What are the treatment options for straightening of the usual lordosis?

Treatment of Straightening of Cervical Lordosis

Begin with conservative management including cervical extension traction combined with physical therapy for at least 3 months, reserving surgical intervention for patients with progressive neurological deficits or failure of conservative treatment. 1

Initial Conservative Approach (First-Line Treatment)

Conservative management should be implemented as the primary treatment strategy for symptomatic loss of cervical lordosis:

• Cervical extension traction combined with physical therapy is the cornerstone of initial treatment, as recommended by the American College of Physicians 1
• Short-term muscle relaxants should be added for associated muscle spasm 1
• Physical therapy exercises focusing on strengthening neck muscles and improving posture are essential 1
• Anti-inflammatory medications to reduce pain and inflammation 1
• Hot/cold therapy for temporary symptomatic relief 1
• Activity modification to avoid positions that exacerbate symptoms 1

Duration of Conservative Trial

• Continue conservative management for 3 months before considering surgical options 1
• One case report demonstrated complete symptom resolution and restoration of cervical lordosis at 4-year follow-up using spinal manipulation combined with intermittent motorized cervical traction over 3 months 2

Surgical Indications

Refer for surgical evaluation under these specific circumstances:

• Progressive neurological deficits at any point during treatment 1
• Failure to respond to conservative treatment after 3 months 1
• Long-standing severe stenosis that may lead to potentially irreversible spinal cord damage 1

Surgical Treatment Options by Disease Extent

Single-Level Disease

• Anterior cervical discectomy and fusion (ACDF) with plating is recommended to maintain lordosis (Class II evidence, strength C) 1
• ACDF with plating maintains lordosis better than ACDF alone, though plating does not necessarily improve clinical outcomes for 1-level disease (Class II evidence, strength B) 1
• ACDF is preferred over anterior cervical discectomy alone to reduce kyphosis risk and increase fusion rate (Class II evidence, strength C) 1

Two-Level Disease

• ACDF with instrumentation is recommended over ACDF alone to improve arm pain (Class II evidence, strength C) 1

Three-Segment Disease

• Anterior corpectomy is recommended, though pseudarthrosis occurs in approximately 10.9% of cases 1

Multilevel Degenerative Myelopathy

• Laminoplasty preserves motion and reduces axial neck pain 1
• Laminectomy with fusion prevents post-laminectomy kyphosis, which occurs in approximately 10% of patients after laminoplasty alone 1

Critical Surgical Considerations and Complications

Kyphosis Prevention

• Development of kyphosis predicts poor outcomes in cervical spine patients (p < 0.05) 1
• Post-surgical kyphosis occurs in approximately 10% of patients after laminoplasty 1

C5 Nerve Palsy Risk

• C5 nerve palsy can develop after surgery, especially when laminae are elevated to an angle >60° during laminoplasty 1

Pseudarthrosis Evaluation

• Evaluate for pseudarthrosis if clinical outcome is poor, as arthrodesis is associated with improved clinical outcome (Class III evidence, strength D) 1

Common Pitfalls to Avoid

• Do not rush to surgery within the first 3 months unless progressive neurological deficits are present 1
• Do not ignore sagittal balance assessment when planning surgical correction, as overall spinal alignment is more important than absolute lordotic angles 3
• Be aware that traditional angular measurements may not account for ventral obstructions to the spinal cord; effective lordosis measurements should be considered 3
• Recognize that long-standing severe stenosis can cause irreversible spinal cord damage, making earlier surgical intervention appropriate in these cases 1