What is the next treatment for a patient with cervical spondylosis (arthritis) and a bulging disc at C4-5, C5-6, and C6-7?

Treatment for Cervical Spondylosis with Bulging Disc

The first-line treatment for a patient with cervical spondylosis and bulging discs at C4-5, C5-6, and C6-7 should be conservative management with NSAIDs and physical therapy for at least 6 weeks before considering more invasive interventions. 1

Initial Conservative Management

Pharmacological Treatment

• NSAIDs: Begin with on-demand (as needed) NSAIDs rather than continuous treatment
  • This approach is recommended for stable cervical spondylosis to minimize gastrointestinal, renal, and cardiovascular risks 2
  • Use full therapeutic doses when pain is present
  • No specific NSAID is preferred over others 2

Physical Therapy and Exercise

• Supervised physical therapy: Strongly recommended as a cornerstone treatment 2, 1

  • Focus on:
    • Maintaining cervical spine mobility
    • Improving posture
    • Strengthening core and neck muscles
    • Gentle stretching exercises
  • Active interventions (supervised exercises) are preferred over passive interventions (massage, ultrasound, heat) 2
  • Land-based physical therapy is preferred over aquatic therapy 2

• Home exercise program: Should be prescribed in addition to supervised therapy 1

  • Daily exercises focusing on cervical range of motion
  • Postural correction exercises
  • Strengthening of deep neck flexors

Monitoring and Assessment

• Regular assessment of:

  • Pain levels
  • Functional limitations
  • Neurological status (to detect any progression of symptoms)
  • Response to conservative treatment

• Consider follow-up MRI if symptoms persist beyond 6 weeks of conservative therapy 1

When to Consider Additional Interventions

If symptoms persist after 6 weeks of consistent conservative management, consider:

1. Local corticosteroid injections: May be beneficial for persistent radicular pain 2, 1

2. Referral for surgical evaluation if:

   • Progressive neurological deficits develop
   • Severe, uncontrolled pain persists despite conservative management
   • Significant functional limitations continue
   • Evidence of myelopathy develops 1, 3

What to Avoid

• Spinal manipulation: Strongly recommended against in patients with cervical spondylosis and disc bulges due to risk of worsening symptoms 1, 4
• Systemic corticosteroids: Not recommended for management of cervical spondylosis 2
• Inadequate NSAID dosing: Ensure full therapeutic doses when used 1

Patient Education

• Educate about the natural history of cervical spondylosis
• Emphasize the importance of consistent exercise and physical therapy
• Discuss activity modifications to reduce pain while maintaining function
• Set realistic expectations about management goals and timeline

Algorithm for Treatment

1. Start with NSAIDs (on-demand) + Physical therapy for 6 weeks
2. If improvement occurs: Continue home exercise program and use NSAIDs as needed
3. If minimal or no improvement after 6 weeks: Consider local corticosteroid injections and/or surgical consultation
4. If neurological symptoms worsen at any point: Immediate surgical consultation

This approach prioritizes conservative management while monitoring for signs that would necessitate more aggressive intervention, focusing on improving function and quality of life while minimizing pain and preventing neurological complications.