Surgery for cervical radiculopathy followed by physiotherapy may resolve symptoms faster than physiotherapy alone, but with few differences at two years

摘要

Summary of: Engquist M, Lo?fgren H, O?berg B, Holtz A, Peolsson A, So?derlund A, et al. Surgery versus nonsurgical treatment of cervical radiculopathy: a prospective, randomized study comparing surgery plus physiotherapy with physiotherapy alone with a 2-year follow- up. Spine 2013;20:1715-1722. Question: Does surgery for patients with cervical radiculopathy followed by physiotherapy result in larger long-term improve- ments in self-reported disability when compared with a physio- therapy program alone? Design: A randomised, controlled trial with concealed allocation and 24 months of follow up. Setting: Three Swedish spinal centres. Participants: Men and women between 18 and 65 years of age with pain (with or without sensory and motor deficit) in one or both arms indicating nerve root involvement caused by disc herniation with or without osteo- phytes, or a stenosis caused by osteophytes, confirmed by magnetic resonance imaging. Symptom duration was between eight weeks and five years, and involved one or two symptomatic disc levels. Key exclusion criteria included obvious myelopathy, and previous surgery to the cervical spine. Randomisation allocated 35 to the surgery plus physiotherapy group and 33 to the physiotherapy group. Interventions: Both groups received an individualised physiotherapy program, which included general/ specific exercises and pain-coping strategies, provided twice a week at the clinic for at least three months, in addition to daily home exercises. In addition, the surgery group received an anterior cervical decompression and fusion (ACDF). Outcome measures: Primary outcome was the Neck Disability Index at 24 months. Secondary measures were pain intensity in the neck and arm (0 to1836-9553/ 2014 Australian Physiotherapy Association. Published by Elsevier B.V. Al100 visual analogue scale) and global assessment of change. Results: A total of 63 patients completed the 24-month follow up (n = 31 surgery and n = 32 physiotherapy). Five patients allocated to physiotherapy had surgery during the study period. There was no difference in reduction in Neck Disability Index scores between the groups at 12 months or 24 months: surgery plus physiotherapy 14.2 (95% CI, 5.6 to 22.7) versus physiotherapy 11.5 (95% CI, 3.0 to 19.9). Over 24 months there was a difference in favour of the surgical group in neck pain intensity (p = 0.039) with a mean difference at 12 months of 18.4 (95% CI, 3.2 to 30.8), but not for arm pain intensity (p = 0.580) or for the proportion of patients rating their symptoms as better/much better (p = 0.28). Conclusion: Surgery for cervical radiculopathy followed by physiotherapy resulted in a more-rapid improvement in neck pain than a physiotherapy program alone, but after 24 months there were few differences between the groups. Thus, a comprehensive physiotherapy program should be tried before surgery for patients with cervical radiculopathy. Margreth Grotlea,b and Kare Birger Hagenc aDivision of Surgery and Clinical Neuroscience, Oslo University Hospital; bOslo and Akershus University College of Applied Sciences, Faculty of Health Sciences; cNational Advisory Unit on Rehabilitation in Rheumatology, Department of Rheumatology, Diakonhjemmet Hospital, Oslo, Norway http://dx.doi.org/10.1016/j.jphys.2014.05.009.