What is the initial management for a patient with multilevel anterior spondylosis?

From the Guidelines

The initial management for a patient with multilevel anterior spondylosis should prioritize conservative treatment, combining pharmacological treatment with physical therapy, as strongly recommended by recent guidelines. This approach is supported by the most recent study 1, which emphasizes the importance of physical medicine and rehabilitation in managing axial spondyloarthritis, a condition closely related to multilevel anterior spondylosis.

Key Components of Conservative Management

• Physical therapy should focus on core strengthening and spinal stabilization exercises, managed by experts in physical medicine and rehabilitation, with a preference for active physical therapy and supervised exercise over passive physical therapy and unsupervised exercise 1.
• Pain management using NSAIDs, such as ibuprofen or naproxen, is recommended as first-line drug treatment for patients suffering from pain and stiffness, taking into account the risks and benefits 1.
• Muscle relaxants like cyclobenzaprine may be added for muscle spasms, and for more severe pain, a short course of oral steroids or epidural steroid injections targeting the affected levels may be considered.
• Activity modification is essential, avoiding positions that exacerbate symptoms while maintaining mobility, and cervical orthoses like soft collars should be used sparingly and only for short periods to prevent muscle atrophy.

Rationale for Conservative Approach

The conservative approach is recommended first because spondylosis is a degenerative condition that often responds to non-surgical management, and many patients experience significant improvement with these measures. Additionally, these interventions address the inflammatory component of spondylosis while promoting proper spinal biomechanics and muscle support to reduce pressure on affected neural structures. The importance of exercise supervision in patients with axial spondyloarthritis is underscored, but the difficulty of providing this healthcare service in many regions permits the consideration of unsupervised home-based exercises for patients who have been trained to properly exercise 1.

Consideration of Surgical Intervention

Surgical intervention should be considered after a trial of conservative management, typically for 6-12 weeks, if significant improvement is not observed, or if there are red flags such as severe neurological deficits or instability. However, the decision to proceed with surgery should be individualized based on the patient's specific condition, symptoms, and response to conservative treatment, as well as considerations of the potential risks and benefits of surgical intervention.

From the Research

Initial Management for Multilevel Anterior Spondylosis

The initial management for a patient with multilevel anterior spondylosis typically involves conservative management strategies.

• Non-narcotic and narcotic pain medications can be used to manage pain 2.
• Epidural steroid injections and transforaminal injections may also be considered for pain relief 2.
• Physical therapy is another important aspect of conservative management, helping to improve and maintain spinal mobility and function 3, 4.
• The use of back supports, including antilordotic orthoses, and job modifications may also be recommended 4.
• In some cases, surgical management may be necessary, especially if conservative management strategies fail 2, 5.

Conservative Treatment Approaches

Conservative treatment for spondylolisthesis, which can be associated with multilevel anterior spondylosis, includes:

• Instruction in exercise and body mechanics 4.
• Strengthening of the abdominals and paraspinal muscles 4.
• Occupational modifications and instruction in body mechanics, deep-heat therapy, avoidance of maximal forward flexion of the lumbar spine, and in severe cases, bed rest 4.
• The use of flexion exercise programs has been shown to be effective in reducing pain and improving outcomes 4.

Surgical Intervention

Surgical intervention may be necessary for patients with severe instability, pain, or neurological deficiency 3, 5.

• The choice of surgical procedure depends on the specific condition and the patient's pathoanatomy 5.
• Anterior cervical decompressive and reconstructive procedures are commonly used for the treatment of multilevel cervical spondylotic myelopathy 5.
• The selection of multiple discectomies compared with corpectomy or discectomy-corpectomy hybrid procedures may be favored due to superior clinical outcomes and postoperative sagittal alignment 5.