Cervical Spondylosis Treatment & Management

Physical therapy

Immobilization of the cervical spine is the mainstay of conservative treatment for patients with severe cervical spondylosis with evidence of myelopathy. Immobilization limits the motion of the neck, thereby reducing nerve irritation. Soft cervical collars are recommended for daytime use only, but they are unable to appreciably limit the motion of the cervical spine. More rigid orthoses (eg, Philadelphia collar, Minerva body jacket) can significantly immobilize the cervical spine (see Special Concerns). The patient's tolerance and compliance are considerations when any of the braces are used. A program of isometric cervical exercises may help to limit the loss of muscle tone that results from the use of more restrictive orthoses. Molded cervical pillows can better align the spine during sleep and provide symptomatic relief for some patients.

Mechanical traction is a widely used technique. This form of treatment may be useful because it promotes immobilization of the cervical region and widens the foraminal openings. However, traction in the treatment of cervical pain was not better than placebo in 2 randomized groups.

The use of cervical exercises has been advocated in patients with cervical spondylosis. Isometric exercises are often beneficial to maintain the strength of the neck muscles. Neck and upper back stretching exercises, as well as light aerobic activities, also are recommended. The exercise programs are best initiated and monitored by a physical therapist.

Passive modalities generally involve the application of heat to the tissues in the cervical region, either by means of superficial devices (eg, moist-heat packs) or mechanisms for deep-heat transfer (eg, ultrasound, diathermy).

Manual therapy, such as massage, mobilization, and manipulation, may provide further relief for patients with cervical spondylosis. Mobilization is performed by a physical therapist and is characterized by the application of gentle pressure within or at the limits of normal motion, with the goal of increasing the ROM. Manual traction may be better tolerated than mechanical traction in some patients. Manipulation is characterized by a high-velocity thrust, which is often delivered at or near the limit of the ROM. The intention is to increase articular mobility or to realign the spine. Contraindications to manipulative therapy include myelopathy, severe degenerative changes, fracture or dislocation, infection, malignancy, ligamentous instability, and vertebrobasilar insufficiency.

Occupational therapy

Patients with upper extremity weakness often lose their ability to perform activities of daily living (ADL), vocational activities, or recreational activities. Lifestyle modifications may involve an evaluation of workplace ergonomics, postural training, neck-school therapy (supervised, small-group therapy), stress management, and vocational assistance. Disability can be improved with specific strengthening exercises of the upper extremities, special splinting to compensate for weakness, and the use of assistive devices that allow the patient to perform previously impossible activities.

Recreational therapy

The recreational therapist can use recreational and community activity to accomplish the following:

• Help the patient maintain his/her physical strength, social skills, and motivation

• Assist the patient and family in adjusting to the disability

• Decrease the patient's atypical behaviors

• Increase the patient's independence

• Reinforce other therapies

• Provide community integration

• Further evaluate the level of functioning in cases of severe disability caused by cervical spondylosis

Cervical spondylosis may result in complications (see Mortality/Morbidity), including the following:

• Cervical myelopathy

• Paraplegia

• Tetraplegia

• Recurrent chest infection

• Pressure sores

• Recurrent urinary tract infection

Indications for surgery include the following:

• Progressive neurologic deficits

• Documented compression of the cervical nerve root and/or spinal cord

• Intractable pain

The aims of surgery are to relieve pain and neuronal structure compression, as well as, in select cases, to achieve stabilization.

Approaches for surgery are anterior or posterior.

Anterior approaches include the following ^{[20, 21, 22]} :

• Diskectomy without bone graft

• Diskectomy with bone graft

• Cervical instrumentation

Posterior approaches include the following ^{[4, 23]} :

• Decompressive laminectomy and foraminotomy

• Hemilaminectomy

• Laminoplasty ^{[24, 25]}

Data from the AOSpine North America Cervical Spondylotic Myelopathy Study show the majority of complications due to surgical treatment of CSM are treatable. Complications that do arise are often associated with greater age, increased operative time, and use of combined anterior-posterior procedures. ^[26]

A literature review by Ma et al indicated that in patients with cervical spondylosis, treatment with anterior cervical diskectomy and fusion (ACDF) was associated with a lower overall success rate and a higher visual analog scale score than was treatment with cervical arthroplasty. However, the mean duration of surgery was shorter with diskectomy/fusion. ^[27]

A study by Lim et al, using the American College of Surgeons National Surgical Quality Improvement Program database, reported that in patients with cervical spondylosis undergoing ACDF, instrumentation can be safely employed. The investigators found that 30-day rates of complications, unplanned reoperation, and readmission did not significantly differ between patients who underwent ACDF with instrumentation and those treated with ACDF without instrumentation. ^[28]

In a retrospective study of elderly patients with cervical spondylosis who were treated with primary one- to two-level anterior cervical spine fusion, Puvanesarajah et al found that major medical complications or mortality are more likely to occur in patients aged 80 years or above than in those aged 65-79 years. Patients aged 80 years or older also had significantly higher rates of dysphagia, aspiration pneumonitis, and reintubation. However, the investigators state that carefully selected patients in this age group could potentially benefit substantially from the surgery. ^[29]

A retrospective study by Passias et al indicated that in patients with morbid obesity, bariatric surgery is associated with improved cervical and lumbar pathology. The investigators reported that by 180 days post surgery, half of the study’s patients who had been diagnosed with cervical or lumbar pathology had stopped seeking inpatient care for the spinal condition. For individuals with cervical spondylosis, that diagnosis no longer applied to (cumulatively) 46%, 70%, 83%, and 94% of them at 90-, 180-, 360-, and 720-day follow-up (respectively). ^[30]

Consultations with the following specialists may be helpful:

• Psychologist or psychiatrist

• Pain management specialist

• Neurologist

• Neurosurgeon and/or orthopedic spinal surgeon

• Urologist

• Internist

• Occupational therapist

• Physical therapist

• Recreational therapist

• Social worker

Injection

Cervical, zygapophyseal, intra-articular steroid injection can be helpful for active synovitis. The facet injections can be diagnostic and therapeutic. Mechanical facet pain is better evaluated with facet joint nerve blocks. Long-term relief can often be accomplished with a rhizotomy procedure. Cervical epidural block might be beneficial in cervical spondylosis, especially if an inflammatory component is present. Epidural and selective nerve root blocks can be diagnostically and therapeutically helpful in cases of radiculopathy. Trigger-point injections may be helpful.

Treatment of bowel and bladder dysfunction

Some patients with bowel dysfunction may benefit from a daily suppository, enema, or oral laxative. The administration should be followed by digital stimulation so that the patient's defecation occurs at a predictable time. Evaluate bladder incontinence with urodynamic studies. Pharmacologic intervention is possible in some patients, but many individuals need an intermittent catheterization program and control of fluid intake. An indwelling catheter is occasionally required if the patient does not have the dexterity to comply with a catheter program.

Rehabilitative nursing

A nurse should be involved in the educational process regarding the development of an effective bowel and/or bladder program and the prevention of pressure sores.

Psychosocial support

Patients with significant disability often react with fear, anxiety, or depression. Postoperative depression is significantly associated with pain intensity, pain interference, and pain-related disability. Results of one study of depression and negative affect among spinal surgery patients suggest postoperative screening for depression and treating depression to improve functional outcomes after spine surgery. ^[31] Referral to a psychologist or psychiatrist for psychotherapy, pharmacotherapy, and/or family counseling may be indicated.