What are the treatment options and referral criteria for a patient with spondylosis?

Treatment and Referral for Spondylosis

For degenerative spondylosis, initiate NSAIDs at maximum tolerated doses as first-line treatment, refer to physical therapy, and reserve rheumatology referral for patients with inflammatory spondyloarthritis (axial SpA) presenting with chronic back pain starting before age 45 with inflammatory features. 1, 2

Initial Treatment Approach

First-Line Pharmacologic Management

• Start NSAIDs at the lowest effective dose initially, then titrate to maximum tolerated doses while weighing cardiovascular, gastrointestinal, and renal risks against benefits 3, 1, 2
• Continuous NSAID use is preferred over on-demand dosing for patients who respond well and remain symptomatic 3, 1, 2
• If the first NSAID is ineffective after 2-4 weeks, trial a different NSAID before escalating therapy 1, 2
• For patients with gastrointestinal risk factors, consider COX-2 selective NSAIDs or add gastroprotective agents 2
• Approximately 75% of patients with axial spondyloarthritis show good or very good response within 48 hours of full-dose NSAID therapy 1, 2

Non-Pharmacologic Interventions

• All patients must be referred to a specialist for structured exercise programs, as these are more beneficial than home exercises alone 1, 2
• Physical therapy should be considered for all patients with spondylosis 1, 2
• Hydrotherapy can be considered for pain management 1
• Smoking cessation is essential, as smoking worsens disease progression 2

Additional Pain Management Options

• Analgesics such as paracetamol and opioids should only be considered for residual pain after NSAIDs and other recommended treatments have failed, are contraindicated, or poorly tolerated 3, 1
• Corticosteroid injections directed to the local site of musculoskeletal inflammation may be considered 3
• For peripheral arthritis, corticosteroid injections are first-line for nonprogressive monoarthritis 1

When to Refer to Rheumatology

Specific Referral Criteria for Inflammatory Spondyloarthritis

Refer to a rheumatologist when patients have chronic low back pain (>3 months) starting before age 45 PLUS at least 4 of the following:

• Back pain occurring before age 35 1
• Waking at night due to back pain symptoms 1, 2
• Buttock pain 1
• Improvement in pain with movement or within 2 days of taking an NSAID 1
• First-degree relative with spondyloarthritis 1
• Current or previous arthritis, enthesitis, or psoriasis 1

Additional Referral Triggers

• Persistently high disease activity despite 2-4 weeks of optimal NSAID therapy 1, 2
• Difficulties performing activities of daily living despite NSAID treatment 1, 2
• Presence of inflammatory back pain characterized by morning stiffness >30 minutes, pain at night/early morning, and improvement with exercise 3
• HLA-B27 positivity in a patient with chronic back pain (post-test probability of 32% for axial SpA) 3
• Evidence of sacroiliitis on x-ray or MRI imaging 3

Pre-Referral Workup

Before referring to rheumatology, obtain:

• ESR and CRP 2
• HLA-B27 testing 2
• Complete blood count 2
• Consider plain radiographs of sacroiliac joints (though MRI is more sensitive for detecting early sacroiliitis) 2

Critical Pitfalls to Avoid

• Do not rule out axial spondyloarthritis based solely on negative HLA-B27 or normal inflammatory markers (ESR/CRP), as 10% of patients are HLA-B27 negative and 50% have normal inflammatory markers 1, 2
• The typical delay between symptom onset and diagnosis is 5-7 years—maintain high clinical suspicion for inflammatory back pain patterns 1, 2
• Plain radiographs may be normal early in disease; MRI is more sensitive for detecting sacroiliitis 2
• Do not use conventional DMARDs (methotrexate, sulfasalazine, leflunomide) for purely axial disease—they are ineffective 3, 2
• Sulfasalazine may only be considered if peripheral arthritis is present 3, 2
• Systemic glucocorticoids for axial disease are not supported by evidence 3

When to Refer to Neurosurgery/Spine Surgery

• Immediate referral to spine surgeon for any patient with acute vertebral fracture 3
• Referral to spine surgeon for suspected spondylolysis or isthmic spondylolisthesis due to risk of disease progression 4
• Severe disabling deformity requiring spinal corrective osteotomy 3
• Refractory pain or disability with radiographic evidence of structural damage requiring total hip arthroplasty 3
• Significant spinal cord compression or progressive neurological deficits 5, 6
• Severe destruction of endplates, spinal abscess formation, mechanical instability, or neurological deficits in cases of spondylodiscitis 7

Immediate Ophthalmology Referral

• Immediate referral to an ophthalmologist is required for any symptoms of uveitis (eye pain or redness) 1

Treatment Escalation Beyond Primary Care

For patients referred to rheumatology with persistently high disease activity despite NSAIDs and physical therapy, biologic DMARDs (TNF inhibitors or IL-17 inhibitors) become the next treatment step 3, 2

Anti-TNF therapy should be given to patients with persistently high disease activity despite conventional treatments 3

Switching to a second TNF blocker might be beneficial, especially in patients with loss of response 3