What is the recommended initial treatment approach for a patient diagnosed with spondylosis, considering their age, medical history, and overall health status?

Initial Treatment for Spondylosis

The recommended initial treatment for spondylosis combines continuous daily NSAIDs at full therapeutic doses with concurrent physical therapy, specifically active supervised exercise programs focused on core strengthening and spinal range of motion. 1, 2

First-Line Pharmacological Management

Start with ibuprofen 1200 mg daily as the first-line NSAID, as this provides effective anti-inflammatory pain relief with the lowest gastrointestinal risk profile among NSAIDs. 2 Use continuous daily dosing rather than "as-needed" dosing, as continuous NSAID therapy provides better symptom control and may reduce radiographic progression in inflammatory spinal conditions. 2, 3

If ibuprofen at 1200 mg daily provides inadequate relief after 1-2 weeks, trial 2-3 different NSAIDs at optimal doses before concluding NSAID failure, as individual response varies significantly. 2, 3 The GI risk hierarchy is: ibuprofen ≤1200 mg daily has the lowest risk, diclofenac/naproxen/high-dose ibuprofen have intermediate risk, and indomethacin has the highest risk. 2

For patients with gastrointestinal risk factors (age >65, history of ulcers, concurrent anticoagulation), add a proton pump inhibitor for gastroprotection, which is equally effective as misoprostol but better tolerated. 2 Alternatively, consider COX-2 selective NSAIDs for long-term continuous use if GI risk factors are present. 1, 3

If NSAIDs are insufficient, contraindicated, or poorly tolerated, analgesics such as paracetamol and opioids may be considered for pain control. 1

Essential Non-Pharmacological Component

Physical therapy must be initiated concurrently with NSAIDs, not sequentially, as this combination provides significant functional improvement. 1, 2 This is a strong recommendation with moderate-quality evidence. 1, 3

Prioritize active supervised exercise programs over passive modalities (massage, ultrasound, heat), as active interventions provide superior outcomes. 1, 3 Specifically, the exercise program should include:

• Core strengthening activities 4
• Hamstring stretching 4
• Spine range of motion exercises 4
• Abdominal curl-ups and posterior pelvic tilts 5

Land-based exercises are preferred over aquatic therapy as the primary approach. 1, 3 Prescribe unsupervised home back exercises as part of ongoing self-management between supervised sessions. 1, 2, 3

Patient education and participation in formal group or individual self-management education should be incorporated. 1

Age and Comorbidity Considerations

For elderly patients with spinal pathology, incorporate fall evaluation and counseling into the management plan. 1, 2

For patients with congenital spinal stenosis or neurologic symptoms, magnetic resonance imaging is the preferred initial diagnostic study. 6 However, because involvement of neurologic structures on imaging may be asymptomatic, neurologic consultation is advised to rule out other neurologic diseases. 6

Critical Contraindications and Pitfalls

Never use systemic glucocorticoids for axial spinal conditions, as they provide no proven benefit in degenerative conditions. 1, 2, 3 However, corticosteroid injections directed to the local site of musculoskeletal inflammation may be considered for peripheral manifestations. 1

Strongly avoid spinal manipulation in patients with advanced spinal osteoporosis or spinal fusion due to fracture risk. 1, 2, 3

Bracing (thoraco-lumbar-sacral orthosis) is not necessary for most patients with symptomatic spondylolysis and grade I spondylolisthesis, as 96% of patients achieve minimal disability with physical therapy and activity restriction alone. 4 Increasing costs and patient noncompliance make bracing prohibitive. 4

Duration and Monitoring

Conservative treatment should be continued for at least 3-6 months before considering it a failure. 7, 5 Conservative management is labor-intensive, requiring regular review and careful selection of medications and physical therapy on a case-by-case basis. 7

Do not perform routine repeat spine radiographs at scheduled intervals for patients with stable imaging. 2 Repeat imaging only if new neurologic symptoms, significant functional decline, or clinical evidence of progression occur. 2 When radiographic monitoring is needed, it should not be performed more often than once every 2 years. 1

When to Escalate Treatment

Surgery should be reserved for patients with moderate to severe myelopathy who have failed a period of conservative treatment, patients whose symptoms are not adequately controlled by nonoperative means, or patients presenting with severe or progressive neurologic deficits. 7, 6 For patients with refractory pain or disability and radiographic evidence of structural damage (particularly advanced hip arthritis), total hip arthroplasty should be considered independent of age. 1