What is the initial management for a patient with cervical spondylosis and potential muscle spasm, as indicated by reversal of cervical lordosis on a neck X-ray?

Management of Cervical Spondylosis with Reversal of Cervical Lordosis

For a patient with cervical spondylosis and muscle spasm indicated by reversal of cervical lordosis on X-ray, the initial management should include conservative measures such as activity modification, neck immobilization, isometric exercises, and medication for pain relief.1

Initial Conservative Management

Physical Interventions

• Neck immobilization with a soft collar may be beneficial for short-term symptom relief, especially when used during periods of acute pain 1
• Cervical extension exercises should be implemented to help restore the normal lordotic curve 2, 3
• Physical therapy focusing on isometric neck strengthening exercises can help stabilize the cervical spine 1
• Intermittent cervical traction may help alleviate nerve root compression and muscle spasm 2

Pharmacological Management

• Cyclobenzaprine (5-10mg three times daily) is indicated as an adjunct to rest and physical therapy for relief of muscle spasm associated with acute, painful musculoskeletal conditions 4
• Cyclobenzaprine should be used only for short periods (up to two or three weeks) as evidence for longer use is limited 4
• Start with 5mg dose in patients with mild hepatic impairment and titrate slowly upward; avoid use in moderate to severe hepatic impairment 4
• Non-steroidal anti-inflammatory drugs may be combined with muscle relaxants, though this combination may increase drowsiness 4

Monitoring and Follow-up

Timeline for Improvement

• Most cases of acute cervical neck pain resolve with conservative treatment measures 5
• However, nearly 50% of patients may continue to have residual or recurrent episodes of pain up to 1 year after initial presentation 5
• Reassessment should occur after 2-3 weeks of conservative therapy 4

Prognostic Factors

• Factors associated with poor prognosis include female gender, older age, coexisting psychosocial pathology, and radicular symptoms 5
• The natural history of cervical spondylosis is variable, with many patients experiencing a slow, stepwise decline, while others may have long periods of quiescence 5

Advanced Imaging Considerations

• If symptoms persist beyond 4-6 weeks or if neurological symptoms develop, MRI should be considered 5
• MRI is the most sensitive test for detecting soft tissue abnormalities associated with neck pain, though it has a high rate of abnormalities in asymptomatic individuals 5
• Radiographs are useful to diagnose spondylosis, degenerative disc disease, malalignment, or spinal canal stenosis, but therapy is rarely altered by radiographic findings alone in the absence of red flag symptoms 5

When to Consider Surgical Referral

• Surgical intervention should be considered if there is:

  • Development of cervical spondylotic myelopathy (CSM) with progressive neurological deficits 5
  • Persistent severe pain despite adequate conservative management 5
  • Evidence of spinal cord compression on imaging with corresponding clinical symptoms 5

• In patients with mild CSM (age younger than 75 years and modified Japanese Orthopaedic Association scale score > 12), both operative and nonoperative management options can be offered, as objectively measurable deterioration is rarely seen acutely 5

Special Considerations

• Reversal of cervical lordosis may be correctable with specific extension-based protocols over a period of 10-12 weeks 3
• Restoration of normal cervical lordosis should be a treatment goal as it may prevent future injury and degenerative changes 3
• For patients with cervical stenosis without myelopathy who have clinical radiculopathy, closer monitoring is warranted as this is associated with development of symptomatic CSM 5

Pitfalls to Avoid

• Do not rely solely on imaging findings for treatment decisions, as spondylotic changes are commonly identified on radiographs and MRI in patients >30 years of age and correlate poorly with the presence of neck pain 5
• Avoid prolonged use of muscle relaxants beyond 2-3 weeks without reassessment 4
• Do not delay appropriate referral for patients with progressive neurological symptoms or signs of myelopathy 5
• Recognize that cervical spondylotic myelopathy is the most serious complication of cervical spondylosis and requires prompt evaluation 6