What is the initial treatment approach for a patient with spondylosis?

Treatment for Spondylosis

NSAIDs are the first-line drug treatment for spondylosis with pain and stiffness, combined with patient education and regular exercise as cornerstone non-pharmacological interventions. 1, 2

Initial Management Algorithm

Non-Pharmacological Treatment (Must Be Initiated Immediately)

• Patient education and regular exercise are mandatory cornerstone treatments that must continue throughout the disease course, with level Ib evidence supporting their use 2
• Supervised group physiotherapy is superior to home exercise alone for patient global assessment outcomes 2
• Individual and group physical therapy should be considered, with patient associations and self-help groups as useful adjuncts 1
• Land-based physical therapy interventions are preferred over aquatic therapy 1
• Unsupervised back exercises should be advised as part of ongoing management 1

First-Line Pharmacological Treatment

• NSAIDs improve spinal pain, peripheral joint pain, and function over 6 weeks with level Ib evidence 2
• Continuous NSAID treatment is preferred for patients with persistent active symptomatic disease 2
• For patients with increased gastrointestinal risk: use either non-selective NSAIDs plus gastroprotective agent (PPIs reduce serious GI events by 60%, RR 0.40) OR selective COX-2 inhibitor (reduces serious GI events by 82%, RR 0.18) 1, 2
• COX-2 inhibitors show no significant difference in cardiovascular risk compared to traditional NSAIDs (RR 0.79) 1

Second-Line Pharmacological Options

• Analgesics (paracetamol, opioids) may be considered for pain control when NSAIDs are insufficient, contraindicated, or poorly tolerated 1, 2
• Corticosteroid injections directed to local sites of musculoskeletal inflammation may be considered 1, 2
• Systemic corticosteroids for axial disease are NOT supported by evidence 1

Disease-Specific Considerations

For Axial Disease (Ankylosing Spondylitis Pattern)

• DMARDs including sulfasalazine and methotrexate have NO evidence for efficacy in treating axial disease 1
• Sulfasalazine may be considered only in patients with peripheral arthritis 1
• Anti-TNF treatment should be given to patients with persistently high disease activity despite conventional treatments 1, 2
• There is no evidence to support obligatory use of DMARDs before or concomitant with anti-TNF treatment in axial disease 1

For Stable Disease

• On-demand treatment with NSAIDs is preferred over continuous treatment 1
• In patients receiving TNFi and NSAIDs, continue TNFi alone and stop NSAIDs 1
• In patients receiving TNFi and conventional synthetic antirheumatic drugs, continue TNFi alone 1
• Do not discontinue biologics as standard approach 1
• Do not taper biologic dose as standard approach 1

Monitoring Strategy

• Disease monitoring should include patient history, clinical parameters, laboratory tests, and imaging according to the ASAS core set 2, 3
• Monitor every 2-6 months depending on symptoms, severity, and drug treatment 2
• Regular-interval use of validated AS disease activity measures is recommended 1
• Regular-interval monitoring of CRP concentrations or ESR over usual care 1
• Radiographic monitoring is generally not needed more often than once every 2 years 2, 3

Surgical Interventions (Reserved for Specific Indications)

• Total hip arthroplasty should be considered in patients with refractory pain or disability and radiographic evidence of structural damage, independent of age 1, 2, 3
• Spinal surgery (corrective osteotomy and stabilization procedures) may be valuable in selected patients with fixed kyphotic deformity or segmental instability 2, 3
• In patients with advanced hip arthritis, total hip arthroplasty is strongly recommended 1
• In patients with severe kyphosis, elective spinal osteotomy is conditionally recommended against 1

Critical Pitfalls to Avoid

• Never use spinal manipulation in patients with spinal fusion or advanced spinal osteoporosis 1
• Do not prescribe systemic corticosteroids for axial disease—no evidence supports this 1
• Do not use DMARDs as monotherapy for axial spondylosis—they are ineffective 1
• Do not mandate switching from originator TNFi to biosimilar in stable patients 1

Treatment Tailoring

Treatment must be individualized based on: current disease manifestations (axial, peripheral, entheseal, extra-articular), disease activity/inflammation, pain levels, function and disability, structural damage including hip involvement and spinal deformities, general clinical status (age, sex, comorbidity, concomitant drugs), and patient wishes and expectations 1