What is the management approach for cervical spondylosis with a disc bulge?

Management of Cervical Spondylosis with Disc Bulge

For cervical spondylosis with disc bulge, begin with conservative management including NSAIDs, short-term muscle relaxants (2-3 weeks maximum), physical therapy, and activity modification for at least 3 months, reserving surgery only for patients with progressive neurological deficits, severe myelopathy, or failure of conservative treatment. 1, 2

Initial Conservative Management (First-Line Treatment)

Pharmacologic therapy:

• NSAIDs are the first-line medication, showing large improvements in spinal pain and function with Level Ib evidence 2
• For patients with gastrointestinal risk factors, use non-selective NSAIDs plus gastroprotective agents or selective COX-2 inhibitors 2
• Short-term muscle relaxants (maximum 2-3 weeks) for muscle spasm 1
• Anti-inflammatory medications for pain control 3, 4

Non-pharmacologic interventions:

• Neck immobilization with cervical collar during acute phase 2, 4
• Home exercise programs focusing on neck stabilization and range of motion (Level Ib evidence for short-term functional improvement) 2
• Group physical therapy shows superior outcomes compared to home exercises alone 2
• Patient education on proper ergonomics and posture 2
• Activity modification to avoid positions that worsen symptoms 1

Expected outcomes with conservative treatment:

• Most acute cervical neck pain resolves with conservative measures 2
• Nonoperative therapy achieves 90% success rates for cervical radiculopathy 2
• However, nearly 50% of patients may have residual or recurrent pain up to 1 year after initial presentation 2
• For mild cervical spondylotic myelopathy (mJOA >12), approximately 70% maintain stable clinical status over 3 years with conservative treatment 3

Diagnostic Imaging Strategy

When to obtain MRI:

• If symptoms persist beyond 4-6 weeks 2
• If neurological symptoms develop (radiculopathy or myelopathy) 2
• MRI is the most sensitive test for detecting soft tissue abnormalities, though it has high rates of abnormalities in asymptomatic individuals 2

Important caveat: 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 2

Indications for Surgical Intervention

Absolute indications:

• Progressive neurological deficits 2, 3
• Moderate to severe cervical spondylotic myelopathy (mJOA ≤12) 2
• Evidence of spinal cord compression on imaging with corresponding clinical symptoms 2

Relative indications:

• Persistent severe pain despite adequate conservative management for 3 months 2, 3
• Mild CSM (mJOA >12) in patients younger than 75 years who fail conservative treatment 2

Surgical Approach Selection

For 1-2 level disease:

• Anterior cervical discectomy and fusion (ACDF) is the preferred approach, achieving good to excellent outcomes in approximately 90% of patients with radiculopathy 3, 5
• Improvement rates of approximately 73-74% with anterior approaches 2
• Fusion rates of 92% with anterior cervical decompression and arthrodesis 6

For 3-level disease:

• Anterior corpectomy is recommended 1
• However, corpectomy carries a 10.9% pseudarthrosis rate 1

For multilevel disease (≥4 segments):

• Posterior approach (laminectomy with fusion or laminoplasty) is preferred 2
• 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) 2
• Laminoplasty preserves motion and reduces axial neck pain 1

Critical surgical consideration: Laminectomy alone is associated with increased risk of postoperative kyphosis (approximately 10% of patients) and late deterioration in 29% of patients, therefore fusion should be added to prevent these complications 1, 2

Prognostic Factors

Factors associated with better outcomes:

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

Factors associated with poor prognosis:

• Female gender 2
• Older age 2
• Coexisting psychosocial pathology 2
• Radicular symptoms 2
• Prolonged severe stenosis leading to potentially irreversible spinal cord damage 1

Surgical Complications to Monitor

Common complications:

• C5 nerve palsy, especially when laminae are elevated to an angle >60° during laminoplasty 1
• Post-surgical kyphosis in approximately 10% of patients after laminoplasty 1
• Pseudarthrosis (nonunion) in approximately 10.9% of cases after corpectomy 1
• Hardware failure, subsidence, and incorrect screw placement 6
• Permanent dysphagia and dysphonia 6

Management of symptomatic pseudarthrosis:

• Revision surgery should be considered for symptomatic pseudarthrosis as arthrodesis is associated with improved clinical outcome 7
• Both posterior and anterior approaches have proven successful for surgical correction, though posterior approaches may be associated with higher fusion rates 7

When to Refer to Specialist

Urgent referral indicated for:

• Progressive neurological deficits 1
• Signs of cervical myelopathy (difficulty with fine motor skills, gait disturbances) 1
• Evidence of significant spinal cord compression on imaging 1
• Failure to respond to conservative treatment after 3 months 1

Critical pitfall to avoid: Do not delay appropriate referral for patients with progressive neurological symptoms or signs of myelopathy, as prolonged severe stenosis can lead to potentially irreversible spinal cord damage 1, 2