Approach

In patients with symptomatic cervical spondylosis, there are 3 main clinical syndromes:

  • Axial neck pain

  • Cervical spondylotic radiculopathy (CSR)

  • Cervical spondylotic myelopathy (CSM).

The last 2 syndromes may overlap and both include degrees of axial neck pain. [2] [6] [7] [8] Neck pain may be acute or chronic, is the most common symptom (and most easily treatable), and may occur with or without neurological symptoms due to radiculopathy and/or myelopathy. The evidence about the effects of individual interventions for these clinical syndromes is often contradictory because of the poor-quality randomised controlled trials (RCTs) conducted in diverse groups and the tendency for interventions to be given in combination. [2] [6] [27]

Axial neck pain

First-line treatment of acute (<6 weeks), non-traumatic axial neck pain is physiotherapy, including cervical traction. [28] [29] Evidence A The degree of axial neck pain can be assessed by simple outcome measures to determine the effects of subsequent treatment. [26] [28] [29] [30] [31] It is unclear whether patient education alone is helpful for treatment. [32] [33] Complementary and alternative treatments demonstrate minimal long-term efficacy. [34]

Depending on the severity of pain, the additional use of NSAIDs may be beneficial in individual patients. [27]

If muscle spasm is a feature of the pain, muscle relaxants and manoeuvres (including heat, massage, and cervical pillows) may be beneficial in some patients. [13] The addition of trigger-point and/or facet joint injections and transcutaneous electrical nerve stimulator (TENS) units may also be beneficial. [7] [10] [17] [31] [35] [36] [37]

Additional treatment modalities include various forms of cervical epidural injection, chiropractic treatment, acupuncture, and other, less orthodox approaches, particularly electrotherapy, laser therapy, and cervical spine manipulation therapy. [13] [24] [28] [31] [36] [37] [38] [39] [40] [41] These therapies may entail additional risks, and the evidence does not support treatment for axial neck pain. [38] [42]

All of these treatments are symptomatic, to relieve specific parts of the patient's complaints, and none have any effect on the underlying cervical spondylosis or affect the long-term nature of the cervical degenerative changes. Very few treatments have any effect beyond 6 weeks. [7] [17]

Chronic neck pain (>6 weeks) may be managed by continuing these symptomatic treatments if they improve the patient's discomfort. Axial neck pain is starting to receive consideration for cervical arthroplasty, although this procedure is not yet approved for axial neck pain alone by organisations such as the FDA. [8] [43] [44] Physicians should refer to local consultants on indications for the procedure in their region. In general, surgery is not helpful for treatment of neck pain, but the evidence is of low quality. [45]

Cervical spondylotic radiculopathy

Radiating arm pain can be severe and is initially managed with oral analgesia combined with physiotherapy and cervical traction. [7] [17] Oral corticosteroid therapy may also benefit individual patients. [17] Because patients initially have severe pain, a combination of these treatments is suggested at the outset to curtail the nerve irritation. [20]

Depending on the timing and outcome of these initial treatments, subsequent more invasive treatments may consist of epidural corticosteroids or cervical nerve root block at the suspected level to maintain a positive effect from the oral corticosteroids. [19] [24] [39] [42]

In most patients (around 75%), the severe arm pain will spontaneously relent by 4 to 6 weeks. The pain eventually resolves with conservative measures, but it may take 1 to 2 years to disappear completely. [8] [19] [46]

If the pain does not resolve and if all symptoms, signs and diagnostic studies converge to indicate pressure on a single nerve root, then surgical nerve decompression may be helpful. [8] [19] [21] [47] There are a variety of surgical approaches for nerve decompression (which continue to be debated), but either anterior cervical discectomy with fusion (ACDF) or posterior nerve decompression procedures are generally selected, based on the patient's symptoms, number of levels of involvement, and specific anatomy from the cervical MRI scan. A minimum of 2 to 3 months of conservative therapy is usually required. Because significant weakness or neurological change is rarely associated with radiculopathy, the primary decision for considering surgical decompression is the patient's subjective degree of pain and the significance of the discomfort. Another approach is cervical arthroplasty, where an artificial disc is placed instead of a bone graft and plate to avoid a fusion and retain motion; multiple randomised studies have been carried out, but these procedures are not yet routinely performed everywhere. [44] [48] [49] Despite these multiple randomised studies, there is not yet any clear evidence regarding improved relief of radicular arm pain with arthroplasty compared with ACDF. However, although there are no clear data yet on the prevention of adjacent segment stenosis over time, arthroplasty may provide a lower rate of re-operation compared with ACDF. [44] [48] [49] [50]

Cervical spondylotic myelopathy

Surgical decompression is the preferred first-line acute treatment in patients with severe symptoms who are good surgical candidates, although 2 RCTs do not show any short-term benefit for mild to moderate myelopathy. [12] [23] Surgical decompression would ideally provide significant space for the spinal cord while retaining mobility of the cervical spine without leading to instability; this ideal treatment does not exist. Usually, adequate treatment of the severe underlying degenerative joint disease (DJD) requires fusion or immobilisation of the segments, leading to loss of range of motion of the cervical spine. [21] [47] With anterior approaches, adjacent segments often develop DJD over time, leading to adjacent segment stenosis. With posterior approaches there can be either instability (following laminectomy alone) or near complete loss of cervical range of motion, with the typical extensive posterior fusion needed. Furthermore, decompression surgery typically only stabilises spinal cord function (with only mild improvement in symptoms) because there is usually existing permanent damage to the spinal cord at the time of surgery. The trend is consequently towards earlier surgery, while the patient has more of a chance of returning to normal function, or surgery while the patient is asymptomatic. [9] [21] [23] [25] [47]

Conservative treatment consists of immobilisation in a hard cervical collar. [9] This is the preferred treatment for patients who are poor surgical candidates. In some countries, although not all, it is also used for those who have mild, chronic symptoms. This conservative treatment has been shown in mild to moderate myelopathy to be equivalent (over 1 to 3 years) to surgical decompression. [23] There are no long-term drugs that are helpful in management of cervical spondylotic myelopathy; short-term corticosteroids may be used as a bridge prior to possible surgical decompression, but for <2 weeks due to their side-effects profile.

Surgical treatment of all levels of cervical myelopathy is considered the standard of care in some countries, with supporting evidence from a prospective multi-centre study. [21] [47] [51] Surgical decompression is therefore typically offered to patients on presentation, although there is variability between individual surgeons. Due to this bias and the worry that patients may experience irreversible deterioration if surgical decompression is delayed, it is very unlikely that any randomised surgical trials for cervical myelopathy will be undertaken. [25]

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