What is the best approach to manage pain in a patient with cervical spondylosis, muscle spasm, and reversal of cervical lordosis?

Management of Pain in Cervical Spondylosis with Muscle Spasm and Reversed Lordosis

Start with a short-term muscle relaxant (cyclobenzaprine 5-10 mg three times daily for 2-3 weeks maximum) combined with NSAIDs, physical therapy, and activity modification as first-line treatment. 1, 2

Initial Pharmacologic Management

Muscle Relaxants

• Cyclobenzaprine is FDA-approved specifically as an adjunct to rest and physical therapy for relief of muscle spasm associated with acute, painful musculoskeletal conditions 2
• Use cyclobenzaprine 5 mg three times daily initially, which has demonstrated statistically significant superiority over placebo for pain relief, with the option to titrate to 10 mg three times daily if needed 2
• Limit use to 2-3 weeks maximum, as adequate evidence for more prolonged use is not available 2
• Cyclobenzaprine produces clinical improvement whether or not sedation occurs, though drowsiness is the most frequent adverse reaction 2

NSAIDs

• NSAIDs are recommended as first-line drug treatment for patients with pain and stiffness, showing large improvements in spinal pain and function 3
• For patients with increased gastrointestinal risk, use non-selective NSAIDs plus a gastroprotective agent, or a selective COX-2 inhibitor 3
• NSAIDs demonstrate convincing level Ib evidence for improving spinal pain over short time periods (6 weeks) 3

Non-Pharmacologic Treatment (Essential Component)

Physical Therapy

• Non-pharmacological and pharmacological treatments are complementary and both are of value in initial and continuing treatment 3
• Physical therapy focusing on neck stabilization and range of motion exercises should be initiated immediately 4
• Home exercise programs improve function in the short term compared with no intervention (Level Ib evidence) 3
• Group physical therapy shows significantly better patient global assessment compared to home exercise alone 3

Activity Modification

• Avoid positions that worsen symptoms 1
• Patient education regarding proper ergonomics and posture is essential 3

Timeline and Monitoring

Conservative Treatment Duration

• Continue conservative management for at least 3 months before considering surgical options 5
• Most cases of acute cervical neck pain resolve with conservative treatment measures 4
• However, nearly 50% of patients may have residual or recurrent pain up to 1 year after initial presentation 4

When to Obtain Imaging

• If symptoms persist beyond 4-6 weeks or if neurological symptoms develop, obtain MRI 4
• MRI is the most sensitive test for detecting soft tissue abnormalities, though it has high rates of abnormalities in asymptomatic individuals 3, 4
• Plain radiographs are useful to diagnose spondylosis and malalignment but rarely alter therapy in the absence of red flag symptoms 4

Red Flags Requiring Urgent Evaluation

Watch for these indicators that warrant immediate specialist referral:

• Progressive neurological deficits (weakness, numbness progressing) 1
• Signs of cervical myelopathy: difficulty with fine motor skills, gait disturbances, bowel/bladder dysfunction 1
• Intractable pain despite adequate conservative therapy 3
• Evidence of spinal cord compression on imaging with corresponding clinical symptoms 4

Important Clinical Considerations

Reversed Cervical Lordosis

• The loss of cervical lordosis does NOT reliably indicate muscle spasm 6
• A cross-sectional study found 19% prevalence of straight cervical spines in acute neck pain, 26% in chronic cases, and 42% in normal populations 6
• Women are more likely than men to have straight cervical spines (odds ratio 2.81) 6
• While some case reports suggest restoration of lordosis correlates with symptom improvement 7, 8, this should not be the primary treatment goal

Prognostic Factors

• Poor prognosis is associated with: female gender, older age, coexisting psychosocial pathology, and radicular symptoms 4
• Younger patients and those with milder disability have better prognosis 5
• Shorter duration of symptoms correlates with better outcomes 4

Surgical Indications (If Conservative Treatment Fails)

Consider surgical referral after 3 months of failed conservative treatment if:

• Persistent severe pain despite adequate conservative management 4
• Development of cervical spondylotic myelopathy with progressive neurological deficits 4
• Evidence of spinal cord compression on imaging with corresponding clinical symptoms 4

Surgical outcomes show good to excellent results in approximately 90% of patients with radiculopathy treated with anterior cervical discectomy and fusion (ACDF) 5

Common Pitfalls to Avoid

• Do not rely solely on imaging findings for treatment decisions, as spondylotic changes are commonly identified in patients >30 years of age and correlate poorly with the presence of neck pain 4
• Do not attribute reversed cervical lordosis automatically to muscle spasm, as this finding is common in asymptomatic individuals 6
• Do not delay appropriate referral for patients with progressive neurological symptoms or signs of myelopathy 4
• Do not use muscle relaxants beyond 2-3 weeks, as evidence for prolonged use is lacking 2
• Avoid spinal manipulation with high-velocity thrusts in patients with spinal fusion or advanced spinal osteoporosis due to risk of spine fractures and spinal cord injury 4