Conservative Management in Spondylosis

1. Dr PradipMate
(Masters In Pharmaceutical Medicine)

2. Introduction
 Cervical spondylosis is a common degenerative condition of the
cervical spine.
 It is most likely caused by age-related changes in the intervertebral
disks.
 Clinically, several syndromes, both overlapping and distinct, are seen.
These include
 Neck and shoulder pain,
 Suboccipital pain and headache,
 Radicular symptoms
 Cervical spondylotic myelopathy (CSM)

3. Cervical dermatomes
Schematic representation of the cervical and T1 dermatomes. There is no C1 dermatome. Patients with nerve
root syndromes may have pain, paresthesias, and diminished sensation in the dermatome of the nerve that is
involved.
Kerry Levin. Cervical spondylotic myelopathy. Up To Date. 2013

4. Progressive degenerative process
Cervical spondylosis refers to a progressive degenerative process affecting the cervical vertebral bodies
and intervertebral discs.
This process can lead to narrowing (stenosis) of the central spinal canal, compressing the cervical
spinal cord and producing a syndrome of spinal cord dysfunction known as cervical spondylotic
myelopathy.
Myelopathy occurs in 5 to 10 percent of patients with symptomatic cervical spondylosis.
Other clinical syndromes associated with cervical spondylosis include neck pain and cervical
radiculopathy
Kerry Levin. Cervical spondylotic myelopathy. Up To Date. 2013

5. A 48-year-old man presented with neck pain and predominantly left-sided radicular symptoms in the arm.
The patient's symptoms resolved with conservative therapy. T2-weighted sagittal MRI shows ventral
osteophytosis, most prominent between C4 and C7, with reduction of the ventral cerebrospinal fluid sleeve.

6. MRI cervical spondylosis
Kerry Levin. Cervical spondylotic myelopathy. Up To Date. 2013

7. Important causes of spinal cord dysfunction
Age Course Clinical features Diagnosis
Cervical spondylotic
myelopathy
Usually >60 years
Progressive or stepwise
course
Moderate-severe cases
demonstrate gait and leg
spasticity and amyotrophy
of hand or arms
MRI cervical spine
Transverse myelitis Children, young adults Subacute Segmental cord syndrome MRI and CSF
Viral myelitis Any age Acute-subacute
Pure motor syndrome or
Segmental cord syndrome
MRI and CSF
Epidural abscess Any age
Subacute; may worsen
abruptly
Segmental cord syndrome MRI
Infarction Usually >60 years Abrupt onset Anterior cord syndrome
MRI with diffusion weighted
sequences
Vascular malformation
>40 years (dural fistula)
20's (intramedullary AVM)
Acute and/or stepwise Radicuomyelopathy MRI, spinal angiography
Subacute combined
degeneration
Any age Slowly progressive Dorsal cord syndrome Vitamin B12 levels
Radiation Any age
Slowly progressive;
beginning 6-12 months after
radiation therapy
Segmental cord syndrome or
Ventral cord syndrome
MRI, clinical history
Syringomyelia Children, young adults Slowly progressive Central cord syndrome MRI
Epidural metastasis Usually >50 years
Subacute, may worsen
abruptly
Segmental cord syndrome MRI
Intramedullary tumor Young adults Slowly progressive Central cord syndrome
MRI with gadolinium
enhancement
ALS Usually >60 years Slowly progressive Pure motor syndrome Electromyography
Kerry Levin. Cervical spondylotic myelopathy. Up To Date. 2013

8. Management
Conservative
Nonsteroidal
anti-inflammatory
drugs (nsaids)
Physical
modalities
Surgery is
occasionally
performed.
Lifestyle
modifications.

9. Management
Medical treatments
for cervical
spondylosis include
Neck immobilization,
Pharmacologic
treatments
No carefully controlled trials
modalities; therefore, these
therapies are often initiated
based on a clinician's preference
Lifestyle
have compared these
modifications
Physical modalities
(eg, traction,
manipulation,
exercises)
or specialty
Comparing the efficacy of these
treatments against no treatment
is difficult
Cervical Spondylosis Treatment & Management.
Available from URL: http://emedicine.medscape.com/article/1144952-treatment

10. Neck immobilization
 Neck immobilization (with a soft collar, Philadelphia collar, rigid orthoses,
Minerva jacket, or a molded cervical pillow for support) is a common,
nonoperative treatment for neck pain and/or suboccipital pain syndromes caused
by spondylosis and cervical radiculopathy.
 Despite widespread use, soft collars are largely believed to work by placebo effect
because they do not appreciably limit motion of the cervical spine.
 They have not been demonstrated to change long-term outcomes. If worn
properly, a soft collar maintains relative flexion.
 The collar should be worn as long as possible during the day
Cervical Spondylosis Treatment & Management.
Available from URL: http://emedicine.medscape.com/article/1144952-treatment

11. Neck immobilization
 As symptoms improve, the collar can be worn only during strenuous
activity.
 Eventually, it can be discontinued.
 More rigid collars and devices may better limit motion of the cervical
spine, but they may reduce muscle tone and cause neck stiffness from
disuse.
 Implement a daily cervical exercise program to limit loss of muscle
tone.
Cervical Spondylosis Treatment & Management.
Available from URL: http://emedicine.medscape.com/article/1144952-treatment

12. Pharmacologic treatment includes several
options.
 NSAIDs are the mainstay of pharmacologic treatment. They are effective in
reducing the biologic effects of inflammation and pain
 Patients who experience more chronic pain symptoms may benefit from tricyclic
antidepressants (TCAs).
 Muscle relaxants such as carisoprodol and cyclobenzaprine may also be beneficial
in patients with a spasm in the neck muscles (which can be related to spondylotic
changes).
 Opioids could be considered in patients who have moderate-to-severe pain due to
significant structural spondylosis
Cervical Spondylosis Treatment & Management.
Available from URL: http://emedicine.medscape.com/article/1144952-treatment

13. Lifestyle modifications
Neck schools
Instruction in
body
mechanics
Relaxation
techniques
Ergonomics
and/or
workplace
modifications
Postural
awareness
Cervical Spondylosis Treatment & Management.
Available from URL: http://emedicine.medscape.com/article/1144952-treatment

14. Lifestyle modifications
 Neck school is a form of small group therapy that provides techniques to patients
who are willing to actively work toward recovery.
 Instruction in body mechanics focuses on low-load concepts.
 These include ;
 Avoiding forward bending and rotation of the neck,
 Avoiding prolonged extension of the neck,
 Avoiding prolonged sitting or standing
 Selecting the proper chair.
 Workplace modifications and ergonomics serve to reduce strenuous neck positions
during work and leisure.
Cervical Spondylosis Treatment & Management.
Available from URL: http://emedicine.medscape.com/article/1144952-treatment

15. Physical modalities
 Cervical mechanical traction, commonly used for cervical
radiculopathy.
 Studies regarding its efficacy are conflicting, with intermittent
traction probably being more effective than static traction.
 Initially, a weight of 10 lb is recommended, eventually increasing to 20
lb as tolerated
Cervical Spondylosis Treatment & Management.
Available from URL: http://emedicine.medscape.com/article/1144952-treatment

16. Physical modalities
 It can be used at home 2-3 times daily for 15 minutes at a time.
 It is contraindicated in patients who have myelopathy, a positive
Lhermitte sign, or rheumatoid arthritis with atlantoaxial subluxation.
 A retrospective study found that cervical traction provided
symptomatic relief in 81% of the patients with mild-to-moderately
severe cervical spondylosis syndromes
Cervical Spondylosis Treatment & Management.
Available from URL: http://emedicine.medscape.com/article/1144952-treatment

17. Manipulation
 Manipulation, most commonly practiced by chiropractors and osteopathic physicians, was
described as early as 4000 years ago.
 Techniques vary and include low-velocity, high-amplitude manipulation; high-velocity,
low-amplitude manipulation (eg, thrusting or impulse manipulation); and nonthrusting
maneuvers.
 Contraindications to cervical manipulation include vertebral fractures, dislocations,
infections, malignancy, spondylolisthesis, myelopathy, various rheumatologic and
connective-tissue disorders, and the presence of objective signs of nerve root compromise
Cervical Spondylosis Treatment & Management.
Available from URL: http://emedicine.medscape.com/article/1144952-treatment

18. Exercises designed for cervical pain
Isometric neck strengthening routines
Neck and shoulder stretching and flexibility exercises
Back strengthening exercises
Aerobic exercises
Cervical Spondylosis Treatment & Management.
Available from URL: http://emedicine.medscape.com/article/1144952-treatment

19. Neck tilting Neck rotation
Tilt your head to the right, trying
to touch your ear to the tip of
your shoulder. Place tension on
the temple with your fingertips.
Hold for a few seconds and
return to the center. Repeat to
the left.
Slowly turn your head to the right.
Place tension on your chin with your
fingertips. Hold for a few seconds
and return to the center. Repeat to
the left.
Kerry Levin. Cervical spondylotic myelopathy. Up To Date. 2013

20. Other commonly used modalities for pain
 Heat
 Cold
 Acupuncture
 Massage
 Trigger-point injection
 Transcutaneous electrical nerve stimulation
 Low-power cold laser
 Most of the passive modalities used for degenerative disease of the
cervical spine are performed by physical therapists and are most
efficacious in combination.
Cervical Spondylosis Treatment & Management.
Available from URL: http://emedicine.medscape.com/article/1144952-treatment

22. IMMOBILIZATION
 For patients with acute neck pain secondary to radiculopathy, a short
course (one week) of neck immobilization may reduce symptoms in
the inflammatory phase.
 Although the effectiveness of immobilization with a cervical collar
has not been proven to alter the course or intensity of the disease
process, it may be beneficial in some patients.
Cervical Radiculopathy: Nonoperative Management of Neck Pain and Radicular Symptoms.
http://www.aafp.org/afp/2010/0101/p33.html

23. TRACTION
 Home cervical traction units may decrease radicular symptoms.
 In theory, traction distracts the neural foramen and decompresses the
affected nerve root.
 Typically, eight to 12 lb of traction is applied at an angle of approximately 24
degrees of flexion for 15- to 20-minute intervals.
 Traction is most beneficial when acute muscular pain has subsided and
should not be used in patients who have signs of myelopathy.
 A recent systematic review of mechanical traction for neck pain of more
than three months duration, with or without radicular symptoms, found
insufficient evidence to recommend for or against its use in the
management of chronic symptoms.
Cervical Radiculopathy: Nonoperative Management of Neck Pain and Radicular Symptoms.
http://www.aafp.org/afp/2010/0101/p33.html

24. Algorithm for nonoperative
treatment of acute cervical
radiculopathy.
Cervical Radiculopathy: Nonoperative Management
of Neck Pain and Radicular Symptoms.
http://www.aafp.org/afp/2010/0101/p33.html

26. Conservative measures
 Nonsurgical treatment often includes some form of cervical immobilization (soft
collar or brace), restriction of high-risk activities and environments (eg, slippery
surfaces, vigorous neck movement, heavy lifting, action sports), and pain
management.
 Patients should also take precautions to avoid whiplash while in vehicle, by adjusting
the headrest to a position at the level of the occiput.
 Although some regimens also include exercises and cervical traction, other clinicians
suggest that these are contraindicated in cervical spondylotic myelopathy .
Kerry Levin. Cervical spondylotic myelopathy. Up To Date. 2013

27. To anticipate symptomatic relief by conservative treatment, it should be
carried out intensively in cases with a short disease duration.
Relationship between outcome and disease duration.
The Spine Journal 1 (2001) 269–273