What is the initial management for MRI-confirmed spondylitis with reversal of normal cervical lordosis?

Initial Management of MRI-Confirmed Spondylitis with Reversed Cervical Lordosis

Begin with NSAIDs at maximum tolerated doses as first-line pharmacological treatment, combined with active supervised physical therapy focusing on spinal mobility and posture correction, while urgently referring to rheumatology within 6 weeks to establish the specific type of spondyloarthritis and determine need for disease-modifying therapy. 1, 2

Immediate Pharmacological Management

• Start NSAIDs at maximum tolerated doses as first-line treatment, accounting for gastrointestinal, cardiovascular, and renal risk factors 2, 3
• NSAIDs remain the cornerstone of initial therapy for axial spondyloarthritis, though disease often becomes refractory over time requiring escalation 3
• Consider short-term analgesics or muscle relaxants for acute symptom control, though evidence for long-term efficacy is limited 4
• Avoid systemic corticosteroids as routine treatment; they are not recommended for axial spondyloarthritis management 1

Physical Therapy and Rehabilitation (Critical Component)

• Initiate active supervised exercise interventions immediately—land-based programs are preferred over passive modalities or aquatic therapy 2
• Focus on exercises that restore and maintain spinal mobility, particularly cervical range of motion and postural correction 3, 5
• Physical therapy is a necessary adjunct to pharmacotherapy and should not be delayed 3
• The reversed cervical lordosis may respond to manipulative correction combined with intermittent motorized cervical traction over 3 months, though this is based on limited case evidence 6

Rheumatology Referral and Disease Classification

• Refer to rheumatology within 6 weeks for comprehensive evaluation and classification of the specific spondyloarthritis subtype 2
• The rheumatologist will determine whether this represents ankylosing spondylitis (radiographic axial SpA) versus non-radiographic axial SpA, which affects treatment algorithms 1
• Additional serological testing may be needed including HLA-B27, inflammatory markers (ESR, CRP), and exclusion of other autoimmune conditions 2

Disease Activity Monitoring

• Assess disease activity every 1-3 months initially including pain levels, functional status, inflammatory markers (CRP/ESR), spinal mobility measures, and response to NSAIDs 2
• Use validated instruments such as BASDAI (Bath Ankylosing Spondylitis Disease Activity Index) and functional measures like BASFI 7
• The MRI has already confirmed active inflammation; do not repeat MRI to confirm activity while on initial NSAID therapy unless disease activity level becomes unclear 1

Escalation Criteria to Biologic Therapy

• If symptoms persist despite 2-3 months of maximum-dose NSAIDs and physical therapy, escalation to TNF-alpha inhibitors or other biologic agents should be considered 2
• Extensive MRI inflammatory activity (bone marrow edema), particularly in the spine, predicts good clinical response to anti-TNF-alpha treatment and aids in the decision to initiate biologics 1
• A Berlin MRI spine score >11 provides a positive likelihood ratio of 6.7 for achieving BASDAI50 response with TNF-alpha inhibitors 1
• TNF-alpha inhibitors (etanercept, adalimumab, infliximab) are the first biologic option, with IL-17 inhibitors (secukinumab, ixekizumab) and JAK inhibitors (tofacitinib) as alternatives 1

Addressing the Reversed Cervical Lordosis

• The reversed cervical lordosis is a structural consequence of chronic inflammation and muscle spasm in axial spondyloarthritis 6, 5
• Control of inflammation through NSAIDs and biologics, combined with physical therapy, is the primary approach to prevent progression 1, 5
• Restoration of cervical lordosis has been demonstrated with manipulative correction and traction over 3-4 months in case reports, though this is not standard guideline-based care 6
• Monitor for development of cervical myelopathy (hand clumsiness, gait disturbance, hyperreflexia) which would require urgent neurosurgical evaluation 5

Critical Pitfalls to Avoid

• Do not delay rheumatology referral—early diagnosis and treatment of inflammatory arthritis improves long-term outcomes 2
• Do not rely on NSAIDs alone if there is evidence of active inflammation on MRI; disease-modifying therapy should be initiated if NSAIDs fail after 2-3 months 1, 2
• Do not obtain repeat spine radiographs at scheduled intervals (e.g., every 2 years) as standard practice; imaging should be driven by clinical need 1
• Do not use disease-modifying antirheumatic drugs (DMARDs) like methotrexate or sulfasalazine as they lack efficacy for axial disease, though they may help peripheral manifestations 1, 3
• Be aware that patients with ankylosed spines are at high risk for unstable fractures from minor trauma—maintain high clinical suspicion for fracture if new pain develops 1

Osteoporosis Screening

• Assess for osteoporosis with hip DXA and AP-spine DXA given the association between axial spondyloarthritis and reduced bone mineral density 1
• If syndesmophytes develop in the lumbar spine, supplement with lateral spine DXA or quantitative CT 1