What is the best management approach for cervical spondylosis?

Management of Cervical Spondylosis

The optimal management of cervical spondylosis requires a combination of non-pharmacological and pharmacological treatments, with surgical intervention reserved for moderate to severe myelopathy or persistent radiculopathy unresponsive to conservative measures. 1

Clinical Presentation and Diagnosis

• Red flag signs requiring immediate surgical evaluation:

  • Gait instability
  • Decreased hand dexterity
  • Hyperreflexia
  • Hoffmann's sign
  • Babinski sign
  • Bladder/bowel dysfunction 1

• Diagnostic imaging:

  • MRI cervical spine without contrast is preferred
  • CT myelography if MRI is contraindicated 1
  • Key findings: severe spinal canal stenosis, T2 hyperintensity within spinal cord (myelomalacia), multiple levels of compression 1

Treatment Algorithm

1. Mild Cervical Spondylosis (mJOA score >12)

• First-line treatment: Conservative management for at least 3 years 2

  • NSAIDs for pain and inflammation 1
  • Short-term immobilization with cervical collar 2, 1
  • Physical therapy with neck muscle strengthening exercises 1
  • Home exercise program after initial instruction 1
  • Activity modification to reduce risk 2, 1

• If symptoms persist or worsen despite 3-6 months of conservative treatment:

  • Consider surgical decompression 2

2. Moderate to Severe Cervical Spondylotic Myelopathy (mJOA score ≤12)

• Surgical decompression is recommended 2, 1
• Benefits maintained for at least 5 years and up to 15 years postoperatively 2
• Surgical approach selection:
  • Anterior approach preferred for 1-3 level disease
  • Posterior approach may be better for ≥4 level disease 1

Surgical Options

1. Anterior Cervical Discectomy and Fusion (ACDF):

   • Good to excellent results in 90-97% of patients 1
   • Preferred for focal anterior compression

2. Posterior Cervical Laminoforaminotomy:

   • Viable option for cervical radiculopathy 1

3. Anterior or Posterior Approach for Pseudarthrosis:

   • Both approaches can be considered for surgical correction
   • Posterior approaches may be associated with higher fusion rates 2

Prognostic Factors and Complications

• Poor prognostic factors:

  • Severe preoperative myelomalacia on MRI
  • Advanced age (particularly over 75 years)
  • Longer duration of symptoms before treatment
  • More severe preoperative neurological dysfunction 1

• Potential complications:

  • Post-perfusion ischemia ("white cord syndrome") in 4-9% of patients
  • Pseudarthrosis (nonunion) after fusion
  • Adjacent segment degeneration after fusion 1
  • Approximately 44% of patients may have substantial neurological impairment 6 months postoperatively 1

Important Considerations

• Prolonged nonoperative management in patients with moderate to severe myelopathy can lead to irreversible spinal cord damage 1
• Patients with suspected cervical myelopathy should be promptly referred to a spine surgeon to avoid permanent neurological deficits 1
• Surgical results for cervical spondylotic myelopathy are modest, with good initial results in about 70% of patients, but functional outcome may decline with long-term follow-up 3
• Conservative treatment can be effective but requires regular review and careful selection of medications and physical therapy on a case-by-case basis 4

Monitoring and Follow-up

• Regular assessment of neurological status during conservative management
• Post-surgical follow-up to monitor for complications and assess neurological recovery
• Long-term monitoring for adjacent segment degeneration in fusion patients