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

Treatment of Cervical Spondylosis

For cervical spondylosis without myelopathy, start with conservative management including NSAIDs, physical therapy, and activity modification for at least 4-6 weeks; however, if moderate to severe cervical spondylotic myelopathy (mJOA score ≤12) develops, proceed directly to surgical decompression as this demonstrates statistically significant neurological improvement maintained for 5-15 years postoperatively. 1

Initial Conservative Management (For Non-Myelopathic Patients)

Pharmacological Treatment:

• NSAIDs are first-line drug treatment, showing large improvements in spinal pain and function with convincing 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% compared to traditional NSAIDs) 1
• Add simple analgesics (acetaminophen, opioids) for breakthrough pain when NSAIDs are insufficient or contraindicated 1

Non-Pharmacological Treatment:

• Home exercise programs improve function in the short term compared with no intervention (Level Ib evidence) 1
• Group physical therapy shows significantly better patient global assessment compared to home exercise alone 1
• Patient education regarding proper ergonomics and posture is essential 1
• Non-pharmacological and pharmacological treatments are complementary and both should be used together throughout the disease course 1

Expected Outcomes:

• Most cases of acute cervical neck pain resolve with conservative treatment 1
• However, nearly 50% of patients may continue to have residual or recurrent episodes of pain up to 1 year after initial presentation 1
• Nonoperative therapy in the acute phase has success rates averaging 90% for cervical radiculopathy 1

When to Obtain Advanced Imaging

• If symptoms persist beyond 4-6 weeks or if 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
• Critical caveat: Do not rely solely on imaging findings for treatment decisions, as spondylotic changes are commonly identified on radiographs and MRI in patients >30 years of age and correlate poorly with the presence of neck pain 1

Indications for Surgical Intervention

Absolute Indications:

• Moderate to severe cervical spondylotic myelopathy (mJOA score ≤12) with progressive neurological deficits 1
• Evidence of spinal cord compression on imaging with corresponding clinical symptoms 1
• Persistent severe pain despite adequate conservative management 1

Relative Indications:

• For patients with mild CSM (age younger than 75 years and mJOA score >12), both operative and nonoperative management options can be offered, as Class II evidence suggests equivalency between surgery and nonoperative management over 3 years 1
• However, mild myelopathy may remain stable in approximately 70-80% of patients over 3 years with conservative management, though 20-30% will progress and require surgery 2

Surgical Approach Selection

For 1-3 Level Disease:

• Anterior approach (ACDF or corpectomy) is preferred 1
• Anterior surgical approaches show improvement rates of approximately 73-74% 1
• Average neurologic improvement of 1.2 Nurick grades with anterior approach 1

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
• Laminectomy with fusion is recommended as an equivalent strategy to laminectomy or laminoplasty for functional improvement in patients with CSM and OPLL 3

Critical Surgical Consideration:

• Laminectomy alone is associated with increased risk of postoperative kyphosis compared to anterior techniques or laminectomy with fusion 1
• Monitor for late deterioration, which occurs in approximately 29% of patients who undergo laminectomy alone 1

Prognostic Factors

Poor Prognosis Indicators:

• Female gender, older age, coexisting psychosocial pathology, and radicular symptoms 1
• Prolonged symptom duration before diagnosis correlates with poorer surgical outcomes 2

Good Prognosis Indicators:

• Younger patients have better prognosis 1
• Shorter duration of symptoms correlates with better outcomes 1
• Better preoperative neurological function predicts better outcomes 1

Special Monitoring Considerations

• For patients with cervical stenosis without myelopathy who have clinical radiculopathy, closer monitoring is warranted as this is associated with development of symptomatic CSM 1
• Do not delay appropriate referral for patients with progressive neurological symptoms or signs of myelopathy 1
• The natural history of cervical myelopathy generally follows one of three patterns: episodic deterioration (75% of patients), slow steady progression (20% of patients), and rapid onset followed by plateau (5% of patients) 2