Conservative Management in Spondylosis ( Dr Pradip Mate )

Dr Pradip Mate(Masters In Pharmaceutical Medicine)

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)

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

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


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.

MRI cervical spondylosis


Age Course Clinical features Diagnosis

Cervical spondyloticmyelopathy

Usually >60 yearsProgressive or stepwise course

Moderate-severe cases demonstrate gait and leg spasticity and amyotrophyof hand or arms

MRI cervical spine

Transverse myelitis Children, young adults Subacute Segmental cord syndrome MRI and CSF

Viral myelitis Any age Acute-subacutePure motor syndrome or Segmental cord syndrome

MRI and CSF

Epidural abscess Any ageSubacute; may worsen abruptly

Segmental cord syndrome MRI

Infarction Usually >60 years Abrupt onset Anterior cord syndromeMRI 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 ageSlowly 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 yearsSubacute, may worsen abruptly

Segmental cord syndrome MRI

Intramedullary tumor Young adults Slowly progressive Central cord syndromeMRI with gadolinium enhancement

ALS Usually >60 years Slowly progressive Pure motor syndrome Electromyography

Important causes of spinal cord dysfunction


Management

Conservative

Nonsteroidalanti-

inflammatory drugs (nsaids)

Physical modalities

Lifestyle modifications.

Surgery is occasionally performed.

Management

Medical treatments for cervical

spondylosis include

Neck immobilization,Pharmacologic

treatmentsLifestyle

modifications

Physical modalities (eg, traction,

manipulation, exercises)

No carefully controlled trials have compared these

modalities; therefore, these therapies are often initiated

based on a clinician's preference 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

http://emedicine.medscape.com/article/1144952-treatment

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



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.



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



Lifestyle modificationsNeck schools

Instruction in body

mechanics

Relaxation techniques

Postural awareness

Ergonomics and/or

workplace modifications



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


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



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

Physical modalities



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



Exercises designed for cervical pain

Isometric neck strengthening routines

Neck and shoulder stretching and flexibility exercises

Back strengthening exercises

Aerobic exercises



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.

Neck tilting Neck rotation

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.


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.



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

http://www.aafp.org/afp/2010/0101/p33.html

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.



Algorithm for nonoperativetreatment of acute cervical radiculopathy.



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 .


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

Healthcare

Conservative Management in Spondylosis ( Dr Pradip Mate )