How do I treat a patient with straightening of cervical lordosis consistent with pain and/or muscle spasm on cervical x-ray?

Treatment of Straightening of Cervical Lordosis with Pain and Muscle Spasm

Begin with workstation ergonomic optimization, regular movement breaks every 30-60 minutes, and referral to physical therapy for range of motion exercises—this conservative approach resolves symptoms in the majority of patients within 4-6 weeks. 1, 2

Initial Conservative Management

Ergonomic modifications form the foundation of treatment:

• Position computer monitor at eye level to maintain neutral cervical spine alignment 2
• Ensure proper chair height with adequate lumbar support to promote overall spinal alignment 2
• Implement mandatory breaks every 30-60 minutes to prevent sustained static postures that perpetuate muscle spasm 1, 2

Physical therapy referral is essential for:

• Range of motion exercises to maintain flexibility and prevent rigidity 1, 2
• Specific strengthening exercises to improve cervical muscle function 1
• Manual therapy techniques to address muscle spasm 1

Pharmacologic Adjuncts for Symptom Control

For acute muscle spasm (short-term use only):

• Cyclobenzaprine 5-10 mg three times daily as adjunct to rest and physical therapy 3
• Use only for 2-3 weeks maximum, as muscle spasm associated with acute painful musculoskeletal conditions is generally of short duration 3
• Start with 5 mg dose and titrate slowly, particularly in patients with hepatic impairment 3

For persistent pain facilitating physical therapy participation:

• Prescribe nerve-stabilizing agents: pregabalin, gabapentin, or duloxetine 1, 2
• These medications improve pain control and facilitate active participation in rehabilitation 1

Critical Contraindication

Never apply cervical collars for this condition—they cause significant harm including:

• Increased intracranial pressure 2
• Pressure sores and skin breakdown 2
• Airway compromise 2
• Complications that escalate after 48-72 hours of use 2

Red Flags Requiring Urgent Evaluation

Obtain MRI cervical spine without contrast if any of the following are present:

• Neurological deficits or myelopathic signs 1
• Constitutional symptoms (fever, weight loss, night sweats) 1
• History of immunosuppression or inflammatory arthritis 1
• Recent significant trauma 1

Advanced Treatment for Refractory Cases

If symptoms persist beyond 6 weeks despite conservative management:

• Consider botulinum toxin type A injections into affected cervical muscles for refractory spasm 1
• Approved formulations include AboBoNT-A (Dysport), rimaBoNT-B (Myobloc), OnaBoNT-A (Botox), and incoBoNT-A (Xeomin) 1

Surgical Referral Indications

Refer to spine surgeon only if:

• Cervical spondylotic myelopathy develops 1
• Clinically significant motor deficits emerge 1
• Severe, prolonged symptoms with low probability of improvement after adequate conservative trial 1

Note that 75-90% of patients with cervical radiculopathy achieve symptomatic relief with conservative non-operative therapy 1, and straightening of cervical lordosis itself does not predict poor outcomes or indicate need for aggressive intervention 4.

Follow-Up Timeline

Reassess at 4-6 weeks to evaluate response to ergonomic modifications and physical therapy 1, 2. Most patients demonstrate significant improvement within this timeframe with appropriate conservative management.