What are the treatment options for cervical spondylosis?

Treatment Options for Cervical Spondylosis

Conservative management should be the first-line treatment for most patients with cervical spondylosis, with surgical intervention reserved for those with progressive neurological deficits, severe persistent pain despite adequate conservative treatment, or evidence of spinal cord compression with corresponding clinical symptoms. 1, 2

Conservative Treatment Options

• Anti-inflammatory medications may be used for mild symptoms without significant neurological deficits 1
• Neck immobilization with cervical collar can be effective, resulting in improvement in 30-50% of patients with minor neurological findings 3
• Physical therapy including:
  • Isometric exercises for neck muscles 3
  • Neck muscle strengthening exercises 4
• Cervical traction plus exercise has shown better improvement compared to NSAIDs alone in patients with chronic cervical spondylosis (P=0.06) 4
• Activity modification to avoid positions or activities that exacerbate symptoms 3

Surgical Intervention

Indications for Surgery

• Progressive neurological deficits, particularly signs of myelopathy 2
• Severe or persistent pain despite adequate conservative management 2
• Evidence of spinal cord compression on imaging with corresponding clinical symptoms 2
• Moderate to severe myelopathy 1

Surgical Approaches

• Anterior cervical approaches (including anterior cervical discectomy and fusion - ACDF) are generally preferred for most cases 2
  • Good to excellent outcomes in approximately 90% of patients with radiculopathy treated with ACDF 1
• Posterior approaches may be indicated in specific cases 1
• Long-term improvement occurs in 70-80% of patients after surgical intervention 3

Treatment Algorithm Based on Clinical Presentation

For Patients with Neck Pain Without Neurological Symptoms

1. Initial conservative management for 4-6 weeks 2

   • Anti-inflammatory medications 1
   • Activity modification 3
   • Physical therapy with isometric exercises 3
   • Neck immobilization if needed 3

2. If symptoms persist beyond 4-6 weeks:

   • Consider MRI to evaluate for structural abnormalities 2
   • Intensify conservative treatment with cervical traction plus exercise 4

For Patients with Radiculopathy

1. Conservative treatment for mild to moderate symptoms 5

   • Medical exercise therapy 5
   • Mechanical cervical traction 5
   • Transcutaneous electrical nerve stimulation 5
   • Pain management education 5
   • Cervical collar 5

2. Consider surgical intervention if:

   • Severe or persistent pain despite conservative treatment 2
   • Progressive neurological deficits 2
   • Surgical treatment has shown better pain relief (VAS scores) than conservative treatment in the first year 5

For Patients with Myelopathy

1. For mild CSM (age younger than 75 years and modified Japanese Orthopaedic Association scale score > 12):

   • Both operative and nonoperative management options can be offered 2
   • Neck immobilization may be reasonable in patients with minor neurological findings 3

2. For moderate to severe myelopathy:

   • Surgical intervention is indicated 1
   • Anterior cervical approaches are generally preferred 2

Prognostic Factors

• Age: Younger patients have better prognosis 1
• Duration of symptoms: Shorter duration correlates with better outcomes 6
• Preoperative neurological function: Better preoperative function predicts better outcomes 6
• Poor prognostic factors include female gender, older age, coexisting psychosocial pathology, and radicular symptoms 2

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 2
• Do not delay appropriate referral for patients with progressive neurological symptoms or signs of myelopathy 2
• Avoid spinal manipulation with high-velocity thrusts in patients with spinal fusion or advanced spinal osteoporosis due to risk of spine fractures, spinal cord injury, and paraplegia 6
• For patients with cervical stenosis without myelopathy who have clinical radiculopathy, closer monitoring is warranted as this is associated with development of symptomatic CSM 2