What is the initial management for cervical spondylosis?

Initial Management for Cervical Spondylosis

The initial management for cervical spondylosis should include non-steroidal anti-inflammatory drugs (NSAIDs) at full therapeutic doses combined with supervised physical therapy. 1

First-Line Treatment Approach

Pharmacological Management

• NSAIDs: Recommended as first-line drug treatment for pain and stiffness

  • Use at full therapeutic doses during disease flares
  • No specific NSAID is preferred over others
  • For patients with increased gastrointestinal risk, consider:
    • Non-selective NSAIDs plus gastroprotective agent (PPI or H2 blocker)
    • OR selective COX-2 inhibitor 2, 1

• Analgesics: Consider for pain control when NSAIDs are:

  • Insufficient
  • Contraindicated
  • Poorly tolerated
  • Options include paracetamol (acetaminophen) and opioids 2

Non-Pharmacological Management

• Physical Therapy: Essential component focusing on:

  • Maintaining spinal mobility
  • Improving posture
  • Strengthening core and neck muscles 1
  • Evidence shows Mulligan's mobilization and Kinesio taping can improve cervical range of motion and deep cervical flexor muscle strength 3

• Patient Education:

  • Information about disease course and management expectations
  • Activity modifications to reduce pain while maintaining function 1

Monitoring Response and Treatment Progression

• Assess response to NSAIDs within 2-4 weeks 1
• Monitor using:
  • Patient history (questionnaires)
  • Clinical parameters
  • Laboratory tests (CRP, ESR)
  • Imaging as needed 2
• Frequency of monitoring should be individualized based on:
  • Symptom severity
  • Disease activity
  • Treatment regimen 2

Second-Line Treatment Options

For Inadequate Response to First-Line Treatment

• Local Corticosteroid Injections: May be considered for localized musculoskeletal inflammation 2

  • Note: Systemic corticosteroids are not recommended for axial disease 1

• For Peripheral Arthritis: Consider sulfasalazine 2, 1

  • Note: DMARDs including methotrexate and sulfasalazine show no efficacy for axial disease 2

• For Persistent High Disease Activity: Consider TNF inhibitors (adalimumab, etanercept, infliximab, golimumab) 1

Surgical Considerations

• Surgery is generally not considered unless:

  • Pain persists despite conservative treatment
  • Progressive neurological deficit occurs 4

• Indications for surgical referral:

  • Progressive neurological deficits
  • Severe, uncontrolled pain
  • Significant functional limitations
  • Failed conservative management 1, 5

• Surgical outcomes for cervical spondylotic radiculopathy show better pain relief compared to conservative treatment in the short term (< 1 year), but similar long-term outcomes for disability and range of motion 6

Important Considerations

• Conservative treatment (including physical therapy, traction, TENS, education) once or twice weekly for 3 months can provide good long-term benefits while avoiding surgical risks 6

• The natural history of cervical spondylosis is often favorable with conservative management, with 30-50% of patients showing improvement with simple measures like neck immobilization 4

• Early diagnosis and treatment are crucial for preventing structural deformities and reducing mortality risk 1