Treatment of Spondylosis
Start with NSAIDs at therapeutic doses combined with physical therapy as first-line treatment for spondylosis, as this combination provides the strongest evidence for symptom relief and functional improvement. 1
Initial Pharmacologic Management
Begin with ibuprofen 1200 mg daily as the first-line NSAID, which provides effective anti-inflammatory pain relief with the lowest gastrointestinal risk profile among NSAIDs. 1
Use continuous daily dosing rather than "as-needed" dosing for ongoing symptoms, as continuous NSAID therapy provides superior symptom control without substantially increasing toxicity. 1
Trial 2-3 different NSAIDs at optimal doses before concluding NSAID failure if ibuprofen at 1200 mg daily provides inadequate relief after 1-2 weeks. 1
Add a proton pump inhibitor (PPI) for gastroprotection in patients with GI risk factors (age >65, history of ulcer disease, concurrent anticoagulation, or corticosteroid use). 1
Understand the GI risk hierarchy: ibuprofen ≤1200 mg daily has the lowest risk, diclofenac/naproxen/high-dose ibuprofen have intermediate risk, and indomethacin has the highest risk. 1
Essential Physical Therapy Component
Initiate physical therapy concurrently with NSAIDs, not sequentially, as physical therapy provides significant functional improvement in degenerative spinal conditions. 1
Prescribe active supervised exercise programs over passive modalities (massage, ultrasound, heat), with land-based exercises preferred over aquatic therapy. 1
Include unsupervised home back exercises as part of the ongoing self-management program for long-term maintenance. 1
Focus the exercise program on core strengthening, hamstring stretching, and spine range of motion exercises, which have demonstrated effectiveness in symptomatic spondylosis. 2
Additional Conservative Measures
Consider epidural steroid injections or transforaminal injections for patients with radiating leg pain or neurogenic intermittent claudication who have inadequate response to NSAIDs and physical therapy. 3
Implement activity modification and neck immobilization (for cervical spondylosis) during acute symptomatic periods. 4
Provide fall evaluation and counseling for elderly patients with spinal pathology to prevent complications. 1
Critical Management Caveats
Strongly avoid systemic glucocorticoids for axial spinal conditions, as they provide no proven benefit in degenerative conditions and carry significant adverse effects. 1
Absolutely contraindicate spinal manipulation in patients with advanced spinal osteoporosis or spinal fusion due to fracture risk. 1
Do not routinely repeat spine radiographs at scheduled intervals for patients with stable imaging; instead, obtain repeat imaging only if new neurologic symptoms, significant functional decline, or clinical evidence of progression occur. 1
Surgical Considerations
Reserve operative therapy for patients who are totally incapacitated by their condition after failing conservative management for 3-4 months minimum. 3, 5
Consider surgical intervention for patients presenting with severe or progressive neurologic deficits, particularly in cervical spondylotic myelopathy or lumbar spinal stenosis with significant functional impairment. 4, 6
Recommend total hip arthroplasty for adults with advanced hip arthritis secondary to spondylosis. 7
Common Pitfalls to Avoid
Do not use "as-needed" NSAID dosing as the primary strategy for chronic symptomatic spondylosis, as continuous dosing provides superior outcomes. 1
Do not prescribe passive physical therapy modalities alone without active supervised exercise, as this provides inferior functional outcomes. 1
Do not delay physical therapy until after NSAID trial, as concurrent initiation provides optimal results. 1
Do not use systemic corticosteroids as a treatment option for degenerative spondylosis, as guidelines strongly recommend against this approach. 1