What is the management approach for cervical spinal degenerative spondylosis?

Management of Cervical Spinal Degenerative Spondylosis

The management of cervical spinal degenerative spondylosis should follow a stepwise approach, beginning with conservative measures for mild symptoms and progressing to surgical intervention for moderate to severe myelopathy or progressive neurological deficits. 1, 2

Initial Assessment and Conservative Management

Conservative Treatment Options

• Neck immobilization: Soft collar for symptomatic relief
• Physical therapy: Isometric exercises to strengthen neck muscles
• Medications:
  • NSAIDs for pain and inflammation
  • Muscle relaxants for associated muscle spasm
  • Neuropathic pain medications (gabapentin, pregabalin) for radicular symptoms

Conservative treatment is particularly appropriate for:

• Patients with mild symptoms
• Neck pain without significant neurological deficits
• Early stages of the disease

This approach results in improvement in 30-50% of patients with minor neurological findings 3.

Indications for Surgical Management

Surgery should be considered when:

1. Progressive neurological deficits are present
2. Moderate to severe myelopathy exists
3. Significant radiculopathy persists despite conservative treatment
4. Activities of daily living are limited due to symptoms
5. Failed conservative therapy after an appropriate trial period (typically 6-12 weeks)

Surgical Approaches

For Cervical Spondylotic Myelopathy (CSM)

Anterior Approaches:

• Anterior cervical discectomy and fusion (ACDF): Recommended for 1-2 level disease
• Corpectomy: Necessary in cases of severe spondylosis with multiple level involvement 4

Posterior Approaches:

• Laminectomy with fusion: Preferred over laminectomy alone due to risk of postoperative kyphosis (which occurs in up to 47% of laminectomy-only cases) 1
• Laminoplasty: Recommended for multilevel CSM or ossification of the posterior longitudinal ligament (OPLL) with an expected 55-60% recovery rate using the Japanese Orthopaedic Association scale 5

Approach Selection Factors

• Number of involved levels: Anterior approach for 1-3 levels; posterior for >3 levels
• Location of compression: Anterior vs posterior cord compression
• Cervical alignment: Kyphosis favors anterior approach; lordosis favors posterior
• Patient factors: Age, comorbidities, bone quality

Surgical Outcomes and Considerations

• Surgical decompression leads to significant neurological recovery in 70-80% of patients with radiculopathy 3
• For myelopathy, good initial results are expected in about 70% of patients, though functional outcomes may decline with long-term follow-up 3
• Timing of surgery: While there is insufficient evidence for optimal timing, early intervention is warranted for rapidly progressive symptoms to prevent further neurological deterioration 1

Potential Complications

• Hardware failure requiring reoperation
• Surgical site infection
• Adjacent segment disease
• Pseudarthrosis
• Postoperative kyphosis (especially with laminectomy alone)

Special Considerations

• Negative risk factors for recovery after laminoplasty include:

  • Long duration of symptoms
  • Severity of stenosis
  • Severity of myelopathy
  • Poorly controlled diabetes 5

• Age as a risk factor has conflicting evidence 5

• For patients with degenerative cervical spondylolisthesis, treatment strategies depend on disease progression:

  • Correction through extension and positioning with fusion for mild cases
  • Corpectomy for severe spondylosis
  • Combined approaches for additional dorsal spinal cord compression 4

Comparative Effectiveness

Recent evidence suggests that surgical treatment provides faster pain relief compared to conservative treatment for cervical spondylotic radiculopathy, especially within the first year 6. However, for patients who don't require rapid pain relief, conservative treatment for 3 months can be beneficial and avoids surgical risks 6.