From the Guidelines
The most appropriate treatment option for this 57-year-old female with degenerative disc disease and multilevel cervical spine stenosis is anterior cervical discectomy and fusion (ACDF) at the most affected levels, as it provides a durable and physiologically dynamic support system that protects the neural structures and decreases mechanical pain 1.
Treatment Options
Treatment options for this patient include:
- Conservative management (first-line approach):
- Physical therapy: 2-3 times per week for 6-8 weeks, focusing on neck strengthening and flexibility
- NSAIDs: Ibuprofen 400-600mg every 6-8 hours or Naproxen 250-500mg twice daily for pain relief
- Muscle relaxants: Cyclobenzaprine 5-10mg at bedtime for muscle spasms
- Cervical traction: 15-20 minutes daily at home with a prescribed device
- If conservative measures fail after 6-8 weeks:
- Epidural steroid injections: 1-3 injections, spaced 2-4 weeks apart
- Consider referral to a pain management specialist for further interventions
- Surgical options (if conservative treatments and injections fail):
- Anterior cervical discectomy and fusion (ACDF) at the most affected levels, which is the preferred surgical approach as it poses less morbidity to the patient in terms of muscle manipulation and wound healing 1
- Posterior cervical laminectomy with or without fusion
Rationale
The treatment approach aims to reduce pain, improve function, and prevent further neurological deterioration. ACDF is a suitable option as it allows for the removal of the entire disc and surrounding bones, providing a durable and physiologically dynamic support system that protects the neural structures and decreases mechanical pain 1. Autologous bone can be harvested from the iliac crest or the ribs to be used as graft material, which is probably the best option whenever possible 1. However, the patient's general medical condition can affect the duration of the fusion maturation process 1.
Considerations
It is essential to consider the patient's overall health and medical condition when deciding on the treatment approach. The anterior approach is familiar to most spine surgeons and poses less morbidity to the patient in terms of muscle manipulation and wound healing 1. The patient's collateral medical illness can impact the quality of the bone, and their general medical condition can affect the duration of the fusion maturation process 1.
From the Research
Treatment Options for Degenerative Disc Disease and Multilevel Cervical Spine Stenosis
- Conservative management strategies may be considered for a 57-year-old female with degenerative disc disease and multilevel cervical spine stenosis, including medications, physical therapy, and exercise 2.
- Physical therapy interventions such as posture training, dynamic shoulder/scapular strengthening, cervical stabilization, stretching, ultrasound, interferential current, and a progressive home exercise program may be effective in managing cervical pain and headaches 3.
- McKenzie exercises, which include posture correction, range of motion exercises, and lateral neck stretches, may also be beneficial in reducing neck pain and disability 4.
- Adding specific cervical and scapulothoracic stabilization exercises to a standard McKenzie protocol may lead to clinically meaningful reductions in neck pain compared to McKenzie therapy alone 4.
- A multimodal management plan, including physical therapy modalities and rehabilitation techniques, may be essential in managing neuropathic pain, which can be a component of degenerative disc disease and multilevel cervical spine stenosis 5.
Conservative Management
- Conservative management of chronic traumatic cervical myelopathy may be effective in improving pain, sleep, and function, as demonstrated in a case report of a 50-year-old male who completed 10 weeks of conservative physical therapy 6.
- Physical therapy may be a viable option for conservative management of musculoskeletal dysfunction and functional limitations resulting from neurofibromatosis type 1, as shown in a case study of a 17-year-old girl with a 16-year history of NF 1 3.
Physical Therapy Modalities
- Physical therapy modalities such as ultrasound, interferential current, and exercise may be important options in the management of neuropathic pain, and may be considered when pharmacotherapy alone is not sufficient 5.
- Psychosocial support and cognitive behavioral therapy may also be taken into consideration as part of a multimodal management plan for neuropathic pain 5.