery) compared with anterior surgery followed by physiotherapy.

• This study included 63 patients with radiculopathy and magnetic resonance imaging-verified nerve root compression. The group was split between those who would get the ACDF surgery in combination with physiotherapy or physiotherapy alone. In the follow-up, 49 of these patients were assessed for active range of neck motion, neck muscle endurance, and hand-related functioning before treatment and at three-, six-, 12-, and 24-month follow-ups.

Results: The researchers found no significant differences between the two groups. In fact both groups showed improvements over time in neck muscle endurance, manual dexterity, and right-handgrip strength. The researchers concluded: “Compared with a structured physiotherapy program alone, ACDF followed by physiotherapy did not result in additional improvements in neck active range of motion, neck muscle endurance, or hand-related function in patients with radiculopathy. We suggest that a structured physiotherapy program should precede a decision for ACDF intervention in patients with radiculopathy, to reduce the need for surgery. ”

References

1 Gebreyohanes A, Erotocritou M, Choi D. Appraising The Evidence for Conservative versus Surgical Management of Motor Deficits in Degenerative Cervical Radiculopathy. Global Spine Journal. 2023 Mar;13(2):547-62. [Google Scholar]
2 Engquist M, Löfgren H, Öberg B, Holtz A, Peolsson A, Söderlund A, Vavruch L, Lind B. Surgery versus nonsurgical treatment of cervical radiculopathy: a prospective, randomized study comparing surgery plus physiotherapy with physiotherapy alone with a 2-year follow-up. [Google Scholar]
3 Engquist M, Löfgren H, Öberg B, Holtz A, Peolsson A, Söderlund A, Vavruch L, Lind B. A 5-to 8-year randomized study on the treatment of cervical radiculopathy: anterior cervical decompression and fusion plus physiotherapy versus physiotherapy alone. Journal of Neurosurgery: Spine. 2017 Jan 1;26(1):19-27. [Google Scholar]
4 Peolsson A, Söderlund A, Engquist M, Lind B, Löfgren H, Vavruch L, Holtz A, Winström-Christersson A, Isaksson I, Öberg B. Physical function outcome in cervical radiculopathy patients after physiotherapy alone compared with anterior surgery followed by physiotherapy: a prospective randomized study with a 2-year follow-up. [Google Scholar]