What is the initial treatment for spondylosis?

Initial Treatment for Spondylosis

The initial treatment for spondylosis should be non-steroidal anti-inflammatory drugs (NSAIDs), which are recommended as first-line drug treatment for pain and stiffness. 1

Treatment Algorithm

Step 1: Non-pharmacological Interventions

• Patient education about the condition
• Regular exercise program
  • Home exercises focusing on core strengthening
  • Supervised physical therapy (more effective than home exercises alone)
  • Hamstring stretching and spine range of motion exercises 2
• Avoid activities that exacerbate symptoms

Step 2: Pharmacological Management

1. First-line: NSAIDs

   • Can be traditional NSAIDs or COX-2 inhibitors
   • Consider continuous rather than on-demand treatment for persistently active disease 1
   • For patients with increased gastrointestinal risk, use either:
     • Non-selective NSAIDs plus a gastroprotective agent
     • A selective COX-2 inhibitor 1

2. Second-line options (if NSAIDs insufficient, contraindicated, or poorly tolerated)

   • Analgesics such as paracetamol (acetaminophen)
   • Opioid medications for residual pain 1

3. Localized treatments

   • Corticosteroid injections directed to local sites of musculoskeletal inflammation 1
   • Epidural or transforaminal injections may help with radicular pain 3

Important Considerations

Medication Precautions

• Monitor for NSAID side effects:
  • Gastrointestinal: Risk of serious GI events is dose-dependent
  • Cardiovascular: Consider cardiovascular risk profile
  • Renal: Monitor renal function in at-risk patients

When to Consider Advanced Treatments

• For persistent symptoms despite conservative management:
  • Disease-modifying antirheumatic drugs (DMARDs) like sulfasalazine may be considered, but only for peripheral arthritis, not axial disease 1
  • Anti-TNF therapy should be considered for persistently high disease activity despite conventional treatments 1

Surgical Considerations

• Surgery is generally reserved for patients with:
  • Advanced hip arthritis (total hip arthroplasty) 1
  • Severe or progressive neurologic deficits 4, 3
  • Patients who are totally incapacitated by their condition 3

Common Pitfalls to Avoid

1. Overuse of systemic corticosteroids - Not supported by evidence for axial disease 1
2. Spinal manipulation in patients with spinal fusion or advanced osteoporosis - Can lead to serious complications including spine fractures and spinal cord injury 1
3. Premature progression to surgical intervention - Conservative management should be tried for at least 3-4 months before considering surgery 5
4. Overlooking the importance of physical therapy - Supervised exercises are more effective than home exercises alone 1
5. Failing to address both pain management and functional improvement - Treatment should aim to improve both symptoms and function 1

By following this treatment approach, most patients with spondylosis can achieve significant pain relief and functional improvement without requiring surgical intervention.