What is the initial treatment for cervical spondylosis?

Initial Treatment for Cervical Spondylosis

Conservative management, including NSAIDs, physical therapy with neck muscle strengthening exercises, and activity modification, is the recommended first-line treatment for cervical spondylosis. 1

Diagnostic Considerations

Before initiating treatment, it's important to determine the severity and specific manifestations of cervical spondylosis:

• Obtain MRI cervical spine without contrast if red flags are present (preferred imaging method)
• Consider CT myelography if MRI is contraindicated 1
• Assess for signs of myelopathy: gait instability, decreased hand dexterity, hyperreflexia, Hoffmann's sign, Babinski sign, and bladder/bowel dysfunction 1

Conservative Management Algorithm

Step 1: Pain Management

• Begin with NSAIDs for pain control 1, 2
• Consider short-term muscle relaxants for significant muscle spasm
• For severe pain, short-term opioid analgesics may be considered, but with caution regarding dependency

Step 2: Physical Interventions

• Short-term immobilization with a cervical collar (not for prolonged use) 1
• Physical therapy focusing on:
  • Neck muscle strengthening exercises
  • Postural training
  • Range of motion exercises 1, 2
• Home exercise program after initial instruction by a physical therapist 3

Step 3: Activity Modification

• "Low-risk" activity modification 1
• Ergonomic adjustments at work and home
• Avoid activities that exacerbate symptoms

Special Considerations

For Radiculopathy

Conservative management is particularly effective for cervical radiculopathy, with good outcomes in most patients 1, 2. Consider:

• Cervical traction as an adjunct therapy
• Selective nerve root injections for persistent radicular pain 2

For Mild Myelopathy

• Nonoperative therapy including cervical collar immobilization, activity modification, anti-inflammatory medications
• Close monitoring for up to 3 years 1
• Regular neurological assessment to detect progression

When to Consider Surgical Referral

Immediate surgical referral is indicated for:

• Moderate to severe myelopathy (mJOA score ≤12) 1
• Progressive neurological deficits
• Failure of conservative management after 4-6 weeks 1, 2

Important Cautions

• Avoid spinal manipulation, especially in patients with spinal fusion or advanced spinal osteoporosis, due to risk of spine fractures, spinal cord injury, and paraplegia 3, 1
• Prolonged nonoperative management in patients with moderate to severe myelopathy can lead to irreversible spinal cord damage 1
• Conservative treatment requires regular review and careful selection of medications and physical therapy on a case-by-case basis 2

Prognosis with Conservative Management

Most patients with cervical spondylosis without significant neurological deficits respond well to conservative management 2, 4. However, patients should be informed that:

• Symptoms may recur and require ongoing management
• The condition is degenerative and may progress over time
• Surgical intervention may eventually be needed if conservative measures fail or neurological symptoms develop

Conservative management is labor-intensive but effective for most patients with cervical spondylosis, particularly those without significant neurological deficits 2. Regular monitoring is essential to detect any progression to myelopathy, which would necessitate surgical intervention.