What is the recommended management approach for a patient with cervical spondylosis?

Management of Cervical Spondylosis

For cervical spondylosis, initial management should prioritize conservative treatment with NSAIDs, physical therapy, and activity modification for at least 3 months, reserving surgery for patients with moderate-to-severe myelopathy (mJOA ≤12), progressive neurological deficits, or failure of conservative therapy. 1

Initial Conservative Management (First-Line for All Patients)

Pharmacological Treatment

• NSAIDs are the first-line drug treatment, 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 proton pump inhibitor (reduces serious GI events by 60%) or selective COX-2 inhibitors (reduces serious GI events by 82%) 1
• Add simple analgesics (acetaminophen or opioids) for breakthrough pain when NSAIDs are insufficient or contraindicated 1
• Short-term muscle relaxants (up to 2-3 weeks) are appropriate for patients with muscle spasm indicated by reversal of cervical lordosis on X-ray 2

Non-Pharmacological Treatment

• Home exercise programs and group physical therapy are both essential, with group therapy showing significantly better patient global assessment compared to home exercise alone 1
• Neck immobilization with a stiff cervical collar for acute symptoms 3
• Activity modification to avoid positions that worsen symptoms 2
• Hot/cold therapy for temporary pain relief 2
• Patient education regarding proper ergonomics and posture 1

Critical Point: Non-pharmacological and pharmacological treatments are complementary and both should be used together throughout the disease course 1. Exercise treatment provides superior long-term recovery compared to medication alone 4.

Diagnostic Imaging Strategy

• 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
• Radiographs are useful to diagnose spondylosis and spinal canal stenosis, but therapy is rarely altered by radiographic findings alone in the absence of red flag symptoms 1

Common 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.

Stratification by Disease Severity

Mild Cervical Spondylotic Myelopathy (mJOA >12, Age <75)

• Both operative and nonoperative management options can be offered, with Class II evidence showing equivalency over 3 years 1
• Approximately 70% of patients with mild CSM maintain their clinical status over 3 years with nonoperative treatment 3
• Continue conservative management with close monitoring for progression 1

Moderate-to-Severe Cervical Spondylotic Myelopathy (mJOA ≤12)

• Surgical decompression is strongly recommended, demonstrating statistically significant improvement in mJOA scores beginning at 6 months and continuing through 24 months postoperatively 1
• Benefits are maintained for 5-15 years postoperatively 1

Cervical Radiculopathy Without Myelopathy

• Nonoperative therapy in the acute phase has success rates averaging 90% 1
• Good to excellent outcomes in approximately 90% of patients with radiculopathy treated with ACDF if surgery becomes necessary 3
• Closer monitoring is warranted as radiculopathy with cervical stenosis is associated with development of symptomatic CSM 1

Surgical Indications (Absolute)

Surgery should be considered when:

• Progressive neurological deficits 1
• Moderate-to-severe myelopathy (mJOA ≤12) 1
• Persistent severe pain despite adequate conservative management for 3 months 1, 3
• Evidence of spinal cord compression on imaging with corresponding clinical symptoms 1
• Difficulty with fine motor skills or gait disturbances (signs of myelopathy) 2

Surgical Approach Selection

For 1-3 Level Disease

• Anterior cervical discectomy and fusion (ACDF) is preferred, with fusion rates of 92% and improvement rates of approximately 73-74% 2, 1
• Anterior corpectomy is recommended specifically for 3-segment disease 2

For Multilevel Disease (≥4 Segments)

• Posterior approach (laminectomy with fusion or laminoplasty) is preferred 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
• Laminoplasty preserves motion and reduces axial neck pain 2

Critical Surgical Pitfall: Laminectomy alone is associated with increased risk of postoperative kyphosis (approximately 10% of patients) and late deterioration occurs in approximately 29% of patients 2, 1. Therefore, laminectomy with fusion is preferred over laminectomy alone 1.

Prognostic Factors

Better outcomes are associated with:

• Younger age 1, 3
• Shorter duration of symptoms 1
• Better preoperative neurological function 1

Poor prognosis is associated with:

• Female gender 1
• Older age 1
• Coexisting psychosocial pathology 1
• Radicular symptoms 1

Monitoring and Follow-Up

• Nearly 50% of patients may continue to have residual or recurrent episodes of pain up to 1 year after initial presentation 1
• Monitor for late deterioration after laminectomy alone (occurs in approximately 29% of patients) 1
• Post-surgical complications include C5 nerve palsy (especially when laminae are elevated to an angle >60°) and pseudarthrosis (approximately 10.9% after corpectomy) 2

Critical Point: Do not delay appropriate referral for patients with progressive neurological symptoms or signs of myelopathy, as long periods of severe stenosis can lead to potentially irreversible damage to the spinal cord 2, 1.