What are the management options for cervical spondylosis?

Management of Cervical Spondylosis

Begin with a 3-month trial of conservative management combining NSAIDs, physical therapy, and activity modification, reserving surgery only for patients with progressive neurological deficits, moderate-to-severe myelopathy, or failure of conservative treatment. 1

Initial Conservative Management (First-Line for 3 Months)

Pharmacological Treatment

• NSAIDs are the first-line medication, demonstrating Level Ib evidence for large improvements in spinal pain and function over 6-week periods 1, 2
• For patients with gastrointestinal risk factors, use either non-selective NSAIDs plus gastroprotective agents OR selective COX-2 inhibitors, which show equivalent efficacy 1, 2
• Short-term muscle relaxants (maximum 2-3 weeks) can be added specifically for muscle spasm 1
• Approximately 70% of patients with mild cervical spondylotic myelopathy maintain stable clinical status over 3 years with conservative treatment alone 1, 3

Non-Pharmacological Treatment

• Non-pharmacological and pharmacological treatments are complementary and should be used together throughout the disease course 1, 2
• Home exercise programs improve function in the short term with Level Ib evidence 2
• Group physical therapy demonstrates significantly better patient global assessment compared to home exercise alone, though both improve function similarly 2
• Patient education regarding proper ergonomics and posture is essential 2
• Neck immobilization with cervical collar can be used in the acute phase, particularly for patients with minor neurologic findings 4

Diagnostic Imaging Strategy

• Obtain MRI if symptoms persist beyond 4-6 weeks OR if any neurological symptoms develop 1, 2
• MRI is the most sensitive test for detecting soft tissue abnormalities, though it has high rates of abnormalities in asymptomatic individuals 1, 2
• Critical pitfall: Do not rely solely on imaging findings for treatment decisions, as spondylotic changes correlate poorly with the presence of neck pain in patients >30 years of age 2
• Radiographs are useful to diagnose spondylosis and spinal canal stenosis, but therapy is rarely altered by radiographic findings alone in the absence of red flag symptoms 2

Indications for Surgical Referral

Absolute Indications (Urgent Referral Required)

• Progressive neurological deficits 1, 2
• Moderate to severe cervical spondylotic myelopathy (modified Japanese Orthopaedic Association scale score ≤12) 1, 2
• Evidence of spinal cord compression on imaging with corresponding clinical symptoms 1, 2

Relative Indications

• Persistent severe pain despite adequate conservative management for 3 months 1, 2
• Mild CSM in patients younger than 75 years who fail conservative treatment 1
• Clinical radiculopathy with cervical stenosis (warrants closer monitoring as this is associated with development of symptomatic CSM) 2

Surgical Approach Selection (When Surgery is Indicated)

For Limited Disease (1-3 Levels)

• Anterior cervical discectomy and fusion (ACDF) is the preferred approach, achieving good to excellent outcomes in approximately 90% of patients with radiculopathy 1, 3
• Anterior surgical approaches show improvement rates of approximately 73-74% 2

For Multilevel Disease (≥4 Segments)

• Posterior approach (laminectomy with fusion or laminoplasty) is preferred 1, 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) 1, 2
• Critical pitfall: Laminectomy alone is associated with increased risk of postoperative kyphosis and late deterioration in approximately 29% of patients 2

Prognostic Factors

Favorable Prognosis

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

Poor Prognosis

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

Natural History and Long-Term Outcomes

• Most cases of acute cervical neck pain resolve with conservative treatment measures 2
• However, nearly 50% of patients may continue to have residual or recurrent episodes of pain up to 1 year after initial presentation 2
• The natural history of cervical spondylosis is variable, with many patients experiencing long periods of stable symptoms or slow progression 3
• Critical consideration: Surgical results show good initial outcomes in about 70-80% of patients, but functional outcome noticeably declines with long-term follow-up 4

Common Pitfalls to Avoid

• Do not delay appropriate referral for patients with progressive neurological symptoms or signs of myelopathy 2
• 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 2
• Monitor surgical patients for common complications including C5 nerve palsy, post-surgical kyphosis, pseudarthrosis (occurring in approximately 10.9% of cases after corpectomy), and hardware failure 1