What is the initial treatment for spondylosis?

Initial Treatment for Spondylosis

NSAIDs are recommended as first-line drug treatment for spondylosis patients with pain and stiffness, combined with non-pharmacological approaches including patient education and regular exercise. 1

Understanding Spondylosis

Spondylosis refers to degenerative changes in the spine, which can affect the:

• Vertebral bodies
• Intervertebral discs
• Facet joints
• Supporting ligamentous structures

These changes can lead to pain, stiffness, and in some cases, neurological symptoms.

Treatment Algorithm

First-Line Treatment

1. Pharmacological Management:

   • NSAIDs (including COX-2 inhibitors) as first-line medication 1
   • For patients with increased gastrointestinal risk: use non-selective NSAIDs with gastroprotective agents or selective COX-2 inhibitors 1
   • Consider continuous rather than on-demand NSAID treatment for persistently active, symptomatic disease 1

2. Non-Pharmacological Management (to be implemented concurrently):

   • Patient education about the condition 1
   • Regular exercise program 1
   • Physical therapy with supervised exercises (more effective than home exercises alone) 1
   • Home exercise program focusing on core strengthening, hamstring stretching, and spine range of motion 2

Second-Line Treatment

If first-line treatment is insufficient:

1. Analgesics:

   • Paracetamol (acetaminophen) and opioid-like drugs for residual pain 1
   • Only when NSAIDs are insufficient, contraindicated, or poorly tolerated 1

2. Local Injections:

   • Corticosteroid injections directed to local sites of musculoskeletal inflammation 1
   • Epidural or transforaminal injections for radiating leg pain or neurogenic claudication 3

For Peripheral Joint Involvement

• Sulfasalazine may be considered for patients with peripheral arthritis 1
• DMARDs (Disease-Modifying Antirheumatic Drugs) are not effective for axial disease 1

For Refractory Cases

• Anti-TNF therapy for patients with persistently high disease activity despite conventional treatments 1
• Surgical intervention only for patients who are totally incapacitated by their condition 3

Important Clinical Considerations

Monitoring and Follow-up

• Regular monitoring of disease activity, but not necessarily at every clinic visit 1
• Assessment of cardiovascular, gastrointestinal, and renal risks when prescribing NSAIDs 1

Cautions and Contraindications

• Avoid systemic glucocorticoids for axial disease as there is no evidence supporting their use 1
• Strongly avoid spinal manipulation with high-velocity thrusts in patients with spinal fusion or advanced spinal osteoporosis due to risk of fractures and neurological injury 1

Special Circumstances

• For patients with advanced hip arthritis, total hip arthroplasty is strongly recommended 1
• Extra-articular manifestations (psoriasis, uveitis, inflammatory bowel disease) should be managed in collaboration with respective specialists 1

Evidence Quality and Considerations

The recommendations are primarily based on guidelines from professional rheumatology societies, with the most recent update from 2015 1. The evidence for NSAIDs in improving spinal pain, peripheral joint pain, and function is strong (level Ib) 1.

Physical therapy and exercise have moderate-quality evidence supporting their use 1, with studies showing that supervised exercise programs result in better patient global assessment than home exercises alone 1.

Conservative management without bracing has shown good outcomes in patients with symptomatic spondylolysis and grade I spondylolisthesis, with 96% of patients achieving minimal disability scores in one study 2.