Treatment algorithm

Your Organisational Guidance

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Aspecifieke nekpijn: diagnose en behandelingPublished by: KCELast published: 2013Douleurs cervicales aspécifiques : diagnostic et traitementPublished by: KCELast published: 2013

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

axial neck pain

1st line – physiotherapy

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axial neck pain
1st line – 

physiotherapy

Physiotherapy is the first-line treatment for axial neck pain, which is a mechanical or musculoskeletal form of pain.[21] Advice on posture, sleeping position, daily activities, work and hobbies, stretching exercises, mobility exercises, and head, neck, and shoulder exercises may benefit individual patients.[41][42]

Infrared heat therapy and transcutaneous electrical nerve stimulation (TENS) may also be beneficial, but high-quality evidence is lacking.[2][6][51]

Cervical manipulation can be associated with serious neurological complications.[44][52]

Although physiotherapy is of most value in the first 6 weeks, it can be continued intermittently as required to treat exacerbations of pain or chronic pain beyond 6 weeks.

Consider – non-steroidal anti-inflammatory drugs (NSAIDs)

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ACUTE
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axial neck pain
Consider – 

non-steroidal anti-inflammatory drugs (NSAIDs)

Additional treatment recommended for SOME patients in selected patient group

May supplement physiotherapy in patients with mechanical neck pain.[21][40]

There is no clinical efficacy difference between various NSAIDs, but many patients tolerate one better than others or may have individual-based treatment preferences.

All NSAIDs may cause gastric irritation. This can be partially alleviated by anti-ulcer medications or taking medicines with food.[2][6]

Primary options

ibuprofen: 300-400 mg orally every 6-8 hours when required, maximum 2400 mg/day

OR

naproxen: 250-500 mg orally twice daily when required, maximum 1250 mg/day

OR

diclofenac potassium: 50 mg orally (immediate-release) twice or three times daily when required

OR

diclofenac sodium: 100 mg orally (extended-release) once daily when required

Consider – muscle relaxants

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ACUTE
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axial neck pain
Consider – 

muscle relaxants

Additional treatment recommended for SOME patients in selected patient group

Because cervical muscle spasm is a critical component of cervical spondylosis, medications may alleviate some of the secondary pain effects in combination with physical measures to relax muscles.[14] There is no clinical efficacy difference between various medications. All medications may cause drowsiness sufficient to interfere with driving or critical activities.[2][6][21]

Primary options

tizanidine: 4 mg orally every 6-8 hours when required initially, increase by 2-4 mg/dose increments according to response, maximum 18 mg/day

OR

methocarbamol: 1500 mg orally four times daily for 2-3 days initially, then decrease dose according to response, usual dose 4000-4500 mg/day given in 3-6 divided doses

OR

diazepam: 5-10 mg orally every 8 hours when required

Consider – trigger-point and/or facet joint injections

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ACUTE
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axial neck pain
Consider – 

trigger-point and/or facet joint injections

Additional treatment recommended for SOME patients in selected patient group

These injections are usually performed by either a radiologist (under CT or fluoroscopy control) or a pain management anaesthesiologist (under fluoroscopic control) as needed.[48]

A long-acting corticosteroid preparation is usually added to a long-acting local anaesthesia medication.[2][6][11]

Trigger-point and/or facet joint injections with corticosteroid (with or without a local anaesthetic) may be considered medically necessary if trigger points have been identified by palpation, if degenerative disease of facet joints is identified, and if medical management therapies such as physiotherapy, NSAIDs (unless contraindicated), and muscle relaxants have not controlled pain.

Primary options

dexamethasone: 4 mg intra-articularly/intrasynovially/into tendon sheath as a single dose

More

cervical spondylotic radiculopathy (CSR)

1st line – analgesics

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ACUTE
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cervical spondylotic radiculopathy (CSR)
1st line – 

analgesics

Medicines are used as first-line treatment for radicular pain in an attempt to reduce symptoms.

There are two common levels of analgesics beyond NSAIDs: codeine-like opioid analgesics such as hydrocodone, and morphine-like opioid analgesics such as oxycodone.

The addictive potential and harm from overdose of opioid drugs should always be considered.

Primary options

ibuprofen: 400-800 mg orally every 6-8 hours when required, maximum 2400 mg/day

OR

naproxen: 250-500 mg orally twice daily when required, maximum 1250 mg/day

OR

diclofenac potassium: 50 mg orally (immediate-release) twice or three times daily when required

OR

diclofenac sodium: 100 mg orally (extended-release) once daily when required

Secondary options

paracetamol/hydrocodone: 5 mg orally every 4-6 hours when required, maximum 60 mg/day

More

OR

oxycodone: 5-10 mg orally (immediate-release) every 4-6 hours when required; 10 mg orally (controlled-release) every 12 hours

Consider – physiotherapy and traction

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ACUTE
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cervical spondylotic radiculopathy (CSR)
Consider – 

physiotherapy and traction

Additional treatment recommended for SOME patients in selected patient group

All patients with cervical radicular pain who have physical difficulty with daily activities should be offered physiotherapy, including posture correction, stretching exercises, and active range-of-movement exercises.[21]

Physiotherapy and particularly cervical traction can help to enlarge foramina narrowed by cervical spondylosis. It may provide further room for nerve roots and subsequently decrease the severity of the nerve tightness (hence partially alleviating the radicular pain).[2][6] Traction regimen of 5 to 8 kg (12 to 18 pounds) for 30 to 45 minutes several times a day is recommended.

Consider – oral corticosteroids

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ACUTE
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cervical spondylotic radiculopathy (CSR)
Consider – 

oral corticosteroids

Additional treatment recommended for SOME patients in selected patient group

Usually limited to 8 to 10 days total due to systemic toxicity, but can be helpful as an initial treatment to decrease nerve irritation and radicular pain.[11][21]

Primary options

prednisolone: 60-80 mg orally once daily for 2-3 days, then taper dose gradually over 10-14 days

2nd line – epidural anaesthesia or cervical nerve root block

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cervical spondylotic radiculopathy (CSR)
2nd line – 

epidural anaesthesia or cervical nerve root block

Depending on the timing and outcome of 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.[23][29][53][56]

To be given by a radiologist or pain management anaesthesiologist.

3rd line – surgical nerve decompression

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ACUTE
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cervical spondylotic radiculopathy (CSR)
3rd line – 

surgical nerve decompression

If the pain does not resolve and if all symptoms, signs and diagnostic studies indicate pressure on a single nerve root, then surgical nerve decompression may be a helpful treatment in some patients.[16][23]

Either anterior cervical discectomy with fusion (ACDF) or posterior nerve decompression procedures are generally selected, based on the patient's symptoms, the number of levels of involvement, and the specific anatomy from the cervical MRI scan.

A minimum of 2 to 3 months of conservative therapy is usually required. Because there is rarely any significant weakness or neurological change 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.[61][62] 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.[61][62][63]

Anterior cervical discectomy is less painful, but swallowing problems may occur.[16][26][65]

Posterior cervical discectomy may be associated with increased neck pain, but does not typically involve a fusion, resulting in preservation of motion.

degenerative cervical myelopathy (DCM)

1st line – surgical decompression

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degenerative cervical myelopathy (DCM)
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moderate to severe symptoms: good surgical candidate
1st line – 

surgical decompression

Surgical decompression is the preferred treatment in patients with moderate and severe symptoms and who are good surgical candidates, although two randomised controlled trials do not show any short-term benefit for mild to moderate myelopathy.[13][26][28][31][60] There are no long-term drug treatments that are helpful in management of DCM; corticosteroids may be used short-term, such as a bridge prior to possible surgical decompression, but for less than a 2-week period due to severe side effects over time. 

Cervical degeneration is usually severe at this point, necessitating multi-level surgery and fusion.[13][28]

There is often existing and irreversible function loss at the time of surgery that usually cannot be alleviated. Surgery is therefore typically considered to stabilise function rather than necessarily improve it. This surgery has higher risks than surgery for radiculopathy, particularly of neurological worsening.

Surgical treatment of all levels of cervical myelopathy is considered the standard of care in some countries, despite no existing specific evidence supporting this option. 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 planned.[30]

1st line – conservative treatment with immobilisation in a hard cervical collar

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ACUTE
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degenerative cervical myelopathy (DCM)
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mild symptoms or poor surgical candidate
1st line – 

conservative treatment with immobilisation in a hard cervical collar

Conservative treatment is the preferred approach for patients who are poor surgical candidates. In some countries, although not all, it is also used for those who have mild, chronic symptoms.

Conservative measures implemented in randomised trials primarily consist of immobilisation in a hard cervical collar, which has been shown to be equivalent (over 1 to 3 years) to surgical decompression in mild to moderate myelopathy.[28] There are no long-term drug treatments that are helpful in management of DCM; corticosteroids may be used short-term, such as a bridge prior to possible surgical decompression, but for less than a 2-week period due to severe side effects over time. 

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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