What is the best treatment for cervical spondylosis?

Best Treatment for Cervical Spondylosis

Conservative management with NSAIDs, physical therapy, and activity modification should be the initial treatment for most patients with cervical spondylosis, reserving surgery for those with moderate-to-severe myelopathy (mJOA ≤12), progressive neurological deficits, or persistent severe pain despite 3-6 months of adequate conservative therapy. 1

Initial Conservative Management (First-Line for Most Patients)

Pharmacologic Treatment

• NSAIDs are the first-line drug treatment, showing large improvements in spinal pain and function with convincing Level Ib evidence over 6-week periods 1
• For patients with increased gastrointestinal risk, use non-selective NSAIDs plus gastroprotective agents or selective COX-2 inhibitors 1
• Anti-inflammatory medications are appropriate for mild symptoms without significant neurological deficits 2

Non-Pharmacologic Treatment

• Home exercise programs improve function in the short term (Level Ib evidence), with group physical therapy showing significantly better outcomes than home exercise alone 1
• Neck immobilization with cervical collar for activity modification is appropriate for mild symptoms and axial neck pain 3
• Patient education regarding proper ergonomics and posture is essential 1
• Cervical traction plus exercise shows more improvement than NSAIDs alone for chronic cervical spondylosis 4

Expected Outcomes with Conservative Treatment

• 75-90% of patients with cervical radiculopathy achieve symptomatic relief with conservative therapy 3
• Most cases of acute cervical neck pain resolve with conservative measures, though 30-50% may have residual or recurrent pain up to 1 year 1, 3
• Nonoperative therapy in the acute phase has success rates averaging 90% for cervical radiculopathy 1

When to Consider Imaging

• If symptoms persist beyond 4-6 weeks or neurological symptoms develop, obtain MRI 1
• MRI is the most sensitive test for detecting soft tissue abnormalities, though it has high rates of abnormalities in asymptomatic individuals 1, 3
• Radiographs are useful to diagnose spondylosis and degenerative disc disease, but therapy is rarely altered by radiographic findings alone without red flag symptoms 1

Indications for Surgical Intervention

Absolute Indications

• Moderate to severe cervical spondylotic myelopathy (mJOA scale score ≤12) - surgical decompression is strongly recommended, showing statistically significant improvement in mJOA scores beginning at 6 months and continuing through 24 months 1
• Progressive neurological deficits despite conservative management 1
• Evidence of spinal cord compression on imaging with corresponding clinical symptoms 1

Relative Indications

• Persistent severe pain despite adequate conservative management for 3-6 months 1, 5
• For mild CSM (mJOA >12 in patients younger than 75 years), both operative and nonoperative management can be offered, as Class II evidence suggests equivalency over 3 years, though approximately 70% maintain clinical status with nonoperative treatment 1, 2

Surgical Approach Selection

For Cervical Spondylotic Myelopathy

• Anterior approach (ACDF or corpectomy) is preferred for 1-3 level disease, showing improvement rates of approximately 73-74% 1
• Posterior approach (laminectomy with fusion or laminoplasty) is preferred for multilevel disease (≥4 segments) 1
• Laminectomy with posterior fusion demonstrates significantly greater neurological recovery (average 2.0 Nurick grade improvement) compared to anterior approach (1.2 grade improvement) or laminectomy alone (0.9 grade improvement) 1

For Cervical Radiculopathy

• Anterior cervical discectomy and fusion (ACDF) shows good to excellent outcomes in approximately 90% of patients with radiculopathy 3, 2

Prognostic Factors

Favorable Prognosis

• Younger age 1, 3, 2
• Shorter duration of symptoms 1
• Better preoperative neurological function 1
• Milder disability at presentation 3, 2

Poor Prognosis

• Female gender 1
• Older age 1
• Coexisting psychosocial pathology 1
• Radicular symptoms 1

Critical Pitfalls to Avoid

• Do not rely solely on imaging findings for treatment decisions - spondylotic changes are commonly identified on radiographs and MRI in patients >30 years of age and correlate poorly with the presence of neck pain 1
• Do not delay appropriate referral for patients with progressive neurological symptoms or signs of myelopathy 1
• 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 1
• Monitor for late deterioration, which occurs in approximately 29% of patients who undergo laminectomy alone 1
• For patients with cervical stenosis without myelopathy who have clinical radiculopathy, closer monitoring is warranted as this is associated with development of symptomatic CSM 1

Treatment Algorithm Summary

1. Start all patients with conservative management: NSAIDs, physical therapy (home exercises progressing to group therapy), activity modification, and patient education 1
2. Continue conservative treatment for 3-6 months unless red flags develop 1, 5
3. Obtain MRI if symptoms persist beyond 4-6 weeks or neurological symptoms develop 1
4. Refer for surgical evaluation if: moderate-to-severe myelopathy (mJOA ≤12), progressive neurological deficits, or persistent severe pain despite adequate conservative therapy 1
5. For mild myelopathy (mJOA >12), either surgical or continued conservative management is acceptable for up to 3 years 1