What is the initial treatment for degenerative cervical disc height and facet arthropathy?

Initial Treatment for Degenerative Cervical Disc Height and Facet Arthropathy

Non-operative management is the appropriate initial treatment for degenerative cervical disc height and facet arthropathy, with 75-90% of patients achieving symptomatic improvement through conservative measures. 1

First-Line Pharmacological Treatment

• Begin with acetaminophen (paracetamol) in doses of up to 4g daily, with ibuprofen as an alternative at 1.2g daily if acetaminophen fails to provide adequate relief 2
• For insufficient relief with initial NSAID therapy, options include:
  • Increasing ibuprofen to 2.4g daily
  • Adding acetaminophen to ibuprofen
  • Switching to alternative NSAIDs such as diclofenac or naproxen 2
• Consider gastroprotective agents in patients at high risk for NSAID-induced gastrointestinal complications 2

Non-Pharmacological Approaches

• Physical therapy focusing on core strengthening and flexibility exercises is a cornerstone of initial treatment 2
• Physical therapy has demonstrated statistically significant clinical improvement for patients with cervical radiculopathy 1
• Acupuncture may be considered as an adjunct to conventional therapy 2
• For persistent facet-related pain, conventional radiofrequency ablation of the medial branch nerves may be considered when previous diagnostic or therapeutic injections have provided temporary relief 2

Treatment Algorithm

1. First 6-8 weeks: Conservative management with medications and physical therapy

   • Begin with acetaminophen and/or NSAIDs 2
   • Initiate physical therapy focusing on cervical strengthening and flexibility 2, 1
   • Consider cervical traction for radicular symptoms 1

2. For persistent symptoms (2-3 months):

   • Consider epidural steroid injections for radicular pain 1
   • For facet-mediated pain, consider medial branch blocks or intra-articular facet injections 2

3. For refractory symptoms (>6 months):

   • Surgical intervention may be considered after at least 6 months of failed comprehensive conservative management 2

Surgical Considerations

• Both anterior cervical discectomy (ACD) and anterior cervical discectomy with fusion (ACDF) are equivalent treatment strategies for 1-level disease with regard to functional outcomes 3
• ACDF may achieve more rapid reduction of neck and arm pain compared to ACD with a reduced risk of kyphosis 3
• For 2-level cervical disc degeneration, anterior cervical plating (ACDFI) is recommended over ACDF to improve arm pain 3
• Cervical arthroplasty is recommended as an alternative to ACDF in selected patients for control of neck and arm pain 3

Important Caveats and Pitfalls

• Regular monitoring for NSAID-related adverse effects is essential, particularly gastrointestinal and cardiovascular complications 2
• MRI findings must always be correlated with clinical symptoms, as false positives and false negatives are common in cervical spine imaging 1
• Chemical denervation is not recommended for routine care of chronic non-cancer pain 2
• For patients with neuropathic pain components, consider tricyclic antidepressants or serotonin-norepinephrine reuptake inhibitors, starting at low doses and titrating gradually 2

Long-term Outcomes

• At 12 months, physical therapy can achieve comparable clinical improvements to surgical interventions, though surgical approaches may provide more rapid relief (within 3-4 months) 1
• Surgical outcomes for relief of arm pain range from 80% to 90% with either anterior or posterior approaches 1
• Degenerative cervical disc disease often involves facet joint degeneration, which has been shown to have close relationships with uncovertebral joint degeneration, spinal stenosis, and Modic changes 4