What are the management options for cervical spondylosis?

Management of Cervical Spondylosis

For cervical spondylosis without myelopathy, begin with conservative management including NSAIDs, physical therapy, and activity modification for at least 4-6 weeks; reserve surgery only for patients with progressive neurological deficits or severe myelopathy (mJOA ≤12). 1

Initial Conservative Management

Pharmacological Treatment

• NSAIDs are the first-line drug treatment for patients with pain and stiffness, showing large improvements in spinal pain and function with Level Ib evidence over 6-week periods 1
• For patients with increased gastrointestinal risk, use non-selective NSAIDs plus a gastroprotective agent, or a selective COX-2 inhibitor 1
• Both traditional NSAIDs and COX-2 inhibitors demonstrate equivalent efficacy for spinal pain relief 2

Non-Pharmacological Treatment

• Non-pharmacological and pharmacological treatments are complementary and both should be used together throughout the disease course 2, 1
• Home exercise programs improve function in the short term compared with no intervention (Level Ib evidence) 1
• Group physical therapy shows significantly better patient global assessment compared to home exercise alone, though both improve function similarly 2, 1
• Patient education regarding proper ergonomics and posture is essential 1
• Neck immobilization with a cervical collar can be beneficial, particularly in acute phases 3

Expected Outcomes with Conservative Treatment

• Most cases of acute cervical neck pain resolve with conservative measures 1
• However, nearly 50% of patients may have residual or recurrent pain up to 1 year after initial presentation 1
• Factors predicting poor prognosis include female gender, older age, coexisting psychosocial pathology, and radicular symptoms 1
• For cervical radiculopathy specifically, nonoperative therapy has success rates averaging 90% in the acute phase 1

Diagnostic Imaging Strategy

Timing and Indications

• If symptoms persist beyond 4-6 weeks or if 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
• Radiographs are useful to diagnose spondylosis, degenerative disc disease, malalignment, or spinal canal stenosis, but therapy is rarely altered by radiographic findings alone in the absence of red flag symptoms 1

Critical Pitfall to Avoid

• Do not rely solely on imaging findings for treatment decisions, as 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

Surgical Intervention Criteria

Absolute Indications for Surgery

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

Relative Indications for Surgery

• Persistent severe pain despite adequate conservative management (typically after 3 months of appropriate conservative therapy) 1, 4
• For patients with mild CSM (age younger than 75 years and mJOA score >12), both operative and nonoperative management options can be offered, as Class II evidence suggests equivalency between surgery and nonoperative management over 3 years 1

Special Monitoring Situations

• 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
• Do not delay appropriate referral for patients with progressive neurological symptoms or signs of myelopathy 1

Surgical Approach Selection

Algorithm Based on Number of Levels

• For 1-3 level disease: anterior approach (ACDF or corpectomy) is preferred 1
• For multilevel disease (≥4 segments): posterior approach (laminectomy with fusion or laminoplasty) is preferred 1
• Combined approaches may be considered for complex cases 1

Surgical Outcomes by Technique

• 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
• Anterior surgical approaches show improvement rates of approximately 73-74% 1
• Laminectomy alone is associated with increased risk of postoperative kyphosis compared to anterior techniques or laminectomy with fusion, though development of kyphosis does not necessarily diminish clinical outcome 2, 1
• Late deterioration occurs in approximately 29% of patients who undergo laminectomy alone 1

Prognostic Factors Affecting Surgical Outcomes

• Younger patients have better prognosis 1
• Shorter duration of symptoms correlates with better outcomes 1
• Preoperative neurological function predicts better outcomes 1
• Preoperative somatosensory-evoked potentials may provide valuable prognostic information in cases where clinical factors don't provide clear guidance 1

Treatment Algorithm Summary

For uncomplicated cervical spondylosis (no myelopathy):

1. NSAIDs plus physical therapy for 4-6 weeks 1
2. If no improvement, obtain MRI 1
3. Continue conservative management for 3 months total 4, 5
4. Consider surgery only if severe persistent pain or radiculopathy develops 1

For mild CSM (mJOA >12):

1. Either conservative management (cervical collar, activity modification, anti-inflammatory medications) or surgery can be offered 1
2. Conservative management can be continued for up to 3 years with close monitoring 1

For moderate to severe CSM (mJOA ≤12):

1. Proceed directly to surgical decompression 1
2. Choose anterior approach for 1-3 levels, posterior for ≥4 levels 1
3. Consider laminectomy with fusion over laminectomy alone to reduce kyphosis risk and improve neurological recovery 1