Early Versus Delayed Surgery for Cervical Disc Herniation

  • Lukas Bobinski
  • Yohan Robinson


Background: Cervical radiculopathy due to disc herniation is a menace both to quality of life and the labor force. Early surgical treatment allows early rehabilitation but is associated with surgical complication risks. Delayed treatment allows many patients to recover with physiotherapy, without affecting the surgical wait list, but late return to work and delayed crossover into surgical treatment may become costly for society.

Objectives: The main goal of this review was to investigate whether the timing of surgery has an impact on clinical outcomes in patients with cervical radiculopathy.

Search Methods: An electronic search for randomized controlled trials published between January 1st, 2000 and December 31st, 2017 was carried out, using following databases:

NLM PubMed MEDLINE, Google Scholar, Cochrane Library and

Selection Criteria: Only randomized controlled trials on treatment of acute cervical radiculopathy were included for further analysis. Studies that did not contain information regarding surgical treatment of cervical radiculopathy and those with more than 10% pediatric patients (<18 years of age) or more than 10% elderly patients (≥65 years of age), were excluded.

Data Collection and Analysis: Of the initial 564 studies, only two underwent qualitative synthesis and only one study, with 58 study participants, could be included in the meta-analysis. Included in the meta-analysis were: neck and arm pain (VAS, range 0–10) and the Neck Disability Index (NDI, range 0–100), presented with mean difference (MD) with a 95% confidence interval (95% CI).

Main Results: The current evidence supports the conclusion that early surgery (within 6 months) contributes to a better outcome with regard to arm pain (p = 0.04, MD −1.4, 95% CI −2.74 to −0.06). There is a trend towards better neck functioning (NDI) after early surgical intervention (p = 0.06, MD −4.80, 95% CI −24.36 to 14.76). No effect of timing on neck pain was seen (p = 0.3, MD −0.9, 95% CI −2.76 to 0.06).

Authors’ Conclusions: There is only weak evidence supporting the conclusion that surgical treatment should be performed within 6 months after debut of radiculopathy because it corresponds with better clinical outcome with regard to arm pain. This finding should therefore be validated by randomized controlled trials, using timing as a comparator.


Degenerative cervical disc disease Surgery Timing 


  1. 1.
    Shedid D, Benzel EC. Cervical spondylosis anatomy: pathophysiology and biomechanics. Neurosurgery. 2007;60(1 Suppl 1):S7–13.PubMedGoogle Scholar
  2. 2.
    Van Zundert J, Harney D, Joosten EA, Durieux ME, Patijn J, Prins MH, Van Kleef M. The role of the dorsal root ganglion in cervical radicular pain: diagnosis, pathophysiology, and rationale for treatment. Reg Anesth Pain Med. 2006;31(2):152–67.CrossRefGoogle Scholar
  3. 3.
    Radhakrishnan K, Litchy WJ, O’Fallon WM, Kurland LT. Epidemiology of cervical radiculopathy. A population-based study from Rochester, Minnesota, 1976 through 1990. Brain. 1994;117(Pt 2):325–35.CrossRefGoogle Scholar
  4. 4.
    Wong JJ, Côté P, Quesnele JJ, Stern PJ, Mior SA. The course and prognostic factors of symptomatic cervical disc herniation with radiculopathy: a systematic review of the literature. Spine J. 2014;14(8):1781–9.CrossRefGoogle Scholar
  5. 5.
    Rhee JM, Yoon T, Riew KD. Cervical radiculopathy. J Am Acad Orthop Surg. 2007;15(8):486–94.CrossRefGoogle Scholar
  6. 6.
    Carette S, Fehlings MG. Clinical practice. Cervical radiculopathy. N Engl J Med. 2005;353(4):392–9.CrossRefGoogle Scholar
  7. 7.
    Burkhardt BW, Brielmaier M, Schwerdtfeger K, Oertel JM. Clinical outcome following anterior cervical discectomy and fusion with and without anterior cervical plating for the treatment of cervical disc herniation-a 25-year follow-up study. Neurosurg Rev. 2017;41(2):473–82.CrossRefGoogle Scholar
  8. 8.
    Hacker RJ. A randomized prospective study of an anterior cervical interbody fusion device with a minimum of 2 years of follow-up results. J Neurosurg. 2000;93(2 Suppl):222–6.PubMedGoogle Scholar
  9. 9.
    Burneikiene S, Nelson EL, Mason A, Rajpal S, Villavicencio AT. The duration of symptoms and clinical outcomes in patients undergoing anterior cervical discectomy and fusion for degenerative disc disease and radiculopathy. Spine J. 2015;15(3):427–32.CrossRefGoogle Scholar
  10. 10.
    de Rooij JD, Gadjradj PS, Huygen FJ, Luijsterburg PA, Harhangi BS. Management of symptomatic cervical disk herniation: a survey among dutch neurosurgeons. Spine (Phila Pa 1976). 2017;42(5):311–7.CrossRefGoogle Scholar
  11. 11.
    Bertalanffy H, Eggert HR. Clinical long-term results of anterior discectomy without fusion for treatment of cervical radiculopathy and myelopathy. A follow-up of 164 cases. Acta Neurochir. 1988;90(3–4):127–35.CrossRefGoogle Scholar
  12. 12.
    Lied B, Roenning PA, Sundseth J, Helseth E. Anterior cervical discectomy with fusion in patients with cervical disc degeneration: a prospective outcome study of 258 patients (181 fused with autologous bone graft and 77 fused with a PEEK cage). BMC Surg. 2010;10:10.CrossRefGoogle Scholar
  13. 13.
    Carreon LY, Glassman SD, Campbell MJ, Andersen PA. Neck Disability Index, short form-36 physical component summary, and pain scales for neck and arm pain: the minimum clinically important difference and substantial clinical benefit after cervical spine fusion. Spine J. 2010;10:469–74.CrossRefGoogle Scholar
  14. 14.
    McGowan J, Sampson M, Salzwedel DM, Cogo E, Foerster V, Lefebvre C. PRESS Peer Review of Electronic Search Strategies: 2015 Guideline Statement. J Clin Epidemiol. 2016;75(Supplement C):40–6.CrossRefGoogle Scholar
  15. 15.
    Guyatt GH, Oxman AD, Vist G, Kunz R, Brozek J, Alonso-Coello P, Montori V, Akl EA, Djulbegovic B, Falck-Ytter Y, Norris SL, Williams JW Jr, Atkins D, Meerpohl J, Schunemann HJ. GRADE guidelines: 4. Rating the quality of evidence--study limitations (risk of bias). J Clin Epidemiol. 2011;64(4):407–15.CrossRefGoogle Scholar
  16. 16.
    Villavicencio AT, Babuska JM, Ashton A, Busch E, Roeca C, Nelson EL, Mason A, Burneikiene S. Prospective, randomized, double-blind clinical study evaluating the correlation of clinical outcomes and cervical sagittal alignment. Neurosurgery. 2011;68(5):1309–16; discussion 1316.CrossRefGoogle Scholar
  17. 17.
    Engquist M, Lofgren H, Oberg B, Holtz A, Peolsson A, Soderlund A, Vavruch L, Lind B. Factors affecting the outcome of surgical versus nonsurgical treatment of cervical radiculopathy: A randomized, controlled study. Spine (Phila Pa 1976). 2015;40(20):1553–63.CrossRefGoogle Scholar
  18. 18.
    Boden SD, Davis DO, Dina TS, Patronas NJ, Wiesel SW. Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation. J Bone Joint Surg Am. 1990;72(3):403–8.CrossRefGoogle Scholar
  19. 19.
    Matsumoto M, Fujimura Y, Suzuki N, Nishi Y, Nakamura M, Yabe Y, Shiga H. MRI of cervical intervertebral discs in asymptomatic subjects. J Bone Joint Surg Br. 1998;80(1):19–24.CrossRefGoogle Scholar
  20. 20.
    Kobayashi N, Asamoto S, Doi H, Ikeda Y, Matusmoto K. Spontaneous regression of herniated cervical disc. Spine J. 2003;3(2):171–3.CrossRefGoogle Scholar
  21. 21.
    Mochida K, Komori H, Okawa A, Muneta T, Haro H, Shinomiya K. Regression of cervical disc herniation observed on magnetic resonance images. Spine (Phila Pa 1976). 1998;23(9):990–5; discussion 996-997.CrossRefGoogle Scholar
  22. 22.
    Cesaroni A, Nardi PV. Plasma disc decompression for contained cervical disc herniation: a randomized, controlled trial. Eur Spine J. 2010;19(3):477–86.CrossRefGoogle Scholar
  23. 23.
    Murphy DR, Hurwitz EL, Gregory A, Clary R. A nonsurgical approach to the management of patients with cervical radiculopathy: a prospective observational cohort study. J Manip Physiol Ther. 2006;29(4):279–87.CrossRefGoogle Scholar
  24. 24.
    Persson LC, Moritz U, Brandt L, Carlsson CA. Cervical radiculopathy: pain, muscle weakness and sensory loss in patients with cervical radiculopathy treated with surgery, physiotherapy or cervical collar. A prospective, controlled study. Eur Spine J. 1997;6(4):256–66.CrossRefGoogle Scholar
  25. 25.
    Gebremariam L, Koes BW, Peul WC, Huisstede BM. Evaluation of treatment effectiveness for the herniated cervical disc: a systematic review. Spine (Phila Pa 1976). 2012;37(2):E109–18.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Lukas Bobinski
    • 1
  • Yohan Robinson
    • 2
  1. 1.Spine Unit, Department of OrthopaedicsUmeå University HospitalUmeåSweden
  2. 2.Department of Orthopaedics, Sahlgrenska AcademyGothenburg UniversityGothenburgSweden

Personalised recommendations