What is the initial management for a straightening disc with slight reversal of the normal cervical lordosis?

Initial Management for Straightening Disc with Slight Reversal of Normal Cervical Lordosis

Conservative management with physical therapy, cervical traction, and pain management should be the first-line treatment for patients with straightening or slight reversal of normal cervical lordosis, as this approach can restore cervical lordosis and relieve symptoms without surgery.

Understanding Cervical Lordosis Reversal

Reversal of the normal cervical lordosis (straightening of the cervical spine) is a common radiographic finding that may be associated with:

• Neck pain
• Cervical radiculopathy (nerve root compression symptoms)
• Reduced range of motion
• Headaches

This condition represents a loss of the normal anterior convexity of the cervical spine, which can increase stress on intervertebral discs, facet joints, and surrounding soft tissues.

Initial Assessment

When evaluating a patient with straightened cervical lordosis:

• Determine if there are neurological symptoms (radiculopathy, myelopathy)
• Assess for "red flag" symptoms requiring urgent intervention:
  • Focal neurological deficits
  • Signs of spinal cord compression
  • Pain from spinal processes
  • Disturbance of consciousness

Treatment Algorithm

Step 1: Conservative Management (First-Line)

For patients without significant neurological deficits:

1. Physical Therapy

   • Cervical extension exercises to restore lordosis
   • Postural training
   • Neck strengthening exercises

2. Manual Therapy

   • Chiropractic manipulation (shown to improve cervical lordosis by 13-14° in some studies) 1
   • Cervical extension-compression traction (demonstrated to restore cervical lordosis) 1, 2

3. Pain Management

   • NSAIDs for pain and inflammation
   • Muscle relaxants for associated muscle spasm
   • Brief course of cervical collar immobilization if needed for acute pain

Step 2: Monitoring and Follow-up

• Re-evaluate after 6-8 weeks of conservative treatment
• Obtain follow-up radiographs to assess improvement in cervical lordosis
• Case reports show that restoration of cervical lordosis correlates with symptom improvement 3, 2

Step 3: Advanced Interventions (If Conservative Treatment Fails)

For patients with persistent symptoms after 6 weeks of conservative management:

1. Imaging

   • MRI cervical spine without contrast (most sensitive for soft tissue abnormalities) 4
   • CT cervical spine without contrast (if better visualization of bony structures is needed) 4

2. Interventional Procedures

   • Epidural steroid injections for radicular symptoms
   • Facet joint injections for facet-mediated pain

3. Surgical Consideration

   • Only if there is:

     • Persistent radiculopathy with corresponding neural compression
     • Progressive neurological deficit
     • Significant pain unresponsive to conservative measures

   • Surgical options may include:

     • Anterior cervical discectomy and fusion (ACDF) with plating to maintain lordosis (Class II evidence) 4
     • Cervical arthroplasty as an alternative to ACDF in selected patients (Class II evidence) 4

Evidence for Conservative Management

Multiple studies support the effectiveness of conservative approaches:

• Alleviating cervical radiculopathy through manipulative correction of reversed cervical lordosis has shown complete symptom relief with restoration of cervical lordosis at 4-year follow-up 3

• Chiropractic biophysics technique with extension-compression cervical traction combined with spinal manipulation decreased chronic neck pain intensity and improved cervical lordosis in 38 visits over 14.6 weeks 1

• Cervical extension traction as part of multimodal rehabilitation has been shown to restore lordosis and relieve symptoms in patients with chronic neck pain 2

Surgical Considerations

If conservative management fails and surgical intervention is considered:

• The addition of a cervical plate during ACDF is recommended to maintain lordosis (Class II evidence) 4
• For single-level disease, cervical arthroplasty is recommended as an alternative to ACDF for control of neck and arm pain (Class II evidence) 4
• For two-level disease, ACDF with instrumentation is recommended over ACDF without instrumentation to improve arm pain (Class II evidence) 4

Key Pitfalls to Avoid

1. Rushing to surgery - Most cases respond to conservative management; surgery should be reserved for cases with progressive neurological deficits or failed conservative treatment

2. Ignoring the radiographic finding - While straightening of cervical lordosis is common in asymptomatic individuals, it should not be dismissed when symptomatic

3. Overreliance on imaging - MRI shows abnormalities in many asymptomatic patients; clinical correlation is essential 4

4. Inadequate duration of conservative treatment - A minimum of 6 weeks of conservative management is recommended before considering more invasive options

By following this structured approach, most patients with straightening or reversal of normal cervical lordosis can achieve symptom relief and improved cervical alignment without surgical intervention.