What is the recommended treatment for cervical spondylosis?

Treatment Recommendations for Cervical Spondylosis

For cervical spondylotic myelopathy (CSM), treatment should be based on disease severity: mild CSM (mJOA score >12) can be treated with either surgical decompression or nonoperative therapy for the first 3 years, while more severe CSM (mJOA score ≤12) should be treated with surgical decompression. 1, 2

Treatment Algorithm Based on Disease Severity

Mild Cervical Spondylosis/Myelopathy (mJOA score >12)

• Nonoperative therapy options include:

  • Prolonged immobilization in a stiff cervical collar 1, 2
  • "Low-risk" activity modification or bed rest 1
  • Anti-inflammatory medications 1, 3
  • Physical therapy with neck muscle strengthening exercises 4
  • Cervical traction (shown to have more beneficial effects than NSAIDs alone) 4

• Conservative treatment is effective in approximately 70% of patients with mild cervical spondylotic myelopathy who maintain their clinical status over 3 years 3

Moderate to Severe Cervical Spondylosis/Myelopathy (mJOA score ≤12)

• Surgical decompression is strongly recommended with benefits maintained for at least 5 years and up to 15 years postoperatively 1, 2
• Surgical intervention is indicated for:
  • Progressive neurological deficits 3
  • Severe or persistent pain unresponsive to conservative measures 3
  • Moderate to severe myelopathy 2

Surgical Approach Selection

• For 1-2 level disease: Anterior cervical discectomy and fusion (ACDF) is effective 2

• For 3-segment disease: Anterior cervical corpectomy with fusion (ACCF) is recommended 2

• Both ACDF and ACCF yield similar results in multilevel spine decompression for lesions at the disc level 1

• The use of anterior plating allows for equivalent fusion rates between these techniques 1

• If anterior fixation is not used, ACCF may provide a higher fusion rate than multilevel ACDF but also has a higher graft failure rate 1

• Posterior approaches:

  • Laminoplasty preserves motion and reduces axial neck pain 2
  • Laminectomy with fusion prevents post-laminectomy kyphosis 2
  • Laminectomy alone is associated with late deterioration compared to other surgical approaches 1

Complications and Considerations

• Potential surgical complications include:

  • Post-surgical kyphosis (occurs in ~10% of patients after laminoplasty) 2
  • C5 nerve palsy (especially when laminae are elevated to an angle > 60°) 2
  • Pseudarthrosis (occurs in ~10.9% of cases after corpectomy) 2, 5
  • Neurological deterioration, deep infection with laminectomy and fusion 2

• Key pitfalls to avoid:

  • Delaying surgical intervention in patients with moderate to severe myelopathy can lead to irreversible spinal cord damage 2
  • Inadequate stabilization during surgery can lead to cage movement and pseudarthrosis 2, 5

Evidence on Surgical vs. Conservative Treatment

• For patients with radiculopathy, surgical treatment provides faster pain relief compared to conservative treatment:

  • Significantly lower neck and arm pain scores at <3 months, 3-6 months, 6 months, and 12 months 6
  • Better NDI (Neck Disability Index) scores at <3 months and 6 months 6
  • However, no significant difference in NDI at 12 months, range of motion, or mental health 6

• Conservative treatment (including medical exercise therapy, mechanical cervical tractions, transcutaneous electrical nerve stimulation, pain management education, and cervical collar) once or twice a week for 3 months can be beneficial in the long term and avoids surgical risks 6