What are the treatment options for cervical spondylosis?

Treatment Options for Cervical Spondylosis

Treatment for cervical spondylosis should begin with conservative management including NSAIDs, physical therapy with neck muscle strengthening exercises, cervical traction, and activity modification, with surgical intervention reserved for patients with moderate to severe myelopathy or those who fail conservative treatment. 1

Classification and Diagnosis

Cervical spondylosis can be categorized into three clinical syndromes:

1. Type I: Cervical Radiculopathy (nerve root compression)
2. Type II: Cervical Myelopathy (spinal cord compression)
3. Type III: Axial Joint Pain (neck pain without neurological symptoms) 2

Key diagnostic findings:

• MRI cervical spine without contrast is the preferred imaging modality
• CT myelography if MRI is contraindicated 1
• Red flags requiring immediate attention: gait instability, decreased hand dexterity, hyperreflexia, Hoffmann's sign, Babinski sign, and bladder/bowel dysfunction 1

Treatment Algorithm

1. Conservative Management (First-line for mild symptoms)

• Medications:

  • NSAIDs for pain and inflammation
  • Muscle relaxants for muscle spasms
  • Short-term oral corticosteroids for acute radicular pain

• Physical Therapy:

  • Neck muscle strengthening exercises
  • Isometric exercises
  • Cervical traction
  • Activity modification 1, 3

• Immobilization:

  • Cervical collar for short-term use
  • "Low-risk" activity modification 4

2. Surgical Management

Indications for surgery:

• Moderate to severe myelopathy (mJOA score ≤12)
• Progressive neurological deficits
• Persistent radicular pain despite conservative treatment
• Bladder/bowel dysfunction 4, 1

Surgical approaches:

• Anterior approach (preferred for 1-3 level disease):

  • Anterior cervical discectomy and fusion (ACDF)
  • Anterior cervical corpectomy

• Posterior approach (preferred for ≥4 level disease):

  • Laminectomy with or without fusion
  • Laminoplasty
  • Posterior cervical laminoforaminotomy 1

Evidence-Based Treatment Recommendations

For Cervical Spondylotic Myelopathy (CSM):

1. Mild CSM (mJOA score >12):

   • Can be treated with either surgical decompression or nonoperative therapy for the first 3 years after diagnosis
   • Nonoperative therapy includes cervical collar immobilization, activity modification, and anti-inflammatory medications 4

2. Moderate to Severe CSM (mJOA score ≤12):

   • Surgical decompression is recommended
   • Benefits are maintained for at least 5 years and up to 15 years postoperatively
   • Earlier intervention is associated with better outcomes 4, 1

For Cervical Radiculopathy:

• First-line treatment is conservative management
• If symptoms persist or worsen after 6-12 weeks, surgical options include:
  • ACDF (90-97% good to excellent results)
  • Posterior cervical laminoforaminotomy 1

Important Considerations and Cautions

1. Delayed diagnosis risks:

   • Prolonged nonoperative management in patients with moderate to severe myelopathy can lead to irreversible spinal cord damage 1

2. Surgical complications:

   • Post-perfusion ischemia ("white cord syndrome") in 4-9% of patients
   • Pseudarthrosis (nonunion) after fusion
   • Adjacent segment degeneration after fusion 1

3. Contraindications for spinal manipulation:

   • Spinal fusion or advanced spinal osteoporosis
   • Risk of spine fractures, spinal cord injury, and paraplegia 4

4. Prognosis:

   • Approximately 44% of patients undergoing decompression for CSM may have substantial neurological impairment 6 months postoperatively
   • Patients with preoperative myelomalacia may have residual spinal cord abnormalities after decompression 1

Special Populations

For patients with advanced hip arthritis and AS:

• Total hip arthroplasty is strongly recommended for those with substantial impact on mobility or quality of life 4

For elderly patients or those with significant comorbidities:

• Careful risk-benefit assessment is needed before considering surgical intervention
• Higher risk of complications in patients over 75 years 1

By following this treatment algorithm and considering the specific clinical presentation of each patient, optimal outcomes can be achieved in the management of cervical spondylosis.