From the Guidelines
The recommended treatment for a patient with straightening of the normal cervical lordosis, moderate to severe left foraminal narrowing at C3-4, and mild to moderate bilateral foraminal narrowing at C4-5, without severe canal stenosis or significant neurological deficits, typically begins with conservative management. This approach is supported by the American College of Radiology's appropriateness criteria for cervical neck pain or cervical radiculopathy, which suggests that most cases of acute cervical neck pain with radicular symptoms resolve spontaneously or with conservative treatment measures 1.
Conservative Management
Conservative management should include:
- Physical therapy focusing on cervical strengthening and posture correction, twice weekly for 6-8 weeks
- Non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen 400-600mg three times daily or naproxen 500mg twice daily for 2-3 weeks to reduce inflammation and pain
- Muscle relaxants like cyclobenzaprine 5-10mg at bedtime may be added for muscle spasms
- Modification of activities to avoid neck strain and ergonomic adjustments at work and home
- A soft cervical collar may provide temporary relief but should be limited to 1-2 weeks to prevent muscle weakening
Rationale
The rationale behind starting with conservative management is that many patients improve without surgery, and these interventions address the pain and functional limitations while avoiding the risks of surgical intervention 1. Additionally, the presence of spondylotic changes, such as those seen in this patient, are common in individuals over 30 years of age and do not always correlate with the presence of neck pain 1.
Further Intervention
For patients with persistent pain, further interventions such as a cervical epidural steroid injection might be considered, typically using methylprednisolone 40-80mg or triamcinolone 40mg. Surgery would only be considered if conservative measures fail after 3-6 months or if neurological symptoms worsen. This approach prioritizes the patient's quality of life, minimizing morbidity and mortality by avoiding unnecessary surgical risks.
From the Research
Cervical Spine Alignment and Treatment
The patient's cervical spine alignment shows some straightening of the normal cervical lordosis, with specific issues at the C3-4 and C4-5 levels.
- The C3-4 level has left uncovertebral joint osteophytic changes, moderate to severe left foraminal narrowing, but no canal stenosis.
- The C4-5 level shows disc osteophytic change with minor posterior bulging of the disc, no canal stenosis, and mild to moderate bilateral foraminal narrowing.
Recommended Treatment
Given the absence of severe canal stenosis or significant neurological deficits, conservative management may be considered as the initial approach 2, 3, 4.
- Conservative therapy, including physical therapy, can minimize invasive intervention and decrease the risks of morbidity 2.
- For patients with cervical radiculopathy, conservative treatments such as physiotherapy, collar, or traction may be effective, although the evidence suggests that no one intervention is superior to others 4.
- Surgery may be considered for patients who fail to improve with conservative treatment or have significant neurological deficits 5, 3, 6.
Considerations for Surgical Intervention
Surgical intervention may be recommended for patients with cervical canal stenosis and cord compression secondary to spondylosis, without clinical evidence of myelopathy, who present with clinical or electrophysiological evidence of cervical radicular dysfunction or central conduction deficits 5.
- Decompression is the surgical treatment of choice for central spinal stenosis without significant grade I spondylolisthesis or deformity 3.
- Fusion may be recommended when spinal stenosis is associated with instability, degenerative spondylolisthesis, deformity, postoperative instability, or recurrent stenosis 3.