What is the recommended treatment for cervical spondylosis?

Management of Cervical Spondylosis

The recommended treatment for cervical spondylosis should begin with conservative management including physical therapy, anti-inflammatory medications, and neck exercises, with surgical intervention reserved for patients with progressive neurological deficits or persistent severe pain despite adequate conservative treatment. 1, 2

Initial Conservative Management

• Most cases of acute cervical neck pain resolve with conservative treatment measures, with nearly 50% of patients experiencing residual or recurrent episodes up to 1 year after initial presentation 1
• Conservative management should include:
  • Anti-inflammatory medications for pain relief and reducing inflammation 3
  • Physical therapy focusing on isometric neck exercises to strengthen supporting musculature 4
  • Neck immobilization during acute pain episodes using a cervical collar 2
  • Activity modification to avoid positions that exacerbate symptoms 4
• Cervical traction combined with exercise therapy has shown better outcomes than NSAIDs alone in managing chronic cervical spondylosis 5

Monitoring and Diagnostic Imaging

• If symptoms persist beyond 4-6 weeks or if neurological symptoms develop, MRI should be considered 1
• MRI is the most sensitive test for detecting soft tissue abnormalities, though it has a high rate of abnormalities in asymptomatic individuals 1
• Regular monitoring is particularly important for patients with cervical stenosis and clinical radiculopathy, as they have higher risk of developing symptomatic cervical spondylotic myelopathy (CSM) 1

Indications for Surgical Intervention

• Surgical intervention should be considered in the following scenarios:
  • Development of cervical spondylotic myelopathy with progressive neurological deficits 1
  • Persistent severe pain despite adequate conservative management (typically 3 months of treatment) 1, 6
  • Evidence of spinal cord compression on imaging with corresponding clinical symptoms 1
• Surgical approaches include anterior and posterior approaches, with anterior cervical discectomy and fusion (ACDF) showing good to excellent outcomes in approximately 90% of patients with radiculopathy 3
• For 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 1

Comparative Effectiveness of Treatments

• Surgical treatment provides faster pain relief compared to conservative treatment, especially for neck and arm pain within the first year after treatment 6
• However, long-term outcomes (12 months and beyond) show diminishing differences between surgical and conservative approaches for neck disability 6
• Conservative treatment, including medical exercise therapy, mechanical cervical tractions, and pain management education once or twice weekly for 3 months, provides good long-term benefits while avoiding surgical risks 6

Important Considerations and Pitfalls

• 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 1
• Do not delay appropriate referral for patients with progressive neurological symptoms or signs of myelopathy 1
• The natural history of cervical spondylosis is variable, with many patients experiencing long periods of stable symptoms or slow progression 3
• Approximately 70% of patients with mild cervical spondylotic myelopathy maintain their clinical status over 3 years with nonoperative treatment 3
• Younger patients and those with milder disability generally have better prognosis 3