What is the initial treatment for spondylosis?

Initial Treatment for Spondylosis

The initial treatment for spondylosis should be NSAIDs as first-line therapy, followed by physical therapy to reduce stiffness and prevent spinal ankylosis. 1

Pharmacological Management

• First-line therapy: NSAIDs

  • Approximately 75% of patients show good response within 48 hours 1
  • Should be used regularly rather than as needed for optimal anti-inflammatory effect
  • Monitor for gastrointestinal, renal, and cardiovascular side effects

• Second-line therapy (for inadequate response to NSAIDs):

  • TNF inhibitors (adalimumab, infliximab, golimumab, certolizumab pegol)
  • About 50% of patients show significant improvement with TNF inhibitors 1
  • For peripheral joint involvement, sulfasalazine may be considered 1

Non-Pharmacological Management

• Physical therapy - strongly recommended alongside medication 1

  • Helps reduce stiffness and prevent spinal ankylosis
  • Improves physical function and quality of life
  • Should include initial instruction by a physical therapist followed by home exercise program

• Home exercise program

  • Conditional recommendation for unsupervised back exercises after initial physical therapy instruction 2
  • Focus on maintaining mobility and strengthening core muscles
  • Regular physical activity is generally endorsed for overall health benefits

Disease Monitoring

• Regular assessment using validated disease activity measures (BASDAI or ASDAS) 2, 1
• Monitor inflammatory markers (CRP or ESR) at regular intervals 2, 1
  • Note that these may not always correlate with clinical symptoms
  • Most helpful in patients with active symptoms to guide treatment

Important Cautions and Contraindications

• Strongly avoid spinal manipulation with high-velocity thrusts in patients with:

  • Spinal fusion
  • Advanced spinal osteoporosis 2, 1
  • Risk of spine fractures, spinal cord injury, and paraplegia has been reported 2

• For patients with specific comorbidities:

  • With inflammatory bowel disease: TNF monoclonal antibodies preferred over etanercept 1
  • With recurrent iritis: TNF monoclonal antibodies preferred over etanercept 1

Surgical Considerations

• Total hip arthroplasty is strongly recommended for patients with advanced hip arthritis 2, 1
• Surgery is generally reserved for patients who fail conservative management 3
• Surgical intervention should only be considered after at least 6 weeks of conservative management 1

Clinical Pearls

• The treatment approach may differ based on the type of spondylosis (ankylosing spondylitis vs. degenerative spondylosis)
• Radiographic follow-up is not necessary more frequently than every 2 years unless significant clinical changes occur 1
• Ensure adequate calcium and vitamin D supplementation to prevent osteoporosis 1
• Patient education about the chronic nature of the condition and the importance of adherence to treatment is essential