Cervical radicular pain (CRP) is typically caused by degenerative disc changes, and the primary clinical manifestations are neck pain, arm pain, or both (1). According to four moderate to high-quality studies, the prevalence of CRP ranges from 1.21 to 5.8 per 1,000 (2). For the majority of cervical disc herniation patients, conservative treatment is still the preferred first step, which includes rest, physical therapy, oral medications, and epidural steroid injections (3). Pharmacological therapy can vary in effectiveness due to individual differences. Long-term use of non-steroidal anti-inflammatory drugs may cause gastrointestinal discomfort and renal impairment; the use of steroids can lead to weight gain, increased blood sugar, and osteoporosis; while opioids can effectively relieve severe pain, they carry the risk of addiction (4). Physical therapy may overlook long-term prevention, with heat therapy posing a risk of burns, and traction and massage therapies potentially exacerbating cervical spine issues if improperly performed (5). Epidural steroid injections can alleviate pain but are often temporary in effect and carry the risk of infection and nerve damage, with steroid side effects similar to those in pharmacological therapy (6). Therefore, if conservative treatment fails to provide the desired results, various percutaneous minimally invasive surgeries can be considered to relieve pain while avoiding open surgery (7–9). These minimally invasive surgeries are designed to relieve pressure or chemical irritation on sensory structures while minimizing damage to normal tissues, thus aiding patient recovery.

Percutaneous cervical nucleoplasty (PCN) is a minimally invasive procedure for treating herniated discs in the cervical, thoracic, and lumbar spines (10). The basic principle of this surgery is to reduce the volume by approximately 1 ml in a hydraulic space, such as a healthy disc, resulting in a volume reduction of about 10%–20%, significantly lowering the pressure. This decrease in pressure may alleviate the chemical and mechanical factors that contribute to symptoms such as pain, sensory loss, and motor function (11). Pulsed radiofrequency (PRF) has been used to treat various chronic pain conditions, including radicular pain, joint pain, myofascial pain, and migraines (12). During PRF treatment, the tissue temperature can reach up to 42°C, preventing the negative effects of irreversible tissue damage (9). Radiofrequency treatment near the dorsal root ganglion has been shown to cause transient sensory loss in the related dermatome, whereas pain relief may last longer, prompting the development of a minimal neurodestructive current delivery mode (13). Previous research has confirmed the effectiveness of PRF stimulation in relieving cervical radicular pain, and many clinicians are now using PRF to treat this condition (8, 14, 15).

Imaging examinations, including MRI, CT and X - ray, play a vital role in the diagnosis and efficacy evaluation of cervical disc plasma radiofrequency ablation. They can clearly display the anatomical structure of the cervical disc, the extent of the lesion, and the condition of surrounding tissues, thus providing accurate basis for pre - operative diagnosis. MRI, with its excellent soft - tissue contrast, can show in detail the protrusion of the intervertebral disc and the compression of the nerve root. CT has a unique advantage in displaying bony structures and can accurately assess the height of the intervertebral disc and the changes in bony structures. X - ray examination can dynamically observe the range of motion of the cervical spine and the overall biomechanical state (16). The results of these imaging examinations provide important background information for subsequent efficacy evaluation, helping doctors accurately assess the therapeutic effect and formulate follow - up treatment plans. In the research on the correlation between imaging parameters and clinical symptoms of cervical disc plasma radiofrequency ablation, studies have shown that there is a significant correlation between disc height, Cobb angle, SVA (sagittal vertical axis) and ROM (range of motion) and patients' clinical symptoms. For example, the recovery of disc height is closely related the to degree of pain relief (17); the changes of Cobb angle and SVA can reflect the overall biomechanical state and balance of the cervical spine (18); and the improvement of ROM is closely related to the functional recovery of patients (19). These studies provide a solid theoretical basis for the imaging evaluation part of this study, which is conducive to a more comprehensive assessment of the clinical efficacy of cervical disc plasma radiofrequency ablation.

Ultrasound-guided interventions around nerve roots have received attention for their neuromodulatory properties. In recent years, pulsed radiofrequency (PRF) and PCN under ultrasound guidance have been successfully carried out in several studies, with positive outcomes (20, 21). However, only temporary pain relief is offered by these two procedures, which are usually performed independently. To improve the safety and efficacy of CRP treatment, we employ ultrasound guidance to view cervical spine structures, avoiding major blood vessels, nerves, and other vital structures. Furthermore, we have combined PCN and PRF treatments, which successfully lessen nerve root compression and inflammation, improving clinical results. We predict that this combination treatment will lower CRP safely and efficiently.

Cervical radicular pain, also known as radicular cervical spondylosis, is the result of cervical nerve root compression. Common symptoms include neck and shoulder pain, as well as radiating pain, numbness, and weakness in the upper extremities (1). This disease is more common in middle-aged people, but in recent years, it has been gradually getting younger, with an incidence ranging from 3.8% and 17.6%, accounting for 60%–70% of cervical spondylosis patients (24). Although most patients can benefit from conservative treatment, such as medication, traction, and physiotherapy, some patients whose conservative treatment is not satisfactory, and require additional treatment options (10, 25, 26). For these patients, two minimally invasive treatment techniques, PCN (27) and spinal nerve root pulsed radiofrequency (PRF) (28) provide new treatment options. PCN reshapes the nucleus pulposus and reduces disc pressure by precisely controlling thermal energy (typically 40℃–70°C) (29), whereas PRF regulates the nervous system and relieves pain through intermittent electrical stimulation (30). These two technologies, which are minimally invasive, safe, and effective, open up new treatment options for patients.

PRF is an advanced neuromodulation technology used to treat chronic pain. The treatment works by delivering pulsed electrical currents to specific nerve roots or dorsal root ganglia, resulting in a local high-voltage field that indirectly activates superficial neurons in the spinal dorsal horn. This process alters nerve sheath cell function, inhibits electrophysiological conduction of nerve fibers, disrupts pain signal transmission, and activates the spinal cord's pain inhibition system (31). Although PRF can significantly reduce pain in the short term, its long-term efficacy may be less than that of direct nerve destruction methods, necessitating repeated treatments to manage pain (12, 31). Furthermore, the efficacy of PRF varies by individual and may be limited against certain types of pain (32). PCN, with its minimal invasiveness, wide application, and clear therapeutic outcomes, offers an alternative to overcome the limitations of PRF (20).

PCN is a minimally invasive surgical procedure that treats cervical disc herniation. It uses low-temperature plasma technology to create a highly ionized plasma region around the electrode via a conductive medium, which severs the molecular chains within the disc tissue, resulting in tissue vaporization and contraction (33). The procedure is performed at relatively low temperatures (typically 40℃–70℃) to prevent thermal injury to surrounding tissues (29). By ablating the protruding portion of the disc, the volume of the disc is reduced, relieving pressure on the nerve roots. PCN has several advantages over open cervical surgery, including minimal invasiveness, quick recovery, fewer complications, and the preservation of spinal structural integrity (16, 34). Furthermore, de Rooi j et al. (35) demonstrated that among patients with single-level cervical disc herniation, there was no statistically significant difference in symptom relief and patient satisfaction between the ACDF and PCN groups one year after surgery. Furthermore, unlike PRF, PCN uses radiofrequency ablation to directly target the protruding part of the cervical disc, effectively reducing disc compression on the nerve roots (21). This direct physical ablation can quickly relieve the symptoms of nerve root compression caused by disc herniation, whereas PRF primarily relieves pain by modulating nerve signal conduction, with less direct impact on the disc structure (8). Next, PCN can repair the annulus fibrosus of the disc using radiofrequency ablation, increasing the disc's structural stability. Conversely, PRF primarily relieves pain by modulating nerve signal transmission, with only minor reparative effects on disc structure (21).

Combining the insights from the aforementioned literature, PCN can effectively address some of the current limitations of PRF. In our clinical practice, we choose between PCN + PRF combination therapy and standalone PRF treatment for chronic cervical radicular pain based on the unique circumstances of each patient. However, no direct comparison of efficacy between these two approaches has yet been published in the clinical literature. Therefore, we chose 26 pairs of patients with CCRP to undergo the two treatment methods described above. The study findings revealed that the NDI of patients in the PCN + PRF group was considerably lower than that of the PRF group after 3 months, the N-VAS and A-VAS scores of patients in the PCN + PRF group were substantially less than those of the PRF group after 6 months, and the CASCS scores of patients in the PCN + PRF group were significantly greater than those of the PRF group after 6 months. The study findings show that, when compared to the PRF group alone, the combined treatment did not show significant differences in the short term, but its benefits gradually emerged in the later stages of treatment (after 3 months), and the variations in therapeutic effects increased over time. Furthermore, based on the modified MacNab criteria, a greater proportion of patients in the PRF + PCN group reported clinical satisfaction than those in the PRF group. The reason could be that PCN acts directly on the intervertebral disc to eliminate the source of compression, whereas PRF reduces pain signals through neural modulation. The combined treatment addresses structural and functional issues, resulting in more comprehensive and effective relief of cervical radicular pain (28). Furthermore, PCN can quickly relieve symptoms in the short term, whereas PRF has long-term analgesic effects. This complementary action enables the combined treatment to provide effective therapeutic results at various stages (15).

In terms of imaging assessment, after a year of follow-up, the intervertebral disc height at the surgical level in the PCN + PRF group was significantly lower than preoperatively. A case–control study (16) found a significant decrease in average intervertebral disc height from 6.04 ± 0.85 mm to 5.76 ± 1.02 mm 3 months after PCN treatment, which is consistent with our findings. The study also found that the amount of intervertebral disc height reduction was unrelated to the significant improvement in visual analog scale (VAS) scores. The reason for the decrease in intervertebral disc height can be summarized as PCN ablation of intervertebral disc tissue, which results in a decrease in disc volume and, as a result, a decrease in disc height. Furthermore, our study discovered that a decrease in intervertebral disc height did not result in the development of new clinical symptoms. Furthermore, when compared to the PRF group, the ROM of the PCN + PRF group increased. Possible explanations include PCN ablation of intervertebral disc tissue using low-temperature plasma technology, which results in a reduction in disc volume (36). This volume reduction alters the biomechanical properties of the cervical spine, reducing the disc's constraining force on adjacent vertebrae and increasing disc mobility. Second, after PCN treatment, the reduction in intervertebral disc height narrows the intervertebral space, which affects cervical spine stability and increases disc mobility (16). Next, PRF regulates nerve signal conduction, which prevents abnormal nerve discharge. By relieving nerve root pain and inflammation, patients may increase their cervical spine's range of motion in a pain-free state, thereby increasing disc mobility (37).

Our study has some limitations. First, it used a retrospective single-center design with a small sample size, making it impossible to rule out selection bias. Future research should include larger-scale prospective, multicenter studies to further validate our findings. Second, because we did not establish a control group of patients who received only PCN treatment, we cannot determine whether the benefit of long-term postoperative pain relief is due to the PCN technology itself or the synergistic effect of PCN combined with PRF treatment. This requires additional well-designed studies to prove. Finally, our sample may not have included all types of cervical radicular pain patients, such as those with varying causes, disease stages, ages, and genders. This may result in differences in the applicability of research findings across patient groups, making it difficult to comprehensively evaluate the efficacy of PCN + PRF combined treatment vs. PRF treatment alone in different types of patients. In future studies, we will refine the types of cervical spondylotic radiculopathy to reach more precise conclusions.

We introduce a novel approach for treating CRP by combining PCN with PRF. This integrated strategy is both effective and safe, consistently reducing pain levels and improving functional outcomes throughout the treatment process.