What are the treatment options for a patient with cervical spondylosis?

Management of Cervical Spondylosis

Symptoms and Clinical Presentation

Begin with conservative management for at least 3 months unless progressive neurological deficits, severe myelopathy, or spinal cord compression are present. 1

Cervical spondylosis typically presents with:

• Intermittent neck pain in middle-aged and elderly patients, which is the most common presentation 2
• Radicular symptoms (arm pain, numbness, weakness) when nerve roots are compressed 3
• Myelopathy symptoms including gait disturbance, balance difficulties, hand clumsiness, and bowel/bladder dysfunction when spinal cord compression occurs 4

Critical red flags requiring urgent evaluation include progressive neurological deficits, gait disturbance, and signs of myelopathy—these indicate spinal cord compression requiring immediate attention. 4

Initial Conservative Treatment (First-Line for 3 Months)

Pharmacological Management

NSAIDs are the first-line medication, showing large improvements in spinal pain and function with Level Ib evidence. 1

• Use traditional NSAIDs or COX-2 inhibitors as they demonstrate equivalent efficacy for spinal pain relief 5
• For patients with gastrointestinal risk factors, use non-selective NSAIDs plus proton pump inhibitors (reduce serious GI events by 60%) or selective COX-2 inhibitors (reduce serious GI events by 82% compared to traditional NSAIDs) 5
• Short-term muscle relaxants (maximum 2-3 weeks) can be added for muscle spasm 1
• Simple analgesics (acetaminophen, opioids) may be added for breakthrough pain when NSAIDs are insufficient or contraindicated 5

Non-Pharmacological Treatment

Non-pharmacological and pharmacological treatments are complementary and both should be used together throughout the disease course. 5

• Physical therapy focusing on neck stabilization and range of motion exercises is recommended 4
• Group physical therapy shows significantly better patient global assessment compared to home exercise alone 1, 5
• Home exercise programs improve function in the short term compared with no intervention (Level Ib evidence) 5
• Activity modification including rest or "low-risk" activities 5
• Patient education regarding proper ergonomics and posture 5

Approximately 70% of patients with mild cervical spondylotic myelopathy maintain stable clinical status over 3 years with conservative treatment. 1

Diagnostic Imaging Strategy

If symptoms persist beyond 4-6 weeks or if neurological symptoms develop, obtain MRI. 1, 5

• MRI is the most sensitive test for detecting soft tissue abnormalities, spinal cord compression, and intramedullary signal changes 1, 5
• Be aware that MRI has high rates of abnormalities in asymptomatic individuals, so correlate findings with clinical symptoms 1, 5
• Radiographs are useful to diagnose spondylosis and degenerative disc disease, but therapy is rarely altered by radiographic findings alone in the absence of red flag symptoms 5

Indications for Surgical Intervention

Absolute Indications (Urgent Referral Required)

Surgical decompression is strongly recommended for patients with moderate to severe cervical spondylotic myelopathy (mJOA score ≤12), demonstrating statistically significant improvement maintained for 5-15 years postoperatively. 5, 4

• Progressive neurological deficits 1, 4
• Moderate to severe cervical spondylotic myelopathy with evidence of spinal cord compression on imaging 1, 4
• Gait and balance difficulties indicating established myelopathy 4
• Long periods of severe stenosis are associated with demyelination and potentially irreversible spinal cord damage 4

Critical pitfall: Do not delay surgery waiting for "failed conservative management" in a patient with established myelopathy and gait disturbance—delaying surgery risks permanent neurological deficit that cannot be reversed even with eventual decompression. 4

Relative Indications

• Persistent severe pain despite adequate conservative management for 3 months 1
• Mild CSM in patients younger than 75 years (mJOA score >12) who fail conservative treatment 1, 5

For mild CSM, both operative and nonoperative management options can be offered, as Class II evidence suggests equivalency between surgery and nonoperative management over 3 years 5

Surgical Approach Selection

For Limited Disease (1-3 Levels)

For 1-2 level disease, anterior cervical discectomy and fusion (ACDF) is the preferred approach, achieving good to excellent outcomes in approximately 90% of patients with radiculopathy. 1, 4

• Anterior decompression and fusion shows improvement rates of approximately 73-74% 5
• Average neurologic improvement of 1.2 Nurick grades with anterior approach 5

For Multilevel Disease (≥4 Segments)

For multilevel disease (≥4 segments), posterior approach (laminectomy with fusion or laminoplasty) is preferred, with laminectomy with posterior fusion demonstrating 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, 5, 4

• Laminectomy with fusion is recommended as fusion prevents iatrogenic instability and provides better long-term outcomes 4
• Laminectomy alone is associated with 29% rate of late deterioration and increased risk of postoperative kyphosis 6, 5
• Laminectomy with fusion or laminoplasty are equivalent strategies for functional improvement 5

Prognostic Factors

Factors Associated with Better Outcomes

• Younger age 1, 5
• Shorter duration of symptoms (symptoms <1 year correlate with better outcomes) 6, 1, 5
• Better preoperative neurological function (higher mJOA scores) 1, 5, 4
• Milder disability at presentation 1, 4
• Earlier surgical intervention correlates with better outcomes 4

Factors Associated with Poor Prognosis

• Female gender 1, 5
• Older age (though age alone is not a contraindication to surgery) 1, 5, 4
• Coexisting psychosocial pathology 1, 5
• Radicular symptoms 1, 5
• Prolonged severe stenosis leading to potentially irreversible spinal cord damage 1, 4
• Multisegmental T2 hyperintensity on MRI strongly correlates with poor outcome if untreated 4

Expected Surgical Outcomes

Approximately 97% of patients have some recovery of symptoms after surgery for cervical stenosis with myelopathy. 4

• Overall improvement rates of 60% across all surgical methods 6
• Common complications include C5 nerve palsy, post-surgical kyphosis, pseudarthrosis (approximately 10.9% after corpectomy), and hardware failure 1
• Revision surgery should be considered for symptomatic pseudarthrosis 1

When to Refer to Specialist

Urgent referral is indicated for:

• Progressive neurological deficits 1
• Signs of cervical myelopathy (gait disturbance, balance difficulties, hand clumsiness) 1, 4
• Evidence of significant spinal cord compression on imaging 1
• Failure to respond to conservative treatment after 3 months 1

Important caveat: Most cases of acute cervical neck pain resolve with conservative treatment measures, but nearly 50% of patients may continue to have residual or recurrent episodes of pain up to 1 year after initial presentation. 5