What is the initial treatment for spondylosis?

Initial Treatment for Spondylosis

NSAIDs are the first-line drug treatment for spondylosis, combined with regular exercise and physical therapy as the cornerstone of non-pharmacological management. 1

Non-Pharmacological Treatment (Start Immediately)

Physical therapy and regular exercise form the foundation of spondylosis treatment and should be initiated at diagnosis. 1

• Supervised physical therapy is superior to home exercises alone and should be prescribed initially, with land-based programs preferred over aquatic therapy 1
• Group physical therapy demonstrates better patient global assessment outcomes compared to individual home exercise programs 1, 2
• After initial supervised instruction, patients should continue with unsupervised back exercises at home as maintenance therapy 1
• Patient education about the condition and self-management strategies is essential from the outset 1, 2

Critical caveat: In patients with spinal fusion or advanced spinal osteoporosis, spinal manipulation with high-velocity thrusts is strongly contraindicated due to risk of fractures, spinal cord injury, and paraplegia 1

Pharmacological Treatment (First-Line)

NSAIDs are recommended as first-line drug therapy for patients with pain and stiffness. 1

• Level Ib evidence demonstrates NSAIDs improve spinal pain, peripheral joint pain, and function over 6-week periods 1, 2
• For active disease, continuous NSAID treatment is preferred over on-demand dosing 1
• Naproxen dosing: 250-500 mg twice daily for rheumatoid arthritis, osteoarthritis, and ankylosing spondylitis; may increase to 1500 mg/day for up to 6 months if needed 3
• Onset of pain relief begins within 1 hour with naproxen 3

For patients with increased gastrointestinal risk: Use either non-selective NSAIDs plus gastroprotective agents OR selective COX-2 inhibitors 1, 2, 4

Cardiovascular, gastrointestinal, and renal risks must be assessed before prescribing NSAIDs. 1

Second-Line Pharmacological Options

• Analgesics (acetaminophen, opioids) should only be considered for residual pain after NSAIDs have failed, are contraindicated, or poorly tolerated 1, 4
• Local corticosteroid injections may be considered for specific sites of musculoskeletal inflammation 1
• Systemic glucocorticoids are NOT recommended for axial disease as there is no supporting evidence 1

Treatment Duration and Monitoring

Conservative management should be attempted for at least 6 weeks to 3 months before considering any surgical intervention. 4

• Most patients improve within the first 4 weeks of conservative management 4
• Regular monitoring using validated disease activity measures (such as Bath AS Disease Activity Index) and acute-phase reactants (CRP or ESR) is conditionally recommended, particularly in patients with active symptoms 1
• Monitoring is not necessary at every clinic visit and can be omitted in clinically stable patients 1

When Initial Treatment Fails

For patients with persistently high disease activity despite conventional treatments (NSAIDs + physical therapy), anti-TNF therapy should be considered according to ASAS recommendations. 1

• There is no evidence requiring DMARD use before or concurrent with anti-TNF therapy for axial disease 1
• DMARDs (including sulfasalazine and methotrexate) have no proven efficacy for axial disease, though sulfasalazine may be considered for peripheral arthritis 1

Common Pitfalls to Avoid

• Never proceed to advanced treatments without documenting adequate trial of NSAIDs plus supervised physical therapy for at least 6 weeks 4
• Do not use spinal manipulation in patients with any degree of spinal fusion or osteoporosis 1
• Avoid systemic corticosteroids for axial symptoms as they lack evidence of benefit 1
• Do not combine NSAIDs with aspirin, as aspirin increases naproxen excretion and the combination increases adverse events without additional benefit 3