Treatment for Mild Degenerative Spondylosis
For mild degenerative spondylosis causing intermittent cervical or lumbar pain without neurologic deficit, start with NSAIDs at maximum tolerated doses combined with regular exercise and patient education; approximately 75% of patients show good response within 48 hours of full-dose NSAID therapy. 1
First-Line Pharmacologic Management
NSAIDs are the cornerstone first-line treatment for degenerative spondylosis with pain and stiffness, providing strong evidence of improvement in spinal pain and functional ability 2, 1. Key considerations include:
- For intermittent mild symptoms, use NSAIDs on an as-needed basis rather than continuous daily dosing 2, 3
- No single NSAID demonstrates superiority over others; selection should be based on individual patient tolerance and risk factors 2
- In patients over 65 years, with prior GI bleeding, or on concurrent corticosteroids, prescribe either a selective COX-2 inhibitor alone OR a non-selective NSAID combined with a proton pump inhibitor 2
- Consider cardiovascular risk when selecting between COX-2 inhibitors and traditional NSAIDs, as both classes carry potential cardiovascular toxicity 2
Essential Non-Pharmacologic Interventions
Exercise and patient education must be initiated immediately and continued throughout treatment 2, 4:
- Spinal extension exercises, deep breathing exercises, neck range of motion, and posture exercises are specifically recommended for maintaining spinal mobility 1
- Low-impact aerobic exercise, strengthening exercises, and swimming or water aerobics provide optimal benefit 1
- Group physical therapy demonstrates superior patient global assessment outcomes compared to home exercise alone, though both improve function 4
Adjunctive Pain Management
When NSAIDs are insufficient, contraindicated, or poorly tolerated:
- Add acetaminophen (paracetamol) or opioid analgesics for residual pain control 2, 3
- Local corticosteroid injections into specific painful enthesitis sites or facet joints may provide targeted relief 2, 5
- Avoid systemic corticosteroids for axial symptoms—they lack efficacy evidence and add unnecessary toxicity 2
Critical Pitfalls to Avoid
- Do not prescribe conventional DMARDs (sulfasalazine, methotrexate) for degenerative spondylosis—these agents have no demonstrated efficacy for axial degenerative disease and are only indicated for inflammatory spondyloarthropathies with peripheral arthritis 2
- Do not delay appropriate imaging if neurologic symptoms develop—magnetic resonance imaging is the preferred initial diagnostic study when radiculopathy or myelopathy is suspected 6
- Do not continue conservative management if progressive neurologic deficit occurs—this mandates prompt surgical consultation 6, 7
Monitoring and Escalation
- Track morning stiffness duration, night pain, and overall pain levels to assess treatment response 1
- Conservative treatment should remain first-line for at least 3 months before considering surgical referral 8, 3
- Surgical intervention is indicated only for refractory pain despite adequate conservative therapy OR for progressive neurologic deficit 6, 7