Cervical Radiculopathy: Why Most Neck-Related Arm Pain Doesn't Need Surgery

According to international Spine Society guidelines, any pain coming from the spine where the primary problem is pain alone does not require surgery. The indications for surgery are disability — foot drop, motor or sensory deficit — or more than moderate to severe canal stenosis on MRI, where pain intervention can buy time but can't treat the disease. If a patient comes to me with a neurological deficit, I immediately refer to the spine surgeon and don't proceed with intervention. If pain is the only presenting symptom, we treat it — there's a very clear demarcation.

If you use opioids for chronic low back pain, knee pain or musculoskeletal pain, yes, they are habit-forming. But for cancer pain, and for pain like sickle cell disease — which we manage on the same lines as cancer pain — they are never habit-forming. Visceral pain is mediated by the sympathetic nervous system and doesn't respond to conventional NSAIDs, so it needs neuropathic agents and opioids in combination; back pain, knee pain and shoulder pain are peripheral musculoskeletal or neuropathic pain and don't carry the same opioid receptor expression, which is why the risk profile is so different between the two.

The nerve cannot truly regenerate in the clinical sense. When there is nerve injury, the patient can go into complex regional pain syndrome Type II. Nerve regeneration takes a very long time and the results are poor — if you believe you can treat a patient through nerve regeneration, in present-day practice that is a myth.

For nerve blocks we use ropivacaine. For steroids, we primarily use dexamethasone in spinal procedures. For joint injections, we usually use Kenacort (triamcinolone).

In India, opioids are scheduled drugs — you need a prescription from a competent doctor: a pain specialist, anaesthesiologist or neurologist, not a general surgeon or ENT. For morphine and fentanyl specifically, the hospital needs a government licence to hold a certain quantity, and we use a special designated government form that we stamp, with patients required to bring a consumption chart we submit to the drug controller. Tramadol, tapentadol and buprenorphine don't need special licensing, but you do need a valid prescription from a competent doctor.

No. If there is no myelopathy, meaning no muscle weakness or severe sensory deficit, the pain can be treated with a cervical epidural injection rather than surgery. Only 3-5% of patients present with true myelopathy, so 95-97% can be managed conservatively.

Myelopathy means muscle weakness or a severe sensory deficit caused by the compressed nerve. Its presence, rather than pain alone, is what determines whether a patient needs surgery instead of a conservative epidural injection.

Live digital subtraction angiography in the catheterisation lab can reveal in real time when a needle has inadvertently threaded into the epidural venous plexus rather than the epidural space, allowing redirection before injecting and avoiding what could be a serious, potentially fatal complication.