Nonsurgical versus Surgical Treatment for Cervical Radiculopathy or Myelopathy: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Nonsurgical versus Surgical Treatment for Cervical Radiculopathy or Myelopathy: A Systematic Review and Meta-Analysis of Randomized Controlled Trials | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review Nonsurgical versus Surgical Treatment for Cervical Radiculopathy or Myelopathy: A Systematic Review and Meta-Analysis of Randomized Controlled Trials Kamran Hassan Dar, Abdulaziz Alzarooni, Justyna Kaczmarek, Cara Mohammed, and 9 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8145135/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose There is conflicting evidence regarding the optimal management strategy for cervical radiculopathy and myelopathy. We conducted a meta-analysis to evaluate the relative effectiveness of nonsurgical treatment and surgical care in adult patients with cervical radiculopathy or myelopathy. Methods We systematically searched PubMed, Embase, and the Cochrane Library to identify randomized controlled trials (RCTs) comparing nonsurgical treatment with surgical treatment. All statistical analyses were performed using RevMan version 5.4. Results Six RCTs met the inclusion criteria. Surgical treatment significantly improved neck pain (SMD 0.70, 95% CI 0.15–1.26) and arm pain (SMD 0.62, 95% CI 0.04–1.19) compared with non-surgical care. Subgroup analysis showed that benefits for neck pain were most pronounced in patients with disc herniation (SMD 1.02, 95% CI 0.11–1.93) and in those with unspecified pathology (SMD 1.23, 95% CI 0.69–1.77), whereas benefits for arm pain were observed only in disc herniation (SMD 1.29, 95% CI 0.90–1.68). Surgical treatment also improved physical function in sensitivity analysis (SMD 0.33, 95% CI 0.06–0.59) and emotional/mood outcomes (SMD 0.22, 95% CI 0.02–0.45) but did not significantly affect patient-reported overall improvement (RR 0.97, 95% CI 0.72–1.31) or analgesic use (RR 1.03, 95% CI 0.77–1.36). Conclusions Surgical management of cervical radiculopathy or myelopathy may provide superior improvements in neck and arm pain, as well as functional and emotional outcomes, compared with non-surgical treatment, particularly in patients with disc herniation. Further high-quality trials are warranted to confirm these findings and define optimal patient selection. cervical radiculopathy cervical myelopathy surgery conservative treatment meta-analysis Figures Figure 1 Figure 2 Figure 3 INTRODUCTION Cervical radiculopathy and cervical myelopathy are common degenerative conditions of the cervical spine that impose a significant burden on healthcare systems worldwide. Epidemiological studies estimate an annual incidence between 0.83 and 1.79 per 1,000 person-years, with lifetime prevalence ranging from 1.2 to 5.8 per 1,000, and a higher predilection for middle-aged adults [ 1 , 2 ]. While distinct in their pathophysiology and clinical presentation, both conditions often coexist and share common etiological factors such as age-related degenerative changes, intervertebral disc herniation, and cervical spondylosis. Cervical radiculopathy is described as radiating arm pain, sensory disturbances, and motor weakness due to compression or irritation of cervical nerve roots [ 3 ]. In contrast, cervical myelopathy results from direct spinal cord compression and presents with gait disturbances, hand clumsiness, and sphincter dysfunction [ 4 ]. Both conditions, if left untreated, can cause persistent pain, progressive functional impairment, and reduced quality of life [ 5 ]. Management strategies range from conservative therapies to surgical intervention. Conservative therapies such as physical therapy, medications, and cervical collar immobilization are often considered the treatment of choice, particularly for cervical radiculopathy, due to its better prognosis without surgical treatment. Nevertheless, more than one million Anterior cervical discectomy and fusion (ACDF) procedures were performed in the United States between 2006 and 2013, and utilization of cervical spine surgery is projected to continue rising [ 6 ]. Despite the high rate of surgical intervention, there has been a paucity of high-level evidence demonstrating long-term superiority of surgical over nonsurgical care for cervical radiculopathy. Surgical interventions such as ACDF, posterior laminoplasty, or disc arthroplasty are commonly employed to decompress neural structures and stabilize the spine. These procedures have demonstrated improvements in pain, neurologic outcomes, and quality of life [ 6 , 7 ]. Despite numerous case series reporting favorable results with surgical treatment, most studies were retrospective and lacked uniform criteria or adequate controls, limiting the strength of their conclusions. The literature presents mixed findings, with some randomized controlled trials (RCTs) indicating comparable effectiveness between conservative and surgical management in patients [ 5 ], while other studies demonstrate the superiority of surgical decompression, particularly in patients with progressive or severe myelopathy [ 4 , 6 ]. Despite decades of research, the optimal management strategy for cervical radiculopathy and myelopathy remains debated. This ongoing uncertainty underscores the need for a comprehensive review of available evidence to guide patient selection and treatment planning. Therefore, this study-level systematic review and meta-analysis of RCTs aims to assess the relative efficacy of surgical and non-surgical treatments for cervical radiculopathy and myelopathy. METHODS This study-level systematic review and meta-analysis was conducted following the guidelines in the Cochrane Handbook for Systematic Reviews of Interventions and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement checklist [ 8 , 9 ]. The protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) under the registration number CRD420251232352. Ethical approval was not required for this study. Data sources and search strategy Cochrane Central Register of Controlled Trials (CENTRAL, via the Cochrane Library), MEDLINE (via Ovid), Embase, and ClinicalTrials.gov were systematically searched from inception to September 2025 using an extensive search strategy. The reference lists of included studies and of similar systematic reviews were also screened to identify additional relevant studies. The search strategy incorporated keywords and Medical Subject Headings (MeSH) terms related to “cervical myelopathy,” “cervical radiculopathy,” “surgery,” “cervical collar,” and “physiotherapy”. 2.2. Eligibility criteria Studies were included if they met the following criteria: (1) employed a randomized controlled trial (RCT) design; (2) patient population: adults (> 18 years of age) with cervical radiculopathy or myelopathy as defined by the trials; (3) intervention: non-surgical management irrespective of the type or duration; and (4) comparator: surgery of any types for the given indication. Studies were excluded if: (1) study designs other than RCTs, such as quasi-randomized trials and observational studies; (2) conducted on animals or children. No language or date restrictions were applied. 2.3. Study selection and data abstraction All records obtained were imported into Rayyan [ 10 ], where duplicate articles were removed. Two authors independently screened the articles based on titles and abstracts, excluding irrelevant studies. Full texts of the remaining articles were thoroughly reviewed, and studies were finalized based on pre-specified eligibility criteria. Any disagreements or conflicts were resolved through discussion with a third independent reviewer. Following study selection, data were extracted into a predefined Google spreadsheet to ensure consistency across studies. Disagreements were addressed through consultation with a third reviewer. Extracted data included study characteristics (authors, location, diagnostic criteria, and follow-up time), patient population details (age, male percentage, and number of patients), interventions (types of non-surgical and surgical interventions), comparators, and both primary and secondary outcomes. 2.4. Outcomes The primary outcomes were the risk of neck pain, arm pain, physical function, and emotional/mood improvement at 2 years after randomization (if not reported at 2 years, we extracted the outcome closest to 2 years). The secondary outcomes included patient-reported symptom improvement and analgesic use. 2.5. Risk of bias assessment Risk of bias was evaluated using the revised Cochrane Risk of Bias Tool for RCTs (RoB 2.0) [ 11 ]. Each trial was assessed across five domains: 1) randomization process; 2) deviations from intended interventions; 3) missing outcome data; 4) measurement of the outcome; and 5) selection of reported results. Based on these domains, studies were classified as having low risk, high risk, or some concerns. A senior investigator was consulted to settle any discrepancies regarding the risk of bias assessment. 2.6. Data synthesis Review Manager (RevMan, Version 5.4; The Cochrane Collaboration, Copenhagen, Denmark) was used to perform the meta-analyses. Continuous outcomes were reported as standard mean differences (SMDs), and dichotomous outcomes were summarized as risk ratios (RRs), each with 95% confidence intervals (CIs). A random-effects model was employed for the meta-analyses. Statistical significance was set at p-value < 0.05. The I² statistic was calculated to assess statistical heterogeneity, with the following thresholds: I² < 30%: low heterogeneity; I² 75%: significant heterogeneity. Following the guidelines in the Cochrane Handbook for Systematic Reviews of Interventions, publication bias was not assessed as the number of included studies was less than 10. Under such conditions, funnel plots and associated statistical tests, such as Egger’s test, lack sufficient statistical power to detect true bias and may yield misleading results [ 12 ] A sensitivity analysis of the primary outcomes was conducted by excluding the study evaluating cervical myelopathy [ 5 ], as the remaining studies focused on cervical radiculopathy. Subgroup analyses based on underlying pathology were conducted for the primary outcome. For the test of subgroup differences, a P - value < 0.1 was considered statistically significant. RESULTS Study Selection and Characteristics of Included Studies A total of six RCTS met the inclusion criteria [ 5 – 7 , 13 , 14 ]. Taso 2025 [ 6 ] reported two separate RCTs reporting radiculopathy due to disc herniation and spondolysis, and were divided into Taso A and Taso B for the purpose of data analysis, respectively. The detailed study screening selection is reported in the PRISMA flowchart (Figure S1 ) The studies reported data on 492 patients with cervical radiculopathy or myelopathy, of whom 241 were treated through surgical treatment and 251 with nonsurgical intervention. Four of these studies evaluated radiculopathy [ 6 , 7 , 13 , 14 ] while the Kandanka et al.[ 5 ] focused on patients with myelopathy. The mean age across studies was 47.7 ± 9.13, with males accounting for 51.4% of participants. Further study characteristics are summarized in Table 1 . Table 1 Characteristics of the included studies. Study ID Location No. of patients (Surgical vs nonsurgical) Disease Nonsurgical intervention Surgical intervention Mean Age (years) Male, % (n) Follow-up time Cesaroni 2009 Italy 115(62 vs53) Cervical radiculopathy due to disc herniation course of rest, analgesics and non-steroidal anti-inflammatory drugs (NSAIDs), and physical therapy. plasma disc decompression (PDD) 45.03 ± 10.72 vs 47.43 ± 11.49 42% (23vs25) 1 year Engquist 2013 Sweden 68(35 vs 33) Cervical radiculopathy, regardless of radiological cause physiotherapy alone for a minimum of 3 months anterior cervical discectomy and fusion (ACDF) + Physiotherapy for a minimum of 3 months 49 ± 8 vs 44 ± 9 52% (14vs19) 2 years Kadanka 2000 Czech Republic 48 (27 vs 21) Cervical myelopathy due to spondylosis cervical collar, anti-inflammatory medication, bed rest (intermittent), avoidance of high-risk activities anterior decompression, corpectomies, laminoplasties, Internal fixation with Caspar plate 55.6 ± 8.6 Vs 52.7 ± 8.1 79% (22vs16) 2 years Persson 1997 Sweden 81 (27 vs 54) Cervical radiculopathy due to spondylosis physiotherapy, cervical collar anterior cervical decompression and fusion (43.5 ± 7.01 vs 48.25 ± 7.31 54% (16vs28) 15–16 months Taso 2025a Norway 89 (45 vs 44) Cervical radiculopathy due to disc herniation multidisciplinary functional intervention within a cognitive framework anterior cervical discectomy and fusion (ACDF) 46 ± 9 vs 43 ± 7 43% (19 vs19) 1 year Taso 2025b Norway 91 (45 vs 46) Cervical radiculopathy due to spondylosis multidisciplinary functional intervention within a cognitive framework anterior cervical discectomy and fusion (ACDF) 51 ± 6 vs 52 ± 6 57% (27vs25) 1 year 3.1. Risk of bias in included studies Among the six trials, three were assessed as of some concern (Cesaroni 2009, Kadanka 2000, Taso 2025a), and the other three were at high risk of bias (Engquist 2013, Persson 1997, Taso 2025b). The main sources of bias were deviation from intended interventions (three studies), measurement of outcome (five studies), and reporting bias (four studies). The quality assessment of the included studies is presented in Figure S2. 3.2 Primary Outcomes 3.2.1. Neck pain A total of five RCTs with 435 patients reported neck pain. Pooled analysis demonstrated a significant reduction (SMD: 0.70; 95% CI 0.15 to 1.26; Fig. 1 ), favoring surgery over nonsurgical management. I 2 value was 87%, indicating a high level of statistical heterogeneity among the studies. Subgroup analysis revealed that surgery provided significant neck pain relief compared with nonsurgical management in patients who developed the disorder secondary to disc herniation (SMD 1.02, 95% CI 0.11–1.93) or an unspecified cause (SMD 1.23, 95% CI 0.69–1.77). However, in patients with spondylosis, no significant difference was noted between non-surgical and surgical management (SMD 0.14, 95% CI − 0.17 to 0.45). The difference between subgroups was statistically significant (p = 0.001), indicating that underlying pathology influenced the treatment effect. 3.2.2. Arm Pain Five RCTs assessed arm pain as an outcome. The overall pooled effect showed that surgical treatment was more effective than nonsurgical treatment at reducing arm pain (SMD 0.62, 95% CI 0.04 to 1.19; Fig. 2 ). Considerable heterogeneity was present (I² = 88%, p < 0.001). In subgroup analysis, surgery was associated with a reduction in arm pain among patients with disc herniation (SMD 1.29, 95% CI 0.90 to 1.68; I² = 39%). In contrast, no statistically significant difference between non-surgical and surgical management was found in patients with spondylosis (SMD 0.28, 95% CI − 0.03 to 0.59; I² = 0%) or in patients with unspecified pathology (SMD − 0.05, 95% CI − 0.54 to 0.44). The difference between subgroups was statistically significant (p < 0.001). 3.2.3. Physical function Physical function was evaluated and reported by five studies. Overall pooled analysis showed no significant difference between nonsurgical and surgical treatment (SMD 0.20, 95% CI − 0.13 to 0.53; Fig. 3 ), with moderate heterogeneity (I² = 62%). Subgroup analysis by underlying cause revealed that surgery significantly improved physical function in patients with disc herniation (SMD 0.53, 95% CI 0.25 to 0.81; I² = 0%). However, diagnosis of spondylosis (SMD − 0.13, 95% CI − 0.61 to 0.35; I² = 46%) and unspecified pathology (SMD 0.11, 95% CI − 0.38 to 0.61) showed no significant difference between nonsurgical and surgical treatment. Subgroup differences were statistically significant (p = 0.05), suggesting that the underlying pathology affects the extent of functional improvement following surgery. Excluding the study evaluating patients with cervical myelopathy [ 5 ], the treatment effect became statistically significant in patients with radiculopathy (SMD 0.33, 95% CI 0.06 to 0.59). Heterogeneity was reduced to I² = 36% (Figure S3) . 3.3: Secondary Outcomes 3.3.1. Emotional/mood improvement Three studies assessed emotional or mood-related outcomes. Pooled analysis demonstrated no significant difference between nonsurgical and surgical treatment (SMD 0.22, 95% CI − 0.02 to 0.45; Figure S4 ). Heterogeneity across studies was negligible (I² = 0%). 3.3.2. Patient reported improvement in symptoms Four studies documented self-reported improvement. No significant difference was found between nonsurgical and surgical groups (RR 0.97, 95% CI 0.72 to 1.31; Figure S5 ). Moderate heterogeneity was observed (I² = 71%). 3.3.3. Use of analgesics Three studies reported on the continued use of analgesics. The pooled analysis demonstrated no significant difference between nonsurgical and surgical groups (RR 1.03, 95% CI 0.77 to 1.36; Figure S6 ). Across individual studies, results were consistent, showing no significant differences. DISCUSSION This systematic review and meta-analysis of six RCTs was conducted to evaluate the relative effectiveness of nonsurgical and surgical treatment for cervical radiculopathy and myelopathy. Our findings indicate that surgical intervention was associated with significantly greater reductions in neck and arm pain than nonsurgical treatment, whereas no differences were observed between groups for physical function, mood, patient-reported improvements, or analgesic use. This study demonstrates that the effectiveness of nonsurgical and surgical treatment for cervical spine conditions depends on the underlying pathology. Surgery provided significant relief for neck and arm pain in patients with disc herniation, while for those with spondylosis, nonsurgical treatment was no different from surgery. These findings emphasize the clinical importance of etiological factors in treatment selection. Patients with cervical disc herniation consistently demonstrated significant improvements in pain and physical function following surgery. Conversely, patients with spondylosis showed no difference between nonsurgical and surgical treatment across all outcomes. Variation in response to treatment can be explained by distinct pathophysiological mechanisms underlying these conditions. Lumbar disc herniations are known to commonly resolve with non-surgical treatment, as documented in multiple studies. But cervical disc herniations rarely shrink back naturally and may not respond well to conservative care [ 15 – 17 ]. Cervical disc herniation causes mechanical compression and acute inflammation of nerve roots, which can be effectively relieved through surgical decompression [ 18 ]. In contrast, cervical spondylosis is a degenerative process characterized by osteophyte formation, ligamentum flavum hypertrophy, and facet joint arthropathy, which may not respond as favorably to surgical intervention due to its multifactorial nature and the potential for continued degenerative changes [ 19 ]. Our findings are strongly supported by the two latest trials published by Taso et al. [ 6 ] which demonstrated significantly lower arm and neck pain in patients diagnosed with disc herniation as the underlying cause of cervical radiculopathy, while reporting no benefit of surgery in patients with spondylosis. Studies by Engquist et al. [ 7 ] and Cesaroni et al. [ 14 ] reported significant reductions in arm and neck pain after surgical intervention. Similarly, our findings are also in agreement with the meta-analysis conducted by Nikolaidis et al. [ 20 ] which favored surgical intervention for pain reduction. However, this study treated cervical radiculopathy as a homogeneous condition without considering the underlying etiology. Our meta-analysis extends beyond by demonstrating that treatment-related benefits are not uniform across all patients, but are specific to the underlying pathology. In our study, surgery provided significant functional improvement in patients with disc herniation, while those with spondylosis and unspecified etiology showed no benefit. This finding aligns with Taso et al. [ 6 ], who reported mean NDI scores of 13.8 in the surgical group versus 19.7 in the nonsurgical group. Conversely, in the spondylosis trial [ 6 ], there was no significant difference between the two groups. A review by Huo et al. [ 21 ] reported that surgical treatment was more effective than non-surgical treatment for rapid short-term improvement; however, at 12 months, both groups were equally effective. Surgical and non-surgical treatments were comparable for improvement in the mood of the patient and self-reported outcomes. Patient satisfaction reflects whether expectations and improvements in quality of life are met. High clinical success rates for surgery do not always equate to proportional satisfaction levels. Although anterior cervical decompression shows ~ 80–95% success in pain relief and neurological improvement, only about two-thirds of patients are fully satisfied [ 22 , 23 ]. This discrepancy can arise from residual symptoms, complications, or unrealized expectations. Engquist et al. [ 7 ] demonstrated that early after treatment, surgical patients at 3 months showed greater improvements versus conservative care. However, by 1–2 years, as pain and function converge between groups, so does satisfaction. Nonsurgical patients become satisfied as symptoms improve with time and rehab, while some post-operative patients experience new concerns that temper initial enthusiasm. In an observational cohort, the surgical group had worse baseline pain yet reported better two-year outcomes, partly due to expectation fulfillment [ 23 ]. Conservative care may satisfy those prioritizing avoiding surgery, whereas surgery may satisfy those seeking quick relief. Our findings must be interpreted within the context of previous meta-analyses. The Cochrane review by Nikolaidis et al. [ 20 ] The findings were limited by the inclusion of only two RCTs. The study by van Middelkoop et al. [ 24 ] found no clear evidence for the benefits of surgery over conservative treatment, but this study was limited by the inclusion of 3 RCTs and treating cervical spine disorders as a homogeneous condition. Similarly, another meta-analysis by Huo et al.[ 21 ] favored surgical treatment for pain outcomes, but without underlying cause-specific stratification. Our analysis addresses the critical limitation of previous meta-analyses by recognizing disc herniation and spondylosis as distinct pathophysiological entities with different treatment responses. Limitations Some limitations should be acknowledged while interpreting the results. Firstly, the inclusion of only 6 RCTs and a small sample size limited the statistical power to detect small differences. Secondly, the impossibility of blinding participants and providers to treatment allocation in surgical versus nonsurgical comparisons raises concerns about bias in patient-reported outcomes. Placebo effects may inflate the apparent benefits of surgical intervention, particularly for subjective measures such as pain, functional disability, and self-reported improvement outcomes. This limitation is evident across all included studies, and that cannot be fully addressed. Furthermore, high heterogeneity was observed in the pooled estimates, likely due to differences in outcome assessment scales, the surgical and nonsurgical methods used, and follow-up periods across studies. However, we performed subgroup and sensitivity analyses to explore heterogeneity. Lastly, the relatively small number of available trials limits our ability to assess publication bias. Future research should focus on long-term multicenter RCTs to evaluate whether early surgical benefits persist beyond two years or if nonsurgical treatment eventually achieves similar results. Also, the cost-effectiveness of surgical and nonsurgical treatment should be systematically evaluated. Conclusions Surgery for cervical radiculopathy or myelopathy may provide superior improvements in neck and arm pain, as well as functional outcomes, particularly in patients with disc herniation. However, it shows no clear advantage over nonsurgical management in terms of patient-reported improvement or analgesic use. Additional high-quality trials are needed to validate these results and refine the criteria for treatment selection. Declarations Author Contribution Study concept and design were led by KHD, AA, JK, CM, AMS, MBP, and KV, with AMA and ZE. Literature search and data collection were performed by KHD, AA, JK, CM, AMS, MBP, KV, ZH, KJ, and SSM. Statistical analysis and interpretation of data were carried out by KHD, AA, JK, CM, AMS, MBP, KV, ZH, KJ, SSM, AAly, AMAA, and ZE. Drafting of the manuscript was undertaken by KHD, AA, JK, CM, AMS, MBP, KV, ZH, KJ, and SSM. Revision of the manuscript for important intellectual content was performed by all authors. Supervision of the study was provided by AMAA and ZE. All authors read and approved the final version of the manuscript Data Availability The data can be made available on request to the corresponding author. References Mansfield M, Smith T, Spahr N, Thacker M (2020) Cervical spine radiculopathy epidemiology: A systematic review. Musculoskelet Care 18:555–567. https://doi.org/10.1002/msc.1498 Radhakrishnan K, Litchy WJ, O’Fallon WM, Kurland LT (1994) Epidemiology of cervical radiculopathy. A population-based study from Rochester, Minnesota, 1976 through 1990. Brain 117(Pt 2):325–335. https://doi.org/10.1093/brain/117.2.325 Margetis K, Magnus W, Mesfin FB (2025) Cervical Radiculopathy. In: StatPearls. 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15:37:34","extension":"html","order_by":11,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":78108,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8145135/v1/63d67ea6789b6062fc01b945.html"},{"id":96307473,"identity":"94dc7903-4a87-44a6-9cbb-44036b66730f","added_by":"auto","created_at":"2025-11-19 15:37:33","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":45672,"visible":true,"origin":"","legend":"\u003cp\u003eEffect of nonsurgical versus surgical treatment on neck pain in patients with cervical radiculopathy or myelopathy.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-8145135/v1/f0d9a62d96afebfd240360af.png"},{"id":96307475,"identity":"37b85d6d-17df-476c-b780-fb2fbe1cfea5","added_by":"auto","created_at":"2025-11-19 15:37:33","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":45481,"visible":true,"origin":"","legend":"\u003cp\u003eEffect of nonsurgical versus surgical treatment on arm pain in patients with cervical radiculopathy or myelopathy.\u003c/p\u003e","description":"","filename":"Figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-8145135/v1/636089056294e9f2cc52c6bf.png"},{"id":96307474,"identity":"0511a2dc-0239-46d3-9816-9c6b7683ddf4","added_by":"auto","created_at":"2025-11-19 15:37:33","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":44859,"visible":true,"origin":"","legend":"\u003cp\u003eEffect of nonsurgical versus surgical treatment on physical function in patients with cervical radiculopathy or myelopathy.\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-8145135/v1/3236693a81976996d6ef42fc.png"},{"id":97137909,"identity":"c759e19c-4bdd-444c-babd-6dc5586bdb30","added_by":"auto","created_at":"2025-12-01 09:58:18","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":916545,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8145135/v1/27884ce1-1104-4bfe-ba4b-d99b9bada34c.pdf"},{"id":96307479,"identity":"5fda3c67-15dc-4a43-8d80-2abec2eb15b8","added_by":"auto","created_at":"2025-11-19 15:37:33","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":125048,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementaryfile.docx","url":"https://assets-eu.researchsquare.com/files/rs-8145135/v1/33551bb1fb29266354c7b648.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Nonsurgical versus Surgical Treatment for Cervical Radiculopathy or Myelopathy: A Systematic Review and Meta-Analysis of Randomized Controlled Trials","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eCervical radiculopathy and cervical myelopathy are common degenerative conditions of the cervical spine that impose a significant burden on healthcare systems worldwide. Epidemiological studies estimate an annual incidence between 0.83 and 1.79 per 1,000 person-years, with lifetime prevalence ranging from 1.2 to 5.8 per 1,000, and a higher predilection for middle-aged adults [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. While distinct in their pathophysiology and clinical presentation, both conditions often coexist and share common etiological factors such as age-related degenerative changes, intervertebral disc herniation, and cervical spondylosis. Cervical radiculopathy is described as radiating arm pain, sensory disturbances, and motor weakness due to compression or irritation of cervical nerve roots [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. In contrast, cervical myelopathy results from direct spinal cord compression and presents with gait disturbances, hand clumsiness, and sphincter dysfunction [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Both conditions, if left untreated, can cause persistent pain, progressive functional impairment, and reduced quality of life [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eManagement strategies range from conservative therapies to surgical intervention. Conservative therapies such as physical therapy, medications, and cervical collar immobilization are often considered the treatment of choice, particularly for cervical radiculopathy, due to its better prognosis without surgical treatment. Nevertheless, more than one million Anterior cervical discectomy and fusion (ACDF) procedures were performed in the United States between 2006 and 2013, and utilization of cervical spine surgery is projected to continue rising [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Despite the high rate of surgical intervention, there has been a paucity of high-level evidence demonstrating long-term superiority of surgical over nonsurgical care for cervical radiculopathy.\u003c/p\u003e\u003cp\u003eSurgical interventions such as ACDF, posterior laminoplasty, or disc arthroplasty are commonly employed to decompress neural structures and stabilize the spine. These procedures have demonstrated improvements in pain, neurologic outcomes, and quality of life [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Despite numerous case series reporting favorable results with surgical treatment, most studies were retrospective and lacked uniform criteria or adequate controls, limiting the strength of their conclusions. The literature presents mixed findings, with some randomized controlled trials (RCTs) indicating comparable effectiveness between conservative and surgical management in patients [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], while other studies demonstrate the superiority of surgical decompression, particularly in patients with progressive or severe myelopathy [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDespite decades of research, the optimal management strategy for cervical radiculopathy and myelopathy remains debated. This ongoing uncertainty underscores the need for a comprehensive review of available evidence to guide patient selection and treatment planning. Therefore, this study-level systematic review and meta-analysis of RCTs aims to assess the relative efficacy of surgical and non-surgical treatments for cervical radiculopathy and myelopathy.\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eThis study-level systematic review and meta-analysis was conducted following the guidelines in the Cochrane Handbook for Systematic Reviews of Interventions and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement checklist [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) under the registration number CRD420251232352. Ethical approval was not required for this study.\u003c/p\u003e\u003cp\u003e\u003cb\u003eData sources and search strategy\u003c/b\u003e\u003c/p\u003e\u003cp\u003eCochrane Central Register of Controlled Trials (CENTRAL, via the Cochrane Library), MEDLINE (via Ovid), Embase, and ClinicalTrials.gov were systematically searched from inception to September 2025 using an extensive search strategy. The reference lists of included studies and of similar systematic reviews were also screened to identify additional relevant studies. The search strategy incorporated keywords and Medical Subject Headings (MeSH) terms related to \u0026ldquo;cervical myelopathy,\u0026rdquo; \u0026ldquo;cervical radiculopathy,\u0026rdquo; \u0026ldquo;surgery,\u0026rdquo; \u0026ldquo;cervical collar,\u0026rdquo; and \u0026ldquo;physiotherapy\u0026rdquo;.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e2.2. Eligibility criteria\u003c/h2\u003e\u003cp\u003eStudies were included if they met the following criteria: (1) employed a randomized controlled trial (RCT) design; (2) patient population: adults (\u0026gt;\u0026thinsp;18 years of age) with cervical radiculopathy or myelopathy as defined by the trials; (3) intervention: non-surgical management irrespective of the type or duration; and (4) comparator: surgery of any types for the given indication.\u003c/p\u003e\u003cp\u003eStudies were excluded if: (1) study designs other than RCTs, such as quasi-randomized trials and observational studies; (2) conducted on animals or children. No language or date restrictions were applied.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e2.3. Study selection and data abstraction\u003c/h2\u003e\u003cp\u003eAll records obtained were imported into Rayyan [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], where duplicate articles were removed. Two authors independently screened the articles based on titles and abstracts, excluding irrelevant studies. Full texts of the remaining articles were thoroughly reviewed, and studies were finalized based on pre-specified eligibility criteria. Any disagreements or conflicts were resolved through discussion with a third independent reviewer.\u003c/p\u003e\u003cp\u003eFollowing study selection, data were extracted into a predefined Google spreadsheet to ensure consistency across studies. Disagreements were addressed through consultation with a third reviewer. Extracted data included study characteristics (authors, location, diagnostic criteria, and follow-up time), patient population details (age, male percentage, and number of patients), interventions (types of non-surgical and surgical interventions), comparators, and both primary and secondary outcomes.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e2.4. Outcomes\u003c/h2\u003e\u003cp\u003eThe primary outcomes were the risk of neck pain, arm pain, physical function, and emotional/mood improvement at 2 years after randomization (if not reported at 2 years, we extracted the outcome closest to 2 years). The secondary outcomes included patient-reported symptom improvement and analgesic use.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003e2.5. Risk of bias assessment\u003c/h2\u003e\u003cp\u003eRisk of bias was evaluated using the revised Cochrane Risk of Bias Tool for RCTs (RoB 2.0) [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Each trial was assessed across five domains: 1) randomization process; 2) deviations from intended interventions; 3) missing outcome data; 4) measurement of the outcome; and 5) selection of reported results. Based on these domains, studies were classified as having low risk, high risk, or some concerns. A senior investigator was consulted to settle any discrepancies regarding the risk of bias assessment.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003e2.6. Data synthesis\u003c/h2\u003e\u003cp\u003eReview Manager (RevMan, Version 5.4; The Cochrane Collaboration, Copenhagen, Denmark) was used to perform the meta-analyses. Continuous outcomes were reported as standard mean differences (SMDs), and dichotomous outcomes were summarized as risk ratios (RRs), each with 95% confidence intervals (CIs). A random-effects model was employed for the meta-analyses. Statistical significance was set at p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05. The I\u0026sup2; statistic was calculated to assess statistical heterogeneity, with the following thresholds: I\u0026sup2; \u0026lt; 30%: low heterogeneity; I\u0026sup2; \u0026lt; 75%: moderate heterogeneity; and I\u0026sup2; \u0026gt;75%: significant heterogeneity.\u003c/p\u003e\u003cp\u003e Following the guidelines in the Cochrane Handbook for Systematic Reviews of Interventions, publication bias was not assessed as the number of included studies was less than 10. Under such conditions, funnel plots and associated statistical tests, such as Egger\u0026rsquo;s test, lack sufficient statistical power to detect true bias and may yield misleading results [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] A sensitivity analysis of the primary outcomes was conducted by excluding the study evaluating cervical myelopathy [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], as the remaining studies focused on cervical radiculopathy. Subgroup analyses based on underlying pathology were conducted for the primary outcome. For the test of subgroup differences, a P\u003cem\u003e-\u003c/em\u003evalue\u0026thinsp;\u0026lt;\u0026thinsp;0.1 was considered statistically significant.\u003c/p\u003e\u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003e\u003cb\u003eStudy Selection and Characteristics of Included Studies\u003c/b\u003e\u003c/p\u003e\u003cp\u003eA total of six RCTS met the inclusion criteria [\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Taso 2025 [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] reported two separate RCTs reporting radiculopathy due to disc herniation and spondolysis, and were divided into Taso A and Taso B for the purpose of data analysis, respectively. The detailed study screening selection is reported in the PRISMA flowchart \u003cb\u003e(Figure \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e)\u003c/b\u003e\u003c/p\u003e\u003cp\u003eThe studies reported data on 492 patients with cervical radiculopathy or myelopathy, of whom 241 were treated through surgical treatment and 251 with nonsurgical intervention. Four of these studies evaluated radiculopathy [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] while the Kandanka et al.[\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] focused on patients with myelopathy. The mean age across studies was 47.7\u0026thinsp;\u0026plusmn;\u0026thinsp;9.13, with males accounting for 51.4% of participants. Further study characteristics are summarized in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCharacteristics of the included studies.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"9\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStudy ID\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLocation\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo. of patients\u003c/p\u003e\u003cp\u003e(Surgical vs nonsurgical)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eDisease\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eNonsurgical intervention\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eSurgical intervention\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eMean Age (years)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eMale, % (n)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003eFollow-up time\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCesaroni 2009\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eItaly\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e115(62 vs53)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eCervical radiculopathy due to disc herniation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ecourse of rest, analgesics and non-steroidal anti-inflammatory drugs (NSAIDs), and physical therapy.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eplasma disc decompression (PDD)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e45.03\u0026thinsp;\u0026plusmn;\u0026thinsp;10.72 vs 47.43\u0026thinsp;\u0026plusmn;\u0026thinsp;11.49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e42%\u003c/p\u003e\u003cp\u003e(23vs25)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e1 year\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEngquist 2013\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSweden\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e68(35 vs 33)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eCervical radiculopathy, regardless of radiological cause\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ephysiotherapy alone for a minimum of 3 months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eanterior cervical discectomy and fusion (ACDF)\u0026thinsp;+\u0026thinsp;Physiotherapy for a minimum of 3 months\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e49\u0026thinsp;\u0026plusmn;\u0026thinsp;8 vs 44\u0026thinsp;\u0026plusmn;\u0026thinsp;9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e52%\u003c/p\u003e\u003cp\u003e(14vs19)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e2 years\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eKadanka 2000\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCzech Republic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e48 (27 vs 21)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eCervical myelopathy due to spondylosis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ecervical collar, anti-inflammatory medication, bed rest (intermittent), avoidance of high-risk activities\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eanterior decompression, corpectomies, laminoplasties, Internal fixation with Caspar plate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e55.6\u0026thinsp;\u0026plusmn;\u0026thinsp;8.6 Vs 52.7\u0026thinsp;\u0026plusmn;\u0026thinsp;8.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e79%\u003c/p\u003e\u003cp\u003e(22vs16)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e2 years\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePersson 1997\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSweden\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e81 (27 vs 54)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eCervical radiculopathy due to spondylosis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ephysiotherapy, cervical collar\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eanterior cervical decompression and fusion\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e(43.5\u0026thinsp;\u0026plusmn;\u0026thinsp;7.01 vs 48.25\u0026thinsp;\u0026plusmn;\u0026thinsp;7.31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e54%\u003c/p\u003e\u003cp\u003e(16vs28)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e15\u0026ndash;16 months\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTaso 2025a\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNorway\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e89 (45 vs 44)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eCervical radiculopathy due to disc herniation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003emultidisciplinary functional intervention within a cognitive framework\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eanterior cervical discectomy and fusion (ACDF)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e46\u0026thinsp;\u0026plusmn;\u0026thinsp;9 vs 43\u0026thinsp;\u0026plusmn;\u0026thinsp;7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e43%\u003c/p\u003e\u003cp\u003e(19 vs19)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e1 year\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTaso 2025b\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNorway\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e91 (45 vs 46)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eCervical radiculopathy due to spondylosis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003emultidisciplinary functional intervention within a cognitive framework\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eanterior cervical discectomy and fusion (ACDF)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e51\u0026thinsp;\u0026plusmn;\u0026thinsp;6 vs 52\u0026thinsp;\u0026plusmn;\u0026thinsp;6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e57%\u003c/p\u003e\u003cp\u003e(27vs25)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e1 year\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003e3.1. Risk of bias in included studies\u003c/h2\u003e\u003cp\u003eAmong the six trials, three were assessed as of some concern (Cesaroni 2009, Kadanka 2000, Taso 2025a), and the other three were at high risk of bias (Engquist 2013, Persson 1997, Taso 2025b). The main sources of bias were deviation from intended interventions (three studies), measurement of outcome (five studies), and reporting bias (four studies). The quality assessment of the included studies is presented in \u003cb\u003eFigure S2.\u003c/b\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003e3.2 Primary Outcomes\u003c/h2\u003e\u003cdiv id=\"Sec11\" class=\"Section3\"\u003e\u003ch2\u003e3.2.1. Neck pain\u003c/h2\u003e\u003cp\u003eA total of five RCTs with 435 patients reported neck pain. Pooled analysis demonstrated a significant reduction (SMD: 0.70; 95% CI 0.15 to 1.26; Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e), favoring surgery over nonsurgical management. I\u003csup\u003e2\u003c/sup\u003e value was 87%, indicating a high level of statistical heterogeneity among the studies. Subgroup analysis revealed that surgery provided significant neck pain relief compared with nonsurgical management in patients who developed the disorder secondary to disc herniation (SMD 1.02, 95% CI 0.11\u0026ndash;1.93) or an unspecified cause (SMD 1.23, 95% CI 0.69\u0026ndash;1.77). However, in patients with spondylosis, no significant difference was noted between non-surgical and surgical management (SMD 0.14, 95% CI \u0026minus;\u0026thinsp;0.17 to 0.45). The difference between subgroups was statistically significant (p\u0026thinsp;=\u0026thinsp;0.001), indicating that underlying pathology influenced the treatment effect.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section3\"\u003e\u003ch2\u003e3.2.2. Arm Pain\u003c/h2\u003e\u003cp\u003eFive RCTs assessed arm pain as an outcome. The overall pooled effect showed that surgical treatment was more effective than nonsurgical treatment at reducing arm pain (SMD 0.62, 95% CI 0.04 to 1.19; Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Considerable heterogeneity was present (I\u0026sup2; = 88%, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eIn subgroup analysis, surgery was associated with a reduction in arm pain among patients with disc herniation (SMD 1.29, 95% CI 0.90 to 1.68; I\u0026sup2; = 39%). In contrast, no statistically significant difference between non-surgical and surgical management was found in patients with spondylosis (SMD 0.28, 95% CI \u0026minus;\u0026thinsp;0.03 to 0.59; I\u0026sup2; = 0%) or in patients with unspecified pathology (SMD \u0026minus;\u0026thinsp;0.05, 95% CI \u0026minus;\u0026thinsp;0.54 to 0.44). The difference between subgroups was statistically significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section3\"\u003e\u003ch2\u003e3.2.3. Physical function\u003c/h2\u003e\u003cp\u003ePhysical function was evaluated and reported by five studies. Overall pooled analysis showed no significant difference between nonsurgical and surgical treatment (SMD 0.20, 95% CI \u0026minus;\u0026thinsp;0.13 to 0.53; Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e), with moderate heterogeneity (I\u0026sup2; = 62%).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eSubgroup analysis by underlying cause revealed that surgery significantly improved physical function in patients with disc herniation (SMD 0.53, 95% CI 0.25 to 0.81; I\u0026sup2; = 0%). However, diagnosis of spondylosis (SMD \u0026minus;\u0026thinsp;0.13, 95% CI \u0026minus;\u0026thinsp;0.61 to 0.35; I\u0026sup2; = 46%) and unspecified pathology (SMD 0.11, 95% CI \u0026minus;\u0026thinsp;0.38 to 0.61) showed no significant difference between nonsurgical and surgical treatment. Subgroup differences were statistically significant (p\u0026thinsp;=\u0026thinsp;0.05), suggesting that the underlying pathology affects the extent of functional improvement following surgery.\u003c/p\u003e\u003cp\u003eExcluding the study evaluating patients with cervical myelopathy [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], the treatment effect became statistically significant in patients with radiculopathy (SMD 0.33, 95% CI 0.06 to 0.59). Heterogeneity was reduced to I\u0026sup2; = 36% \u003cb\u003e(Figure S3)\u003c/b\u003e.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003e3.3: Secondary Outcomes\u003c/h2\u003e\u003cdiv id=\"Sec15\" class=\"Section3\"\u003e\u003ch2\u003e3.3.1. Emotional/mood improvement\u003c/h2\u003e\u003cp\u003eThree studies assessed emotional or mood-related outcomes. Pooled analysis demonstrated no significant difference between nonsurgical and surgical treatment (SMD 0.22, 95% CI \u0026minus;\u0026thinsp;0.02 to 0.45; \u003cb\u003eFigure S4\u003c/b\u003e). Heterogeneity across studies was negligible (I\u0026sup2; = 0%).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section3\"\u003e\u003ch2\u003e3.3.2. Patient reported improvement in symptoms\u003c/h2\u003e\u003cp\u003eFour studies documented self-reported improvement. No significant difference was found between nonsurgical and surgical groups (RR 0.97, 95% CI 0.72 to 1.31; \u003cb\u003eFigure S5\u003c/b\u003e). Moderate heterogeneity was observed (I\u0026sup2; = 71%).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section3\"\u003e\u003ch2\u003e3.3.3. Use of analgesics\u003c/h2\u003e\u003cp\u003eThree studies reported on the continued use of analgesics. The pooled analysis demonstrated no significant difference between nonsurgical and surgical groups (RR 1.03, 95% CI 0.77 to 1.36; \u003cb\u003eFigure S6\u003c/b\u003e). Across individual studies, results were consistent, showing no significant differences.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThis systematic review and meta-analysis of six RCTs was conducted to evaluate the relative effectiveness of nonsurgical and surgical treatment for cervical radiculopathy and myelopathy. Our findings indicate that surgical intervention was associated with significantly greater reductions in neck and arm pain than nonsurgical treatment, whereas no differences were observed between groups for physical function, mood, patient-reported improvements, or analgesic use. This study demonstrates that the effectiveness of nonsurgical and surgical treatment for cervical spine conditions depends on the underlying pathology. Surgery provided significant relief for neck and arm pain in patients with disc herniation, while for those with spondylosis, nonsurgical treatment was no different from surgery. These findings emphasize the clinical importance of etiological factors in treatment selection.\u003c/p\u003e\u003cp\u003ePatients with cervical disc herniation consistently demonstrated significant improvements in pain and physical function following surgery. Conversely, patients with spondylosis showed no difference between nonsurgical and surgical treatment across all outcomes. Variation in response to treatment can be explained by distinct pathophysiological mechanisms underlying these conditions. Lumbar disc herniations are known to commonly resolve with non-surgical treatment, as documented in multiple studies. But cervical disc herniations rarely shrink back naturally and may not respond well to conservative care [\u003cspan additionalcitationids=\"CR16\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. Cervical disc herniation causes mechanical compression and acute inflammation of nerve roots, which can be effectively relieved through surgical decompression [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. In contrast, cervical spondylosis is a degenerative process characterized by osteophyte formation, ligamentum flavum hypertrophy, and facet joint arthropathy, which may not respond as favorably to surgical intervention due to its multifactorial nature and the potential for continued degenerative changes [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOur findings are strongly supported by the two latest trials published by Taso et al. [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e] which demonstrated significantly lower arm and neck pain in patients diagnosed with disc herniation as the underlying cause of cervical radiculopathy, while reporting no benefit of surgery in patients with spondylosis. Studies by Engquist et al. [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] and Cesaroni et al. [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] reported significant reductions in arm and neck pain after surgical intervention. Similarly, our findings are also in agreement with the meta-analysis conducted by Nikolaidis et al. [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] which favored surgical intervention for pain reduction. However, this study treated cervical radiculopathy as a homogeneous condition without considering the underlying etiology. Our meta-analysis extends beyond by demonstrating that treatment-related benefits are not uniform across all patients, but are specific to the underlying pathology.\u003c/p\u003e\u003cp\u003eIn our study, surgery provided significant functional improvement in patients with disc herniation, while those with spondylosis and unspecified etiology showed no benefit. This finding aligns with Taso et al. [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], who reported mean NDI scores of 13.8 in the surgical group versus 19.7 in the nonsurgical group. Conversely, in the spondylosis trial [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], there was no significant difference between the two groups. A review by Huo et al. [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] reported that surgical treatment was more effective than non-surgical treatment for rapid short-term improvement; however, at 12 months, both groups were equally effective.\u003c/p\u003e\u003cp\u003eSurgical and non-surgical treatments were comparable for improvement in the mood of the patient and self-reported outcomes. Patient satisfaction reflects whether expectations and improvements in quality of life are met. High clinical success rates for surgery do not always equate to proportional satisfaction levels. Although anterior cervical decompression shows\u0026thinsp;~\u0026thinsp;80\u0026ndash;95% success in pain relief and neurological improvement, only about two-thirds of patients are fully satisfied [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. This discrepancy can arise from residual symptoms, complications, or unrealized expectations. Engquist et al. [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] demonstrated that early after treatment, surgical patients at 3 months showed greater improvements versus conservative care. However, by 1\u0026ndash;2 years, as pain and function converge between groups, so does satisfaction. Nonsurgical patients become satisfied as symptoms improve with time and rehab, while some post-operative patients experience new concerns that temper initial enthusiasm. In an observational cohort, the surgical group had worse baseline pain yet reported better two-year outcomes, partly due to expectation fulfillment [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Conservative care may satisfy those prioritizing avoiding surgery, whereas surgery may satisfy those seeking quick relief.\u003c/p\u003e\u003cp\u003eOur findings must be interpreted within the context of previous meta-analyses. The Cochrane review by Nikolaidis et al. [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e] The findings were limited by the inclusion of only two RCTs. The study by van Middelkoop et al. [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] found no clear evidence for the benefits of surgery over conservative treatment, but this study was limited by the inclusion of 3 RCTs and treating cervical spine disorders as a homogeneous condition. Similarly, another meta-analysis by Huo et al.[\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e] favored surgical treatment for pain outcomes, but without underlying cause-specific stratification. Our analysis addresses the critical limitation of previous meta-analyses by recognizing disc herniation and spondylosis as distinct pathophysiological entities with different treatment responses.\u003c/p\u003e\u003cp\u003e\u003cb\u003eLimitations\u003c/b\u003e\u003c/p\u003e\u003cp\u003eSome limitations should be acknowledged while interpreting the results. Firstly, the inclusion of only 6 RCTs and a small sample size limited the statistical power to detect small differences. Secondly, the impossibility of blinding participants and providers to treatment allocation in surgical versus nonsurgical comparisons raises concerns about bias in patient-reported outcomes. Placebo effects may inflate the apparent benefits of surgical intervention, particularly for subjective measures such as pain, functional disability, and self-reported improvement outcomes. This limitation is evident across all included studies, and that cannot be fully addressed. Furthermore, high heterogeneity was observed in the pooled estimates, likely due to differences in outcome assessment scales, the surgical and nonsurgical methods used, and follow-up periods across studies. However, we performed subgroup and sensitivity analyses to explore heterogeneity. Lastly, the relatively small number of available trials limits our ability to assess publication bias. Future research should focus on long-term multicenter RCTs to evaluate whether early surgical benefits persist beyond two years or if nonsurgical treatment eventually achieves similar results. Also, the cost-effectiveness of surgical and nonsurgical treatment should be systematically evaluated.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eSurgery for cervical radiculopathy or myelopathy may provide superior improvements in neck and arm pain, as well as functional outcomes, particularly in patients with disc herniation. However, it shows no clear advantage over nonsurgical management in terms of patient-reported improvement or analgesic use. Additional high-quality trials are needed to validate these results and refine the criteria for treatment selection.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eStudy concept and design were led by KHD, AA, JK, CM, AMS, MBP, and KV, with AMA and ZE. Literature search and data collection were performed by KHD, AA, JK, CM, AMS, MBP, KV, ZH, KJ, and SSM. Statistical analysis and interpretation of data were carried out by KHD, AA, JK, CM, AMS, MBP, KV, ZH, KJ, SSM, AAly, AMAA, and ZE. Drafting of the manuscript was undertaken by KHD, AA, JK, CM, AMS, MBP, KV, ZH, KJ, and SSM. Revision of the manuscript for important intellectual content was performed by all authors. Supervision of the study was provided by AMAA and ZE. All authors read and approved the final version of the manuscript\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe data can be made available on request to the corresponding author.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMansfield M, Smith T, Spahr N, Thacker M (2020) Cervical spine radiculopathy epidemiology: A systematic review. 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J Spinal Disord Tech 18:121\u0026ndash;126. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1097/01.bsd.0000154452.13579.b2\u003c/span\u003e\u003cspan address=\"10.1097/01.bsd.0000154452.13579.b2\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKobayashi N, Asamoto S, Doi H et al (2003) Spontaneous regression of herniated cervical disc. Spine J 3:171\u0026ndash;173. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/s1529-9430(02)00556-9\u003c/span\u003e\u003cspan address=\"10.1016/s1529-9430(02)00556-9\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003evan Geest S, Kuijper B, Oterdoom M et al (2014) CASINO: Surgical or Nonsurgical Treatment for cervical radiculopathy, a randomised controlled trial. BMC Musculoskelet Disord 15:129. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1186/1471-2474-15-129\u003c/span\u003e\u003cspan address=\"10.1186/1471-2474-15-129\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMargetis K, Tadi P (2025) Cervical Spondylosis. StatPearls [Internet]. StatPearls Publishing\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNikolaidis I, Fouyas IP, Sandercock PA, Statham PF (2010) Surgery for cervical radiculopathy or myelopathy. Cochrane Database Syst Rev 2010:CD001466. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/14651858.CD001466.pub3\u003c/span\u003e\u003cspan address=\"10.1002/14651858.CD001466.pub3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLuyao H, Xiaoxiao Y, Tianxiao F et al (2022) Management of Cervical Spondylotic Radiculopathy: A Systematic review. Global Spine J 12:1912\u0026ndash;1924. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/21925682221075290\u003c/span\u003e\u003cspan address=\"10.1177/21925682221075290\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMoreland DB, Asch HL, Clabeaux DE et al (2004) Anterior cervical discectomy and fusion with implantable titanium cage: initial impressions, patient outcomes and comparison to fusion with allograft. Spine J 4:184\u0026ndash;191 discussion 191. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.spinee.2003.05.001\u003c/span\u003e\u003cspan address=\"10.1016/j.spinee.2003.05.001\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eG\u0026uuml;l A, van Geest S, Kuijper B et al (2025) The CASINO trial: surgical versus conservative management in patients with cervical radiculopathy due to intervertebral disc herniation: a prospective cohort study. Eur Spine J 34:3398\u0026ndash;3407. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00586-025-09045-y\u003c/span\u003e\u003cspan address=\"10.1007/s00586-025-09045-y\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003evan Middelkoop M, Rubinstein SM, Ostelo R et al (2013) Surgery versus conservative care for neck pain: a systematic review. Eur Spine J 22:87\u0026ndash;95. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/s00586-012-2553-z\u003c/span\u003e\u003cspan address=\"10.1007/s00586-012-2553-z\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"cervical radiculopathy, cervical myelopathy, surgery, conservative treatment, meta-analysis","lastPublishedDoi":"10.21203/rs.3.rs-8145135/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8145135/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e\u003cp\u003eThere is conflicting evidence regarding the optimal management strategy for cervical radiculopathy and myelopathy. We conducted a meta-analysis to evaluate the relative effectiveness of nonsurgical treatment and surgical care in adult patients with cervical radiculopathy or myelopathy.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eWe systematically searched PubMed, Embase, and the Cochrane Library to identify randomized controlled trials (RCTs) comparing nonsurgical treatment with surgical treatment. All statistical analyses were performed using RevMan version 5.4.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eSix RCTs met the inclusion criteria. Surgical treatment significantly improved neck pain (SMD 0.70, 95% CI 0.15\u0026ndash;1.26) and arm pain (SMD 0.62, 95% CI 0.04\u0026ndash;1.19) compared with non-surgical care. Subgroup analysis showed that benefits for neck pain were most pronounced in patients with disc herniation (SMD 1.02, 95% CI 0.11\u0026ndash;1.93) and in those with unspecified pathology (SMD 1.23, 95% CI 0.69\u0026ndash;1.77), whereas benefits for arm pain were observed only in disc herniation (SMD 1.29, 95% CI 0.90\u0026ndash;1.68). Surgical treatment also improved physical function in sensitivity analysis (SMD 0.33, 95% CI 0.06\u0026ndash;0.59) and emotional/mood outcomes (SMD 0.22, 95% CI 0.02\u0026ndash;0.45) but did not significantly affect patient-reported overall improvement (RR 0.97, 95% CI 0.72\u0026ndash;1.31) or analgesic use (RR 1.03, 95% CI 0.77\u0026ndash;1.36).\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eSurgical management of cervical radiculopathy or myelopathy may provide superior improvements in neck and arm pain, as well as functional and emotional outcomes, compared with non-surgical treatment, particularly in patients with disc herniation. Further high-quality trials are warranted to confirm these findings and define optimal patient selection.\u003c/p\u003e","manuscriptTitle":"Nonsurgical versus Surgical Treatment for Cervical Radiculopathy or Myelopathy: A Systematic Review and Meta-Analysis of Randomized Controlled Trials","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-19 15:37:29","doi":"10.21203/rs.3.rs-8145135/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"99fcb4f9-26e2-4f0a-8d65-826e4677ab8f","owner":[],"postedDate":"November 19th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-11-28T12:09:02+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-19 15:37:29","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8145135","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8145135","identity":"rs-8145135","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}