Management of Cervical Spondylosis in Ankylosing Spondylitis
For AS patients with cervical neck pain, stiffness, and limited motion without neurological deficits, initiate combined NSAIDs plus structured physical therapy immediately, obtain baseline cervical spine radiographs, and maintain heightened vigilance for even minor trauma given the catastrophic fracture risk in these patients. 1, 2, 3
Initial Assessment and Risk Stratification
The cervical spine in AS patients represents a uniquely vulnerable structure requiring special consideration beyond typical cervical spondylosis management:
Obtain cervical spine radiographs (AP, lateral, and odontoid views) at initial presentation to establish baseline structural changes, degree of ankylosis, and identify any occult fractures, as even minor trauma can cause fractures in the rigid "bamboo spine." 1, 4, 5
Systematically assess for "red flag" features including recent trauma (even seemingly trivial), progressive neurological symptoms (weakness, numbness, balance difficulty), or radicular pain, as these mandate immediate MRI evaluation. 2, 6
Document baseline neurological examination including motor strength in all extremities, sensory testing, reflexes, and gait assessment, as AS patients with cervical trauma develop severe neurological deficits in 57% of cases with 35% mortality—twice that of normal spines. 4, 5
Inquire specifically about any recent falls or minor head/neck trauma, as fractures in AS typically result from hyperextension injuries through former intervertebral spaces and are frequently missed on initial evaluation, leading to delayed diagnosis in 15-21% of cases. 4, 7, 5
Pharmacological Management
NSAIDs form the cornerstone of symptomatic treatment for axial pain and stiffness in AS:
Prescribe continuous NSAID therapy at full anti-inflammatory doses (not just as-needed dosing), as there is Level Ib evidence demonstrating large improvements in spinal pain and function over 6-week periods. 1, 2, 3
For patients with gastrointestinal risk factors, use either non-selective NSAIDs plus proton pump inhibitors (which reduce serious GI events by 60%) or selective COX-2 inhibitors (which reduce serious GI events by 82% compared to traditional NSAIDs). 1, 2
Add simple analgesics (acetaminophen or short-term opioids) for breakthrough pain when NSAIDs alone provide insufficient relief or are contraindicated. 2
Continue NSAID therapy long-term, as both pharmacological and non-pharmacological treatments are complementary and valuable throughout the disease course in AS. 1, 3
Non-Pharmacological Management
Physical therapy and exercise are equally important as medications in AS management:
Prescribe regular home exercise programs focusing on spinal mobility and posture, as Level Ib evidence shows home exercise improves function in the short term compared to no intervention. 1, 2, 3
Refer for group physical therapy sessions, which demonstrate significantly better patient global assessment outcomes compared to home exercise alone, though both improve function similarly. 1, 2, 3
Emphasize gentle range-of-motion exercises and postural training rather than high-impact activities, given the increased fracture risk in ankylosed spines. 3
Provide patient education regarding proper ergonomics, fall prevention strategies, and the critical importance of reporting any trauma or new neurological symptoms immediately. 1, 2, 3
Imaging Strategy
The imaging approach differs significantly from typical cervical spondylosis due to AS-specific complications:
Obtain baseline cervical spine radiographs (AP, lateral, and flexion-extension views if safe) to document degree of ankylosis, alignment, and exclude fractures, as radiographs are useful for diagnosing spondylosis and spinal canal stenosis. 1, 2
Perform MRI cervical spine without contrast if symptoms persist beyond 4-6 weeks, worsen despite treatment, or if any neurological symptoms develop, as MRI is the most sensitive test for detecting soft tissue abnormalities, cord compression, and myelopathy. 2, 6
Obtain urgent MRI if the patient reports any recent trauma (even minor), develops new weakness, numbness, or balance difficulty, as these symptoms suggest possible cervical myelopathy or occult fracture requiring immediate evaluation. 2, 6, 7
Consider CT cervical spine if MRI is contraindicated or if radiographs show suspicious findings, as CT provides superior bone detail for fracture assessment and surgical planning. 6
Repeat radiographic monitoring generally no more often than every 2 years unless clinical deterioration occurs, though exceptions exist for rapidly progressing cases. 1, 3
Monitoring and Follow-Up
AS patients with cervical involvement require closer surveillance than typical spondylosis:
Schedule follow-up at 2-4 weeks initially to assess response to NSAIDs and physical therapy, with instructions to return immediately if symptoms worsen or new neurological deficits develop. 2, 6
Monitor disease activity using validated instruments including patient history, clinical parameters (BASFI for function, VAS for pain, spinal mobility measures), laboratory tests (ESR), and imaging according to the ASAS core set. 1, 3
Reassess neurological examination at each visit, documenting any changes in motor strength, sensation, reflexes, or gait, as progressive deficits warrant urgent imaging and specialist referral. 2, 6
Educate patients to avoid high-velocity spinal manipulation, as this carries risk of spine fractures, spinal cord injury, and paraplegia in patients with spinal fusion or advanced disease. 2
Indications for Specialist Referral
Certain clinical scenarios mandate prompt rheumatology or spine surgery consultation:
Refer to rheumatology if persistently high disease activity despite NSAIDs and physical therapy, as anti-TNF treatment should be given to patients with inadequate response to conventional treatments. 3
Refer urgently to spine surgery if any neurological deficits develop (weakness, numbness, myelopathic signs), as surgical decompression may be necessary to prevent irreversible neurological damage. 1, 2
Refer to spine surgery for evaluation if imaging shows spinal stenosis, myelopathy, or cauda equina syndrome, as these are established indications for surgical intervention in AS. 1
Refer immediately to spine surgery if fracture is suspected or confirmed, as cervical fractures in AS are unstable, require anterior-posterior stabilization (preferably in one or two stages), and carry high morbidity and mortality if diagnosis is delayed. 4, 5
Critical Pitfalls to Avoid
Several unique hazards exist when managing cervical spine disease in AS patients:
Never dismiss neck pain after even trivial trauma in AS patients, as fractures typically occur through former intervertebral spaces (usually C5-C7), are often non-displaced initially, and are frequently missed on plain radiographs due to distorted anatomy, leading to delayed diagnosis in 21% of cases. 8, 4, 7, 5
Do not rely solely on imaging findings for treatment decisions, as spondylotic changes are commonly identified on radiographs and MRI in patients >30 years and correlate poorly with neck pain in the general population, though in AS the clinical context differs significantly. 2, 6
Avoid delaying MRI in patients with any neurological symptoms, as AS patients with cervical trauma who experience delayed diagnosis present with more severe neurological deficits and have worse postoperative improvement than those diagnosed promptly. 7, 5
Do not perform isolated anterior stabilization if surgery becomes necessary, as early implant failure occurred in 50% (5 of 10) of single-session anterior-only stabilizations in AS cervical fractures, compared to no failures with combined anterior-posterior approaches. 5
Never attribute new symptoms to "just AS" without excluding fracture or myelopathy, as extensive cervical erosions with atlantoaxial subluxation can occur in AS, and cervical spine radiographs are essential for AS patients presenting with neck pain. 8