What are the management options for spondylosis?

Management of Spondylosis

The optimal management of spondylosis requires a combination of non-pharmacological and pharmacological treatments tailored to the patient's specific symptoms, disease severity, and clinical presentation. 1

Assessment and Monitoring

• Disease monitoring should include patient history, clinical parameters, laboratory tests, and imaging according to clinical presentation 1
• Radiographic monitoring is generally not needed more often than once every 2 years, though exceptions exist for rapidly progressing cases 1
• Assessment should consider disease activity/inflammation, pain levels, function, disability, structural damage, and comorbidities 1

Non-Pharmacological Management

Physical Therapy and Exercise

• Regular exercise and physical therapy are cornerstone treatments for spondylosis 1
• Home exercise programs improve function in the short term compared to no intervention 1
• Core strengthening activities, hamstring stretching, and spine range of motion exercises have shown excellent outcomes in symptomatic patients 2
• Group therapy shows better patient global assessment outcomes than individual therapy alone 1

Bracing and Orthoses

• For symptomatic spondylolysis, a custom-fit thoracolumbar orthosis for approximately 3 months followed by physical therapy has shown 95% excellent results 3
• However, recent evidence suggests that non-bracing conservative management with physical therapy alone can be effective, with 96% of patients achieving minimal disability scores 2

Patient Education

• Patient education about the condition and self-management strategies is essential 1
• Patient associations and self-help groups may provide additional support 1

Pharmacological Management

First-Line Treatment

• NSAIDs are recommended as first-line drug treatment for patients with pain and stiffness 1
• There is convincing level Ib evidence that NSAIDs improve spinal pain, peripheral joint pain, and function over short periods (6 weeks) 1
• For patients with increased gastrointestinal risk, consider either:
  • Non-selective NSAIDs plus a gastroprotective agent
  • A selective COX-2 inhibitor 1

Second-Line Treatment

• Analgesics such as paracetamol and opioids might be considered for pain control when NSAIDs are insufficient, contraindicated, or poorly tolerated 1

Local Injections

• Corticosteroid injections directed to local sites of musculoskeletal inflammation may be beneficial 1
• Systemic corticosteroids for axial disease are not supported by evidence 1

Disease-Modifying Treatments

• There is no evidence for the efficacy of DMARDs, including sulfasalazine and methotrexate, for axial disease 1
• Sulfasalazine may be considered in patients with peripheral arthritis 1
• Anti-TNF treatment should be given to patients with persistently high disease activity despite conventional treatments 1

Surgical Management

• Total hip arthroplasty should be considered in patients with refractory pain or disability and radiographic evidence of structural damage 1
• Spinal surgery, including corrective osteotomy and stabilization procedures, may be valuable in selected patients 1
• For spondylolysis with or without low-grade spondylolisthesis not responding to conservative management, direct pars interarticularis repair can be considered 4
• Among surgical techniques, pedicle screw-based direct pars repair has shown the highest fusion rate (90.21%) and lowest complication rate (12.8%) 4

Treatment Algorithm

1. Initial Management (0-3 months):

   • NSAIDs for pain and inflammation 1
   • Physical therapy focusing on core strengthening and flexibility 2
   • Patient education about condition and activity modifications 1

2. If inadequate response (3-6 months):

   • Consider alternative analgesics 1
   • Evaluate for bracing if appropriate 3
   • Local corticosteroid injections for focal inflammation 1

3. For persistent symptoms (>6 months):

   • Consider anti-TNF treatment for high disease activity 1
   • Surgical evaluation for patients with structural damage and refractory symptoms 1, 4

Common Pitfalls and Caveats

• Overreliance on imaging findings without correlation to clinical symptoms can lead to unnecessary interventions 1
• Failure to incorporate both pharmacological and non-pharmacological approaches limits treatment effectiveness 1
• Systemic corticosteroids should be avoided for axial disease due to lack of evidence and potential side effects 1
• Regular monitoring is essential as disease progression can vary significantly between patients 1