What is the appropriate management approach for a patient with relatively advanced multilevel degenerative changes in the cervical spine and reversal of the normal cervical lordosis?

Management of Advanced Multilevel Degenerative Cervical Spine Changes with Reversal of Normal Lordosis

Conservative management with physical therapy focused on cervical lordosis restoration should be the first-line approach for patients with multilevel degenerative changes in the cervical spine and reversal of normal cervical lordosis, as this can improve nerve root function and pain without the risks of surgical intervention.

Initial Assessment and Diagnosis

The radiographic findings describe:

• Reversal of normal cervical lordosis
• Multilevel intervertebral disc height loss
• Uncovertebral arthropathy and facet arthropathy at C3-4, C4-5, C5-6, C6-7
• No fractures, bone destruction, or prevertebral soft tissue swelling
• Normal C1-C2 alignment

Clinical Correlation

When evaluating these findings, it's important to:

• Assess for neurological deficits (radiculopathy, myelopathy)
• Evaluate pain severity and functional limitations
• Determine if symptoms correlate with imaging findings

Management Algorithm

Step 1: Conservative Management (First-Line)

1. Physical Therapy with Focus on Cervical Lordosis Restoration

   • Cervical extension exercises and stretching
   • Cervical extension traction (3× per week for 10 weeks)
   • This approach has been shown to significantly improve nerve root function and pain in patients with cervical spondylotic radiculopathy 1

2. Pain Management

   • NSAIDs for anti-inflammatory effect
   • Muscle relaxants for associated muscle spasm
   • Short-term use of mild analgesics if needed

3. Activity Modification

   • Ergonomic adjustments (proper desk/computer height)
   • Postural education
   • Avoid prolonged neck flexion

Step 2: For Persistent Symptoms (After 6-8 Weeks of Conservative Care)

1. Consider Referral for Interventional Pain Management

   • Epidural steroid injections
   • Facet joint injections
   • Medial branch blocks

2. Advanced Imaging

   • MRI cervical spine if not already obtained (especially if neurological symptoms are present)
   • MRI is the most sensitive test for detecting soft tissue abnormalities associated with neck pain 2

Step 3: Surgical Consideration (For Refractory Cases)

Consider surgical consultation if:

• Progressive neurological deficits
• Intractable pain despite conservative measures
• Significant functional limitations

Surgical options may include:

• Anterior cervical corpectomy and fusion (ACCF) with stand-alone cages has been shown to be safe and effective for multilevel degenerative cervical spine disease 3

Evidence-Based Considerations

1. Correlation Between Cervical Lordosis and Pain

   • Research has shown an inverse linear correlation between increased cervical lordosis and pain scores (r = −0.49; p = 0.005), suggesting that restoration of lordosis can reduce pain 1
   • Cervicothoracic lordosis correlates positively with mental and physical quality of life components and negatively with neck disability index 4

2. Importance of Lordosis Restoration

   • Improved cervical lordosis correlates with significant improvements in nerve root function and pain rating in patients with cervical spondylotic radiculopathy at both short and long-term follow-up 1

3. Age and Gender Considerations

   • While total cervical lordosis doesn't significantly differ between genders, the internal architecture does vary - males have smaller upper cervical lordosis and higher lower cervical lordosis than females 5
   • These differences should be considered when planning treatment

Common Pitfalls to Avoid

1. Overreliance on Imaging Findings

   • The presence of degenerative changes on imaging doesn't necessarily correlate with symptoms
   • A study found no significant difference in cervical curvature between patients with and without neck pain 6

2. Premature Surgical Intervention

   • Surgery should be reserved for cases with progressive neurological deficits or failure of conservative management
   • Conservative approaches focusing on lordosis restoration can provide significant long-term benefits 1

3. Inadequate Immobilization During Acute Flares

   • While long-term immobilization is not recommended, short-term use of soft collars during acute pain flares may be beneficial
   • When immobilization is required, jaw thrust techniques are preferred over head tilt with chin lift to minimize cervical spine movement 2

By following this structured approach with emphasis on cervical lordosis restoration through physical therapy, most patients with multilevel degenerative cervical spine changes can achieve significant improvement in symptoms without requiring surgical intervention.