Treatment of Moderate Cervical Spondylosis
For moderate cervical spondylosis without myelopathy, initiate conservative management with NSAIDs, activity modification, and physical therapy for at least 3 months before considering surgical intervention. 1, 2
Initial Conservative Management
Start with NSAIDs as first-line pharmacological treatment, which demonstrate large improvements in spinal pain and function with Level Ib evidence. 1 For patients with gastrointestinal risk factors, use either non-selective NSAIDs plus a gastroprotective agent or a selective COX-2 inhibitor. 1
Non-Pharmacological Interventions
- Combine pharmacological and non-pharmacological treatments from the outset, as both are complementary and valuable throughout the disease course. 1
- Prescribe home exercise programs focusing on neck stabilization and range of motion, which improve function in the short term compared to no intervention (Level Ib evidence). 1, 3
- Refer to group physical therapy if available, as it shows significantly better patient global assessment compared to home exercise alone. 1
- Implement activity modification including rest or "low-risk" activities to reduce mechanical stress on the cervical spine. 3
- Consider neck immobilization with a cervical collar for symptomatic relief, which results in improvement in 30-50% of patients. 4
When to Escalate Treatment
Red Flags Requiring Urgent Evaluation
Refer immediately for surgical evaluation if any of the following develop:
- Progressive neurological deficits indicating spinal cord compression. 1, 5
- Gait and balance difficulties, which indicate cervical myelopathy requiring urgent attention. 5
- Persistent severe pain despite 3 months of adequate conservative management. 1, 2
- Clinical radiculopathy with abnormal EMG findings, as this is associated with development of symptomatic cervical spondylotic myelopathy. 6
Critical Pitfall to Avoid
Do not delay surgical referral in patients with established myelopathy waiting for "failed conservative management." Long periods of severe stenosis are associated with demyelination of white matter and may result in necrosis of both gray and white matter leading to potentially irreversible deficit. 5 Delaying surgery risks permanent neurological deficit that cannot be reversed even with eventual decompression. 5
Monitoring and Follow-Up
- Obtain MRI if symptoms persist beyond 4-6 weeks or if neurological symptoms develop, as it is the most sensitive test for detecting soft tissue abnormalities. 1
- Monitor patients with clinical radiculopathy more closely, as they are at higher risk for developing symptomatic cervical spondylotic myelopathy. 1
- Reassess at 3 months to determine if conservative management is providing adequate symptom control. 3, 7
Expected Outcomes with Conservative Treatment
- Most cases of acute cervical neck pain resolve with conservative measures, though nearly 50% may have residual or recurrent episodes up to 1 year after initial presentation. 1
- Approximately 70% of patients with mild cervical spondylotic myelopathy maintain clinical gains after nonoperative treatment over 3 years. 6, 3
- Conservative treatment is labor-intensive, requiring regular review and careful selection of medications and physical therapy on a case-by-case basis. 2
Factors Associated with Poor Prognosis
Be aware that female gender, older age, coexisting psychosocial pathology, and radicular symptoms are associated with worse outcomes. 1 These patients may require more aggressive monitoring and earlier consideration of surgical intervention.
Important Caveat
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 Treatment decisions should be based primarily on clinical symptoms and functional impairment, not imaging alone.