What is the best treatment approach for spondylosis?

Treatment Approach for Spondylosis

The optimal treatment for spondylosis combines physical therapy with on-demand NSAIDs as first-line therapy, progressing to TNF inhibitors for patients with persistent symptoms, while avoiding spinal manipulation in patients with spinal fusion or advanced osteoporosis. 1, 2

Initial Management

Pharmacological Treatment

• NSAIDs: Conditionally recommended on-demand rather than continuous treatment for stable ankylosing spondylitis (AS) 1
  • No particular NSAID is preferred over others 2
  • For patients with inflammatory bowel disease, no specific NSAID is recommended as preferred choice 1

Non-Pharmacological Interventions

• Physical therapy: Strongly recommended over no physical therapy 1
  • Land-based physical therapy conditionally recommended over aquatic therapy 1
• Exercise program:
  • Unsupervised back exercises are conditionally recommended 1
  • Should not substitute initial instruction by a physical therapist 1
• Self-management education: Conditionally recommended in either group or individual format 1
• Fall evaluation and counseling: Conditionally recommended 1

Treatment for Persistent Symptoms

Biological Therapy

• TNF inhibitors (infliximab, adalimumab, certolizumab, golimumab):

  • Strongly recommended for patients with active AS despite NSAID treatment 2
  • If patient is on TNFi and NSAIDs, conditionally recommended to continue TNFi alone 1
  • If patient is on TNFi and conventional synthetic antirheumatic drug, conditionally recommended to continue TNFi alone 1
  • Conditionally recommended against co-treatment with low-dose methotrexate 1

• IL-17 inhibitors (secukinumab, ixekizumab):

  • Alternative for patients with active AS despite NSAID treatment 2
  • TNF inhibitors conditionally recommended over IL-17 inhibitors as first biologic 2

• Biologic therapy considerations:

  • Conditionally recommended against discontinuation of biologics 1
  • Conditionally recommended against tapering biologic dose as standard approach 1
  • Strongly recommended continuing treatment with originator TNFi over mandated switching to biosimilar 1

Specific Clinical Scenarios

Advanced Hip Arthritis

• Total hip arthroplasty: Strongly recommended over no surgery 1
  • Provides significant improvements in pain, function, and hip range of motion 1, 2
  • Should be performed by experienced orthopedic surgeons 1, 2

Severe Kyphosis

• Elective spinal osteotomy: Conditionally recommended against 1
  • May be considered only in highly selected patients with severe kyphosis and lack of horizontal vision 2

Spinal Fusion or Advanced Osteoporosis

• Spinal manipulation: Strongly recommended against 1
  • High risk of spine fractures, spinal cord injury, and paraplegia 1

Ocular Manifestations

• Acute iritis: Strongly recommended treatment by ophthalmologist 1
• Recurrent iritis:
  • Conditionally recommended prescription of topical glucocorticoids for prompt at-home use 1
  • TNFi monoclonal antibodies conditionally recommended over other biologics 1

Disease Monitoring

• Disease activity assessment:
  • Conditionally recommended regular use of validated AS disease activity measures 1, 2
  • Conditionally recommended regular monitoring of CRP or ESR 1, 2
  • Conditionally recommended against using a treat-to-target strategy with ASDAS target < 1.3 (or 2.1) 1

Pitfalls and Caveats

• Avoid spinal manipulation with high-velocity thrusts in patients with spinal fusion or advanced spinal osteoporosis due to risk of severe complications 1
• Radiographic follow-up generally not necessary more frequently than every 2 years unless significant clinical changes occur 2
• Screen for comorbidities including uveitis, inflammatory bowel disease, and psoriasis 2
• Consider calcium and vitamin D supplementation with DXA scan monitoring for osteoporosis risk 2