Treatment of Cervical Spondylitis
Initial treatment of cervical spondylitis should combine NSAIDs as first-line pharmacotherapy with supervised physical therapy and patient education, reserving surgery only for patients with progressive neurological deficits or severe myelopathy. 1, 2
Initial Pharmacological Management
NSAIDs are the cornerstone of first-line drug treatment, demonstrating Level Ib evidence for improving spinal pain and function over 6-week periods. 1, 2
For patients with standard gastrointestinal risk: Use traditional NSAIDs (naproxen, ibuprofen, diclofenac) at standard anti-inflammatory doses. 1
For patients with increased GI risk: Use either non-selective NSAIDs plus a proton pump inhibitor (reduces serious GI events by 60%, RR 0.40) OR selective COX-2 inhibitors (reduces serious GI events by 82%, RR 0.18). 2
For breakthrough pain: Add simple analgesics (acetaminophen or short-term opioids) when NSAIDs are insufficient or contraindicated. 2
For muscle spasm: Short-term muscle relaxants (maximum 2-3 weeks) can be added. 3, 4
Comparative studies show no clear superiority of one NSAID over another, and COX-2 inhibitors demonstrate equivalent efficacy to traditional NSAIDs for spinal pain relief. 1, 2
Non-Pharmacological Treatment (Essential Component)
Non-pharmacological and pharmacological treatments are complementary and both must be used throughout the disease course. 1, 2
Physical Therapy Approach
Home exercise programs: Improve function in the short term compared to no intervention (Level Ib evidence), though should not substitute for initial professional instruction. 1
Supervised group physical therapy: Shows significantly better patient global assessment compared to home exercise alone, despite similar functional improvements. 1, 2
Patient education: Include proper ergonomics, posture training, and activity modification to avoid positions that worsen symptoms. 2, 4
Spa therapy: Demonstrates cost-effectiveness over 3 months for physical functioning. 1
Critical Safety Warning
Strongly avoid spinal manipulation with high-velocity thrusts in patients with spinal fusion or advanced spinal osteoporosis due to documented case reports of spine fractures, spinal cord injury, and paraplegia, particularly with cervical spine manipulation. 1, 2
Monitoring Strategy
Disease activity monitoring: Use validated measures (Bath Ankylosing Spondylitis Disease Activity Index) at regular intervals for patients with active symptoms to guide treatment adjustments. 1
Acute phase reactants: Monitor CRP or ESR regularly in active disease, though not necessary at every visit for clinically stable patients. 1
Imaging timeline: If symptoms persist beyond 4-6 weeks or neurological symptoms develop, obtain MRI (most sensitive for soft tissue abnormalities, though high false-positive rate in asymptomatic individuals). 2, 3
Indications for Surgical Referral
Urgent specialist referral is indicated for:
Progressive neurological deficits (weakness, sensory loss, gait disturbance). 2, 3, 4
Signs of cervical spondylotic myelopathy (difficulty with fine motor skills, gait disturbances, hyperreflexia). 2, 4
Evidence of spinal cord compression on imaging with corresponding clinical symptoms. 2, 3
Persistent severe pain despite 3 months of adequate conservative management. 2, 3
Surgical Approach Selection (When Indicated)
For 1-3 level disease: Anterior cervical discectomy and fusion (ACDF) or corpectomy, achieving good-to-excellent outcomes in approximately 90% of radiculopathy patients. 2, 3
For multilevel disease (≥4 segments): Posterior approach (laminectomy with fusion or laminoplasty), with laminectomy plus posterior fusion showing significantly greater neurological recovery (average 2.0 Nurick grade improvement vs. 1.2 for anterior approach). 2, 3
Prognostic Factors
Factors predicting poor outcomes that warrant closer monitoring: 2, 3
- Female gender
- Older age (>75 years)
- Coexisting psychosocial pathology
- Radicular symptoms
- Longer symptom duration
Factors predicting better outcomes: 2, 3
- Younger age
- Shorter symptom duration
- Better preoperative neurological function
Common Pitfalls to Avoid
Do not rely solely on imaging findings: Spondylotic changes are commonly identified on radiographs and MRI in patients >30 years and correlate poorly with neck pain presence. 2
Do not delay referral for myelopathy: Prolonged severe stenosis can lead to potentially irreversible spinal cord damage. 3, 4
Recognize natural history: Most acute cervical neck pain resolves with conservative treatment, though nearly 50% may have residual or recurrent episodes up to 1 year after initial presentation. 2