What is the recommended treatment for a patient diagnosed with degenerative disc disease and mild cervical facet arthropathy?

Treatment for Degenerative Disc Disease and Cervical Facet Arthropathy

Begin with conservative management for at least 6-8 weeks, as 75-90% of patients achieve symptomatic improvement without surgery. 1

Initial Conservative Treatment Algorithm

First-Line Pharmacological Management

• Start with acetaminophen up to 4g daily as the initial analgesic. 1
• If acetaminophen provides inadequate relief, switch to ibuprofen 1.2g daily. 1
• For insufficient pain control with initial NSAID therapy, escalate by either:
  • Increasing ibuprofen to 2.4g daily, OR
  • Adding acetaminophen to ibuprofen, OR
  • Switching to alternative NSAIDs (diclofenac or naproxen). 1
• Add gastroprotective agents if the patient has risk factors for NSAID-induced gastrointestinal complications (age >65, history of peptic ulcer disease, concurrent anticoagulation, or corticosteroid use). 1

Physical Therapy Protocol

• Initiate structured physical therapy focusing on cervical strengthening and flexibility exercises immediately. 1
• Physical therapy demonstrates statistically significant clinical improvement for cervical radiculopathy and degenerative conditions. 1
• Continue therapy for a minimum of 6-8 weeks before considering escalation. 1

Additional Conservative Modalities

• Activity modification and ergonomic adjustments should be implemented concurrently with pharmacological treatment. 2
• Consider acupuncture as an adjunct to conventional therapy for patients with persistent pain. 1
• Cervical collar immobilization may be used for short-term symptom relief, though prolonged use should be avoided to prevent deconditioning. 2

Treatment Escalation for Persistent Symptoms (2-3 Months)

Interventional Pain Management

• For radicular pain persisting beyond 2-3 months of conservative management, consider epidural steroid injections. 1
• For facet-mediated axial neck pain with temporary relief from previous diagnostic injections, conventional radiofrequency ablation of the medial branch nerves may be considered. 1

Neuropathic Pain Management

• If neuropathic pain components are present (burning, shooting pain, allodynia), add tricyclic antidepressants or serotonin-norepinephrine reuptake inhibitors. 1
• Start at low doses and titrate gradually to minimize side effects. 1

Surgical Consideration Threshold (>6 Months)

Surgery should only be considered after at least 6 months of failed comprehensive conservative management, unless progressive neurological deficits are present. 1

Surgical Indications

• Persistent radicular symptoms with documented neural compression on MRI that correlates with clinical findings after 6+ weeks of conservative treatment. 3
• Progressive neurological deficits (weakness, sensory loss) despite conservative management. 3
• Significant functional deficit impacting quality of life and activities of daily living. 3
• Moderate to severe foraminal stenosis or central canal stenosis with corresponding clinical symptoms. 3

Surgical Options Based on Pathology

For single-level disease with radiculopathy:

• Anterior cervical discectomy and fusion (ACDF) provides 80-90% success rates for arm pain relief and achieves more rapid symptom reduction (within 3-4 months) compared to continued conservative treatment. 3, 1
• Both anterior cervical discectomy (ACD) and ACDF are equivalent for functional outcomes in 1-level disease, though ACDF achieves more rapid pain reduction and reduced kyphosis risk. 1

For 2-level cervical disc degeneration:

• ACDF with anterior cervical plating (instrumentation) is recommended over ACDF alone, as it improves fusion rates from 72% to 91% and reduces pseudarthrosis risk from 4.8% to 0.7%. 3, 1

For lateral soft disc herniation or foraminal stenosis:

• Posterior laminoforaminotomy is effective for soft lateral cervical disc displacement or cervical spondylosis with lateral recess narrowing, with success rates of 78-93%. 2, 3
• This approach preserves motion and avoids anterior approach risks. 3

For multilevel disease with preserved lordosis:

• Laminoplasty may be considered for multilevel posterior compression. 4

Critical Pitfalls to Avoid

• Do not proceed to surgery without documenting at least 6 weeks of structured conservative therapy with specific dates, frequency, and response to treatment. 3
• Always correlate MRI findings with clinical symptoms before recommending surgery, as false positives and false negatives are common in cervical spine imaging. 3, 1
• Monitor regularly for NSAID-related adverse effects, particularly gastrointestinal bleeding and cardiovascular complications. 1
• Avoid premature surgical intervention, as 75-90% of patients improve with conservative management. 3, 1
• Do not perform fusion at levels that do not meet moderate-to-severe stenosis criteria, even if adjacent levels require surgery. 3

Long-Term Outcome Expectations

• At 12 months, physical therapy achieves comparable clinical improvements to surgical interventions, though surgery provides more rapid relief within 3-4 months. 3, 1
• Surgical outcomes for arm pain relief range from 80-90% with either anterior or posterior approaches. 3, 1
• Functional improvement of 90.9% can be expected following appropriate surgical intervention in properly selected patients. 3