Cervical Radiculopathy Trial (CRT)

A Randomised Controlled Trial Comparing the Effectiveness of Surgical and Nonsurgical Treatment for Cervical Radiculopathy

The primary aim of the present project is to compare the effectiveness of surgery and nonsurgical treatment in patients with cervical radiculopathy caused by either disc herniation or spondylosis. Secondary aims are to evaluate cost-effectiveness and predicting factors of success of the two treatments, and to explore the terms success rate and expectations by asking the patients to fill in their expected primary outcome score at baseline.

Cervical radiculopathy is usually caused by disc herniation or spondylosis. Prognosis is expected to be good in most patients but there is limited scientific evidence about the indication for non-surgical and surgical treatment. Two randomised controlled trials comparing cervical decompression and non-operative treatment with cost-effectiveness analysis and assessment of expectations and predictors of outcome. The main research question will be evaluated at one-year follow-up. To test the hypothesis that the effectiveness of surgery as measured by the change in Neck Disability Index (NDI) and arm pain at 1-year follow-up in patients with cervical radiculopathy is not different from non-surgical treatment in: Study 1: one level disc herniation (C5/6 or C6/7) Study 2: one or two level spondylosis (C5/6 and/or C6/7) To test the hypothesis that surgery is more effective in patients with more clinical finding (dermatomal sensory loss, myotonal weakness and reflex disturbance) at baseline when adjusted for other possible predictors such as age, gender, baseline pain, duration, radiological findings, expectations, and psychological factors). To estimate cost-effectiveness for health care costs and societal costs (including sickness absence) in surgical versus non-surgical patients. To assess radiological (MRI and CT) measurements of foraminal area and nerve compression and if changes can predict clinical changes (NDI and arm pain) at 1-year . To evaluate treatment outcome expectations at baseline asking the patients to fill in their expected improvement.

Patients will attend an experienced specialist in physical medicine and rehabilitation and a physiotherapist.

Anterior discectomy will be performed and a microscope is used. After separation of the platysma muscle the pre-vertebral space is reached by an approach medial to the sternocleido-mastoid muscle and the carotid artery and lateral to the trachea and oesophagus. Then the disc is incided and the corpora are distracted to perform discectomy. Usually the posterior ligament is cut and the spinal root is decompressed and if necessary the arthritic rims are removed. An inter-vertebral fusion device is inserted, two levels are allowed in the spondylosis study.

Patients will first attend an experienced specialist in physical medicine and rehabilitation who will answer concerns and questions and if necessary repeat the information given before inclusion. The aim of the brief intervention is to promote better understanding and coping of the condition. The intervention will include supervision by a physiotherapist (6 sessions altogether) and provide advice on how to handle secondary neck muscle pain and dysfunction, reduce eventual fear avoidance, and advice to stay active.

Consists of ten questions about pain related disability and include items such as by example headache, concentration, reading and sleep. Each item is rated by choosing one of five response categories and transformed to a total score from 0 to 100 (worst possible). The Norwegian version has been validated in patients with neck pain and with cervical radiculopathy.

EQ-5D-5L includes five domains: mobility; self-care, daily activities, pain/discomfort, and anxiety/depression and each has three response categories. The responses are transformed into and index to value the patients' health related quality of life for the cost utility analyses. Patients score their health from 0 (as bad as possible) to 100 (best possible) by EQ-VAS. The Norwegian version has been validated in patients with back pain, idiopathic scoliosis, and cervical radiculopathy.

Perceived recovery or change of the main symptom rated on a numeric scale ranging from -9 (worst possible change) to 9 (best possible change)

Sickness absence data will be collected from the National Social Security Institution for the year before and after inclusion.

Exploring patient expectations ahead of treatment. The patients are asked to fill out the Neck Disability Index pretending they are at 52 weeks post treatment and selecting the lowest category they would be content with for each item. The patients are also asked to report what they expect their symptoms to be like 52 weeks ahead (ranging from much worse to much better), registered for arm pain, neck pain and headache separately.

Exploring global success rate by asking the patients about how the arm pain and neck pain is compared to prior to treatment (ranging from much worse to much better).

Inclusion Criteria: Age 20 to 65 years. Study 1: Neck and arm pain for at least 3 months with a corresponding herniation involving one cervical nerve root (C6 or C7) Study 2: Neck and arm pain for at least 3 months with a corresponding spondylosis involving C6 and/or C7) . Pain intensity of arm pain of at least 4 on a scale from 0 (no pain) to 10 (worst possible pain) Willing to accept either of the treatment alternatives NDI > 30 Exclusion Criteria: Patients with any previous cervical fractures or cervical spine surgery; Signs of myelopathy; Rapidly progressive paresis or paresis < grade 4; Pregnancy; Arthritis involving the cervical spine; Infection or active cancer; Generalised pain syndrome; Serious psychiatric or somatic disease that exclude one of the treatment alternatives; Concomitant shoulder disorders that may interfere with outcome; Abuse of medication/narcotics, Not able to understand written Norwegian, Not willing to accept one of the treatment alternatives.

Taso M, Sommernes JH, Kolstad F, Sundseth J, Bjorland S, Pripp AH, Zwart JA, Brox JI. A randomised controlled trial comparing the effectiveness of surgical and nonsurgical treatment for cervical radiculopathy. BMC Musculoskelet Disord. 2020 Mar 16;21(1):171. doi: 10.1186/s12891-020-3188-6.