What is the recommended treatment for cervical spondylosis?

Recommended Treatment for Cervical Spondylosis

For cervical spondylosis, begin with combined NSAIDs and physical therapy as first-line treatment, reserving surgery only for patients with progressive myelopathy or severe radiculopathy unresponsive to 3-6 months of conservative management. 1

Initial Conservative Management (First 4-6 Weeks)

Pharmacological Treatment

• NSAIDs are the first-line drug treatment for pain and stiffness, showing 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 (PPIs reduce serious GI events by 60%, RR 0.40) or selective COX-2 inhibitors (reduce serious GI events by 82% compared to traditional NSAIDs, RR 0.18) 2
• Both traditional NSAIDs and COX-2 inhibitors demonstrate equivalent efficacy for spinal pain relief 1
• Simple analgesics (acetaminophen, opioids) may be added for breakthrough pain when NSAIDs are insufficient or contraindicated 2

Non-Pharmacological Treatment

• Non-pharmacological and pharmacological treatments must be used together throughout the disease course 1
• Home exercise programs focusing on neck stabilization and range of motion improve function in the short term (Level Ib evidence) 1
• Group physical therapy shows significantly better patient global assessment compared to home exercise alone 1
• Patient education regarding proper ergonomics and posture is essential 1
• Activity modification including rest or "low-risk" activities is recommended 1

When to Obtain Advanced Imaging

• If symptoms persist beyond 4-6 weeks or 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
• Plain radiographs are useful to diagnose spondylosis and spinal stenosis, but therapy is rarely altered by radiographic findings alone without red flag symptoms 1

Critical pitfall: 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 1

Prognosis 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
• Poor prognostic factors 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

Indications for Surgical Referral

Absolute Indications (Do Not Delay Referral)

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

Relative Indications

• Persistent severe pain despite 3-6 months of adequate conservative management 1, 3
• Cervical stenosis with clinical radiculopathy (requires closer monitoring as this is associated with development of symptomatic CSM) 1

Special Consideration for Mild CSM

• For patients with mild CSM (age <75 years and mJOA score >12), both operative and nonoperative management options can be offered 1
• Class II evidence suggests equivalency between surgery and nonoperative management over 3 years for mild CSM, though this evidence has limitations including nonblinded allocation and selection bias 1

Surgical Approach Selection (When Surgery is Indicated)

Based on Number of Levels Involved

• 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

Expected Surgical Outcomes

• Anterior surgical approaches show improvement rates of approximately 73-74% 1
• 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
• Laminectomy alone is associated with increased risk of postoperative kyphosis and late deterioration occurs in approximately 29% of patients 1
• Younger patients and those with shorter symptom duration typically have better surgical outcomes 1

Long-Term Monitoring

• Monitor for development of myelopathy symptoms: gait disturbance, hand clumsiness, bowel/bladder dysfunction 1
• For patients who undergo laminectomy alone, monitor for late deterioration (occurs in ~29% of cases) 1
• Continue home exercise programs and physical therapy for ongoing symptom management 1

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